Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Studio City Rehabilitation Center during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, cerebral infarction, and severe cognitive impairment experienced changes in condition, including confusion, altered gaze, left-sided weakness, and facial twitching. A COC assessment initially included vital sign values, but later documentation only stated that vital signs were within normal limits without recording actual values, and 15-minute monitoring with vital signs reported by an RN was not charted. The DON confirmed there was no documented evidence of vital signs after the second noted change in condition, contrary to the facility’s charting policy requiring complete and accurate documentation of services and condition changes.
A resident with pneumonia and other comorbidities had an order for amoxicillin-clavulanate to be given twice daily for seven days. On one morning, the resident would not eat or open their mouth, and the assigned LVN did not administer the ordered medications, including the antibiotic, but documented on the MAR that seven medications were given. The LVN did not correct the MAR entry or document the refusal, and did not promptly notify the supervisor or MD of the missed antibiotic dose. The DON later confirmed that this constituted inaccurate documentation and that facility policy requires accurate charting of refusals and same-day MD notification for refused antibiotics.
A resident with multiple diagnoses, including pneumonia, had physician orders for several medications, among them an oral antibiotic. On a morning when the resident would not eat and would not open their mouth, an LVN did not administer seven ordered medications but nonetheless signed them as given on the MAR, including the antibiotic. The LVN did not document that the medications were not given, did not correct the erroneous MAR entries, and did not record a refusal or reason. The LVN also failed to notify the MD at the time of the missed antibiotic dose and only informed a supervisor several hours later. The DON confirmed this resulted in inaccurate documentation and was inconsistent with facility policies requiring complete, accurate charting and same-day MD notification for antibiotic refusal.
A resident's medical record did not accurately reflect a history of scabies, despite hospital discharge documentation and facility surveillance data indicating the diagnosis and ongoing treatment. The DON confirmed that the diagnosis section should have included this information to ensure complete and accurate records, as required by facility policy.
A resident with stroke history, COPD, weakness, incontinence, and limited mobility developed MASD and then facility-acquired pressure ulcers after staff failed to promptly assess reported skin changes, complete required body checks, remove the brief to inspect the skin, obtain a physician order before applying wound dressings, and give ordered pain medication before wound care. The resident was later found to have a Stage 3 sacral pressure ulcer and a Stage 2 left buttock pressure ulcer; the report also cites failures involving heel protectors for one resident and correct LALM settings for another resident at risk for skin breakdown.
Incomplete informed consent documentation was found for three residents. One resident’s consents for Lorazepam and Quetiapine did not list the medication name, dose, or frequency. Another resident had a Depakote consent missing nurse verification details and no consent on file for Remeron. A third resident’s left-hand mitten restraint consent lacked the physician’s signature, the date risks and benefits were explained, and documentation of how the LPN verified consent.
Call lights not kept within residents’ reach. Three residents with significant care needs, including impaired cognition, total ADL dependence, and high fall risk, were observed with their call lights placed out of reach: one under a draw sheet, one on top of an overhead light, and one hanging over a side rail while the resident faced away from it. Staff stated the call lights should have been within reach before leaving the room, and the facility policy required call lights to be within reach for prompt assistance.
Failure to Follow Required Restraint Procedures: Surveyors found that several residents were subjected to restraint-like interventions without the required assessment, order, consent, or care plan. A tab alarm was used without timely quarterly review, pillows were tucked under fitted sheets, a left-hand mitten was applied without the proper documentation, and a resident was placed in a reclined Geri chair without the required restraint process. Staff and the DON acknowledged these practices restricted movement and were treated as restraints.
A resident had PRN Xanax without a 14-day stop date, another resident had Ativan ordered without a physician order for adverse side effect monitoring, and a third resident received concurrent Seroquel and Risperdal without documented psychosis symptoms or a clinical rationale for dual antipsychotic use. Staff and the DON confirmed the missing documentation and monitoring issues in the clinical record.
Failure to Develop and Implement Required Care Plans: Multiple residents had specialized interventions, including a Geri chair, bilateral hand mitts, buspirone for anxiety, a restraint bed against the wall, and pressure injury risk/wounds, but the record showed missing or incomplete care plans. Staff and the DON confirmed the care plans were not in place when the interventions began, despite residents having significant cognitive, functional, and medical impairments.
Failure to Rotate Insulin Injection Sites: Licensed nurses did not rotate sq insulin administration sites for three residents with DM and significant cognitive impairment. One resident had repeated insulin glargine use without site rotation, and another had multiple insulin lispro injections given in the same abdominal area back-to-back. LVN and DON interviews confirmed the sites were not rotated as ordered, and the report cited the potential for bruising, lipodystrophy, and cutaneous amyloidosis.
The facility failed to ensure safe, individualized RNA splinting orders for two residents with severe cognitive impairment and ROM limitations. One resident’s PT and OT trials only supported short wear times for a left AFO and left hand/elbow splints, yet the RNA order directed four to six hours. Another resident’s PT and OT documentation supported three hours for the left knee splint and AFO and four hours for the left hand/elbow splints, but the RNA order also directed four to six hours. During observation, RNA staff applied the splints according to the longer orders, and PT, OT, and the DOR stated therapy was responsible for determining safe wear time.
The facility failed to maintain a safe environment for several high-risk residents. A resident with severe cognitive impairment was left in bed with the bed brake unlocked, another resident was left in a high bed position, two residents had wheelchairs and bedside furniture placed on top of floor mats, one resident did not have ordered floor mats in place, and another resident had three bottles of eye drops left unattended at bedside despite not being safe to self-administer medications.
Catheter tubing left looped and urinals unlabeled. Multiple residents with Foley or suprapubic catheters had tubing observed with dependent loops or kinks, with urine pooling in the tubing, despite care plans and orders calling for proper alignment and unobstructed drainage. Staff stated the loops could prevent free urine flow and allow backflow. In addition, two urinals at one resident’s bedside were not labeled with the resident’s name and room number, and staff stated labeling was needed to prevent switching and cross-contamination.
A facility failed to rotate SQ insulin injection sites for three residents with DM, despite orders requiring site rotation and documentation showing repeated use of the same areas. The DON and an LVN stated the repeated site use did not follow the physician orders and could cause lipodystrophy and insulin malabsorption. The facility also allowed a resident to self-administer a Breo inhaler even though the order required clinician administration and the IDT had determined self-administration was not safe due to cognitive and functional impairment.
A resident refrigerator for outside food was not managed per policy. A resident with intact cognition and decision-making capacity was not told about the designated refrigerator for food from home, while CNA staff said leftovers were being discarded because they believed no storage refrigerator was available. The dining area refrigerator was found at 46 degrees F with expired milk yogurt inside, and the AD, MS, and DON all acknowledged the temperature was out of range and the expired food should have been removed.
Arbitration agreements for three residents did not include language stating that residents or their representatives could communicate with federal, state, or local officials, including surveyors and the Ombudsman. The DOA and ADM confirmed the forms and related questionnaire lacked this information. The affected residents had varying cognitive and decision-making abilities, and each agreement was signed by a family member or representative.
The facility failed to maintain infection control when oxygen tubing and nebulizer equipment were left on the floor in two residents’ rooms, including one resident with RSV-related bronchitis and another with chronic respiratory failure and oxygen dependence. Staff observed the tubing on the floor, and an LPN and the DON stated it should not have been there because of contamination concerns. The facility also cleaned foam-padded side rails with a disinfectant intended for hard, non-porous surfaces, even though the IP, MS, and DON identified the padding as porous and not appropriate for that chemical.
A resident was observed self-administering a Breo inhaler after an LPN prepared it, even though the order was for clinician administration and the resident’s self-administration evaluation found it was not safe due to cognitive and physical/functional impairment. The LPN stated she allowed self-administration because it was the resident’s preference, despite the IDT not approving it and the facility policy requiring IDT determination of safety.
Advance directive documentation was incomplete for one resident and a current copy of an executed AD was missing from another resident’s chart. One resident with respiratory failure, trach, and quadriplegia had no record that AD information was discussed with the RP or that assistance was offered or declined, while another resident with respiratory failure, ventilator dependence, and severe cognitive impairment had an AD acknowledgment form but no copy of the AD in the medical record. Staff stated the required documentation and chart copy were not obtained or maintained.
Ripped Bed Rail Padding: A resident with respiratory failure, ventilator dependence, severe cognitive impairment, and total ADL dependence had foam padding on bilateral upper side rails with several rips. RN observed the damage and said it should be replaced for aesthetics, while the DON stated the padding should be in good shape and the resident should have a homelike environment for dignity. Facility policy required a safe, clean, comfortable, homelike environment and equipment to be maintained and replaced as needed.
Wound Care Provided Without an Order: A resident with dementia, oxygen dependence, osteomyelitis, and multiple pressure ulcers had ordered wound care in place for several existing wounds. During wound care, an RN identified a new pressure ulcer on the top of the resident’s right great toe and applied hydrogel and a gauze dressing before notifying the MD and obtaining an order, contrary to the facility’s wound care and change-of-condition process.
Failure to Empty Full Colostomy Bag: A resident with a colostomy reported discomfort because the pouch had been full since shift change and had not been emptied. Staff observed the pouch full of fecal contents, and an LVN stated it needed to be emptied or changed. The resident’s orders required the bag to be changed as needed if full, dislodged, or leaking, and the DON stated it should have been emptied during shift change and as needed.
Oxygen Therapy and Tubing Not Maintained as Ordered: One resident with respiratory failure, tracheostomy, and severe cognitive impairment had oxygen tubing dated beyond the weekly change interval required by facility policy, and another resident with encephalopathy, interstitial pulmonary disease, and heart failure was observed with the NC resting on the chest instead of in the nostrils. Staff, including the RT, TN, LVN, and DON, confirmed the tubing should have been changed weekly and that the resident’s oxygen was supposed to be in place per the physician’s order.
Failure to Provide Ordered Pain Medication Before Wound Care: A resident with pressure injuries and documented pain did not receive ordered Acetaminophen before wound treatment. Staff interviews showed the treatment was completed without verifying pain medication had been administered, and the DON stated analgesia should be given after pain is assessed and before wound care as ordered. The resident had a sacral pressure ulcer and a left buttock pressure ulcer, and the care plan included assessing for pain and medicating as ordered.
An LPN failed to demonstrate competency in pressure injury care for a resident who was at risk for PUs and had multiple comorbidities, including prior stroke, COPD, MI type 2, weakness, and mobility impairment. The nurse applied bordered gauze dressings and provided MASD treatment without a physician order, did not remove the brief or assess the skin during treatment, and later acknowledged she had panicked when she saw open wounds. The DON stated the nurse was not competent because she failed to identify, report, and prevent the resident’s pressure injuries, and the record showed no documented competency assessment specific to pressure injury care.
A facility failed to accurately account for one dose of tramadol 50 mg for a resident in a medication cart. An LPN stated she gave the missing dose but did not sign the controlled drug record at the time because she was busy with other tasks, even though facility policy required immediate documentation when the dose was removed from the supply.
