Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
Improper dumpster storage and refuse disposal were observed when two black dumpsters were overflowing and not fully closed while not in use. The area around the dumpsters also had scattered debris, including green beans, carrots, soiled gloves, empty food containers, plastics, and trash bags. The DS and HS stated the open lids and leftover food debris could attract pests and spread germs, and facility policy required dumpsters to have tight-fitting lids and surrounding areas to be kept clean.
A Dietary Aide was observed repeatedly throwing menu tickets containing resident names, room numbers, diet information, and food preferences into a trash can during dishwashing. The DS confirmed the tickets should have been separated for shredding because they contained protected resident information, and facility policy required resident identifiable information and personal and medical records to remain confidential.
A resident with a physician order for a right arm sling at all times was observed without the sling, and staff acknowledged the order was not being followed. In a separate event, a resident with impaired cognition and multiple diagnoses had a new open wound on the left lower leg that was found under an adhesive dressing, but it had not been assessed, documented, reported to the MD, or placed under a treatment order and care plan when first discovered.
A facility failed to ensure two residents received ordered hearing aids and failed to arrange an ophthalmology consult for a resident with worsening vision. One resident was observed with both hearing aids out of the ear canal despite an order for daily use, another was found without hearing aids during the morning pass and said she could not hear well, and the SSD stated an ophthalmology visit was missed because insurance authorization had not been completed.
Dietary staff failed to follow the menu and standardized recipes for green beans and roast pork. Staff added butter to green beans without measuring per the recipe, served roast pork portions below the ordered 3 oz amount for regular and therapeutic diets, and did not keep separate pans for small and large portion diets. The DS stated the portions should match the spreadsheet and that eyeballing portions could lead to inaccurate serving sizes.
Surveyors found multiple sanitation and food safety failures in the kitchen, including a torn refrigerator gasket, dirty refrigerator and freezer shelves, residue in condiment and ice scoop containers, a can opener with metal shavings, dented cans mixed with usable cans, and wet pans stacked in storage. An aide also touched a trash can lid and then handled bread without washing hands. In addition, several food-contact items were cracked or chipped, lids were stored uncovered near sanitizer, and refrigerator/freezer thermometers were broken or showed improper temperatures.
Incomplete and inaccurate resident documentation was identified for three residents. One resident’s chart lacked documentation of a received influenza vaccine, another resident was incorrectly listed as English speaking despite speaking Spanish and needing an interpreter, and a third resident’s admission record and MDS did not reflect active vision-related diagnoses even though the chart and resident statements documented left-eye blindness, worsening right-eye vision, and a history of retinal detachment.
A facility failed to develop comprehensive person-centered care plans for two residents by not addressing one resident’s communication impairment and another resident’s primary language, Spanish. One resident had a stroke-related condition, dysphagia, cognitive impairment, and was non-verbal, yet the communication care plan was not developed until later and no communication board was present in the room during observation. The other resident had severe cognitive impairment, spoke only Spanish, and needed an interpreter, but the care plan did not identify the language or include communication interventions.
Failure to provide a communication board for a non-verbal resident. A resident with toxic encephalopathy, acute respiratory failure with hypoxia, ESRD, moderate cognitive impairment, and unclear speech was observed in bed with a sign directing staff to use a communication board, but no board was present. CNA and LVN staff confirmed the board was missing, and the DON stated the resident was not provided one, limiting the resident’s ability to communicate needs and delaying care.
RN 2 did not maintain CPR/BLS certification from a provider that included the required hands-on skills component. File review showed the certification came from an online provider, and RN 2 stated the course was entirely online with reading, videos, and questions only, with no CPR skills demonstration. The DSD confirmed the certification needed hands-on validation under the facility CPR policy.
A facility failed to keep resident areas free from accident hazards by not following ordered fall precautions and dietary restrictions. One resident at high fall risk had a nightstand and bedside commode placed on top of the floor mat, another resident with a g-tube and NPO order had water pitchers and food at bedside despite severe dysphagia and aspiration history, and a third resident identified as fall risk had no floor mat at bedside. Staff observations and record review showed the residents’ care plans and orders called for these safety measures.
Two residents with indwelling urinary catheters were observed with looped tubing and urine not draining into the drainage bag. One resident had metabolic encephalopathy, severe sepsis with septic shock, and fluctuating capacity, while the other was dependent for ADLs with chronic respiratory failure, hemiplegia/hemiparesis, functional quadriplegia, neurogenic bladder, and a recent UTI. LPNs stated the tubing should not have loops because urine would not flow properly and could back up or contribute to infection.
