Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Tarzana Health And Rehabilitation Center during CMS and state inspections, most recent first.
Inaccurate Fall Risk Assessments were completed for two residents. One resident had diagnoses including PE, hypotension, GBS, and a history of falling, and after an assisted fall the assessment failed to reflect the fall in the history section and marked SBP as no noted drop between lying and standing even though the resident could not stand. The other resident had diagnoses including ME, hemiplegia, aphasia, epilepsy, hypotension, and dementia, used a wheelchair, was dependent for ADLs, and had assessments that left vision blank and also marked SBP as no noted drop between lying and standing despite inability to stand.
DSD Not Approved and Reference Checks Incomplete The facility allowed an LVN to function as DSD and provide CNA orientation and in-service training without Department approval, even though the approved NATPN listed a different DSD. The LVN stated she had not received approval and had not applied for it, while the ADM said the facility had two full-time DSDs and the LVN worked the p.m. shift. The facility also lacked a policy for former employment reference checks and hired staff without properly verifying prior employment. Personnel files showed references from friends, spouses, and co-workers instead of former employers, and the DON stated these sources could not confirm job performance, length of employment, resident abuse history, or rehire eligibility.
Failure to Complete Required Pre-Employment Screening: The facility failed to complete required pre-employment screening for two LVNs and the DSD before hire. Reference checks were incomplete or limited to a spouse, friends, and co-workers, with no documented contact with former employers or HR, and the ADM stated a criminal background check alone was sufficient for one employee despite the facility policy requiring background, reference, and credential checks with documentation of screening.
Failure to Notify Physician of Repeated Insulin Refusals: A resident with ESRD, type 2 DM, diabetic neuropathy, and dialysis dependence repeatedly refused scheduled insulin doses. The MAR showed multiple refusals of the 6:30 a.m. insulin dose, and an LVN and the DON confirmed there was no documented evidence that the physician was notified after the repeated refusals, despite the facility’s expectation to notify after three consecutive refusals.
Missing PTSD-Specific Care Plan: A resident admitted with PTSD had intact cognition and a positive trauma screen, but the care plan did not include a PTSD-specific plan. The SSD and DON both confirmed that no care plan had been developed to address the resident's PTSD, including interventions to identify and manage triggers or referral to a psychologist, despite facility policies requiring individualized, measurable care planning for medical, nursing, and psychosocial needs.
Failure to Provide Trauma-Informed Care for a Resident with PTSD: A resident with PTSD and intact cognition had a physician order for psych services, but the resident was never seen by a psychologist during the stay. The resident reported triggers such as yelling and raised voices, yet the record contained no documented PTSD triggers. The SSD confirmed the lack of psych eval and trigger documentation, and acknowledged the resident's PTSD-related needs were not addressed.
Failure to Arrange DME Before Discharge: A resident with osteoarthritis of the R hip, gait and mobility impairment, muscle weakness, and repeated falls was discharged home without therapy-recommended DME in place. The MDS showed the resident needed extensive help with transfers and ADLs, and the PT discharge summary recommended a 2-wheel walker, wheelchair, and BSC for safe functional mobility. The discharge summary did not show that DME had been requested or arranged, and the FM, SSD, DOR, CM, and DON all stated the equipment should have been ordered before discharge.
Failure to Document Grievance and Missing Property Report: A resident with cellulitis, severe sepsis, gait and mobility abnormalities, and muscle weakness had moderately impaired cognitive skills and needed assistance with ADLs. The resident's wife reported an eye concern and later reported missing slippers, but the concerns were not documented in the grievance log, no follow-up was documented in Social Services notes, and no theft and loss report was completed even though staff said the slippers were reportedly found.
Inaccurate MDS Coding for IV Feeding: A resident with metabolic encephalopathy, MS, and type 2 DM had an MDS that coded parenteral/IV feeding in Section K. Record review showed a short IV NS order and a note that IV fluids were started for decreased oral intake, but the nutritional assessment marked IV fluids in the look-back period as No. Interviews with the MDSA, MDSC, RD, and DON confirmed there were no clinical indications supporting ongoing IV hydration, yet the MDS was still coded as if IV feeding was provided.
Incorrect Insulin Dose Administered: A resident with DM, sepsis, and mobility impairment did not receive Insulin Lispro as ordered. The MAR documented a blood sugar of 545 mg/dl, and the physician’s sliding scale required 18 units, but the administration note showed only 15 units were given. The MDSA and DON confirmed the dose should have matched the physician order.
Failure to Honor Resident Food Preference: A resident with severe cognitive impairment and a pureed diet order did not receive pureed fruit listed on the meal card as a food add. The DS confirmed the item should have been served, retrieved it from the kitchen, and stated staff failed to follow the meal ticket to honor the resident’s preferences.
Incomplete Admission Nursing Assessments: RN Supervisors did not complete Clinical Admission assessment documentation for two residents upon admission/readmission. One resident had cellulitis, severe sepsis with septic shock, gait and mobility abnormalities, muscle weakness, and DM, while the other had encephalopathy, ESRD, stroke sequelae, and dialysis dependence. RN 2 and the DON reviewed the forms and found multiple sections blank or incomplete, including neurologic, mood/behavior, respiratory, gastrointestinal, genitourinary, nutrition, skin, care planning, and clinical suggestions.
Failure to Protect Resident from Physical Abuse: A resident was repeatedly punched in the face by another resident while lying in bed, resulting in bleeding gums and a loose tooth. Staff interviews and records showed the aggressor had a history of violent behavior and was witnessed walking to the resident’s bed and striking him several times with a closed fist. The assaulted resident reported the attack was unprovoked and said he felt scared during the incident.
A resident’s attending physician did not provide the required H&P after the initial visit, and the note was not available in the chart until after discharge. The resident had diagnoses including polyneuropathy, epilepsy, and depression, and the delayed H&P documented a history of violent behavior, anxiety, agitation, verbal aggression, and physical aggression. Before the H&P was received, the resident was observed striking a bedbound roommate in the face multiple times.
A resident with muscle weakness, diverticulitis with perforation and abscess, and moderately impaired cognition, who required varying levels of assistance with ADLs, was observed in bed with the call light not within reach, hanging behind the headboard. During a subsequent observation and interview, an LVN confirmed the call light was out of reach and repositioned it next to the resident’s hand, stating call lights should always be next to residents and that CNAs are responsible for ensuring accessibility. The DON later affirmed that call lights must be clipped by the bed and within reach so residents can call for assistance, and facility policy requires staff to ensure the call system is accessible to residents while in bed.
A resident admitted with CHF and moderate cognitive impairment did not receive a baseline care plan within 48 hours of admission to address CHF-related needs. The MDS nurse, responsible for initiating diagnosis-related care plans, confirmed that no CHF-specific baseline care plan existed, even though the resident required assistance with multiple ADLs. The DON acknowledged that baseline care plans are important on admission, and facility policy requires timely development of a baseline care plan including goals, physician and dietary orders, and interventions based on admission information, but these requirements were not followed for this resident’s CHF diagnosis.
A resident with metabolic encephalopathy, impaired gait, and lack of coordination, whose care plan required a mechanical lift with two staff for transfers, was observed on a shower chair with a lift sling attached while only one CNA operated the mechanical lift controls, briefly raising and lowering the resident. The CNA reported she attempted to adjust the tall resident’s position to prevent the resident’s head from touching the lift bar and did so without waiting for a second staff member, despite knowing the resident was a two-person assist. The DON confirmed that mechanical lift transfers are to be performed with two staff, consistent with facility policy on accidents and supervision.
A resident with diastolic CHF and HTN had physician orders for furosemide and losartan that included hold parameters for systolic blood pressure (SBP) less than 110 mmHg and, for losartan, heart rate less than 60 bpm. Review of the MAR and interview with the MDS nurse showed that licensed nurses administered both medications on two occasions when the resident’s SBP was below the ordered threshold. The MDS nurse confirmed the medications should have been held according to the orders, and the facility’s medication administration policy required obtaining vital signs and holding medications when they fell outside prescribed parameters.
A resident with intact cognition and multiple conditions, including CHF, HTN, and type 2 DM, repeatedly refused ordered potassium chloride and metoprolol succinate over multiple consecutive days, as documented on the MAR. An LVN acknowledged the resident’s repeated refusals and stated that facility practice is to notify the physician after three or more refusals, but also acknowledged not documenting any physician notification. The DON confirmed the pattern of refusals and the expectation that the physician be notified after three consecutive refusals, while facility policy required reporting and documenting medication refusals, yet there was no documentation that the physician had been informed.
A resident with intact cognition and multiple comorbidities, including chronic respiratory failure, pneumonia, dysphagia, DM2, CHF, and HTN, required assistance with ADLs such as toileting hygiene and showering. Review of the medical record by the MRD showed that full body skin assessments were documented only a few times during the stay, rather than on a weekly basis. The facility’s Skin Assessment P&P required a head-to-toe skin assessment by an RN or LPN on admission/readmission and weekly thereafter, as well as after changes in condition or new pressure injuries. The DON acknowledged that licensed nurses should have completed weekly skin assessments for this resident, but the record lacked documentation of consistent weekly assessments as required.
A resident with dementia, hearing loss, and impaired vision had care plans requiring use of eyeglasses and hearing aids when out of bed, with staff responsible for ensuring these devices were worn and functioning. During observation, the resident was seen in a wheelchair in the lobby without eyeglasses or hearing aids. The ADON and an LVN both acknowledged the resident should have been wearing these devices, and the LVN reported the hearing aids were not charged and thus unavailable, despite the documented plan of care and facility policies requiring assistance with hearing aids and implementation of comprehensive care plans.
A resident with severely impaired cognition, dependence in ADLs, and a left humerus fracture did not receive a recliner wheelchair that had been recommended by PT due to poor sitting balance and a non–weight-bearing upper extremity. The DORS did not order the recliner wheelchair because she believed it was not covered under Medicare Part A, despite facility policy and Medicare guidance indicating DME is covered under the SNF PPS. The DON later confirmed that the failure to order the recliner wheelchair and communicate with nursing caused a delay in treatment with potential for functional decline and decreased mobility.