A used single-dose vial of testosterone injection for a resident was found in a med cart with half the contents missing instead of being discarded after use. An LPN stated the vial should have been thrown away after the last use, and the facility policy required single-use vials to be discarded immediately after use.
Improperly Labeled Open Food Item: An opened bag of mini tortillas was found in the kitchen without an open date. The DS stated the bag should have been dated, and later explained that open dates are used to monitor expiration dates and prevent contamination. Facility policy requires food items to be covered, dated, and labeled, including open dates for opened containers of PHF.
PT Progress Note Signed by Another Therapist: A resident with metabolic encephalopathy, dysphagia, and severe cognitive impairment had a PT progress note signed by the DOR, an OT, instead of the PT who completed it. The DOR stated the PT did not sign the note and signed on his behalf, while the PT confirmed he wrote the note but did not sign it. Facility policy required documentation to be objective, complete, accurate, and signed by the individual documenting.
Incomplete Antibiotic Surveillance and Missing Ceftriaxone Monitoring: A resident with respiratory failure, trach, and G-tube was treated with IV ceftriaxone for atypical pneumonia after a CXR and CBC supported infection. The IP found the respiratory infection surveillance form was incomplete even though the resident met criteria, and the record lacked documented shift-by-shift monitoring for ceftriaxone adverse effects in the LNs’ notes during the antibiotic course.
Exposed wires were found on the bed controller equipment for two residents. One resident had respiratory failure, a tracheostomy, schizophrenia, severe cognitive impairment, and total dependence for ADLs, while the other had respiratory failure, a tracheostomy, seizures, incapacitation, severe cognitive impairment, and total dependence for ADLs. During observation, an LVN noted the bed control box and cord had exposed wires and stated the condition should have been reported for replacement; the DON stated bed controllers should have no frayed or exposed wires.
MDS assessments were not accurately completed for five residents. Two residents with documented mood disorder diagnoses were not coded in Section I for bipolar disorder or mood disorder, one resident’s OT/PT minutes and days were omitted from Section O, and two residents’ restorative nursing ROM and splinting days were not correctly recorded. The DON and MDS staff acknowledged the MDS should reflect the resident’s diagnoses, therapies, and restorative services based on the RAI Manual.
A room measured 418.5 sq. ft. but had five beds and five residents, exceeding the allowed room capacity. During observation, the room had ample space for beds, overbed tables, dressers, and equipment, and an LVN stated there were no concerns about the room size. Facility records, including a waiver request and accommodation analysis, documented an approved capacity of five residents.
Bedroom Space Requirements Not Met: The facility failed to provide at least 80 sq. ft. per resident in three shared rooms. One room with 4 beds measured 290.93 sq. ft., and two rooms with 3 beds measured 215.2 sq. ft. and 213.58 sq. ft., leaving each resident with less than the required space. Observations noted residents had ample room to move and staff reported no concerns, but the rooms still did not meet the facility's stated bedroom space requirements.
Three residents who were exposed to scabies and received physician-ordered prophylactic treatment did not have individualized care plans developed to address their exposure, treatment, or monitoring. Despite documentation of treatment administration, the DON confirmed that care plans were not created as required by facility policy, resulting in a lack of documented guidance for staff regarding scabies management.
Two residents did not receive medications according to physician orders: one was given oxycodone for pain levels below the ordered threshold, and another received diltiazem despite a systolic blood pressure below the hold parameter. The DON confirmed that nursing staff did not follow orders or facility policy regarding medication administration.
Three residents with various chronic conditions and cognitive impairments received Elimite cream for scabies prophylaxis without a diagnosis or testing, following a single confirmed case in another resident. Nursing staff and the DON confirmed that the medication was given as a precaution, despite facility policy requiring confirmation of suspected cases and no evidence of an outbreak.
The facility did not place a resident on contact isolation after a physician ordered a skin scraping to rule out scabies, and failed to ensure timely skin monitoring and documentation for three residents as ordered by a physician. Staff confirmed that contact precautions and documentation were not initiated as required by facility policy.
A resident with severe cognitive impairment and total dependence for ADLs was found with a blanket tied around the lower body and secured to a wheelchair, effectively restraining movement. Although there was a physician order for a self-release seat belt, there was no order or consent for the use of the blanket as a restraint. Staff and nursing leadership confirmed the blanket was not a self-release device and its use as a restraint was not authorized or in accordance with facility policy.
A resident with multiple risk factors for pressure ulcers was found to have excessive layers of linen and padding placed between them and a low air loss mattress (LALM), contrary to both manufacturer instructions and facility policy. Staff interviews revealed inconsistent knowledge of proper procedures, with some staff using up to eight layers instead of the required two, potentially compromising the effectiveness of the LALM in preventing pressure ulcers.
A resident with multiple health issues experienced a change in condition and was found on a floor mat. Although an immediate X-ray was ordered, it was not performed promptly, and the Attending Physician was not notified of the delay until the next morning, contrary to the facility's policy requiring prompt notification.
A facility failed to maintain accurate medical records for a resident with multiple diagnoses, including dementia. A Change of Condition record inaccurately documented the notification time of the Responsible Party. Interviews with staff revealed discrepancies in the documentation, which did not align with the facility's policy on accurate record-keeping.
The facility failed to maintain a safe and homelike environment for residents by not keeping temperatures within the required range and not ensuring clean shower rooms. Observations showed temperatures below the required minimum and unsanitary conditions in shower rooms, including feces on a shower chair and unattended items. Staff acknowledged these issues, and the facility's policy emphasized the importance of a clean and comfortable environment, which was not upheld.
A resident with severely impaired cognition was physically abused by another resident with a history of altered behavior patterns. The incident occurred when one resident punched the other in the face, resulting in swelling and discoloration. Despite existing care plans and policies, the facility failed to prevent this incident, highlighting a deficiency in monitoring and protecting residents from abuse.
The facility failed to ensure call lights were within reach for several residents, including those with severe cognitive impairments and high fall risks. Despite care plans and policies emphasizing the need for accessible call lights, observations revealed that call lights were often placed out of reach, preventing residents from calling for assistance. Staff interviews confirmed the oversight and acknowledged the potential risks associated with this deficiency.
The facility failed to ensure residents were free from physical restraints without proper documentation, affecting multiple residents. A resident was found with mitten restraints without a physician's order or consent. Two residents had their beds placed against the wall, considered a restraint, without necessary assessments. Another resident had all side rails up, and one had pillows restricting movement, both without proper documentation. Staff confirmed the lack of required orders and consents, emphasizing the importance of these measures for safety and resident rights.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Beds were used as restraints without care plans, urinary catheters lacked documentation, and a resident with PTSD had no care plan. Additionally, a resident on Melatonin was not monitored for sleep effectiveness, risking unnecessary medication use.
The facility failed to rotate injection sites for insulin and enoxaparin for several residents, as required by professional standards and facility policy. This deficiency was identified through a review of medication administration records and confirmed by nursing staff interviews, highlighting repeated use of the same injection sites over several months.
Two residents in a facility were not provided with proper pressure ulcer care due to issues with their low air loss mattresses (LALM). One resident's LALM was not powered on, while another's was set incorrectly according to their weight. These deficiencies were identified during observations and interviews, highlighting a failure to adhere to professional standards of practice in preventing pressure injuries.
Failure to Document Vital Signs During Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting vital signs during a change of condition. The resident was admitted with metabolic encephalopathy, cerebral infarction, and unspecified dementia, and had severely impaired cognitive skills for daily decision making per the MDS dated 2/14/2026. On 2/26/2026 at 10:30 a.m., a Change of Condition (COC) Assessment Form documented that the resident was confused, unable to make eye contact, and staring to the right side, with vital sign values recorded in the Background section of the form. Later, at 12 p.m., the resident was observed with increased weakness on the left side of the body and facial twitching, and the COC Assessment Form stated that the resident’s vital signs were within normal range, but no actual vital sign values were documented to support this. During a telephone interview, RN 1 stated that licensed nurses were monitoring the resident every 15 minutes, including vital signs, but acknowledged that she did not document this monitoring in the resident’s medical record and that she should have documented the resident’s COC progress or decline. In a subsequent interview and concurrent record review with the DON, the DON confirmed there was no documented evidence of the resident’s vital signs after the second COC at 12 p.m. on 2/26/2026 and stated that failure to document vital signs after a COC could result in miscommunication among the healthcare team. The facility’s Charting and Documentation policy, last reviewed on 4/16/2025, required that all services provided and any changes in the resident’s condition be documented in an objective, complete, and accurate manner, which was not followed in this case.
Failure to Accurately Document and Administer Ordered Antibiotic
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered antibiotic was not administered as prescribed. The resident was admitted with diagnoses including UTI, vascular dementia, protein-calorie malnutrition, pneumonia, and anxiety disorder. A physician’s order dated 1/19/2026 directed that amoxicillin-potassium clavulanate 875 mg-125 mg be given by mouth every 12 hours for seven days for a bacterial infection, and the care plan initiated the same day identified this medication for treatment of pneumonia with an intervention to administer medications as ordered and assess for complications. On 1/20/2026, the MAR showed that the resident was documented as having received the ordered amoxicillin-potassium clavulanate at 9 a.m. However, during interview and concurrent record review, the LVN assigned to the resident that day stated that the resident was not eating breakfast and would not open his mouth, so the morning medications, including the antibiotic, were not actually given. The LVN acknowledged that she signed off seven medications on the MAR as given even though they were not administered and did not enter any note indicating that the medications were signed off in error. She further stated that she should have documented the error and notified her supervisor and the physician when the resident refused the antibiotic. The DON confirmed during interview and record review that if a resident refuses or is unable to take medications, the nurse should not sign them as given but should document the refusal and the reason, and that the MD must be notified within the shift of a missed or refused antibiotic. The DON stated that the documentation on the MAR was inaccurate because the medications were not given and that the MD was not notified of the missed antibiotic, although the MD was notified of the resident’s lethargy as a change of condition. Review of facility policies showed that charting must be objective, complete, and accurate, and that medication refusal must be documented with physician notification the same day for antibiotics, which did not occur in this case.
Inaccurate MAR Documentation and Failure to Document Antibiotic Refusal
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident in accordance with professional standards. The resident was admitted with multiple diagnoses, including UTI, vascular dementia, protein-calorie malnutrition, pneumonia, and anxiety disorder, and had physician orders for several medications, including sertraline, Colace, cranberry tablets, memantine, Liquacel, acetaminophen, and later amoxicillin-potassium clavulanate for pneumonia. The facility’s policies required that documentation in the medical record be objective, complete, and accurate, and that medication refusals be documented with physician notification, particularly for antibiotics. On the date in question, the Medication Administration Record (MAR) showed that the resident received seven ordered medications, including the antibiotic amoxicillin-potassium clavulanate, at a morning administration time. However, the assigned LVN reported that the resident was not eating breakfast and would not open his mouth, and therefore the morning medications were not actually given. Despite this, the LVN signed off all seven medications on the MAR as if they had been administered and did not enter any note indicating that the medications were signed off in error or that they were refused or not taken. During interviews, the LVN acknowledged that the medications were not given, that she had signed them as administered by accident, and that she did not complete the required corrections on the MAR to indicate wrong documentation. She also stated she did not notify the physician at the time the antibiotic was refused and only informed her supervisor several hours later when the resident also refused lunch. The DON confirmed that if a resident refuses or is unable to take medications, the nurse should not sign them as given, should document the refusal and the reason, and should notify the MD within the shift for missed or refused antibiotics. The DON characterized the MAR entries as inaccurate documentation and noted that the facility’s policies required accurate charting and same-day physician notification for refusal of antibiotics.
