Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 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 Sunray Healthcare Center during CMS and state inspections, most recent first.
Failure to Properly Respond to Alleged Physical Abuse: A resident with dementia, severe cognitive impairment, and right-hand impairment was allegedly forcefully grabbed by a housekeeper, causing the resident to scream in pain. The RN did not report the allegation to leadership or outside authorities, did not document it in the chart, allowed the housekeeper to remain on duty, and did not ensure separate private interviews. The housekeeper’s abuse prevention training was also overdue.
Unsafe food storage practices were identified when an open bottle of thickened coffee was kept in the reach-in fridge beyond the manufacturer’s 14-day use window after opening, and bulk sugar was stored in bins lined with regular trash bags instead of food-grade liners. The DS confirmed the thickened coffee should have been discarded and acknowledged that trash bags were not appropriate for food storage and could contaminate food.
A resident with a urinary catheter had the drainage bag observed hanging uncovered on the side of the bed with urine visible. TN stated the bag was not covered with a privacy bag and needed to be covered, and the DON confirmed catheter bags should be covered to protect privacy and dignity. The facility’s Dignity policy also stated staff should help keep urinary catheter bags covered.
Incomplete Inventory of Resident Personal Property: A resident with severely impaired cognition and extensive ADL dependence had inconsistent and incomplete clothing and possessions records after multiple admissions/readmissions. The inventory forms alternated between no belongings, belongings at the facility, and see previous inventory instead of listing items in detail, and the resident was observed asking for a bag while the closet and drawer were empty. The DON stated the inventory lists were not properly completed.
A resident admitted with cellulitis and DM had IV antibiotics ordered for bilateral foot cellulitis, but the MDS incorrectly showed no foot skin problems and no antibiotic use. Surveyors observed swollen, red lower limbs and an open wound on the left foot, and the MDS nurse confirmed the cellulitis diagnosis and IV antibiotics were not coded correctly.
Failure to Develop ROM Care Plan: A resident with thrombocytopenia, alcoholic cirrhosis, dysphagia, epilepsy, HTN, and vascular dementia had an order for restorative nursing ROM to both lower extremities, but the MDS nurse confirmed there was no care plan for the ROM treatments. The resident’s MDS showed moderate cognitive impairment and significant ADL and bed mobility assistance needs, while the facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables.
Failure to assist a dependent resident with meals. A resident with severe cognitive impairment, altered mental status, and dysphagia was care planned for staff meal assistance due to aspiration risk, but was observed in bed with a breakfast tray and no staff assisting while unable to feed himself. CNA staff confirmed the resident was dependent for feeding and said the family usually fed him, and the DON stated the resident was dependent on staff for care and activities.
A resident with a urinary catheter had the drainage bag hanging on the side of the bed and touching the floor. TN confirmed the condition and stated the bag should not touch the floor for infection control, and the DON stated the bag should be kept off the floor to protect residents from UTIs. The facility policy also stated catheter tubing and drainage bags should be kept off the floor.
Controlled Medication Documentation Discrepancy: A resident with seizures and severe cognitive impairment received Lacosamide via G-Tube, but the MAR and CDR did not match. The MAR showed two scheduled doses on each of two days, while the CDR lacked documentation for one dose on each day. An LVN and the DON both confirmed the missing CDR entries, and the facility policy required controlled substance records to include the nursing signature and be reconciled with the MAR.
Missing Monthly Pharmacist Medication Regimen Review: A resident with schizophrenia, HTN, and hypothyroidism had an order for risperidone, but the consultant pharmacist’s monthly MRR did not clearly identify the resident’s medication review or document the resident’s response to Risperdal. The DON could not locate a specific MRR for the antipsychotic, and the facility’s policy required a comprehensive monthly pharmacist review of each resident’s medication therapy and chart.
A facility failed to ensure three 3-bed rooms met the required square footage per resident. A room waiver request showed each room measured 231 sq. ft., or 77 sq. ft. per bed, below the 240 sq. ft. minimum for a 3-bed room. Surveyors observed the rooms during tour and noted staff had enough space to provide care, privacy curtains were present, and the rooms had direct corridor access; residents interviewed had no concerns about room size.
A resident with multiple medical conditions, including diverticulitis, muscle weakness, dysphagia, depression, and colostomy status, who was cognitively able to make decisions and required moderate to maximum assistance with ADLs, reported that a CNA providing night-shift care handled them roughly, threw towels onto their chest and colostomy site, and made threatening gestures with closed fists while warning the resident not to speak up. The facility suspended the CNA during an investigation but then allowed the CNA to return to work and provide direct care before receiving the required one-on-one in-service on abuse prevention and resident rights. The QA nurse and DSD confirmed that this abuse-related in-service was not completed until after the CNA had already resumed resident care, contrary to facility policy requiring such training prior to direct-care duties.
A resident with depression and chronic anxiety, who had intact cognition and an order for psychology consult and treatment as needed, reported that a CNA interacted with her in a threatening and aggressive manner, after which she experienced increased nocturnal anxiety, fear of falling asleep, and later stated she did not feel safe. Despite these documented emotional and behavioral changes, no behavioral or change-of-condition assessment was completed, no psychologist notes were present, and the care plan was not revised to address the new behavioral health symptoms. Facility staff, including social services and the MDS coordinator, confirmed that required behavioral assessments were not done, and the DON was unaware of the resident’s expressed lack of safety, contrary to facility policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning.
A resident with severe cognitive impairment, dysphagia, and a full-code status was given a cookie by a visitor despite being on a pureed diet. Shortly afterward, the resident was found pale, unresponsive, not moving, and with food in the mouth. A CNA, an RNA, and an LVN responded but did not assess responsiveness, did not check for a pulse or breathing, and did not initiate CPR as required by facility policy and CPR guidelines. Instead, they focused on performing the Heimlich maneuver and moving the resident between the bed and a chair. CPR was only started after an RT arrived, found no pulse, and directed staff to return the resident to bed and begin resuscitation, resulting in a delay in basic life support for a full-code resident.
A resident with dementia, severe dysphagia, and a pureed gratification diet was care planned as at risk for aspiration but had no specific nursing interventions for dysphagia or diet management. The facility had a policy requiring visitors to inform nursing staff when bringing food and prohibiting sharing food with other residents, but staff did not educate visitors, did not document checks of outside food, and posted no signage about these requirements. A visitor who routinely brought food for another resident was never counseled about restrictions and, during a visit, gave a regular-texture chocolate chip cookie to the cognitively impaired resident on a pureed diet without consulting staff. Staff later found the resident unresponsive with cookie pieces in the mouth, attempted the Heimlich maneuver and CPR, and the resident was pronounced dead by paramedics, demonstrating a failure to prevent unsafe food from entering the resident environment and to provide adequate supervision for a high-aspiration-risk resident.
Surveyors found that the facility failed to develop individualized, person-centered care plans for dysphagia for four residents with documented swallowing disorders, cognitive impairment, and specialized diet or enteral feeding orders. Although each resident had diagnoses such as dysphagia, dementia, aphasia, or prior pneumonitis and required pureed or fortified diets or GT feedings, their care plan reports either lacked dysphagia care plans entirely or listed aspiration risk without any nursing interventions. The DON, an LVN, and the QAN all confirmed that facility policy requires each diagnosis to have a specific care plan with interventions such as diet orders, aspiration precautions, monitoring for coughing and shortness of breath, swallow evaluations by speech therapy, and education, and acknowledged that these dysphagia care plans were not initiated on admission. Staff stated that without such care plans, nurses would not know the specific treatment and interventions needed, creating a potential increased risk for aspiration and pneumonia.
Controlled medication accountability records were incomplete in the medication room. Four eKITs containing controlled medications were not reconciled at each shift change, and seven Antibiotic or Controlled Drug Record logs awaiting disposal lacked the required DON or RN/LVN verifying signatures. The RN and DON acknowledged the missing reconciliation and signatures, and facility policy required shift-by-shift inventory and documented disposal with two licensed nurses.
Failure to Rotate Insulin Injection Sites: The DON, QAN, and nursing staff failed to rotate insulin injection sites for multiple residents despite physician orders and the facility P&P requiring site rotation. Records showed repeated insulin doses given in the same abdominal or arm sites for residents with DM, including residents who were cognitively intact and residents who could not reliably communicate or understand. Staff acknowledged the sites should have been rotated to prevent hardening or lipohypertrophy.
Improper Disposal of Hazardous Medications in Non-Hazardous Waste Bin: A white pharmaceutical waste bin in a medication room contained loose tablets and capsules, three used insulin pens, and three aerosolized inhalers. RN and DON both acknowledged that insulin pens and Albuterol inhalers should not have been placed in the non-hazardous bin, and the DON stated the facility failed to destroy hazardous medications in the appropriate waste container per policy and regulations.
Unsafe food storage and food handling practices were observed in the kitchen and on a nursing unit. A resident refrigerator contained an unlabeled nutritional supplement and a pack of hot dogs with no received date, and a Dietary Aide was observed wearing multiple pieces of jewelry while handling food items for lunch trays. The DS stated that food items on nursing units should be labeled and dated, and that jewelry is not permitted during food prep except for limited exceptions in policy.
Failure to develop a care plan for a resident’s right-hand mitten use. A resident with a trach, G-tube, and significant functional impairments had a physician order for a padded mitten to prevent pulling medical devices, lines, and tubing, but the care plan was not created until months later. Staff confirmed the resident had no care plan in place for the mitten during that period, despite the order being acknowledged in care conference notes and the resident continuing to wear the mitten.
Oxygen Cannula Tubing Not Labeled With Change Date A resident with COPD, chronic respiratory failure with hypoxia, and dependence on supplemental O2 was observed using nasal cannula tubing that was not labeled with the date it was changed. LVN, IP, RN, and DON all confirmed the tubing was not dated and stated the facility policy required the cannula and tubing to be changed every 7 days. The resident had an active order for O2 at 2 L/min via nasal cannula and weekly tubing changes.
Food Preferences Not Honored: A resident with GI diagnoses and risk for malnutrition/dehydration had documented food dislikes and a fortified high-protein diet, but the lunch tray still included mixed vegetables the resident had said he did not want. The DS acknowledged staff were not looking at the meal ticket, and the DON stated residents may not eat if served foods they do not like.
The facility did not complete required competency evaluations and skills checklists for two CNAs, as mandated by its policies. The DSD confirmed missing documentation for both CNAs, and the DON acknowledged that without these evaluations, the facility could not assess staff knowledge or training needs.