A resident with a history of PTSD and major depressive disorder did not have a comprehensive care plan addressing PTSD, despite staff awareness and documented trauma history. The care plan lacked specific interventions for PTSD, contrary to facility policy requiring person-centered plans for all identified needs.
A resident with a history of PTSD and major depressive disorder did not receive appropriate behavioral health services beyond psychiatric visits, despite staff awareness and documentation of her condition. Facility staff confirmed that no additional interventions or assessments were implemented to address her PTSD, contrary to facility policy requiring person-centered behavioral health care.
A resident who lacked capacity to make decisions due to medical conditions had their admission packet e-signed by themselves instead of their designated representative. Facility staff and policy confirmed that the representative should have signed, but this did not occur, resulting in the resident not being properly represented in healthcare decisions.
Unsafe Room and Lobby Temperatures: A resident with Alzheimer’s disease and severe cognitive impairment was observed in a room that remained below the required temperature range, with the bedside temperature measured multiple times in the high 60s and the room control set to cool instead of heat. The lobby was also observed below range, with temperatures in the low-to-mid 60s until staff turned the system on. The DON stated temperatures should be maintained between 71 F and 81 F in resident rooms and lobby areas, and the MS stated the facility had only been documenting room temperatures, not other areas.
Inadequate Perineal Care for an Incontinent Resident: A resident with Alzheimer's disease, UTI, and occasional bladder and bowel incontinence required maximal assistance with toileting hygiene. During observed care, a CNA used one wet towel for both the front and back perineal areas, did not rinse the area, and did not use a separate section of washcloth or new wipe as required by the facility's perineal care policy. The CNA stated the care was not thorough because total morning care would be provided later, and the DON confirmed the method did not follow protocol.
During a COVID-19 outbreak, staff failed to follow infection control protocols, including improper mask use by two staff members, lack of hand hygiene by a therapist and a housekeeper after resident care and trash handling, and unsafe transport of trash bags in contact with clothing. These actions did not align with facility policy and CDC guidelines for infection prevention.
Incomplete discharge summaries and missing discharge documentation: The facility failed to provide three residents with discharge summaries that included a recap of the stay and complete discharge instructions. Records and staff interviews showed missing or inaccurate details about therapy, dietary, social services, activities, functional status, continence, and DME/HH needs. For one resident, family reported the HH contact information and walker were not provided as expected, and for another resident, staff could not locate proof that the discharge summary was given to the resident or family.
A resident did not receive the medically-related social services needed to achieve the highest possible quality of life, resulting in unmet social and psychosocial needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with severe cognitive impairment and multiple health conditions experienced a delay in laboratory testing after developing diarrhea. The initial stool specimen was not picked up by the lab, causing a delay in obtaining and processing a second sample. This resulted in a delayed diagnosis of C. diff and a subsequent delay in starting antibiotic treatment, contrary to facility policy requiring timely lab services.
A resident did not receive a comprehensive explanation or proper informed consent for a psychotropic medication, as the consent form lacked the physician's signature and dose frequency. Additionally, two residents were not informed of the names and indications of several medications before administration by an LPN, contrary to facility policy. These actions prevented residents from being fully informed and involved in their care.
A resident with limited mobility and a history of fractures did not receive active range of motion (AROM) exercises to both arms as recommended by occupational therapy. The care plan and restorative nursing aide documentation only included AAROM to the legs, and staff interviews confirmed that the AROM task for the arms was not entered into the electronic system. This omission resulted in the resident not receiving the prescribed interventions to maintain upper extremity range of motion.
Surveyors found multiple deficiencies, including a shower room with standing water and a leaking shower head that were not reported or repaired, incomplete and inaccurate fall risk assessments after resident falls, and failure to implement care plan interventions such as keeping beds in low positions and providing padded siderails for seizure precautions. These lapses involved residents with cognitive impairment, seizure disorders, and fall risks, and staff acknowledged the importance of these interventions and assessments.
Multiple residents did not receive prescribed medications as ordered due to lapses in pharmacy delivery, failure to reorder in advance, and staff not following physician parameters for administration. This included missed doses of antidepressants, migraine medication, vitamin D supplements, and improper administration of blood pressure and bowel management medications, with staff and leadership confirming these errors.
Two residents experienced medication errors when one did not receive a prescribed vitamin D supplement due to unavailability, and another received a calcium with vitamin D supplement outside the scheduled time window. These incidents resulted in a medication error rate above 5%, as facility staff did not follow established medication administration protocols.
An LVN prepared six medications for a resident and left them unattended on top of a medication cart while entering the resident's room to take vital signs. The medications remained unsupervised and accessible until the LVN returned to administer them in two trips. Both the LVN and DON acknowledged that this action failed to meet the facility's policy for safe and secure medication storage, which requires medications to be attended or locked at all times.
The facility did not consistently follow infection control protocols, including failing to use enhanced barrier precautions for a resident with a gastrostomy tube, not labeling or timely replacing oxygen tubing for two residents, and not labeling a urinal with a resident identifier. These actions were not in accordance with facility policy and staff expectations, as confirmed by interviews and record reviews.
Two residents experienced lapses in dignity and privacy when one resident's urinary catheter bag was left uncovered, and another resident was not afforded privacy during bathing as staff repeatedly entered the shower room without knocking. These actions were inconsistent with facility policies requiring the use of privacy bags for catheter drainage and staff to knock before entering rooms occupied by residents.
A resident with severe cognitive impairment and a history of falls was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. This was confirmed by a CNA and acknowledged by the DON.
A resident with bilateral lower extremity amputations showed significant improvement in performing sit-to-stand transfers with prosthetic legs, but this change was not documented or reported to the physician as required. As a result, the resident did not receive further PT services to support increased independence with mobility.
A resident with a history of left femur fracture and ongoing mobility issues was not accurately assessed for range of motion (ROM) limitations in three consecutive MDS assessments. Despite therapy evaluations, care plans, and staff observations confirming a left leg ROM impairment and the need for assistance, the MDS documentation repeatedly indicated no ROM limitations. This resulted in inaccurate information being reported in the federal database.
The facility did not develop care plans for two residents: one requiring continuous oxygen therapy for respiratory failure and another receiving regular hydromorphone for chronic pain. In both cases, staff confirmed that care plans addressing these specific needs were missing, despite facility policy requiring comprehensive, measurable care plans for all identified resident needs.
The facility did not timely update care plans for two residents: one with epilepsy did not have a care plan intervention for padded side rails added after a physician's order, and another with an indwelling catheter did not have their care plan reviewed or revised for over six months. Staff confirmed that care plans are required to be reviewed quarterly and after changes in condition, but these requirements were not met, resulting in deficiencies in individualized care.
A resident with recent knee surgery and mobility limitations was unable to participate in transfers or therapy for 12 days due to the facility's failure to provide a properly fitting knee immobilizer. Therapy and nursing documentation showed the resident remained bedbound, and interviews confirmed the resident experienced sadness and depression as a result. The delay in obtaining the necessary device led to a preventable decline in the resident's ability to perform activities of daily living (ADLs) and maintain mobility.
A resident requiring partial to moderate assistance with ADLs, including bathing, was not consistently offered or provided showers or bed baths according to facility policy. Staff failed to document whether bathing was offered, received, or refused on multiple days, and did not ask the resident for her bathing preference, resulting in inadequate personal hygiene care.
A resident with a history of diabetes, a foot ulcer, and prior DVT did not receive ordered vascular studies or a follow-up with a vascular surgeon after a staff transition led to a lapse in care coordination, despite these needs being documented in the care plan and medical record.
A resident with a stage 4 pressure ulcer and severe cognitive impairment was found with a low air loss (LAL) mattress set incorrectly at 225 lbs instead of the required 87 lbs, as indicated on the mattress. This error was confirmed by an LVN and occurred despite physician orders and care plans specifying the need for proper mattress settings to manage the resident's wound. The facility's policy and the manufacturer's guide both emphasized the importance of correct support surface settings for pressure injury prevention and care.
Two residents with indwelling catheters did not receive proper care: one did not receive catheter care or monitoring after hospital readmission due to missing physician orders, and another had a catheter collection bag positioned at bladder level instead of below, contrary to policy and care plan requirements.
Inaccurate Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that licensed nurses accurately completed Fall Risk Assessments for two residents. For one resident, the record showed an admission and readmission with diagnoses including PE, hypotension, Guillain-Barre syndrome, and a history of falling. The MDS indicated intact cognition, impaired ROM in both lower extremities, dependence on staff for toileting hygiene, lower body dressing, bed mobility, and transfers, and maximal assistance with showering and rolling in bed. After an assisted fall with left leg pain radiating to the foot, the resident requested transfer to a hospital and a physician order was obtained for transfer to an acute care hospital. The Fall Risk Assessment for that resident identified a witnessed fall as the triggering event, but the history of falls section stated there were no falls within the past three months despite documentation of the fall on the same date in the COC evaluation. The SBP section was marked as no noted drop between lying and standing, even though the DON stated the resident was unable to stand. During interview, the MDS nurse stated the fall incident was not included in the assessment and that the assessment should be completed accurately and thoroughly to identify fall risk factors and support care planning. For the second resident, the record showed diagnoses including metabolic encephalopathy, hemiplegia, hemiparesis following cerebral infarction, aphasia, epilepsy, hypotension, and dementia. The MDS indicated severely impaired cognition, impaired ROM in one upper extremity and both lower extremities, dependence on staff for all ADLs except eating, transfers not attempted, and wheelchair use. Two Fall Risk Assessments were reviewed; both marked balance problems while standing and walking and marked SBP as no noted drop between lying and standing, and one assessment left the vision status section blank. The MDS nurse stated the resident was dependent for all ADLs, unable to stand, used a wheelchair, and that the SBP and vision sections were completed incorrectly and incompletely.