Failure to Accurately Document Resident Diagnosis in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident by not documenting the resident's history of scabies in the diagnosis section of the medical record. The resident was admitted and readmitted with multiple diagnoses, including dementia, type 2 diabetes mellitus, and chronic kidney disease. Upon review, the resident's discharge summary from a general acute care hospital indicated a diagnosis of scabies, with instructions to continue ivermectin treatment and maintain isolation. Surveillance data collected at the facility also noted the resident's scabies diagnosis and ongoing treatment. Despite this, the resident's official diagnosis list in the facility's records did not include a history of scabies. During interviews, the DON acknowledged that the diagnosis should have reflected the resident's history of scabies, even if resolved, to provide an accurate synopsis of the resident's condition. The facility's policy required that documentation in the medical record be objective, complete, and accurate, but this standard was not met in this instance, resulting in inaccurate documentation for the resident.
Failure to Identify and Treat Pressure-Related Skin Breakdown
Penalty
Summary
Resident 10 was admitted with diagnoses including prior cerebral infarction, COPD, myocardial infarction type two, generalized muscle weakness, and gait and mobility abnormalities. The resident was documented as having intact skin on admission, but was also identified as incontinent of bowel and bladder, needing partial/moderate assistance with bed mobility, and being at risk for pressure ulcers. The resident’s skin risk assessment was last completed early in the stay and later became outdated as the resident’s condition changed. The facility failed to identify and respond to skin changes as they developed. Staff documented skin peeling and redness between the buttocks, but the change was not promptly assessed and reported. CNA documentation later identified an open sacrococcyx wound, and staff observed bordered gauze dressings on the left buttock and sacrococcyx without dates or initials. The treatment nurse stated she did not know who applied the dressings at first, later stated she had applied them, and acknowledged that the resident had open wounds. The resident’s Daily Body Check Reports were not completed on multiple dates, including dates when staff later stated they had observed skin problems. The resident’s MASD treatment was also not carried out as documented. Staff stated that the resident’s brief was not removed during treatment on one occasion, so the skin underneath was not assessed, and the treatment nurse stated she only applied barrier cream to the perianal area. A physician’s order was not obtained before bordered gauze was applied to the wounds, and ordered acetaminophen was not administered before wound care. On 8/13/2025, the wound care consultation identified a Stage 3 pressure ulcer on the sacrum and a Stage 2 pressure ulcer on the left buttock. The report also states that the facility failed to provide heel protectors for one resident and failed to ensure a low air loss mattress was set correctly for another resident who was at risk for pressure injury.
Incomplete informed consent documentation for psychotropic medications and restraint use
Penalty
Summary
The facility failed to ensure residents were fully informed of their health status, care, and treatments through complete informed consent documentation for psychotropic medications and a restraint. The deficiency involved three sampled residents and was identified through record review and staff interviews. The facility’s policy required staff to verify that the resident’s record contained documentation of informed consent before initiating psychotherapeutic drugs or physical restraints. For one resident with Alzheimer’s disease, anxiety disorder, and dementia, the chart showed orders for Lorazepam and Quetiapine, but the informed consents dated 7/26/2025 did not identify the medication name, dosage, or frequency of intake. RN review confirmed the consents lacked those details, and the DON stated the consents should include the drug name, dose, and frequency so the resident would be well informed of the medication regimen. For another resident with anxiety disorder, major depressive disorder, and mood disorder, the chart showed orders for Depakote Sprinkles and Remeron. The informed consent for Depakote did not include how consent was verified, the licensed nurse’s signature, title, or date of verification, and there was no informed consent for Remeron in the medical record. RN review confirmed the missing verification information and absence of a Remeron consent, and the DON stated psychotropic medication consents should include the mode of verification and be obtained before administration. For a third resident with Parkinson’s disease, dementia, and a history of falling, the chart showed an order for left-hand mitten use every shift due to attempts to pull on life-sustaining equipment. The informed consent for the mitten did not include the physician’s signature or the date the physician explained the risks and benefits of the restraint, and it did not show how the licensed nurse verified the consent with the resident or representative. LVN review confirmed those omissions, and the DON stated the physician should sign and date the consent and the nurse should document how the consent was verified.
Call lights not kept within residents’ reach
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring the pad call light was within reach for three sampled residents. During observation, interview, and record review, Resident 158 was found lying in bed awake and alert, responding by mouthing words, and stated he was unable to find his call light and did not know where it was placed. The LVN stated the call light had been placed under the draw sheet and was not reachable. Resident 158’s record showed diagnoses including ventilator dependence, contractures, and type 2 DM, with intact cognition, total assistance for most ADLs, and high fall risk. The care plan directed staff to keep the call light within easy reach and encourage use for assistance. Resident 148’s record showed diagnoses including psychosis, tracheostomy, and anxiety disorder, with incapacitation, severely impaired cognition, inability to understand others or make needs known, total assistance with all ADLs, and high fall risk. During observation, the resident was lying in bed asleep, and the call light was placed on top of the overhead light. A CNA stated the call light was away from the resident and could not be reached. The care plan directed staff to attach the call light to the bed within the resident’s access. Resident 41’s record showed diagnoses including respiratory failure, tracheostomy, and neurogenic bladder, with no capacity to understand and make decisions, severely impaired cognition, inability to understand others or make needs known, total assistance with all ADLs, and high fall risk. During observation, the resident was lying in bed turned to the right side, and the call light was hanging over the left side rail and was not within reach because the resident was facing away from it. The facility’s policy stated staff shall ensure the call light is within the resident’s reach when in the room or toilet and that lights are answered promptly. RN and nursing staff stated the call lights should have been placed within reach before leaving the room.
Failure to Follow Required Restraint Procedures
Penalty
Summary
The facility failed to ensure residents were free from physical restraints unless needed for medical treatment for five sampled residents. Surveyors observed and reviewed records showing that several devices and positioning methods were used without the required restraint processes, including assessment, physician order, informed consent, and care planning when applicable. For Resident 76, the record showed an order for a tab alarm in bed and wheelchair, and the care plan called for quarterly assessment of the device. Surveyors observed the tab alarm in use, and the last restraint-physical evaluation had been completed on 3/26/2025. The LVN and DON stated the tab alarm functioned as a physical restraint and should have been reassessed quarterly, but one quarterly evaluation was missed. For Resident 6, surveyors observed rolled pillows tucked under the fitted sheet on both sides while the resident lay in bed. Staff stated the pillows were supposed to be placed on top of the fitted sheet and that placing them under the sheet was not acceptable because the resident could not remove them and it was considered a restraint. The record did not show a physician order for pillows tucked under the fitted sheet. For Resident 148, surveyors observed a left-hand mitten in use on multiple occasions. The record did not show a physician order, informed consent, restraint assessment, or care plan for the mitten. Staff stated the mitten was being used because the resident had attempted to pull on life-sustaining tubes, and the DON and RN stated that prior to using a restraint, the facility should obtain the order, consent, assessment, and care plan. The record instead showed an order for a left freedom splint, not the mitten. For Resident 51, surveyors observed a pillow under the fitted sheet on the right side and a wedge pillow under the fitted sheet on the left side while the resident was in bed. Staff stated pillows should not be placed under the fitted sheet and that doing so could be considered a restraint because the resident could not remove them. The medical record did not show an order, assessment, or care plan for pillows under the fitted sheet. For Resident 79, surveyors observed the resident in a Geri chair in a fully reclined position with the feet and legs elevated to hip height, placing the resident in a laying position. The resident stated he was not comfortable and wanted to sit up but could not. Staff stated the resident was placed in the reclined Geri chair because of left-sided weakness, sliding in the chair, and attempts to stand. The record review and staff interview showed the facility had not completed the required physical restraint assessment, informed consent, physician order, or care plan before use of the Geri chair in this manner.
Unnecessary Psychotropic Medication Use and Inadequate Documentation
Penalty
Summary
The facility failed to ensure the resident drug regimen was free from unnecessary psychotropic medications for three sampled residents. For one resident admitted with anxiety disorder, ataxia, and a history of falls, the record showed an order for Xanax 0.25 mg every 6 hours as needed for anxiety, but the order did not include a 14-day stop date. The resident’s MDS indicated intact cognition and the ability to make self-understood and understand others. During record review and interview, staff stated the PRN Xanax should have had a 14-day stop date to evaluate effectiveness and prevent prolonged use, and the DON stated the absence of a stop date was a deficiency. For another resident with diagnoses including psychosis, tracheostomy, and anxiety disorder, the record showed an order for Ativan 0.5 mg every 6 hours as needed for anxiety for 14 days, along with monitoring for episodes of anxiety manifested by restlessness leading to shortness of breath. The care plan addressed anxiety and side effects monitoring, but the record did not contain a physician’s order for monitoring adverse side effects of the Ativan. During interview, the RN stated there should have been a physician’s order for side effect monitoring, and the DON stated such an order should have been obtained for the resident’s safety. For a third resident admitted with unspecified psychosis, the record showed orders for Risperdal 1 mg twice daily and Seroquel 100 mg at bedtime, both via gastrostomy tube, for psychosis manifested by inability to cope with daily living activities causing anger and internal stimuli leading to stress and frustration. The clinical record did not contain documentation of symptoms such as hallucinations, delusions, disorganized behavior, or lack of emotional expression, and it did not contain a documented rationale for using both antipsychotics at the same time. Staff interviews stated the resident’s behaviors included yelling, resisting care, and refusing assistance, and the DON stated those behaviors did not align with psychosis and that the record lacked a clinical rationale for the concurrent use of the two antipsychotics.