A resident with severe cognitive impairment and total dependence on staff was found in an environment with a strong urine odor and a dirty, wet fall mat near the bed. The CNA acknowledged the odor and unclean conditions, noting that the resident's incontinence brief had not been changed due to being busy with other residents. The facility's policy for a clean and homelike environment was not upheld.
A resident with severe cognitive impairment and multiple medical diagnoses did not receive the ordered amount of enteral nutrition due to a feeding pump being turned off, resulting in only 200 ml being infused over 12 hours instead of the prescribed 960 ml. The discrepancy was confirmed by the DON, and the facility's policy requiring adequate nutritional support was not followed.
The facility failed to ensure timely and accurate medication administration, including late administration of blood pressure medication without physician notification, incomplete documentation of controlled substances, and lack of proper reassessment after PRN medication use. Additionally, two residents received insulin injections in the same sites without proper rotation, contrary to care plans and facility policy.
Staff did not adhere to the RCS diet guidelines by serving garlic bread to residents on a controlled-carbohydrate diet, despite clear instructions in the facility's food portioning and serving guide. Both the dietary aide and supervisory staff confirmed that garlic bread should not have been provided to these residents, as it was not part of the prescribed RCS meal plan.
Dietary staff failed to properly clean and sanitize cups, trays, and dishes, with food residue and tape remaining on items after dishwashing. Clean dishware was stored to air dry while still visibly soiled, and food particles were present on counters where clean items were placed. Staff interviews confirmed that dishes were not adequately scraped or rinsed before washing, resulting in improper cleaning and storage of kitchenware.
Three staff members, including an RN, LVN, and CNA, were found to have started employment without completed background checks, contrary to facility policy. This was discovered during a review following a resident's report of rough handling during care, which led to an abuse investigation. The facility's own policies required background checks before employment, but these were either delayed or missing for the staff involved.
Two residents with significant mobility impairments and pressure injuries did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Staff observations confirmed that the call lights were either placed out of reach or left dangling off the bed, preventing the residents from calling for assistance when needed.
A resident with moderate cognitive impairment and acute kidney failure was discharged from Medicare Part A skilled services without being provided the required Notice of Medicare Non-Coverage (NOMNC). Facility staff and records confirmed the NOMNC was not issued, despite policy requiring advance notification before benefits end.
A resident with multiple advanced pressure ulcers, who was fully dependent on staff and in a persistent vegetative state, was not repositioned every two hours as required by the care plan and facility policy. Observations showed the resident remained on the same side for over three and a half hours, and staff confirmed the lapse in care, despite clear interventions and use of a low air loss therapy mattress.
Two residents requiring ventilator and oxygen support were observed with oxygen tubing resting on the floor, contrary to infection control policies. Both residents had significant respiratory conditions and care plans aimed at preventing infection. Staff, including the RT, IP, and DON, acknowledged that tubing on the floor was an infection control issue.
A resident with multiple medical conditions had a physician's order for 1% hydrocortisone cream without a stop date, allowing indefinite use. The consultant pharmacist identified this during a monthly medication regimen review and recommended adding a stop date or discontinuing the medication. Despite this, staff did not clarify the order with the physician, and the recommendation was not acted upon, contrary to facility policy.
A resident with multiple medical conditions received several scheduled medications late and without required vital sign checks prior to administration. An LVN administered the medications via G-tube hours after the scheduled time, did not notify supervisory staff or the physician about the delay, and failed to assess blood pressure and heart rate immediately before giving antihypertensive medication, as required by physician orders. These actions resulted in a medication error rate of 25%, exceeding the acceptable threshold.
A facility failed to create a person-centered care plan for a resident with major depressive disorder. Despite the resident's diagnosis being noted in the MDS, the care plan did not address depression, and staff confirmed the absence of necessary behavioral monitoring. The facility's policy mandates comprehensive care plans, which were not implemented in this case.
A facility failed to conduct weekly skin assessments for a resident with MASD, as required by their care plan. The resident, with multiple health issues, had their condition worsen to an unstageable pressure injury with necrotic tissue. The facility's policy required a comprehensive care plan, which was not followed.
A mobile linen cart was found uncovered and unattended in a hallway, exposing linens and violating the facility's infection control policies. Staff interviews confirmed the requirement to keep linen carts covered to prevent infection spread. The facility's policies mandate protection of clean linen during transport and storage.
A facility failed to develop a care plan for a resident with a stage four pressure injury on the left trochanter, despite the resident's complex medical conditions and dependency on staff for daily activities. The absence of a care plan was confirmed by the DON and was contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to conduct background checks for an LVN and a CNA before hiring, as required by their policy to prevent abuse, neglect, and exploitation. This oversight was discovered during a review of employee files, where the checks were missing, and a search with the OIG system found no results. The DON emphasized the importance of these checks to ensure resident safety.
A facility failed to document necessary diagnoses for a resident receiving psychotropic medications. The resident's MDS did not reflect compulsive hoarding disorder or anxiety, despite being prescribed Ativan and Prozac. The MDSN confirmed a miscoding error, and the DON acknowledged the oversight, which could lead to unnecessary treatment.
A resident on oxygen was found smoking in their room, but the facility failed to update the smoking care plan or document smoking education. Despite initial assessments indicating the resident did not smoke, a later assessment confirmed smoking habits. The facility's oversight increased the risk of negative outcomes to the resident's well-being.
Two residents requiring substantial assistance with ADLs were neglected in their care. One resident was left in a soiled incontinence brief for 45 minutes despite calling for help, while another had a dry flaky substance around the eye that was not cleaned overnight. Staff were aware but did not provide timely assistance, citing reasons such as being on break. The facility's policies emphasize the importance of providing necessary care, but these were not followed, leading to neglect.
A resident with major depressive disorder was not provided necessary behavioral health care, as the facility failed to monitor and report symptoms of depression, update care plans, or ensure visits from mental health professionals. Despite known depressive symptoms, the resident was not systematically monitored or receiving medication, leading to unmanaged behavioral health needs.
The facility failed to provide sufficient nursing staff, resulting in delayed care for two residents who required assistance with personal care. CNAs reported being overburdened with assignments, making it difficult to respond promptly to residents' needs. Observations and interviews confirmed that residents experienced delays in receiving help, and family members expressed concerns about staffing levels. Despite claims of stabilized staffing, the facility did not meet required staffing hours, impacting the quality of care.
The facility failed to properly store and label medications, including insulin and inhalation powders, leading to potential risks for residents. Medications were found expired or improperly stored in medication rooms and carts, and timolol eye drops were left unattended during administration.
The facility failed to maintain safe food storage and preparation practices, including improperly labeled and stored thickened milk and juice, unmonitored thaw dates for nutritional supplements, and a dirty, worn can opener blade. These deficiencies posed a risk of foodborne illness to residents.
A facility failed to maintain a functional audible call system, impacting prompt response to resident needs. A resident with significant mobility and health issues reported the system was broken, and staff confirmed the announcement feature had been non-functional for months. Observations showed inconsistency in the system's operation, and temporary measures were in place to address the issue.
A resident's privacy was compromised when an LVN failed to close the bedside curtain during medication administration, violating the resident's right to dignity and privacy. The resident, with intact cognition and requiring assistance for personal hygiene, was observed during this incident. Interviews confirmed the importance of privacy, and the facility's policy emphasized maintaining dignity and respect.
Failure to Properly Respond to Alleged Physical Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program, Abuse and Neglect, and Abuse Investigation and Reporting policies and procedures for one resident with dementia, severe cognitive impairment, and significant functional dependence. The resident’s record showed diagnoses including dementia, cerebral infarction, and transient ischemic attack, and assessments documented maximum assistance with ADLs and severely impaired cognition. The care plan identified risk for decline in ROM due to upper and lower extremity weakness, and later records noted decreased ROM in the right hand and that the resident reported loss of function in that hand after a stroke. On 5/9/2026, the resident’s family alleged that a housekeeper forcefully grabbed and attempted to pry open the resident’s right hand while the resident was outside smoking, causing the resident to scream in pain and repeatedly state he could not move or open his hand. The family reported the incident to the RN on duty. The housekeeper denied physically touching the resident and stated she was demonstrating how to massage the hand. The resident later had a splint on the right arm during observation. The housekeeper’s abuse prevention training was overdue, with the employee file showing the mandatory in-service had been past due since 4/30/2026. The RN did not report the allegation to the ADM, DON, local police, the Ombudsman, or CDPH, and did not document the incident in the resident’s medical record. The RN also allowed the housekeeper to remain on duty after the complaint. Interviews were not conducted separately in a private location, and the housekeeper, RN, CNA, family, and resident were together in the resident’s room discussing the incident. The housekeeper also stated she went to the resident’s room to confront the family about the accusation. Facility leadership stated that forcibly pulling a resident’s extremity causing pain was physical abuse and that interviews should have been separate, but the incident was not handled that way.
Unsafe Food Storage Practices in Kitchen
Penalty
Summary
Safe food storage practices were not maintained in the kitchen when an open bottle of thickened coffee was found in the reach-in refrigerator with a receive date of 3/20/2025 and an open date of 2/27/2026. During the observation, the dietary supervisor reviewed the manufacturer's instructions and confirmed the product was required to be refrigerated after opening and used within 14 days. The dietary supervisor stated the thickened coffee should have been discarded because it had been in the refrigerator for more than 14 days and said serving it could have been bad and had the potential to make residents sick. Bulk sugar was also observed stored in large bins lined with regular plastic trash bags rather than food-grade liners. The dietary supervisor confirmed the liners were trash bags and not food grade, stated the facility had food-grade liners, and acknowledged that trash bags were not good for food storage. During follow-up interview, the dietary supervisor stated the trash bags had chemicals and could contaminate the food, and that staff should not have used them. The facility policy required refrigerated foods to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded, and the FDA Food Code cited that unacceptable materials can adversely affect food safety and quality.
