Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunny Hills Post Acute during CMS and state inspections, most recent first.
A resident with a sacral fracture and moderate cognitive impairment missed scheduled doses of Buprenorphine and Ozempic, but nursing notes only stated the meds were on order and did not show PCP notification. The MAR confirmed missed doses, the LVN verified the omissions, and the DON stated the resident’s pain and blood sugar could not be managed effectively when the meds were not given.
A resident with a sacral fracture and moderate cognitive impairment received PRN hydromorphone for severe pain, but pain reassessments were documented more than 1 hour after the medication was given on two occasions. The LVN stated pain should have been reassessed after an hour, and the DON stated the delayed reassessment was not acceptable because the resident’s pain could have been unmanaged.
A resident with sacral fracture and moderate cognitive impairment missed ordered doses of a buprenorphine patch for pain and Ozempic for diabetes because the meds were not delivered or followed up with the pharmacy. The DON and pharmacy staff stated Ozempic required a high-cost authorization form and the buprenorphine patch required PCP signature/authorization, but these were not received. A box of buprenorphine patches brought in by the resident’s FM was used without documented PCP approval or verification per policy.
A resident with hemiplegia, hemiparesis post-stroke, syncope, and gait abnormalities was care planned as at risk for falls, with interventions including maintaining the bed in a low position at night. The MDS showed the resident had clear speech, was usually understood and understands, and needed substantial/maximal assistance with ADLs. Despite a fall risk assessment indicating fall risk and intermittent confusion, progress notes and staff interviews revealed the resident repeatedly raised the bed after staff lowered it and did not comply with instructions to keep the bed low. The DON and Charge Nurse acknowledged the resident’s non-compliance and the increased fall risk from the elevated bed, yet the care plan was not revised to reflect the resident’s non-compliance or to add individualized interventions, contrary to the facility’s Fall Prevention Program policy requiring monitoring of interventions and revision of the plan of care as needed.
Call lights were not kept within reach or were not the proper type for several residents with significant cognitive and physical impairments. A resident with dementia and depression, a resident with severe cognitive impairment and fall risk, a resident with aphasia and hemiplegia, a resident with contractures and functional quadriplegia, and a resident with Alzheimer’s disease and contractures were observed with call lights behind the bed, on a wall hook, under the bed, or as a push-button device the resident could not use. Staff and the DON acknowledged the call lights were not accessible as required by the residents’ care plans and needs.
A resident with impaired cognition and no capacity to make medical decisions was given psychotropic meds including Risperidone and PRN Lorazepam, but the consent forms showed consent was obtained from the resident instead of the RP. The RN stated informed consent should have been verified with the RP, who should have been informed of the risks and benefits before continued use of the meds.
A resident admitted with spinal infections and receiving heparin for DVT prophylaxis had scattered ecchymosis on both arms noted on observation, but the bruising was not documented on the skin check or reported to the MD. RN confirmed the MD was only notified about a pressure injury and an open wound, while the bruising present on admission was not communicated.
A resident’s MDS oral/dental status was coded incorrectly and did not reflect that she was edentulous. The resident, who had dx including dysphagia, COPD, and depression and was cognitively intact, was observed eating lunch and stated she had no upper or lower natural teeth. The MDSN confirmed the assessment was inaccurate and did not match the resident’s actual oral/dental status.
A resident with diagnoses including schizoaffective disorder, bipolar disorder, schizophrenia, dementia, anxiety disorder, Parkinson's disease, and psychosis had an inaccurate PASARR Level I screening that identified no serious mental illness and did not trigger a Level II evaluation. The H&P noted the resident lacked decision-making capacity, the MDS showed severe cognitive impairment and dependence for ADLs, and interviews confirmed Admissions only uploaded the PASARR while Social Services was not involved, despite facility policy assigning PASARR status review and referral responsibilities to Social Services or designee.
Failure to Develop and Implement Resident Care Plans: The facility did not develop a care plan for a resident with no natural teeth, despite dysphagia, COPD, and depression, and the resident was observed eating lunch in bed and stated she had no upper or lower teeth. The facility also did not implement an indwelling catheter care plan for another resident with obstructive and reflux uropathy, Alzheimer’s disease, and dementia, as no urinary output was documented even though the care plan required intake and output monitoring.
Failure to revise fall care plan after repeated falls. A resident with muscle weakness, DM, hypertensive heart disease, and a UTI had severely impaired cognition and needed assistance with ADLs. IDT notes documented multiple unwitnessed falls, and after another unwitnessed fall the resident’s fall care plan was not updated. RN and DON confirmed the care plan had not been revised, despite the resident’s history of frequent falls.
A resident with hemiplegia/hemiparesis after a CVA, muscle weakness, falls history, and a sacral Stage 2 pressure ulcer was assessed as needing maximal help with toileting, bathing, and dressing and moderate help with transfers. The resident was repeatedly observed in bed wearing a gown and jacket, stated staff were not getting her up, and reported she had been in bed for months except for rare occasions when male staff were available. CNA documentation listed transfers as not applicable instead of resident refused, and an LPN and the DON acknowledged the resident was not bedbound, had no bedrest order, and should have had daily mobility and ADL care addressed.
A facility failed to keep bilateral floor mats in place for a resident on fall precautions and failed to provide padded grab bars for a resident on seizure precautions. One resident had dementia, difficulty walking, multiple spine fractures, severe cognitive impairment, and a documented fall risk, yet only one floor mat was observed at the bedside. Another resident with epilepsy and dementia was observed with unpadded bilateral grab bars despite orders for padded grab bars, and an LPN and the DON confirmed the padding should have been in place.
Foley Catheter Urine Changes Not Reported: A resident with an indwelling Foley catheter, quadriplegia, and impaired decision-making had urine with sediment, cloudiness, and blood. An LVN and the DON stated these were abnormal findings and a change in condition that required assessment and physician notification, but the record review showed the catheter was ordered to be changed for blockage, leaking, pulled out, or excessive sediment, and the resident required close monitoring for possible UTI signs.
PICC dressing and securement device not changed as ordered: A resident with a PICC for IV antibiotics had the dressing and securement device left in place beyond the ordered interval. Staff documented changes on the IV record, but an RN stated she had only assessed the site and did not actually change the dressing or securement device, and the DON confirmed they should have been changed on admission.
Oxygen Therapy Not Given Per Physician Order: A resident with acute respiratory failure with hypoxia, pneumonia, and COPD was observed receiving O2 at 5 LPM via NC even though the active MD order was for 2 LPM to keep O2 saturation above 92%. RN and DON both acknowledged the resident should not have been above the ordered rate, and the facility P&P stated oxygen is administered under a physician order.
Pain Medication Given Outside Ordered Pain Range: A resident with hemiplegia, hemiparesis, and OA reported severe pain in the shoulder, hip, and lower back, usually rating it 8/10. Although the Norco order was for moderate pain only, staff repeatedly administered it for severe pain; the resident said it helped briefly before the pain returned, and the DON and LPN acknowledged the medication was being given outside the ordered pain range.
Missing Dialysis E-kit at Bedside: A resident with ESRD receiving scheduled hemodialysis did not have the required bedside dialysis E-kit available during multiple observations. The care plan required the kit to be at the bedside and checked every shift, but an LVN found no E-kit in the bedside area or nearby storage. The DON stated the kit should be readily available for dialysis-related emergencies such as bleeding.
RN 2 was not competent with PICC dressing care for a resident admitted with osteomyelitis and discitis. The resident’s PICC dressing and securement device were ordered to be changed on admission and weekly, but the dressing remained dated from before admission when observed, and RN 2 stated she had documented changes without actually changing the dressing or securement device. RN 2 also confused PICC care with PIV care, despite having attended an in-service on IV maintenance and PICC dressing changes.
Failure to monitor for bleeding signs with heparin therapy: A resident receiving heparin for DVT prophylaxis had no orders to monitor for signs of bleeding. An LVN confirmed the lack of monitoring orders, and the DON stated the resident was at high risk for bleeding and should have been monitored every shift for signs such as hematuria, GI bleed, and nose bleeds. The facility policy for anticoagulants stated the plan of care should alert staff to monitor for adverse consequences.
Two residents received medications outside ordered hold parameters. One resident with a history of stroke and hypertensive heart disease was given midodrine multiple times when SBP was above the ordered limit, and another resident with hemiplegia, AFib, and ESRD was given metoprolol on several occasions when HR was below the ordered limit. Nursing staff acknowledged the parameter checks and the MARs showed the medications were administered despite the ordered restrictions.
Incomplete IV and PICC Line Documentation: Two residents had inaccurate and incomplete nursing documentation related to IV antibiotics and PICC care. One resident with osteomyelitis and an infected knee prosthesis had blank IV MAR entries for ordered antibiotics and IV flushes, and the DON stated she forgot to document the doses she administered. Another resident with spinal osteomyelitis and discitis had PICC dressing and securement changes documented even though the RN stated she only assessed the site and did not actually change them; the resident also stated the dressing had not been changed since admission.
A resident with an indwelling Foley catheter, BPH, dementia, DM, and CKD had the catheter drainage bag observed touching the floor while the resident was in bed. An LVN stated the bag should be kept off the floor and below the bladder to prevent contamination and backflow, and the DON stated the bag should be kept off the floor and placed in a clean basin when the resident was in bed.
A resident with severe cognitive impairment, malnutrition, and a recent UTI had STAT labs ordered, which returned an elevated WBC count significantly above the normal range. Documentation showed that the physician and family were notified only of the resident’s weight loss, with no evidence that the abnormal WBC result was reported or that a COC was completed. In interviews, an LVN, an RN, and the DON all confirmed that abnormal labs should be reported to the physician and responsible party and documented as a COC, and the facility’s policy required notification of significant changes in condition, but this did not occur for the elevated WBC.
A resident with a stage 4 sacrococcygeal pressure injury and osteomyelitis, who was cognitively intact but dependent on staff for ADLs, received wound care from an LVN while wearing a soiled incontinence brief containing feces. The LVN removed the old dressing, cleansed and redressed the wound per physician orders, then replaced the same soiled brief instead of cleaning the resident and applying a clean brief, despite facility care plan and policy requirements to keep skin clean, minimize moisture, and prevent fecal contamination of pressure injuries.
