Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Temple Park Convalescent Hospital during CMS and state inspections, most recent first.
A resident was sent to the hospital for low Hgb and further evaluation, then later cleared by the hospital physician for discharge back to the facility. Facility staff refused readmission because of one HR reading of 45 bpm and believed the resident did not meet the admission criteria of a stable HR of at least 60 bpm, even though the resident had a bed hold, belongings still in the room, and the hospital CM reported the NP said the resident could return. Additional HR readings in the hospital record included 52, 58, 53, 56, 62, 45, and 52 bpm.
A resident with dementia, repeated falls, poor safety awareness, and high fall risk fell twice in a short period after staff did not reassess or change fall interventions following the first fall. After returning from the hospital, the resident remained restless and agitated, was placed in a wheelchair near the nurses’ station, and then stood up unassisted and fell again, causing a right eyebrow skin tear and right knee abrasion. Staff and the DON acknowledged the resident needed closer supervision and possibly a sitter, but no timely care plan changes or increased monitoring were in place before the second fall.
Missing witness signatures were found on the medication disposal record for non-controlled medications. During review with the DON, the binder showed multiple medications documented as disposed without witness signatures, even though the facility instruction and policy required destruction by an LPN or RN with another licensed nurse as witness and the record to include the witnesses' signatures.
Kitchen Food Storage and Sanitation Deficiencies: An opened yogurt container was left in a refrigerator without an open date or use-by date, two cutting boards in the food prep area had deep knife marks, and 13 emergency water containers were not labeled as potable or dated. Staff stated opened foods must be dated, damaged cutting boards should be replaced, and emergency water supplies should be labeled and tracked.
Missing Documentation After Hemodialysis Returns: The facility failed to document when a resident with ESRD and HTN returned from recurring HD appointments. An LVN stated the return assessment was not documented, and an RN identified multiple missing progress notes for the resident’s returns from HD. The DON stated it was best practice to document when a resident came back from an appointment.
A resident with Alzheimer’s disease and a Stage 4 sacral pressure ulcer had a care plan that only addressed skin impairment risk and turning/repositioning, but did not include the current wound status or physician-ordered wound treatment. Records showed ongoing wound care orders for cleansing with Dakin’s solution and applying a collagen sheet, and staff confirmed the care plan was not revised to reflect the resident’s current wound condition and treatment plan.
Failure to rotate insulin injection sites: A resident with DM, HTN, CKD, and severely impaired cognition received insulin glargine SQ in the same abdominal areas on multiple occasions despite an order to rotate injection sites. MAR/LAR review showed repeated use of the left upper and left lower abdomen, and RN and DON stated site rotation was important to avoid skin issues and lipohypertrophy. FDA labeling for Lantus also directs rotation of injection sites.
Incorrect LALM Setting for Resident With Stage 3 Pressure Ulcer: A resident with severe cognitive impairment, DM, hemiplegia, hemiparesis, dementia, Alzheimer's disease, and a stage 3 pressure ulcer to the left buttock was observed on a Protekt Aire 6000 LALM set at 130 lbs. TN stated the setting was incorrect because it should have matched the resident's 101-lb weight, and the DON confirmed the mattress should be set according to the manufacturer's weight guide. The resident's care plan included LALM use for skin management, and the physician ordered staff to monitor the mattress setting every shift.
Unclear Meropenem IV Order Was Not Clarified: A resident with UTI, sepsis due to E. coli, ESBL resistance, dementia, and other diagnoses was readmitted with discharge instructions that listed Meropenem IV every 12 hours and every 8 hours. An RN changed the order from every 12 hours to every 8 hours without clarifying the unclear instructions with the physician, and the resident then received Meropenem 1 gram IV every 8 hours for 14 doses. The DON stated the instructions were not clear and the order should have been clarified.
A resident with HIV received Biktarvy together with ferrous sulfate and magnesium oxide despite an electronic alert for a severe drug interaction. The LVN was unsure about the interaction until reviewing the order, and the DON and ADON confirmed the alert and noted pharmacy information indicating Biktarvy levels could be reduced when taken with food and supplements.
Failure to Arrange Dental Consultation and Treatment: A resident with DM2, anemia, dysphagia, and major depressive disorder had missing and broken teeth, no dentures, and no recent dental visit despite wanting treatment completed and reporting the need for a dental consult. Records showed dental consultation was listed as needed, the care plan identified dental problems, and staff, including the SSD, DPC, and DON, acknowledged the resident was not provided dental services.
A resident with a history of acute bronchitis and COPD, who required partial assistance with ADLs and had intact cognition, developed a new persistent cough with green mucus but was not receiving treatment. A CNA first noticed the cough several days earlier after assisting with a shower and, despite knowing of a prior hospitalization for a similar cough, did not report it to licensed nursing staff, assuming they were aware. The CN confirmed that no report of a new cough was received and that the EMR, the primary source for documenting changes in condition, contained no entry about this new onset cough, contrary to the facility’s policy requiring changes in condition to be communicated via the 24-hour report system and documented as care plan revisions.
A resident with intact cognition and multiple ADL assistance needs was hospitalized for a persistent cough and returned with a diagnosis of acute bronchitis and new antibiotic orders, but the EMR care plan was never revised to include the new diagnosis, respiratory monitoring, or treatment interventions. Over the following weeks, the resident developed a persistent cough with green mucus, which a CNA noticed but did not report to a nurse, and no change in condition was documented. The CN and MDS nurse confirmed that the EMR, identified as the primary source for clinical guidance, lacked an updated care plan for acute bronchitis, and staff had not reported the new cough. Although the DON later stated a paper care plan existed, it was not readily available in the chart and had not been accessed by staff, contrary to facility policy requiring timely, comprehensive, and regularly revised care plans.
A nurse administered Benadryl to a resident but did not document the administration on the MAR as required by facility policy. The omission was confirmed through observation and staff interview, despite the resident having a history of muscle weakness, hypertension, and dementia.
A resident with multiple diagnoses and intact cognition was given Benadryl 25 mg by an LVN without a physician's order, and the medication was left unattended at the bedside rather than being directly administered and observed. The LVN did not verify the order in the MAR before giving the medication, and the RN Supervisor confirmed the absence of a physician order, in violation of facility policy.
A resident with diabetes and a sacral pressure ulcer, who was on enhanced barrier precautions and receiving metronidazole 500 mg via gastrostomy tube for infection, did not receive one of the ten prescribed doses of the antibiotic. This was confirmed through review of the MAR and medication bubble pack by two LVNs, indicating a failure to administer medication as ordered by the physician.
A nurse was observed leaving bubble packs of medications on top of an unattended medication cart while administering meds to a resident who required assistance with daily activities. This action was not in line with facility policy, which requires all medications to be secured and not left on top of the cart when out of the nurse's sight.
A resident with diabetes, dementia, and MASD to the buttocks did not receive the required weekly skin assessments and documentation as outlined in the care plan and facility policy. Although daily treatments were recorded, there was no evidence that licensed nurses completed or documented weekly evaluations of the MASD, making it unclear if the condition improved before discharge.
A resident with diabetes, muscle weakness, and mobility impairment experienced difficulty moving his wheelchair due to cluttered hallways filled with linen carts, hampers, and shower chairs on both sides. Multiple staff, including an LVN, infection preventionist, RN supervisor, and DON, confirmed the hallway was crowded and acknowledged the safety issue, which was not in line with facility policy.
A resident with severe cognitive impairment and limited capacity to consent was admitted without an advance directive in place, and facility staff did not verify, document, or communicate the resident’s advance directive status as required by policy. The resident was considered full code by default, and there was no evidence that the responsible party or physician was notified or involved in decision-making regarding end-of-life care.
A resident with cognitive impairment and multiple medical conditions was observed using a hand mitten restraint without an associated care plan. Despite staff obtaining physician orders and consent for the mitten, no care plan was developed or implemented, and required monitoring for skin integrity and circulation was not documented, contrary to facility policy.
A resident dependent on staff for ADLs and at risk for skin breakdown was left soiled for about 20 minutes before being cleaned, despite staff awareness and facility policies requiring prompt hygiene care. Staff delays and lack of immediate assistance contributed to the deficiency.
A resident with type 2 diabetes and moderate cognitive impairment received consecutive insulin injections in the same abdominal sites, contrary to facility policy requiring site rotation. Staff and the DON confirmed that injection sites were not rotated as documented in the MAR, despite having access to previous site information and clear policy guidelines.
A treatment nurse did not complete required weekly monitoring and documentation of a resident's unstageable pressure ulcers, despite the resident's complex medical conditions and care plan requirements. The last wound assessment was recorded weeks prior, and both the nurse and DON acknowledged the lapse, which was contrary to facility policy and could have allowed the wounds to worsen.