Uncovered urinary catheter bag
Penalty
Summary
The facility failed to protect the privacy and dignity of Resident 90 by not ensuring the urinary catheter drainage bag was covered as required by the facility’s Dignity policy. Resident 90 was admitted on 2/7/2020 and readmitted on 4/13/2026 with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, encounter for surgical aftercare following surgery on the genitourinary system, and agoraphobia. The resident’s MDS dated 2/16/2026 indicated extensive assistance to total dependence from staff for ADLs including bed mobility, transfer, dressing, toilet use, and personal hygiene. During a facility tour on 4/18/2026 at 9:26 AM, Resident 90’s urinary catheter drainage bag was observed hanging on the side of the bed, uncovered, with urine visible in the bag. During a concurrent observation and interview on 4/19/2026 at 12:01 PM, Treatment Nurse 1 stated the urinary catheter bag was not covered with a privacy bag and that it needed to be covered. The DON later stated that urinary catheter bags had to be covered with privacy bags for residents’ privacy and dignity. The facility’s Dignity policy, reviewed 8/2025, stated that staff are expected to promote dignity and assist residents, including helping keep urinary catheter bags covered.
Incomplete Inventory of Resident Personal Property
Penalty
Summary
The facility failed to protect one resident’s personal belongings by not creating a complete inventory of the resident’s possessions upon admission and readmission, as required by the facility’s Personal Property policy. Resident 90 was originally admitted on 2/7/2020 and was readmitted multiple times, with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, respiratory failure, and agoraphobia. The resident’s Minimum Data Set dated 2/16/2026 indicated severely impaired cognition for daily decision-making and extensive assistance to total dependence for activities of daily living. The resident’s clothing and possessions records showed inconsistent and incomplete documentation, including entries stating no belongings, belongings at the facility, and see previous inventory, rather than a detailed inventory of items. During interview, Resident 90 repeatedly asked for a bag and could not explain what it was. CNA 6 observed that the resident’s closet and drawer contained no clothes or bags, and stated the resident had been moved from another room after hospitalization. The SSD stated he did not have the resident’s personal belongings in his office, and the DON stated the inventory lists were not properly completed and did not include personal belongings in a detailed report.
Incorrect MDS Coding for Cellulitis and IV Antibiotics
Penalty
Summary
The facility failed to accurately code the MDS for a resident admitted with cellulitis of the left and right lower limbs and type 2 DM. The resident’s admission record and order summary showed IV Vancomycin and piperacillin tazobactam were ordered for right and left foot cellulitis, but the MDS dated [DATE] indicated no foot skin problems and no antibiotic use. The MDS also documented the resident’s cognitive skills for daily decisions as intact and that the resident required assistance with ADLs. During a concurrent observation and interview, the resident was seen with swollen skin and redness on both lower limbs and an open wound on the left foot, and stated he had a wound on both legs, with the left leg swollen and tender and the left foot having an open wound. The treatment nurse stated the resident had multiple skin conditions on both lower legs and foot and was being seen by a wound care specialist. The MDS nurse reviewed the assessment and stated the cellulitis diagnosis and IV antibiotic medications were not coded and that the MDS was coded incorrectly; the nurse stated these items should have been coded as yes.
Failure to Develop ROM Care Plan
Penalty
Summary
The facility failed to develop a care plan for range of motion (ROM) for Resident 2. Resident 2 was admitted with diagnoses including thrombocytopenia, alcoholic cirrhosis of the liver, dysphagia, epilepsy, hypertension, and vascular dementia. The resident’s record showed an order for the Restorative Nursing Assistant program three times a week for active range of motion (AROM) and passive range of motion (PROM) to both lower extremities. The Minimum Data Set dated 4/2/2026 indicated Resident 2 had moderate cognitive impairment and required supervision or touching assistance for eating, with partial/moderate assistance to total dependence for other ADLs and bed mobility. During interview and record review, the MDS Nurse stated there was no care plan for the ROM treatments and that the ROM care plan for Resident 2 was not developed. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident.
Failure to Assist a Dependent Resident With Meals
Penalty
Summary
Facility staff failed to ensure Resident 6 received assistance with meals in accordance with the resident’s plan of care. Resident 6 was admitted on 10/4/2024 and readmitted on 1/24/2026 with diagnoses including seizures, other encephalopathy, type 2 diabetes, and acute pancreatitis. The H&P dated 1/26/2026 noted a history of renal failure, altered mental status, and that the resident did not have capacity to make medical decisions. The MDS dated 3/9/2026 indicated severely impaired cognitive skills and dependence on staff for toileting hygiene, oral hygiene, transferring, showering/bathing, personal hygiene, eating, sitting to lying, and sitting to stand. The care plan dated 1/19/2026 identified Resident 6 as at risk for aspiration related to dysphagia and directed nursing staff to assist with meals as needed and encourage slow eating and small bites. During observation on 4/19/2026 at 8:12 AM, Resident 6 was lying in bed, talking to self, not responding to verbal cue, with a breakfast tray on the bedside table, and no staff were assisting the resident. CNA 5 stated at 8:30 AM that Resident 6 was dependent on staff for feeding and had not yet been fed, adding that the family usually fed him. Later that day, FM 1 was observed feeding Resident 6 and stated it usually took a long time to feed him and that some CNAs did not take time to feed him. The DON stated Resident 6 was confused and dependent on staff for care and activities, and that it was the facility staff’s responsibility to ensure the resident’s care and needs were met.
Urinary Catheter Drainage Bag Touched the Floor
Penalty
Summary
The facility failed to ensure appropriate urinary catheter care for one of two sampled residents, Resident 90, by allowing the urinary catheter drainage bag to touch the floor. Resident 90 was admitted on 2/7/2020 and later readmitted with diagnoses including hydronephrosis with renal and ureteral calculous obstruction, encounter for surgical aftercare following surgery on the genitourinary system, and agoraphobia. The Minimum Data Set dated 2/16/2026 indicated Resident 90 required extensive assistance to total dependence from staff for activities of daily living, and the History and Physical dated 4/13/2026 noted a history of hydronephrosis and that the resident had the capacity to make medical decisions. During a facility tour on 4/18/2026 at 9:26 AM, the surveyor observed Resident 90's urinary catheter drainage bag hanging on the side of the bed and touching the floor. On 4/19/2026 at 12:01 PM, Treatment Nurse 1 confirmed the drainage bag was touching the floor and stated it should not touch the floor for infection control and prevention purposes. The DON later stated the drainage bag should not touch the floor or be placed on a basin to protect residents from urinary tract infections. The facility's Catheter Care, Urinary policy, reviewed in 8/2025, stated the catheter tubing and drainage bag should be kept off the floor.
Controlled Medication Documentation Discrepancy
Penalty
Summary
The facility failed to ensure safe medication administration and accurate accountability of controlled medications for one resident receiving Lacosamide for seizure disorder. Resident 6 was admitted with diagnoses including seizures and encounter for attention to gastrostomy tube, and the record showed severe cognitive impairment and dependence for many activities of daily living. The resident’s physician ordered Lacosamide oral solution 10 mg/ml, 20 ml via G-Tube every 12 hours. During a concurrent medication area observation, record review, and interview, the MAR and CDR for April 2026 were compared for Resident 6’s Lacosamide. The MAR showed two documented doses administered on 4/2/2026 and two documented doses administered on 4/4/2026, with scheduled times of 9 AM and 9 PM each day. However, the CDR did not match the MAR: on 4/2/2026, only the 9 AM dose was documented as removed and there was no CDR documentation for the 9 PM dose; on 4/4/2026, only the 9 PM dose was documented as removed and there was no CDR documentation for the 9 AM dose. The LVN reviewing the records stated there were no licensed nurse initials on the CDR to show the 9 AM dose on 4/4/2026 had been removed for administration, and stated that if the nurse did not document it, it did not happen. The DON also confirmed the MAR showed the resident received two doses on each of those days, but the CDR lacked documentation for one scheduled dose on each day. The facility policy stated controlled substance records are to contain the resident name, medication, quantity, time of administration, method of administration, and nursing signature, and that controlled substance inventory is monitored and reconciled with MARs and other records.
Missing Monthly Pharmacist Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review for Resident 4 and documented review of the resident’s chart and medication response. Resident 4 was admitted with diagnoses including schizophrenia, HTN, and hypothyroidism. The resident’s order summary showed Risperidone 1 mg by mouth two times a day for schizophrenia manifested by sudden angry outburst. The consultant pharmacist’s medication regimen review binder for reviews created between 12/1/2025 and 12/12/2025 listed Resident 4 among 35 residents whose medications were reviewed, but it did not identify which medications were reviewed or include any recommendations for Resident 4. During interview and record review, the DON was unable to locate a medication regimen review for Resident 4’s risperidone. When a different MRR for Primidone was presented, it still did not specify the medications reviewed, and the MRR did not indicate Resident 4’s response to Risperdal. The facility policy stated the consultant pharmacist performs a comprehensive MRR at least monthly and reviews the resident’s response to medication therapy, either onsite or remotely, to access clinically relevant information.
Room Size Waiver for Three 3-Bed Rooms
Penalty
Summary
The facility failed to ensure three resident rooms met the required square footage per resident. During review of the untiled room waiver letter dated 4/19/2026, the facility requested a waiver for three resident rooms that each had three resident beds and measured 231 square feet, which equaled 77 square feet per bed. The letter stated that the minimum requirement for a 3-bedroom room should be at least 240 square feet, and that the rooms were free of projections or other obstructions that could impede safe and independent movement of wheelchairs and/or other mobility devices. During the initial tour on 4/18/2026, surveyors observed the three rooms and noted that nursing staff had enough space to provide care to the unidentified residents, there were curtains to provide privacy for each resident, and the rooms had direct access to the corridors. During a group interview on 4/19/2026 with several residents, no concerns were raised regarding the size of the rooms. The Department recommended approval of the room waiver request.
Failure to Provide Required Abuse-Prevention In-Service Before CNA Returned to Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy requiring appropriate in‑service training on resident rights and abuse prevention prior to staff having direct-care responsibilities. A resident admitted with diagnoses including diverticulitis, muscle weakness, dysphagia, depression, and colostomy status had documented cognitive capacity to understand and make decisions and required moderate to maximum assistance with ADLs. On a specified date, progress notes documented that this resident reported an allegation of abuse involving a CNA on the night shift. According to the resident’s report in the progress notes, the CNA allegedly woke the resident aggressively, threw two towels on the resident’s chest and another towel on the colostomy site, and turned and pulled the resident while providing incontinence care. The resident further alleged that the CNA made arm gestures with two closed fists and stated that if the resident spoke up about what happened, the resident would be hit, causing the resident to feel afraid of the CNA. The facility initiated an investigation and suspended the CNA pending the outcome, as reflected in the facility’s 5‑day conclusion of the facility‑reported incident. Record review showed that the CNA returned to work and provided resident care on a later date, as indicated by the time sheet. The Quality Assurance Nurse’s in‑service record for the CNA was dated after the CNA had already returned and provided care. In interviews, the Quality Assurance Nurse confirmed that he did not provide an in‑service to the CNA prior to the CNA resuming resident care, and the Director of Staff Development acknowledged she was responsible for providing one‑on‑one in‑service training before the CNA provided care but had not done so. The Administrator confirmed that the CNA was called back to work after the investigation was concluded and that in‑service training was not completed before the CNA’s shift, contrary to the facility’s policy requiring staff training on preventing, recognizing, and reporting abuse, and on resident dignity and respect, prior to having direct-care responsibilities.