A resident with anemia, muscle weakness, severe cognitive impairment, and oropharyngeal dysphagia, who had physician orders and a nutritional care plan for 1:1 feeding assistance, was left with an open meal tray and no CNA present to help despite verbally stating a need for assistance. The tray remained unattended for about 20 minutes before a CNA not assigned to the resident briefly assisted, left to get water, and then returned to resume feeding. The assigned CNA later admitted she opened the tray, left to pass other trays, and did not return as planned, while staff interviews and facility policy confirmed that residents requiring 1:1 feeding should not have trays served until an attendant is ready to assist.
Two residents who required significant assistance with ADLs experienced a lack of clean linens, incontinent pads, towels, and blankets due to repeated shortages in linen storage and carts. Staff confirmed that these shortages led to delays in providing clean bedding and personal care, resulting in residents remaining in soiled or uncomfortable conditions until more linens were delivered. Facility policies required clean linens, but these were not consistently available, affecting resident comfort and care.
A resident with diabetes, anxiety disorder, and impaired cognition was not assessed or treated for scabies after exposure from a roommate who tested positive. Despite reporting persistent itching and rash to staff, no skin assessment was documented, and the resident was not isolated or tested. Staff interviews confirmed that required monitoring and infection control procedures were not followed, contrary to facility policy.
A resident with osteoporosis was administered Alendronate Sodium daily instead of the recommended weekly dose due to an incorrectly entered physician order. Nursing staff did not identify or clarify the error despite medication alerts and packaging instructions, resulting in the resident receiving the medication more frequently than intended.
A resident with Alzheimer's disease and dementia, identified as an elopement risk, was left unsupervised after being assisted to the restroom. The resident exited through an unmonitored, open front door while the receptionist was away from her post, and staff did not respond promptly to the door alarm. The resident was later found outside after falling from her wheelchair, sustaining multiple fractures and injuries. The facility did not follow its own policies for supervision and elopement prevention, leading to the incident.
The facility failed to provide a safe, clean, and homelike environment for residents, with observations of dusty vents, peeling paint, and broken fixtures in several rooms. Staff interviews confirmed that maintenance and cleaning issues were not addressed promptly, despite the facility's policies emphasizing the importance of a sanitary and safe environment.
A resident with moderate cognitive impairment and multiple diagnoses did not swallow scheduled stool softener medications, as observed when pills were left on the bedside table. An LVN confirmed the oversight, and the DON stated that nurses should ensure residents ingest all medications. Facility policy required observation of medication consumption.
A resident with a history of falls was admitted without a baseline care plan indicating fall risk or preventive interventions. The resident later experienced an unwitnessed fall, resulting in injuries and a hospital transfer. Facility staff confirmed the absence of a timely care plan increased fall risk, contrary to policy requiring a plan within 48 hours.
The facility failed to follow gastrostomy tube (GT) orders and protocols for four residents, leading to incorrect feeding formula administration and improper medication flushing. A resident received the wrong GT feeding formula, while others did not have their GT flushed as prescribed, risking medication errors and tube clogging. LVNs admitted to not following procedures due to insufficient training, and the facility's policies were not adhered to, posing risks to residents' health.
Two residents experienced medication administration errors due to improper GT flushing and inadequate training of nursing staff. The errors resulted in a medication error rate of 25.81%, significantly above the acceptable threshold.
Two residents in the facility experienced significant medication errors related to insulin administration. One resident received Humulin R insulin without the required coordination with meal times, while another was given Insulin Aspart significantly earlier than their meal. The facility failed to notify physicians or clarify orders, and there was a lack of insulin training for staff.
The facility failed to properly store and label medications for five residents, including unrefrigerated Insulin Lispro, expired Humulin R, and improperly stored Lorazepam Oral Solution. An oral inhaler was also not labeled with an open date. Additionally, the destruction of non-controlled medications was not witnessed as required, leading to potential health risks.
The facility failed to maintain safe food storage practices, as refrigerator temperatures were not logged for two days, a container of grated cheese was unlabeled, and an open bag of tortillas was improperly stored. These actions violated the facility's policies, risking food spoilage and contamination.
The facility failed to implement proper infection control practices, including not wearing appropriate PPE during G-tube handling, allowing medical tubing to touch the floor, and not labeling oxygen humidifier bottles. These actions put residents at risk of infection, as confirmed by staff interviews and observations.
A resident with severe cognitive impairment was observed with bedrails in use without a physician's order or informed consent from the responsible party (RP). The facility's policy required informed consent before using bedrails, but the RP was not informed of the risks and benefits, violating their right to make an informed decision.
A resident with severe cognitive impairment and multiple health issues was found with her call light out of reach, preventing her from communicating with staff. Despite care plan interventions requiring the call light to be accessible, it was positioned above her head, leading to distress as she was unable to request assistance. An LVN confirmed the importance of the call light being within reach to prevent frustration.
A facility failed to protect a resident's confidential information by not removing identifiable health information from an IV medication bag before disposal. An RN confirmed that RNs were responsible for managing IV therapy and should blacken out resident information before disposal. The facility's policy emphasized the importance of maintaining confidentiality.
Three residents in a shared room experienced dissatisfaction due to old, yellow stains on the ceiling and an unfinished painted wall. Despite a previous water leak being repaired, the staining was not addressed, leading to an unappealing living space. The residents, with various medical conditions and cognitive impairments, expressed their unhappiness with the room's appearance.
The facility failed to conduct timely background criminal checks for four employees, as required by its policy. Interviews and record reviews revealed that checks were either delayed or not conducted at all, contrary to the facility's procedures. This lapse in protocol was acknowledged by the Director of Staff Development.
Two residents in an LTC facility were found to lack person-centered care plans addressing their specific needs. One resident, with severe cognitive impairment and using bedrails, had no care plan for monitoring safety and effectiveness. Another resident, whose primary language was Korean, had no care plan for overcoming language barriers, hindering effective communication. These deficiencies were contrary to the facility's policies on care planning and communication.
A facility failed to meet professional standards of care for three residents. A resident with sleep apnea and COPD did not receive BIPAP therapy as ordered, with nurses falsifying MAR entries. Another resident with multiple health issues did not receive medications and monitoring as prescribed, with missing documentation indicating non-compliance. A third resident's blood sugar was not checked as ordered, with no documentation to confirm the task was completed.
The facility failed to provide communication aids for two residents who did not speak English, impacting their ability to communicate needs. A resident who spoke Korean and another who spoke Spanish were not given communication boards, despite their medical conditions and care plans indicating the need for such aids. Staff interviews confirmed the absence of these aids, contrary to the facility's policy on effective communication.
A resident with a history of breast cancer reported a new bump under her breast and requested a mammogram, but the LTC facility failed to schedule the appointment despite a physician's order. The resident, who had chronic kidney disease, type 2 diabetes, and major depressive disorder, was frustrated by the lack of follow-up. The nursing department was responsible for scheduling the mammogram based on the resident's insurance, but this was not done, violating the facility's policy on assisting residents with follow-up appointments.
A long-term care facility failed to properly manage pressure ulcer prevention and care for three residents. One resident with a Stage IV pressure ulcer did not receive adequate interventions, as necessary padding was often missing, and the care plan lacked specific measures to prevent further skin breakdown. Additionally, two residents had their low air loss mattresses set incorrectly, making them too firm and increasing the risk of pressure ulcers. These deficiencies highlight a failure to adhere to the facility's pressure injury prevention policy.
The facility failed to ensure safe oxygen administration for three residents by not dating nasal cannulas, allowing tubing to touch the floor, and not posting precautionary signs outside rooms. These deficiencies posed risks of respiratory infection and fire hazards, contrary to facility policies.
Failure to Notify PCP of Missed Pain and Diabetes Medications
Penalty
Summary
The facility failed to notify Resident 1’s PCP when prescribed Buprenorphine and Ozempic were not administered. Resident 1 was admitted with an unspecified fracture of the sacrum and had moderate cognitive impairment on the MDS dated 4/2/2026. The MDS also showed the resident needed assistance with ADLs, including setup or clean-up help for personal hygiene, substantial/maximal assistance for bathing, and partial/moderate assistance for rolling and transferring. The MAR for 4/2026 showed that Resident 1 did not receive Buprenorphine on 4/8/2026 and 4/15/2026 and did not receive Ozempic on 4/6/2026, 4/13/2026, 4/20/2026, and 4/27/2026. Nursing progress notes from 4/6/2026 through 4/27/2026 documented only that the medications were on order and did not indicate that the PCP was notified about the missed doses. During interview, the LVN confirmed the missed administrations, and the DON stated that if Buprenorphine and Ozempic were not given, the resident’s blood sugar and pain could not be managed effectively. The DON later stated the progress notes did not show that the PCP had been notified.
Delayed Pain Reassessment After PRN Analgesic Administration
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met when the facility failed to ensure Resident 1’s pain was reassessed in a timely manner after PRN pain medication was administered. Resident 1 was admitted with diagnoses including an unspecified fracture of the sacrum and follow-up care for fracture healing. The MDS dated 4/2/2026 indicated moderate cognitive impairment, setup or clean-up assistance for some ADLs, substantial/maximal assistance for showering/bathing, and partial/moderate assistance for rolling and transferring. The physician ordered Hydromorphone HCl 4 mg by mouth every 4 hours PRN for severe pain. The MAR showed the medication was given on 4/8/2026 at 8:49 p.m. for 9/10 pain and on 4/10/2026 at 7:52 p.m. for 10/10 pain. Progress notes documented pain reassessments at 10:18 p.m. and 11:27 p.m., respectively, which were more than one hour after the medication administrations. During interview, the LVN stated pain should have been reassessed after an hour, and the DON stated it was not acceptable to reassess more than one hour after the medication because the resident’s pain could have been unmanaged.