A lighter was found unattended on a resident's bedside table, despite the resident's care plan and facility policy requiring supervised smoking and secure storage of smoking materials. Staff interviews revealed inconsistent understanding of the policy, and the facility's procedures were not followed, resulting in a potential fire hazard.
A resident with respiratory conditions was observed using oxygen nasal cannula tubing that was wrapped around a trash can at the bedside, resulting in unsanitary conditions. Both a CNA and an LVN confirmed the tubing was dirty and needed replacement, in violation of facility policy requiring clean respiratory equipment. The DON also acknowledged that soiled tubing should be exchanged to prevent infection.
Two opened insulin pens were found stored in the medication refrigerator past their labeled discard dates, contrary to facility policy. Both an LVN and the DON acknowledged that such medications should have been discarded, and the facility's policy requires outdated drugs to be removed from storage. This failure created the potential for medication dispensing errors.
A facility failed to develop a care plan for a resident's right-hand swelling, noted during a record review and interview with the DON. The resident, with multiple diagnoses including dementia and diabetes, had a documented change in condition indicating edema, but no care plan was in place. The facility's policy requires care plans based on comprehensive assessments, which was not followed in this case.
A resident with severe cognitive impairment and multiple medical conditions was not offered substitute meals when consuming less than 50% of their meals, as required by facility policy. This oversight was confirmed by the DON and documented in the resident's CNA Daily Charting Form, highlighting a potential risk for malnutrition and health decline.
A resident with dementia and Alzheimer's disease, requiring substantial assistance with personal hygiene, was observed with inadequate mouth care, including a creamy substance at the mouth corner and a coated tongue. Despite the care plan's requirement for daily oral care, staff failed to provide comprehensive mouth care, leading to a deficiency in the facility's care standards.
A facility failed to document a resident's fluid and oral intake accurately on several occasions. The resident, with severe cognitive impairment and requiring assistance with daily activities, had missing entries in the CNA daily charting forms for specific afternoon shifts. The DON acknowledged the oversight, and the facility's policy on accurate documentation was not followed.
During a COVID-19 outbreak, a resident was observed not wearing a mask, and staff were not fit tested for N95 masks. Additionally, staff screening protocols were not followed, as observed with a dietary staff member who screened after attending a meeting. The facility lacked systems to ensure compliance with mask-wearing, fit testing, and screening protocols, increasing the risk of infection spread.
A facility failed to report alleged abuse between two residents and an injury of unknown origin to the State Agency. One incident involved a physical altercation between two residents over alleged theft, resulting in a skin tear. Another resident with severe cognitive impairments was found with a bruise of unknown origin, but no investigation or reporting was conducted. The facility did not adhere to its policies on abuse prevention and reporting, exposing residents to potential continued abuse.
A resident with severe cognitive impairments was found with a bruise under the left eye, which was not reported or investigated by the facility. Interviews with staff revealed that the injury was not consistent with a scratch, and the facility failed to follow its policies for reporting and investigating such incidents. The facility's policies required reporting to external agencies and implementing a 72-hour monitoring protocol, which were not adhered to.
The facility failed to ensure nurses had the competencies to assess pressure ulcers, leading to a stage 3 ulcer being unrecognized in a resident with diabetes and dementia. Additionally, the facility did not follow its abuse policy when a resident with severe cognitive impairments was found with a bruise of unknown origin, and no investigation or reporting was conducted.
The facility failed to manage and report abuse incidents involving three residents due to the absence of a full-time abuse coordinator. A resident reported being assaulted by a roommate, and another resident was found with unexplained bruising. The facility did not follow its policies on reporting and investigating these incidents, leading to deficiencies in resident protection and compliance with regulations.
A resident with severe cognitive impairments and a history of wandering ingested hand sanitizer due to inadequate supervision and a hazardous environment. The resident was left unsupervised at the nurses' station, leading to hospitalization for toxic encephalopathy. Observations revealed unattended areas with accessible toxic substances, including hand sanitizer and cleaning chemicals. Staff interviews confirmed the lack of supervision and failure to address the resident's behavior in the care plan.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairments and multiple diagnoses, leading to a deficiency. The resident's records contained incorrect information about their condition and treatment, which was confirmed by the DON. This failure was contrary to the facility's policy on charting and documentation, which requires complete and accurate records to ensure effective communication among the care team.
A resident with dementia did not have their care plan updated after the discontinuation of dementia medications Namenda and Aricept. The facility's MDS Coordinator and DON acknowledged the failure to revise the care plan, which was required to monitor the resident for increased confusion and behavioral changes. This oversight was contrary to the facility's policy for developing a resident-centered care plan.
A facility failed to prepare a resident for a safe discharge by not involving the primary caregiver in the process and not providing necessary medical equipment and supplies. The resident, with multiple medical conditions, was discharged without the caregiver receiving required training and resources, leading to significant challenges and stress for the caregiver.
The facility failed to label various food items with use-by dates and did not discard expired ground beef. Additionally, temperature logs for refrigerators and freezers were not maintained on two specific dates, which could potentially cause food-borne illnesses.
The facility failed to maintain the dignity of two residents. One resident's urinary collection bag was not covered with a privacy bag, and another resident was fed by a CNA standing over them instead of sitting at eye level. These actions were against the facility's policies and negatively impacted the residents' dignity.
The facility failed to ensure that a call light was within reach for a resident with Huntington disease and mildly impaired cognition. The call light was found on the floor, not within the resident's easy reach, which was confirmed by a CNA and acknowledged by the DON. The facility's policy requires call lights to be within easy reach when residents are in bed or confined to a chair.
The facility failed to ensure Advance Directive Acknowledgement forms were thoroughly completed for two residents. One resident's form was unsigned and incomplete, while another's form was signed but lacked necessary information. This could result in the residents' medical decisions not being honored.
The facility failed to provide a communication device or board for a resident who primarily spoke Chinese, despite the resident's severe cognitive impairment and language barrier. Staff acknowledged the absence of such a device, and the care plan did not include this necessary intervention, contrary to the facility's policy.
The facility failed to provide adequate assistance with ADLs for a visually impaired resident, leading to difficulties in locating and consuming food items. Staff did not consistently inform the resident about the placement of food, resulting in inadequate nutrition and self-care.
The facility failed to ensure that a CNA had an up-to-date BLS certificate, which had expired. Despite this, the CNA was found to be working in the facility. Both the DSD and DON confirmed the expiration and acknowledged the potential risk to residents receiving outdated medical care.
A facility failed to provide a visually impaired resident with activities that stimulate her senses, resulting in emotional distress and boredom. The resident did not receive a radio or TV, lacked a care plan for activities, and did not have a quarterly activity participation review. Staff were unaware of the resident's preferences and requests, leading to a decline in her quality of life.
A resident with severe cognitive impairment and multiple pressure ulcers did not receive appropriate care as the wound vac was found off and unplugged, and the care plan was not updated to reflect the current treatment. Both the IP and DON confirmed these deficiencies, which could worsen the resident's condition.
A resident's urinary catheter was not securely anchored, contrary to the care plan and facility policy, potentially causing pain and urethral trauma. Observations confirmed the catheter was not secured, and the Infection Preventionist and DON acknowledged the oversight.
Failure to Readmit Resident After Hospital Clearance
Penalty
Summary
The facility failed to readmit a resident after hospital discharge even though the hospital physician had cleared the resident for return and the facility had a bed available. Resident 1 was transferred from the facility to a general acute care hospital for low hemoglobin and further evaluation. The hospital discharge summary later documented that the resident had been treated for acute kidney injury and low hemoglobin, that the acute kidney injury had resolved, and that the resident was medically cleared for discharge back to the facility. The facility declined readmission because staff focused on a single documented heart rate of 45 bpm and believed the resident did not meet the facility’s admission criteria requiring a stable heart rate of at least 60 bpm. During interviews, the AC, ADON, and DON stated the resident was not readmitted because of the low heart rate reading, even though the resident’s room and belongings remained at the facility and the resident had a bed hold. The DON also stated she was awaiting additional direction from the NP before approving the resident’s return. Hospital documentation showed additional heart rate readings of 52 bpm, 58 bpm, 53 bpm, 56 bpm, 62 bpm, 45 bpm, and 52 bpm over several days, and the hospital CM stated the facility’s NP had said the resident could be readmitted and the CM should contact the AC for processing. The DON later stated she was not aware of the additional documented heart rate readings and acknowledged the resident could be admitted with those readings. Facility policy stated residents discharged to the hospital may be readmitted upon the first available bed if they require services provided by the facility and meet admission criteria.