Failure to Assess and Address Behavioral Health Needs After Alleged Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with depression and chronic anxiety received necessary behavioral health care and services following an alleged abuse incident. The resident was admitted with diagnoses including HTN, hyperlipidemia, depression, a colostomy, and a gastrostomy, and had intact cognition and decision-making capacity. Physician orders dated 10/23/2025 included a psychology consult and treatment as needed, and the resident’s care plan identified a psychosocial well-being problem related to a language barrier, with interventions including consultations with pastoral care, social services, and psych services. On 1/1/2026, the resident reported an allegation of abuse involving a CNA on the night shift. According to nursing progress notes, the resident stated that the CNA woke her aggressively, threw towels on her chest and colostomy site, pulled and turned her while providing care, and made arm gestures with two closed fists while telling her that if she spoke up about what happened she would be hit. The resident reported feeling afraid of this CNA. Subsequent physician documentation on 1/5/2026 noted that the resident, who had a chronic anxiety disorder per her husband, experienced increased nighttime anxiety and was afraid to fall asleep after this interaction. A progress note on 1/8/2026 documented that the resident stated she did not feel safe. Despite these documented changes in the resident’s emotional and behavioral status, the facility did not complete a behavioral assessment or change-of-condition assessment related to the 1/1/2026 incident. The Social Services Supervisor confirmed that trauma assessments are to be done on admission, quarterly, and at change of condition, and acknowledged that no behavioral assessment was done for the resident’s change in condition on 1/1/2026 and that there were no psychologist progress notes for the resident. The MDS Coordinator also stated there were no behavioral assessments done for the resident for 1/1/2026. The Quality Assurance Nurse described that, in general, an abuse allegation should trigger emotional distress monitoring, psych evaluation, social services consultation, and care plan updates when a resident continues to feel unsafe, but the record showed the resident’s increased anxiety and expressed lack of safety were not identified and addressed through care-planned behavioral health interventions. The facility’s own policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning require identification, documentation, and interdisciplinary evaluation of new or changing behavioral symptoms and revision of the care plan when there is a significant change in condition, which did not occur in this case. During interviews, the Social Services Supervisor reported that the resident had made remarks about certain people of different ethnicities being loud, harmful, and unfriendly, and that the resident was not comfortable with certain staff of a different ethnicity, suggesting possible past trauma, but no related behavioral or trauma-focused assessment was documented after the incident. The DON stated she was not aware that the resident had reported not feeling safe on 1/8/2026 and indicated that the nurse should have notified the physician of this statement. Overall, the facility failed to recognize and assess the resident’s increased anxiety and fear following the alleged abuse, failed to initiate required behavioral assessments or a documented change-of-condition process, and failed to implement or document appropriate behavioral health and psychological services as outlined in the resident’s orders and the facility’s policies.
Failure to Promptly Assess and Initiate CPR for an Unresponsive Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff promptly assessed and initiated CPR for a resident who was a documented full code. The resident had severe cognitive impairment, dysphagia, dementia, COPD, a feeding tube, and a POLST and physician order directing that CPR and full treatment be provided to prolong life by all medically effective means. On the day of the incident, a visiting family member of the resident’s roommate brought cookies into the room. After the roommate requested cookies, the visitor fed a cookie to the cognitively impaired resident without consulting staff, despite the resident being on a pureed diet and unable to safely swallow solid foods. Shortly thereafter, the visitor observed the resident shaking, pale, and choking, and called for help. CNA1 responded and found the resident sitting up in bed, pale to bluish, with eyes open and wide, food running from the mouth, no movement, no gasping, no coughing, and no reaction to touch or to a finger sweep of the mouth. CNA1 reported that the resident did not blink, move, push back, or show any rise and fall of the chest. Despite recognizing these signs and being BLS certified (though her prior certificate was expired and her most recent certificate had been issued without her actually taking the class), CNA1 did not check for responsiveness in the prescribed manner, did not check for a pulse, and did not initiate CPR. Instead, she began performing the Heimlich maneuver two to three times and then, with RNA1, transferred the resident from the bed to a chair to continue the Heimlich. RNA1 and LVN1 each entered the room after hearing that a patient was choking. Both acknowledged that they did not assess the resident for responsiveness or check for a pulse before performing or continuing the Heimlich maneuver. RNA1 stated he did not have time to check for a pulse and focused on positioning the resident and performing abdominal thrusts, first in bed and then in a chair. LVN1 stated she was told the resident was choking and immediately performed the Heimlich maneuver without checking for breathing or a pulse, later acknowledging that CPR may have been delayed because the pulse was not checked. Multiple staff, including CNA2 and the DON, observed the resident as unresponsive, pale, not moving, and not alert, yet none of the first responders checked the resident’s pulse or initiated CPR at that time. RT1 arrived to find the resident sitting in a chair, appearing lifeless, not breathing, and without the universal sign of choking. RT1 checked the resident’s pulse, found none, and instructed staff to return the resident to bed and start CPR. Only at that point was CPR initiated. Interviews with the DON and Medical Director confirmed that facility policy and standard CPR protocols required that, upon finding an unresponsive resident, staff should immediately assess responsiveness, check for breathing and pulse, and, if no pulse is found, initiate CPR without delay. The facility’s own CPR policy required assessment of respirations and heartbeat, activation of emergency services, and initiation of CPR in the absence of a palpable pulse. The surveyors determined that CNA1, RNA1, and LVN1 failed to follow these required steps, resulting in a delay in CPR for a full-code resident who was unresponsive, not moving, and without a pulse when first found.
Removal Plan
- Implement a QAPI Performance Improvement Project (PIP) regarding CPR with return demonstrations.
- Educate all nurses on the procedure for initiating CPR and issue CPR certifications.
- Conduct CPR drills.
- Do not permit nurses to work without a CPR card until certification is completed.
- Audit residents' medical charts and identify residents who do not have a POLST.
Failure to Control Visitor Food and Supervise Resident on Pureed Diet Resulting in Choking Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident on a pureed gratification diet received food consistent with the ordered diet and to implement accident-prevention measures related to outside food brought by visitors. The resident had diagnoses including dysphagia oropharyngeal phase, dementia, prior pneumonitis due to inhalation of food and vomit, COPD, and required enteral feeding with only a pureed texture diet ordered for oral gratification. The resident’s care plan identified a risk for aspiration related to dysphagia but contained no nursing interventions addressing dysphagia, aspiration precautions, or the pureed diet. The Director of Nursing stated that each diagnosis required a specific care plan with interventions such as aspiration precautions, diet type, monitoring swallowing, and proper positioning, and acknowledged that this resident’s care plan did not include such interventions. The facility also failed to implement and operationalize its policy on Foods Brought by Family/Visitors. The written policy required family and visitors to inform nursing staff when foods were brought for a resident and prohibited sharing such foods with other residents. The DON stated that staff were supposed to tell family and visitors to check with nurses when bringing food, but there was no documentation of licensed nurses checking outside food, no education given to visitors regarding outside food, and no signs posted for visitors about the policy or about not sharing food with other residents. A family member visitor reported that staff saw her bring food into the facility almost weekly for another resident and never said anything, and that staff did not explain any rules or policies on outside food or what foods were safe or unsafe. On the day of the incident, a visitor brought chocolate chip and oatmeal cookies for the roommate of the resident on a pureed diet. While feeding a cookie to the roommate, the visitor reported that the resident on the pureed diet repeatedly asked for a cookie. The visitor then gave the resident a chocolate chip cookie without asking any staff if it was appropriate. After approximately five to ten minutes, the visitor observed the resident shaking, pale, and appearing to choke, and called for help. A CNA entered and found the resident in bed, unresponsive, pale, with food running from the mouth, and removed pieces of cookie from the mouth with a finger sweep. Additional staff, including a restorative nursing assistant, LVN, and respiratory therapist, responded and attempted the Heimlich maneuver, suctioning, and CPR. The resident was ultimately found to have no pulse and was later pronounced dead by paramedics. The facility’s failure to ensure supervision, environmental safeguards, and enforcement of the outside food policy allowed unsafe, non-pureed food to be provided to a resident with severe cognitive impairment and high aspiration risk, resulting in the resident receiving food inconsistent with the ordered pureed diet and choking. Family interviews further showed that the resident’s responsible party was not informed of any policy for outside food or steps to prevent the resident from being fed unsafe food from outside. This family member stated there were no signs or measures in place to remind the resident not to eat or to tell others not to feed him, despite his poor memory and history of ingesting unsafe substances, including laundry detergent prior to admission. The DON confirmed that staff were informed of residents on aspiration precautions only verbally at morning huddles and that there were no posted signs for visitors regarding food brought by family or visitors. The medical director and registered dietitian both confirmed that the resident was ordered a pureed texture diet due to dysphagia and that only pureed foods should have been given, with the expectation that families would be educated and would not give food without consulting nurses. These combined failures in care planning, visitor education, supervision, and enforcement of the outside food policy led directly to the resident being given a regular-texture cookie, choking, and dying.
Removal Plan
- The Administrative Consultant educated the Administrator (ADM) and the Director of Nursing (DON) on the policy regarding Food Brought by Family/Visitors.
- The DON conducted in-services for all staff on the policy regarding Food Brought by Family/Visitors.
- A third-party software sent text and email messages to all residents and their responsible parties educating them to inform nursing staff when foods are brought to the facility for a resident and instructing them not to share/distribute food to other residents.
- The facility posted signage throughout the facility regarding the Food Brought by Family/Visitor policy.
- The receptionist or designee encouraged visitors to sign in on the Visitor Log and indicate whether they brought food/drinks; if food/drinks were brought, LVNs ensured the items were appropriate for the resident’s prescribed diet and educated visitors not to share food/drinks with other residents.