Missed ordered medications and unverified home medication
Penalty
Summary
The facility failed to ensure that Resident 1’s ordered medications were available and administered as prescribed, and failed to ensure that medication brought to the facility by a family member was verified and authorized before use. Resident 1 was admitted with diagnoses including an unspecified fracture of the sacrum and had moderate cognitive impairment, required assistance with activities of daily living, and needed partial to moderate assistance with mobility and transfers. The resident’s orders included Buprenorphine Transdermal Patch weekly for pain and Ozempic weekly for diabetes management. The Medication Administration Record for April 2026 did not show administration of the Buprenorphine Transdermal Patch on two scheduled dates and did not show administration of Ozempic on four scheduled dates. Progress notes documented that the medications were not given because they were on order. During interview, LVN 1 stated the missing Buprenorphine patch placed the resident at risk for pain and that the missed Ozempic doses placed the resident at risk for issues with blood sugar control. The DON stated the staff did not follow up with the pharmacy regarding the missing medications. Pharmacy staff stated Ozempic was never dispensed because it required a high-cost authorization form that the facility did not provide, and the Buprenorphine patch was never dispensed because the pharmacy did not receive the PCP’s signature and authorization. A box of Buprenorphine patches was brought in by the resident’s family member, but the record did not show PCP approval to continue the medication or verification of the medication brought from home. Facility policy required medications brought from home to be verified by a pharmacist or physician before use, and the medication administration policy required discrepancies to be corrected and reported.
Failure to Revise Fall Risk Care Plan for Non-Compliant Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to revise and individualize a fall risk care plan for a resident who was non-compliant with keeping the bed in the lowest position, as required by the facility’s Fall Prevention Program policy. The resident had diagnoses including hemiplegia and hemiparesis following a stroke, syncope and collapse, and other abnormalities of gait and mobility. An MDS dated 1/13/2026 documented that the resident had clear speech, was usually understood and understands, and required substantial/maximal assistance with toileting, bathing, and lower body dressing. The resident’s care plan, dated 1/20/2025, identified the resident as at risk for falls related to gait/balance problems and a fall at home, and included interventions such as anticipating and meeting needs, placing the call light within reach, encouraging use of the call light, maintaining a safe environment, and keeping the bed in low position at night. However, the care plan did not document that the resident was non-compliant with maintaining the bed in the lowest position, nor that education regarding safety precautions had been provided, despite evidence of ongoing non-compliance. A fall risk assessment dated 2/9/2025 indicated the resident was at risk for falls and had intermittent confusion. Progress notes dated 4/6/2026 at 2:52 p.m. recorded that the resident’s bed was observed elevated, the bed was lowered by staff, and the resident raised the bed again. During an observation and interview at the bedside with the DON, the bed height was approximately 30 inches from the floor, and the DON stated the height was too high and that the resident was non-compliant with instructions to keep the bed low. In a separate interview, the Charge Nurse also stated the resident did not comply with staff instructions and education to maintain the bed in the lowest position. Despite these findings and the facility policy requiring that interventions be monitored for effectiveness and the plan of care revised as needed, the resident’s care plan had not been updated to reflect the non-compliance or additional interventions.
Call lights not kept within reach or matched to resident needs
Penalty
Summary
The facility failed to ensure call lights were within reach or were the proper type for five sampled residents. The deficiency involved Resident 31, Resident 44, Resident 95, Resident 48, and Resident 99, all of whom had care plans or assessments indicating the call light should be accessible and, in some cases, tailored to their needs. The report states the issue had the potential to negatively impact the residents’ psychosocial well-being and result in delayed provision of care and services. Resident 31 had diagnoses including Alzheimer’s disease, dementia, and depression, and the MDS showed moderately impaired cognitive skills and need for moderate assistance with ADLs. The care plan directed staff to provide a safe environment, including having the call light in reach. During observation, the call light was found behind the bed and not within reach, and later it was again observed attached to the back side of the bed while the resident was visibly upset and trying to reach it. Resident 31 stated she needed help using the restroom but could not call the nurse because she could not reach the call light. CNA staff confirmed it was not within reach and stated it should always be placed within reach. Resident 44 had diagnoses including difficulty walking, dementia, hypertensive heart disease with heart failure, acute kidney failure, and multiple vertebral fractures. The MDS and H&P showed severe cognitive impairment, need for assistance with toileting, bathing, transfers, and walking, and that the resident was at risk for falls. The care plan directed staff to place the call light within reach. During observation, the call light was hanging from a wall hook and CNA staff stated it was not within reach. Resident 95 had hemiplegia/hemiparesis following cerebral infarction, aphasia, apraxia, anxiety disorder, and dysphagia, with severe cognitive impairment and dependence for toileting, bathing, dressing, and personal hygiene. The call light was observed hanging behind the resident’s head on the bedpost, and the resident indicated she could not reach it. CNA staff stated it should have been within reach and admitted it had not been returned after care. Resident 48 had contractures of both elbows and wrists, functional quadriplegia, dysphagia, and adult failure to thrive, with severe cognitive impairment and total dependence for ADLs. The care plan required the call light to be within reach and reachable. During observation, a push-button call light was present, but the resident could not activate it because of limited ROM in the elbows and wrists. RN staff later stated the call light was not the most appropriate device and that the resident would have benefitted from a call pad because she could not call or ask for help when needed. Resident 99 had diabetes mellitus, Alzheimer’s disease, dysphagia, schizoaffective disorder, and contractures of the knees and ankles, with severe cognitive impairment and dependence for ADLs. During observation, the call light was found on the floor under the bed. Staff interviews and the DON stated call lights were required to be within residents’ reach and should not be placed on the floor or under the bed.
Failure to Verify Psychotropic Consent With Resident’s Representative
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medication was obtained from and verified with Resident 3’s representative party. Resident 3 was initially admitted to the facility and later readmitted, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease, heart failure, atrial fibrillation, and end stage renal disease. The MDS dated 11/11/2025 indicated the resident’s cognitive skills for daily decision making were moderately impaired and that the resident was dependent on staff for toileting, bathing, and upper and lower body dressing. The H&P dated 11/11/2025 stated Resident 3 did not have the capacity to understand and make medical decisions. A physician order dated 11/18/2025 included Lorazepam 1 mg every six hours as needed for anxiety, and the MAR showed Risperidone 0.5 mg three times daily from 11/18/2025 through 12/10/2025. During interview and record review, the psychotropic consent forms for Risperidone and Lorazepam were found to be dated 11/16/2025 and indicated consent was obtained from Resident 3. The RN stated she was responsible for obtaining verification of informed consent, but because Resident 3 was unable to make medical decisions, consent should have been verified with the resident’s representative party rather than Resident 3.
Failure to Notify Physician of Admission Bruising
Penalty
Summary
The facility failed to notify the resident’s physician of scattered ecchymosis on both arms that were present on admission for one sampled resident, who was admitted with diagnoses including osteomyelitis of the lumbar vertebrae, lumbar discitis, and spondylosis. The resident’s history and physical indicated he had the capacity to understand and make decisions. He was also receiving heparin sodium injections for DVT prophylaxis, and the physician orders did not include monitoring for signs of bleeding. During observation, the resident was seen lying in bed with scattered bruising on his arms, and he stated the bruises developed in the general acute care hospital when he started heparin. The facility’s skin check documented a sacral pressure injury and an open wound to the left upper arm, but did not document the scattered ecchymosis. RN 1 stated the bruising should have been included on the skin check so the physician would be notified, and confirmed the physician was notified only of the pressure injury and open wound, not the ecchymosis. The facility policy required prompt physician notification of changes requiring notification, including circumstances that could require alteration of treatment.
Inaccurate MDS Oral/Dental Status Coding
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one sampled resident, Resident 50, specifically in the oral and dental status section. Resident 50 was admitted and later readmitted to the facility with diagnoses including dysphagia, COPD, and depression. The H&P dated 1/8/2026 indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident’s cognitive skills for daily decision making were intact and that she required supervision or touching assistance for ADLs. The MDS did not indicate that Resident 50 had any oral or dental issues. During observation and interview on 2/24/2026, Resident 50 was seen eating lunch and stated she did not have her upper and bottom natural teeth. In a concurrent interview and record review, the MDS Nurse stated the oral/dental status was coded incorrectly and should have reflected that the resident was edentulous. The MDS Nurse stated the inaccurate assessment did not reflect the resident’s actual oral and dental status and that accuracy was important for outcome measures, quality indicators, and developing an individualized care plan based on the resident’s actual needs.
Inaccurate PASARR Screening for Resident with Serious Mental Illness Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for one sampled resident. Resident 11 was originally admitted to the facility and later readmitted, and the record showed diagnoses of schizoaffective disorder, bipolar disorder, schizophrenia, dementia, anxiety disorder, Parkinson's disease, and unspecified psychosis. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills for daily decision making and dependence for toileting, bathing, dressing, and personal hygiene. The resident's PASARR Level I screening, dated 7/24/2024, identified the resident as negative for serious mental illness or intellectual/developmental disability and indicated that a PASARR Level II evaluation was not required. However, the DON acknowledged that the resident's diagnoses included schizoaffective disorder, bipolar type, bipolar disorder, and schizophrenia, and stated the PASARR should have indicated serious mental illness based on those diagnoses. Interviews showed the Admissions Department obtained and uploaded the PASARR from the hospital, but did not follow up on the screening, while Social Services stated it was not responsible for PASARR screenings. The facility policy stated Social Services, or designee, was responsible for maintaining PASARR status and referring residents when serious mental disorder, intellectual disability, or related condition was identified.
Failure to Develop and Implement Resident Care Plans
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with dysphagia, COPD, depression, and no upper or lower natural teeth. The resident was admitted and readmitted to the facility, had intact cognitive skills for daily decision making, and required supervision or touching assistance with ADLs. During observation, the resident was seen eating lunch in bed and stated she did not have her natural teeth. A review of the medical record showed no care plan addressing the resident’s edentulous status. The MDS nurse stated a care plan should have been developed to address specific interventions related to nutritional needs, safe eating, oral health needs, and monitoring for complications related to the resident’s lack of teeth. The facility also failed to implement interventions for another resident with an indwelling catheter. The resident had diagnoses including obstructive and reflux uropathy, Alzheimer’s disease, and dementia, and required moderate assistance with ADLs. The resident’s care plan directed staff to monitor and document intake and output, but review of the EMR showed no documented urinary output from 1/22/2026 through 2/24/2026. The LVN stated urinary output was required for residents with indwelling catheters to assess urinary function and identify potential complications, and the DON stated the care plan interventions were not implemented.
