Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Sunset Manor Conv Hosp during CMS and state inspections, most recent first.
Call Lights Not Kept Within Reach: Two residents had call lights that were not accessible while in bed. One resident with confusion, gait/balance problems, and high fall risk had the call light hanging low on the bed rail and could not reach it. Another resident with COPD, confusion, and a history of falls had the call light on the floor until a CNA placed it on the blanket. Staff and the facility P&P stated call lights should be within reach and accessible.
Incomplete and missing AD documentation was found for two residents. One resident’s ADAF lacked the MRN, RP name and relationship, and staff signatures, while another resident had no POLST or AD acknowledgement form in the binder or EMR. The DON, SSD, and MR all confirmed the forms were incomplete or absent, and the residents had cognitive impairment or dementia noted in their records.
Psychotropic Medication Monitoring and Target Behavior Deficiencies: The DON confirmed that one resident receiving Divalproex, Clozapine, Olanzapine, and Trazodone had no documented monitoring for adverse side effects despite care plan directions to monitor psychotropic use. For another resident receiving Duloxetine for depression, the care plan used sad facial expressions as the target behavior, and the DON stated this was not a specific target behavior even though the resident could express needs and feelings.
Two residents did not have resident-specific care plans for identified needs. One resident with ESRD, dialysis, and an AV shunt had an active EBP order, but the care plan did not address the infection control intervention. Another resident with pneumonia, a left BKA stump infection, and severe cognitive impairment had an order for Bactrim DS for the infection, but no care plan was developed for antibiotic therapy or monitoring for response, side effects, or adverse reactions.
Care Plan Not Updated for PJP Prophylaxis: A resident admitted with respiratory failure and depression had an antibiotic care plan for encephalitis, but when the physician later ordered Bactrim DS for PJP prophylaxis, the care plan was not revised to reflect the new treatment. The QAN and DON stated the plan was not updated to guide staff on the resident’s antibiotic care and treatment.
A resident with dementia and severely impaired cognition, whose preferred language was Cantonese, did not have a communication board in the room. RNA confirmed the resident did not speak or understand English and stated that non-English speaking residents should have a communication board with pictures and descriptions in their spoken language to help communicate basic needs. The DON also stated that non-English speaking residents should have a communication board to express needs and help staff address them appropriately.
Failure to Secure Foley Catheter: A resident with an indwelling FC for obstructive and reflux uropathy due to BPH was observed with the catheter tubing hanging on the side of the bed and not secured with a securement device. The DSD and DON stated the tubing should have been anchored on the resident’s thigh to prevent it from being pulled out and to avoid injury during care and movement, consistent with the facility’s P&P.
Missing Oxygen Warning Sign Outside Resident Room: A resident with pneumonia, dementia, and HF was receiving oxygen via NC at 2 l/min for shortness of breath/wheezing, but no oxygen-in-use warning sign was posted outside the room. The IPN and DON both stated that residents on oxygen therapy should have a warning sign posted to indicate oxygen was in use and smoking was prohibited, and the facility policy also directed staff to place an oxygen warning sign on the resident's door.
Bed rails used without order, consent, or documented need. A resident with osteoarthritis, a recent knee replacement, and moderately impaired cognition was observed with bilateral siderails up even though the BRA said bed rails were not needed, the resident said they were not needed, and the EMR had no physician order or consent for their use. Staff and the facility P&P stated informed consent and a physician order were required before installation.
Laundry Dryer Lint Trap Not Maintained: One of two laundry dryers had multiple thick patches of light brown material on the lint trap during observation. HKP 1 said the lint trap was not being monitored or documented because the log was unreadable, and the HKP Sup said lint had accumulated and the log had been filled out in advance by staff. The facility policy required lint traps to be cleaned and inspected every 2 hours and documented on the designated log.
A resident with COPD, anxiety, depression, intact cognition, and independence with ADLs had care plans identifying fall risk and hoarding behavior, with interventions to maintain a clutter-free environment and for the IDT to follow up on hoarding to protect others’ safety. Social services documented educating the resident about clutter-related safety hazards and the resident’s refusal to store belongings elsewhere, but no further follow-up or alternative interventions were recorded. On observation, the resident’s bed area was surrounded by boxes, crates, and bags of clothes, leaving little space to access the roommate’s bed, and both the roommate and a CNA reported staff had difficulty providing care due to the clutter. The facility therefore failed to implement the care-planned interventions to keep the area free of clutter.
Delayed Resident Mail Delivery: A resident with COPD, acute pulmonary edema, and anxiety disorder, who had intact cognition and decision-making capacity, did not receive SSI mail within 24 hours of delivery to the facility. Social Service staff stated the mail was held for weeks before being given to the resident, the facility had no documentation to track receipt or delivery of mail and packages, and mail was not delivered on weekends because no Social Service staff were available.
Nursing staff did not implement a person-centered care plan for a resident with cognitive impairment and complex medical needs, failing to monitor symptoms of confusion and physical abusiveness as required by the care plan. Interviews and record reviews confirmed the absence of documentation or monitoring over several months, despite facility policy mandating such interventions.
A resident with multiple complex medical conditions and cognitive impairment received hydrocodone-acetaminophen via G-tube for pain, but the PRN order did not specify the required pain severity for administration. Nursing staff administered the medication for pain levels between 4 and 9, despite facility policy requiring clarification of such orders to indicate the appropriate pain level. Staff and the DON confirmed the order was incomplete and not entered according to policy.
Three residents were not properly informed about their right to formulate an advance directive (AD), with one resident not receiving any AD information and two others having inaccurately completed AD Acknowledgement Forms. Staff interviews confirmed the importance of AD documentation, and facility policy required providing this information and ensuring accurate records, but these procedures were not followed.
The facility did not act on pharmacist recommendations for two residents, including ordering a lab test to monitor for rhabdomyolysis risk in a resident receiving both a statin and fibric acid, and discontinuing Benadryl for another resident as advised. Both recommendations were documented but not implemented, leaving unnecessary medications in use.
Surveyors observed a bottle of basil pesto sauce in the kitchen freezer with an unreadable best by or use by date. The Assistant confirmed the date was not legible and recognized the importance of date marking for food safety. Facility policy requires all ready-to-eat foods to be clearly marked with a date to ensure proper consumption or disposal.
A resident who required substantial assistance for daily activities was found unable to reach their call light, which was wrapped outside the bedrail. The resident reported being unable to locate or access the device, and an LVN confirmed it was not within easy reach, contrary to facility policy requiring call lights to be accessible to residents.
A resident with diabetes, dysphagia, and a pressure ulcer, who was dependent on staff and preferred Vietnamese, was not provided with a communication board as required by the care plan. Staff relied on a coworker for translation, but no alternative communication method was available when that coworker was absent, contrary to facility policy.
A resident with diabetes, dysphagia, and a heel pressure injury was observed multiple times with both heels resting on the mattress, despite a physician's order to free float the heels using pillows. The resident was fully dependent on staff, and both staff and policy confirmed the need for heel offloading to prevent further pressure injury, but the intervention was not implemented.
A resident receiving hemodialysis with a physician-ordered daily fluid restriction did not have their intake monitored or limited as required. Nursing and dietary staff failed to document or enforce the fluid restriction, and the resident reported being unaware of any limits, consuming fluids freely. The DON confirmed there was no system in place to track or restrict the resident's fluid intake, contrary to facility policy and physician orders.
A resident who spoke only Spanish was asked to sign a binding arbitration agreement presented solely in English, without explanation in their preferred language. Staff interviews confirmed the resident did not understand the document, and facility policy required such agreements to be explained in a language the resident understands.
A room in the Sub Acute Unit was found to have five beds, with four occupied, exceeding the regulatory limit of four residents per room. Staff and the administrator confirmed the arrangement, and a waiver request was in process, but the room was not in compliance at the time of the survey.
The facility did not ensure that nine resident rooms met the required minimum of 80 sq ft per resident in multiple occupancy rooms. Staff and residents reported that there was enough space for care and mobility, and observations confirmed that care was provided without difficulty. The facility submitted a waiver request, stating that resident safety and care were not compromised by the current room sizes.
A facility failed to follow its infection control policies when an LVN did not wash hands with soap and water after caring for a resident with C. difficile, using hand sanitizer instead. The LVN cited the resident's roommate's use of the restroom as the reason. Interviews with the DON and IP confirmed the importance of proper handwashing to prevent infection spread.
A resident with severe cognitive impairment and multiple health conditions sustained a hand laceration due to a damaged bed remote control coil line. The facility failed to maintain the equipment in good condition, and the CNA did not prevent the resident from grabbing the hazardous coil, resulting in the injury requiring hospital treatment.