Failure to Reassess and Supervise a High-Fall-Risk Resident After Repeated Falls
Penalty
Summary
The facility failed to ensure adequate supervision and fall-prevention interventions for a resident who was assessed as high risk for falls. The resident had dementia, repeated falls, poor vision, balance problems, decreased muscular coordination, intermittent confusion, and poor safety awareness. The resident also required extensive assistance with most activities of daily living and depended on staff for wheelchair mobility. The resident’s care plan identified the resident as being at risk for falls and stated that staff should promptly assess the need for the resident to avoid getting up unassisted. After a witnessed fall at the nurse’s station, the resident was transferred to the hospital and later returned to the facility. The record review showed no evidence that the facility reassessed the resident’s fall risk, modified the care plan, or implemented new interventions after that first fall. The resident was then placed back in front of the nurse’s station while still restless and agitated. Staff administered Ativan to calm the resident, but the resident remained in a wheelchair and was again observed attempting to stand up unassisted and falling to the floor, sustaining a skin tear to the right lower eyebrow and an abrasion to the right knee, which required another hospital transfer. Interviews with nursing staff and the DON confirmed that the resident was very unsteady, required closer supervision, and may have needed a sitter after the first fall. Staff stated the resident was agitated, yelling, and hitting staff after returning from the hospital, and that the second fall occurred when staff were not close enough to prevent the resident from getting up. The DON acknowledged that the resident fell twice within a five-hour period and stated the facility was still revising the fall care plan after both events. The facility policy required staff to monitor the resident’s response to fall interventions and re-evaluate whether current interventions should be changed if the resident continued to fall.
Missing Witness Signatures on Medication Disposal Records
Penalty
Summary
The facility failed to ensure medication dispositions were completed by a licensed nurse and witnessed as required because there was no documentation of the witnesses' signatures on the medication disposal record. During a concurrent interview and record review with the DON, the facility's Medication Disposal binder for non-controlled medications was reviewed and showed three medications listed as disposed on 5/18/2026 and 18 medications listed as disposed on 5/24/2026 without documented witness signatures. The DON stated that the medication destruction record instructed that drugs be destroyed in the facility by a licensed nurse and another licensed nurse to witness, and the facility policy, Discarding and Destroying Medications, indicated the medication disposition record should contain the signatures of the witnesses.
Kitchen Food Storage, Cutting Board, and Emergency Water Labeling Deficiencies
Penalty
Summary
The facility failed to follow sanitary food and water safety practices in the kitchen by leaving an opened container of blueberry yogurt in Refrigerator 2 without an open date or use-by date. During observation, two of three cutting boards in the dry food preparation area had deep knife marks, and the Dietary Supervisor stated the yellow cutting board had knife marks that were easily felt. Kitchen staff stated that opened food items must be labeled with the open date and use-by date, and that cutting boards should be replaced when they have visible cuts or feel rough to the touch because bacteria and small plastic particles can transfer to food during meal preparation. The facility also failed to label 13 five-gallon emergency water containers in kitchen storage as potable water for human consumption. The containers were observed without delivery dates and without any indication that they were safe for drinking, food preparation, or cooking during an emergency. The Maintenance Supervisor stated the containers were designated as potable water for resident and staff consumption and should have been labeled and documented with the delivery date, expiration date, and supplying company. The Dietary Supervisor stated it was best practice for the emergency water containers to be labeled with the date received to ensure proper tracking.
Missing Documentation After Hemodialysis Returns
Penalty
Summary
The facility failed to maintain accurate and complete medical records for Resident 84 by not documenting when the resident returned from hemodialysis appointments. Resident 84 was admitted with diagnoses including ESRD and HTN, had intact cognition, and required assistance with activities of daily living. The physician orders included outpatient hemodialysis on Tuesday, Thursday, and Saturday, and the MDS indicated the resident was on hemodialysis. During record review and interviews, LVN 2 acknowledged forgetting to document when Resident 84 returned from hemodialysis and stated that documentation was supposed to be completed when the resident came back from an appointment so staff could show the care provided and monitor for any issues after dialysis. RN 1 reviewed progress notes and identified missing documentation for multiple hemodialysis return dates, and stated that documenting the resident's return from appointments provides an accurate nursing assessment and communication between the nursing team. The DON stated that it was best practice to document when a resident came from an appointment.
Care plan not updated for resident’s Stage 4 sacral pressure ulcer
Penalty
Summary
The facility failed to revise the care plan for one resident with a Stage 4 sacral pressure ulcer by not including the resident’s current wound status and treatment plan. The resident was admitted with Alzheimer’s disease and a sacral Stage 4 pressure ulcer, and later records showed the resident remained at risk for pressure injury and was dependent for personal hygiene, showering, toileting, hygiene, and oral hygiene. A physician treatment order dated 4/24/2026 directed cleansing the sacrococcyx pressure injury with Dakin’s solution and applying a collagen sheet, but the care plan report dated 7/18/2025 only identified the resident as at risk for skin impairment and included turning and repositioning every two hours. During a concurrent observation and interview, the resident had a wound dressing on the sacral area. The Treatment Nurse stated the wound physician examined the resident every two weeks and provided wound orders and the treatment plan. The MDS nurse stated the care plan did not include the current wound status and treatment plan and should reflect the wound physician orders and the resident’s current wound condition and treatment. The DON stated the care plan should have been revised by treatment nurses and staff nurses to reflect the current condition of the wound and treatment plan as ordered by the physician, and that when care plans were not revised and kept current, it resulted in delays in necessary care and treatment, which may lead to deterioration in the resident’s wound.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nurses failed to rotate the subcutaneous injection sites when administering insulin glargine to Resident 5. Resident 5 was admitted with diagnoses including DM, HTN, and CKD, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS dated 4/24/2026 indicated severely impaired cognition for daily decision-making, mostly needing maximal assistance with ADLs, and that the resident was receiving a high-risk hypoglycemic medication. During record review with RN 1, the MAR and LAR showed insulin glargine 20 units SQ every 12 hours with an order to rotate injection sites. The records showed injections were given in the left upper quadrant abdomen on 5/17/2026 at 9:00 PM and 5/18/2026 at 9:00 AM, and in the left lower quadrant abdomen on 5/24/2026 at 9:00 PM and 5/25/2026 at 9:00 AM. RN 1 stated it was important to rotate SQ sites because of possible skin issues and malabsorption, and the DON stated staff were supposed to rotate insulin sites due to the possibility of lipohypertrophy. FDA labeling for Lantus indicated it should be administered subcutaneously into the abdominal area, thigh, or deltoid and rotate injection sites.
Incorrect LALM Setting for Resident With Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to maintain the correct Low Air Loss Mattress (LALM) setting for a resident with a stage 3 pressure ulcer to the left buttock. The resident was admitted with diagnoses including type 2 DM, hemiplegia, hemiparesis, dementia, Alzheimer's disease, and a contracture. The MDS indicated severely impaired cognition, dependence for multiple activities of daily living, and risk for pressure ulcers. The resident's care plan identified the stage 3 left buttock pressure ulcer and included use of a LALM for skin management, and the physician ordered staff to monitor the placement, setting, and functional ability of the LALM every shift. During observation, the resident was on a Protekt Aire 6000 LALM set at 130 lbs. Treatment Nurse 1 stated this setting was incorrect and that the mattress should be set to the setting closest to the resident's weight of 101 lbs., which she identified as 80 lbs. The DON also stated the mattress setting should match the resident's weight according to the manufacturer's guidelines and confirmed the resident should have been on the correct setting. The facility policy stated the air mattress was intended to decrease pressure from the resident's weight and promote healing or prevention of pressure ulcers, and the operational manual directed users to adjust the mattress according to the patient's weight and comfort.
Unclear Meropenem IV Order Was Not Clarified
Penalty
Summary
The facility failed to clarify a physician order for Meropenem IV for a resident who had been readmitted with metabolic encephalopathy, UTI, sepsis due to E. coli, dementia, ESBL resistance, and hypertension. The resident’s hospital discharge instructions indicated Meropenem 1000 mg IV every 12 hours and every 8 hours with a stop date, and the facility’s discontinuation record showed the prior order for Meropenem 1 gram IV every 12 hours was discontinued because the order was updated. A subsequent physician order dated the next day directed Meropenem 1 gram IV every 8 hours, and RN 2 confirmed that order. The resident was observed with an IV in the left hand and stated she was receiving antibiotics through the IV because she had a UTI. The IV administration record showed the resident received Meropenem 1 gram IV every 8 hours for a total of 14 doses. During interviews, LVN 4 stated she reviewed the discharge instructions with the NP to clarify the Meropenem order and was told to continue it every 12 hours, but the next day saw the order had been changed to every 8 hours by RN 2. RN 2 stated he changed the order from every 12 hours to every 8 hours without calling the physician to clarify the unclear discharge instructions. The DON stated the discharge instructions were not clear on whether Meropenem was to be given every 12 hours or every 8 hours, and that RN 2 should have clarified the order with the physician to ensure it was correct.
