Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Care Center On Hazeltine, Llc during CMS and state inspections, most recent first.
Failure to Reconcile Controlled-Substance Emergency Kits: Surveyors found multiple eKITs containing CSs in a medication cart and medication room without accountability logs showing shift-by-shift reconciliation. An LVN and the ADON confirmed the kits were not counted at each shift change as required by facility policy for controlled substances and emergency kits.
Food storage and sanitation practices were not followed in the kitchen and resident refrigerator. Staff observed unlabeled bins of potatoes and onions, a dirty sweet and sour sauce container, an overdue ice machine water filter, missing daily temps on the resident fridge log, and chocolate milk plus vanilla and chocolate ice cream stored without resident names or dates.
A resident with anxiety disorder and a history of falls was admitted with documentation showing intact cognitive skills for daily decision making, but the H&P stated the resident lacked capacity to make health care decisions. The SSD stated the advance directive was offered to the resident, who declined assistance, but the resident's responsible party was not offered help with formulating an AD despite the resident's lack of capacity.
A resident with ventricular fibrillation, MI, and ESRD was receiving clopidogrel and Eliquis and was identified as high risk for bleeding. The MAR documented repeated yes entries for signs and symptoms of bleeding across multiple shifts, but there was no progress note or SBAR documentation showing the physician was notified, despite the order to report any bleeding signs and the facility policy requiring physician communication before the next anticoagulant dose.
Failure to Notify Ombudsman of Resident Discharge: A resident with difficulty walking, nicotine dependence, and anxiety disorder was discharged after completing IV antibiotic therapy. The SSD gave the Notice of Transfer form to the resident but did not fax it to the Ombudsman, stating he was told it was not necessary because the resident initiated the discharge; RN 3 stated the Ombudsman should have been notified, and facility policy required forwarding transfer notices to the Ombudsman.
A resident with neurogenic bladder, CKD, and a history of UTIs had an indwelling catheter observed with coiled, kinked tubing containing yellow liquid while the drainage bag hung beside the bed. An LVN and RN both stated the tubing should be straight and below bladder level to allow free drainage, and the facility policy and catheter insert directions called for unobstructed flow.
Improper Storage of Eye Drops with Oral Medications: Medication Cart 1 contained an eye drop solution stored in the same bin as oral medications, including sodium chloride tablets, glucosamine capsules, and oyster shell calcium tablets. An LVN stated eye drops and oral meds should be stored separately, and the ADON confirmed internal and external meds should be kept apart. The facility policy required externally used drugs to be stored separately from drugs for internal use.
A resident's water pitchers were observed on the floor beside the bed while the resident was sleeping. The DSD/IPN confirmed the pitchers should be placed on a clean nightstand or bedside table and stated the floor is a dirty surface that can contaminate the water.
A resident reported emotional abuse by an LVN, who was initially suspended but later allowed to return to work under supervision. The resident was not informed of this arrangement and felt uncomfortable with the LVN's continued involvement in her care. The facility failed to adhere to its Abuse Prohibition and Prevention Program policy, which emphasizes protecting residents' rights.
A resident with dementia was physically assaulted by their roommate, who threw a cup at them, causing a forehead laceration that required hospital treatment. The aggressive resident, diagnosed with schizophrenia, acted in response to being called a racial slur. Facility staff confirmed the incident as physical abuse, and the facility's abuse prevention policy was reviewed.
A resident with diabetes mellitus did not receive insulin injections in accordance with professional standards, as the facility failed to rotate injection sites. Despite the care plan and physician's orders requiring site rotation, insulin was repeatedly administered in the same areas of the abdomen. This was confirmed by the resident, nursing staff, and the Director of Nursing, who acknowledged the importance of site rotation to prevent skin damage.
A facility failed to properly monitor a resident on apixaban for side effects, such as bruising, which was noted in the SBAR but not documented in the MAR. The resident, with a history of epilepsy, acute kidney failure, atrial fibrillation, and dementia, was dependent on staff for daily activities. The LVN and DON acknowledged the documentation lapse, and the facility lacked a specific policy for monitoring anticoagulant side effects, relying instead on manufacturer's guidelines.