DSD Not Department-Approved and Employment Reference Checks Not Properly Completed
Penalty
Summary
The facility failed to ensure that the designated Director of Staff Development (DSD) was approved by the Department to serve in that role. The approved Nurse Assistant Training Program Notice identified a DSD other than LVN 1, and the facility was required to notify the Department within 30 calendar days after employing a new DSD. Records showed LVN 1 began working at the facility as an LVN, was later changed to DSD on the payroll action form, and was listed on the facility’s Department Heads listing as the DSD. During interviews, the Administrator stated the facility had two full-time DSDs, with LVN 1 working the p.m. shift, while LVN 1 stated she had been functioning as a full-time DSD and had been highly involved in CNA in-services and training. LVN 1 stated she had not received Department approval to serve as DSD and had not submitted an application for such approval. The facility also failed to develop and implement policy and procedures requiring former employment reference checks before hire. The Administrator stated the facility did not have a policy addressing employment reference checks during the new employee hiring process. Review of LVN 1’s personnel file showed the Reference Check Control Form was blank for employment references, even though LVN 1 had already been hired. The DON stated the references documented were only a friend and former co-workers, and that these sources would not be able to provide relevant information such as length of employment, job performance, history of resident abuse, or eligibility for rehire. Additional personnel files showed the same pattern. LVN 4’s reference check form listed the applicant’s wife and two co-workers as references, but did not identify their job titles or positions. The DON stated the facility should verify work experience and any history of resident abuse through appropriate employment references and document the name and title of the person contacted. The DSD’s own personnel file also showed references from friends and a co-worker rather than former employers. The Administrator stated that friends or co-workers could provide information about whether a potential employee had a history of resident abuse, and that a criminal background check with no adverse findings was sufficient after reviewing the facility’s abuse, neglect, and exploitation policy.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to complete required pre-employment screening before hiring three of six sampled employees: two LVNs and the DSD. For LVN 1, the personnel file and Reference Check Control Form dated 3/25/2025 showed the employment reference section was left blank, and the date of hire was 3/26/2025. During interview and record review with the ADM and DON, the DON stated the facility did not document attempts to contact former employers such as HR or the DSD, and that the references obtained were only from a friend and co-workers who could not provide relevant information such as length of employment, work performance, history of resident abuse, or re-hire eligibility. For LVN 4, the Reference Check Control Form dated 5/11/2025 showed the facility contacted the potential employee's wife and two co-workers, with a date of hire of 5/12/2026. During interview and record review, the ADM and DON stated the documentation did not identify the titles or positions of the individuals contacted, and the DON stated the facility should verify work experience and document the name and title of each person contacted. For the DSD, the personnel file contained Confidential Reference Checks signed 10/30/2020 showing contact with friends and a co-worker, with a date of hire of 11/3/2020. The ADM stated a criminal background check had been completed and showed no criminal offenses, and further stated that friends or co-workers could provide information about a history of resident abuse, so former employers did not need to be contacted. The facility's Abuse, Neglect, and Exploitation policy required background, reference, and credential checks and documentation that screening occurred.
Failure to Notify Physician of Repeated Insulin Refusals
Penalty
Summary
The facility failed to provide resident-centered care and services for one resident by not notifying the physician after the resident repeatedly refused scheduled insulin administration. The resident was admitted on 5/2/2023 and later readmitted with diagnoses including ESRD, type 2 DM, diabetic neuropathy, and dependence on renal dialysis. The MDS dated 4/7/2026 indicated the resident’s cognition was intact and that the resident required varying levels of assistance with bathing, toileting, eating, oral hygiene, and personal hygiene. The resident had an order for Insulin Regular Human Injection Solution to be given per sliding scale, and the MAR for May 2026 showed refusals of the 6:30 a.m. insulin dose on 5/12/2026, 5/13/2026, 5/14/2026, 5/16/2026, 5/17/2026, 5/18/2026, and 5/19/2026. During interview and record review, an LVN stated the resident picks and chooses when insulin is received and confirmed there was no documented evidence that the physician was notified of the repeated refusals. The DON stated that after three consecutive days or doses of medication refusal, the charge nurse is responsible for notifying the physician and initiating a COC document, and stated the physician should have been notified of the repeated insulin refusals.
Missing PTSD-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one sampled resident with a history of PTSD. The resident was admitted with PTSD, had intact cognition, and the H&P documented that the resident had the capacity to understand and make decisions. The MDS showed the resident required supervision or touching assistance with showering and toileting hygiene, set up or clean-up assistance with personal hygiene, and was independent with oral hygiene and eating. A Trauma Informed Care Screener completed at admission was positive for trauma, and a psychiatric progress note later documented the resident's history of PTSD. During interview and record review, the SSD reviewed the resident's care plans and stated that there was no care plan specific to PTSD, and that Social Services was responsible for initiating it because it related to psychosocial well-being. The DON also reviewed the care plans and stated that the resident should have had a PTSD-specific care plan to ensure appropriate interventions, including referral to a psychologist and interventions to identify and manage PTSD triggers. The facility's Comprehensive Care Plans policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs, and the Trauma Informed Care policy called for individualized interventions, collaboration with appropriate professionals, and evaluation of triggers and re-traumatization.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure trauma-informed care was provided for one resident with a diagnosis of PTSD. The resident was admitted with diagnoses that included diverticulitis of the intestine and PTSD, and the MDS dated 3/24/2026 indicated cognition was intact. The resident required supervision or touching assistance with showering and toileting hygiene, set up or clean-up assistance with personal hygiene, and was independent with oral hygiene and eating. The resident's order summary dated 12/17/2025 included a physician's order to see a psychologist, but the resident stated on 5/20/2026 that she had not been arranged to see or speak with a psychologist at any time during her stay. During interview, the SSD confirmed the resident had not been seen by a psychologist while residing in the facility and stated that psychological services would be beneficial given the PTSD diagnosis. The SSD did not provide an explanation for why the resident had not been referred to or evaluated by a psychologist despite the order. The resident also stated that PTSD-related triggers included people yelling and people raising their voices. The SSD reviewed the record and stated there was no documented evidence identifying the resident's PTSD-related triggers. The SSD stated that identifying trauma triggers is important to ensure appropriate medical and non-medical interventions and support tailored to the resident's needs, and acknowledged the facility failed to provide trauma-informed care by not addressing resident-specific needs related to PTSD and by failing to identify and document the resident's PTSD triggers.
Failure to Arrange Recommended DME Before Discharge
Penalty
Summary
The facility failed to ensure that therapy-recommended durable medical equipment (DME) was arranged before discharge for one resident. The resident was admitted with diagnoses including osteoarthritis of the right hip, abnormalities of gait and mobility, muscle weakness, and repeated falls. The Minimum Data Set dated 4/29/2026 indicated the resident’s cognitive skills for daily decision making were intact, but the resident required extensive assistance with toileting, showering, lower body dressing, footwear, and transfers, including sit-to-lying and sit-to-stand. A physician order dated 5/11/2026 directed that the resident be discharged home that day. The Post Discharge Plan of Care and Summary dated 5/11/2026 indicated the discharge summary was provided to the resident, but it did not show that DME had been requested or arranged prior to discharge. During interviews and record review, the resident’s family member stated the resident should not have been discharged without a wheelchair because it was needed for safe mobility in the home. The Social Services assessment indicated the resident required DME for a successful discharge. The PT discharge summary listed discharge recommendations for assistive devices for safe functional mobility, including a two-wheel walker, wheelchair, and bedside commode. The Social Services Director, Director of Rehabilitation, Case Manager, and DON each stated that the recommended DME should have been ordered and in place before discharge, and the facility policy on discharge planning required the individualized discharge care plan to address identified equipment needs.
Failure to Document Grievance and Missing Property Report
Penalty
Summary
The facility failed to implement its Resident and Family Grievance policy by not documenting and logging a grievance reported by a resident's wife regarding the resident's eye condition. Resident 1 was admitted with cellulitis of the right upper limb, severe sepsis with septic shock, abnormalities of gait and mobility, and muscle weakness. The Minimum Data Set dated 10/12/2025 indicated the resident's cognitive skills for daily decision making were moderately impaired, and the resident required varying levels of assistance with oral hygiene, personal hygiene, and toileting hygiene. During interview and record review, the Social Services Director stated that the wife reported concerns about the resident's eye condition and that the concern was medically related, so it was referred to nursing. However, the concern was not entered into the Resident Grievance/Complaint Log for December 2025 or January 2026. The Social Services Director stated the concern could have constituted a grievance and should have been documented in the log, but it was not because nursing staff were notified immediately and the concern was assumed to have been addressed. There was also no documented evidence in the resident's Social Services Notes that the Social Services Director followed up on the wife's concern. The facility also failed to implement its Theft and Loss policy for the same resident when the resident's wife reported that the resident's slippers were missing. The Social Services Director stated staff searched for the missing item immediately and that the slippers were reportedly found shortly thereafter, but no theft and loss report was completed and no documented evidence was provided to verify the slippers were located. The facility's policy required staff to complete a theft and loss report if the property was not found and to include details such as the missing item, estimated value, date and time of the loss if known, and actions taken.
Inaccurate MDS Coding for IV Feeding
Penalty
Summary
The facility failed to ensure that Resident 3’s MDS was accurately coded for Section K. Resident 3 was readmitted with diagnoses including metabolic encephalopathy, multiple sclerosis, and type 2 diabetes, and the MDS dated 3/23/2026 indicated severely impaired cognitive skills for daily decision making, supervision or touching assistance with eating, partial or moderate assistance with oral hygiene and personal hygiene, dependence for toileting, and parenteral/IV feeding while in the facility. Record review showed a physician order dated 3/18/2026 for 0.9% Sodium Chloride Solution at 50 mL per hour IV every shift for hydration for two days. A physician progress note dated 3/20/2026 documented family concerns about decreased oral intake and that IV fluids were started. However, the nutritional assessment documented that parenteral nutrition/IV fluids within the last 7 days was marked No. During interviews, the MDSA stated Section K is completed by the RD, and the MDSC stated that because Resident 3 had an order and received IV fluids during the look-back period, the RD was able to document parenteral/IV feeding on the MDS. The MDSC also reviewed the record and stated there were no clinical indications supporting the need for ongoing IV hydration. The RD stated she reviewed labs, physician notes, and physician orders, but found no clinical indications that Resident 3 required IV fluids for hydration and did not question the physician’s order. The DON stated the MDS Section K was not accurately coded because there were no clinical indications supporting the need for IV hydration, and the MDSC should have verified the accuracy before completion and signature.