Severe Biktarvy Interaction Not Addressed
Penalty
Summary
The facility failed to ensure a severe drug-to-drug interaction was reviewed and acted upon for one sampled resident with HIV, polyneuropathy, muscle weakness, and COPD. The resident had an order for Biktarvy 50/200/25 mg daily, and the order entry included an alert for a drug interaction. On 5/27/2026, the resident was observed receiving Biktarvy together with ferrous sulfate 325 mg and magnesium oxide 400 mg, along with other medications, and took all 11 medications orally at once at the bedside. During interviews later that day, the LVN stated she was unsure whether there was a drug interaction until she reviewed the electronic order and saw that magnesium and ferrous sulfate had severe interactions that could decrease the concentrations and therapeutic effects of Biktarvy. The DON also reviewed the order and confirmed the interaction alert icon indicated a potential drug-to-drug interaction. The ADON reviewed pharmacy information and stated Biktarvy concentration could be reduced by 49% if taken in a fed state, noting the resident received the medication after breakfast. The consultant pharmacist’s recommendation reviewed during the survey did not mention the interaction between Biktarvy and the iron and magnesium supplements. The facility policy stated that if a medication was identified as having potential adverse consequences or was suspected of causing adverse consequences, the staff preparing or administering it had to contact the attending physician or medical director.
Failure to Arrange Dental Consultation and Treatment
Penalty
Summary
The facility failed to ensure dental services were provided to Resident 24, who had diagnoses including major depressive disorder, type 2 diabetes mellitus, anemia, and dysphagia. The resident’s records showed an onsite mobile dental form dated 10/25/2025 indicating the resident wanted the dental treatment recommendations completed, and the order summary dated 3/9/2026 listed dental consultation as needed with treatment to be completed as indicated by the resident’s condition. The MDS dated 3/13/2026 indicated the resident had no natural teeth or tooth fragments, needed partial/moderate assistance with oral hygiene, and required supervision or touching assistance when eating. The care plan dated 4/10/2026 identified dental health problems, missing teeth, and that dental care consultations should be coordinated as needed. During observation and interview on 5/28/2026, Resident 24 had some missing and broken teeth and was not wearing dentures. The resident stated some natural teeth were gone, some were broken, and the resident had not been seen by a dentist for a long time, despite telling staff about needing a dental consultation. CNA 3 stated the resident had missing and broken teeth and took additional time to chew food. The SSD and DPC stated the resident was not provided dental services, and the DON stated the resident should have been seen by the dentist. The DON also stated Social Services should have arranged the dental services and that dental consultations were provided as needed, monthly, quarterly, or every six months. The facility policy titled Dental, vision, and hearing evaluations stated dental evaluations are done to assure residents can function at their highest practical level and include assessing the need, obtaining a physician’s order, and arranging the evaluation as soon as possible.
Failure to Report and Document Resident’s New Onset Cough
Penalty
Summary
The facility failed to ensure that a significant change in condition was promptly reported to licensed nursing staff for one resident when a CNA did not report a new, persistent cough for approximately four days. The resident had been admitted with acute bronchitis and COPD and, per the most recent MDS, had intact cognitive skills and required partial assistance with most ADLs and supervision for eating. During an observation and interview in the resident’s room, the resident was seen coughing forcefully and was briefly unable to speak; she then reported having the cough for a few weeks, believed she was secreting green mucus the previous day, and stated she was not receiving any treatment for the cough at that time. The resident also reported a prior hospitalization a few months earlier for bronchitis. In an interview, the CNA stated she first noticed the resident coughing after assisting with a shower several days earlier and knew the resident had previously gone to the hospital for a persistent cough in January, but she did not report the current cough to a licensed nurse because she assumed the nurses were already aware. The Charge Nurse confirmed that the resident had been sent to the hospital in January for evaluation of a persistent cough and that the EMR and verbal reports were the expected methods for communicating and documenting changes of condition. The Charge Nurse verified that no one had reported the new onset cough and that the EMR contained no documentation of a new cough since the January episode. Review of the facility’s “Changes in Resident Condition” policy indicated that changes in resident status are to be communicated through the 24-hour report management system and documented as revisions when they affect the care plan, which did not occur in this case.
Failure to Revise and Maintain Accessible EMR Care Plan After Hospitalization for Acute Bronchitis
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and maintain an accessible, comprehensive care plan in the EMR following a resident’s significant change in condition and hospitalization for acute bronchitis. The resident was admitted with a diagnosis of acute bronchitis and later hospitalized again for a persistent cough, returning to the facility on 1/27/2026 with a confirmed diagnosis of acute bronchitis and new antibiotic orders. The MDS dated 2/5/2026 showed the resident had intact cognitive skills and required partial assistance with multiple ADLs and supervision for eating. Despite this, review of the EMR showed no evidence that the care plan had been updated to address the new diagnosis, respiratory monitoring needs, antibiotic treatment, or associated interventions after the resident’s return from the hospital. The MDS nurse confirmed that the resident had a new diagnosis and new medication orders upon readmission and that the EMR care plan had not been revised accordingly. On 4/15/2026, the resident was observed coughing forcefully in bed and reported having a cough for a few weeks with green mucus the previous day, and stated she was not receiving any treatment for the cough at that time. A CNA reported first noticing the resident’s cough several days earlier after assisting with a shower but did not report it to a licensed nurse, assuming the nurses were already aware, and the charge nurse verified that no new onset cough had been reported as a change in condition in the EMR. The charge nurse also confirmed that the EMR is the primary and expected location for reviewing and revising care plans and that the resident’s care plan there did not include acute bronchitis or respiratory monitoring needs. The DON stated that any licensed nurse can update the care plan upon admission or readmission and that a care plan for the condition existed on paper, but this paper care plan was not readily available in the resident’s chart and staff present had not seen or accessed it; it was only produced after the surveyor pointed out its absence from the EMR. The facility’s policy required individualized comprehensive care plans with measurable objectives, identification of responsible professional services, and revisions as changes in condition dictate, but these requirements were not met for this resident’s acute bronchitis and related care needs.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for one of three sampled residents. Specifically, a registered nurse supervisor administered Benadryl 25 mg orally to a resident but did not document the administration on the Medication Administration Record (MAR) at the time the medication was given. The omission was confirmed during an interview with the nurse, who acknowledged that documentation should have occurred immediately after the medication was administered. Observation confirmed that the resident received the medication, but the corresponding entry on the MAR for that date was left unsigned. The resident involved had a history of generalized muscle weakness, hypertension, and dementia, and was assessed as having intact cognition. Facility policy required that the individual administering medication must initial the MAR after giving each medication and before administering the next, including recording the date, time, dosage, route, symptoms, and the signature and title of the person administering the drug. The failure to document the administration of Benadryl was contrary to this policy and was identified through both record review and staff interview.
Medication Administered Without Physician Order and Improper Supervision
Penalty
Summary
A deficiency occurred when a resident was administered Benadryl 25 mg orally without a physician's order. The resident, who had diagnoses including generalized muscle weakness, hypertension, and dementia but was assessed as having intact cognition, requested Benadryl for itching. The medication was provided by an LVN, who did not verify the presence of a physician's order prior to administration. The LVN admitted to not checking the Medication Administration Record (MAR) or confirming the order before giving the medication, stating it was a mistake and acknowledging the importance of verifying orders to prevent medication errors. Additionally, the Benadryl tablet was left unattended on the resident's bedside table, rather than being administered directly and observed by the nurse. The Registered Nurse Supervisor confirmed that there was no physician order for the Benadryl and that facility policy requires medications to be administered only as prescribed and in accordance with orders. The facility's failure to obtain a physician order and to ensure proper administration and observation of the medication constituted a significant medication error.
Missed Dose of Physician-Ordered Antibiotic
Penalty
Summary
A resident with diagnoses including diabetes mellitus and a sacral pressure ulcer was admitted to the facility and placed on enhanced barrier precautions due to a gastrostomy tube and pressure injury. The resident's care plan included the administration of antibiotic medications as ordered by the physician. A physician's telephone order was received to administer metronidazole 500 mg via gastrostomy tube every eight hours for the pressure sore. According to the Medication Administration Record (MAR) and the resident's metronidazole bubble pack, the resident was supposed to receive a total of 10 doses of metronidazole over a specified period. Upon review, it was found that only nine doses of metronidazole were administered, as confirmed by both the MAR and the medication bubble pack. This discrepancy was acknowledged by two LVNs during a concurrent interview and record review. The facility's policy and procedures required medications to be administered in a safe and timely manner as prescribed, but the resident missed one dose of the ordered antibiotic.