A resident with severe cognitive impairment sustained a laceration on the hand due to a damaged bed remote control coil line in an LTC facility. The outer plastic layer of the coil line was broken, exposing a sharp edge that caused the injury. The Maintenance Assistant revealed that checking the bed remote control was not part of routine tasks, leading to the oversight. The Director of Nursing emphasized the need for regular equipment checks to ensure safety.
The facility failed to maintain its infection control program for two residents with scabies. A resident was confirmed to have scabies, but a line list was not initiated immediately, and infection control measures were not implemented for another resident highly suspicious of scabies. The facility did not follow its infection control policy or local guidelines, compromising infection prevention efforts.
A resident's medication was left unattended at the bedside, contrary to professional standards. The resident, with type 2 diabetes and COPD, had Gabapentin capsules left in a medicine cup, which the resident saved for later use. The DON confirmed that medications should not be left at the bedside and must be observed being taken by residents, as per facility policy.
A CNA entered a COVID-19 isolation room without full PPE, wearing only an N95 mask, despite facility policy and posted precautions requiring a gown, gloves, face mask, and eye protection. The incident involved a resident exposed to a COVID-19 positive roommate. Interviews confirmed the PPE requirements, and the CNA acknowledged the need for full PPE to prevent virus spread.
A resident with contractures and functional quadriplegia did not receive proper nail care, as CNAs failed to trim and clean fingernails or notify LVNs about overgrown toenails. LVNs did not inform the SSD to arrange for a podiatrist. Observations confirmed the resident's nails were long and dirty, posing a risk of injury and infection. The facility's policy for regular nail care was not followed.
The facility failed to provide reasonable accommodation of needs for two residents. One resident with severe mobility limitations was unable to use the call light, and another high-risk fall resident had an inaccessible call light. Staff did not follow the facility's policies on call light accessibility and accommodation of needs.
The facility failed to provide Advance Directive (AD) information for two residents, leading to potential treatment against their will. One resident with type 2 diabetes and fluctuating decision-making capacity did not have a completed AD form, while another resident with hypertension and impaired cognition had no AD assessment performed. Interviews confirmed the facility did not follow its policy on documenting AD information upon admission.
The facility failed to provide appropriate care for two residents with catheters, leading to potential risks of trauma and infection. One resident's indwelling catheter was not connected to a stabilization device, and another resident's suprapubic catheter was not covered or secured, as observed by staff.
The facility failed to follow its P&P for enteral feeding for two residents. One resident's G-tube dressing was not changed as required, and another resident was lying flat during feeding, contrary to care plan instructions. These lapses had the potential to cause infection and aspiration.
The facility failed to ensure proper respiratory care and safety for two residents receiving oxygen therapy. One resident's nasal cannula tubing was not stored in a plastic bag when not in use, and another resident did not have a spare tracheostomy tube readily available at the bedside, contrary to facility policies.
The facility failed to attempt appropriate alternatives before installing bed rails for two residents with dementia and epilepsy. The assessments did not document how the attempted alternatives failed or consider other available options like bolsters or bumpers, contrary to the facility's policy.
The facility failed to provide a safe and sanitary environment, leading to potential infection risks for five residents. Issues included improper wound care for a resident, failure to change curtains during deep cleaning for two residents, and inadequate hand hygiene and PPE use by staff. These deficiencies were confirmed by facility staff and were against the facility's policies.
A facility failed to create a comprehensive care plan for a resident with multiple pressure injuries, despite the resident's high risk for developing such injuries. The absence of a detailed care plan for each injury was confirmed by nursing staff and the ADON, putting the resident at risk of worsening conditions due to lack of proper treatment and monitoring.
A facility failed to ensure a resident with a tracheostomy and chronic respiratory failure was provided with a Passy-Muir Valve (PMV) for effective communication. Despite a physician's order and staff training, the PMV was not utilized, leading to communication difficulties for the resident.
The facility failed to follow its own policy for pressure injury prevention for a resident with multiple pressure injuries. Despite an active MD order for bilateral heel protectors, the protectors were not observed on the resident, potentially worsening existing injuries. Staff interviews confirmed the oversight, highlighting a lapse in adherence to wound management protocols.
The facility failed to adhere to the prescribed turning and repositioning schedule for a resident with severe cognitive impairment and multiple stage 4 pressure ulcers. Observations and staff interviews revealed that the resident was left in the same position for extended periods, contrary to the facility's policy, leading to the potential for further skin damage and delayed wound healing.
The facility failed to ensure that a resident's right-hand splint was maintained and properly applied according to the care plan and facility policy. The resident, diagnosed with muscle wasting and contracture, was on a Restorative Nursing Program requiring splints for four hours daily. Observations and staff interviews confirmed non-compliance, placing the resident at risk for contractures and decline in physical function.
The facility failed to follow policy and procedure for the use of a Hoyer Lift, leaving a resident suspended in the air unsupervised. The resident, who had multiple medical conditions, was at risk of falling and sustaining serious injury due to the CNA operating the lift alone.
The facility failed to provide adequate supervision or assistance during meals for a resident with severe cognitive impairment and Parkinson's disease, leading to potential further weight loss. Observations revealed the resident struggled to eat independently due to tremors and was often left unattended, resulting in most of her food being untouched. Staff interviews indicated a lack of familiarity with the resident's needs and inconsistent documentation. The resident's weight log showed a significant decline, and the facility's policies on weight management and meal supervision were not followed.
The facility failed to label and date the midline intravenous catheter for a resident with type 2 diabetes mellitus and hyperglycemia, as required by the care plan and facility policy. This oversight was confirmed by the Infection Preventionist Nurse and the Assistant Director of Nursing, posing a potential risk of infection.
The facility failed to ensure accurate MDS assessments for two residents' discharge destinations. One resident discharged to a SNF was incorrectly coded as discharged to home, while another resident discharged to home was coded as discharged to a GACH. These errors were confirmed through record reviews and staff interviews, highlighting the importance of accurate coding for CMS reporting and resident care.
The facility failed to ensure that a resident room accommodated no more than four residents, as required by regulations. Room [ROOM NUMBER] had five beds, with four occupied, leading to potential privacy concerns and crowded conditions. The facility had requested a room waiver, stating that the room's size was adequate for the residents' needs and did not compromise their health and safety.
The facility failed to ensure that 14 rooms met the required 80 square feet per resident in multiple resident rooms. Despite the Administrator's plan to request a room waiver and staff and residents indicating that care was not compromised, the deficiency was noted due to non-compliance with regulatory square footage requirements.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. One resident was admitted with diagnoses including muscle wasting and atrophy, gait abnormalities, and schizophrenia, and was assessed as high risk for falls due to intermittent confusion, being chairbound, balance problems, and needing assistive devices. The resident’s care plan identified risk for falls related to confusion, gait and balance problems, and being unaware of safety needs, and directed staff to place the call light within reach and encourage its use for assistance. During observation, the resident was awake and lying in bed but could not find the call light, which was hanging on the lower left side of the bed rail and was not reachable. The DSD confirmed the call light was hanging on the left side of the bed and could not be reached by the resident. A second resident was admitted with diagnoses including COPD and a history of falling, and the H&P described the resident as weak, confused, and unable to make decisions regarding care. The resident’s care plan identified risk for recurrent falls and directed staff to provide a safe environment with the call light within reach and prompt response to requests for assistance. During observation, the resident was in bed with the call light on the floor. A CNA picked up the call light and placed it on the resident’s blanket, stating it should not be on the floor and needed to be within reach so the resident could call if anything was needed. Staff interviews and the facility policy stated the call system should be accessible to residents while in bed or other sleeping accommodations.
Incomplete and Missing Advance Directive Documentation
Penalty
Summary
The facility failed to ensure its policies and procedures on Advance Directives were implemented for two residents by not keeping Advance Directive documentation complete and available in the medical record. For one resident, the Advance Healthcare Directive Acknowledgement Form dated 9/17/2025 was reviewed and did not include the resident’s medical record number, the resident representative’s name and relationship, or the names of the facility staff who signed the form. The Social Services Director stated the form was not accurately done and was not complete, and the Director of Nursing stated the form should be completely filled out because it was an important legal document used to follow the resident’s and representative’s wishes for end-of-life care. That resident’s record also showed diagnoses including metabolic encephalopathy and dementia, and the History and Physical dated 9/18/2025 stated the resident had dementia and was unable to make any decisions. The facility’s policy on Documentation in Medical Record stated documentation should be accurate, relevant, and complete, and each entry would be signed with the name and credentials of the person making the entry. The policy on Resident’s Rights Regarding Treatment and Advance Directives stated any decision making regarding the resident’s choices would be documented in the medical record. For a second resident admitted on 4/11/2026, the binder and electronic medical record were reviewed and there was no copy of the POLST or Advance Directive acknowledgement form in either location. The Medical Records staff stated the resident had been in the facility for five weeks and the documents were not present in the binder or uploaded in the EMR. The resident’s MDS dated 4/15/2026 showed moderately impaired cognition and varying levels of assistance needed with activities of daily living. RN 2 and the DON stated the POLST and Advance Directive acknowledgement form should be completed on admission and kept in the binder and EMR so staff could identify the resident’s end-of-life wishes and preferences.