A facility failed to provide appropriate respiratory care for two residents on oxygen therapy. One resident with acute respiratory failure, hypoxia, atelectasis, and COPD was observed with a nasal cannula improperly placed, with only one prong in the nostril and the other resting outside the nose. Another resident with pneumonia, pleural effusion, and COPD was observed with the cannula prongs resting on the chin while oxygen was running, and staff did not assess baseline SPO2 before applying PRN oxygen or re-assess after application. Staff stated the cannula was not positioned correctly and that both prongs should be inside the nose.
Bent window screen in a shared resident room created an approx. 1-inch gap between the screen and window, affecting two residents. One resident was cognitively intact and needed supervision or touching assistance for most ADLs, while the other had severe cognitive impairment and needed substantial assistance for most ADLs. The MS confirmed the screen was bent and said pests could get into the room; the ADON stated the screen should be intact to keep residents safe and comfortable.
Inaccurate MDS Documentation of Vision and Dental Status: A resident’s MDS did not accurately reflect vision loss, retinal detachment, or dental findings. The resident reported blindness in one eye, worsening vision in the other, and loose upper bridge teeth, while the MDS showed adequate vision, no vision-related active dx, and no dental concerns. The MDSN and DON stated the assessment and documentation were inaccurate and did not reflect the resident’s active medical dx.
Failure to Timely Report Unexplained Fractures: A resident with metabolic encephalopathy, psychosis, and dementia had an acute olecranon fracture and a suspected humerus fracture found on X-ray after c/o pain and transfer to the ER. The DON stated there were no witnessed falls or accidents, the resident could not explain the injuries due to severe cognitive impairment, and the abnormal X-ray results were not reported or investigated because the DON was not informed.
A resident with metabolic encephalopathy, psychosis, and dementia had a physician order to wear a right arm sling at all times after fractures of the R shoulder and R elbow were identified. Although the sling was documented as being in place and the resident was observed wearing it, the care plan record contained no plan addressing the sling or related care needs, and the DON confirmed no such care plan had been developed.
Incomplete documentation of a resident’s COC was identified when the chart showed a stat X-ray order for pain, followed by an ER transfer for a fracture, but no nursing progress notes or COC form explained the pain complaint, physician notification, or events leading to the transfer. The resident had metabolic encephalopathy, psychosis, dementia, and severely impaired cognition, and the DON and MDSC confirmed the record lacked the needed timeline and assessment documentation.
A resident with low back pain, anxiety disorder, a history of TIA, and severely impaired cognition was ordered to follow up with neurosurgery for a lumbar infarction. The facility scheduled the appointment, but Social Services stated there was not enough time to arrange transportation, the request was returned to CMA staff, and there was no documentation that the resident attended the visit. The DON confirmed the follow-up was not completed due to transportation issues and was not rescheduled.
A resident with low back pain, anxiety, and a hx of TIA had a physician-ordered neurosurgery follow-up that was scheduled but not completed. The DON stated there was no documentation that the resident went out for the appt, Social Services said transportation was not arranged in time, and the missed visit was not rescheduled before the resident was discharged. The facility policy required staff to assist residents with scheduling and attending ordered follow-up appts.
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.
Improper Dumpster Storage and Refuse Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when two black dumpsters outside the facility were observed overflowing with garbage and not completely closed while not in use. During the observation, the Dietary Supervisor stated the lids were not completely closed and explained that the dumpsters needed to be fully closed to prevent trash from attracting flies and rats. The Dietary Supervisor also stated that pests such as rats carry germs and may potentially spread infection to residents. The area surrounding the dumpsters was also observed to contain scattered debris on the ground, including green beans, carrots, soiled gloves, empty food containers, plastics, and trash bags. The Dietary Supervisor stated there were food particles on the ground in front of the dumpsters and that leftover foods may attract pests such as rats. The Housekeeping Supervisor stated the area contained food particles left on the ground, that the dumpster surroundings were cleaned using a leaf blower and then swept, and that a leaf blower would not be able to clean food debris on the ground. Facility policy required refuse containers and dumpsters to have tight-fitting lids or covers, to be kept covered when not being loaded, and for surrounding areas to be kept clean so debris and insect or rodent attractions are minimized.