Incorrect Insulin Dose Administered
Penalty
Summary
The facility failed to ensure that a resident with cellulitis of the right upper limb, severe sepsis with septic shock, gait and mobility abnormalities, muscle weakness, and diabetes received Insulin Lispro as ordered by the physician. The resident’s admission record showed moderately impaired cognitive skills for daily decision making, and the MDS indicated the resident needed assistance with personal and toileting hygiene. The care plan for diabetes included administration of diabetes medications as ordered, and the physician’s order specified Insulin Lispro sliding scale coverage, including 18 units for a blood sugar level greater than 400 mg/dl, to be given subcutaneously four times a day for TPN use and DM. On 12/21/2025, the resident’s MAR documented a blood sugar level of 545 mg/dl at 9:00 a.m. During record review and interview, the MDS Assistant confirmed that the resident should have received 18 units of insulin based on the physician’s sliding scale order. However, the administration note showed that the resident received 15 units of insulin at 9:49 a.m. The DON stated that the correct insulin dosage should have been administered in accordance with the physician’s order, and that accurate insulin administration is necessary to comply with orders and prevent adverse outcomes, including hyperglycemia.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 4, received a meal that accommodated the resident’s food preference. Resident 4 was readmitted with diagnoses including vascular dementia, a history of falls, and Alzheimer’s disease. The Minimum Data Set dated 3/16/2026 indicated the resident’s cognition was severely impaired and that the resident required partial/moderate assistance with eating and oral hygiene, substantial/maximal assistance with personal hygiene, and was dependent on staff for toileting hygiene. The physician’s order specified a regular pureed texture diet with thin consistency, fortified foods three times daily with small meal portions, and the care plan for a nutrition problem related to dementia included an intervention to honor the resident’s food preferences within diet parameters. The resident’s meal card listed an added item of pureed fruit. During lunch observation, Resident 4’s tray was served without pureed fruit. The Dietary Supervisor reviewed the meal card and stated that pureed fruit should have been served as indicated on the meal card and that food adds on residents’ meal tickets represent food preferences and should be included on meal trays. The Dietary Supervisor retrieved pureed fruit from the kitchen and served it to the resident. Later, the Dietary Supervisor stated kitchen staff failed to serve the pureed fruit and that staff should follow residents’ meal tickets to ensure preferences and choices are accommodated. The facility policy stated staff shall accommodate resident allergies, intolerances, and preferences and that resident preferences and allergies shall be obtained during assessment and added to the resident’s tray ticket.
Incomplete Admission Nursing Assessments
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for two sampled residents by not ensuring the RN Supervisors completed the Clinical Admission assessment documentation upon admission. For Resident 1, the admission record showed the resident was admitted with diagnoses including cellulitis of the right upper limb, severe sepsis with septic shock, gait and mobility abnormalities, muscle weakness, and diabetes. The MDS indicated moderately impaired cognitive skills for daily decision making and varying levels of assistance needed with oral hygiene, personal hygiene, and toileting hygiene. During interview and record review, RN 2 stated that RN Supervisors are responsible for assessing residents and documenting the assessment on the facility’s Clinical Admission form. RN 2 reviewed Resident 1’s Clinical Admission form and stated it was not completed. The DON also reviewed the form and identified multiple sections as incomplete or blank, including Neurologic Group Assessment, Mood & Behavior, Respiratory, Gastrointestinal, Genitourinary, Screening, Care Planning, and Clinical Suggestions. For Resident 5, the admission record showed the resident was originally admitted and later readmitted with diagnoses including encephalopathy, ESRD, unspecified sequelae of cerebral infarction, and dependence on renal dialysis. The MDS indicated moderately impaired cognition and dependence on staff for oral hygiene, toileting hygiene, and personal hygiene. RN 2 reviewed Resident 5’s Clinical Admission form and stated the assessment was not completed, and the DON identified multiple incomplete or blank sections, including Neurologic Group Assessment, Mental Status, Mood & Behavior, Gastrointestinal, Nutrition, Genitourinary, Skin, Care Planning, and Clinical Suggestions. The DON stated the RN Supervisor should have completed all sections of the nursing assessment and that incomplete admission documentation could result in inaccurate development of the resident’s plan of care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him repeatedly in the face with a closed fist while he was lying in bed. The assaulted resident had been admitted with diagnoses including hypertensive heart disease with heart failure, osteoporosis, and bed confinement status, and his history and physical indicated he could make needs known but could not make medical decisions. The resident later reported that the attack was unprovoked, that the other resident yelled and cursed before striking him, and that he felt startled and scared during the incident. Records and staff interviews showed that the assaulted resident sustained bleeding gums and a loose tooth after the altercation. Progress notes documented that blood was observed in his mouth and that his gums were bleeding. The resident was observed wiggling an upper left incisor, which was loose. The physician progress notes also stated that the resident reported another resident walked up to him and hit him on the face. The resident’s MDS indicated intact cognition and extensive assistance with ADLs. The resident who struck him had been admitted shortly before the incident and had diagnoses including polyneuropathy, epilepsy, depression, violent behavior, and anxiety disorder. His H&P documented acute agitation, verbal aggression, and physical aggression at a previous facility. Staff interviews confirmed that he walked from his bed to the other resident’s bed and punched him several times in the face. The CNA who witnessed the event stated he saw approximately two to three punches land before separating the residents, and the LVN stated she observed bleeding from the upper front gums. The DON stated the actions were willful and intentional and constituted physical abuse. The facility policy defined physical abuse to include punching.
Delayed Physician H&P Documentation
Penalty
Summary
The facility failed to ensure that the attending physician provided a History and Physical note after the initial visit for a newly admitted resident. Resident 2 was admitted with diagnoses including polyneuropathy, epilepsy, and depression, and the H&P completed on 4/12/2026 also documented violent behavior, anxiety disorder, acute agitation, verbal aggression, and physical aggression at the prior facility. The MDS indicated the resident had intact cognition. On 4/16/2026, a CNA witnessed Resident 2 strike his bedbound roommate in the face multiple times with a closed fist during a change in condition event. The Medical Records Director stated the attending physician saw the resident on 4/12/2026, but the H&P was not provided to the facility at that time; it was later emailed on 4/16/2026 and not uploaded into the electronic record until after the resident had already been discharged. The DON stated physicians are expected to provide documentation the same day of the visit and that a newly admitted resident should have a completed H&P on file following the initial visit.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach while the resident was in bed. The resident had been originally admitted in late January and re-admitted in late April with diagnoses including muscle weakness and diverticulitis of the large intestine with perforation and abscess with bleeding. An MDS assessment indicated the resident had moderately impaired cognitive skills for daily decision-making, required setup or clean-up assistance with eating, supervision with oral hygiene, partial/moderate assistance with toileting hygiene, and substantial/maximal assistance with showering or bathing. During an observation in the resident’s room, the resident was seen in bed with the call light not within reach, hanging on the wall behind the headboard. In a concurrent observation and interview with an LVN in the same room, the resident remained in bed with the call light still not within reach, again observed hanging behind the headboard. The LVN then reached over the headboard, clipped the call light, and placed it next to the resident’s right hand, stating that the call light should always be next to the resident for safety and that CNAs are responsible for ensuring call lights are within residents’ reach because they are always checking on residents. In a separate interview, the DON stated that call lights should always be within residents’ reach, clipped by the bed, so residents can easily call staff when they need help or assistance, and that if call lights are not within reach, residents may not be able to call for assistance when needed. Review of the facility’s policy on call lights indicated staff will be educated on proper use of the call light system and must ensure the call light is within reach of the resident and accessible while the resident is in bed or other sleeping accommodations.
Failure to Develop Baseline Care Plan for CHF on Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission to address a resident’s primary admitting diagnosis of congestive heart failure (CHF). The resident was admitted with CHF and had an MDS assessment showing moderately impaired cognitive skills for daily decision-making and functional needs including assistance with oral hygiene, eating, personal hygiene, and dependence for toileting hygiene and bathing. Review of the admission record and baseline care plans showed no documented baseline care plan specific to CHF, despite CHF being the primary admitting diagnosis. The MDS nurse, who stated that diagnosis-related care plans are initiated by the MDS department, confirmed that there was no baseline care plan for CHF and acknowledged that one should have been in place. The DON stated that baseline care plans are important to be initiated on admission to ensure nursing staff provide appropriate care based on admitting diagnoses and to allow staff to evaluate and revise interventions as needed. The facility’s own policy titled “Baseline Care Plan,” last reviewed on 4/24/2025, requires that a baseline care plan be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. The policy also specifies that the admitting or supervising nurse must gather information from the admission assessment, hospital transfer information, physician orders, and discussions with the resident or representative to establish initial goals and interventions addressing current needs and health and safety concerns. Despite these requirements, no baseline care plan addressing the resident’s CHF was developed within the required timeframe.