Psychotropic Medication Monitoring and Target Behavior Deficiencies
Penalty
Summary
The facility failed to prevent unnecessary use of psychotropic medications for two residents by not following its policy and the residents’ care plans. For one resident admitted with muscle wasting and atrophy, schizophrenia, and unspecified psychosis, the record showed orders for Divalproex for mood stabilization, Clozapine for schizophrenia with auditory hallucinations, Olanzapine for psychosis with increased aggression, and Trazodone for depression with inability to sleep. The care plans identified these psychotropic medications and directed nursing staff to administer them as ordered and monitor for side effects, but the DON stated there was no monitoring done for adverse side effects of Divalproex, Clozapine, Olanzapine, and Trazodone, and that side effects should be monitored every shift by licensed nurses. For another resident admitted with respiratory failure and depression, the care plan identified Duloxetine for depression and directed staff to monitor, document, and report adverse reactions and medication effectiveness. The care plan described the resident’s depression as manifested by sad facial expressions, and the order summary showed Duloxetine 30 mg daily for depression manifested by sad facial expressions. During interview, the DON stated that sad facial expression was not a specific target behavior and that the resident was able to express needs and feelings. The facility’s policy on psychotropic medication stated these medications are to be used only when appropriate for a specific, diagnosed, and documented condition and that the resident’s response, including progress toward the goal and presence or absence of adverse consequences, must be documented in the medical record. The deficiency was based on the lack of monitoring for adverse side effects for one resident’s multiple psychotropic medications and the use of a nonspecific target behavior for another resident’s Duloxetine order and care plan.
Failure to Develop Resident-Specific Care Plans for EBP and Antibiotic Therapy
Penalty
Summary
Failure to develop and implement specific, individualized care plans was identified for two residents. Resident 14 was admitted with ESRD and dependence on renal dialysis, and the MDS indicated dialysis was being received. The OSR showed an active order for Enhanced Barrier Precautions related to a right arm AV shunt, and during observation Resident 14 had a right upper arm dressing and stated dialysis was received three times weekly. However, review of the current care plan showed no care plan addressing the EBP order, and the LVN stated a care plan should have been in place to prevent infection of the AV shunt. Resident 26 was admitted with pneumonia, infection of the left lower extremity amputation stump, and PVD. The MDS indicated severely impaired cognition and dependence or partial assistance with several activities of daily living. The OSR showed an order for Bactrim DS twice daily for left BKA infection, and the DSD confirmed the resident was on antibiotic therapy through 5/25/2026. Review of the care plan showed no care plan developed for the antibiotic therapy, and the DSD stated there was no care plan for the use of antibiotics. The DON stated care plans should be resident-specific and should include interventions and goals to guide staff in providing necessary care and monitoring effectiveness. The facility policy on Comprehensive Care Plans stated the facility was to develop and implement a comprehensive person-centered care plan for each resident and that the plan would describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Care Plan Not Updated for PJP Prophylaxis
Penalty
Summary
The facility failed to revise Resident 73’s care plan to reflect Pneumocystis Jirovecii Pneumonia (PJP) prophylaxis after the physician ordered Bactrim DS 800-160 mg by mouth every Monday, Wednesday, and Friday for PJP. Resident 73 was admitted on 2/6/2026 with diagnoses including respiratory failure and depression, and the initial care plan addressed antibiotic therapy for encephalitis with an intervention for licensed nursing staff to administer the antibiotic as ordered by the physician. A review of the resident’s MDS dated 5/7/2026 showed moderately impaired cognition for daily decision making and varying levels of assistance needed with activities of daily living. The Order Summary Report dated 5/14/2026 listed Bactrim DS for PJP, but the care plan was not updated to reflect this change. During interview, the QAN stated the care plan was not revised when the order was received, and the DON stated the licensed nurse did not update the care plan to reflect what the resident was treated for.
Failure to Provide Communication Board in Resident’s Preferred Language
Penalty
Summary
The facility failed to ensure that a non-English speaking resident was provided with a communication board or device in a language the resident understood. Resident 2 was admitted with diagnoses including dementia, anxiety, and a history of falling. The resident’s MDS dated 5/7/2026 identified Cantonese as the preferred language and indicated severely impaired cognition for daily decision making. The MDS also showed the resident required partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene, and was dependent for toileting, showering, and lower body dressing. During observation and interview, Resident 2 was speaking a language other than English, and RNA 1 stated the resident spoke Cantonese and did not speak or understand English. RNA 1 also stated Resident 2 did not have a communication board in the room, and that residents whose primary language was not English should have a communication board with pictures and descriptions in their spoken language to help communicate basic needs. The DON stated that all non-verbal, alert and oriented residents and non-English speaking residents should have a communication board in the room to express needs and allow staff to address those needs appropriately. The facility policy on Effective Communication stated staff would communicate with residents using techniques identified in the plan of care, including communication boards or writing materials.
Failure to Secure Foley Catheter
Penalty
Summary
The facility failed to ensure Resident 27’s Foley catheter was secured on the resident’s thigh in accordance with the facility’s policy and procedure for indwelling catheter use and removal. Resident 27 was admitted with obstructive and reflux uropathy and benign prostatic hyperplasia, and the care plan identified an indwelling catheter related to the urinary condition. The resident’s MDS indicated moderately impaired cognition and dependence on staff for toileting and several activities of daily living. During observation, Resident 27 was awake and lying in bed with the Foley catheter hanging on the right side of the bed. The Director of Staff and Development observed that the catheter tubing was not secured with a securement device and stated it should have been secured properly on the resident’s right thigh to prevent the tubing from being pulled out and to prevent injury during movement or ADLs. The DON also stated the catheter tubing needed to be secured with a securement device to ensure it would not be pulled out during care and prevent injury to the resident. The facility policy stated the catheter should be anchored to prevent excessive tension, urethral tears, dislodgement, kinks in the tubing, and to keep it positioned below the bladder.
Missing Oxygen Warning Sign Outside Resident Room
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had an oxygen-in-use warning sign posted outside the room. Resident 26 was admitted with diagnoses including pneumonia, dementia, and heart failure. The care plan identified altered respiratory status and difficulty breathing, and the MDS showed severely impaired cognition and dependence for some activities of daily living. The order summary indicated the resident had an order for oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath and wheezing. During a concurrent observation and interview, Resident 26 was in bed receiving oxygen at 2 l/min via nasal cannula, and the Infection Prevention Nurse stated there was no oxygen-in-use warning sign posted outside the room. The nurse stated residents on ongoing oxygen therapy should have a warning sign posted outside the room indicating oxygen was in use and smoking was prohibited. The DON also stated residents on oxygen therapy should have an oxygen-in-use warning sign posted outside the room to alert visitors and residents not to smoke inside the room. The facility policy titled Oxygen Concentrator stated to place an oxygen warning sign on the resident's door.
Bed rails used without order, consent, or documented need
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of bed rails/siderails for Resident 64. Resident 64 was admitted with diagnoses including osteoarthritis and right knee joint replacement surgery. The Bed Rails Assessment dated 4/11/2026 indicated the resident did not need bed rails, and the Minimum Data Set dated 4/15/2026 showed moderately impaired cognition, supervision or touching assistance with oral hygiene, upper body dressing, and personal hygiene, partial/moderate assistance with toileting and lower body dressing, and dependence with showering. On 5/19/2026, surveyors observed Resident 64 sitting on the edge of the bed with bed rails/siderails up on both sides of the bed. CNA 2 stated the resident was able to sit, stand, and walk with supervision, and the resident stated the siderails were not needed and had not been requested. Record review showed no active order for bilateral 1/2 bed rails and no consent for their use in the EMR. Staff interviews confirmed that residents with bed siderails should have a physician's order and consent before installation, and the facility's P&P required informed consent after alternatives had been attempted and then a physician's order for the specified bed rail.