- The Registered Dietitian posted a Dietary Log outside the kitchen for staff to cross-check special requests from residents/staff/family to ensure requests follow physician dietary orders posted in the kitchen.
- The Interdisciplinary Team identified residents with mechanically altered diets and updated their care plans.
Failure to Develop Individualized Dysphagia Care Plans for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement specific, individualized person-centered care plans for residents with dysphagia. For Resident 1, the admission record showed diagnoses including oropharyngeal dysphagia, dementia, prior pneumonitis due to inhalation of food and vomit, COPD, and the need for GT care. The care plan report dated 9/15/2025 identified a risk for aspiration related to dysphagia but contained no nursing interventions. Physician orders later directed enteral feeding with Jevity 1.5 at a specified rate and duration, and a pureed diet for oral gratification, but these orders were not translated into a detailed dysphagia care plan with measurable interventions. During interview, the DON acknowledged that Resident 1’s care plan lacked nursing interventions to address dysphagia and the pureed diet, despite the resident’s diagnosis and aspiration risk. For Residents 2, 3, and 4, surveyors found similar omissions. Resident 2 was admitted with diagnoses including aphasia, dysphagia following cerebral infarction, dementia, and adult failure to thrive, and had severe cognitive impairment per the MDS. The MDS documented extensive assistance needs for ADLs, and a physician order directed a controlled carbohydrate, pureed texture, thin consistency diet. Resident 3 was admitted with gastrostomy, dysphagia, and dementia, had moderate cognitive impairment, was dependent for multiple ADLs, and had orders for a fortified pureed thin diet. Resident 4 was re-admitted with aphasia and dysphagia following cerebral infarction, had moderate cognitive impairment, required substantial to total assistance for eating and other ADLs, and had orders for a fortified/high protein, no added salt, pureed thin diet. Despite these diagnoses and diet orders, record review showed that none of these three residents had a specific dysphagia care plan initiated upon admission or thereafter. Multiple staff interviews confirmed the absence of required dysphagia care plans and clarified facility expectations. The DON, LVN 2, and the Quality Assurance Nurse each stated that every resident diagnosis and identified problem should have a care plan, that care plans are individualized guides for treatment, and that dysphagia care plans should include interventions such as diet orders, aspiration precautions (e.g., upright positioning, head of bed elevation), monitoring for coughing and shortness of breath, monitoring swallowing, speech therapy/swallow evaluations, and education for residents and families. They each acknowledged that Residents 2, 3, and 4 had dysphagia diagnoses and pureed diet orders but did not have dysphagia care plans initiated on admission. The facility’s written policy on comprehensive person-centered care plans required measurable objectives and timetables for each resident’s needs, ongoing assessment, and revision of care plans with changes in condition or orders, but these requirements were not met for the four residents with dysphagia. Staff further stated that the lack of dysphagia care plans created a potential for increased risk of aspiration and pneumonia because nurses would not know the specific plan of care, treatment, and interventions needed for these residents’ swallowing difficulties. The DON, LVN 2, and the QAN each articulated that without a dysphagia care plan, nurses lacked clear guidance on necessary precautions and monitoring. This combination of documented diagnoses, diet orders, and acknowledged facility policy, contrasted with the absence of corresponding individualized dysphagia care plans and interventions, formed the basis of the cited deficiency under the requirement to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for each resident. The facility’s own policy and staff descriptions emphasized that care plans should reflect recognized standards of practice, include services to attain or maintain the highest practicable well-being, and be updated on admission, quarterly, with changes in condition, and with new physician orders. Despite this, the care plan reports for all four residents lacked a specific dysphagia problem and associated interventions, even though each resident had documented swallowing disorders and specialized diet or feeding orders. The survey findings therefore centered on the gap between policy and practice: the facility did not translate known dysphagia diagnoses and physician orders into individualized, measurable care plan interventions for these residents, as confirmed by record review and staff interviews.
Controlled medication reconciliation and disposal record deficiencies
Penalty
Summary
The facility failed to reconcile four medication emergency kits (eKITs) containing controlled medications in the medication room during shift changes for September 2025. During observation and interview with an RN, the four eKITs labeled 105, 126, 266, and 280 were stored in the refrigerator and contained controlled medications, but there was no accountability log showing reconciliation of the controlled medication inventory at every shift change. The RN stated that all controlled medications, including eKITs containing controlled medications, should be reconciled at every shift. The facility also failed to include the signatures of the DON or an RN with an LVN on seven Antibiotic or Controlled Drug Record accountability logs awaiting disposal in a locked cabinet. During observation, interview, and record review with the DON, the seven logs did not contain verifying signatures, and the DON stated the signatures could not be located. The DON stated that the DON and LVNs counted the controlled medications upon receipt of the logs, but they overlooked signing and dating the seven logs. Facility policy stated that controlled medications, including emergency supply medications, are to be physically inventoried at each shift change by two licensed nurses and documented on the accountability record, and that disposal of refused, unused, or wasted controlled medications must be documented in the presence of two licensed nurses.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that three sampled residents were free from significant medication errors related to insulin administration site rotation. The deficiency involved Resident 6, Resident 44, and Resident 47, whose records showed repeated insulin injections given to the same body sites despite physician orders and the facility’s insulin administration policy requiring rotation of injection sites. Facility staff acknowledged during interviews that insulin sites should have been rotated to prevent hardening or lipohypertrophy. Resident 6 was admitted with diagnoses including DM2, a foot ulcer, sepsis, UTI, GERD, HTN, major depressive disorder, anemia, and acquired absence of the right leg below the knee. The H&P indicated the resident had capacity, and the MDS showed the resident could make himself understood and understand others. The order summary included orders for Insulin Glargine and Insulin Lispro with instructions to rotate injection sites. Review of the location of administration reports showed repeated administration of Insulin Glargine to the abdomen LLQ and RUQ on consecutive days, and repeated administration of Insulin Lispro to the abdomen LUQ on multiple dates. The resident’s care plan also included an intervention to rotate the site for insulin injections. Resident 44 was admitted with type 2 DM and other encephalopathy. The H&P indicated the resident was awake, alert, and responsive to verbal commands but did not have mental capacity, and the MDS indicated the resident rarely understood others and rarely could make himself understood. The order summary included orders for Insulin Glargine and Insulin Regular with instructions to rotate injection sites. Review of the administration reports showed Insulin Regular was given consecutively in the abdomen LUQ, and Insulin Glargine was also given consecutively in the abdomen RUQ and LUQ on multiple occasions. During interviews, the QAN, RN, LVN, and DON stated insulin sites needed to be rotated and that staff had the ability to check the EMR to see where the previous injection had been given. Resident 47 was admitted with type 2 DM and was cognitively intact per the MDS. The resident received Lispro insulin per sliding scale before meals and at bedtime. Review of the blood glucose monitoring records showed multiple instances where Lispro was administered consecutively in the same site, including the abdomen, left arm, and other abdominal quadrants across July, August, and September. The care plan identified the resident as at risk for hypo/hyperglycemia and included an intervention to rotate the insulin injection site. During interviews, the QAN and DON confirmed the sites were not rotated on the identified occasions and stated there was no documentation explaining why the insulin was given in the same site.
Improper Disposal of Hazardous Medications in Non-Hazardous Waste Bin
Penalty
Summary
The facility failed to properly store and dispose of medications and biologicals when used insulin pens and aerosolized inhalers were found in the non-hazardous pharmaceutical waste bin in Medication Room [ROOM NUMBER]. During an observation on 9/30/2025 at 11:08 a.m., RN 1 observed a white pharmaceutical waste bin containing several loose medication tablets and capsules, three disposed insulin pens, and three disposed aerosolized inhalers. The bin was labeled for non-hazardous pharmaceutical waste and specifically indicated that hazardous waste, P-listed chemicals or medicines, U-listed chemicals or medicines, DEA-listed controlled substances, and D-listed chemicals or medicines were not to be placed in it. During the same observation, RN 1 stated that insulin pens and inhalers should not be disposed of in the non-hazardous white pharmaceutical bin. During an interview later that day, the DON acknowledged that the bin contained insulin pens, including Lantus and Aspart, and inhalers including Albuterol. The DON stated that the white non-hazardous pharmaceutical bin should not contain insulin pens because they contain hazardous materials and aerosolized inhalers because they can explode. The DON also stated the facility failed to destroy hazardous medications in the appropriate waste container according to state laws, regulations, and facility policy and procedures. A review of the facility policy titled Medication Destruction, last reviewed 8/28/2025, indicated that all medications are to be placed in the proper waste container per facility policy and that the facility maintains a contract with a waste disposal company specifying pick-up and disposal procedures. The report also cited federal regulations identifying metacresol as a toxic characteristic and Albuterol inhalers as incompatible hazardous waste pharmaceuticals, supporting the finding that the insulin pens and inhalers were placed in the wrong disposal container.
Unsafe Food Storage and Jewelry Use During Food Preparation
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the resident refrigerator located at the nurses station. During observation, a carton of nutritional supplement was found with no label, name, or date, and a frozen pack of hot dogs in a cellophane bag was found with no received date. In interview, the Dietary Supervisor stated that nursing staff are expected to put the room number and date received on food items, that she overlooked the freezer area during her check, and that she did not know who placed the food in the resident refrigerator. The facility policy titled Food Receiving and Storage stated that foods and snacks kept on nursing units are to be labeled with the resident's name, the item, and the use by date. The facility also failed to ensure sanitary food preparation practices when a Dietary Aide was observed wearing multiple pieces of jewelry while handling food in the kitchen. The aide was seen wearing earrings, a bracelet, and a necklace while handling juices that were to be placed on lunch trays. The Dietary Supervisor stated that only a wedding ring is allowed in the kitchen and that jewelry is not permitted because it can be dropped into food, but also stated that some kitchen staff still wear jewelry despite reminders. Facility policies on dress code, personal hygiene, and preventing foodborne illness stated that jewelry should be limited and kept to a minimum during food handling.