Single-Staff Use of Mechanical Lift Contrary to Two-Person Transfer Requirement
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who required a mechanical lift with two-person assistance for transfers received that level of assistance. The resident had diagnoses including metabolic encephalopathy, abnormalities of gait and mobility, and lack of coordination, and an H&P documented that the resident did not have the capacity to understand or make decisions. The resident’s MDS showed a need for assistance with several ADLs, and the care plan for ADL self-care performance specified that transfers required a mechanical lift with two staff assisting. During observation, the resident was seated on a shower chair with a mechanical lift sling in place and the sling straps attached to the lift hooks when a single CNA operated the mechanical lift controls, briefly elevating the resident from the shower chair and then lowering the resident back down. In an interview, the CNA stated she was assigned to the resident on the day of the incident and that it was the resident’s shower day. She reported she was setting up the resident on the mechanical lift and waiting for another CNA to assist with transferring the resident back to bed when she noticed the resident’s forehead touching the metal bar of the lift. Because the resident was tall, she decided to elevate the resident from the shower chair and adjust the resident and the lift so the resident’s head would not contact the bar, doing so without a second staff member present. The CNA acknowledged she knew the resident was a two-person assist and that she made a mistake by elevating and moving the lift alone. The DON confirmed that facility practice and expectations are that two staff members are present when using a mechanical lift for transfers to ensure resident safety, and the facility’s Accidents and Supervision policy stated that residents will receive adequate supervision and assistive devices to prevent accidents.
Failure to Hold Antihypertensive Medications Outside Ordered BP Parameters
Penalty
Summary
The facility failed to ensure that licensed nurses held a resident’s antihypertensive medications when the resident’s blood pressure was outside the physician’s ordered parameters. Resident 1 was admitted with diagnoses including diastolic congestive heart failure and essential hypertension, and had moderately impaired cognitive skills for daily decision making, requiring varying levels of staff assistance with activities of daily living. Physician orders for this resident included furosemide 40 mg by mouth once daily for diastolic heart failure, to be held for systolic blood pressure (SBP) less than 110 mmHg, and losartan 12.5 mg by mouth once daily for hypertension, to be held for SBP less than 110 mmHg or heart rate less than 60 beats per minute. Review of the Medication Administration Record for the month showed that licensed nurses administered both furosemide and losartan to the resident on two occasions when the SBP was below the ordered hold parameter: once with an SBP of 107 mmHg and once with an SBP of 98 mmHg. During interview, the MDS nurse confirmed that the medications should not have been administered on those dates based on the physician’s parameters and acknowledged that nurses are expected to obtain vital signs prior to giving blood pressure medications and to hold medications when vital signs fall outside the prescribed limits. The facility’s medication administration policy stated that medications are to be administered as ordered by the physician, including obtaining and recording vital signs when applicable and holding medications when vital signs are outside the physician’s prescribed parameters, which was not followed in this case.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician after multiple refusals of prescribed medications. The resident was admitted with chronic respiratory failure, pneumonia, dysphagia, type 2 DM, CHF, and HTN, and had documented capacity and intact cognition. Physician orders included daily potassium chloride 20 mEq as a supplement related to Lasix use and metoprolol succinate 50 mg daily for HTN. Review of the MAR for February showed the resident refused potassium chloride on multiple consecutive days (2/17–2/19 and 2/23–2/28) and refused metoprolol succinate on multiple series of consecutive days (2/3–2/6, 2/9–2/12, 2/16–2/18, and 2/20–2/22). The March MAR showed continued refusals of potassium chloride on multiple consecutive days (3/4–3/9 and 3/11–3/14). During interview, an LVN who administered medications to the resident acknowledged that the resident sometimes refused ordered medications and stated that when a resident refuses medication three or more times, the physician should be notified. The LVN further stated that they did not document that the physician was notified of the resident’s medication refusals. In a concurrent interview and record review, the DON confirmed that the MARs showed multiple refusals of potassium chloride and metoprolol succinate and stated that nursing staff should notify the prescribing physician when a resident refuses medications three consecutive times. The facility’s Medication Administration policy indicated that medications are to be administered as ordered by the physician and that staff must report and document any refusals, but there was no documentation that the physician was notified of these repeated refusals.
Failure to Complete Weekly Skin Assessments per Facility Policy
Penalty
Summary
The facility failed to complete weekly skin assessments for one resident in accordance with its Skin Assessment policy and procedure. The resident was admitted on 1/19/2026 with multiple diagnoses, including chronic respiratory failure, pneumonia, dysphagia, type 2 diabetes, congestive heart failure, and hypertension. A History and Physical dated 1/20/2026 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 1/26/2026 indicated intact cognition. The MDS further showed the resident required set-up assistance with eating, supervision with oral hygiene, upper body dressing, and personal hygiene, and was dependent on staff for toileting hygiene and showering. During interview and record review, the Medical Records Director stated that the resident’s skin assessments were documented only on 1/19/2026, 1/20/2026, 2/2/2026, and 3/1/2026, and confirmed there were no other documented skin assessments in the medical record. The facility’s Skin Assessment policy, last reviewed on 4/24/2025, required a full body, head-to-toe skin assessment by a licensed or registered nurse upon admission or readmission and weekly thereafter, and additionally after a change of condition or any newly identified pressure injury. The Director of Nursing stated that licensed nurses should have conducted the resident’s weekly skin assessments during the admission, but the documentation showed that weekly assessments were not consistently completed as required by the policy.
Failure to Implement Care Plan for Vision and Hearing Devices
Penalty
Summary
Surveyors identified a deficiency in the implementation of a resident’s comprehensive care plan related to vision and hearing needs. The resident was admitted with diagnoses including metabolic encephalopathy, UTI, hearing loss, and dementia, with assessments showing severely impaired cognition and dependence on staff for most ADLs. The resident’s care plan for impaired visual function, revised 1/6/2026, directed staff to remind the resident to wear glasses when up and to ensure the glasses were worn, clean, free from scratches, and in good repair. A separate care plan for communication problems related to bilateral hearing loss, revised 1/7/2026, indicated the resident required hearing aids to communicate and that staff were to ensure the availability and functioning of adaptive communication equipment. On observation on 2/26/2026 at 1:45 p.m., the resident was seen sitting in a wheelchair in the lobby without eyeglasses or hearing aids in place. During a concurrent observation and interview at 1:50 p.m., the ADON confirmed that the resident should be wearing eyeglasses and hearing aids when out of bed. In a later interview at 2:45 p.m., an LVN stated the resident should be wearing hearing aids and eyeglasses when out of bed, but reported the hearing aids were not currently charged and therefore not available for the resident to wear, despite the plan of care requiring their use. The Administrator also confirmed that the resident should be wearing hearing aids and eyeglasses when out of bed as indicated in the care plans. Facility policies on care and use of hearing aids and on comprehensive care plans required assistance with hearing aids and implementation of person-centered care plans with measurable objectives and timeframes to meet identified needs.
Failure to Provide Recommended Recliner Wheelchair DME
Penalty
Summary
The facility failed to provide a recliner wheelchair, a recommended piece of DME, to a resident following a physical therapist’s assessment and order. The resident had been readmitted with diagnoses including an unspecified displaced fracture of the neck of the left humerus, UTI, and metabolic encephalopathy, and had a Minimum Data Set indicating severely impaired cognition and dependence on staff for toileting hygiene, bathing, dressing, personal hygiene, and mobility. On 12/26/2025, Physical Therapist 1 documented that the resident was compliant with skilled interventions, required extra time to process new information, and recommended a recliner wheelchair due to poor sitting balance and a non–weight-bearing left upper extremity. Despite this recommendation, the resident did not receive a recliner wheelchair and was later observed awake and lying in bed. The Director of Rehabilitation Services stated that the resident did not have a recliner wheelchair and explained that she initially believed the recliner wheelchair would not be covered under Medicare Part A, so she did not order it. After reviewing the Medicare Benefit Policy Manual, she acknowledged that the recliner wheelchair should have been ordered at the time of the therapist’s recommendation and that it was important to follow the recommendation to prevent the resident from sliding or falling forward from the wheelchair. The DON confirmed that the recliner wheelchair should have been ordered following the therapist’s assessment and that the failure of the Director of Rehabilitation Services to order the equipment and communicate with nursing resulted in a delay in treatment, with the potential to cause functional decline and decreased mobility. The facility’s policy, based on the Medicare Benefit Policy Manual Chapter 8, indicated that DME for Part A inpatients is covered as part of the SNF prospective payment system and is not separately payable.
Failure to Develop PTSD-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's history of post-traumatic stress disorder (PTSD). The resident was admitted with diagnoses including major depressive disorder and had a positive trauma screen, with documentation indicating a history of trauma related to an attempted assault in her 20s. The resident's Minimum Data Set showed intact cognitive skills and a need for assistance with daily activities. Despite these findings and a psychiatric note confirming ongoing PTSD-related anxiety, the care plan did not specifically address PTSD. During interviews and record reviews, it was confirmed that staff were aware of the resident's PTSD, but no care plan interventions specific to PTSD were in place. The Assistant Director of Nursing acknowledged that a care plan for PTSD should have been developed, including interventions such as referral to a female psychologist. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed for the resident's PTSD.
Failure to Provide Resident-Centered Behavioral Health Services for PTSD
Penalty
Summary
The facility failed to provide resident-centered behavioral health services to a resident with a documented history of post-traumatic stress disorder (PTSD) and major depressive disorder. The resident was admitted with these diagnoses, and assessments, including the Trauma Informed Care Screener and the Minimum Data Set, confirmed both the presence of trauma and intact cognitive skills. Despite the resident's disclosure of PTSD to staff and documentation in the care plan and psychiatric notes indicating ongoing PTSD-related anxiety, the facility did not implement specific behavioral health interventions beyond psychiatric visits. Interviews with facility staff, including the LVN, DON, and ADON, revealed that no additional behavioral health services or interventions were provided to address the resident's PTSD. Staff acknowledged awareness of the resident's condition but confirmed that no assessments or services were in place to identify triggers or prevent behavioral responses related to PTSD. The facility's own policy required person-centered behavioral health care, but this was not followed for the resident in question.