Laundry Dryer Lint Trap Not Maintained
Penalty
Summary
The facility failed to keep one of two laundry dryers in a safe, operating, and sanitary condition for residents. During a concurrent observation and interview in the laundry room, one dryer was found with multiple random thick patches of light brown material on the dryer lint trap. Housekeeping 1 stated the lint trap was not being monitored, signed, or completed on the Dryer Lint Clean Out Schedule Form because the form was unreadable, and stated the lint trap needed to be cleaned every 2 hours to avoid potential fire. During a concurrent interview and record review, the Housekeeping Supervisor stated the dryer lint trap was thick and lint had accumulated. The supervisor stated the lint trap should have been cleaned every 2 hours to avoid fire and prevent infection. The supervisor also stated the Dryer Lint Clean Out Schedule Form had been filled out by mistake by Housekeeping staff that morning, with entries completed in advance through 8:00 PM on 5/21/2026, and stated the form should be completed timely after each cleaning, not in advance. The facility policy required laundry staff to clean and inspect dryer lint traps every 2 hours during operational hours and whenever excessive lint buildup was observed, and to document each cleaning on the designated log.
Failure to Implement Care Plan to Control Clutter and Maintain Safe Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement the care plan interventions to maintain a safe, clutter-free environment for a resident at risk for falls. The resident was admitted with COPD, anxiety disorder, and depression, and had minor memory impairments but intact cognitive skills and independence with ADLs and mobility. The resident’s care plan documented a risk for falls related to incontinence and a history of falls, with interventions that included providing a safe environment free from spills and clutter. A separate care plan for hoarding behavior related to anxiety and depression directed the IDT to follow up with the resident regarding hoarding and to intervene as necessary to protect the rights and safety of others. Despite these identified needs and interventions, there were no updates or changes to the care plan after its initiation. Social services documented that the resident had been educated about how excessive clutter around the bed posed a safety hazard to both the resident and roommates, and that the resident refused offers to store belongings in an alternate location. However, from that point through the survey period, there were no additional notes in the medical record indicating ongoing assistance or encouragement to remove clutter from the room. During observation, the resident’s bed was surrounded by stacked boxes, crates, and bags filled with clothes, leaving minimal space to access the roommate’s bed. The roommate and a CNA reported that staff had difficulty assisting other residents in the room due to the clutter around the resident’s bed. This demonstrated that the facility did not carry out the care-planned interventions to maintain a safe, clutter-free environment as required by its comprehensive care plan policy.
Delayed Resident Mail Delivery
Penalty
Summary
The facility failed to ensure that one sampled resident received mail and other packages within 24 hours of delivery. Resident 1 was admitted with diagnoses including COPD, acute pulmonary edema, and anxiety disorder. The resident’s H&P indicated the resident had capacity to make medical decisions, and the MDS indicated intact cognition and independence with dressing, bathing, toileting hygiene, and personal hygiene. During interview and record review, Resident 1 stated that Social Service gave the resident SSI mail dated 9/1/2025 in November 2025. The Social Service Director stated the letter had been received by the facility for a couple of weeks before being delivered to the resident in October 2025, and that the facility had no documentation to trace or record the date mail was received and delivered. The Social Service Assistant stated Social Service was responsible for delivering resident mail but there was no documentation to track receipt and delivery. The BOA stated Social Service was responsible for delivering letters and packages after receiving them, and that mail and packages were not delivered on weekends because there was no Social Service staff available. The DON stated the facility did not have a policy and procedure for tracing received mail and packages and delivering them to residents.
Failure to Implement Person-Centered Care Plan and Monitor Resident Symptoms
Penalty
Summary
The facility failed to ensure that nursing staff implemented a person-centered care plan for a resident with multiple complex medical conditions, including hemiplegia, hemiparesis following a nontraumatic intracerebral hemorrhage, acute kidney failure, and neuromuscular dysfunction of the bladder. The resident was documented as having fluctuating capacity to understand and make decisions, and was assessed as moderately impaired in cognitive skills, requiring substantial to maximal assistance with daily activities. The care plan specifically identified increased confusion and physical abusiveness towards staff, with an intervention to monitor for worsening symptoms. Despite these documented needs and interventions, interviews and record reviews with nursing staff and the DON revealed that there was no documentation or evidence that the care plan was implemented, specifically regarding the monitoring of the resident's symptoms of confusion and physical abusiveness. The facility's own policy required that qualified staff be notified of their responsibilities and that interventions be carried out as specified in the care plan. However, for several months, there was no monitoring record or documentation to indicate that staff had followed the care plan interventions for this resident.
Failure to Specify Pain Severity in PRN Analgesic Order
Penalty
Summary
The facility failed to ensure that a licensed nurse implemented the facility's policy and procedure regarding medication orders by not specifying the severity of pain for a PRN hydrocodone-acetaminophen order for one resident. The resident, who had significant medical conditions including hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and aphasia, was cognitively impaired and dependent on staff for care. The medication order for hydrocodone-acetaminophen via G-tube was written as 'every four hours as needed for pain' without indicating the pain severity (such as moderate or severe pain) or using a numerical pain scale, as required by facility policy. Record reviews and staff interviews confirmed that the medication was administered for pain levels ranging from 4 to 9, but the original order did not specify the pain level threshold for administration. Both nursing staff and the Director of Nursing acknowledged that the order should have been clarified with the physician to specify the appropriate pain level for administration. Facility policies required PRN orders to specify the condition for use and for staff to clarify incomplete orders, but this was not followed in this instance.
Failure to Provide and Accurately Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that three residents and/or their representatives were provided with information regarding their right to formulate an advance directive (AD). One resident, who was readmitted with diagnoses including diabetes mellitus, cirrhosis of the liver, and dependence on renal dialysis, was found to be cognitively intact and capable of making decisions. However, both the paper and electronic charts lacked documentation of an AD, and the resident confirmed not being informed about ADs or provided with related information by staff. For two other residents, review of their records revealed that the AD Acknowledgement Forms were filled out inaccurately. One resident, with moderate cognitive impairment and requiring significant assistance with daily activities, had an AD form that did not accurately indicate whether the resident or their responsible party had executed an AD. The Social Service Director acknowledged the form was not completed correctly. The other resident, who had intact cognition and required assistance with personal care, also had an AD form that was filled out incorrectly, as confirmed by the LVN who completed the form. Interviews with facility staff, including the DON and LVNs, confirmed the importance of AD documentation for understanding and recording residents' wishes regarding medical treatment. The facility's policy required providing information about ADs and ensuring proper documentation upon admission, but this was not followed for the three residents in question.
Failure to Act on Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly drug regimen review were acted upon for two residents. For one resident with diagnoses including diabetes, cirrhosis, and renal dialysis dependence, the pharmacist recommended ordering a fasting lipid panel (FLP) to monitor for increased risk of rhabdomyolysis due to concurrent use of Fenofibrate and Atorvastatin. The pharmacist also advised re-evaluating the necessity of continuing both medications together. This recommendation was documented, but there was no evidence that the physician responded or that the recommended laboratory test was ordered, and the resident continued to receive both medications. For another resident with a history of infectious and parasitic diseases, the pharmacist recommended discontinuing as-needed Benadryl and starting Claritin for chronic itching. Despite this recommendation being documented in the resident's record, there was no evidence that Benadryl was discontinued, and the medication remained active in the resident's orders. Nursing staff confirmed that the recommendation had not been implemented and that there was no clinical documentation indicating follow-up on the pharmacist's suggestion. The facility's policy required that all pharmacist-identified irregularities be acted upon according to established procedures, with urgent issues communicated to the DON or designee. In both cases, the facility did not follow through on the pharmacist's recommendations, resulting in the potential for unnecessary medication administration.
Unlabeled Pesto Sauce in Kitchen Freezer
Penalty
Summary
During an initial tour and observation of the facility kitchen, surveyors found a 22-ounce bottle of basil pesto sauce stored in the freezer with an unreadable best by or use by date. The Assistant confirmed that the date was not legible and acknowledged the importance of such dates for determining food safety and when to discard products. Review of the facility's policy indicated that all ready-to-eat, time/temperature control for safety foods must be clearly marked with a date to ensure they are consumed or discarded appropriately. The failure to maintain a readable date on the pesto sauce represented a lapse in adherence to the facility's food safety and date marking procedures.
Call Light Inaccessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident who required substantial to maximal assistance with personal hygiene, eating, and repositioning. The resident, who had diagnoses including diabetes mellitus and a fungal nail infection, was observed lying in bed with the call light wrapped outside of the left bedrail, making it inaccessible. The resident reported being unable to find or reach the call light. During the observation, a Licensed Vocational Nurse confirmed that the call light was not within easy reach and acknowledged that the resident needed help to access it. The facility's policy and procedure required staff to ensure call lights are within reach and secured as needed. This failure to follow policy resulted in the resident not having timely access to assistance.