Failure to Revise Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to revise the comprehensive fall prevention care plan after a resident’s fourth fall. Resident 74 was admitted and readmitted to the facility with diagnoses including muscle weakness, diabetes with poor blood sugar control, hypertensive heart disease, and a UTI. The resident’s MDS dated 12/19/2025 indicated severely impaired cognitive skills for daily decision making, maximal assistance needed for showering, dressing, and taking off footwear, and moderate assistance needed for toileting. Interdisciplinary notes showed three unwitnessed falls on 9/19/2025, 1/5/2026, and 2/9/2026. After another unwitnessed fall on 2/19/2026, the resident’s SBAR note and care plans were reviewed and no revisions had been made to the fall care plan. RN 2 stated the normal process after a fall was to assess the resident, notify the physician, and modify the care plan, but this was not done after the 2/19/2026 fall. The DON also confirmed the care plan had not been revised and stated it should have been reviewed and updated to evaluate current interventions and add measures such as floor mats.
Failure to Provide Needed ADL Assistance and Transfers
Penalty
Summary
The facility failed to ensure staff provided necessary assistance with ADLs for one resident who required help with transfers and dressing. The resident had diagnoses including hemiplegia and hemiparesis following a CVA, muscle weakness, a history of falls, and a Stage 2 pressure ulcer of the sacral region. The resident’s H&P indicated decision-making capacity, while the MDS later showed moderately impaired cognitive skills for daily decision making and documented the resident needed maximal assistance for toileting, bathing, and dressing, and moderate assistance for transfers between bed and toilet. The resident’s care plans identified a need for restorative nursing, PROM and AAROM, mobility support, positioning, and assistance with daily care to promote hygiene, functional mobility, and sitting up in a wheelchair for meals and activities. The ADL Transfer Flow Sheet documented transfers as not applicable on multiple consecutive days. During repeated observations, the resident was found lying in bed awake and alert, wearing a hospital gown and covered with a jacket, and the resident stated staff did not get her out of bed. The resident stated she had been in bed for approximately five months, had only been out of bed twice, wanted to get up and attend activities, and remained in bed every day without getting dressed. During interviews, the resident stated staff told her the nurses were female and unable to get her up, and that she had to wait for two male staff to assist her. The resident also stated staff had previously attempted to use a Hoyer lift incorrectly, causing pain, and after that staff did not attempt to get her up except on two occasions when male staff were available. CNA 3 acknowledged the resident did not get out of bed during the observed period and admitted documenting not applicable instead of resident refused on the ADL flow sheet, and not reporting the refusals to the charge nurse. LVN 5 stated the resident was weight-bearing, could pivot during transfers, required a two-person assist, and had no bedrest order or mobility restriction, and the DON stated that if a resident experienced discomfort with a transfer method, staff should have explored alternative methods and that remaining in bed for extended periods could place the resident at risk for contractures, pressure ulcers, and decline in well-being.
Missing fall mats and seizure padding
Penalty
Summary
The facility failed to ensure bilateral floor mats were in place for a resident with fall precautions. Resident 44 was admitted with diagnoses including difficulty walking, dementia, and multiple vertebral fractures. The resident’s MDS showed severely impaired cognitive skills, moderate assistance needed for toileting and bathing, maximal assistance needed for transfers and walking, and a history of one fall since admission. The H&P identified the resident as at risk for falls and lacking capacity to understand and make decisions, and the fall risk assessment and care plan both identified fall risk with an intervention for bilateral floor mats at the bedside. During observation, Resident 44 was seen sleeping in bed with a fall mat on the right side only, and no mat on the left side. A CNA stated the resident was supposed to have two floor mats and confirmed with the charge nurse that bilateral floor mats were required. An LVN stated the resident was on fall precautions and should have fall mats on both sides of the bed, with the bed in the lowest locked position, and stated that having only one mat could be an issue because the resident could fall from the opposite side of the bed where no mat was in place. The facility also failed to ensure padded grab bars were in place for a resident on seizure precautions. Resident 37 had diagnoses including epilepsy and dementia. The resident’s MDS indicated moderately impaired cognition and need for supervision or touching assistance with several activities of daily living. The H&P stated the resident could make needs known but could not make medical decisions. Observations showed the resident lying in bed with unpadded bilateral grab bars, and an LVN confirmed there was no padding on the grab bars. The resident’s active orders directed staff to apply padded grab bars for seizure precautions, and the LVN and DON stated the resident had a history of seizures and should have padded side rails/grab bars in place to prevent injury during seizure activity.
Foley Catheter Urine Changes Not Reported
Penalty
Summary
Care and services related to urinary Foley catheter management were not provided appropriately for one sampled resident with an indwelling Foley catheter. The resident was admitted and later readmitted to the facility and had diagnoses including dysphagia, bradycardia, hepatic encephalopathy, and quadriplegia. The resident's H&P stated the resident was not able to make medical or financial decisions, and the MDS indicated moderately impaired cognitive skills and dependence for ADLs. A physician order dated 12/3/2025 directed an indwelling Foley catheter size 18 with changes for blockage, leaking, pulled out, or excessive sediment. During interview, an LVN stated normal urine should be yellow, clear, and free from cloudiness, sediment, blood, or foul odor, and that the particles observed in the urine were most likely sediment. The LVN stated this was a change in condition that should have triggered a change-of-condition assessment and physician notification per the care plan. The DON also stated that sediment, cloudy urine, or blood were abnormal findings and constituted a change in condition requiring assessment and physician notification, and that residents with quadriplegia may be unable to feel pain or discomfort related to urinary issues and therefore required close monitoring for non-verbal signs and symptoms of infection. The facility policy on notification of changes stated that the facility must promptly inform the resident and physician when there is a change requiring notification, including deterioration in health status or clinical complications.
PICC Dressing and Securement Device Not Changed as Ordered
Penalty
Summary
The facility failed to change one resident’s PICC line dressing and securement device in accordance with the physician’s orders. Resident 138 was admitted with diagnoses that included osteomyelitis of the lumbar vertebrae, lumbar discitis, and spondylosis, and the H&P indicated he had the capacity to understand and make decisions. The order summary required the PICC line securement device and transparent dressing to be changed upon admission and every seven days during the evening shift. During observation, Resident 138 was seen with a PICC line to the right upper arm, and the dressing was dated 2/13/2026. The resident stated the facility had not changed the PICC line dressing since admission. RN 3 stated the dressing and securement device should have been changed upon admission and that they had been in place for 11 days. RN 2 reviewed the IV administration record and stated she had documented dressing and securement device changes, but she had actually only assessed them and did not change them. The DON stated the dressing and securement device should have been changed upon admission, and that leaving them on for 11 days allowed the adhesive to begin to peel off and expose the insertion site to air and bacteria.
Oxygen Therapy Not Given Per Physician Order
Penalty
Summary
Facility staff failed to provide oxygen therapy in accordance with the facility policy and physician orders for Resident 137. Resident 137 was admitted and later readmitted to the facility with diagnoses including acute respiratory failure with hypoxia, pneumonia, and COPD. The resident’s MDS dated 2/7/2026 indicated severely impaired cognitive skills for daily decision making, dependence on staff for multiple activities of daily living, and receipt of oxygen therapy. The H&P dated 1/10/2026 stated the resident did not have the mental capacity to make decisions. During observations on 2/23/2026 and 2/24/2026, Resident 137 was seen lying in bed receiving oxygen at 5 LPM via nasal cannula. During a concurrent observation and interview on 2/24/2026, RN 1 lowered the oxygen to 2 LPM and stated the resident’s oxygen should not have been infusing at 5 LPM. A concurrent record review showed the active order was to administer oxygen at 2 LPM via nasal cannula to maintain oxygen saturation above 92%. RN 1 stated the resident should not be above 2 LPM based on the physician order, and the DON stated licensed nurses were responsible for administering oxygen per physician order. The facility policy stated oxygen is administered under orders of a physician.
Pain Medication Given Outside Ordered Pain Range
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and osteoarthritis. The resident’s MDS indicated intact cognition and use of opioid medication, while the H&P stated the resident did not have the mental capacity to make decisions. The physician’s order directed Norco 10-325 mg by mouth every six hours as needed for moderate pain rated four to six on a 10-point scale, and the care plan directed staff to administer pain medication as ordered. During interview, the resident stated he had pain in his right shoulder, right hip, and lower back, usually rated as an eight out of ten, and said Norco helped for about 30 minutes before the pain returned after two hours, leaving him frustrated because he had to wait four more hours for the next dose. Record review showed the resident was repeatedly given Norco when he reported severe pain rated seven to ten, including multiple administrations for pain levels of 7 or 8 throughout February 2026. The LVN stated the resident regularly requested Norco for pain and usually rated his pain as an eight out of ten, but acknowledged the order was for moderate pain and not severe pain. The LVN stated giving the ordered dose for severe pain would not be as effective in managing the resident’s pain. The DON also stated the resident reported severe pain but was administered Norco for moderate pain, and that this under-medicating would cause the resident to continue to be in pain. The facility’s pain management policy stated pain management must be provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences.
Missing Dialysis Emergency Kit at Bedside
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for a resident receiving hemodialysis. Resident 45 was admitted with end stage renal disease and was ordered to receive hemodialysis on Mondays, Wednesdays, and Fridays. The resident’s MDS indicated cognition was intact and that moderate assistance was required for activities of daily living. The care plan for the resident’s hemodialysis needs, initiated on 11/6/2024 and revised on 1/4/2026, stated the resident must have a bedside hemodialysis emergency kit and that the kit was to be checked every shift. During observations on 2/23/2026 and 2/24/2026, no dialysis E-kit was present or readily accessible at the resident’s bedside. During a concurrent observation and interview on 2/24/2026, an LVN inspected the bedside and surrounding storage areas and also found no dialysis E-kit. The LVN stated residents receiving dialysis should have a dialysis E-kit available at the bedside for immediate use in the event of dialysis-related complications such as bleeding. The DON later stated residents receiving dialysis were at risk for bleeding from the access site and that a dialysis E-kit should be kept at the bedside and readily available in case of an emergency.