Failure to Obtain Representative Signature for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked decision-making capacity had their admission packet e-signed by their designated representative. Instead, the admission assistant obtained an electronic signature from the resident, despite documentation in the resident's History and Physical (H&P) examinations indicating the resident did not have the capacity to understand or make decisions due to conditions such as metabolic encephalopathy, urinary tract infection, immunodeficiency, and dementia. The admission occurred after the resident was diagnosed with these conditions, and both the H&P dated shortly after admission and a subsequent H&P confirmed the resident's incapacity. During interviews and record reviews, both the admission assistant and the admission director acknowledged that the resident's representative should have been the one to e-sign the admission packet, as per the facility's policy and the resident's documented incapacity. The facility's policy states that a resident's representative has the right to exercise the resident's rights to the extent those rights are delegated. The failure to have the representative sign the admission documents resulted in the resident not being rightfully represented in important healthcare decisions.
Unsafe Room and Lobby Temperatures
Penalty
Summary
The facility failed to maintain room temperatures within the required range of 71 degrees Fahrenheit to 81 degrees Fahrenheit in one sampled resident’s room and in the lobby areas. Resident 1 was admitted on 5/1/2022 and re-admitted with diagnoses including Alzheimer’s disease and UTI. The resident’s MDS dated 9/25/2025 indicated severely impaired cognition and the need for maximal assistance with toileting hygiene, showering, lower body dressing, bed mobility, and transfers. During observation on 11/20/2025, Resident 1 was found lying in bed under three layers of blankets, and the room temperature at the bedside was measured at 69.6 F, then 68.5 F, and later 69.3 F, all below the required range. The Temperature Control Box for the room was observed set to cool rather than heat, and the Maintenance Supervisor stated it should have been set to heat. In the facility lobby, the temperature was observed between 63.1 F and 65.1 F during the same day’s observation. The Temperature Control Box for the lobby showed 69 F and was turned off until Maintenance Assistant 1 opened it and turned the system on, setting it to 72 F. The assistant stated the staff member responsible for turning it on each morning had been busy with other tasks. The DON stated temperatures should be maintained between 71 F and 81 F in all areas, including resident rooms and lobby areas, and the Maintenance Supervisor stated the facility had only been documenting room temperatures, not other areas, for the prior two years. The facility policy titled Safe and Homelike Environment stated that common areas, including the lobby, should be kept between 72 and 82 degrees Fahrenheit.
Inadequate Perineal Care for an Incontinent Resident
Penalty
Summary
The facility failed to ensure appropriate perineal care for a resident who was occasionally incontinent of both bladder and bowel function and required maximal assistance with toileting hygiene, showering, lower body dressing, bed mobility, and transfers. The resident had diagnoses including Alzheimer's disease and UTI. During a morning observation, a CNA provided perineal care in bed by wetting a big towel in the resident's bathroom and applying perineal cleanser, but did not use a basin and used the same towel throughout the care. The CNA cleaned the front perineal area with one end of the towel, dried it with the other end, and then turned the resident to clean the buttocks with the same towel previously used for the front area. The CNA did not fold the towel or rinse the perineal area during care. When interviewed after the care was completed, the CNA stated that only one big towel was used because total morning care would be provided later and that the perineal areas were not cleaned thoroughly at that time. The DON later stated that the CNA used only one towel for both front and back perineal areas, which did not follow the facility's perineal care protocol. The facility's policy stated that perineal care should be provided to incontinent residents to promote cleanliness and comfort, prevent skin irritation, and observe skin condition, and that females should be gently rinsed and dried, repeating on the opposite side using a separate section of washcloth or a new disposable wipe.
Failure to Implement Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control practices during an ongoing COVID-19 outbreak, as evidenced by multiple staff not adhering to mask-wearing protocols and hand hygiene requirements. Specifically, two staff members, an Activity Assistant and a Certified Occupational Therapy Assistant, were observed wearing surgical masks below their noses, only covering their mouths, while in resident care areas. Both staff acknowledged awareness of the ongoing outbreak and their training on proper mask use, but did not maintain correct mask positioning during their duties. Additionally, hand hygiene lapses were observed among staff. A Physical Therapist did not perform hand hygiene after removing gloves and before touching a resident and their wheelchair following a therapy session. The therapist admitted that hand hygiene should have been performed to prevent the spread of germs. Similarly, a Housekeeping staff member failed to perform hand hygiene after handling trash in a restroom and before touching the janitor cart. The staff member acknowledged the lapse and the importance of hand hygiene in infection control. Further, the same Housekeeping staff member was observed transporting four trash bags with bare hands, allowing the bags to come into contact with her clothing. The staff member stated that the bags were heavy and difficult to keep away from her body. The Director of Nursing confirmed that a cart should have been used to prevent cross-contamination. Facility policies and CDC guidelines reviewed during the survey supported the need for proper mask use, hand hygiene, and safe trash handling to prevent the transmission of infectious diseases.
Incomplete discharge summaries and missing discharge documentation
Penalty
Summary
The facility failed to ensure that discharge summaries for three residents included a recapitulation of each resident’s stay and complete, appropriate discharge information and instructions. The deficiency was identified through interview and record review and involved residents discharged to private homes. The report states that the incomplete discharge documentation had the potential to result in unsafe discharge, incomplete documentation of the resident’s transfer or discharge in the medical record, and inadequate communication of necessary discharge information to the resident or representative. For one resident admitted with hemiplegia and hemiparesis following cerebral infarction, the record showed discharge to a private home with no HH services. The MDS discharge assessment indicated intact cognition, independence with eating, oral/personal hygiene, and bed mobility, and need for setup or supervision with transfers, walking, toileting hygiene, and toilet transfer. The discharge summary provided to family did not include a recapitulation of the resident’s stay or discharge information for Therapy Services, Dietary Services, Social Services, and Activities Services. It also documented bowel and bladder incontinence and assistance needs that did not match the MDS. The family member stated the summary did not include HH contact information, the resident did not receive the walker that was needed, and the summary inaccurately referred to a lower level of care placement. For a second resident admitted with a right acetabular fracture and history of falling, the MDS discharge assessment showed intact cognition, moderate assistance needed for toileting hygiene, showering, and lower body dressing, supervision or touching assistance for eating, oral hygiene, bed mobility, transfers, and walking, and occasional urinary incontinence. The physician order indicated discharge home with HH services and DME including a walker, wheelchair, and commode. The discharge summary signed by the recipient did not include recapitulation of the stay or discharge information for Therapy Services, Social Services, and Activities Services. The RN stated the summary incorrectly documented bowel and bladder incontinence and independence with function, and did not include the equipment needed at home. For a third resident admitted with MS and a right femur fracture, the MDS discharge assessment showed intact cognition, moderate assistance needed for toileting/personal hygiene, showering, and lower body dressing, supervision or touching assistance for bed mobility, transfers, and walking, and bowel and bladder incontinence. The physician order indicated discharge home with HH RN/PT/OT services and DME including a rollator walker and bedside commode. Staff were unable to locate a copy of the discharge summary with the recipient’s acknowledgement in the chart, and the RN and DON stated there was no documentation that the discharge summary was given to the resident or family in the progress notes or chart.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated residents did not receive adequate social services support as required to address their individual needs and promote their well-being. The lack of appropriate social services limited residents' ability to attain or maintain their optimal physical, mental, and psychosocial functioning.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Delay in Laboratory Services Resulted in Delayed Diagnosis and Treatment
Penalty
Summary
The facility failed to provide timely laboratory services as ordered by a nurse practitioner for a resident with multiple medical conditions, including thyroid disorder, diabetes mellitus, and obesity. The resident, who was severely cognitively impaired and fully dependent on staff for care, experienced a change in condition marked by three episodes of foul-smelling diarrhea. The nurse practitioner ordered laboratory tests, an anti-diarrheal solution, and a registered dietician consult. A physician order was placed to collect a stool specimen, which was collected and stored in the refrigerator. However, the laboratory did not pick up the initial stool specimen, resulting in a delay in obtaining a second specimen. The second specimen was sent out two days later, and the positive result for C. difficile toxins was not received until several days after the initial collection. This delay in laboratory processing led to a delay in confirming the diagnosis and starting the necessary antibiotic treatment. Facility policy required timely provision of laboratory services, but this was not followed in this instance.
Failure to Obtain Informed Consent and Inform Residents of Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and able to participate in their care and treatment, specifically regarding medication administration and informed consent for psychotropic medications. For one resident with diagnoses including post-traumatic stress disorder and schizophrenia, the facility did not obtain a complete informed consent for the administration of Zyprexa, a psychotropic medication. The consent form lacked the physician's signature and did not specify the dose frequency. According to facility policy, the physician's signature is required to confirm that the risks and benefits of the medication were explained to the resident or their responsible party. The resident's records indicated that while the individual could make needs known, they could not make medical decisions, further emphasizing the importance of proper consent procedures. Additionally, during medication administration observations, a nurse failed to inform two residents of the names and indications of several medications prior to administration. The nurse admitted to not providing this information because the medication cups were not clearly labeled, which prevented the residents from being informed about their treatment and making choices such as refusing specific medications. The Director of Nursing confirmed that this omission was contrary to facility policy and restricted the residents' rights to be informed and involved in their care. The facility's own policies require that residents be informed in advance about the care and treatments they will receive, including the names and purposes of medications, and that informed consent be obtained for psychotropic medications. The failure to follow these procedures resulted in residents not being fully informed or able to participate in decisions regarding their care, as evidenced by the lack of proper consent documentation and the omission of medication information during administration.