Failure to Care Plan for Right-Hand Mitten Use
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for Resident 7 after a physician order was received for a right-hand mitten to prevent the resident from pulling out medical devices, lines, and tubing. Resident 7 was admitted with diagnoses including traumatic subdural hemorrhage, tracheostomy, and gastrostomy, and the MDS dated 6/18/2025 indicated impairments in the upper and lower extremities and dependence on staff for oral hygiene, toileting, bathing, dressing, and personal hygiene. The physician order for the right-hand mitten was dated 7/2/2025, but the care plan for the mitten was not created until 9/29/2025. During the review, the facility’s multidisciplinary care conference notes dated 9/16/2025 acknowledged the physician order for the right-hand mitten. On 11/17/2025, the resident was observed with the mitten on the right hand, and CNA 2 stated nurses removed the mitten and checked the skin integrity, and that the resident would scratch herself when the mitten was removed. The Treatment Nurse and MDS Nurse both confirmed that the care plan for episodes of pulling medical devices was created on 9/29/2025 and that the resident did not have a care plan for the mitten from the initial order date until that time. The facility policy on restraints stated that care plans for residents in restraints would reflect interventions addressing the immediate medical symptoms and underlying problems causing the symptoms, and include measures to reduce and eliminate the need for restraint use.
Oxygen Cannula Tubing Not Dated Per Policy
Penalty
Summary
The facility failed to provide necessary respiratory care services for one sampled resident by not labeling the resident’s oxygen cannula tubing with the date it was changed according to the facility’s policy. Resident 12 was admitted with diagnoses including COPD, unilateral pulmonary emphysema, dependence on supplemental oxygen, type 2 DM, pulmonary hypertension, supraventricular tachycardia, and chronic respiratory failure with hypoxia. The resident’s care plan identified a goal of reduced signs and symptoms of respiratory infections and included an intervention to give oxygen inhalation as ordered. Resident 12’s history and physical indicated the resident had been admitted to the facility after hospitalization for a COPD exacerbation and sepsis. The record also showed that the physician could not obtain the resident’s mental capacity at that time, while the MDS later indicated the resident had the ability to understand others and make himself understood. During a concurrent observation and interview, Resident 12 was seen using oxygen cannula and tubing that did not have a label showing the date it was changed, and LVN 4 stated the tubing was not dated. The facility’s Infection Preventionist observed the same condition and stated the oxygen cannula and tubing had to be changed every 7 days per facility policy. The IP stated that not changing the cannula and tubing could cause an infection control issue. RN 1 and the DON also stated that failure to change the oxygen cannula and tubing according to policy could expose the resident to an infection control issue. The resident’s order summary showed an active order for oxygen at 2 liters per minute via nasal cannula and to change the nasal cannula every week on Monday and as needed, with the resident’s name and date labeled.
Food Preferences Not Honored
Penalty
Summary
The facility failed to ensure that one resident’s documented food preferences were honored. The resident was admitted with diagnoses including Guillain-Barre Syndrome, gastro-esophageal reflux, and peptic ulcer disease, and the care plan identified the resident as being at risk for malnutrition and dehydration with interventions that included honoring food preferences and updating them as needed. The resident’s progress notes documented that the Dietary Supervisor spoke with the resident and recorded dislikes of string beans, collard greens, green peas, and mixed vegetables, with dietary to honor those preferences and provide alternatives. The resident’s Dietary Profile/Preferences later listed a fortified high-protein diet, regular texture, thin consistency, ice cream at lunch and dinner, and dislikes of string beans, collard greens, green peas, corn, and mixed vegetables. During observation of the lunch tray, the resident stated his food preferences were not honored and that kitchen staff sometimes placed disliked items on the plate instead of foods he liked. The meal ticket showed specific likes and dislikes, but the observed lunch tray contained mixed vegetables, including green peas, corn, and green beans. The DS stated staff were not looking at the meal ticket and acknowledged the resident would feel unheard because his preferences were not honored. The DA stated each ticket was read to the cook, and the DON stated residents wanted to eat what they liked so they would not lose weight.
Failure to Complete Required Staff Competency Evaluations
Penalty
Summary
The facility failed to conduct required staff competency evaluations for two of three sampled certified nursing assistants (CNAs), as mandated by its own policies and procedures. Specifically, one CNA did not have a performance skills checklist in their employee file, and another CNA, who was hired several months prior, did not have a documented performance evaluation. The Director of Staff Development (DSD) acknowledged that she was new to the system and was unaware of when the skills checklist for one CNA was performed, and also confirmed that the performance evaluation for the other CNA had not been completed. The DSD stated that performance evaluations are generally performed ninety days after hire and then annually, but these were missing for the two CNAs in question. The Director of Nursing (DON) confirmed that an audit of employee files had been conducted, and without the required performance evaluations and skills checklists, the facility would not be able to determine if staff lacked knowledge or required additional training. The facility's policies require that job performance be reviewed at the end of a 90-day probationary period and at least annually thereafter, and that competency requirements and training for nursing staff are established and monitored by nursing leadership. The absence of these evaluations and documentation for the two CNAs represents a failure to ensure that staff have the appropriate competencies to care for residents as required by facility policy.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
Facility staff failed to maintain a clean, odor-free, and homelike environment for a resident with severe cognitive impairment and total dependence on staff for daily living activities. Observations revealed a strong urine odor around the resident's bed and room entrance, as well as a dirty, wet, and smelly gray fall mat at the right side of the bed. The fall mat was noted to have foot prints, scuff marks, and a drying sticky wet mark. A Certified Nursing Assistant (CNA) acknowledged the strong urine odor and the unclean condition of the fall mat, attributing the situation to not having had a chance to change the resident's incontinence brief due to being occupied with other residents. The resident involved had multiple medical diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The Minimum Data Set assessment indicated the resident was totally dependent on staff for bed mobility, dressing, toileting, bathing, and personal hygiene. The facility's policy required a safe, clean, comfortable, and homelike environment with pleasant, neutral scents, but these standards were not met in this instance.
Failure to Administer Prescribed Enteral Nutrition Due to Pump Malfunction
Penalty
Summary
Facility staff failed to administer the prescribed amount of enteral nutrition to a resident with multiple complex medical conditions, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The resident was totally dependent on staff for all activities of daily living and had severe cognitive impairment. The physician's order specified that the resident should receive diabetic source enteral feeding at 1.2 calories per milliliter, 80 ml per hour for 20 hours, totaling 1600 ml or 1920 calories, with a scheduled pause from 8 am to 12 pm. Observation at the resident's bedside revealed that the enteral feeding pump was turned off, and only 200 ml of formula had been infused over a 12-hour period, instead of the ordered 960 ml. The feeding bottle had been hung the previous evening, and the discrepancy was confirmed during an interview with the DON, who acknowledged the resident did not receive the required nutrition due to the pump not functioning as intended. The facility's policy required adequate nutritional support through enteral nutrition as ordered, but this was not followed in this instance.
Medication Administration and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure safe medication administration and accurate accountability of controlled medications for four residents. For one resident with hypertension and dependence on a ventilator, blood pressure medication (Amlodipine) was administered late on six occasions, and the physician was not notified of the delays. Additionally, the nurse did not check the resident's blood pressure immediately prior to administering the medication, as required by the physician's order. The facility's policy required medications to be administered within one hour of the scheduled time and for vital signs to be checked if necessary, but these procedures were not followed. For the same resident, there was a discrepancy between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR) for a dose of Oxycodone/APAP, a controlled medication. The CDR indicated a dose was removed and administered, but the MAR lacked documentation of administration and pain assessment. The nurse responsible did not document the administration or the resident's pain level, contrary to facility policy, which requires immediate documentation of all medications administered, including PRN effectiveness. Another resident with epilepsy and anoxic brain damage had discrepancies in the documentation and administration of Ativan, a controlled medication. The CDR, MAR, physician's order, and pharmacy label did not match, and the inventory of the medication was inconsistent. The resident was not reassessed for effectiveness of PRN Ativan within the required 30 minutes, and the physician's order lacked a maximum dose and clear instructions for when to notify the physician. Additionally, two residents with diabetes received insulin injections in the same sites repeatedly, without proper rotation, despite care plans and facility policy requiring site rotation to prevent complications.
Failure to Follow RCS Diet Guidelines During Meal Service
Penalty
Summary
Staff failed to follow the facility's Reduced Concentrated Sweets (RCS) diet guidelines for residents requiring blood sugar control. On the specified lunch service, both regular and RCS diet trays were observed receiving garlic bread, despite the facility's food portioning and serving guide indicating that garlic bread should not be served to residents on the RCS diet. The lunch menu and the serving guide clearly differentiated between the regular and RCS diets, with the RCS diet omitting garlic bread and providing a reduced portion of dessert. During interviews, the dietary aide responsible for assembling trays confirmed that garlic bread was added to both regular and RCS trays, acknowledging that this was not in accordance with the diet spreadsheet and could affect blood sugar levels. The dietary supervisor and registered dietitian also confirmed that the RCS diet should not have included garlic bread and that staff are required to follow the diet spreadsheets to ensure residents receive the correct nutrition per diet orders. Facility policy on controlled-carbohydrate diets emphasized the importance of following specified portion sizes and meal components for blood sugar management.
Improper Cleaning and Storage of Kitchenware
Penalty
Summary
Surveyors observed that dietary staff failed to ensure proper cleaning and sanitization of resident cups, trays, and dishes in the kitchen. During the inspection, a dietary aide was seen removing trays, cups, and bowls from the dishwashing machine and storing them to air dry, despite visible food particles and residue remaining on the items. Some trays also had tape stuck to them, and the counter where clean dishes were placed was covered with food particles, including grains from breakfast cereal. The dietary aide admitted to returning visibly dirty dishes to be rewashed but did not notice other soiled items that were stored as clean. The dietary supervisor confirmed the presence of food residue and tape on the trays and acknowledged that the counter was contaminated with food particles from the dishes. Further interviews revealed that the dishwasher operator had not adequately scraped or rinsed the dishes before loading them into the dishwashing machine, resulting in grits and other food debris remaining on the trays and bowls after washing. The facility's policy required all utensils, counters, shelves, and equipment to be kept clean and in good repair, and the FDA Food Code specified that food debris should be scraped and, if necessary, pre-flushed or scrubbed before washing. These procedures were not followed, leading to improper cleaning and storage of kitchenware used by residents.