Failure to Protect Resident Identifiable Information
Penalty
Summary
The facility failed to ensure confidential resident information was protected when Dietary Aide 2 repeatedly discarded menu tickets in the grey trash can during the dishwashing process in the dishmachine area. During observations, the aide was seen throwing leftover food, plastic, and multiple menu tickets into the trash, including several instances where menu tickets were placed directly into the waste container while trays were being stripped. During a concurrent observation and interview, the Dietary Supervisor stated the menu tickets contained residents' names, food preferences, diet, room number, date, likes, and dislikes, and confirmed it was not appropriate to throw them in the trash because they contained personal information protected by HIPAA. The supervisor stated the correct process was to separate the meal tickets for shredding before discarding. Facility policy stated resident identifiable information must be protected from unauthorized disclosure and that personal and medical records must remain confidential.
Failure to Follow Sling Order and Assess New Wound
Penalty
Summary
Licensed nurses failed to follow a physician order for a resident with osteoarthritis and a history of falling who was ordered to have a right arm sling on at all times. The resident’s admission record, H&P, MDS, and physician orders showed the resident was dependent on staff for bathing, dressing, and toileting, and the sling order was entered on 5/22/2026. During observation, the resident did not have the sling on his right arm, and a CNA stated the resident used to wear it all the time but had not been wearing it lately. An LVN later observed the same issue and stated the sling should have been on at all times per the order but was not present. Family also stated the resident needed the sling on at all times to prevent pain. The DON stated licensed nurses and CNAs must follow physician orders and clarify any confusion, and acknowledged staff did not follow the order by not applying the resident’s right arm splint. The facility policy on prevention of decline in range of motion stated the facility would provide care in accordance with professional standards of practice, including appropriate equipment such as braces or splints. A second resident with toxic encephalopathy, generalized muscle weakness, and cellulitis to both legs had a new open wound on the left lower leg that was not assessed, documented, reported to the physician, or placed under an order and care plan when first found. The resident had moderately impaired cognition and required assistance with dressing, footwear, toileting, and bathing. During observation, the resident had an adhesive dressing on the left lower leg, and the resident stated it had been placed over the weekend and had not been looked at since then. When the dressing was removed, the treatment nurse found an open wound with moderate serosanguinous drainage, measured it, and stated there was no prior documentation of the wound and no knowledge of who applied the dressing. Staff interviews confirmed the doctor had not been notified and no treatment order had been obtained before the dressing was applied.
Failure to Provide Hearing Aids and Arrange Ophthalmology Consultation
Penalty
Summary
The facility failed to ensure proper assistive devices were provided for hearing and vision services for three sampled residents. For Resident 43, the record showed diagnoses including decreased hearing and dementia, and the physician ordered hearing aids to be applied daily or as needed, turned on in the morning, and turned off at night. The care plan also included interventions to ensure the availability and functioning of the hearing aids and to monitor hearing impairment. During a concurrent observation and interview, Resident 43 was found with both hearing aids not inserted in the ear canal, and the RN stated nursing staff should monitor that the hearing aids remain in place throughout the day so the resident can hear. For Resident 79, the record showed the resident wore hearing aids and had potential communication problems related to hearing impairment. The physician ordered hearing aids to be placed in the ears every day shift and removed, stored, and charged every evening shift. During interview, LVN 7 stated the morning nurse administers the hearing aids and the evening Charge Nurse collects them at bedtime. During a concurrent observation and interview, Resident 79 was sitting in a wheelchair listening to music without hearing aids, stated, "I can't hear well, please increase the volume," and LVN 7 then stated the hearing aids had not been administered during that morning medication pass and should have been provided as ordered. The facility policy also stated staff are to assist residents with insertion of hearing aids and monitor function and care. For Resident 87, the record showed impaired visual function, with the resident reporting vision loss in the left eye and diminishing vision in the right eye, and a history of retinal detachment in the left eye. The physician order summary included that the resident may see an ophthalmologist, and the care plan called for scheduling consultations with eye specialists as needed. The Social Service assessment indicated the resident was referred to ancillary services. However, the ophthalmology appointment was not completed because insurance authorization was required beforehand, and the resident was not seen when the ophthalmologist was at the facility. The SSD stated she missed this step and accepted full responsibility, and the DON stated social services are responsible for arranging and scheduling referrals for ancillary services.