Failure to Develop and Implement Required Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents receiving specialized interventions. Resident 79, admitted with CVA, left-sided hemiplegia, weakness, lack of coordination, and a history of falls, was observed in a Geri chair in a fully reclined position with the feet elevated. The resident stated the position was uncomfortable and that the resident wanted to sit up but could not. Staff stated the chair was used because of left-sided weakness and concern for falling, yet the DON confirmed there was no care plan for the Geri chair even though the facility policy required one. Resident 66, who had cognitive impairment, severe impairment in daily decision-making, and dependence for all ADLs, had physician orders for bilateral hand mitts to prevent pulling on life-sustaining equipment. The record review and interview showed the resident had a care plan entry for physical restraint in use, but the care plan addressing the bilateral mitts had not been developed and implemented when the mitt orders were initiated. Staff stated the care plan was needed so staff would know how to monitor the mitts and protect the resident’s skin, and the DON stated the plan should have been initiated when the mitts were ordered. Resident 148, who had psychosis, a tracheostomy, anxiety disorder, and severe cognitive impairment, had orders for buspirone for anxiety manifested by pulling on life-sustaining tubes. Review of the record and interview with nursing staff showed there was no care plan developed and implemented when the antianxiety medication was first started. Resident 96, who had epilepsy, hemiplegia/hemiparesis, cerebral infarction, and lacked capacity to make decisions, also did not have a care plan for the restraint bed placed against the wall. In addition, Resident 10, admitted with stroke-related diagnoses, COPD, MI type two, weakness, and mobility abnormalities, was identified as at risk for pressure ulcers on the Braden Scale and later found to have sacral and left buttock pressure injuries, yet the care plan was not implemented for the pressure ulcer risk and wound needs described in the record and wound consultation.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nurses failed to rotate subcutaneous insulin administration sites for three residents who were receiving insulin for diabetes mellitus. The report identified that the facility did not ensure insulin was administered in accordance with professional standards and physician orders for Residents 4, 13, and 35. The deficiency was identified through observation, interview, and record review, and the report states the practice had the potential for adverse effects such as excessive bruising, lipodystrophy, and cutaneous amyloidosis. Resident 4 was admitted and later readmitted with diagnoses including type 2 diabetes mellitus, respiratory failure, and dependence on a respirator. The resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition and use of a high-risk hypoglycemic medication. The report includes an insulin lispro order for the resident, but the excerpt provided does not include the administration-site details for this resident. Resident 13 was admitted and later readmitted with chronic respiratory failure, dependence on a respirator, and type 2 diabetes mellitus. The resident did not have the capacity to understand and make decisions, and the MDS indicated rarely to never being able to make self understood or understand others, with severely impaired cognition. The resident had orders for insulin regular human by sliding scale every 6 hours and insulin glargine at bedtime with instructions to rotate injection sites. A review of the insulin location of administration report from 6/2025 to 8/2025 showed repeated insulin glargine administration without rotation. During interview, LVN 5 stated there were multiple instances where licensed staff did not rotate insulin sites for Resident 13, and the DON stated staff should have rotated the sites to prevent lipodystrophy. Resident 35 was admitted with diagnoses including severe acute bronchitis from RSV, sepsis, dementia, and diabetes mellitus. The resident’s MDS indicated the resident rarely or never understood others or made themself understood and was dependent on staff for eating, bathing, dressing, oral and personal hygiene, toileting, and mobility. The resident had an order for insulin lispro before meals and at bedtime with instructions to rotate injection sites. Review of the insulin location of administration record showed repeated use of the abdomen left lower quadrant on multiple administrations, with several entries noted as not rotated from the previous site. LVN 5 stated the licensed nurses did not follow the physician’s orders because the sites were not rotated, and the DON stated frequent repetition of insulin site administration could lead to lipodystrophy and malabsorption of insulin.
Inappropriate RNA Splint Wear-Time Orders for Two Residents
Penalty
Summary
The facility failed to ensure appropriate ROM and splinting services were provided for two residents with significant mobility limitations and contractures. Resident 33 was admitted with diagnoses including acute and chronic respiratory failure and functional quadriplegia, and the MDS showed severe cognitive impairment with functional ROM limitations in both upper extremities and one lower extremity. Resident 112 was admitted with diagnoses including adult failure to thrive and heart failure, and the MDS showed severe cognitive impairment with functional ROM limitations in one upper extremity and both lower extremities. For Resident 33, the record showed physician orders for an RNA program with PROM to both upper and lower extremities followed by a left resting hand splint, left elbow splint, and left lower extremity AFO for four to six hours or as tolerated. PT documentation showed the resident was trialed with a left AFO for 30 minutes and then one hour, and PT stated it was still determining an appropriate RNA program and had not documented that the resident could safely wear the AFO for four to six hours. OT documentation showed the resident was trialed with a left resting hand splint for 30 minutes, with OT noting the resident tolerated 30 minutes without redness or skin breakdown. Despite this, during observation the RNA applied the left resting hand splint, left elbow splint, and left AFO and stated the splints would be left on for at least four to six hours because that was the RNA order. For Resident 112, the record showed an RNA program for AAROM/PROM and splinting to the left knee extension splint, left AFO, left elbow splint, and left hand splint for four to six hours as tolerated. PT documentation showed the resident tolerated splinting for three hours without skin irritation or discomfort, and the PT discharge summary stated the resident could safely wear the left foot drop splint and left knee extension splint for three hours. OT documentation showed the resident tolerated the left resting hand splint and left elbow extension splint for four hours, and the OT discharge summary stated the resident could safely wear those splints for four hours. During observation, the RNA applied all four splints after ROM and sitting at edge of bed, while the resident stated he did not want to wear the splints for too long and wanted to wear them for only two hours. Interviews with PT and the DOR confirmed PT and OT were responsible for determining safe wear times, and both stated the RNA orders exceeded the wear times established in therapy documentation.
Multiple Fall-Prevention and Medication Storage Failures
Penalty
Summary
The facility failed to provide an environment free from accident hazards for multiple residents who were identified as high risk for falls or injury. For Resident 66, who had severely impaired cognitive skills and was dependent on staff for all ADLs, a concurrent observation showed the resident in bed with the pedal brake not engaged while staff were providing care. LVN 6 and CNA 5 completed care and left the bed unlocked, and LVN 6 stated the bed should have been locked for the resident’s safety. For Resident 158, who was incapacitated and required total assistance with all ADLs, the resident was observed lying in bed in a high position without staff present. LVN 9 and RT 1 stated the bed was in a high position and should not have been left that way, and RT 1 later stated a low bed is one where the top of the mattress measures 17 inches from the floor. The DON stated residents should not be left unattended with the bed in a high position and that the bed should be placed in a low position after care. For Resident 40 and Resident 125, both of whom had fall-related interventions including low bed and floor mats, observations showed equipment placed on top of the floor mats. Resident 40’s room had a wheelchair on top of the bilateral floor mat, and Resident 125’s room had a bedside drawer and side table on top of the floor mats. Staff and the DON stated there should be no furniture or equipment on top of the mats because it defeats their purpose. For Resident 124, who had physician orders and a care plan for low bed with floor mat, observations on multiple occasions showed no fall mats at the bedside. For Resident 112, three bottles of eye drops were left unattended on the bedside rolling table in a shared room, despite the resident being assessed as not safe for self-administration of medication and the ADON stating medications should not be left at bedside.
Catheter tubing left looped and urinals unlabeled
Penalty
Summary
The facility failed to ensure appropriate catheter care and UTI prevention measures for multiple residents with indwelling urinary catheters or suprapubic catheters. Resident 11 had a Foley catheter ordered for wound management, and the care plan directed staff to maintain proper alignment for drainage. During observation, the catheter tubing had a dependent loop below the drainage bag with urine pooling in the tubing, and the RN stated the tubing should drain by gravity so urine does not back up and cause infection. Resident 51 had a Foley catheter ordered for neuromuscular dysfunction of the bladder, and the care plan directed proper alignment of the catheter. During observation, the tubing was looped, and the LVN stated urine could not flow freely and may backflow and cause a UTI. The DON also stated looped tubing can affect urine flow and increase infection risk. Resident 41 had an indwelling urinary catheter ordered for neurogenic bladder, with orders for daily catheter care, monitoring for UTI signs, and securing the tubing to minimize dislodging. During observation, the catheter tubing had a loop preventing urine from flowing freely into the bag, with urine and white sediments in the loop. Resident 168 had a suprapubic catheter ordered for obstructive uropathy with urinary retention, and the care plan directed proper alignment of the catheter. During observation, the suprapubic catheter tubing was looped with urine and sediments in the loop. Staff stated the tubing should have no loops because this would hinder free urine flow and could cause backflow and infection. Resident 4 had an indwelling catheter ordered for urinary dysfunction, and the care plan directed proper alignment of the Foley catheter. During observation, the tubing had a loop with urine and sediments, and staff stated there should be no loop or kink to prevent backflow of urine to the bladder. The facility also failed to ensure urinal bottles were labeled for two residents. Resident 125 was occasionally incontinent of urine and stool, and during observation two urinals hanging at the bedside were not labeled with the resident’s name and room number. Resident 155 was frequently incontinent of urine, and the record review showed an order for cranberry tablets for UTI prophylaxis, but the report ends before the full catheter or urinal-related finding is completed. For Resident 125, the LVN stated urinals should be labeled with the resident’s name and room number to prevent accidental switching and cross-contamination leading to UTI. The DON stated it was the responsibility of CNAs to ensure urinals were labeled with the resident’s name and room number to prevent switching and cross-contamination.
Failure to Rotate Insulin Sites and Unsafe Self-Administration of Breo
Penalty
Summary
The facility failed to ensure that insulin injection sites were rotated for three sampled residents who were receiving subcutaneous insulin. Resident 4 had diagnoses including type 2 diabetes mellitus, respiratory failure, and dependence on a respirator, and the record showed an order for insulin every 6 hours with instructions to rotate sites. The Location of Administration Report from 6/2025 to 8/2025 showed insulin aspart was administered, but the report did not reflect site rotation as required. Resident 13 had diagnoses including chronic respiratory failure, dependence on a respirator, and type 2 diabetes mellitus, and the record showed orders for regular insulin by sliding scale and insulin glargine at bedtime with instructions to rotate injection sites. The Location of Administration Report from 6/2025 to 8/2025 showed insulin glargine was administered, and the DON stated licensed staff should have rotated the insulin sites to prevent lipodystrophy. The DON also stated that frequent repetition of insulin site administration could lead to lipodystrophy and malabsorption of insulin, resulting in hypo or hyperglycemia, and stated that not rotating insulin administration site is a medication error. Resident 35 had diagnoses including severe acute bronchitis from RSV, sepsis, dementia, and diabetes mellitus. The resident was dependent on staff for eating, bathing, dressing, oral and personal hygiene, toileting, and mobility. The order for insulin lispro directed staff to rotate injection sites, but review of the Location of Administration Report showed repeated use of the abdomen-left lower quadrant on multiple administrations, with several entries noted as not rotated from the previous site. LVN 5 stated the sites were used back-to-back and not rotated, and that the licensed nurses did not follow the physician's orders because the sites were not rotated. The facility also failed to prevent unsafe self-administration of Breo inhaler by Resident 48. The resident's order specified Breo inhaler was to be clinician administered, and the Self-Administration of Medication Evaluation stated the IDT determined it was not safe for the resident to administer drugs due to cognitive and physical/functional impairment, and that the resident was not approved for self-administration. Despite this, the resident was observed self-administering the inhaler while it was prepared by an LVN, and the LVN stated she allowed it because it was the resident's preference.