Medications Left Unattended on Medication Cart
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) prepared medications for a resident and left the bubble packs containing the medications on top of the medication cart while stepping inside the resident's room. The medication cart was left unattended with the medications on top, making them accessible to others. This action was observed during a medication pass and was not in accordance with the facility's policy, which requires that no medications be left on top of the cart and that the cart be locked and secured when not in direct view of the nurse. The resident involved had a history of pneumonia and generalized muscle weakness and was assessed as cognitively intact but required varying levels of assistance with daily activities. Both the LVN and the assistant director of nursing (ADON) confirmed during interviews that medications should not be left unattended on top of the cart for safety reasons. Facility policies reviewed also specified that all drugs and biologicals must be stored securely and not left accessible on the cart.
Failure to Document Weekly Skin Assessments for MASD
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with multiple diagnoses, including diabetes mellitus, difficulty in walking, and dementia, and who had moisture associated skin damage (MASD) on the buttocks. The care plan required weekly assessment and documentation of the MASD, including measurements and observations of the affected area. However, there was no documentation that these weekly assessments were completed as required by the care plan and facility policy. Record reviews and staff interviews confirmed that while daily treatments for the MASD were documented, there was no evidence of weekly skin assessments or documentation of the MASD's status or progress. The lack of documentation made it impossible to determine whether the MASD had healed prior to the resident's discharge. The facility's policy required licensed nurses to document the status of all skin conditions at least weekly, but this was not done for this resident.
Cluttered Hallway Creates Accident Hazard for Resident with Mobility Impairment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for one of three sampled residents. During observations, the hallway was found to be cluttered with linen carts, dirty linen hampers, trash hampers, and shower chairs placed on both sides, creating obstacles. A resident with diabetes mellitus, muscle weakness, and mobility issues, who was cognitively intact and independent in activities of daily living, reported difficulty self-propelling his wheelchair due to the clutter. Multiple staff members, including an LVN, infection preventionist, registered nurse supervisor, and director of nursing, acknowledged that the hallway was crowded and that items should be placed on one side to allow safe passage. The facility's policy emphasized the importance of keeping the environment as free from hazards as possible, but observations and staff interviews confirmed that this was not being followed at the time of the survey.
Failure to Ensure Advance Directive Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident had an advance directive in place or that the resident’s wishes regarding advance directives were properly documented and communicated. The resident, who was admitted and later readmitted with diagnoses including metabolic encephalopathy, cerebral infarction, and moderate intellectual disabilities, was found to have limited capacity to consent and was severely cognitively impaired. Documentation from the care conference indicated the resident did not have an advance directive and did not wish to formulate one, but there was no evidence that the responsible party or legal representative was involved in this decision-making process, despite the resident’s impaired capacity. Interviews with facility staff revealed that the Discharge Planner did not verify the existence of an advance directive upon admission or readmission, nor did she document follow-up with the Regional Center or notify the physician of the resident’s advance directive status. The Director of Nursing confirmed that the facility’s policy required inquiry about advance directives prior to or upon admission, but this was not followed. As a result, the resident was considered full code by default, and the facility did not have documentation to support the resident’s or representative’s wishes regarding end-of-life care.
Failure to Implement Care Plan for Resident Using Hand Mitten Restraint
Penalty
Summary
The facility failed to implement a care plan for a resident who was using a hand mitten, which is considered a restraint. The resident, admitted with diagnoses including cerebral infarction, legal blindness, and requiring assistance with personal care, was observed with a hand mitten on the right hand. Staff interviews and record reviews revealed that there was no care plan in place for the use of the hand mitten, despite the resident's cognitive impairment and the presence of a physician's order and consent for the mitten after admission. The Minimum Data Set (MDS) did not trigger a care plan for the mitten because the need was identified after the initial assessment, and the nurse who obtained consent did not initiate the care plan as required. Further interviews with nursing staff and the Director of Nursing confirmed that no interdisciplinary team meeting was held and no care plan was developed for the hand mitten. Facility policy requires that care plans for restraints address both immediate medical symptoms and underlying causes, but this was not followed. The lack of a care plan resulted in the absence of documented monitoring for skin integrity, circulation, and other risks associated with restraint use, as required by facility policy.
Delay in Providing Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living, including personal hygiene and incontinence care, was left soiled for approximately 20 minutes before being cleaned. The resident had a history of muscle weakness, hemiplegia, hemiparesis, and was at risk for skin breakdown, as documented in the care plan and medical records. Orders were in place for frequent skin assessments and specialized equipment, such as a low air loss mattress, due to an existing stage 3 pressure injury. On the day of the incident, staff were aware that the resident had soiled himself. The treatment nurse acknowledged the need for assistance but was waiting for help. A CNA entered the resident's room but left without providing care, stating he was looking for someone to assist him. The CNA was later observed assisting another resident before returning with a second CNA to clean the original resident. This resulted in a delay of about 20 minutes from the time staff were notified of the need for care to when the resident was actually cleaned. Interviews with staff, including the DON, confirmed that the delay was not in accordance with facility policy, which requires prompt cleaning to maintain hygiene and prevent infection or skin breakdown. Facility policies reviewed emphasized the importance of timely perineal care and assistance with ADLs for residents unable to perform these tasks independently.
Failure to Rotate Insulin Injection Sites per Facility Policy
Penalty
Summary
The facility failed to administer insulin according to its policy by not rotating injection sites for a resident with type 2 diabetes. Review of the resident's Medication Administration Records (MAR) over two months showed that consecutive doses of insulin were given in the same abdominal quadrants on multiple occasions. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that staff had access to previous injection site information and acknowledged that insulin should not be administered in the same location for consecutive doses. The facility's policy also required rotation of injection sites to ensure safe administration. The resident involved had moderate cognitive impairment and was receiving hypoglycemic medication for diabetes management. Physician orders specified subcutaneous administration of Humulin R Insulin per sliding scale before meals and at bedtime. Despite these orders and the facility's policy, staff failed to rotate injection sites, as confirmed during interviews and record reviews. This failure was identified through review of documentation and staff interviews, which indicated that the practice was not followed as required.
Failure to Monitor and Document Pressure Ulcer Progression
Penalty
Summary
Treatment Nurse 1 (TN1) failed to monitor and document the progression of pressure ulcers for a resident who was readmitted with multiple complex diagnoses, including metabolic encephalopathy, dementia, HIV, chronic respiratory failure, congestive heart failure, and dysphagia. The resident was identified as having two unstageable pressure ulcers—one on the medial back and one on the coccyx—both related to immobility. The care plan required weekly documentation of wound measurements, descriptions, and monitoring for changes, but this was not completed as required. The last documented Pressure Sore Skin Problem Report for the resident was completed on 2/28/2025, with no subsequent reports found in the record. TN1 acknowledged during an interview that he was responsible for monitoring and documenting the resident's pressure ulcers weekly but admitted to falling behind due to feeling overwhelmed by the volume of required documentation. Both TN1 and the Director of Nursing (DON) confirmed that weekly documentation was necessary to track the progression of the wounds and ensure appropriate treatment. A review of the facility's policy and procedure confirmed the expectation for nursing staff to assess and document pressure ulcers, including location, stage, measurements, and other relevant factors. The lack of ongoing weekly documentation and monitoring for this resident's pressure ulcers constituted a failure to follow the care plan and facility policy, with the potential for the resident's pressure ulcers to worsen.
Unattended Lighter Left at Bedside in Violation of Smoking Policy
Penalty
Summary
A deficiency occurred when a lighter was found unattended and unsecured on a resident's bedside table, despite facility policy prohibiting residents from keeping lighters or cigarettes in their rooms. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and nicotine dependence, and was assessed as requiring supervised smoking. The resident's care plan and risk assessments indicated that smoking should only occur in designated areas under supervision, and that the facility should monitor for unsafe smoking materials. During observations, the resident was seen smoking in the designated area while a green fluorescent lighter was left on the bedside table in his room, unattended. Staff interviews revealed inconsistent understanding and enforcement of the facility's smoking policy. While some staff members stated that lighters should not be kept at the bedside and recognized the fire hazard, others, including the DON, indicated that residents were allowed to keep lighters and cigarettes at the bedside. The Activities Director confirmed that the facility had procedures for storing smoking materials in locked boxes and that staff were expected to check for contraband items. A review of the facility's smoking policy confirmed that residents assessed as safety risks were not permitted to keep lighters or cigarettes in their possession, and smoking was only allowed in designated outdoor areas under supervision. Despite these policies and the resident's care plan, the lighter was left unattended in the resident's room, creating a potential fire hazard and risk of injury.