RN Competency Issue With PICC Dressing Changes
Penalty
Summary
The facility failed to ensure RN 2 was competent with PICC line dressing changes for one sampled resident, Resident 138. Resident 138 was admitted with diagnoses that included osteomyelitis of the lumbar vertebrae, discitis in the lumbar region, and spondylosis. The resident’s H&P indicated he had the capacity to understand and make decisions. The physician’s orders required the PICC line securement device and transparent dressing to be changed upon admission and then every seven days on the evening shift. During observation on 2/23/2026, Resident 138 was seen with a PICC line in the right upper arm, and the dressing was dated 2/13/2026. The resident stated the PICC line had been inserted during the hospital admission for antibiotic treatment and that the facility had not changed the PICC line dressing since admission. RN 2 later reviewed the resident’s IV Administration Report and stated she had documented PICC dressing and securement device changes on 2/22/2026 and 2/23/2026, but she had not actually changed them. RN 2 also stated she was confused about the facility’s IV Therapy policy and thought it applied to all IVs, including PICC lines, and she realized it was not relevant to PICC dressing changes because only PIV sites were changed every 72 hours. The facility’s records showed RN 2 had attended an in-service on IV maintenance, tubing, site checks, and PICC/midline dressing changes. The DON stated PICC lines were to be changed upon admission and every seven days, and that PICC care differed from PIV care because PIV sites were changed every 72 hours while PICC dressing changes were done per order. The DON also stated RN 2’s competency with PICC care was important to ensure the resident’s PICC line dressing was changed on time to prevent bloodstream infection.
Failure to Monitor for Bleeding Signs with Heparin Therapy
Penalty
Summary
The facility failed to monitor signs and symptoms of bleeding for one of five sampled residents who was receiving heparin. Resident 138 was admitted with diagnoses that included osteomyelitis of the vertebra in the lumbar region, discitis in the lumbar region, and spondylosis. The resident’s H&P dated 2/20/2026 indicated the resident had the capacity to understand and make decisions. The active order summary on 2/25/2026 showed heparin sodium injection 1000 units/mL, 0.5 mL subcutaneously two times a day for DVT prophylaxis. During a concurrent interview and record review on 2/24/2026, LVN 2 reviewed the resident’s orders and stated there were no orders to monitor for signs of bleeding related to heparin. LVN 2 stated the resident was on heparin therapy to prevent blood clots and that heparin increased the resident’s risk for bleeding. During an interview on 2/25/2026, the DON stated the resident was at high risk for bleeding and should have been monitored every shift for signs of bleeding. The DON identified hematuria, gastrointestinal bleed, nose bleeds, and other signs of internal bleeding as symptoms that would require quick intervention. The facility policy titled High Risk Medications- Anticoagulants stated the resident’s plan of care shall alert staff to monitor for adverse consequences.
Medication Administration Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication errors when medications were administered outside of ordered hold parameters. Resident 4 had diagnoses including hemiplegia and hemiparesis following cerebral infarction and hypertensive heart disease with heart failure. An order dated 1/11/2026 directed staff to give midodrine 5 mg by mouth three times daily for hypotension and to hold the medication if systolic blood pressure was greater than 110 mm Hg. Review of the MAR showed midodrine was administered multiple times when the resident’s systolic blood pressure was above the ordered limit, including repeated administrations in January and February 2026. The LVN stated she was responsible for checking the blood pressure and hold parameters before giving the medication and acknowledged that she administered midodrine when it should have been held. Resident 3 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease, heart failure, atrial fibrillation, and end stage renal disease. An order dated 1/28/2026 directed metoprolol 25 mg by mouth every six hours and to hold it if systolic blood pressure was less than 110 mm Hg or heart rate was less than 60 bpm. Review of the MAR showed metoprolol was administered on four occasions when the heart rate was below the ordered parameter, including 1/10/2026, 2/16/2026, 2/19/2026, and 2/21/2026. The MAR did not include additional documentation explaining why the medication was given outside the parameters. During interviews, nursing staff stated that midodrine should be held when blood pressure was above the ordered limit and that metoprolol should be held when the resident’s vital signs were outside the ordered parameters. The DON stated midodrine was to be held if systolic blood pressure was outside the parameters, and the RN stated metoprolol given outside the parameters placed the resident at risk for slowed heart rate or cardiac arrest. Facility policy stated that vital signs should be obtained and recorded when applicable and medications should be held for vital signs outside the physician’s prescribed parameters.
Incomplete IV and PICC Line Documentation
Penalty
Summary
The facility failed to ensure licensed nurses accurately and completely documented the administration of IV antibiotics and the PICC line dressing change for two residents. One resident was admitted with acute osteomyelitis of the right tibia and fibula and infection and inflammatory reaction due to an internal right knee prosthesis. That resident’s MDS indicated moderately impaired cognition and need for moderate assistance with toileting, showering, and upper body dressing. The order summary included IV Amikacin once daily, IV Tigecycline every 12 hours, IV Cefoxitin every 12 hours, and IV saline flushes before and after IV doses every shift. During interview and record review, the DON stated she was the RN assigned on 1/3/2026 and did not document the morning IV antibiotic doses, explaining she was busy and forgot to document the administration. The IV MAR was left blank for Amikacin at 9:00 a.m., Tigecycline at 8:00 a.m. and 8:00 p.m., Tigecycline at 8:00 p.m. on 2/20/2026, an IV flush during the 11 p.m. to 7 a.m. shift on 2/21/2026, and Cefoxitin at 6:00 a.m. on 2/22/2026. The DON stated accurate documentation was needed to show treatments were completed as ordered and to reflect the care provided, and that missing documentation could affect peak and trough monitoring for Amikacin. A second resident was admitted with osteomyelitis of the lumbar vertebra, lumbar discitis, and spondylosis, and the H&P stated the resident had capacity to understand and make decisions. The order summary directed that the PICC line securement device and transparent dressing be changed on admission and every seven days during the evening shift. During observation, the PICC dressing was dated 2/13/2026, and the resident stated no one had changed the dressing since admission. RN 2 later stated she had documented PICC dressing and securement device changes on 2/22/2026 and 2/23/2026, but she had only assessed the site and had not actually changed the dressing or securement device. The DON stated the IV administration record was intended to communicate the accurate date the PICC dressing and securement device were changed, and that the resident’s dressing and securement device were not changed as documented.
Foley Drainage Bag Left Touching Floor
Penalty
Summary
The facility failed to implement infection control practices for one resident with an indwelling Foley catheter when the catheter drainage bag was observed touching the floor. Resident 7 was admitted and later readmitted to the facility and had diagnoses including BPH, dementia, DM, and CKD. The resident’s MDS indicated cognition was intact and that the resident required maximum assistance with ADLs. The care plan for the indwelling Foley catheter directed that the catheter be kept below the level of the bladder and that the resident have no signs or symptoms of urinary infection. During observations on 2/23/2026 and 2/24/2026, Resident 7 was lying in bed with the catheter drainage bag on the right side of the bed and touching the floor. During a concurrent observation and interview, an LVN stated the drainage bag should be kept off the floor and below the level of the bladder to prevent contamination and backflow, and that the bag should not have been touching the floor because of infection control. The DON later stated the drainage bag should be kept off the floor and placed in a clean basin when the resident was in bed, and that failing to keep it off the floor exposed it to contamination.
Failure to Notify Physician and Responsible Party of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and the responsible party of a change of condition related to abnormal lab results for one of five sampled residents. The resident had diagnoses including mild protein-calorie malnutrition and a urinary tract infection, and was documented as lacking capacity to make medical decisions, with severe cognitive impairment and dependence on staff for ADLs. A physician’s order directed that STAT labs, including a CBC, CMP, and urine culture and sensitivity, be obtained. The lab report from that testing showed an elevated WBC count of 15,200 cells/µL, above the normal reference range of 4,000–10,000 cells/µL. Review of the SBAR communication form for that date showed that the physician and family were informed of the resident’s weight loss, but there was no documentation that the physician or responsible party were notified of the elevated WBC or that a change of condition (COC) was completed. During interviews, an LVN acknowledged that the WBC was elevated, that no COC was completed, and that the physician and responsible party should have been notified. An RN stated that any abnormal lab results should be reported to the physician and documented as a COC, and that the resident had a change from baseline labs warranting such action. The DON stated that nurses must complete a COC when labs are abnormal and notify the physician and responsible party so all are aware of the abnormal results. The facility’s “Notice of Changes” policy indicated the facility must inform the physician and/or family or legal representative when there is a significant change in the resident’s condition, such as deterioration in health, mental, or psychosocial status, which did not occur in this case regarding the elevated WBC.
Failure to Maintain Cleanliness During Stage 4 Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves a failure to follow proper infection control practices during pressure injury wound care for Resident 2, who was admitted with a stage 4 pressure injury to the sacrococcygeal area and osteomyelitis of the vertebra, sacral, and sacrococcygeal region. During an observed wound care procedure, the LVN performed a dressing change while the resident was wearing a soiled incontinence brief containing a small amount of brown feces. The LVN removed the old dressing, cleansed the wound with normal saline, completed the wound care, and then replaced the same soiled brief on the resident, stating that the brief was dirty with stool but that she would wait for a CNA to change it later. Resident 2’s records showed that the resident had decision-making capacity, no cognitive impairment, and was dependent on staff for ADLs including toileting and personal hygiene. The care plan directed staff to keep the resident’s skin clean and provide skin care per facility guidelines, and the physician’s order specified daily cleansing and dressing of the stage 4 pressure injury. Facility staff, including the LVN, RN, and DON, acknowledged that residents should be cleaned of stool and urine and provided with a clean brief before wound care to prevent contamination of the pressure injury. The facility’s pressure injury prevention and management policy stated that treatment and services are to be provided to heal pressure injuries and prevent infection, including minimizing exposure to moisture and keeping skin clean, especially from fecal contamination.