Outside Food Refrigerator Not Monitored or Cleared of Expired Food
Penalty
Summary
The facility failed to follow its policy for outside food storage for one sampled resident refrigerator. Resident 82 was admitted with diagnoses including Parkinson's disease, hypothyroidism, and hyperlipidemia. The resident's H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident could make self understood, understand others, had intact cognition, and participated in healthcare management decisions. During interview, Resident 82 stated no one had told her there was a refrigerator for food brought from home, and she had been discarding leftovers because she believed they would spoil by the next day. CNA 4 stated Resident 82 had been told leftovers were discarded after 2 hours because there was no refrigerator for storage, and CNA 4 was not aware of a refrigerator available for residents' outside food. The DSD stated food from home should be stored at the resident refrigerator located in the dining area, and the facility policy stated the facility would maintain one refrigerator and freezer for resident use. During a concurrent observation and interview, the resident refrigerator in the dining area was observed at 46 degrees F and contained a six-pack of unopened milk yogurt. The Activities Director stated she was responsible for checking the temperature and contents of the refrigerator, that the temperature should be 40 degrees F or below, and that temperatures above 40 degrees should be reported to the Maintenance Supervisor. She also stated the food brought from home should be labeled with the resident's name, room number, and date received. The Activities Director identified the six-pack of milk yogurt as expired with an expiration date of 7/23/2025 and stated she should have reported the abnormal temperature and discarded the expired yogurt. The Maintenance Supervisor stated he was responsible for the weekly temperature check of the resident refrigerator and that the daily check was performed by the Activities Director. He stated he did not receive a report that the refrigerator temperature was 46 degrees F and that he could have fixed it right away to prevent food from spoiling. The DON reviewed the policy and photos of the refrigerator and stated the refrigerator temperature was 46 degrees F and that expired six-pack milk yogurt was present. The DON stated the Activities Director was responsible for monitoring the refrigerator daily, reporting abnormal temperatures to the Maintenance Supervisor, and discarding expired yogurt. The facility policy stated activity staff or designee would check the refrigerator and freezer daily, notify the Maintenance Supervisor and Administrator if temperatures were not within range, and discard expired food items.
Arbitration Agreements Omitted Required Communication Rights
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement for three sampled residents stated that the resident or representative was allowed to communicate with federal, state, or local officials, including federal and state surveyors, federal or state health department employees, and representatives of the Office of the State Long Term Care Ombudsman. During interview and record review, the Director of Admission and the Administrator confirmed that the arbitration agreement forms used for these residents did not contain this verbiage, and the questionnaire used before signing also did not include a question about communication with these outside officials or agencies. Resident 30 was admitted with diagnoses including muscle weakness, dysphagia, and overactive bladder. The resident's H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated moderately impaired cognition and that an authorized representative participated in assessment and goal setting. The arbitration agreement for this resident was signed by the resident's representative, but the form did not include the required language about communication with outside officials. The DOA stated the agreement should have included that language to ensure residents or family had a better understanding when making decisions. Resident 85 was admitted with diagnoses including heart failure, major depression, and unspecified psychosis. The H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated severely impaired cognition and family participation in assessment and goal setting. The arbitration agreement was signed by the resident's daughter, but it also lacked the language allowing communication with federal, state, or local officials and the Ombudsman. Resident 101 was admitted with diagnoses including hypokalemia, anxiety disorder, and unspecified psychosis. The H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated intact cognition and participation by the resident and family in care planning. The arbitration agreement signed by the resident's son likewise did not include the required communication language. The facility's policy titled Contact with External Agencies stated residents are not prohibited from communicating with officials or agencies independent from or having oversight of the facility and are not restricted from contacting federal, state, or local individuals or agencies regarding any matter, including matters subject to arbitration.
Infection Control Lapses With Oxygen Tubing and Porous Side Rail Cleaning
Penalty
Summary
The facility failed to maintain its infection prevention and control program when oxygen tubing and nebulizer equipment were left on the floor in two residents’ rooms. One resident had diagnoses including severe acute bronchitis from RSV, sepsis, dementia, and diabetes mellitus, and was dependent on staff for eating, bathing, dressing, oral and personal hygiene, toileting, and mobility. The resident had orders for ipratropium bromide and ipratropium-albuterol nebulizer treatments. During observation, a clear plastic bag containing an aerosol mask and oxygen tubing was seen on the floor next to the resident’s nightstand, and it remained there during a later observation. CNA 6 confirmed the bag was on the floor and stated it should not have been there. LVN 4 stated the tubing and mask should not be on the floor because of infection risk, and the DON stated oxygen tubing found on the floor should be removed and replaced with new tubing. A second resident had diagnoses including chronic respiratory failure with hypoxia, dependence on supplemental oxygen, dementia, and osteomyelitis, and was dependent on staff for bathing, dressing, oral and personal hygiene, toileting, and mobility. The resident had an order for ipratropium-albuterol nebulizer treatments and a care plan addressing risk for respiratory distress. During observation, an aerosol mask and oxygen tubing were placed on the nightstand, with the tubing hanging from the nebulizer and touching the floor. A later observation confirmed the tubing remained on the floor. RNA 2 confirmed the tubing was on the floor, and CNA 7 stated it should not have been on the ground. LVN 4 again stated tubing on the dirty floor could become contaminated and transfer bacteria to the resident when used, and the DON stated the tubing should have been off the floor. The facility also failed to use an appropriate disinfectant on porous padded side rails. In Room A, a resident’s upper bilateral side rails were padded with foam/porous tube noodles. Housekeeping staff stated they cleaned the padded side rails using DC 1 by spraying it on a rag and wiping the rails. The Infection Preventionist and Maintenance Supervisor reviewed the product label and stated DC 1 and DC 2 were intended for hard, non-porous surfaces and should not be used on porous surfaces. The DON reviewed the product information and stated the foam tube coverings on the side rails were porous and could absorb the chemical. The product information for DC 1 identified it as a germicidal disinfectant cleaner for hard, non-porous inanimate surfaces, and the Safety Data Sheet included warnings for skin, eye, inhalation, and swallowing exposure.
Unsafe Self-Administration of Breo Inhaler
Penalty
Summary
The facility failed to ensure self-administration of a Breo inhaler was evaluated and considered safe by the interdisciplinary team for one resident. During observation, the resident was seen self-administering the inhaler after it had been prepared by an LVN. The resident’s admission record showed she was admitted to the facility on [DATE], and her history and physical documented shortness of breath. Her order summary listed Breo inhaler, one puff by mouth daily for shortness of breath, as clinician administered. The resident’s self-administration evaluation dated 7/2/2025 indicated the IDT determined it was not safe for her to administer drugs because of cognitive impairment and physical/functional impairment secondary to multiple diagnoses, and that she preferred licensed nurses to administer medications. Despite this, the LVN stated she allowed the resident to self-administer the Breo inhaler because it was the resident’s preference, even though the order was for clinician administration and the evaluation did not approve self-administration. The facility policy stated residents may self-administer medication only if the IDT has determined the practice would be safe.
Advance Directive Documentation and Record Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure that advance directive discussions were documented for one resident. Resident 32 was admitted with respiratory failure, a tracheostomy, and quadriplegia, and the history and physical dated 9/26/2024 indicated the resident was incapacitated. The resident’s advance directive acknowledgment form dated 9/26/2024 did not show whether the resident and/or responsible party was provided information about formulating an advance directive, whether assistance was offered, or whether assistance was declined. During interview and record review, the Director of Social Services stated she did not provide information regarding formulation of an advance directive to the responsible party, did not offer assistance, and did not document whether the responsible party declined or was not interested. She also stated there was no documentation in the medical record that advance directive information was provided, assistance was offered, or that the responsible party declined assistance. The Director of Nursing stated advance directives are discussed during quarterly meetings and that social services should document that information was provided, assistance was offered if desired, and the opportunity to decline was given. The facility also failed to ensure a current copy of an advance directive was maintained in the medical record for another resident. Resident 4 was admitted and later readmitted with respiratory failure, dependence on a respirator, and a history of cardiac arrest. The history and physical dated 10/27/2024 indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognition. The advance directive acknowledgment form dated 10/2/2024 indicated the resident had executed an advance directive, but the medical record did not contain a copy. The Social Services Designee and other staff stated the copy should have been obtained and filed in the chart, and that it had not been followed up for several months.
Ripped Bed Rail Padding
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for one sampled resident. Resident 71 was admitted with diagnoses including respiratory failure and dependence on a respiratory ventilator. The resident's MDS dated 7/3/2025 indicated severely impaired cognitive skills for daily decision making and dependence on staff for all ADLs. The resident also had an order dated 7/1/2024 for padded side rails to decrease potential injury related to a history of seizure disorder. During a concurrent observation and interview on 8/14/2025 at 12:34 p.m., RN 5 observed that the foam padding on the resident's bilateral upper side rails had several rips. RN 5 stated he would contact maintenance to replace the foam padding and said it should be replaced because of aesthetics. During an interview on 8/15/2025 at 10:50 a.m., the DON stated the bed rail padding should be in good shape and that the resident should be in a homelike environment for dignity. The facility's policy titled Homelike Environment stated residents are provided with a safe, clean, comfortable and homelike environment, and the policy titled Equipment stated equipment will be cleaned, maintained, and replaced as needed.
Wound Care Provided Before Physician Order Was Obtained
Penalty
Summary
The facility failed to ensure treatment and care were provided in accordance with physician orders for Resident 16, who had diagnoses including chronic respiratory failure with hypoxia, oxygen dependence, dementia, and osteomyelitis. The resident’s record also showed a history of right foot osteomyelitis, dependence on staff for bathing, dressing, oral and personal hygiene, toileting, and mobility, and the presence of two unhealed stage 4 pressure ulcers and two unhealed unstageable pressure ulcers on admission or readmission. Resident 16 had physician orders dated 7/16/2025 for wound care to the left great toe, left hip, right first metatarsal head, and right fifth metatarsal head, with cleansing, Santyl ointment, calcium alginate dressing, and bordered gauze. During a wound care observation, the treatment nurse provided the ordered wound care to those areas and also identified a newly noted pressure ulcer on the top of the resident’s right great toe. The nurse then applied treatment to that newly identified area and placed a dressing on it. During follow-up interview and record review, the treatment nurse stated the facility process was to report any new skin issue to the physician, obtain an order, and then initiate treatment, but acknowledged the new wound on the right great toe was treated before the physician was notified and before an order was obtained. The nurse stated hydrogel and a gauze dressing were applied without an order. The DON confirmed the facility policy required calling the physician and obtaining an order before treatment of a new skin issue, and acknowledged the nurse did not follow that process.
Failure to Empty Full Colostomy Bag
Penalty
Summary
The facility failed to ensure appropriate colostomy care for a resident admitted with a colostomy, elevated white blood cell count, and abnormalities of gait and mobility. The resident’s H&P indicated he had the capacity to understand and make decisions, while the MDS showed he sometimes could make himself understood and understand others, had moderately impaired cognition, required partial/moderate assistance with personal/toileting hygiene, and was at risk for pressure ulcer/injuries. The physician’s orders directed staff to change the colostomy bag as needed if full, dislodged, or leaking, cleanse the site with normal saline, apply a new bag every day shift, and monitor the site and surrounding skin each day shift for redness, skin breakdown, and signs and symptoms of infection. The resident told staff that his colostomy bag had been full since the morning shift change and that he had discomfort because it had not been emptied. During observation, the resident’s colostomy bag was noted to be full of fecal contents, and the LVN stated it needed to be emptied or changed. The LVN also stated the bag should be checked periodically to prevent it from becoming full and dislodged, and that she was not aware of the resident’s complaint. Review of the MAR showed no initials recorded for the PRN colostomy bag change in 8/2025. The DON stated the colostomy bag should have been emptied during shift change and as needed to prevent dislodging and skin irritation at the colostomy site.