Failure to Provide Communication Aid for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an effective communication method for a non-English speaking resident who preferred Vietnamese and was dependent on staff for activities of daily living. The resident had significant medical conditions, including diabetes mellitus, dysphagia, and a pressure ulcer, and was unable to understand or make herself understood in English. Observations revealed that there was no communication board at the resident's bedside, despite the care plan specifying the need for one due to the language barrier. Staff interviews confirmed the absence of a communication board and indicated reliance on a coworker for translation, who was not always available. The facility's policy required language assistance through various means, including bilingual staff, interpreters, or communication aids, but these were not provided in this case. The lack of an effective communication method had the potential to impact the resident's ability to express needs and receive necessary care and services. The deficiency was identified through observation, interviews with staff and the resident's responsible party, and review of the resident's records and facility policies.
Failure to Follow Physician's Order for Heel Offloading in Pressure Injury Care
Penalty
Summary
The facility failed to follow a physician's order to keep both heels of a resident free-floating, a technique intended to prevent pressure on the heels and promote healing of an existing pressure injury. The resident, who was admitted with diagnoses including diabetes mellitus, dysphagia, and a pressure-induced deep tissue injury of the right heel, was observed on multiple occasions lying in bed with both heels resting directly on the mattress. The resident was dependent on staff for all activities of daily living and had limited ability to communicate. Record review confirmed an active order to free float both heels using pillows, and staff interviews acknowledged the importance of this intervention for preventing new pressure injuries and supporting healing of the existing one. The facility's policy also required evidence-based interventions, such as offloading heels, for residents at risk or with pressure injuries. Despite these directives, the required intervention was not implemented as observed by surveyors.
Failure to Follow Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
Facility staff failed to follow physician orders for a resident who required hemodialysis four times a week and had a prescribed daily fluid restriction of 1200 ml. The physician's order specified that nursing staff were to provide 240 ml per day shift, 240 ml per evening shift, and 120 ml per night shift, totaling 600 ml, while dietary was to provide 200 ml for each meal, totaling another 600 ml. Upon review, there was no documentation in the resident's medical record regarding the restriction of fluid intake, and the Director of Nursing confirmed that there was no system in place to monitor the resident's daily fluid intake. The resident, who was cognitively intact and able to make decisions, reported that staff did not inform them of any fluid restrictions and that they typically drank as much as they wanted. The facility's policy required adherence to physician-ordered fluid restrictions, but this was not followed in practice for this resident, who had diagnoses including diabetes mellitus, cirrhosis of the liver, and dependence on renal dialysis.
Failure to Provide Arbitration Agreement in Resident's Preferred Language
Penalty
Summary
A deficiency occurred when a resident whose primary language was Spanish was presented with a binding arbitration agreement (AA) written in English during the admission process. The resident, who had diagnoses including atrial fibrillation, hypertension, and dependence on supplemental oxygen, was documented as having the capacity to understand and make decisions. The resident's preferred language was clearly indicated as Spanish in the Minimum Data Sheet, and both the resident and staff confirmed that the resident spoke and read only Spanish. Despite this, the Admission Director presented the AA in English and requested the resident's signature, without ensuring the resident understood the document. Interviews with facility staff, including the Admission Director and the Director of Nursing, confirmed that the AA was not explained or provided in a language the resident understood. The facility's policy required that such agreements be explained in a form and manner, including language, that the resident understands. The resident later stated they did not know what the AA meant, indicating the agreement was not fully understood at the time of signing.
Room Occupancy Exceeds Regulatory Limit
Penalty
Summary
The facility failed to ensure that a multiple resident room in the Sub Acute Unit accommodated no more than four residents, as required. During the health recertification survey, it was observed that room [ROOM NUMBER] contained five beds, with four of them occupied by residents. The room also included side tables, a dresser, and resident care equipment. Staff reported that there was sufficient space to provide care and treatment, including for residents with ventilators, and that the room was large enough to accommodate the residents. The facility administrator confirmed that the room had more than four residents and stated that a waiver for six beds was being requested. Documentation reviewed indicated the room had 500.4 square feet and the waiver request asserted that the room's size and configuration did not compromise resident safety or care. However, at the time of the survey, the room was not in compliance with the regulation limiting occupancy to four residents per room.
Failure to Meet Minimum Room Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 9 of 28 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as observed during a health recertification survey. Specifically, rooms 16, 19, 20, 21, 22, 25, 26, 27, and 32 did not meet the square footage requirement. The deficiency was identified through observation, interviews with staff and residents, and review of facility records. The facility had not changed the number of beds in these rooms from the previous year and had submitted a waiver request for these rooms, indicating awareness of the space issue. Despite the deficiency, staff and residents reported that there was adequate space for movement and care activities, including the use of wheelchairs, walkers, and Hoyer lifts. Observations confirmed that residents could move freely and that staff could provide necessary care without difficulty. The facility's waiver request and client accommodation analysis stated that the room sizes did not adversely affect resident safety, care, or privacy, and that the needs of the residents were being met within the existing space.
Failure to Follow Hand Hygiene Protocols for C. difficile
Penalty
Summary
The facility failed to implement its infection prevention and control program, specifically regarding hand hygiene and the management of C. difficile infections. During an observation, a Licensed Vocational Nurse (LVN) was seen taking vital signs of a resident diagnosed with C. difficile without following proper handwashing procedures. After completing the task, the LVN used hand sanitizer instead of washing hands with soap and water, as required by the facility's policy for handling C. difficile cases. The LVN acknowledged the mistake, citing the resident's roommate's use of the restroom as the reason for not washing hands. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that the LVN should have waited to wash hands with soap and water to prevent the spread of infection. The facility's policies clearly state that handwashing with soap and water is mandatory for conditions involving C. difficile to prevent cross-contamination. The failure to adhere to these policies posed a risk of spreading the infection within the facility.
Failure to Maintain Safe Environment Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for Resident 1, as outlined in their policies and procedures. The Maintenance Director did not have a schedule for maintenance services for Resident 1's bed remote control coil line, which was damaged. This oversight led to the coil line being broken, with the outer hard plastic layer peeled off, exposing a sharp edge. This hazardous condition was not identified or addressed by the maintenance staff, as checking the bed remote control was not part of their routine tasks. During care, Certified Nurse Assistant 2 did not prevent Resident 1 from grabbing onto the damaged bed remote control coil line, which was hanging on the right bed side rail. As a result, Resident 1 sustained a laceration on the inner right hand between the thumb and index finger. The injury required medical attention, including seven surgical sutures for wound closure, and Resident 1 was transferred to a general acute care hospital for treatment. Resident 1 had a history of type II Diabetes Mellitus, heart failure, and respiratory failure, and was non-verbal with severely impaired cognition. The facility's failure to maintain equipment in good condition and provide adequate supervision during care directly contributed to the injury sustained by Resident 1. The incident highlights the importance of routine checks and maintenance of medical equipment to ensure resident safety.
Failure to Maintain Safe Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to maintain the resident's bed remote control coil line in safe operating condition, resulting in a laceration on a resident's inner right hand. The resident, who was non-verbal and had severely impaired cognition, sustained a 2-centimeter laceration between the thumb and index finger due to the damaged hard plastic covering of the bed remote control coil line. The outer layer of the coil line was broken, exposing a sharp edge that caused the injury when the resident grabbed it during repositioning by a CNA. The Maintenance Assistant confirmed that checking the bed remote control was not part of the routine maintenance tasks and was only done upon request. This oversight led to the resident's injury, as the broken coil line was not identified and repaired in a timely manner. The Director of Nursing acknowledged the importance of routinely checking all medical devices and equipment to ensure they are in good condition for resident safety. The facility's preventive maintenance program policy indicated that a schedule of maintenance services should be developed to maintain equipment in a safe and operable manner.