Failure to Provide Recommended Active Range of Motion Exercises to Resident's Arms
Penalty
Summary
The facility failed to provide active range of motion (AROM) exercises to both arms for a resident with limited range of motion and mobility concerns, as recommended by occupational therapy (OT) upon discharge. The resident, who had a history of morbid obesity, healed traumatic fracture, and falls, was admitted with specific OT and physical therapy (PT) recommendations for restorative nursing aide (RNA) interventions. The OT discharge summary specifically recommended AROM to both arms, while the PT discharge summary recommended AROM to both legs. However, the resident's care plan and RNA documentation only included active assistive range of motion (AAROM) to both legs, with no mention or documentation of AROM to the arms. Multiple reviews of the resident's records, including the care plan, RNA documentation, and joint mobility assessments, confirmed that AROM to the arms was not provided or documented from January through June. Interviews with staff, including the RNA, interim director of rehabilitation, occupational therapist, and MDS coordinator, revealed that the OT's recommendations for AROM to both arms were not entered into the facility's electronic documentation system by the previous director of rehabilitation. As a result, the RNA program for the resident did not include the required AROM exercises for the arms, despite clear recommendations and supporting documentation from therapy staff. Observations further confirmed that the RNA only performed AAROM to the resident's legs and did not provide any ROM exercises to the arms. The facility's policy on prevention of decline in range of motion required interventions to maintain or improve ROM, but this was not followed in the resident's case. The failure to implement and document the recommended AROM exercises for both arms had the potential to result in a decline in the resident's upper extremity range of motion.
Failure to Prevent Accident Hazards and Implement Fall Risk Interventions
Penalty
Summary
A deficiency was identified when a shower room was found to have accident hazards, including a broken shower head leaking water onto the floor and a clogged drain resulting in approximately two inches of cloudy water accumulating in one of the showers. Maintenance staff confirmed that these issues had not been reported prior to the surveyor's observation, and acknowledged that such hazards could lead to slips and falls. Facility policy required prompt reporting and repair of non-functioning equipment to maintain a safe environment, but this was not followed in this instance. Another deficiency involved the failure to implement and accurately complete fall risk assessments for residents after falls. In one case, a resident with a history of falls and cognitive impairment experienced a fall, but the post-fall risk assessment was incomplete, omitting critical information such as recent fall history, gait and balance status, and predisposing diseases. In a separate case, a resident's post-fall risk assessment was inaccurately completed, with the nurse failing to document the correct number of falls in the past three months, resulting in a lower risk score than appropriate. Facility policy required thorough and accurate completion of fall risk assessments to guide interventions, but this was not adhered to. Additional deficiencies were observed in the implementation of care plan interventions. One resident, identified as being at risk for falls, was found in bed with the bed in a high position, contrary to the care plan directive to keep the bed in the lowest position. Staff confirmed the bed should have been kept low to prevent injury. Another resident with a seizure disorder and a care plan intervention for padded siderails was observed in bed without the required padding. Nursing staff acknowledged that the absence of padded siderails did not align with the care plan and could result in injury during a seizure. These findings demonstrate failures to follow individualized care plans and facility policies designed to prevent accidents and injuries.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the timely availability and administration of prescribed medications for multiple residents, resulting in missed doses and medication errors. One resident with depression and a history of stroke did not receive the antidepressant Paxil from 5/31/2025 to 6/04/2025 due to a lapse in pharmacy deliveries, as confirmed by pharmacy records and staff interviews. The same resident also experienced a gap in the availability of Sumatriptan, a medication for migraines, which was not available for several days and had to be supplied by a family member after insurance issues delayed pharmacy delivery. Staff and the DON acknowledged that the medications were not available as required, and the facility's own policies for medication reordering and handling unavailable medications were not followed. Another resident with chronic kidney disease and heart failure was prescribed Hydralazine for hypertension, with specific instructions to hold the medication if systolic blood pressure was below 120 mmHg. However, the MAR showed that Hydralazine was administered on multiple occasions when the resident's systolic blood pressure was below the prescribed threshold. The nurse involved confirmed that the medication should have been held according to the physician's order, and the facility's policy required adherence to such parameters. A third resident with chronic pain and polyneuropathy was prescribed senna for bowel management, with orders to hold the medication if the resident had loose stools. Despite documentation of loose stools on several days, senna was administered as scheduled, and the resident reported not ingesting the medication after realizing its purpose. The nurse admitted to administering senna despite the resident's report of loose stools, and the ADON confirmed that this was not in accordance with the physician's order. Additionally, another resident did not receive ergocalciferol as prescribed because the medication was not available in the facility at the scheduled time, which was acknowledged as a medication error by the nurse and DON.
Medication Error Rate Exceeds 5% Due to Missed and Mistimed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 27 opportunities, resulting in a 7.41% error rate. One error involved a resident with chronic kidney disease who did not receive their prescribed ergocalciferol supplement because the medication was not available in the medication cart or anywhere in the facility at the time of administration. The nurse responsible acknowledged that medications should be ordered in advance and available for timely administration, but this did not occur, leading to the omission. Another error occurred when a different resident received their prescribed calcium with vitamin D3 supplement at a time inconsistent with the physician's order. The medication was administered outside the facility's policy-defined 60-minute window for scheduled medication times. The nurse administering the medication recognized this as a failure to follow the '5 rights' of medication administration and the facility's guidelines for medication timing. Interviews with the Director of Nursing and the involved nurses confirmed that both incidents were considered medication errors according to facility policy and procedures. The facility's policies require medications to be administered as ordered by the physician and within a specified time frame, and both errors were attributed to failures in following these established protocols. The documentation review further supported that the medications were not administered as prescribed, confirming the deficiencies.
Unattended Medications Left on Cart by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed preparing six medications, including calcium with vitamin D, aspirin, atenolol, losartan, sennosides, and vitamin B12, for a resident. The LVN placed these medications in cups on top of a medication cart and left them unattended while entering the resident's room to take vital signs. During this time, the medication cart was not supervised, and the medications remained accessible on top of the cart. The LVN then returned to the cart, took three medication cups into the resident's room for administration, and subsequently returned for the remaining three cups to complete the administration process. During interviews, the LVN acknowledged leaving the medications unattended and stated that medications should always be supervised and securely stored. The Director of Nursing (DON) confirmed that the LVN failed to safely store and supervise the medications, noting that without supervision, other residents could potentially access the medications. Review of the facility's policy indicated that medications must be stored safely and securely, accessible only to authorized personnel, and that medication carts must be locked or attended by authorized staff.
Failure to Implement Infection Control Practices for Medical Devices and Equipment
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices for multiple residents. One resident with a gastrostomy tube was not placed on enhanced barrier precautions (EBP) as required by facility policy, despite the presence of an indwelling medical device. The room lacked EBP signage and a PPE supply cart, and the Infection Prevention Nurse confirmed that these should have been in place to reduce the risk of bacterial transmission. The facility's policy indicated that EBP is necessary for residents with devices such as feeding tubes, but this was not followed for the resident in question. Another deficiency was observed with a resident receiving oxygen therapy. The oxygen tubing was not labeled with the date it was last changed, and staff could not confirm when it had been replaced. Facility policy and staff interviews indicated that oxygen tubing should be changed and labeled at least weekly to prevent infection, but this was not done. In a separate instance, a different resident's oxygen tubing was not replaced weekly as required, with the tubing in use for more than three weeks, contrary to the facility's infection control protocol. Additionally, a resident's urinal was found at the bedside without a resident identifier label. Staff confirmed the urinal was not labeled, and the DON stated that labeling is necessary to prevent cross-contamination. However, the Director of Medical Records noted that there was no specific policy addressing urinal labeling. The facility's general infection prevention and control policy requires measures to prevent the development and transmission of communicable diseases, but these specific practices were not consistently implemented.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity in two separate instances involving two residents. In the first case, a resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, who was cognitively moderately impaired and required assistance with hygiene, had an indwelling urinary catheter. During observation, it was noted that the resident's urinary catheter bag was not covered with a privacy bag, contrary to facility policy and staff statements that such coverage is required to promote dignity. Both the MDS Coordinator and Assistant Director of Nursing confirmed that the catheter bag should have been covered, and the facility's policy explicitly stated that privacy bags must be used at all times for catheter drainage bags. In the second instance, another resident with type 1 diabetes mellitus, end stage renal disease, and a below-knee amputation, who required moderate assistance for bathing, reported that staff did not knock before entering the shower room while he was showering. The resident stated that staff entered multiple times to drop off soiled linens without knocking, which he felt violated his dignity and privacy. The CNA assisting the resident confirmed that several staff members entered the shower room without knocking, and the Director of Nursing acknowledged that staff are required to knock before entering any room occupied by a resident to preserve privacy and dignity. Both incidents were found to be inconsistent with the facility's policies on promoting and maintaining resident dignity, which require staff to treat residents with respect, ensure privacy, and use privacy bags for catheter drainage. The deficiencies were identified through interviews, record reviews, and direct observation, with staff and leadership confirming the expectations and acknowledging the lapses.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident's call light was not kept within reach, as required by the facility's policy and the resident's care plan. The resident, who had a history of falls, severe cognitive impairment, and required maximal assistance for most activities of daily living, was observed asleep in bed with the call light found on the floor. This was confirmed by a Certified Nursing Assistant during the observation. The resident's care plan specifically included the intervention to keep the call light within reach and encourage its use for assistance. The Director of Nursing confirmed that call lights should be accessible to residents. The facility's policy also required staff to ensure call lights are within reach and secured as needed. The failure to keep the call light accessible represented a lack of adherence to both the care plan and facility policy.
Failure to Notify Physician of Resident's Significant Improvement in Mobility
Penalty
Summary
The facility failed to notify the primary physician of a significant improvement in a resident's condition, specifically regarding the resident's ability to perform sit-to-stand transfers using both prosthetic legs. The resident, who had a history of bilateral lower extremity amputations and was admitted with diagnoses including Type 1 diabetes mellitus, was initially assessed by physical therapy (PT) as requiring moderate to maximal assistance for transfers and was not ambulating due to safety concerns. After discharge from PT, the resident was placed on a Restorative Nursing Aide (RNA) program for sit-to-stand transfers in the parallel bars, with the care plan instructing staff to monitor for changes and refer to nursing or rehabilitation with any change in condition. Over time, the resident demonstrated significant improvement, becoming able to perform sit-to-stand transfers with minimal or no assistance and expressing a strong desire to progress to walking. Despite this improvement, the change was not documented in the medical record, nor was it reported to the charge nurse or the primary physician as required by facility policy. Interviews with staff revealed that while the improvement was verbally communicated among RNA and PT staff, it was not formally reported or documented, and the required notification to the physician did not occur. As a result of this failure to communicate and document the resident's improvement, the resident continued with the RNA program and did not receive a reassessment or further PT services that could have supported greater independence with mobility, including walking. The facility's policy required notification of the physician and consultation when there was a significant change in a resident's physical condition, but this process was not followed in this case.