Oxygen Therapy and Tubing Not Maintained as Ordered
Penalty
Summary
Resident 6 had diagnoses including respiratory failure, tracheostomy, and gastrostomy, and the record indicated the resident lacked capacity to understand and make decisions, had severely impaired cognition, required total assistance with activities of daily living, and received oxygen therapy. The physician ordered oxygen titration to keep oxygen saturation above 92% every shift and as needed, and the care plan directed staff to apply oxygen as needed or as ordered for risk of respiratory distress. During observation on 8/11/2025, the resident’s oxygen tubing connected to the ventilator was dated 8/3/2025, and the respiratory therapist stated the tubing should have been changed on 8/10/2025 because facility policy required weekly changes. The DON also stated the tubing should have been changed weekly and that the dated tubing should have been replaced on 8/10/2025. Resident 169 had diagnoses including encephalopathy, interstitial pulmonary disease, and heart failure, and the history and physical described the resident as alert and confused. The physician ordered oxygen at 2 L/min via nasal cannula, with titration up to 5 L/min for oxygen saturation less than 90%, and monitoring of oxygen saturation every shift. The care plan identified the resident as at risk for respiratory distress and directed staff to monitor oxygen saturation as needed or ordered and apply oxygen as needed or ordered. During observation on 8/11/2025, the resident’s oxygen tubing was resting on the chest and was not in the nostrils to deliver oxygen. During interview, the treatment nurse stated the nasal cannula should have been in the resident’s nostrils to deliver the ordered oxygen and said she did not know how long the oxygen had been off the resident. The LVN stated charge nurses were responsible for ensuring residents were receiving oxygen therapy and should round at least every 2 hours to check oxygen delivery. The DON stated the resident was required to receive oxygen therapy at all times per physician’s order and that licensed staff and CNAs were responsible for ensuring the oxygen was on the resident.
Failure to Provide Ordered Pain Medication Before Wound Care
Penalty
Summary
The facility failed to provide pain management before wound treatment for one resident with pressure injuries. The resident was admitted with diagnoses including sequelae of cerebral infarction, COPD, myocardial infarction type two, generalized muscle weakness, and gait and mobility abnormalities. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS later indicated the resident could make self understood and understand others, required partial/moderate assistance with bed mobility, was always incontinent of bowel and bladder, and was at risk for pressure ulcers with a Braden score of 17. Physician orders dated 8/12/2025 directed Acetaminophen 325 mg, two tablets by mouth every day shift prior to wound care and treatment. The same date, wound orders were in place for a sacrococcyx pressure ulcer to be cleansed with normal saline, treated with Santyl, and covered with bordered gauze, and for a left buttock pressure ulcer to be cleansed with normal saline, treated with hydrogel, and covered with bordered gauze. The care plan for the actual unstageable sacrococcyx pressure sore included assessing for signs and symptoms of pain or discomfort and medicating as ordered. On 8/12/2025, the resident told surveyors the wound on the back was starting to hurt and that the resident was in pain. On 8/13/2025, staff interviews showed the wound treatment was performed without verifying that the ordered pain medication had been given beforehand. TN 1 stated she did not recall confirming pain medication administration and proceeded with wound treatment with PA 1 without verifying it. LVN 2 stated she had not administered any pain medication to the resident during her shift and that Acetaminophen was intended to be given before wound treatment to help prevent pain during the procedure. The DON stated pain medication should be provided after pain is assessed and before wound treatment as ordered. The wound care consultation documented a stage three sacral pressure ulcer and a stage two left buttock pressure ulcer, with debridement performed on the sacral wound.
Incompetent wound care and failure to follow orders
Penalty
Summary
The facility failed to ensure Treatment Nurse 1 demonstrated clinical competency and skills to care for residents at risk for pressure ulcers/injuries. Resident 10 was admitted with diagnoses including prior cerebral infarction, COPD, myocardial infarction type two, generalized muscle weakness, and gait and mobility abnormalities. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident could make self understood and understand others, required partial/moderate assistance with bed mobility, was always incontinent of bowel and bladder, and was at risk for pressure ulcers. On 8/12/2025, during observation at the bedside, two bordered gauze dressings were seen on Resident 10’s left buttock and sacrococcyx area without dates or staff initials. Treatment Nurse 1 removed the dressings and stated the resident had two open wounds, but said she did not know who applied the dressings and then left the room. A later interview with Treatment Nurse 1 established that she had applied the two bordered gauze dressings herself, had panicked when she saw the wounds, and had left the room. She also stated that she had provided MASD treatment on 8/11/2025, but did not remove the resident’s brief or assess the skin, did not assess the left and right buttocks, and only applied barrier cream to the perianal area. Treatment Nurse 1 further stated that she applied the bordered gauze dressing without a physician’s order and acknowledged that the facility protocol required reporting new skin issues to the physician, obtaining a treatment order, and then initiating treatment. The Director of Nursing stated the lack of demonstrated skills and care by Treatment Nurse 1 could have contributed to the development and worsening of pressure ulcers in Resident 10, and stated Treatment Nurse 1 was not competent because she failed to identify, report, and prevent pressure ulcers. The employee record review showed no documented clinical skills competency assessment specific to the care of residents with pressure injuries, and the DON was aware of a prior performance correction notice showing Treatment Nurse 1 had previously provided treatment without a physician’s order.
Controlled Medication Not Properly Documented
Penalty
Summary
The facility failed to accurately account for one dose of tramadol 50 mg for Resident 112 in Station 3 Cart. During a concurrent observation and interview, the Controlled Drug Record for tramadol showed two doses left, but the medication card contained only one dose. LVN 4 stated she had administered the missing dose to Resident 112 around 10:40 AM that day but had not signed the Controlled Drug Record at that time because she was busy with other tasks. LVN 4 stated she was required to sign the log immediately after the medication was removed from the bubble pack. She also stated that failing to sign for narcotics increases the risk of accidental overdose if medication is given too often and increases the risk for diversion. The facility policy titled Controlled Medications stated that when a controlled medication is administered, the licensed nurse must immediately enter the nurse's signature on the accountability record at the time the medication is removed from the supply.
Improper Storage of Used Single-Dose Testosterone Vial
Penalty
Summary
A used single-dose vial of testosterone injection for Resident 170 was found in Station 4 Cart during a concurrent observation and interview with LVN 6. The vial had half of its contents missing, and the product labeling stated that single-dose vials of testosterone injection should be discarded after use. LVN 6 stated the vial for Resident 170 was a single-dose vial and should have been discarded after its last use rather than kept in the medication cart. During the interview, LVN 6 stated that using medication from a single-dose vial more than once increases the risk that the resident could develop an infection because the preparation is not preserved, and that this could cause medical complications possibly resulting in hospitalization. The facility policy titled Medication Storage in the Facility stated medications and biologicals are to be stored safely, securely, and properly according to manufacturer recommendations, and outdated, contaminated, or deteriorated medications are to be immediately removed and disposed of. The policy titled Vials and Ampules of Injectable Medications stated ampules and single-use vials are discarded immediately after use.
Improperly Labeled Open Food Item
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when one opened bag of mini tortillas was found without an opened date. During a concurrent observation and interview on 8/11/2025 at 7:46 a.m., the Dietary Supervisor stated the bag should have an open date. During a later interview on 8/15/2025 at 3:18 p.m., the Dietary Supervisor stated that open dates are used for open containers to monitor expiration dates, support food safety, and prevent contamination. The facility policy titled "Dating and Labeling," last reviewed 4/16/2025, states that food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas, and that opened containers of potentially hazardous foods should have an open date.
PT Progress Note Signed by Another Therapist
Penalty
Summary
The facility failed to ensure medical records were maintained in accordance with professional standards when Resident 15’s PT progress note dated 8/1/2025 was signed by the Director of Rehabilitation, an OT, instead of the PT who completed the documentation. Resident 15 was admitted with diagnoses including metabolic encephalopathy and dysphagia, and the MDS dated 7/30/2025 indicated severe cognitive impairment and dependent assistance with oral hygiene, showering, dressing, rolling, and shower transfers. The MDS also showed the resident received PT three days in the last seven days. The OSR showed an order dated 7/25/2025 for clarification of PT four times a week for four weeks. During interview and record review, the DOR stated PT 2 did not sign the progress report and that the DOR signed on PT 2’s behalf, while PT 2 stated he completed the note but did not have time to sign it and asked the DOR to sign for him. The facility’s charting and documentation policy required documentation to be objective, complete, accurate, and include the signature and title of the individual documenting, and the PT job description included responsibility for weekly progress notes and 14-day progress notes per facility policy.
Incomplete Antibiotic Surveillance and Missing Monitoring for Ceftriaxone
Penalty
Summary
The facility failed to implement its antibiotic stewardship and infection prevention and control program for one sampled resident who was admitted with respiratory failure, a tracheostomy, and a gastrostomy, and who had severely impaired cognition and required total assistance with all activities of daily living. The resident’s record showed a physician order for ceftriaxone sodium 1 gram IV daily for atypical pneumonia after a chest x-ray and CBC were obtained, with the CBC showing a WBC of 16.2 and the chest x-ray indicating atypical pneumonia. During interview and record review, the Infection Preventionist stated the Surveillance Data Collection Form for Respiratory Infections was incomplete and did not include the three criteria required to show the resident actually had an infection rather than a symptom. The IP stated the resident met criteria on the surveillance form because the chest x-ray showed atypical pneumonia, the resident had desaturation, and the WBC was 16.2. The IP also stated the form should have been completed to ensure the antibiotic use was appropriate and that all staff involved in the resident’s care were aware of the reason for the antibiotic. The record review also showed no documented monitoring for adverse effects of ceftriaxone in the licensed nurses’ notes on multiple shifts during the antibiotic course. The care plan for possible side effects or adverse reactions related to antibiotic therapy directed staff to assess for signs and symptoms of adverse reactions and notify the physician as indicated, and the DON stated nurses were supposed to monitor residents for antibiotic side effects every shift and document this in the nurses’ notes during treatment and for three days after completion. The facility policy required all clinical infections treated with antibiotics to be reviewed by the IP or designee and all antibiotic regimens to be documented on the facility-approved surveillance tracking form, including start date, stop date, outcome, and adverse events.
Exposed Wires on Bed Controllers
Penalty
Summary
The facility failed to maintain resident bed controller equipment in safe operating condition for two residents, Resident 44 and Resident 92, because their bed controller cords had frayed or exposed wires. During observation of Resident 44 in bed, the bed control box was next to the resident’s hand and the base of the control had exposed wires. The LVN stated the exposed wires should have been reported to maintenance for replacement and that the condition placed the resident at risk for electrocution. Resident 44’s record showed diagnoses including respiratory failure, tracheostomy, and schizophrenia. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident was not able to understand others or make needs known, had severely impaired cognition, and required total assistance with all ADLs. During the observation, the resident was lying in bed with the bed control within reach. During observation of Resident 92 in bed, the bed control was next to the resident’s side and the cord wrapped around the right siderail had exposed wires. The LVN stated the base of the bed control box and the cord had exposed wires and that maintenance should have been notified for replacement. Resident 92’s record showed diagnoses including respiratory failure, tracheostomy, and seizure, and the H&P stated the resident was incapacitated. The MDS indicated the resident was sometimes able to understand others and make needs known, had severely impaired cognition, and required total assistance with all ADLs.