Failure to Complete Pre-Employment Background Checks for Direct Care Staff
Penalty
Summary
The facility failed to ensure that three out of ten staff members, including a registered nurse, a licensed vocational nurse, and a certified nurse assistant, had background checks completed prior to their employment. Review of employee files revealed that background checks for these staff members were either conducted years after their hire dates or only after a random review, rather than before employment as required by facility policy. The Director of Staff Development confirmed that some background checks were missing or delayed, and the Director of Nursing acknowledged the risk posed by employing staff without completed background checks. An incident involving a resident who required assistance with personal care, and who had diagnoses including gout and toxic encephalopathy, highlighted the deficiency. The resident reported being handled roughly by a CNA during incontinent care, leading to an abuse investigation. It was discovered that the CNA involved had not undergone a background check prior to hire. Facility policies reviewed indicated that background checks were to be completed before employment, but this was not followed in these cases.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for resident needs by not ensuring that the call light was within reach for two residents. For one resident with limited mobility, muscle weakness, pressure-induced deep tissue injuries, and a history of falls, multiple care plans specified that the call light should be within easy reach at all times and that the resident should be encouraged to use it for assistance. However, during an observation, the call light was found above the resident's head, resting on the mattress and facing the back wall, making it inaccessible. The resident was unable to call for assistance after an incontinent episode until staff intervened. Another resident, diagnosed with pressure ulcers and functional quadriplegia, also had care plans indicating the need for the call light to be within reach and for staff to encourage its use. During observation, the call light was clipped to the top of the mattress and left dangling off the side of the bed, again not within the resident's reach. Staff confirmed that if the call light was not accessible, the resident could not call for help. The assigned CNA was not present at the time, but other CNAs were reportedly available in the hallway. Interviews with staff, including the DON, confirmed that nursing staff are expected to ensure call lights are in place at the beginning of each shift and that call lights should always be accessible to residents. The facility's policy also requires that the call light be accessible to residents when in bed. Despite these policies and care plan interventions, the call lights were not within reach for the two residents at the time of observation.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare Part A skilled services were ending. The resident, who was admitted for acute kidney failure and was moderately cognitively impaired, required substantial assistance with daily activities. According to the facility's records, the resident's last covered day for Medicare Part A services was documented, and the discharge was planned with the resident returning home with home health services. However, there was no evidence that the NOMNC was issued to the resident as required. During interviews and record reviews, both the Business Office Administrator and the Director of Nursing were unable to locate the NOMNC or determine if the discharge was beneficiary-initiated. The facility's policy required that a NOMNC be issued at least two calendar days before Medicare benefits end, but the documentation and staff interviews confirmed that this did not occur for the resident in question.
Failure to Reposition Bedbound Resident with Pressure Ulcers Every Two Hours
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers, including Stage III and Stage IV wounds, was not repositioned every two hours as required by their care plan and facility policy. The resident, who was in a persistent vegetative state and fully dependent on staff for all activities of daily living, was observed lying on her left side for over three and a half hours without being repositioned. Multiple staff interviews confirmed that the resident should have been turned at least every two hours to prevent further skin breakdown and to comply with the care plan interventions. The resident's medical history included acute and chronic respiratory failure, non-traumatic subarachnoid hemorrhage, COPD, ventilator dependence, and persistent vegetative state. The care plan specifically addressed the need for frequent repositioning due to the presence of pressure ulcers on several body sites, and the use of a low air loss therapy mattress was ordered for wound management. Despite these interventions, direct observations and staff interviews revealed that the resident was not repositioned as required, and staff acknowledged the lapse in care. Facility policies on prevention of pressure injuries and repositioning outlined the necessity of individualized repositioning schedules, with a minimum standard of every two hours for bed-bound residents. The Director of Nursing and other staff verified that the resident had not been repositioned according to the care plan, and that simply placing a pillow under the resident did not constitute a proper repositioning. The failure to follow the established care plan and facility policy resulted in the identified deficiency.
Oxygen Tubing Found on Floor for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who required ventilator and oxygen support. For both residents, observations revealed that oxygen tubing connected to their ventilators was resting on the floor. Resident 29, who was in a persistent vegetative state with chronic respiratory failure, tracheostomy, and under hospice care, was observed with oxygen tubing touching the floor in their room. Resident 63, who was ventilator-dependent with chronic respiratory failure, COPD, ALS, and had mental capacity, was also observed with oxygen tubing on the floor. Both residents had care plans with goals to remain free of infection, and physician orders for oxygen therapy and ventilator support. During interviews, the respiratory therapist acknowledged the tubing was on the floor and agreed it could be an infection control issue, stating the tubing would be replaced. The infection preventionist and DON also confirmed that oxygen tubing touching the floor constituted an infection control problem. The facility's infection control policy required maintaining a safe and sanitary environment to prevent and control infections, and staff were to be trained on these practices. Despite these policies, the observed practice of allowing oxygen tubing to rest on the floor represented a failure to adhere to infection control standards.
Failure to Clarify Physician Order for Topical Steroid After Pharmacist Recommendation
Penalty
Summary
The facility failed to clarify a physician's order for hydrocortisone cream as recommended by the consultant pharmacist during the monthly medication regimen review for one resident. The resident had been readmitted with multiple diagnoses, including Type 2 diabetes, rash, schizophrenia, dementia, and psychosis. The physician's order directed the use of 1% hydrocortisone cream to the right side of the nose and face every six hours as needed for itching, but did not include an end date, allowing for indefinite use. During the consultant pharmacist's medication regimen review, it was noted that the order for hydrocortisone cream lacked a stop date. The pharmacist recommended that the topical steroid be used for no more than four weeks at a time and advised facility staff to request the physician to add a stop date or discontinue the medication. Despite this recommendation, the order remained unchanged and the cream continued to be available for indefinite use. Interviews with facility staff, including an LVN and the DON, confirmed that the pharmacist's recommendation was not acted upon. Both staff members acknowledged that recommendations from the consultant pharmacist should be communicated to the physician and followed up, but in this case, the order was neither clarified nor discontinued as advised. The facility's policy required that such recommendations be acted upon and documented, but this process was not completed for the resident in question.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, as evidenced by seven medication errors out of 28 observed opportunities, resulting in a 25% error rate for one resident. The errors were identified during a medication administration observation for a resident with diagnoses including hypertension, ventilator dependence, and a gastrostomy tube. The resident required multiple medications to be administered via G-tube, with specific physician orders and parameters for administration, such as holding blood pressure medications if certain vital sign thresholds were not met. During the observed medication pass, a licensed vocational nurse prepared and administered eight scheduled morning medications several hours past the prescribed time without notifying a supervisor or the physician. The nurse did not check the resident's blood pressure or heart rate immediately prior to administering the antihypertensive medication, instead relying on vital signs taken four hours earlier. This was contrary to the physician's order, which required current vital sign assessment before administration. The nurse also failed to inform the nurse practitioner or physician about the delay in medication administration, as required by facility policy. Interviews with facility staff, including the nurse practitioner, registered nurse, director of nursing, and medical director, confirmed that the nurse should have checked the resident's vital signs immediately before administering the blood pressure medication and should have notified the physician about the late administration. Facility policy required medications to be given within one hour of the scheduled time and for staff to notify the physician if this was not possible. The failure to follow these procedures resulted in multiple medication errors for the resident.
Failure to Develop Care Plan for Resident's Depression
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with major depressive disorder. The resident, who was admitted with diagnoses including myopathy, schizophrenia, and major depressive disorder, was found to have no care plan addressing their depression. The comprehensive Minimum Data Set (MDS) indicated the resident was free of cognitive impairment and required assistance with bed mobility, transfer, and personal hygiene. Despite the diagnosis of depression being noted, the care plan revised on March 17, 2025, did not include measures to address this condition. During interviews, both a Licensed Vocational Nurse (LVN) and the MDS Nurse confirmed the absence of a care plan for the resident's depression. The LVN highlighted the need for a behavioral monitoring care plan to observe signs of depression, such as crying, lack of appetite, and refusal of care, which were not documented. The MDS Nurse acknowledged the lack of a care plan and stated that the issue should be discussed during the facility's quarterly interdisciplinary team meeting. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables, which was not implemented for this resident.
Failure to Implement Weekly Skin Assessments
Penalty
Summary
The facility failed to implement the care plan intervention of conducting weekly skin assessments for a resident, which was a requirement due to the resident's existing skin condition. The resident was admitted with multiple diagnoses, including visual loss, hypertension, morbid obesity, anemia, heart failure, and arrhythmia. The care plan, dated 11/14/24, specified weekly skin assessments due to moisture-associated skin damage (MASD). However, the facility did not perform these assessments for three consecutive weeks, as verified by the Director of Nursing (DON). The resident's condition worsened, with the MASD progressing to an unstageable pressure injury with necrotic tissue. The resident was at risk for unavoidable pressure injury due to complex medical conditions and episodes of noncompliance with care, including refusing turning, repositioning, and wound care. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables, which was not adhered to in this case.
Uncovered Linen Cart Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that a mobile linen cart was covered while unattended. During an observation in the hallway outside the activity room, a mobile linen cart was found with its flap open, exposing the linen inside. This observation was confirmed during an interview with a Certified Nursing Assistant (CNA), who acknowledged that the cart should have been covered for infection control purposes. Further interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the linen cart should not be left uncovered to prevent the spread of infection. The Infection Preventionist (IP) also stated that uncovered linens could lead to the spread of infection and that staff had been trained to cover the carts. The facility's policy and procedure documents indicated that clean linen should be protected from dust and soiling during transport and storage, and that all personnel would be trained on infection control practices.
Failure to Develop Care Plan for Resident's Pressure Injury
Penalty
Summary
The facility failed to develop a care plan for a resident with a stage four pressure injury on the left trochanter. This deficiency was identified during a review of the resident's records and confirmed by the Director of Nursing (DON). The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, and cerebrovascular accident, was dependent on staff for activities of daily living and had severely impaired cognition. Despite these conditions, there was no care plan in place for the resident's significant wound, which required specific treatment with Santyl ointment as per physician's orders. The absence of a care plan for the resident's pressure injury was contrary to the facility's policy and procedures, which mandate the development and implementation of a comprehensive, person-centered care plan for each resident. This plan should include measurable objectives and timetables to address the resident's physical, psychosocial, and functional needs. The lack of a care plan for the resident's wound posed a risk of not providing appropriate, consistent, and individualized care, as confirmed by the DON during the survey.
Failure to Conduct Background Checks for Staff
Penalty
Summary
The facility failed to implement its policy and procedure titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program' by not conducting background checks for two staff members, a Licensed Vocational Nurse (LVN 1) and a Certified Nurse Assistant (CNA 2), prior to their employment. This oversight was discovered during a review of employee files with the Director of Staff Development (DSD), where it was found that the background checks were missing from the files of these two staff members. The DSD confirmed that the background checks should have been present in the files but were not, and a subsequent search with the OIG background check system yielded no results for these individuals. The Director of Nursing (DON) stated that background checks are a prerequisite for hiring to ensure that employees do not have any legal issues that could pose a risk to resident safety and well-being. The facility's policy, dated April 2021, mandates conducting employee background checks as part of its commitment to protecting residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including facility staff. The failure to adhere to this policy increased the risk to the health and rights of the residents in the facility.