Failure to Provide Timely 1:1 Feeding Assistance and Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide required 1:1 feeding assistance and timely meal support to a resident identified as being at risk for malnutrition. During a noon meal observation in the resident’s room, the resident was positioned in high Fowler’s with a towel placed around the chest and an open meal tray set on the bedside table. When asked, the resident opened his eyes, nodded that he wanted to eat, and verbally stated he needed help eating, but no CNA was present to assist. The tray remained open and unattended in front of the resident for approximately 16 minutes before any staff entered the room to help. When CNA 1, who stated the resident was not on her assignment, entered the room, she indicated she could assist and provided one spoonful of food before leaving to get water, then returned several minutes later to resume feeding. CNA 1 acknowledged that the resident required 1:1 feeding assistance and that leaving a tray open for a long time could cause the food to become cold, which she stated was not acceptable. Review of the resident’s records showed diagnoses including anemia, muscle weakness, and oropharyngeal dysphagia, with a history and physical indicating capacity to understand and make decisions, and an MDS documenting severe cognitive impairment and dependence on staff for ADLs, with partial/moderate assistance needed for eating. Physician’s orders and the nutritional care plan both specified that the resident was a 1:1 feeder and required 1:1 feeding assistance. CNA 3, who was assigned to the resident on the day of the observation, reported that her practice was to pass trays to other residents first and then bring trays to residents needing 1:1 feeding. She stated that she placed a towel on the resident, opened the meal tray in front of him, observed him open his eyes, and then left the room to pass other trays, intending to return in about 10 minutes but did not check back or return to see if he was eating. CNA 3 acknowledged that leaving the tray open could cause the food to get cold and that it was not acceptable to leave a tray unattended for 20 minutes in front of a resident who could not eat independently. RN 1 and the DON both stated that residents requiring 1:1 feeding should not have trays left in front of them without assistance, and the facility’s “Meal Supervision and Assistance” policy specified that meals should not be served until the attendant is ready to assist the resident.
Failure to Provide Adequate Linens and Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two of six sampled residents by not ensuring the availability of sufficient linens, incontinent pads, towels, and blankets. Multiple observations revealed that linen storage stations and carts were repeatedly found without essential items such as blankets, incontinent pads, towels, and sheets at various times of the day and night. Staff interviews confirmed that linen shortages occurred, particularly at the start of shifts and during nighttime hours, resulting in residents having to wait for clean linens to be delivered from the laundry department. One resident, with diagnoses including gait disturbance, spondylosis, and COPD, required substantial to maximum assistance with activities of daily living (ADLs) and reported that only their diaper was changed during nighttime care, not the sheets or blankets. The resident expressed a desire for fresh and clean blankets. Another resident, with hemiplegia, metabolic encephalopathy, and diabetes, was dependent on staff for ADLs and reported that nurses ran out of sheets and towels during the night, leading to situations where only the diaper was changed and not the sheets, resulting in discomfort from sweaty sheets. Staff interviews corroborated the residents' accounts, with laundry and nursing staff acknowledging the importance of having adequate linens available for resident care and comfort. The facility's policies required the provision and maintenance of clean bed and bath linens, but the observed and reported shortages indicated a failure to meet these standards, directly impacting the residents' environment and care.
Failure to Assess and Treat Resident After Scabies Exposure
Penalty
Summary
The facility failed to assess and treat a resident after exposure to scabies, following the positive diagnosis of the resident's roommate. Despite the resident's history of diabetes mellitus and anxiety disorder, as well as impaired cognitive skills and dependence on staff for personal care, there was no documented skin assessment in the medical record. The resident reported persistent itching and a rash, which she identified as scabies, and stated that staff did not assess her skin or address her symptoms. Observation confirmed the presence of a red rash, and the resident indicated she had informed staff of her condition. Interviews with staff revealed that the treatment nurse was not aware of the resident's skin issues and had not been notified of the rash, despite acknowledging that monitoring should have begun after the roommate's positive scabies result. The infection preventionist nurse admitted to not assessing or isolating the exposed resident, and the DON confirmed that exposed residents should be isolated and assessed. The facility's policy required assessment and isolation of residents exposed to scabies, but these procedures were not followed, resulting in the resident experiencing ongoing discomfort and an increased risk of transmission.
Medication Administration Exceeds Recommended Dose
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes mellitus, osteoporosis, and muscle weakness, was administered Alendronate Sodium at a dosage exceeding the manufacturer's recommended frequency. The physician's order was incorrectly entered as a daily administration of 70 mg, rather than the intended weekly dose. This error was not identified by the nursing staff, despite medication alerts and packaging instructions indicating the correct weekly dosing schedule. The resident received the medication on three separate days within a week, as documented in the Medication Administration Record. The error was further confirmed through interviews with the resident, who reported receiving the medication more frequently than prescribed, and with the pharmacist, who stated that the pharmacy only supplied four tablets and the packaging clearly indicated weekly dosing. The pharmacist also noted that exceeding the recommended dose could result in adverse effects. Interviews with the DON and a registered nurse revealed that the medication alert indicating the excessive dosage was overlooked, and the order was not clarified with the nurse practitioner or physician until after the error was discovered. The facility's policy required medications to be administered according to physician orders and manufacturer specifications, but this protocol was not followed in this instance.
Plan Of Correction
Determines that the disputed findings are relied upon in a manner adverse to the interests of the provider either by the governmental agencies or third party. Corrective action for residents found to have been affected by this deficiency: - The Physician and/or NP of resident #1 was notified of the medication administration error on May 18, 2025, and the order was clarified. - The Physician was contacted on May 18, 2025, and labs were ordered for resident #1 to rule out any abnormality. Resident's Calcium level was normal, and no other abnormalities were noted. - An order was also obtained for monitoring of Dysphagia. - DON provided 1:1 education with the licensed nurse on May 19, 2025. Identification of others at risk: - DON and/or Designee audited residents with Alendronate 70 mg on May 20, 2025, and no other resident was affected by this practice. Measures that will be put into place to ensure that this deficiency does not recur: - Starting on May 19, 2025, the Director of Nursing initiated in-service with Licensed Nurses on the facility's policy titled "Medication Errors" and "Medication Administration." - Med Pass competency was initiated by the DON/Designee on May 29, 2025, and will be continued by the DSD/Designee on med pass observation to at least one (1) licensed nurse per month for three (3) months. Findings will be reported to the Director of Nursing for follow-up. - Pharmacy Nurse Consultant will perform med pass observation during their monthly scheduled visit. Findings will be reported to the Director of Nursing for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: - The Director of Nursing will review all new residents with Alendronate orders to ensure orders are transcribed accurately for three (3) months. - The Director of Nursing will provide a summary trend analysis of the facility's compliance on a monthly basis for three months to the QA committee for further evaluation and recommendations until substantial compliance is sustained.
Failure to Prevent Elopement and Provide Supervision Results in Resident Injury
Penalty
Summary
A facility failed to provide adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease and dementia and was assessed as lacking capacity for decision-making, had a documented history of wandering and previous attempts to leave the facility without informing staff. The resident's care plan specifically identified the risk for elopement and included interventions such as anticipating needs, encouraging activity participation, and frequent visual checks for safety. Despite these documented risks and interventions, the resident was left unsupervised in a wheelchair in the hallway after being assisted to the restroom, and staff did not maintain the required level of monitoring. On the day of the incident, the resident was observed propelling herself down the hallway and was later seen in the front lobby. The facility's front exit door was left wide open and unmonitored when the receptionist left her post unattended to use the restroom. No staff were present to observe or redirect the resident, and the door alarm was not responded to in a timely manner. The resident exited the facility unsupervised, traveled to an adjacent property, and fell from her wheelchair onto the street. The incident was not immediately noticed by staff, and the resident was found by a passerby who called emergency services. As a result of the elopement and fall, the resident sustained multiple injuries, including fractures to the nose, jaw, and ribs, a laceration to the lip, a hematoma, and damage to dental implants. Interviews with staff and review of records confirmed that the facility did not follow its own policies and procedures regarding supervision, elopement prevention, and door monitoring. The lack of supervision and failure to ensure the function and monitoring of exit doors directly led to the resident's elopement and subsequent injuries.
Removal Plan
- Resident 1 was placed on 1:1 supervision with staff educated on supervision until a safe plan is determined by the IDT.
- In-service education was provided to the weekend and evening receptionist regarding not leaving their post unattended.
- In-service education regarding monitoring/supervision, wandering, and elopement policy was provided to the receptionist and facility staff on shift, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel.
- Facility doors were checked for appropriate function by the Maintenance Director.
- A head count of all in-house residents was initiated and all residents were accounted for.
- Elopement assessments were completed on all residents by the DON/designee.
- Two residents identified at risk for elopement were reviewed by the DON/designee for appropriate care plan interventions.
- In-service education regarding wandering and elopement was provided to facility staff, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel. Staff on leave or PRN will be in-serviced on their next scheduled shift.
- An IDT meeting was conducted for the two residents identified as at risk for elopement.
- The DON or designee will audit new admissions with elopement risks and ensure appropriate interventions are in place.
- The SSD or designee will review all new admissions to ensure an elopement risk assessment has been completed, and those residents identified at risk are updated in the Elopement binder. Audits will be conducted until substantial compliance is achieved.
- New hires will receive education on wandering, elopement, and resident safety by the DON, SSD, or designee(s) upon hire and annually thereafter. Ongoing in-service trainings regarding wandering, elopement, resident safety, and resident monitoring/supervision will be performed.
- Elopement risk binders were reviewed and updated by the DON and Administrator. Binders are available at each nursing station and reception area, updated by the SSD with oversight by the DON.
- Elopement code drills were initiated on all shifts and will continue by Administrator/DON and/or DSD.
- A check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. Frequency increased.
- A check of facility doors and alarms will be performed by the Maintenance Department until substantial compliance is achieved. Any findings will be corrected immediately and trends reported to the QA/QAPI Committee.
- The QAPI Committee will review and discuss elopement and supervision for all residents during QAPI meetings to determine effectiveness and provide feedback and program modification until compliance is maintained.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for 8 out of 9 residents in the affected rooms. Observations revealed that the activity room had ceiling vents covered in dust, with strands hanging over them, and walls with dried food spots. In several residents' rooms, paint was peeling off the walls behind headboards, and one room had a plastic baseboard sticking out from the wall. These conditions were confirmed by interviews with housekeeping and maintenance staff, who acknowledged the importance of cleanliness and maintenance for resident safety and hygiene. Interviews with staff revealed that deep cleaning was conducted monthly, but issues such as dirty walls and broken fixtures were not addressed promptly. The housekeeping staff stated that they informed the supervisor about maintenance issues, but these were not resolved in a timely manner. The maintenance supervisor and director of nursing both emphasized the need for a clean and safe environment, as outlined in the facility's policies and procedures. However, the facility's failure to adhere to these policies resulted in unsanitary conditions and potential safety hazards for the residents.