Menu and Portion Control Failures in Dietary Service
Penalty
Summary
The facility failed to follow its menu and standardized recipes for residents on regular, therapeutic, small portion, and large portion diets. During trayline observation, dietary staff added three scoops of butter to the green beans, even though the standardized recipe for green beans called for 1 1/2 lbs. of margarine for the specified yield. The Dietary Supervisor stated that following the recipe is important to provide the right nutrition and that measuring ingredients is necessary to avoid giving residents more or less nutrients than intended; the supervisor also stated the taste would be affected if recipes were not followed. The facility also did not serve the prescribed portion size for roast pork. The menu spreadsheet and standardized recipe indicated a 3 oz portion of pork roast with gravy for the regular and therapeutic diets, but during observation the portions weighed 2.2 oz, 2.4 oz, and 2.2 oz. The Dietary Supervisor stated the portion size should be 3 oz of meat plus gravy and that the meat was cut and weighed to ensure the right portion size, but after cutting it was placed back in the oven and shrank. The facility further failed to separate and accurately portion meat for small and large portion diets. The menu spreadsheet listed 2 oz for small portion diets and 4.5 oz for large portion diets, but only one pan of roast pork was observed on the steamtable with no separate pans for those diets. The Dietary Supervisor stated small and large portion roast pork should be in separate pans for easy identification, and staff stated they served large portions by combining two meat portions, which weighed 5 oz, while a small portion weighed 2 oz. The Dietary Supervisor stated the expectation was to follow the spreadsheet and that eyeballing portions would lead to inaccurate serving portions.
Unsafe food storage, sanitation, and temperature monitoring practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen and related food storage areas. During observation, surveyors found a torn gasket on a snack reach-in refrigerator, dirt and food debris on refrigerator and freezer shelves, dust buildup in the walk-in refrigerator, and accumulation of salt, sugar, pepper, and artificial sweetener residue in a condiment container. The can opener had dirt and hair-like particles near the blade and metal shaving residue, and the ice scoop container had brown residue. The Dietary Supervisor stated these conditions were not acceptable because they could contaminate food and contribute to cross-contamination. Surveyors also observed four dented cans stored with non-dented cans in the dry storage area, despite a designated area for dented cans. The Dietary Supervisor stated dented cans should be separated because the food inside could be contaminated and was not safe to eat. The report also noted that Dietary Aide 1 touched the trash can lid and then went to retrieve bread without washing hands first. The Dietary Supervisor stated handwashing was required after touching unsanitary items and before handling food to prevent cross-contamination. Additional observations showed pans stacked wet in storage, a can opener covered with black electrical tape, a knife container with cracks and dirt debris, 10 of 10 resident trays with cracks and chips, and an ice scoop holder that was not a cleanable surface. The lid storage container was uncovered and stored near a red bucket containing QUAT sanitizer. Surveyors also found a refrigerator in the water room at 50 F, broken thermometers in resident refrigerator and freezer units, and a resident refrigerator temperature of 62 F. The Dietary Supervisor stated working thermometers were needed to monitor storage temperatures and prevent food spoilage.
Incomplete and Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three sampled residents. For one resident, the medical record did not contain documentation of the 2025 influenza vaccine even though the resident had received the vaccine at an outside hospital. The Infection Prevention Nurse stated there was no record of the vaccine in the facility chart, and the Assistant Director of Nursing stated the facility should have documented the vaccination so staff would know it had been given and so the resident would not be vaccinated again unnecessarily. The facility policy on influenza vaccination required the resident’s medical record to show whether the vaccine was received, refused, or not given because of a medical contraindication. For another resident, the admission record incorrectly listed English as the primary language even though the resident spoke Spanish. The Minimum Data Set identified Spanish as the preferred language and indicated the resident needed or wanted an interpreter to communicate with health care staff. The resident stated she only spoke Spanish, and an LVN also stated the resident only spoke Spanish. The ADON acknowledged that the admission record should have reflected Spanish rather than English because the incorrect language entry could lead to miscommunication. For the third resident, the admission record and MDS did not reflect active vision-related diagnoses despite documentation elsewhere in the chart showing vision loss in the left eye and diminishing vision in the right eye, with a history of retinal detachment in the left eye. A progress note documented the resident’s report of these vision problems, and the resident also stated she was blind in the left eye and that her right eye vision was worsening. The MDS Nurse stated there should have been an active diagnosis for vision loss and retinal detachment and that the resident’s vision and dental status should have been documented accurately. The DON also stated the resident’s active diagnoses for vision and dental health were not reflected in the documentation, and the facility policy required assessments, observations, and services to be recorded accurately, objectively, and completely.