Failure to Maintain Sanitary Oxygen Tubing for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with multiple respiratory diagnoses, including pneumonia, acute and chronic respiratory failure with hypoxia, and COPD. The resident was receiving oxygen via nasal cannula tubing, which was observed wrapped around a trash can at the bedside. Both a CNA and an LVN confirmed that the tubing was left in this unsanitary position and acknowledged it was dirty and needed to be replaced. The facility's own policy required replacement of nasal cannula tubing every seven days or when soiled, and staff recognized that the current tubing was a potential source of infection. Record review showed that the resident's care plan included monitoring for signs and symptoms of respiratory infection, and the facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent the spread of communicable diseases. Despite these policies, the unsanitary handling of the oxygen tubing was observed and confirmed by staff, and the DON stated that soiled tubing should be exchanged to prevent infection. The deficiency was identified through direct observation, staff interviews, and review of facility policies and resident records.
Failure to Discard Expired Insulin Pens per Facility Policy
Penalty
Summary
Surveyors observed that two opened insulin pens, a Novolog Flexpen and a Lantus Solostart pen, were stored in the facility's medication refrigerator past their labeled discard dates. The Novolog Flexpen was labeled with an open date of 3/8/2025 and a discard date of 4/5/2025, while the Lantus Solostart pen had an open date of 2/5/2025 and was labeled for discard. Both pens remained in the refrigerator despite being past their use dates. During interviews, both an LVN and the DON confirmed that opened insulin pens should not be kept in the refrigerator and that medications labeled for discard should be removed and not left in storage. A review of the facility's policy and procedure for medication storage indicated that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed. The failure to remove and discard the expired insulin pens was not in accordance with the facility's policy and created the potential for medication dispensing errors, as staff could inadvertently administer medication that should have been discarded.
Failure to Implement Care Plan for Resident's Hand Swelling
Penalty
Summary
The facility failed to develop and implement a care plan for a resident's right-hand swelling, which was noted on January 5, 2025. This deficiency was identified during a review of the resident's records and an interview with the Director of Nursing (DON). The resident, who was admitted with multiple diagnoses including diabetes mellitus, dementia, muscle weakness, hypertension, dysphagia, abnormal posture, and Alzheimer's disease, had a documented change in condition indicating right-hand edema. Despite this change, there was no care plan addressing the edema in the resident's records, as confirmed by the DON. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition and varying levels of assistance required for daily activities. The facility's policy and procedures for care planning, reviewed in June 2024, state that care plans should be based on comprehensive assessments and developed by an interdisciplinary team. However, the absence of a care plan for the resident's right-hand edema suggests a failure to adhere to these procedures, potentially impacting the delivery of care and services to the resident.
Failure to Offer Meal Substitutes for Resident with Impaired Cognition
Penalty
Summary
The facility failed to ensure that a resident was offered a substitute meal when they consumed less than 50% of their meal, as required by the facility's policy. This deficiency was identified during a review of the resident's CNA Daily Charting Form, which documented multiple instances where the resident's intake was less than 50% for various meals, yet no substitute was offered. The Director of Nursing verified these entries and acknowledged that a substitute should have been offered and documented. The resident involved had a complex medical history, including diagnoses of diabetes mellitus, dementia, muscle weakness, hypertension, dysphagia, abnormal posture, and Alzheimer's disease. The resident was assessed to have severely impaired cognition and required varying levels of assistance for daily activities, including eating. The facility's failure to offer meal substitutions as per their policy had the potential to result in malnutrition, dehydration, and an overall decline in the resident's health and medical condition.
Failure to Provide Regular Mouth Care for a Resident
Penalty
Summary
The facility failed to provide regular mouth care for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including dementia and Alzheimer's disease, required substantial assistance with personal hygiene, including oral care. Observations on December 30th revealed that the resident had a creamy substance at the corner of the mouth, a tongue coated with white crust, and dry, crusted lower lips. Despite these observations, the certified nursing assistant (CNA) only wiped the creamy substance from the resident's mouth without providing comprehensive oral care. The resident's care plan, initiated in October and November, indicated the need for daily mouth care and highlighted the risk of oral pain, weight loss, and infection due to dental health problems. The facility's policy on Activities of Daily Living (ADLs) required that residents unable to perform ADLs independently receive necessary services, including oral hygiene. However, the observations and interviews with staff, including a registered nurse supervisor, indicated that the resident's mouth care needs were not adequately met, resulting in the deficiency noted in the report.
Incomplete Documentation of Resident's Fluid and Oral Intake
Penalty
Summary
The facility failed to ensure complete and accurate documentation of fluid and oral intake for a resident, identified as Resident 1, on specific dates. Resident 1, who was admitted with diagnoses including dementia and Alzheimer's disease, required substantial assistance with various activities of daily living and moderate assistance with eating. The Minimum Data Set indicated severe cognitive impairment, necessitating careful monitoring of oral and fluid intake. However, the Certified Nursing Assistant (CNA) daily charting forms for the afternoon shifts on four specific dates were found to be incomplete, with no recorded data on Resident 1's intake. During interviews, the registered dietitian emphasized the importance of monitoring oral and fluid intake to detect any changes in the resident's condition. The Director of Nursing (DON) confirmed the omission in documentation and acknowledged that the nurse responsible had forgotten to document the intake. The facility's policy on charting and documentation, which requires all services and changes in a resident's condition to be documented objectively and accurately, was not adhered to in this instance.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during an active COVID-19 outbreak. One of the sampled residents, who had moderate cognitive impairments and required assistance with activities of daily living, was observed not wearing a mask in the facility's front lobby. The Director of Nursing (DON) acknowledged that the resident had refused to wear a mask but could not provide documentation that a mask was offered. This oversight occurred while the facility was experiencing an active outbreak, increasing the risk of COVID-19 transmission. Additionally, the facility did not ensure that staff were fit tested for N95 respirators. Two Licensed Vocational Nurses (LVNs) admitted they had not been fit tested for the N95 masks they were wearing. The Infection Prevention Nurse (IPN) confirmed that there was no system in place to ensure new staff were fit tested upon hire, and the last audit for fit testing was conducted five months prior. The facility's policy required annual fit testing or whenever there was a change in the employee's facial structure or mask model, but this was not adhered to, potentially compromising mask effectiveness. Furthermore, the facility failed to ensure proper staff screening before shifts. Dietary Staff (DS) was observed self-screening after attending a meeting, contrary to the protocol requiring screening before entering the facility. The receptionist indicated uncertainty about who was responsible for ensuring compliance with screening requirements, and the facility did not require visitor temperature checks. The Infection Prevention Nurse admitted there was no system to ensure staff entering through the back door were properly screened and tested, which could increase the risk of infection spread.
Failure to Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not reporting alleged abuse between two residents and an injury of unknown origin to the State Agency. The first incident involved two residents, where one resident accused the other of stealing money, leading to a physical altercation. The accused resident reportedly used racial slurs and threw ice, prompting the other resident to retaliate by hitting him with a stick, resulting in a skin tear. Despite the severity of the incident, there was no documented evidence that the physical abuse was reported to the Ombudsman or the Department of Public Health (DPH). In the second incident, a resident with severe cognitive impairments was found with a bruise of unknown origin. The resident was unable to recall the cause of the injury due to confusion and dementia. The Assistant Director of Nursing (ADON) speculated that the resident might have scratched himself or hit his head against the siderail, but admitted that the bruise was inconsistent with a scratch. No investigation was conducted, and the event was not reported to the police, DPH, or the Ombudsman, as required by the facility's policy. The facility's policy on unusual occurrence reporting and abuse prevention requires reporting allegations of abuse, neglect, and misappropriation of resident property. It also mandates the protection of residents from abuse by anyone, including other residents, and requires staff training on abuse prevention and reporting. The facility failed to adhere to these policies by not investigating or reporting the incidents within the required timeframes, thereby exposing residents to potential continued abuse.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not reporting an injury of unknown origin for one of the residents to the State Agency. The resident, who had severe cognitive impairments and was dependent on staff for all activities of daily living, was found with a bruise under the left eye. The bruise was not consistent with a scratch, and no one witnessed the events leading to the injury. Despite this, the facility did not conduct an investigation or report the incident to the appropriate authorities, including the police, Department of Public Health, and the Ombudsman. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) acknowledged the bruise was not consistent with a scratch and admitted that no investigation was completed. The Assistant Administrator (AADM) confirmed that the bruise should have been considered an injury of unknown origin, requiring investigation and reporting to external agencies. The AADM also noted that a 72-hour monitoring protocol should have been implemented. The facility's policies and procedures, which were reviewed, clearly outlined the requirement to report unusual occurrences, including injuries of unknown origin, to relevant agencies. The policies also emphasized the need for staff training in abuse prevention and the investigation and reporting of any allegations of abuse. However, these procedures were not followed in this instance, leading to a deficiency in the facility's compliance with its own policies and federal regulations.