Failure to Ensure Resident Swallowed Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, swallowed scheduled stool softener medications during medication administration. This oversight was observed when two small, white, circular pills were found inside a plastic cup on Resident 3's bedside table. Resident 3, who was admitted with diagnoses including primary generalized osteoarthritis and chronic obstructive pulmonary disease, had moderate cognitive impairment and required substantial assistance with activities of daily living. The physician's orders for Resident 3 included taking Docusate Sodium Oral Tablet 100 mg, two tablets by mouth twice a day for bowel management. During an interview, a Licensed Vocational Nurse (LVN) confirmed that Resident 3 did not take the pills and acknowledged that the facility did not ensure the resident took all her medications. Another LVN stated that it was inappropriate to leave medication at a resident's bedside, as it could lead to missed doses or other residents taking medication not prescribed to them. The Director of Nursing (DON) confirmed that nurses should ensure residents ingest or swallow all medications during administration and that it was not acceptable to leave pills at a resident's bedside. The facility's policy on medication administration required licensed nurses to observe residents consuming their medication.
Failure to Initiate Baseline Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to initiate a baseline care plan for a resident with a history of falls, which is a requirement to be completed within 48 hours of admission. The resident, who was admitted with diagnoses including contusion, laceration, hemorrhage of the brainstem, and repeated falls, did not have a baseline care plan indicating a high risk for falls or interventions to prevent further incidents. This omission was identified during a review of the resident's records, which showed that the baseline care plan dated several days after admission lacked necessary fall prevention measures. The deficiency was further highlighted when the resident experienced an unwitnessed fall in the bathroom, resulting in skin tears and a hospital transfer for evaluation. Interviews with facility staff, including an LVN and the DON, confirmed that the absence of a baseline care plan for a resident with a history of falls placed the resident at risk for repeated falls. The facility's policy mandates the development of a resident-centered baseline care plan within 48 hours of admission, which was not adhered to in this case.
Failure to Implement Gastrostomy Tube Orders and Protocols
Penalty
Summary
The facility failed to implement gastrostomy tube (GT) orders in accordance with its policy for four residents. Resident 56 received the incorrect GT feeding formula, Glucerna 1.2 instead of the prescribed Glucerna 1.5, which was intended to manage their diabetes and nutritional needs. This error was identified during an observation and confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the mistake and the potential impact on the resident's blood sugar and nutritional status. For Residents 81, 41, and 35, the facility did not adhere to the prescribed protocol for flushing the GT before and after medication administration. Observations revealed that medications were administered without the required flushing, which could lead to medication errors and potential clogging of the GT. LVNs involved in the administration process admitted to not following the correct procedures, citing insufficient training as a reason for the oversight. The facility's policies and procedures were not followed, as evidenced by the discrepancies between the prescribed orders and the actual practices observed. The Director of Staff Development and the Regional Nurse Consultant confirmed that the standard practice was not adhered to, and there was a lack of proper training documentation for some of the LVNs involved. This failure to follow established protocols and ensure staff competency in GT management posed significant risks to the residents' health and safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 25.81% error rate during medication administration for two residents. Resident 81 and Resident 41 were both affected by improper medication administration through their gastrostomy tubes (GT). The errors were identified during observations and interviews with the nursing staff responsible for administering the medications. Resident 81, who has a history of hemiplegia, hemiparesis, and dysphagia, was not administered medications as per the physician's orders. The Licensed Vocational Nurse (LVN) responsible for Resident 81's care did not flush the GT before and after each medication, as required. Additionally, the medications were not mixed adequately, leading to residual medication remaining in the cups. The LVN admitted to insufficient training in GT medication administration, which contributed to the errors. Similarly, Resident 41, diagnosed with epilepsy and dysphagia, also experienced medication administration errors. The LVN did not flush the GT before or after administering medications, contrary to the facility's policy and physician's orders. The LVN acknowledged the oversight and the need for additional water to ensure proper medication delivery. The Regional Nurse Consultant confirmed that the standard practice was not followed, which could lead to clogged GTs and incomplete medication delivery.
Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 36 and Resident 55, were free from significant medication errors, specifically concerning the administration of insulin. Resident 36, who has Type II diabetes mellitus and hypertension, was administered Humulin R insulin at 11:30 AM daily, despite the resident's enteral feeding being turned off from 9 AM to 1 PM. This administration was not in accordance with the physician's order to administer the insulin before meals, nor was it aligned with the manufacturer's specifications. The facility did not document any notification to the physician regarding this discrepancy, nor was there any clarification of the order, leading to repeated administration errors over a period of time. Resident 55, also diagnosed with Type II diabetes mellitus, was administered Insulin Aspart before meals as per a sliding scale. However, the insulin was given significantly earlier than the meal was provided, with an observed instance where the insulin was administered over an hour before the resident received lunch. This was contrary to the manufacturer's instructions to administer Insulin Aspart within 5-10 minutes before a meal. The facility's failure to coordinate insulin administration with meal times was not documented or addressed, and there was no evidence of physician notification or order clarification. The facility's policy on the timely administration of insulin was not adhered to, as evidenced by the lack of coordination between insulin administration and meal times for both residents. Interviews with staff, including the Director of Staff Development and the Regional Nurse Consultant, highlighted the importance of administering fast-acting insulins like Humulin R and Insulin Aspart in conjunction with meals to prevent hypoglycemia. The absence of insulin training on the facility's checklist for licensed nurses further contributed to the medication errors observed.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals for five residents, leading to potential health risks. An unopened vial of Insulin Lispro for Resident 2 was found unrefrigerated in a medication cart, contrary to the manufacturer's requirement to refrigerate until opened. Additionally, a vial of Humulin R for Resident 17 was stored past its expiration date, which should have been discarded according to the manufacturer's guidelines. Controlled medications requiring refrigeration, such as Lorazepam Oral Solution for Residents 15 and 42, were improperly stored at room temperature instead of being refrigerated as per the manufacturer's instructions. Furthermore, an oral inhaler, Trelegy Ellipta, for Resident 92 was opened without being labeled with an open date, which is necessary to track its shortened expiration period once opened. The facility also failed to follow its policy for the destruction of discontinued and expired non-controlled medications. The process was not witnessed by a second nurse, as required, and documentation was incomplete, with only one nurse's initials recorded. This lack of adherence to proper procedures for medication storage and disposal increased the risk of residents receiving ineffective or potentially harmful medications.
Deficient Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. The temperature for Refrigerator 1 was not logged for two consecutive days, which was confirmed by the Dietary Supervisor (DS) during an interview. The DS acknowledged that refrigerator temperatures were supposed to be checked daily to ensure they were functioning correctly and to prevent food spoilage. The absence of temperature records for those days meant that any potential issues with the refrigerator's temperature could go unnoticed, risking the spoilage of produce stored inside. Additionally, a container of grated cheese inside Refrigerator 2 was found without a label indicating the product name, open date, and use by date. The DS admitted that the cheese had been transferred into the container without proper labeling, which could lead to confusion and the use of expired products. Furthermore, an open bag of tortillas was observed to be ripped and not stored in a tight-lidded container, as required. The DS stated that such items should be placed in sealable containers to prevent contamination. These practices were in violation of the facility's policies and procedures, which require daily temperature logging and proper labeling and storage of food items.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices for several residents, leading to potential risks of infection. Licensed nurses did not adhere to Enhanced Barrier Precautions when handling a gastrostomy tube for a resident. Despite signage indicating the need for gowns and gloves, a nurse only wore gloves and failed to don a gown while administering medication through the G-tube. This oversight was confirmed through interviews with various staff members, including the Infection Preventionist Nurse and the Director of Staff Development, who emphasized the necessity of wearing gowns during such procedures to prevent infection transmission. In another instance, the facility did not maintain proper hygiene standards for medical equipment. The nasal cannula tubing for a resident was repeatedly observed touching the floor over several days, posing a risk of contamination. Similarly, the indwelling urinary catheter tubing for two residents was also found touching the floor, which could lead to infections. Staff interviews highlighted the importance of ensuring that such tubing does not contact the floor as part of infection prevention practices. Additional deficiencies included an unlabeled oxygen humidifier bottle for a resident, which should have been dated to ensure timely changes for infection control. Furthermore, a resident's bed linens were placed back on the bed after falling to the floor, contrary to the facility's policy on handling soiled linens. These practices were inconsistent with the facility's infection prevention and control program, which mandates proper handling and separation of clean and soiled linens, as well as adherence to enhanced barrier precautions for high-contact resident care activities.