Incomplete care plans for communication and language needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two sampled residents by not addressing Resident 3’s communication impairment and not addressing Resident 10’s primary language, Spanish. The report states the facility’s policy required comprehensive care plans with measurable objectives, timeframes, resident-specific interventions, and identification of how communication would occur for non-English speaking residents. Resident 3 was originally admitted on 3/23/2026 and re-admitted on 5/11/2026 with diagnoses including toxic encephalopathy, acute respiratory failure with hypoxia, dysphagia following a cerebral infarction, and moderate cognitive impairment. The MDS indicated unclear speech, that the resident was usually understood and usually understood others, and that the resident was dependent with ADLs and mobility. The H&P dated 5/13/2026 stated Resident 3 was non-verbal and lacked capacity to understand and make decisions. On 6/16/2026, the resident was observed lying in bed looking at the television, making eye contact but offering no verbal response, with a sign above the bed stating to use a communication board; however, no communication board was present in the room. During interview and record review, ADON 1 stated the communication impairment existed before 6/16/2026 and that the communication care plan was not developed until that date. Resident 10 was admitted on 1/27/2026 with diagnoses including metabolic encephalopathy and diabetes mellitus. The MDS indicated severe cognitive impairment, dependence for toileting, bathing, lower body dressing, and footwear, and supervision or touching assistance for oral hygiene and personal hygiene. The MDS also identified Spanish as the preferred language and indicated the resident needed or wanted an interpreter to communicate with health care staff. Resident 10 stated she only speaks Spanish, and LVN 5 stated she only speaks Spanish and that she could communicate enough to provide care because she speaks a little Spanish. ADON 1 reviewed the care plans and stated Resident 10’s care plan did not identify Spanish as the primary language or include interventions for staff to use, and stated there should be a care plan addressing the resident’s language.
Failure to Provide Communication Board for Non-Verbal Resident
Penalty
Summary
The facility failed to provide proper care and treatment to maintain or improve a resident’s communication abilities by not ensuring that Resident 3 had a communication board available. Resident 3 was originally admitted on 3/23/2026 and re-admitted on 5/11/2026 with diagnoses including toxic encephalopathy, acute respiratory failure with hypoxia, and end stage renal disease. The resident’s MDS dated 5/15/2026 indicated moderate cognitive impairment, unclear speech, usually understood, usually understands, adequate vision, and dependence with ADLs and mobility. The H&P dated 3/15/2026 described Resident 3 as non-verbal and lacking capacity to understand and make decisions. During observation on 6/16/2026, Resident 3 was lying in bed looking at the television, made eye contact when greeted, and gave no verbal response. A sign above the head of bed stated, “Use Communication Board,” but no communication board was present in the room. CNA 4 stated that a communication board is used to help non-verbal residents or residents whose speech cannot be understood, and said that if the sign was for Resident 3, the board should have been present. CNA 4 also stated that no communication board was found in the room. LVN 6 stated that a communication board is a laminated paper tool used for residents with language deficits or impairments and that without it, residents would not be able to communicate their needs. LVN 6 said the board was very important for Resident 3 to point to pictures to express needs and that not having it could cause frustration and stress and delay care. ADON 1 stated Resident 3 was non-verbal and communicated by nodding yes or no, and that a communication board would help the resident point to pictures. The DON stated Resident 3 was not provided with a communication board and that without it staff would not know what the resident wanted or needed, causing delays in care and affecting the resident’s feelings of frustration, depression, sadness, embarrassment, and self-esteem. Facility policies on effective communication, dignity, and resident rights also identified communication boards as an adaptive technique and recognized the resident’s right to reasonable accommodation of needs and preferences.
RN lacked CPR certification with hands-on skills validation
Penalty
Summary
The facility failed to ensure that RN 2 maintained current CPR certification from a CPR provider whose training included a hands-on session in accordance with accepted national standards. During employee file review with the DSD, RN 2’s BLS certification was found to have been obtained from an online CPR provider, and the DSD stated she did not know whether the certification was entirely web based without the required in-person hands-on component. RN 2 later stated that the BLS course she completed was entirely online and consisted of reading materials, watching videos, and answering questions, with no hands-on component or requirement to demonstrate CPR skills. During a later interview, the DSD stated RN 2 needed to obtain BLS certification that included a hands-on component where skills are validated, and said this was necessary to ensure staff competency in performing CPR. Review of the facility’s CPR policy showed that staff were to maintain current CPR certifications through a provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards, and that online knowledge components were acceptable only when in-person skills demonstration was also required.