Inadequate Infection Control Measures for Scabies
Penalty
Summary
The facility failed to maintain its infection control and prevention surveillance program for two residents, leading to a deficiency in infection control measures. Resident 1 was confirmed to have scabies following a positive skin scraping test. Despite this confirmation, the facility did not initiate a scabies line list immediately, as was done during a previous COVID outbreak. The Infection Preventionist (IPN) acknowledged that a line listing was not initiated until requested, and it was incomplete, lacking information on staff potentially exposed to Resident 1. The Director of Nursing (DON) was unaware of the need for a line listing and did not report the incident to the Public Health Department, considering it isolated. Resident 2 was identified as highly suspicious for scabies, yet infection control measures were not implemented. The resident had a generalized body rash, and treatment for scabies was initiated based on a dermatologist's assessment. However, there was no skin scraping to confirm the diagnosis, and the facility's staff did not clarify the suspicion of scabies with the dermatologist. The Treatment Nurse (TN) carried out orders for scabies treatment without informing the DON or confirming the suspicion of scabies. The Infection Prevention Nurse (IPN) noted that the facility's process required clarification of new orders for anti-scabies treatment, which was not done in this case. The facility's policy and procedure for infection control prevention surveillance were not followed, as evidenced by the lack of a line listing and failure to implement control measures for Resident 2. The local Public Health Guidelines for Scabies Prevention and Control were also not adhered to, as they require the preparation of a line listing for symptomatic patients and their contacts. The deficiency in infection control measures compromised the facility's ability to prevent the potential spread of infections.
Medication Mismanagement: Unattended Medication at Bedside
Penalty
Summary
The facility failed to adhere to professional standards of practice when a resident's medication was left unattended at the bedside. The resident, who was admitted with diagnoses including type 2 diabetes and Chronic Obstructive Pulmonary Disease, was found with two white capsules of Gabapentin in a clear plastic medicine cup on the bedside table. The resident stated that the medication was given by a licensed nurse earlier in the morning but was not taken immediately because the resident preferred to save it for later use when experiencing increased pain. The Director of Nursing confirmed that medications should not be left at the bedside and that licensed nursing staff are required to observe residents taking their medication at the time it is administered. This practice is crucial to ensure that residents actually take their medication as ordered, preventing potential complications and mismanagement of medical conditions. The facility's policy on medication administration mandates that staff observe resident consumption of medication and document any refusals.
Inadequate PPE Use in COVID-19 Isolation Room
Penalty
Summary
The facility failed to adhere to its infection control practices for Coronavirus Prevention and Response when a Certified Nursing Assistant (CNA) entered a COVID-19 isolation room without wearing the required Personal Protective Equipment (PPE). The incident involved Resident 5, who was placed under COVID-19 isolation due to exposure to a COVID-19 positive roommate. The CNA entered the room wearing only an N95 mask, despite signage indicating the need for full PPE, including a gown, gloves, face mask, and eye protection. This action was contrary to the facility's policy and the posted Novel Respiratory Precautions. Interviews conducted with the CNA and the Infection Preventionist Nurse (IPN) confirmed the requirement for full PPE when entering isolation rooms. The CNA acknowledged the need for full PPE to prevent the spread of COVID-19, and the IPN reiterated that all staff must comply with these precautions. Resident 5 was aware of the COVID-19 status of their roommate and the necessity for staff to wear protective equipment. The facility's policy, dated 2022, clearly outlined the PPE requirements for healthcare personnel entering rooms of residents with suspected or confirmed SARS-CoV-2 infection.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to adhere to its policy and procedure for nail care for a resident with contractures in both hands. The resident, who was admitted with diagnoses including contracture of the hands, functional quadriplegia, and chronic respiratory failure, was observed to have long and overgrown fingernails and toenails with a brown substance underneath. The resident's care plan indicated a need for assistance with activities of daily living due to physical limitations, yet the necessary nail care was not provided. Certified Nursing Assistants (CNAs) did not trim or clean the resident's fingernails, nor did they notify Licensed Vocational Nurses (LVNs) about the overgrown toenails. The LVNs also failed to inform the Social Services Director (SSD) to arrange for a podiatrist to address the toenail issue. Observations and interviews with staff confirmed that the resident's nails were long, dirty, and posed a risk of injury and infection, particularly given the resident's contracted hands. The Director of Nursing (DON) stated that residents' nails should be assessed daily and maintained as part of ADL care. However, the facility's policy, which required regular nail care and assessments, was not followed. This oversight had the potential to cause harm to the resident, as the long nails could lead to cuts, scrapes, and infections.
Failure to Provide Reasonable Accommodation of Needs for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents, Resident 270 and Resident 2. Resident 270, who was admitted with myotonic muscular dystrophy, contractures, and dependence on a ventilator, was unable to use the call light due to his inability to move his arms and hands. Despite being alert and able to communicate his needs, the call light was pinned behind his head and out of reach. Staff interviews revealed that alternative call light options were available but were not provided to Resident 270, leading to his inability to notify staff for assistance, including critical needs like suctioning his trach tube. Resident 2, who had a history of falls and was assessed as high risk for falls, also experienced a failure in accommodation. The resident's care plan indicated that the call light should be within reach due to his severe cognitive impairment and dependence on staff for daily activities. However, during an observation, the call light was found hanging on the siderails and covered with a pillow, making it inaccessible. Staff interviews confirmed that the call light should have been within the resident's reach to ensure safety and timely assistance. The facility's policies and procedures on call light accessibility and accommodation of needs were not followed in both cases. The policies required staff to evaluate and provide special accommodations for residents' unique needs, but this was not done for Resident 270 and Resident 2. This failure had the potential to result in both residents being unable to notify staff for their needs and possibly in emergencies.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information on Advance Directives (AD) for two residents, leading to potential treatment and services being administered against their will. Resident 45 was admitted with type 2 diabetes mellitus and had fluctuating capacity to understand and make decisions. Despite this, the AD Acknowledgement Form for Resident 45 was not completed. Interviews with the Assistant Social Service Director (ASSD) and the Assistant Director of Nursing (ADON) confirmed that the form needed to be filled out completely, and it was the resident's right to formulate an AD upon admission to ensure care and treatment aligned with their wishes. Similarly, Resident 47, who was admitted with hypertension and had moderately impaired cognition, did not have an AD assessment performed. The ASSD confirmed that there was no documentation indicating that AD information was offered to Resident 47 or their Responsible Party. The facility's policy required that AD information be documented upon admission to provide care and treatment according to the resident's wishes. The failure to follow this policy was confirmed through interviews and record reviews.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for the residents' suprapubic and indwelling catheters as ordered by the physician and indicated in the residents' care plans. Resident 15, who had diagnoses including hydroureter, chronic kidney disease, and urinary retention, was observed with an indwelling catheter that was not connected to a stabilization device, posing a risk of catheter-related trauma. The Licensed Vocational Nurse (LVN) confirmed that the catheter tubing needed to be connected to the stabilization device to prevent injury or trauma to the urethra. Resident 11, diagnosed with neuromuscular dysfunction of the bladder and urinary tract infections, was observed with a suprapubic catheter that was not covered with a dressing and was not secured with a stabilization device. The resident was seen touching the catheter site, which increased the risk of infection. The LVN and the Infection Preventionist Nurse (IPN) both stated that the catheter site needed to be covered and the tubing secured to prevent pulling, dislodgement, and infection. The Assistant Director of Nursing (ADON) confirmed that the catheter stabilization device is essential to prevent accidental pulling, injury, trauma, and possible hospitalization. The facility's policy and procedure on indwelling catheter use and removal emphasized the importance of keeping the catheter anchored to prevent excessive tension, urethral tears, or dislodgement, and ensuring the catheter is positioned below the level of the bladder to facilitate urine flow and prevent kinks in the tubing.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to follow its Policy and Procedure (P&P) for enteral feeding for two residents. For Resident 2, the gastrostomy tube (G-tube) dressing was not changed per protocol. The resident's care plan indicated the need for daily dressing changes to prevent infection, but during an observation, the dressing was found to be loose, dirty, and dated three days prior. Staff interviews confirmed that the dressing should be changed daily as ordered by the physician to prevent infection, but this was not done as documented in the Treatment Administration Record (TAR). The facility's P&P also required documentation of the procedure, which was not properly followed in this case. For Resident 274, the facility failed to ensure proper positioning during enteral feeding. The resident was observed lying flat on the bed while the feeding was ongoing, contrary to the care plan that required the head of the bed to be elevated between 30 to 45 degrees during feeding. Staff interviews revealed that the enteral feeding should be paused when changing the resident's linens or clothing to prevent aspiration, but this protocol was not followed. The facility's P&P indicated that the resident's plan of care should direct staff regarding proper positioning, which was not adhered to in this instance. These failures had the potential to cause infection for Resident 2 and the risk of aspiration for Resident 274. The facility's policies and procedures were not followed, leading to these deficiencies. Staff interviews and record reviews confirmed that the required care and documentation were not consistently provided, highlighting lapses in adherence to established protocols for enteral feeding and gastrostomy site care.