Deficiencies in Pressure Ulcer Assessment and Abuse Reporting
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to adequately assess pressure ulcers, specifically in the case of a resident with a stage 3 pressure ulcer. The resident, who was admitted with conditions including diabetes mellitus, dysphagia, and dementia, was identified as high risk for skin breakdown. Despite multiple assessments by the treatment nurse, Director of Nursing (DON), Desk Nurse, and Infection Preventionist Nurse/Quality Assurance Nurse, the resident's skin was initially reported as intact. However, the DON later admitted that the facility failed to appropriately assess and identify the pressure ulcer, which could lead to the resident not receiving the necessary treatments. Additionally, the facility did not implement its abuse policy and procedure effectively, as evidenced by the case of another resident who was found with a bruise of unknown origin. This resident, who had severe cognitive impairments and was dependent on staff for all activities of daily living, was observed with a significant bruise under the left eye. The Assistant Director of Nursing (ADON) suggested possible causes for the bruise but admitted that no investigation was conducted, and the event was not reported to the appropriate authorities, such as the police, Department of Public Health, and the Ombudsman. The facility's policies and procedures, including those for pressure ulcer assessment and unusual occurrence reporting, were not followed. The DON's job description emphasizes the responsibility for ensuring nursing services meet residents' needs, including proper assessment and reporting of incidents. However, the failure to assess the pressure ulcer and investigate the bruise indicates a lapse in adhering to these protocols, potentially compromising resident care and safety.
Failure to Manage and Report Abuse Incidents
Penalty
Summary
The facility failed to have a full-time abuse coordinator, which resulted in the mismanagement of abuse and neglect incidents involving three residents. Resident 3, who was cognitively intact, reported being physically assaulted by his roommate, Resident 4, after a dispute over alleged theft. Despite the incident being reported, there was no documented evidence that it was reported to the appropriate authorities, such as the Department of Public Health or the Ombudsman, as required by the facility's policy. Resident 5, who had severe cognitive impairments and was dependent on staff for all activities of daily living, was found with unexplained bruising. The Assistant Director of Nursing admitted that the bruise was not consistent with a scratch and that no investigation was conducted to determine the cause of the injury. The facility's policy requires that injuries of unknown origin be investigated and reported, but this was not done in Resident 5's case. The facility's policies on unusual occurrence reporting and abuse prevention were not followed, as evidenced by the lack of reporting and investigation of the incidents involving Residents 3, 4, and 5. The absence of a full-time abuse coordinator contributed to these deficiencies, as the facility did not ensure the protection of residents from abuse or conduct necessary investigations and reporting as required by federal and state regulations.
Resident Safety Compromised by Inadequate Supervision and Hazardous Environment
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for a resident identified with wandering episodes, as outlined in the resident's care plan. The resident, who had severe cognitive impairments and a history of wandering and placing items in their mouth, was left unsupervised at the nurses' station. During this time, the resident ingested approximately 160 cc of hand sanitizer, which led to their admission to a General Acute Care Hospital with a diagnosis of toxic encephalopathy and dehydration. Further observations revealed additional safety hazards within the facility. The reception area was found unattended with a half-full bottle of hand sanitizer accessible to residents. In the dining room, the resident was observed unsupervised with an open bottle of sanitizing wipes within reach. Additionally, the maintenance room, which stored cleaning solutions and chemicals, was found unlocked and unattended, providing residents with potential access to hazardous substances. Interviews with facility staff confirmed the lack of supervision and the presence of accessible toxic substances. The Licensed Vocational Nurse admitted that the resident was known to place items in their mouth, yet this behavior was not addressed in the care plan. The Director of Nursing acknowledged the potential toxicity of hand sanitizer if ingested by residents, especially those on medication. The facility's policies and procedures regarding the installation and use of alcohol-based hand rub dispensers were not adequately followed, contributing to the unsafe environment.
Inaccurate Medical Records for a Resident
Penalty
Summary
The facility failed to maintain accurate medical records for one of the nine sampled residents, leading to a deficiency in accordance with accepted professional standards and practices. Specifically, the medical records for a resident, who was initially admitted and later readmitted with diagnoses including toxic encephalopathy, dementia, COPD, and aphasia, contained inaccurate information. The Minimum Data Set (MDS) for this resident indicated severe cognitive impairments and a need for substantial assistance with Activities of Daily Living (ADLs). The deficiency was identified during a review of the resident's admission nursing risks evaluation and assessments, which contained incorrect information about the resident's condition and treatment. The Director of Nursing confirmed the facility's failure to identify the wrong information, acknowledging that this could compromise the resident's care. The facility's policy and procedures on charting and documentation emphasized the need for complete and accurate documentation to facilitate communication among the interdisciplinary team, which was not adhered to in this case.
Failure to Update Dementia Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia, which had the potential to negatively affect the delivery of care and services. The resident, who was admitted with diagnoses including dementia and a history of falling, had a care plan initiated for impaired cognitive function related to dementia. However, after the discontinuation of the dementia medication Namenda, the care plan was not updated to reflect the change in medication and the potential for increased confusion. The resident's Minimum Data Set (MDS) indicated moderately impaired cognitive skills, and the care plan included interventions such as asking yes/no questions, administering medications as ordered, and engaging the resident in structured activities. Despite these interventions, the care plan was not revised after the discontinuation of Aricept, another dementia medication, which was ordered after Namenda was discontinued. The facility's MDS Coordinator acknowledged the requirement to update the care plan following the discontinuation of dementia medications but failed to do so. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the facility did not develop a person-centered care plan with interventions after the discontinuation of Aricept. The facility's policy required the Interdisciplinary Team to identify a resident-centered care plan to maximize function and quality of life, but this was not adhered to, resulting in a lack of appropriate care and monitoring for the resident.
Failure to Prepare Resident for Safe Discharge
Penalty
Summary
The facility failed to sufficiently prepare a resident for a safe and orderly discharge to their home. The resident, who was cognitively intact and required assistance with various activities of daily living, was discharged without involving their primary caregiver in the discharge process. This lack of involvement meant that the caregiver did not receive necessary training, education, or resources to adequately care for the resident at home. Additionally, essential medical equipment and supplies, such as a hospital bed and caregiving services, were not provided as promised by the facility. The resident had multiple medical conditions, including functional quadriplegia, neuromuscular dysfunction of the bladder, and essential hypertension, which required significant care and support. The resident's care plan included interventions to manage these conditions, but these were not communicated to the caregiver. The social worker admitted to not meeting with the caregiver to discuss and provide the required education for a safe discharge, which was against the facility's policy. The caregiver expressed feeling stressed and unprepared due to the sudden change in discharge plans and the lack of support from the facility. The caregiver had to make costly arrangements, such as installing a ramp, and faced difficulties in navigating the apartment and managing the resident's care. The facility's failure to involve the caregiver and ensure the provision of necessary medical equipment and supplies resulted in significant challenges for the caregiver and compromised the resident's safety and well-being.
Failure to Label Food and Maintain Temperature Logs
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling various food items with their use-by dates. Specifically, sliced ham, ground chicken, chicken meat, sliced bacon, creamy Italian dressing, and sausage were found in the refrigerator without use-by date labels. Additionally, ground beef was found in the refrigerator past its use-by date and had not been discarded. The Dietary Supervisor Assistant confirmed that all food items should be labeled with an open date and a use-by date, and that the ground beef should have been discarded immediately after its expiration date. Furthermore, the temperature logs for the refrigerators and freezers were not maintained on two specific dates, which is a requirement to ensure food safety. During interviews, the Dietary Supervisor and the Director of Nursing both acknowledged that the staff should label all food products with open and use-by dates and monitor refrigerator and freezer temperatures three times a day. The facility's policy on labeling and dating food was reviewed, which indicated that newly opened food items should be labeled with an open date and a use-by date, and that correct temperatures for storing and handling food should be maintained. The failure to follow these procedures had the potential to cause food-borne illnesses among the residents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents, Resident 85 and Resident 92. For Resident 85, the facility did not cover the urinary collection bag with a privacy bag, despite the resident having an indwelling catheter and being cognitively intact. This was observed during a room inspection, and the MDS Coordinator Assistant confirmed that the urinary collection bag should have been covered to promote dignity. However, the Director of Nursing stated that covering the urinary collection bag was not required inside residents' rooms, indicating a discrepancy in the facility's practices and policies regarding resident dignity. For Resident 92, the facility failed to provide dignified care during meal assistance. The resident, who had diagnoses including muscle weakness, dysphagia, and dementia, was observed being fed by a CNA who was standing over the resident instead of sitting at eye level. The CNA admitted to not using a chair because it took too long, despite a folding chair being available at the bedside. The Director of Nursing confirmed that staff should be seated at the same level as the resident to ensure proper control and dignity during feeding. The facility's policy on meal assistance also emphasized the importance of feeding residents with attention to safety, comfort, and dignity, which was not adhered to in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident 90, who was admitted with diagnoses including Huntington disease, hypertension, and abnormalities in gait and mobility. The resident had mildly impaired cognition and required moderate assistance with various activities of daily living. The care plan for Resident 90 indicated that the call light should be within reach to allow the resident to communicate their needs. However, during an observation, it was found that the call light was on the floor and not within the resident's easy reach. Certified Nurse Assistant 3 confirmed this observation and acknowledged that the call light should always be within reach. The Director of Nursing also stated that call lights should always be within a resident's easy reach to ensure staff can respond to their needs. The facility's policy, reviewed in May 2023, indicated that call lights should be placed within easy reach when residents are in bed or confined to a chair. This deficiency had the potential to result in residents not being able to call for assistance when needed.