Failure to Maintain Safe Environment and Ordered Fall Precautions
Penalty
Summary
The facility failed to provide an environment free from accident hazards for three residents by not following ordered fall precautions and dietary restrictions. Resident 36 had diagnoses including unsteadiness on feet, lack of coordination, and fractures of the right tibia/fibula and left fibula. The resident’s MDS showed moderately impaired cognition and dependence or supervision for ADLs, and the care plan identified the resident as high risk for falls with an intervention to keep floor mats properly positioned and flat. During observation, a nightstand and bedside commode were placed on top of the left side floor mat in the resident’s room. Resident 168 had diagnoses including DM, HTN, and cerebral infarction, with intact cognition and a feeding tube noted on the MDS. The resident had physician orders for NPO status and continuous enteral feeding with water flushes. The record also included a swallow study showing severe pharyngeal dysphagia with potential aspiration events and an esophagram that was stopped after the resident aspirated contrast into the trachea and left lung bronchi. Despite these orders and findings, staff observed three water pitchers at the bedside, and later an unopened bag of chips and crackers was also observed on the bedside table. The resident stated he wanted to eat and reported drinking water, and a CNA stated the resident was not allowed to eat anything by mouth and was on g-tube feeding. Resident 58 was admitted with acute respiratory failure with hypoxia, atelectasis, and COPD, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed severely impaired cognition and need for assistance with multiple ADLs and functional mobility. The fall risk assessment and care plan identified the resident as at risk for falls and included an intervention to apply a floor mat at bedside. During observation, no floor mat was present at the bedside. Staff and the DON acknowledged that the floor mat was part of the fall prevention intervention and was absent.
Looped urinary catheter tubing observed in two residents
Penalty
Summary
The facility failed to ensure that two sampled residents with indwelling urinary catheters did not have loops or kinks in the catheter tubing. Resident 187 was admitted with diagnoses including metabolic encephalopathy, severe sepsis with septic shock, and abnormalities of gait and mobility, and the H&P noted fluctuating capacity to understand and make decisions. The resident had a physician order for a urinary catheter for 45 days from admission. During observation, the resident’s catheter tubing was seen with a loop and urine was not draining into the drainage bag. LVN 1 and LVN 5 both stated the tubing should not have loops because urine would not flow properly and urine accumulation in the tubing may cause infection. Resident 49 was admitted with diagnoses including chronic respiratory failure, hemiplegia and hemiparesis, and functional quadriplegia. The MDS indicated the resident was dependent for ADLs and had a urinary catheter and a UTI in the last 30 days. The care plan included monitoring and reporting signs and symptoms of UTI, and the physician ordered a urinary catheter due to neurogenic bladder dysfunction. During observation, Resident 49’s catheter tubing was also seen with a loop and urine was not draining into the drainage bag. LVN 7 stated the tubing should not have loops because urine can back up and cause UTI. The facility policy on indwelling catheters stated they are to be used in accordance with current standards of practice with interventions to prevent complications, including UTI.
Improper Oxygen Cannula Placement and Missing PRN Oxygen Assessment
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who were receiving oxygen therapy. Resident 58 had diagnoses including acute respiratory failure with hypoxia, atelectasis, and COPD, and was assessed as having severely impaired cognition and requiring assistance with daily care and functional mobility. Resident 14 had diagnoses including pneumonia, pleural effusion, and COPD, was also assessed as having severely impaired cognition, and was dependent with activities of daily living and functional mobility. Both residents were on oxygen treatment while at the facility. For Resident 58, the physician ordered oxygen via nasal cannula at 2 LPM, titrated to maintain SPO2 at or above 92% every shift. During observation, Resident 58 was wearing oxygen at 2 LPM via nasal cannula, but one prong was inserted into the left nostril and the other was resting externally against the left nostril. The LVN stated both prongs should be inside the nose for oxygen to be properly delivered, and the DON stated the cannula must be correctly placed with both prongs inside the resident's nose and the tubing secured around the ears. For Resident 14, the physician ordered oxygen at 1 LPM via nasal cannula PRN to keep SPO2 at or above 92% every shift. During observation, Resident 14 was lying in bed with the oxygen cannula tubing looped around the ears, but the prongs were resting on the chin and not in the nose, while the concentrator was turned on and set at 1 LPM. The ADON stated the cannula was not positioned correctly and that the resident's oxygen saturation should have been assessed before applying PRN oxygen and re-assessed after it was applied; the ADON stated these assessments were not done. The record review also showed a pulse oximetry reading of 93% on room air, and staff stated they did not know when the PRN oxygen had been applied.