MDS assessments were not accurately coded for diagnoses, therapy, and restorative nursing services
Penalty
Summary
The facility failed to ensure accurate MDS assessments for five sampled residents by incorrectly completing Section I for active diagnoses and Section O for therapies and restorative nursing programs. The report identified that two residents with documented mood disorder diagnoses had MDS assessments that did not include bipolar disorder or mood disorder in Section I, despite admission records, physician documentation, psychiatric documentation, medication orders for Depakote, and interdisciplinary team documentation showing those diagnoses were active in the clinical record. For one resident, the MDS Section O therapy coding did not reflect OT and PT minutes or days provided during the assessment period. The resident’s record showed skilled OT and PT services were provided, but the MDS recorded zero and blank entries for therapy minutes and days. During interview, MDS staff stated they had not entered therapy minutes or days because they believed it was only required for certain insurance types, and they acknowledged the MDS should follow the RAI Manual and be accurate. For two other residents, the MDS Section O restorative nursing coding did not match the restorative nursing documentation. One resident’s record showed an RNA program for active assistive ROM to both upper and lower extremities five times a week, with documentation showing four days of 15-minute AAROM sessions, but the MDS recorded zero days of restorative nursing ROM. Another resident’s record showed an RNA program for PROM to both upper and lower extremities with bilateral hand splints, knee splints, and AFOs every day, but the MDS did not indicate the resident received RNA PROM and splint application during the assessment period. The DON and MDS staff stated the MDS should accurately reflect the resident’s diagnoses, treatments, and services based on the RAI Manual.
Excess Residents in a Room Beyond Allowed Capacity
Penalty
Summary
The facility failed to ensure that one of 65 resident rooms, room [ROOM NUMBER], accommodated no more than four residents per room. During observation on 8/11/2025 at 10:10 a.m., room [ROOM NUMBER] had five beds and five residents residing in the room. The room measured 418.5 square feet and was observed to have ample space for beds, overbed tables, dressers, equipment, and sufficient space for the provision of necessary care and services. During interview on 8/11/2025 at 9:40 a.m., LVN 4 stated there were no concerns regarding the room’s size. A later review of the Administrator’s written request for a continued room waiver indicated that room [ROOM NUMBER] had five beds, and the Client Accommodation Analysis Form dated 8/15/2025 showed an approved capacity of five residents in the 418.5 square foot room. The facility policy titled Bedrooms stated that residents are to be provided with clean, comfortable, and safe bedrooms that meet federal and state requirements.
Bedroom Space Requirements Not Met
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for three of 65 resident rooms. Room [ROOM NUMBER] had four beds and measured 290.93 sq. ft., room [ROOM NUMBER] had three beds and measured 215.2 sq. ft., and room [ROOM NUMBER] had three beds and measured 213.58 sq. ft. The Client Accommodation Analysis Form dated 8/15/2025 identified these rooms as providing less than 80 square feet per resident, with calculated space of 72.7 sq. ft. per resident, 71.7 sq. ft. per resident, and 71.2 sq. ft. per resident, respectively. The minimum square footage for a 3-bed room is 240 sq. ft., and the minimum square footage for a 4-bed room is 320 sq. ft. During general observation on 8/11/2025 and 8/12/2025, residents had ample space to move freely inside the rooms, and there was sufficient space for beds, side tables, and resident care equipment. Staff interviewed on 8/15/2024 at 11:38 a.m. reported no concerns regarding the size of rooms 19, 22, or 23. A letter submitted by the Administrator on 8/15/2025 stated that the shape, size, and location of the resident beds were in accordance with the special needs of the residents and would not adversely affect residents' health and safety or impede their ability to obtain their highest practicable wellbeing. The facility policy titled, Bedrooms, last reviewed 4/14/2025, stated that shared bedrooms must provide at least 80 square feet per resident and single bedrooms at least 100 square feet.
Failure to Develop Care Plans for Scabies Exposure
Penalty
Summary
The facility failed to develop comprehensive care plans addressing potential exposure to scabies for three residents. Each resident had documented physician orders for prophylactic treatment with Elimite 5% cream following probable exposure to scabies, and the treatment was administered and recorded in the Treatment Administration Record. However, there was no evidence that individualized care plans were created to address the exposure, treatment, or monitoring for scabies for these residents. Resident 1 was admitted with multiple diagnoses, including diabetes mellitus, chronic pain syndrome, and COPD. The resident's cognitive status was reported as intact on the Minimum Data Set, and the resident required supervision for activities of daily living. Resident 2 had metabolic encephalopathy, generalized muscle weakness, and unspecified dementia, with severely impaired cognitive skills and total dependence on staff for daily activities. Resident 3 had atherosclerosis heart disease, unspecified chest pain, and cardiomegaly, with moderately impaired cognitive skills and a need for moderate assistance with some activities. All three residents received the prescribed prophylactic treatment for scabies exposure, as documented in their records. During an interview and record review with the Director of Nursing, it was confirmed that no care plans were developed for the residents' possible exposure to scabies. The facility's policy required the development of individualized nursing care plans to promote continuity of care, but this was not followed in these cases. The lack of care plans for scabies exposure and treatment was acknowledged by the Director of Nursing, who stated that this omission could result in nurses not following the appropriate plan of care for scabies treatment and prevention.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for two residents. For one resident with diagnoses including diabetes mellitus, low back pain, and COPD, the physician order specified that oxycodone 30 mg should be administered by mouth every six hours as needed for severe pain levels of seven to ten. However, the Medication Administration Record (MAR) showed that licensed nurses administered oxycodone when the resident's pain level was six on multiple occasions. The Director of Nursing (DON) confirmed that the nurses did not follow the physician's order and should have performed a proper pain assessment and contacted the physician for any necessary adjustments. For another resident with metabolic encephalopathy, secondary hypertension, and dementia, the physician order required diltiazem 60 mg to be given every six hours for high blood pressure, with instructions to hold the medication if the systolic blood pressure (SBP) was below 110. The MAR indicated that diltiazem was administered when the resident's SBP was 108/70. The DON acknowledged that the medication should have been held according to the physician's order to prevent further decrease in blood pressure. A review of the facility's policy and procedure for medication administration emphasized the importance of following the five rights of medication administration and adhering to physician orders, including taking vital signs immediately before administering medications when required. The DON confirmed that the facility's policy was to follow the physician's order, and the failures identified were not in accordance with this policy.
Unnecessary Administration of Scabies Prophylaxis
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary medications when Elimite cream, a treatment for scabies, was administered as prophylaxis despite the absence of a scabies diagnosis or outbreak. Resident 1, with a history of diabetes mellitus, chronic pain syndrome, and COPD, was admitted with intact cognitive skills and required supervision for daily activities. The resident received Elimite cream following a physician's order for asymptomatic prophylaxis after a roommate was diagnosed with scabies, despite not being tested or showing symptoms. Resident 2, diagnosed with metabolic encephalopathy, generalized muscle weakness, and unspecified dementia, was dependent on staff for all activities of daily living and also received Elimite cream as a preventive measure. Similarly, Resident 3, with a history of atherosclerosis, chest pain, and cardiomegaly, and moderate cognitive impairment, was given Elimite cream for the same reason. In all cases, the residents did not have a diagnosis of scabies, nor were they tested for the condition prior to administration of the medication. Interviews with nursing staff and the Infection Preventionist confirmed that Elimite was administered to these residents as a precaution after a single positive case of scabies was identified in another resident who had been readmitted from the hospital. The Director of Nursing acknowledged that the facility's policy required scraping and confirmation of suspected cases, and that a scabies outbreak is defined as two confirmed cases. The administration of Elimite in these circumstances was recognized as unnecessary, as there were no new suspected or confirmed cases among the treated residents.
Failure to Implement Infection Control Measures for Suspected Scabies
Penalty
Summary
The facility failed to implement appropriate infection control measures for three residents following a physician's order to rule out scabies. Specifically, after a physician ordered a skin scraping for one resident to test for scabies, the resident was not placed on contact isolation as required by facility policy. Observations confirmed that there was no contact isolation signage or personal protective equipment (PPE) available at the resident's door, and both the Infection Preventionist and Director of Nursing acknowledged that contact isolation should have been initiated when the order was given. Additionally, the facility did not ensure that skin monitoring was performed and documented for three residents after a physician ordered such monitoring. Review of the Treatment Administration Records (TAR) and progress notes revealed that skin monitoring was not started until two days after the physician's order, resulting in a gap in monitoring and documentation. Nursing staff confirmed that this delay occurred and acknowledged that it could lead to a delay in care. The facility's policies and procedures require the initiation of transmission-based precautions and timely documentation of infection surveillance data. However, these protocols were not followed in this instance, as evidenced by the lack of contact isolation and delayed skin monitoring for the affected residents. The failures were confirmed through interviews with staff and review of medical records and facility policies.
Unauthorized Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and total dependence for activities of daily living was found in a wheelchair with a white blanket wrapped around his lower abdomen to knees, with the edges secured to the wheelchair, effectively restraining him. The resident had a physician order and consent for a self-release seat belt, but there was no order or consent for the use of a blanket as a restraint. The facility's records indicated the resident lacked capacity to make decisions, and the Minimum Data Set confirmed severe impairment in daily decision-making. Observations revealed that the blanket was tied at the back of the wheelchair, and staff interviews confirmed that the blanket was not a self-release device and should not have been used in that manner. Both the LVN and CNAs interviewed stated that the resident could not have tied the blanket himself, and that staff should have checked to ensure no unnecessary restraints were applied. The Assistant Director of Nursing and Director of Nursing both acknowledged that the use of the blanket as a restraint was not authorized, and that the facility's policy for restraint use, which requires assessment, physician order, and monitoring, was not followed in this case. The facility's policy defined physical restraints as any device or material that the resident cannot remove easily and which restricts freedom of movement. The policy also outlined the need for assessment, physician order specifying the restraint, purpose, and monitoring, as well as informed consent. In this incident, these procedures were not followed, resulting in the unauthorized use of a physical restraint on the resident.
Failure to Follow LALM Protocols for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for a resident who was at risk due to multiple medical conditions, including diabetes mellitus, heart failure, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. Despite a physician order for a low air loss mattress (LALM) to manage and prevent pressure ulcers, staff placed multiple layers of linen and padding—totaling eight layers—between the resident and the LALM, contrary to both the manufacturer's instructions and facility policy, which specified no excessive padding should be used. Observations and interviews revealed inconsistent understanding among staff regarding the correct number of linen layers to use with the LALM. A CNA identified eight layers, while an RN believed four layers were appropriate, and the Infection Preventionist and DON both stated that only two layers, including the incontinence brief, should be present. Facility policy and the LALM operation manual both emphasized the importance of avoiding excessive padding to prevent interference with the mattress's pressure-relieving function. This failure to follow established protocols had the potential to contribute to the development or worsening of pressure ulcers for the resident.