Failure to Document Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident had current documented diagnoses to support the administration of psychotropic medications. The resident was admitted with a diagnosis of dementia and muscle weakness. However, the care plans indicated the use of Ativan for anxiety and Prozac for compulsive hoarding disorder, neither of which were documented as active diagnoses in the resident's Minimum Data Set (MDS). The MDS, a federally mandated resident assessment tool, did not reflect diagnoses of compulsive hoarding disorder, depression, or anger outburst, which were necessary to justify the prescribed medications. During interviews, the Minimum Data Set Nurse (MDSN) confirmed a miscoding error, acknowledging that new orders were discussed in clinical meetings but not accurately captured in the MDS. The Director of Nursing (DON) also confirmed that the MDS did not indicate the necessary diagnoses, which could lead to unnecessary treatment without proper documentation. The facility's policy required the MDS coordinator to ensure appropriate edits before transmitting MDS data, but this was not adhered to, resulting in the deficiency.
Failure to Update Smoking Care Plan for Resident on Oxygen
Penalty
Summary
The facility failed to ensure that a resident, who was administered oxygen, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident was found smoking in his room, and the smoking care plan was not updated or revised. This oversight increased the risk of a negative outcome to the resident's physical and psychosocial well-being. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, depression, anxiety, and intellectual disability. Despite these conditions, the Minimum Data Set indicated the resident was cognitively intact, which was inconsistent with the list of diagnoses. The facility's records showed discrepancies in the resident's smoking status, with initial assessments indicating the resident did not smoke. However, a later assessment confirmed the resident was a smoker and used electronic cigarettes. The facility's smoking care plan included interventions such as explaining the facility's smoking policies and fire safety, but there was no documentation verifying these interventions were implemented. The facility's policy required re-evaluation of a resident's smoking status upon significant changes, but the care plan was not updated after the resident was found smoking in his room. An LVN acknowledged that the smoking care plan should have been updated and that the smoking education provided to the resident was not documented.
Neglect in Resident Care for ADLs
Penalty
Summary
The facility failed to protect two residents from neglect, as observed in the care of their activities of daily living (ADLs). Resident 77, who required substantial assistance with personal hygiene, was left in a soiled incontinence brief for 45 minutes despite calling out for help multiple times. The resident expressed feelings of being dirty, unimportant, and frustrated due to the lack of timely assistance. Observations revealed that both a CNA and an LVN were aware of the resident's calls for help but did not provide immediate assistance, citing reasons such as the assigned CNA being on lunch break. Resident 48, who was dependent on others for personal hygiene due to visual impairment and other medical conditions, was observed with a dry flaky substance around the right eye, which had not been cleaned since the previous night. The resident expressed discomfort and requested assistance to clean the eye. The CNA acknowledged the resident's need for total care and the necessity to clean the eye to prevent further discomfort or potential infection. The facility's policies on ADLs and abuse and neglect emphasize the importance of providing necessary care to maintain residents' hygiene and prevent neglect. However, the observations and interviews indicate a failure to adhere to these policies, resulting in neglect of the residents' needs. The Director of Staff Development and the Director of Nursing acknowledged the expectations for staff to respond to residents' needs and the potential consequences of neglect, such as skin breakdown and eye infections.
Failure to Provide Behavioral Health Care for Resident with Depression
Penalty
Summary
The facility failed to provide necessary behavioral health care for a resident diagnosed with major depressive disorder. The resident, who was admitted with multiple diagnoses including major depressive disorder, was not monitored for signs and symptoms of depression as outlined in their care plan. The care plan, which was supposed to include interventions such as monitoring and reporting acute episodes of sad feelings, was not updated or reviewed quarterly, and there was no evidence of monitoring or reporting to the physician as needed. The resident expressed feelings of frustration and sadness, which were not adequately addressed by the facility. Despite the resident's care plan indicating the need for psychologist visits every three weeks, there was no record of such visits or evaluations by a psychiatrist or psychologist. Interviews with staff revealed that the resident's depressive symptoms were known, but there was no systematic monitoring or documentation of these symptoms, and the resident was not receiving medication for depression. The facility's policy on behavioral assessment and monitoring was not followed, as the nursing staff failed to identify, document, and inform the physician about changes in the resident's mental status. The Director of Nursing acknowledged that the resident was not being monitored due to the absence of medication for depression and a lack of orders from a psychologist or psychiatrist. This oversight resulted in the resident's behavioral health needs being unmanaged, contrary to the facility's obligation to provide necessary care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to meet the needs of two residents, Resident 77 and Resident 39. Both residents experienced delays in receiving assistance for personal care needs, such as being cleaned and changed. Certified Nursing Assistants (CNAs) reported being assigned over 15 residents each, making it impossible to provide quality care. Observations and interviews revealed that Resident 77 was left calling for help to be changed, and staff were unable to respond promptly due to high workloads. Resident 77 was admitted with chronic osteomyelitis, abnormalities of gait and mobility, and congestive heart failure, requiring substantial assistance with activities of daily living. The resident was observed calling out for help to be changed, and staff were seen passing by without responding. Interviews with CNAs and Licensed Vocational Nurses (LVNs) confirmed that the facility was consistently short-staffed, leading to delays in responding to residents' needs and affecting the quality of care provided. Family members and staff expressed concerns about the facility's staffing levels, with reports of long wait times for phone calls and call lights. The Director of Staff Development acknowledged the potential impact of insufficient staffing on resident care, while the Director of Nursing admitted that the facility had not met required staffing hours in the subacute unit. Despite claims of stabilized staffing, the facility's policy indicated a need for sufficient nursing staff to ensure resident safety and well-being, which was not met in this instance.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and removal of undated and expired medications, specifically insulin, fluticasone-salmeterol, lansoprazole suspension, and gabapentin solution, as per manufacturer's requirements. This affected multiple residents across different medication storage areas, including the Station A Medication Room and various medication carts. Observations revealed that insulin vials and pens were either not labeled with an open date or were stored beyond their expiration dates, which could lead to ineffective treatment for residents with diabetes. In the Middle Medication Cart, several insulin products were found to be expired, including Insulin Lispro Kwik Pen, Basaglar Kwik Pen, Admelog SoloStar, and Humulin N KwikPen. Additionally, fluticasone and salmeterol inhalation powder was found to be expired. These medications were not removed from the cart as required, potentially compromising their effectiveness and safety for residents with conditions such as diabetes and respiratory issues. Furthermore, during medication administration, timolol eye drops were left unattended on a resident's bedside cart, posing a risk for misplacement or misuse. The facility's policy and procedure for medication labeling and storage were not adhered to, as medications were not stored in locked compartments or under proper conditions, and labels did not consistently include necessary information such as expiration dates and resident names.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. There was a carton of thickened milk stored in the refrigerator without an open date, and a carton of thickened apple juice was mislabeled with a use-by date that exceeded the facility's guidelines for fruit juice storage. Additionally, a peeled onion was improperly stored at room temperature in the bulk onion storage container, which should have been refrigerated. The Dietary Supervisor acknowledged these issues, stating that opened products should be marked and used within seven days according to facility guidelines. Furthermore, nutritional supplements labeled to be stored frozen and used within 14 days of thawing were not monitored for the correct thaw date. Thirty strawberry-flavored nutrition supplements were found in the refrigerator with different thaw dates, leading to uncertainty about their freshness. The Dietary Supervisor admitted to not knowing the real thaw date due to multiple dates being recorded and subsequently discarded the supplements. This oversight had the potential to cause foodborne illness among residents consuming these supplements. Additionally, a can opener blade in the kitchen was found to be dirty with sticky brown residue and was worn and nicked, making it difficult to clean properly. The Dietary Supervisor confirmed that the blade needed replacement as it could not be adequately cleaned and sanitized, posing a risk of contamination. The facility's policy on sanitization requires all equipment to be maintained in good repair and free from defects that could affect their use or cleaning, which was not adhered to in this instance.
Deficiency in Audible Call System Functionality
Penalty
Summary
The facility failed to ensure that the audible resident call system remained functional, which had the potential to prevent staff from answering call lights promptly. The call light for a specific room was not audible when pressed, as observed during the survey. A resident admitted with Guillain-Barre Syndrome, spinal stenosis, and muscle weakness, who was dependent on staff for mobility and at risk for pressure ulcers, reported that the call system was broken. The resident expected an automated voice announcement when the call light was activated, which was not functioning as intended. Interviews with staff revealed that the call light system was supposed to light up outside the room and announce the room number, but the announcement feature had not been working for about six months. Maintenance staff confirmed that while the light was visible on the panel across from the nurse's station and outside the room, the room number announcement was not audible. Observations on different days showed inconsistency in the audible system's functionality. The Director of Nursing emphasized the importance of both audible and visual systems working, while the Administrator mentioned that CNAs were stationed at the end of hallways to visually monitor call lights as a temporary measure.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain dignity and privacy for Resident 63 by not closing the bedside curtain during medication administration. This incident was observed when the Director of Nursing (DON) instructed Licensed Vocational Nurse (LVN) 4 to assist LVN 3 with a medication pass. LVN 3 entered Resident 63's room with prepared medications but did not close the bedside curtain while administering them. This action violated the resident's right to privacy and dignity. Resident 63 was admitted to the facility with diagnoses including Type II Diabetes Mellitus and unspecified anemia. The resident had intact cognition and required assistance for personal hygiene. Interviews with the DON and LVN 4 confirmed the importance of closing the bedside curtain to ensure privacy and dignity, and it was noted that LVN 3 did not follow this protocol. The facility's policy on dignity, reviewed in August 2024, emphasized treating residents with dignity and respect, including maintaining privacy during care and treatment procedures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,766 citations issued within 25 miles in the last 12 months — including the 36 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rehabilitation Center On Pico | 0 mi | ★★★★★ | 18 | 0 |
| St Andrews | 0.5 mi | ★★★★★ | 0 | 0 |
| Alcott Rehabilitation Hospital | 0.7 mi | ★★★★★ | 16 | 0 |
| Sunnyview Care Center | 0.8 mi | ★★★★★ | 4 | 0 |
| Windsor Gardens Convalescent Hospital | 0.8 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sunray Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.