Bent Window Screen Left Gap in Shared Resident Room
Penalty
Summary
The facility failed to ensure a window screen in a shared resident room did not have a gap, affecting two residents. During observation on 6/17/2026 at 11:15 a.m., the window screen for the window facing outside the facility was bent, creating a gap between the screen and the window. During a concurrent observation and interview on 6/18/2026 at 12:25 p.m., the Maintenance Supervisor validated the screen was bent and stated there was an approximate inch-wide gap at the side of the screen. Resident 67 was originally admitted on 3/2/2016 and most recently readmitted on 4/12/2026 with diagnoses including encounter for attention to gastrostomy and CHF. The resident's MDS dated 5/22/2026 indicated the resident was cognitively intact and required supervision or touching assistance for most ADLs. Resident 91 was originally admitted on 3/7/2017 and most recently readmitted on 11/11/2021 with diagnoses including atherosclerotic heart disease and osteoarthritis of both hips. The resident's MDS indicated severe cognitive impairment and substantial assistance for most ADLs. The Maintenance Supervisor stated the window does slide open and the screen should not be like that because pests could get into the room. ADON 1 stated the screen should be intact and not have a gap to ensure the residents are safe and comfortable.
Inaccurate MDS Documentation of Vision and Dental Status
Penalty
Summary
The facility failed to ensure that Resident 87’s MDS accurately reflected the resident’s vision status, dental status, and active diagnoses. The resident was admitted with diagnoses including type 2 DM, cardiomyopathy, HTN, and hyperlipidemia. The MDS dated [DATE] indicated intact cognition, adequate vision in adequate light, no vision-related active diagnosis, and no broken or loose teeth, mouth pain, or facial pain. Record review showed that the resident had reported vision loss in the left eye and diminishing vision in the right eye, with a history of retinal detachment in the left eye. The resident’s order summary included physician orders allowing consultation with a dentist and an ophthalmologist. The social service assessment also indicated referral to ancillary services for optometry/ophthalmology and dental consult status. In addition, the onsite skilled dental care record dated 5/22/2026 documented loose upper bridge teeth. During observation and interview, Resident 87 stated she was blind in the left eye, could only see shadows, and that her right eye vision was deteriorating. The MDS Nurse stated the assessment was not accurate and that there should have been an active diagnosis for vision loss and retinal detachment, along with proper documentation of vision and dental status. The DON also stated that the MDS contained inaccuracies in the resident’s vision and dental documentation and did not reflect the resident’s active medical diagnoses.
Failure to Timely Report Unexplained Fractures
Penalty
Summary
The facility failed to timely report to the State Survey Agency an acute fracture of the tip of the right olecranon process with associated soft tissue swelling and a suspected fracture involving the greater tuberosity of the right humerus for one resident. The resident had diagnoses including metabolic encephalopathy, unspecified psychosis, and unspecified dementia, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognition, and the resident had a stat X-ray order for the right shoulder and elbow related to pain. The X-ray of the right elbow showed an acute fracture of the olecranon tip with soft tissue swelling, and the right shoulder X-ray showed a suspected fracture of the greater tuberosity of the right humerus. The resident was transferred to the ER for further evaluation and treatment due to the fracture. The DON stated the resident had no witnessed falls or accidents and could not explain the cause of the pain and injuries because of the resident's cognitive status. The DON also stated the abnormal X-ray results were not reported or investigated because she had not been informed of them, and that if notified she would have investigated and reported the incident as an injury of unknown origin. Facility policy required unexplained injuries and injuries of unknown source to be investigated and reported within required timeframes, including immediately or within 2 hours for serious bodily injury.
Failure to Care Plan Right Arm Sling Use
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for one resident to address the use of a right arm sling following an injury. The resident was originally admitted and later readmitted with diagnoses including metabolic encephalopathy, unspecified psychosis, and unspecified dementia. The resident's H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition. A physician's order dated 5/22/2026 directed the resident to wear a right arm sling at all times, and the MAR showed the sling was in place at all times as ordered. The resident had been transferred to the hospital after facility X-rays showed fractures of the right shoulder and right elbow, and returned with the sling in place on the right arm. During observation, the resident was seen sitting in a wheelchair with a black sling on the right arm. Review of the care plans from 11/3/2025 to 6/3/2026 showed no care plan addressing the right arm sling, and both the MRD and DON stated that no care plan had been developed for this need. The DON stated that a care plan should have been developed to address the sling and related care needs, and the facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes.