Incomplete Advance Directive Acknowledgement Forms
Penalty
Summary
The facility failed to ensure the Advance Directive Acknowledgement forms were completed thoroughly for two residents. For Resident 36, who was admitted with diagnoses including polyneuropathy, dementia, and hypertension, the form was not signed by the resident or her legal representative and did not indicate if the resident had executed an Advance Directive. This was confirmed during a review of the resident's medical chart with the Social Services Director, who acknowledged the incomplete form dated 8/15/2023. For Resident 85, admitted with diagnoses including muscle weakness and paraplegia, the form was signed by the resident but was not completed to indicate whether the resident had executed an Advance Directive. This was confirmed during a review with the Social Service Assistant, who stated that staff were required to complete the form thoroughly. The Director of Nursing confirmed that the forms for both residents were not completed as required, which could result in the residents' medical decisions not being honored.
Failure to Provide Communication Device for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident was provided a communication device or board in a language the resident could understand. Resident 25, who was admitted with diagnoses including chronic obstructive pulmonary disease, dementia, hypertension, and depression, had a fluctuating capacity to understand and make decisions. The Minimum Data Set (MDS) indicated that the resident was severely cognitively impaired and had a psychosocial wellbeing problem related to a language barrier. Despite this, the care plan did not include an intervention like a communication board to assist the resident in communicating with staff. During observations and interviews, it was noted that Resident 25 primarily spoke Chinese and had difficulty communicating in English. Certified Nurse Assistant 3 and Licensed Vocational Nurse 2 both acknowledged the resident's language barrier and the absence of a communication device or board in the resident's room. The Minimum Data Set Coordinator admitted that she did not include a communication board in the care plan, despite recognizing its importance. The Director of Nursing confirmed that the lack of a communication device could hinder accurate communication between the resident and staff. The facility's policy indicated that residents should be provided with communication boards if they use a language other than the dominant language of the facility, but this was not followed in Resident 25's case.
Failure to Assist Visually Impaired Resident with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for a resident with severely impaired vision, identified as Resident 29. Despite the resident's need for supervision and assistance with meal setup due to his blindness, staff did not consistently provide the necessary support. During an observation, Resident 29 struggled to locate food items on his tray and required help from a Certified Nursing Assistant (CNA) to find his utensils and add sugar to his coffee. The CNA acknowledged that the resident needed assistance with meal setup and directions about the location of food items, which was not properly provided by the staff initially. In another instance, Resident 29 was unaware of a sandwich placed on his side table because staff did not inform him about it or its location. This lack of communication prevented the resident from consuming the snack. A CNA confirmed that staff were required to inform Resident 29 about the placement of food items due to his visual impairment. The Director of Nursing (DON) also acknowledged that the resident needed meal setup assistance and that the nutrition evaluation was not completed correctly, leading to insufficient care. The facility's policy on supporting ADLs indicated that residents unable to carry out ADLs independently should receive necessary services to maintain good nutrition and hygiene. However, the observations and interviews revealed that the staff did not consistently follow this policy, resulting in inadequate care for Resident 29. The failure to provide proper meal setup and communication about food placement directly impacted the resident's ability to maintain adequate nutrition and self-care.
Expired BLS Certificate for CNA
Penalty
Summary
The facility failed to ensure that one of the six sampled staff, a Certified Nursing Assistant (CNA 2), had an up-to-date Basic Life Support (BLS) certificate. A review of CNA 2's employee file indicated that the BLS certificate had expired. Despite this, CNA 2 was found to be working in the facility on a date after the certificate had expired. During interviews and record reviews, both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that CNA 2's BLS certificate had expired and had not been renewed. The DON acknowledged that staff CPR certificates were to be renewed every two years and that not having a valid BLS certificate could potentially result in residents receiving outdated medical care. The facility's policy on emergency procedures for cardiopulmonary resuscitation (CPR) indicated that personnel should have completed training on CPR and BLS, and that clinical staff, including non-licensed personnel, should maintain certification in BLS/CPR. The failure to ensure that CNA 2's BLS certification was current had the potential to result in residents receiving emergency care that was not up to date, which could lead to resident harm or death.
Failure to Provide Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with visual impairment and functional limitations was provided with activities that stimulate the resident's senses. Specifically, the facility did not provide the resident with a radio or television, did not formulate a care plan for activities, and did not perform an activity participation review quarterly. This resulted in the resident experiencing emotional distress, feeling that her days were empty, and expressing frustration and discomfort due to boredom. The resident, who was admitted with diagnoses including adult failure to thrive, cachexia, muscle weakness, dysphagia, difficulty in walking, dementia, and schizophrenia, was dependent on assistance for various activities of daily living. Despite the resident's severe cognitive impairment and visual impairment, the facility did not conduct an activity participation review after the initial review on 12/26/2023. The resident's care plan did not address activities, and the activity attendance records indicated inconsistent room visits and lack of engagement in activities. Interviews with staff revealed that the resident enjoyed sensory stimulation, nail care, listening to music, and watching TV, but these preferences were not adequately addressed. The Activities Director and other staff members were unaware of the resident's request for a radio and the absence of a TV in her room. The facility's policy required quarterly activity evaluations and care plans to reflect the resident's preferences, but these were not followed, leading to a decline in the resident's quality of life.
Failure to Ensure Proper Pressure Ulcer Care and Update Care Plan
Penalty
Summary
The facility failed to ensure that Resident 98 received appropriate pressure ulcer care as per their policy and procedure. Specifically, the facility did not ensure that the resident's wound vac was on and functioning. During an observation, the wound vac was found off and unplugged, which was verified by the Infection Preventionist (IP). The IP acknowledged that the wound vac should be on continuously to drain the resident's wound and prevent it from getting bigger. The Director of Nursing (DON) also confirmed that the wound vac should be on continuously as per the physician's orders. Additionally, the facility failed to revise Resident 98's care plan to include the wound vac treatment that was initiated. The care plan, which was last revised before the wound vac treatment started, did not reflect the current treatment plan. Both the IP and the DON confirmed that the care plan should have been updated to reflect the resident's current treatment needs. The care plan is essential for staff to know the resident's needs and ensure they receive the appropriate care. Resident 98 was admitted with multiple diagnoses, including a Stage 4 pressure ulcer of the sacral region and a Stage 3 pressure ulcer of the right buttock. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependence on assistance for various activities of daily living. The failure to ensure the wound vac was functioning and the care plan was updated had the potential to worsen the resident's pressure ulcer, leading to severe complications.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident's urinary indwelling catheter was securely anchored, which had the potential to cause pain and urethral trauma. Resident 84, who was admitted with diagnoses including urinary tract infection, diabetes, and chronic kidney disease, had severe cognitive impairment and required total assistance with toileting hygiene. The resident's care plan included specific instructions to secure the catheter to prevent dislodgement and complications. However, during observations on two separate occasions, the catheter was found not to be anchored, and the Infection Preventionist confirmed that the catheter should have been secured to prevent dislodgement. The Director of Nursing stated that staff were expected to secure the catheter with a stabilization device or a bedside Foley clamp, as per the facility's policy. The facility's policy on Foley Catheter Care, revised in April 2023, also indicated that the catheter should remain secured to reduce friction and movement at the insertion site. Despite these guidelines, the catheter was not anchored during the observations, indicating a failure to adhere to the prescribed care plan and facility policy, potentially compromising the resident's safety and comfort.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 8,284 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rehabilitation Center Of Los Angeles | 0.6 mi | ★★★★★ | 40 | 0 |
| Westlake Convalescent Hospital | 0.7 mi | ★★★★★ | 4 | 0 |
| Bonnie Brae Skilled Nursing | 0.8 mi | ★★★★★ | 9 | 0 |
| Angels Nursing Health Center | 0.8 mi | ★★★★★ | 13 | 0 |
| Garden Crest Rehabilitation Center | 1.1 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.