Failure to Ensure Proper Respiratory Care and Safety
Penalty
Summary
The facility failed to ensure proper respiratory care and resident safety for two residents receiving oxygen therapy. For Resident 30, who was admitted with a history of falling and Chronic Obstructive Pulmonary Disease (COPD), the nasal cannula tubing was observed to be rolled and inserted into the handle of the oxygen concentrator instead of being stored in a plastic bag when not in use. This was confirmed by the Director of Staff and Development (DSD) and the Assistant Director of Nursing (ADON), who both stated that the nasal cannula tubing should be stored in a plastic bag to prevent infection and cross-contamination. The facility's policy on Oxygen Administration also indicated that oxygen tubing and masks or cannulas should be kept covered in a plastic bag when not in use. For Resident 274, who was ventilator-dependent and had fluctuating capacity to understand and make decisions, there was no spare tracheostomy tube readily available at the bedside. This was observed and confirmed by Respiratory Therapist 2 (RT 2) and the Respiratory Supervisor (RT Sup), who stated that an emergency trach tube needed to be easily accessible at the bedside to maintain a patent airway during an emergency. The facility's policy on Sudden Respiratory Distress Differential Diagnosis also indicated that emergency airway management supplies, including a replacement trach tube, should be at the resident's bedside or within close proximity.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt appropriate alternatives before installing bed rails for two residents, both diagnosed with dementia and epilepsy. Resident 17 was admitted on 3/2/2023 and was observed on 4/9/2024 with both upper siderails up. The bedrail assessment for Resident 17 indicated that alternatives such as lowering the bed and using pillows were attempted but did not specify how these alternatives failed. The MDS Nurse Coordinator mentioned that other alternatives like bolsters or bumpers could have been used, which was confirmed by the Director of Nursing (DON). However, these alternatives were not documented as attempted in the resident's assessment records. Similarly, Resident 170, admitted on 10/12/2023, was also found to have bed rails installed without sufficient documentation of failed alternatives. The assessment for Resident 170 only mentioned the use of pillows as an alternative but did not explain their ineffectiveness. The DON confirmed that bolsters or bumpers were available but not documented as attempted alternatives in the resident's records. The facility's policy requires a person-centered approach and the use of appropriate alternatives before installing bed rails, which was not followed in these cases.
Infection Control Deficiencies in Wound Care, Curtain Changes, and PPE Use
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections for five sampled residents. Specifically, the facility did not ensure that wound care for Resident 35 was performed in a manner that would prevent the introduction of potentially contaminated material into the wound. During an observation, LVN 7 used a disposable measuring guide stored without any cover to measure the wound, which was against the facility's policy that required sterile or clean instruments for wound care. The Infection Prevention Nurse confirmed that the measuring guide should not have been used as it could be contaminated, and the facility's policy indicated that wound care should be provided to decrease potential for infection and cross-contamination. Resident 35 had moderate cognitive impairment and required assistance with personal care, making proper wound care essential for their health and safety. The facility also failed to change curtains during deep cleaning for two residents, Resident 8 and Resident 61, out of 28 rooms. Resident 8, who had enterocolitis due to clostridium difficile and a history of urinary tract infections, reported that the curtains had not been changed since admission. Similarly, Resident 61, who had type 2 diabetes mellitus and chronic obstructive pulmonary disease, stated that the curtains in their room had not been changed since admission. The Housekeeping Supervisor confirmed that curtains should be changed during deep cleaning to prevent the spread of infections, but the facility's policy did not specify the frequency for changing curtains. The Infection Prevention Nurse emphasized that curtains are highly touched areas and should be changed to prevent infection spread. Additionally, the facility did not ensure proper hand hygiene and glove use by staff. The Infection Prevention Nurse did not change gloves or perform hand hygiene after touching Resident 42's indwelling catheter before touching the resident's breathing treatment mask and tube. Resident 42 had severely impaired cognition and required total dependence on staff for daily activities. The Assistant Director of Nursing confirmed that staff needed to change gloves and perform hand hygiene before and after touching contaminated equipment. Furthermore, the Nurse Practitioner did not wear the required PPE while performing a physical assessment on Resident 274, who was on Enhanced Barrier Precaution due to the presence of medical devices and chronic wounds. The Infection Preventionist and Medical Director confirmed that proper PPE was necessary to prevent the transmission of multidrug-resistant organisms.
Failure to Implement Comprehensive Care Plan for Resident with Multiple Pressure Injuries
Penalty
Summary
The facility failed to initiate and implement a care plan for a resident (Resident 274) who had multiple pressure injuries (PIs) upon admission. The resident was admitted with several PIs, including unstageable PIs on the sacral region, right and left buttocks, right ankle, right heel, and other areas. Despite having a high risk for developing pressure injuries as indicated by the Braden Scale, the facility did not create a comprehensive care plan for all of the resident's PIs. This omission was confirmed during interviews with the Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RN Sup), who acknowledged that the care plan should have included all PIs to ensure proper treatment and monitoring. The resident's medical history included dependence on a ventilator, a gastrostomy tube, and a tracheostomy tube, which further complicated their condition. The facility's records showed that there were active medical orders to treat the PIs, but these were not reflected in a comprehensive care plan. The LVN and RN Sup both stated that the absence of a care plan for each PI could lead to worsening conditions or infections, as staff would not be aware of the specific interventions required for each injury. The Assistant Director of Nursing (ADON) also confirmed that the charge nurse was responsible for initiating the care plan and that it should have been completed upon admission. The facility's policies and procedures indicated that care plans should include measurable objectives and timeframes to meet the resident's needs, and should be updated as necessary. However, the failure to list each PI in the care plan put the resident at risk of their injuries worsening due to lack of proper treatment and monitoring.
Failure to Provide Communication Aid for Resident with Tracheostomy
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy and chronic respiratory failure was provided with a Passy-Muir Valve (PMV) for effective communication. The resident, who was dependent on staff for various activities of daily living, had unclear speech and limited ability to make self-understood. Despite having a physician's order for the PMV, the staff did not utilize the device, leading to communication difficulties. The resident's care plan indicated the need for communication aids, but the staff were unaware of the PMV's availability and its use for the resident's communication needs. During observations and interviews, it was found that the resident's PMV was stored in a drawer and not used by the staff. Licensed nurses and a respiratory therapist confirmed that they were trained to apply the PMV, but the device was not utilized to assist the resident in communicating effectively. The facility's policy stated that the PMV should be provided to the resident with a physician's order and applied by trained staff, but this was not followed, resulting in the resident's unmet communication needs.
Failure to Follow Pressure Injury Prevention Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for pressure injury prevention for Resident 274. Despite having an active medical doctor's order for bilateral heel protectors to manage multiple pressure injuries, the protectors were not observed on the resident during an inspection. Resident 274 had several pressure injuries, including unstageable pressure injuries on the left lateral mid foot, left medial foot, left medial malleolus, right lateral malleolus, and right lateral mid foot, as well as deep tissue injuries on the right heel and lower back. The resident was also at high risk for developing new pressure injuries, as indicated by a Braden Scale assessment. Interviews with staff, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Assistant Director of Nursing, confirmed that the heel protectors were not applied as ordered, which could potentially worsen the resident's existing pressure injuries or lead to new ones. The facility's policies on skin integrity foot care and pressure injury prevention and management were reviewed and indicated that appropriate offloading devices and evidence-based interventions should be implemented for residents at risk of pressure injuries. Despite these policies, the facility did not adhere to the medical doctor's order for bilateral heel protectors for Resident 274, leading to a failure in pressure injury prevention and management. This oversight was confirmed through observations, interviews, and record reviews, highlighting a significant lapse in the facility's adherence to its own protocols and procedures for wound management and pressure injury prevention.
Failure to Adhere to Turning and Repositioning Schedule for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services for a resident with pressure ulcers by not adhering to the prescribed turning and repositioning schedule. The resident, who had severe cognitive impairment and was totally dependent on staff for daily activities, was observed to have been left in the same position for extended periods, contrary to the facility's policy of turning and repositioning every two hours. This was confirmed through multiple observations and interviews with staff, as well as a review of the resident's care plan and turning and repositioning log. The resident had multiple stage 4 pressure ulcers and was at high risk for further skin breakdown. Despite the facility's policy and the resident's care plan indicating the need for frequent repositioning, the resident was not turned and repositioned as required. This lapse in care was observed on several occasions, including during the resident's dialysis days when the resident was out of the facility for extended periods. Staff interviews corroborated that the turning and repositioning schedule was not consistently followed, leading to the potential for further skin damage and delayed wound healing.