Incomplete documentation of resident change of condition and hospital transfer
Penalty
Summary
The facility failed to maintain complete medical records for one resident by not documenting a change of condition and the events leading to a hospital transfer. The resident had diagnoses including metabolic encephalopathy, unspecified psychosis, and unspecified dementia, and the History and Physical Examination stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognition. The record showed a physician order for a stat X-ray of the right shoulder and elbow related to pain, followed by a nursing progress note stating the X-ray results were reported to the physician and the resident was transferred to the ER for further evaluation and treatment due to a fracture. During interview and record review, the MDS Coordinator and DON both stated they could not find documentation explaining why the physician was contacted and the stat X-ray was ordered, and there were no progress notes documenting the resident’s complaints of pain that prompted the physician notification. They also stated the record should have included a nursing progress note or COC form describing the resident’s change in status and the events leading to the hospital transfer. The facility policy on documentation required the medical record to contain enough information to provide a picture of the resident’s progress and to include accurate, relevant, and complete documentation of assessments, observations, and services provided.
Missed neurosurgery follow-up due to transportation not arranged
Penalty
Summary
The facility failed to assist and arrange transportation services for a follow-up neurosurgery specialist appointment ordered for one resident. The resident was admitted with diagnoses including low back pain, anxiety disorder, and a history of TIA, and the MDS dated 2/24/2026 indicated severely impaired cognition with need for assistance or supervision with multiple activities of daily living, including showering, toileting hygiene, dressing, bed mobility, and transferring. The resident’s discharge summary from the acute care hospital indicated follow-up with a neurosurgery specialist, and the physician later entered orders and progress notes continuing to direct follow-up with neurosurgery for low back pain and a small L3-4 infarction. The facility scheduled a neurosurgery appointment for 12/22/2025, and the transportation requisition was given to Social Services. However, Social Services staff stated there was not enough time to arrange transportation, and the request form was returned to Case Manager Assistant 1 to rearrange the appointment. During interviews and record review, the Social Services Director could not locate documentation showing whether the appointment occurred, and the DON stated there was no documentation that the resident went out to a clinic for the appointment. The DON also stated the follow-up neurosurgery appointment was not completed due to transportation issues and was not rescheduled. CMA 1 stated the appointment was thought to have been completed and was not informed by nursing staff or Social Services that the resident missed the follow-up appointment, and SSA 1 stated transportation was never arranged for the appointment.
Missed Neurosurgery Follow-Up Appointment
Penalty
Summary
The facility failed to follow a physician-ordered follow-up neurosurgery appointment for a resident admitted with low back pain, anxiety disorder, and a history of TIA. The resident's admission record, MDS, discharge summary, physician orders, and progress notes showed that the resident had severe cognitive impairment and required assistance with multiple activities of daily living. The discharge summary indicated follow-up with a neurosurgery specialist, and subsequent physician notes and orders continued to document the need for neurosurgery follow-up for low back pain with small L3-4 infarction. The facility scheduled a neurosurgery appointment for 12/22/2025, and the transportation requisition was given to Social Service staff. During interviews, the SSD stated there was only one neurosurgery appointment and could not locate documentation showing whether it occurred. The DON stated the appointment was made, but there was no documentation that the resident went out to a clinic for it. SSA 2 stated Social Services arranged transportation after appointments were made, but there was not enough time to arrange transportation for the appointment, and the transportation request form was returned to CMA 1. Further interviews showed that transportation was never arranged by Social Services, and the follow-up neurosurgery appointment was not completed. The DON stated the resident was discharged from the facility on 2/24/2026, and the appointment was not rescheduled. CMA 1 stated the appointment was rearranged on 12/18/2025 and the transportation requisition was given to SSA 1 the same day, but CMA 1 believed the appointment had been completed and was not informed by nursing staff or Social Services that it had been missed. The facility policy stated staff would assist residents in scheduling and attending follow-up appointments as ordered by the physician.
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.
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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
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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 | ★★★★★ | 30 | 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 | ★★★★★ | 36 | 0 |
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