Failure to Accurately Assess and Document Resident's Range of Motion Limitation
Penalty
Summary
The facility failed to accurately assess a resident's range of motion (ROM) limitations, specifically regarding the left leg, during three consecutive quarterly Minimum Data Set (MDS) assessments. Despite multiple therapy evaluations and care plans indicating a history of left femur fracture, ongoing ROM impairment, and the need for assistance with mobility and activities of daily living, the MDS assessments consistently documented that the resident had no functional ROM limitations in either leg. This discrepancy was identified through a review of therapy evaluations, care plans, and direct observation, all of which confirmed the presence of a left leg ROM limitation. The resident in question was admitted with significant medical history, including morbid obesity, a healed traumatic fracture, and a history of falls. Therapy records from both occupational and physical therapy documented the resident's need for moderate to maximal assistance with bed mobility, transfers, and lower body care, as well as specific recommendations for active and active assistive ROM exercises to both legs. Observations and interviews with staff and the resident further confirmed the left leg's reduced ROM and ongoing need for restorative interventions. Despite this clear documentation and direct evidence, the MDS assessments failed to reflect the resident's actual ROM limitations, resulting in inaccurate data being entered into the federal database. The MDS Coordinator acknowledged that the assessments were inaccurate and that the information from therapy evaluations should have been incorporated into the MDS to ensure an accurate representation of the resident's condition.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Opioid Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident with diagnoses including atrial fibrillation and congestive heart failure, who was dependent on staff for all activities of daily living and had severely impaired cognitive skills, there was a physician's order for continuous oxygen therapy due to acute respiratory failure with hypoxia. However, upon review, staff could not locate a care plan addressing the resident's oxygen therapy, and both the MDS Coordinator and DON confirmed that a care plan should have been in place. In a separate case, another resident with chronic pain syndrome and intact cognition was receiving hydromorphone for moderate to severe pain on a regular basis, as documented in the Medication Administration Record. Despite the consistent administration of this opioid medication, there was no care plan addressing the resident's use of hydromorphone, including monitoring for adverse reactions or effectiveness. The DON acknowledged that a care plan should have been developed for this medication regimen. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs.
Failure to Timely Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to timely update and revise care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of epilepsy and a physician's order for padded side rails to reduce injury risk, the care plan was not updated to include this intervention until over two months after the order was issued. The care plan for seizure disorder was only revised to include padded side rails well after the physician's directive, despite staff acknowledging that timely updates are necessary to ensure consistent implementation of safety measures. Another resident with an indwelling catheter for urinary retention had a care plan that was not reviewed or revised for more than six months, despite facility policy requiring quarterly reviews. The care plan, which included interventions to monitor for urinary tract infection and proper catheter bag positioning, was last updated in November of the previous year and not subsequently reviewed, even though the resident continued to require catheter care. Interviews with facility staff confirmed that care plans are expected to be reviewed quarterly and after any change in condition, to ensure interventions remain effective and all pertinent information is included. The failure to adhere to these review and revision schedules was acknowledged by staff, who stated that such lapses could result in inadequate care and supervision. Facility policy also mandates comprehensive, person-centered care plans that are regularly updated to reflect residents' needs as identified in assessments.
Failure to Provide Timely Medical Device Resulting in Decline in ADLs and Mobility
Penalty
Summary
A resident with a history of sepsis, falls, left knee injury requiring surgery, and major depressive disorder was admitted to the facility and required a left knee immobilizer and right CAM walker boot for safe mobility and transfers. Therapy assessments indicated the resident previously functioned independently but now required assistance for mobility and ADLs due to recent injuries. Both physical and occupational therapy documented that the left knee immobilizer did not fit properly, causing it to slide down and making transfers and ambulation unsafe. As a result, therapy sessions were halted, and the resident was unable to participate in standing activities, ambulation, or transfers out of bed. Despite physician orders for orthopedic and orthotic consultations to obtain a properly fitting knee immobilizer, there was a significant delay in acquiring the device. The resident remained in bed for 12 days, as documented by therapy and nursing staff, due to the absence of a suitable knee immobilizer. During this period, the resident did not receive therapy or assistance with transfers, and documentation indicated that transferring was not applicable or that the resident was totally dependent with at least two-person assistance. The case management team was unaware of the resident's current status and the arrival of a new immobilizer, and there was no documentation of the facility's efforts to expedite obtaining the device. Interviews with staff, the resident, and family confirmed that the resident was confined to bed and unable to participate in therapy or transfers due to the lack of a properly fitting knee immobilizer. The resident expressed feelings of sadness and depression as a result of being bedbound and unable to progress with therapy. The facility's policy required that residents' abilities in ADLs not decline unless unavoidable, but the lack of timely provision of the necessary medical device led to a preventable decline in the resident's mobility and ADL participation.
Failure to Provide Consistent Bathing Care and Document Resident Preferences
Penalty
Summary
A resident with diagnoses of morbid obesity and type 2 diabetes mellitus, who was assessed as having moderately impaired cognitive skills and requiring partial to moderate assistance with activities of daily living (ADLs), was not consistently provided with appropriate bathing care. The resident reported only receiving bed baths and not being offered showers, despite expressing varying preferences for either a shower or a bed bath. Staff did not ask the resident for her preference, and documentation was lacking regarding whether the resident was offered, received, or refused showers or bed baths on multiple days. Review of the Certified Nurse Assistants' ADL task documentation revealed that during two separate weeks, the resident received only one bed bath each week, with no documentation for the remaining days to indicate if bathing was offered or refused. The Assistant Director of Nursing confirmed that, based on the resident's functional abilities, she should be able to shower with partial assistance and that residents are to receive either a shower or bed bath twice weekly. Facility policy also required staff to assist residents with bathing to maintain proper hygiene. The lack of consistent bathing care and documentation constituted a failure to ensure the resident's personal hygiene needs were met.
Failure to Coordinate Ordered Vascular Studies and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with a history of diabetes mellitus, a foot ulcer, and a previous deep vein thrombosis (DVT) received ordered vascular studies and a follow-up appointment with a vascular surgeon. The resident was admitted with significant medical concerns, including chronic left arm swelling and pain following a DVT and removal of a peripherally inserted central catheter (PICC). The vascular surgeon ordered comprehensive venous and arterial ultrasounds of both the upper and lower extremities, with instructions for a follow-up appointment after the studies were completed. These orders were documented in the resident's medical record and care plan, which also included interventions to obtain and monitor diagnostic work as ordered. Despite these documented orders, the resident did not receive the required vascular studies or the follow-up appointment. The resident reported that he had been waiting several weeks for the studies and was unaware of the reason for the delay, noting that the staff member who previously coordinated his appointments had left. The current case manager confirmed that the need for these studies and follow-up was not communicated to her during the transition. Facility leadership acknowledged responsibility for coordinating such care and recognized the importance of the ordered tests. The facility's policy requires that residents receive care and services according to professional standards and care plans, but this was not followed in this instance.
Incorrect LAL Mattress Setting for Pressure Ulcer Management
Penalty
Summary
A resident with a history of a stage 4 pressure ulcer of the sacral region, who was dependent on staff for activities of daily living and had severely impaired cognitive skills, was admitted and readmitted to the facility. Physician orders and the resident's care plan specified the use of a low air loss (LAL) mattress for wound management, with instructions to determine and set the appropriate mattress settings based on the resident's needs. The manufacturer's guide for the LAL mattress indicated that the mattress should be set according to the patient's weight or comfort level. During an observation, the resident was found asleep in bed with the LAL mattress set to 225 lbs, despite a sticker on the mattress indicating it should be set to 87 lbs. This incorrect setting was confirmed by a Licensed Vocational Nurse, who acknowledged the discrepancy. The Director of Nursing also confirmed the importance of correct mattress settings for pressure ulcer prevention and management. The facility's policy emphasized the use of appropriate pressure-redistributing support surfaces for residents at risk or with existing pressure injuries. The failure to set the LAL mattress to the correct setting constituted a deficiency in providing appropriate pressure ulcer care.
Failure to Provide Proper Catheter Care and Positioning
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, resulting in two deficiencies. For one resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, the facility did not provide indwelling catheter care or monitoring after the resident was readmitted from the hospital. The resident's physician order summary and treatment administration records showed no evidence of catheter care or monitoring after the readmission, and there were no physician orders for catheter care in the medical record. The assistant director of nursing confirmed that catheter care was not reinstated upon the resident's return from the hospital, despite facility policy requiring catheter care every shift and as needed. For another resident with urinary retention and type 2 diabetes mellitus, the facility failed to ensure proper positioning of the urinary catheter collection bag. During observation, the resident was seen sitting in a wheelchair with the catheter collection bag placed at the same level as the bladder, rather than below it as required. The registered nurse present confirmed that the collection bag should be positioned below the bladder to prevent backflow of urine, in accordance with facility policy and the resident's care plan. Both deficiencies were identified through interviews, record reviews, and direct observation. The facility's own policies and procedures, as well as the residents' care plans, specified the required catheter care and positioning, but these were not followed in the cases observed.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tarzana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eisenberg Village | 0.9 mi | ★★★★★ | 22 | 0 |
| Park View Nursing And Subacute | 1.7 mi | ★★★★★ | 7 | 0 |
| Grancell Village Of The Jewish Homes For The Aging | 1.9 mi | — | 5 | 0 |
| Joyce Eisenberg Keefer Medical Center D/p Snf | 1.9 mi | ★★★★★ | 28 | 0 |
| Woodland Care Center | 2.1 mi | ★★★★★ | 19 | 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.