Failure to Obtain Informed Consent for Bedrail Use
Penalty
Summary
The facility failed to ensure that the responsible party (RP) of a resident was informed in advance about the risks and benefits of using bedrails. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed with bilateral bedrails up. However, there was no physician's order for the use of bedrails, nor was there any documentation indicating that the RP had consented to their use. This lack of informed consent violated the RP's right to make an informed decision regarding the resident's care. Interviews with the registered nurse (RN) and the Director of Nursing (DON) revealed that the facility's policy required informed consent from the resident or their RP before bedrails could be used. The RN acknowledged that the bedrails should not have been applied without a physician's order and the RP's consent. The DON confirmed that an assessment for the need and risk of bedrails should have been completed, and the RP should have been informed of the associated risks. The facility's policy on the proper use of bedrails also emphasized the necessity of obtaining informed consent prior to their installation and use.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which prevented the resident from effectively communicating with staff. The resident, who had multiple diagnoses including muscle weakness, anxiety disorder, dementia, and functional quadriplegia, was observed lying in bed with the call light positioned above her head, out of reach. The resident expressed distress by yelling that she was cold and needed to be covered up, indicating her inability to use the call light to request assistance. The resident's care plan included interventions to anticipate and meet her needs, including having a call light within reach, but this was not adhered to. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependence on assistance for daily activities. The facility's policy on fall prevention required that call lights and frequently used items be within reach, but this was not followed in the resident's case. An interview with an LVN confirmed the importance of having the call light within reach to prevent the resident from becoming frustrated and angry when her needs were unmet. The failure to ensure the call light was accessible was a deficiency in the facility's care for the resident.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by not removing identifiable health information from an intravenous (IV) medication bag before disposing of it in the trash. During an observation, an empty IV medication bag with identifiable health information was found in the trash can in a resident's room. This oversight was noted for a resident who had been admitted with multiple diagnoses, including diabetes mellitus, dysphagia, sepsis, and dementia. The resident's cognitive skills for daily decision-making were severely impaired, as indicated in their Minimum Data Set (MDS). A registered nurse (RN) confirmed that only RNs were responsible for managing IV therapy and were required to blacken out the resident's information on the IV medication bag before disposal. The RN acknowledged that it was unacceptable to find the IV medication bag with identifiable information in the trash and emphasized the importance of protecting the resident's dignity and confidentiality. The facility's policy on confidentiality, revised in December 2022, stated the importance of securing and maintaining the confidentiality of residents' personal and medical records.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for three residents who shared a room with visible old, yellow stains on the ceiling and an unfinished painted wall. During observations, the ceiling near the door had a yellow stain, and the wall had an uneven surface and paint color. Interviews with the residents revealed dissatisfaction with the appearance of their living space, with one resident describing the stain as an 'eye sore' and another expressing dislike for the 'ugly' ceiling and wall. The residents involved had various medical conditions, including chronic kidney disease, depression, type 2 diabetes mellitus, and dementia, with varying levels of cognitive impairment. The Regional Maintenance Director acknowledged that a previous water leak had been repaired, but the staining was not painted over by the former Maintenance Director. The facility's policy on providing a safe and homelike environment was not adhered to, as the necessary repairs were not completed in a timely manner.
Failure to Conduct Timely Background Checks on Employees
Penalty
Summary
The facility failed to conduct background criminal checks for four randomly selected employees prior to hire and upon completion of orientation, as required by the facility's policy. This deficiency was identified during interviews and record reviews conducted with the Director of Staff Development (DSD). The review revealed that a Registered Nurse (RN) hired in 2003 did not have a background check until 2007. Additionally, a Licensed Vocational Nurse (LVN) hired in 2023 had their background check completed after their orientation, and two other LVNs hired in 2024 had no background checks conducted upon hire. The facility's policy, revised in January 2024, mandates that criminal conviction record checks be conducted on all personnel applying for employment, in compliance with state and federal regulations. These checks are to be completed after a contingent offer of employment but before the conclusion of the employee's orientation. The DSD acknowledged that background checks should be done prior to hiring to ensure that individuals with criminal backgrounds are not employed, highlighting a lapse in adherence to the facility's established procedures.
Deficiencies in Care Planning for Residents with Special Needs
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in their care. Resident 331, who was admitted with severe cognitive impairment and multiple diagnoses including sepsis, dementia, and COPD, was observed using bedrails without a corresponding care plan. The absence of a care plan meant there were no documented interventions to monitor the resident's skin, assess the risk of entrapment, or evaluate the effectiveness of the bedrails, potentially compromising the resident's safety and care. Similarly, Resident 66, whose primary language was Korean and who had moderately impaired cognitive skills, did not have a care plan addressing her language barrier. Despite her difficulty in communicating and understanding verbal messages, no communication board or other aids were provided to facilitate effective communication. This oversight could hinder the staff's ability to provide appropriate care and support to the resident, as they might not fully understand her needs or concerns. The facility's policies on the proper use of bedrails and effective communication were not adhered to, as evidenced by the lack of care plans for these residents. The policies required that care plans include measurable objectives and timeframes to meet the residents' needs, which were not implemented in these cases. The failure to develop and implement these care plans could delay the delivery of necessary care and services to the affected residents.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents due to the actions and inactions of licensed nurses. For Resident 14, who was diagnosed with obstructive sleep apnea and COPD, the nurses did not follow the physician's order to provide BIPAP therapy at bedtime. Despite the Medication Administration Record (MAR) indicating that the BIPAP machine was used on several dates, interviews with the resident and nurses revealed that the machine was not provided. The nurses admitted to falsifying the MAR entries, citing reasons such as being in a hurry or not knowing how to use the machine. This failure to provide necessary respiratory support could have led to negative outcomes for the resident. For Resident 30, who had multiple diagnoses including diabetes mellitus, dysphagia, and dementia, the facility failed to administer medications and monitor vital signs as ordered. The MAR for October 2024 showed missing documentation for several physician-ordered tasks, such as evaluating pain, monitoring temperature and oxygen saturation, and administering medications like melatonin and atorvastatin. Interviews confirmed that these tasks were not completed, and the lack of documentation indicated non-compliance with physician orders. This inconsistency in care could have delayed necessary treatment and affected the resident's health. Resident 49, who was diagnosed with diabetes mellitus, hypertension, and anemia, also experienced a lapse in care. The facility did not perform a blood sugar check as ordered on a specific date, and there was no documentation to indicate that the task was completed. The facility's policies and procedures emphasized the importance of accurate and timely documentation, yet these were not followed. The failure to monitor blood sugar levels as ordered could have put the resident at risk for complications related to diabetes management.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure effective communication for two residents who did not speak the dominant language, English. Resident 66, whose primary language is Korean, was admitted with several medical conditions including a fracture, dysphagia, and end-stage renal disease. Despite her moderately impaired cognitive skills and difficulty communicating, no communication board or device was provided to assist her in expressing her needs. Observations revealed that Resident 66 struggled to communicate with staff, leading to frustration and unmet needs, such as requesting orange juice instead of cranberry juice. Similarly, Resident 92, who primarily speaks Spanish, was not provided with a Spanish language communication board as indicated in their care plan. Resident 92 has a history of pulmonary mycobacterial infection, COPD, and chronic respiratory failure, and requires an interpreter for effective communication. Despite these needs, staff were observed speaking English to Resident 92, and no communication board was present at the bedside, potentially delaying necessary care. Interviews with facility staff, including CNAs, LVNs, and RNs, confirmed the absence of communication aids for both residents. Staff acknowledged the importance of providing communication boards to facilitate understanding and prevent delays in care. The facility's policy on effective communication emphasizes accommodating residents' communication needs, yet this was not adhered to in the cases of Residents 66 and 92.
Failure to Schedule Mammogram for Resident with Breast Cancer History
Penalty
Summary
The facility failed to follow up on a mammogram appointment for a resident, resulting in a deficiency. The resident, who had a history of breast cancer, noticed a hard bump under her right breast and informed her healthcare team about it. Despite the physician ordering a mammogram screening in August 2024, the nursing department did not set up an appointment, leaving the resident without the necessary diagnostic follow-up. This oversight led to the resident feeling frustrated with her healthcare team. The resident's medical history included chronic kidney disease stage four, type 2 diabetes mellitus, and major depressive disorder. The resident's cognition was intact, and she had the capacity to understand and make decisions. The Director of Nursing confirmed that the nursing department was responsible for scheduling the mammogram based on the resident's insurance. The facility's policy required staff to assist residents in scheduling and attending follow-up appointments as ordered by the physician, which was not adhered to in this case.
Inadequate Pressure Ulcer Management in LTC Facility
Penalty
Summary
The facility failed to adequately implement pressure ulcer interventions for three residents, leading to deficiencies in care. Resident 82, who was at high risk for pressure ulcer development due to quadriplegia and other conditions, had a Stage IV pressure ulcer that was not properly managed. Despite being educated on the importance of repositioning and using padding to protect bony prominences, Resident 82 preferred to remain in a Geri chair for extended periods, which contributed to the pressure ulcer's persistence. Observations revealed that the necessary padding was often not provided, and the care plan lacked specific interventions to prevent further skin breakdown. Resident 331's low air loss mattress (LALM) was not set to the correct weight, which compromised its effectiveness in preventing pressure ulcers. The mattress was observed to be set at a significantly higher weight than the resident's actual weight, making it too firm and increasing the risk of skin breakdown. The treatment nurse acknowledged the incorrect setting and the potential risk it posed to the resident, who was already at high risk for pressure ulcer development. Similarly, Resident 92's LALM was also set incorrectly, with the weight setting far exceeding the resident's actual weight. This error resulted in a mattress that was too hard, potentially contributing to the resident's existing moisture-associated skin damage. The facility's policy on pressure injury prevention was not adequately followed, as evidenced by the failure to ensure that the LALM settings matched the residents' weights, thereby compromising the intended protective measures against pressure ulcers.
Deficient Oxygen Administration Practices
Penalty
Summary
The facility failed to implement safe oxygen administration practices for three residents, leading to several deficiencies. Resident 14's nasal cannula was not dated with an open date, and the tubing was observed touching the floor on multiple occasions. Additionally, there was no precautionary sign indicating oxygen use outside Resident 14's room. These practices were not in line with the facility's policy, which requires oxygen equipment to be dated and changed weekly, and for precautionary signs to be posted. Resident 54's nasal cannula was also observed touching the floor on several occasions, and there was no sign indicating oxygen use outside their room. Resident 54 had a history of chronic kidney disease and cardiomegaly and was dependent on staff for various activities of daily living. The lack of precautionary signage and improper handling of oxygen equipment posed a risk of respiratory infection and fire hazards. Similarly, Resident 99's room lacked a precautionary sign despite the presence of an oxygen concentrator at the bedside. Resident 99 had a history of respiratory failure, COPD, pulmonary edema, and dementia, and required continuous oxygen for shortness of breath. The absence of a no-smoking sign was acknowledged by a registered nurse as a potential fire risk. The facility's policy mandates that oxygen warning signs be placed on the doors of rooms where oxygen is in use, which was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near La Mirada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Imperial Healthcare Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Whittier Hills Health Care Ctr | 2.3 mi | ★★★★★ | 35 | 0 |
| Dept Of State Hospitals - Metropolitan Snf | 2.9 mi | ★★★★★ | 29 | 2 |
| Whittier Hospital Medical Ctr D/p Snf | 3 mi | ★★★★★ | 1 | 0 |
| Bonita Hills Post Acute | 3 mi | ★★★★★ | 44 | 0 |
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