Failure to Maintain and Properly Apply Hand Splint
Penalty
Summary
The facility failed to ensure that a resident's right-hand splint was maintained and properly applied in accordance with the facility's policy and procedure. The resident, who had diagnoses including muscle wasting and contracture of both hands, was on a Restorative Nursing Program to address potential decline in range of motion. The care plan required staff to apply wrist and hand splints to the resident's right and left wrist/hand for four hours daily, five times a week, or as tolerated. However, during an observation, the splint on the resident's right wrist/hand was found not connected and was observed on the resident's bed, indicating non-compliance with the care plan and facility policy. Interviews with the Licensed Vocational Nurse, Restorative Nurse Assistant, and Assistant Director of Nursing confirmed that the splints needed to be kept in place as scheduled to prevent further contracture and maintain mobility. The facility's policy on Restorative Nursing Programs indicated that residents identified during a comprehensive assessment process would receive services from restorative aides, including splint or brace assistance. The failure to ensure the proper application and maintenance of the splint placed the resident at risk for contractures and potential decline in physical function.
Failure to Follow Hoyer Lift Policy and Procedure
Penalty
Summary
The facility failed to supervise and follow policy and procedure for the use of a Hoyer Lift, a mechanical device that requires two staff members to operate, for Resident 274. During an observation, it was noted that a Certified Nurse Assistant (CNA) operated the Hoyer Lift alone, lifting Resident 274 from the bed and leaving the resident suspended in the air unsupervised while the CNA walked away to close the curtain. This action was against the facility's policy, which mandates that two staff members must be present during the operation of the Hoyer Lift to ensure the resident's safety. Resident 274 had multiple medical conditions, including pressure injuries, dependence on a ventilator, and a gastrostomy tube, which required careful handling. The resident's care plan indicated the need for assistance from two or more persons for transfers. Despite this, the CNA proceeded to use the Hoyer Lift alone, and the Licensed Vocational Nurse (LVN) present was occupied with other tasks and not available to assist. This left Resident 274 at risk of falling and sustaining serious injury. Interviews with the CNA, LVN, Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that the facility's policy requires two staff members to be present during the use of the Hoyer Lift. The ADON and DSD emphasized the importance of this policy to prevent accidents and ensure resident safety. The facility's policy and the manufacturer's instructions both clearly state that residents should never be left unattended during lifting, highlighting the severity of the deficiency in this incident.
Failure to Provide Adequate Meal Assistance
Penalty
Summary
The facility failed to provide adequate supervision or assistance during meals for a resident with severe cognitive impairment and Parkinson's disease, leading to potential further weight loss. The resident, admitted with diagnoses including dementia and Parkinson's disease, required supervision or touching assistance with eating due to severe cognitive impairment and functional limitations in both upper and lower extremities. Observations revealed that the resident struggled to eat independently due to noticeable tremors and was often left unattended during meals, resulting in most of her food being untouched and her nutritional supplement unopened. On multiple occasions, staff failed to provide the necessary assistance. For instance, during one observation, the resident was seen holding a coffee cup with tremors and unable to eat her meal, which remained untouched. The dietary supervisor and nursing assistants did not intervene or assist the resident adequately. Interviews with staff indicated a lack of familiarity with the resident's needs and inconsistent documentation regarding the level of assistance required. The resident expressed that she would eat more if assisted, highlighting the impact of her tremors on her ability to feed herself. The resident's weight log showed a significant decline from 162 pounds to 133 pounds over several months, indicating ongoing nutritional issues. The care plan and nutritional assessments noted the need for monitoring and encouragement to eat, but these interventions were not effectively implemented. The facility's policies on weight management and meal supervision were not followed, contributing to the resident's inadequate nutrition and weight loss.
Failure to Label and Date Midline Intravenous Catheter
Penalty
Summary
The facility failed to label and date the midline intravenous catheter for Resident 45, which was necessary for infection control. Resident 45 was admitted with type 2 diabetes mellitus and hyperglycemia and had fluctuating capacity to understand and make decisions. The resident's care plan required the dressing of the midline catheter to be changed every seven days and labeled with the date, time, and initials of the licensed nurse. However, during an observation, it was found that the midline intravenous site was not dated, which was confirmed by the Infection Preventionist Nurse. The Assistant Director of Nursing confirmed that the IV site should be labeled to prevent infection. The facility's policy on Peripheral Intravenous Catheter Insertion, Maintenance, and Removal also indicated that the dressing should be labeled with the date, time, and initials. The failure to follow this policy had the potential to result in an infection for Resident 45, who had moderately impaired cognition and required total dependence on staff for activities of daily living.
Inaccurate MDS Assessments for Discharge Destinations
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the discharge destinations for two residents. Resident 68, who was discharged to a Skilled Nursing Facility (SNF), was incorrectly coded in the MDS assessment as being discharged to home. This discrepancy was confirmed during an interview with the facility's Minimum Data Set Nurse (MDSN), who acknowledged the error and emphasized the importance of accurate coding for providing correct information to the Centers for Medicare and Medicaid Services (CMS). Resident 68's admission record and physician's order both indicated a transfer to a SNF, contradicting the MDS assessment's coding of discharge to home. Similarly, Resident 67, who was discharged to home with home health services, was inaccurately coded in the MDS assessment as being discharged to a General Acute Care Hospital (GACH). This error was confirmed through a review of Resident 67's admission record, physician's order, post-discharge plan of care, and progress notes, all of which indicated a discharge to home. Interviews with the MDS coordinator and the Director of Nursing (DON) further confirmed the inaccuracy, highlighting the necessity of accurate MDS assessments for the continuation of care and accurate reporting to CMS. The facility's policy on conducting accurate resident assessments, revised in December 2022, was not adhered to in these instances.
Room Exceeding Resident Capacity
Penalty
Summary
The facility failed to ensure that one of its resident rooms accommodated no more than four residents, as required by regulations. Specifically, room [ROOM NUMBER] in the Sub Acute Unit had five beds, with four of them occupied by residents. This was confirmed during an entrance conference with the facility Administrator, who acknowledged the situation and mentioned that the facility would continue to request a room waiver for this room. Observations during the Health Recertification Survey showed that the room contained beds, side tables, dressers, and resident care equipment, and staff were able to move freely within the room. However, the room still exceeded the maximum allowed number of residents per room, which could lead to privacy concerns and crowded conditions. Licensed Vocational Nurse 6 also confirmed the presence of five beds in the room and stated that there was enough space to provide care and treatment, including for residents with ventilators, without issues. The facility had submitted a room waiver request indicating that the room's 494 square footage was adequate for the residents' special needs and did not compromise their health and safety or the care provided. The deficiency was identified during the Health Recertification Survey conducted from 4/9/2024 to 4/12/2024. The facility's letter requesting a room waiver, dated 4/9/2024, stated that the room's size and configuration were in accordance with the special needs of the residents and did not adversely affect their health and safety. Despite this, the room still did not comply with the regulatory requirement of accommodating no more than four residents, leading to the identification of this deficiency. The facility's actions and inactions in maintaining more than the allowed number of residents in a single room were the primary factors leading to this deficiency.
Failure to Meet Square Footage Requirements in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 14 of 28 rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. The rooms in question were Rooms 15, 16, 17, 19, 20, 21, 22, 23, 25, 26, 27, 32, 33, and 35. During the Health Recertification Survey, it was observed that these rooms did not meet the required square footage per resident. Despite this, the facility's Administrator stated that a room waiver would be requested for these rooms, indicating that the current room sizes did not adversely affect the health, safety, or care of the residents. The facility's letter requesting the waiver and the Client Accommodations Analysis supported this claim, stating that the residents' safety and care were not compromised by the existing room sizes. Interviews with staff and residents corroborated that there was enough space to provide care and that the room sizes did not impede the movement of wheelchairs and walkers or the provision of nursing care and treatments, including for residents with ventilators. During interviews, both a Certified Nurse Assistant and a Licensed Vocational Nurse confirmed that there was sufficient space in the rooms to provide care and move equipment without issues. Additionally, a resident who used a wheelchair stated that he could move freely in and out of his room without any concerns. Observations during the survey also indicated that residents had adequate space to move freely inside the rooms, and each resident had beds and bedside tables with drawers. The room sizes did not affect the care and services provided to the residents when nursing staff were observed providing care. Despite the facility's efforts to justify the room sizes, the deficiency was noted due to the failure to meet the regulatory square footage requirements per resident in multiple resident rooms.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 6,971 citations issued within 25 miles in the last 12 months — including the 30 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Post Acute | 0.3 mi | ★★★★★ | 3 | 0 |
| Greater El Monte Community Hos | 0.9 mi | ★★★★★ | 13 | 0 |
| Madera Post Acute Center | 1.5 mi | ★★★★★ | 26 | 0 |
| Eastland Subacute And Rehabilitation Center | 1.9 mi | ★★★★★ | 4 | 0 |
| Rosemead Healthcare Center | 1.9 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.