Delayed Physician Notification for Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of the Attending Physician (AP) for a resident who experienced a change in condition. The resident, admitted with diagnoses including a urinary tract infection, osteoporosis with a vertebra fracture, and unspecified dementia, was found sitting on a floor mat. A Certified Nursing Assistant (CNA) informed a Licensed Vocational Nurse (LVN) about the situation, and the AP was notified, resulting in an immediate order for a left leg X-ray. However, the X-ray was not performed promptly, and the AP was not informed of this delay until the following morning. The facility's policy requires prompt notification of the physician upon a change in condition, but this was not adhered to, as the AP was not informed within the expected timeframe. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the staff should have notified the AP within two hours if the stat X-ray was not completed. The delay in communication resulted in a failure to obtain timely instructions from the physician for the resident's proper management.
Inaccurate Documentation of Resident's Change of Condition
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, which was identified during a survey. The resident was admitted with diagnoses including a urinary tract infection, age-related osteoporosis with a current pathological vertebra fracture, and unspecified dementia. A Change of Condition (COC) record indicated that the resident was found sitting on the floor mat, and the Responsible Party (RP) was notified. However, discrepancies were found in the documentation of the notification time. The COC incorrectly stated that the RP was notified on the same day at midnight, while it should have been documented as the following day. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the documentation was inaccurate, and the time of notification was not properly recorded in the COC and Progress Notes. The facility's policy and procedure on charting and documentation emphasized the importance of accurate and complete records to facilitate communication among the interdisciplinary team. The RN admitted to documenting the wrong date for the RP notification, which was confirmed during the review of the facility's policy and procedure.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for three residents, as evidenced by the facility's inability to maintain temperatures within the required range of 71 to 81 degrees Fahrenheit. Observations revealed that the temperatures in various rooms and areas of the facility were below the minimum required, with some areas as low as 60 degrees Fahrenheit. This failure was acknowledged by the Maintenance Assistant and Maintenance Supervisor, who confirmed that the facility's heating system was not functioning properly, particularly affecting certain rooms and areas. The Director of Nursing also confirmed that the facility's temperatures were not within the regulatory requirements, which could lead to discomfort for the residents. Additionally, the facility did not ensure that shower rooms were kept clean and sanitary. Observations in the shower rooms revealed unsanitary conditions, including towels and gloves on the floor, feces on a shower chair, and unattended disposable briefs and razors. Licensed Vocational Nurse 2 and the Maintenance Assistant both acknowledged these issues, stating that the equipment and rooms should be cleaned and disinfected after each use to prevent infection and maintain a homelike environment. The Director of Nursing confirmed that the facility staff failed to clean the equipment and shower rooms after resident care, which did not provide a clean and homelike environment for the residents. The residents involved in this deficiency had significant medical conditions and cognitive impairments, which made them dependent on the facility staff for their activities of daily living and unable to make decisions for themselves. The facility's policy and procedure on providing a homelike environment emphasized the importance of maintaining a clean, sanitary, and orderly environment with comfortable and safe temperatures. However, the facility's failure to adhere to these standards resulted in a deficiency that had the potential to impact the residents' comfort and well-being.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the face. The incident involved Resident 1, who had severely impaired cognition due to dementia and Alzheimer's disease, and Resident 2, who also had severely impaired cognition and a history of altered behavior patterns. On the day of the incident, Resident 1 was wheeling towards his bed when Resident 2, who was sitting on his own bed, stood up, grabbed Resident 1's call light, and punched Resident 1 in the face. This resulted in swelling and discoloration on Resident 1's face and eyes. The incident was witnessed by Resident 3, who immediately reported it to the nursing station. Upon assessment by the RN Supervisor, Resident 1 was found with facial swelling and discoloration, and was administered Tylenol for pain. Resident 2's plan of care had previously identified episodes of anger and inability to cope with stimuli, but the facility failed to prevent the physical aggression towards Resident 1. The facility's policies on monitoring residents with behavioral symptoms and preventing abuse were not effectively implemented, as evidenced by the incident. The staff, including direct caregivers and nursing supervisors, were responsible for monitoring residents with potential for conflict and anger, but the measures in place were insufficient to prevent the physical abuse of Resident 1 by Resident 2.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for several residents, which is a critical component of providing reasonable accommodation for resident needs and preferences. Resident 35, who was admitted with diagnoses including cerebral infarction and muscle weakness, was observed with the call light on the floor, out of reach. Despite the care plan indicating the need for the call light to be within easy reach, staff failed to notice and rectify this during their visits to the resident's room. Interviews with staff, including a CNA and LVN, confirmed the oversight and acknowledged the potential risk for falls when residents cannot access their call lights. Similarly, Resident 144, who had a history of traumatic subdural hemorrhage and severely impaired vision, was found with the call light placed on a bedside drawer, away from reach. The care plan for this resident also specified the need for the call light to be within easy reach due to the resident's high fall risk. Staff interviews revealed an understanding of the importance of call light accessibility, yet the deficiency persisted, indicating a lapse in adherence to the facility's policy. Residents 104 and 134, both with severe cognitive impairments and high fall risks, were also observed with call lights out of reach. Despite care plans and facility policies emphasizing the necessity of having call lights accessible, these residents were unable to call for assistance due to improper placement of the call lights. The DON confirmed that the pad call lights should be placed adjacent to the residents' bodies to ensure activation, highlighting a consistent failure across multiple cases to adhere to established protocols.
Failure to Obtain Proper Documentation for Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, affecting several residents. For Resident 6, the facility did not obtain a physician's order, informed consent, or perform a restraint use assessment for the use of left-and-right hand mitten restraints. The resident, who was dependent on staff for activities of daily living and had a history of pulling out a gastrostomy tube, was observed with mitten restraints without the necessary documentation or assessments. Staff confirmed the lack of consent and order, acknowledging the importance of these measures to determine the necessity and safety of the restraints. For Residents 126 and 9, the facility placed their beds against the wall, which was considered a restraint, without obtaining a physician's order, informed consent, or performing an assessment. Both residents had cognitive impairments and were dependent on staff for daily activities. Staff confirmed the absence of necessary documentation and assessments, emphasizing the importance of informed consent and safety evaluations to respect the residents' rights and ensure their safety. Resident 467 was found with all four side rails up, considered a restraint, without a physician's order, informed consent, or assessment. The resident had a high fall risk and was dependent on staff for mobility and daily activities. Similarly, Resident 30 had pillows tucked under fitted sheets to prevent falling out of bed, which restricted movement and was considered a restraint. The facility failed to obtain the necessary documentation and assessments for these measures, highlighting a pattern of non-compliance with restraint use protocols.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. For Resident 9, the bed was placed against the wall, which was considered a restraint, yet there was no care plan addressing this. Similarly, Resident 126's bed was also placed against the wall without a care plan, and Resident 467 was observed with all four side rails up, also considered a restraint, without an accompanying care plan. These actions were not documented in care plans, which are essential for ensuring consistent and safe care. Resident 116 had a urinary catheter in place, but there was no care plan documenting its use, reasons for insertion, or interventions to mitigate potential adverse effects. Resident 30 was found with pillows tucked under the fitted sheet to prevent movement, which was considered a restraint, yet there was no care plan addressing this practice. Additionally, Resident 59 used a self-release seat belt in a wheelchair for positioning, but there was no care plan to guide staff on its use and ensure safety. Resident 111, diagnosed with PTSD, did not have a care plan addressing this condition, which is crucial for guiding staff in providing appropriate interventions. Furthermore, Resident 126 was prescribed Melatonin for sleep, but there was no monitoring of sleep hours to assess the medication's effectiveness, as outlined in the care plan. This lack of documentation and monitoring could lead to the use of unnecessary medications. The facility's failure to implement these care plans resulted in inconsistent care and potential harm to the residents.
Failure to Rotate Injection Sites for Insulin and Enoxaparin
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous injection sites for insulin and enoxaparin administration for several residents. This deficiency was identified for five residents who were receiving insulin and one resident who was receiving enoxaparin. The failure to rotate injection sites was observed through a review of medication administration records and confirmed during interviews with nursing staff. The facility's policy and procedure, as well as manufacturer guidelines, clearly indicated the necessity of rotating injection sites to prevent adverse skin conditions such as lipodystrophy and localized cutaneous amyloidosis. Resident 116, who was admitted with diagnoses including type 2 diabetes mellitus and acute kidney failure, had multiple instances where insulin was administered in the same area without rotation. Similarly, Resident 38, who was on anticoagulant therapy with enoxaparin, also had repeated injections in the same site. The records showed that the facility's staff did not follow the prescribed orders to rotate injection sites, which was confirmed by interviews with the Registered Nurse and the Director of Nursing. Other residents, including Residents 12, 56, 125, and 49, also experienced similar issues with insulin administration. The records indicated repeated use of the same injection sites over several months, contrary to the facility's policy and the manufacturer's guidelines. Interviews with nursing staff and the Director of Nursing further confirmed the failure to rotate injection sites, which could lead to skin abnormalities. The facility's policy and procedures, as well as the manufacturer's guidelines, were not followed, resulting in this deficiency.
Failure to Ensure Proper Use of Low Air Loss Mattresses
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, leading to deficiencies in their care. Resident 67, who was admitted with conditions such as hemiplegia, peripheral vascular disease, and venous thrombosis, was found to have a low air loss mattress (LALM) that was not powered on. This mattress is crucial for distributing the resident's body weight to prevent skin breakdown. Despite the resident's high risk for skin breakdown and the care plan's directive to ensure the LALM is inflated, the power was off during an observation. The Director of Nursing (DON) confirmed that the staff should have turned on the power to provide necessary therapy, and the failure to do so could lead to the development or worsening of pressure injuries. For Resident 469, who was admitted with respiratory failure and a stage 3 pressure ulcer, the LALM was not set according to the resident's weight. The resident's care plan included the use of pressure-relieving devices, and the resident was assessed as high risk for skin breakdown. However, the LALM was set at 160, while a sticker on the device incorrectly indicated it should be set at 200. The Treatment Nurse (TN) acknowledged that the setting should be based on the resident's weight, which was 136 pounds, and that the sticker could mislead staff into setting the LALM incorrectly. The DON stated that the staff should have clarified the correct setting with the attending physician to ensure appropriate therapy. These deficiencies highlight the facility's failure to adhere to professional standards of practice in preventing pressure injuries. The incorrect use and settings of the LALMs for both residents had the potential to contribute to the development or worsening of pressure ulcers, as confirmed by the observations and interviews with the facility's staff.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 5,339 citations issued within 25 miles in the last 12 months — including the 39 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Studio City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Imperial Care Center | 0 mi | ★★★★★ | 5 | 0 |
| Providence St Elizabeth Care Center | 2.1 mi | ★★★★★ | 33 | 2 |
| Sherman Village Hcc | 2.1 mi | ★★★★★ | 48 | 1 |
| Four Seasons Healthcare & Wellness Center, Lp | 2.2 mi | ★★★★★ | 20 | 0 |
| Vineland Post Acute | 2.8 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.