A resident in an LTC facility received an excessive dose of duloxetine due to a medication error. Despite a physician's order to reduce the dose to 20 mg, the resident continued to receive 30 mg for 21 days. The error was discovered when an LVN noticed the discrepancy during medication administration. The DON confirmed the pharmacy delivered the wrong dosage, and staff failed to verify the medication against the order, violating the facility's medication administration policy.
A resident with major depressive disorder was prescribed duloxetine 20 mg daily, but due to an error, received 30 mg for 21 days. The error was discovered during a medication administration observation when an LVN noticed the discrepancy. The DON confirmed the pharmacy delivered the wrong dosage and staff failed to verify it against the physician's order, leading to a medication error.
The facility was found to have deficient food storage and sanitation practices, including an unwrapped sausage patty in the freezer, a staff member's undated Gatorade bottle in the refrigerator, and dirty shelves and utensil bins. The Dietary Supervisor noted that kitchen cleaning was not performed over the weekend, leading to unsanitary conditions.
A facility failed to maintain infection control when an LVN did not wash hands between administering G-tube medications and an insulin injection to a resident with anemia, colon cancer, and vascular dementia. The LVN acknowledged the lapse, and the facility's policy required hand hygiene in such situations.
A facility failed to create a comprehensive care plan for a resident with dementia, who primarily speaks Armenian. The care plan did not address the resident's language needs, resulting in communication barriers. Observations revealed the absence of a necessary communication board, and staff confirmed the resident's inability to understand English. The facility's policy requires culturally competent care plans, but this was not reflected in the resident's care plan.
A resident with severe cognitive impairment and limited English proficiency was not provided with a communication board in their preferred language, Armenian. Despite the resident's care plan indicating a need for communication assistance, the facility failed to specify language needs, resulting in the absence of a necessary communication device until noted by a surveyor. The DON confirmed the requirement for such devices for non-English speaking residents.
A facility failed to discard a discharged resident's medicated ointment, which remained accessible in a treatment cart. The resident, diagnosed with CHF and dementia, had been discharged, but their Preparation H ointment was not removed as per the facility's policy. The DON confirmed the medication should have been discarded.
A resident with dysphasia, anorexia, dementia, and schizophrenia did not receive a fortified diet as ordered by the physician, despite being at risk for weight loss. The Dietary Supervisor and RN confirmed the oversight, and the facility's policies were not followed, resulting in a deficiency in meeting the resident's nutritional needs.
The facility failed to protect residents from physical abuse, resulting in an altercation where one resident punched another, causing injuries that required medical treatment. Both residents had mental health disorders and required varying levels of supervision and assistance. The incident was confirmed by surveillance video and staff interviews.
Failure to Reconcile Controlled-Substance Emergency Kits
Penalty
Summary
The facility failed to reconcile controlled-substance emergency kits in one medication room and one medication cart. During observation, surveyors found one eKIT labeled 16 in Medication Cart 1 without an accountability log showing controlled-substance inventory counts at every shift change for 12/2025. In a concurrent interview, LVN 3 stated that all controlled substances, including medication eKITs containing controlled substances, should be reconciled and counted at every shift, and acknowledged that the eKIT in Medication Cart 1 had not been reconciled in 12/2025. In Medication room [ROOM NUMBER], surveyors observed one eKIT labeled 24 in the refrigerator and one eKIT labeled 8 at room temperature, both containing controlled substances, and neither had an accountability log for shift-by-shift reconciliation for 12/2025. LVN 2 stated these eKITs should be reconciled at every shift. The ADON later confirmed that the eKIT labeled 16 in Medication Cart 1, the eKIT labeled 24 in the refrigerator, and the eKIT labeled 8 at room temperature all contained controlled substances and were not reconciled at every shift in 12/2025. Facility policy required controlled substances and narcotic eKits to be counted and verified at each shift change by incoming and outgoing nurses.
Food Storage, Labeling, and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and proper food handling practices in the kitchen and resident refrigerator areas. During a concurrent kitchen observation and interview on 12/15/2025 at 7:53 a.m., one bin of potatoes and one bin of onions were observed without labels showing the date received. The CK verified the finding and stated that perishable food should be labeled with the date received so staff know what to use first. The Dietary Supervisor later stated that all perishable food delivered to the facility should be labeled with the date received due to food safety, and the facility policy required foods to be covered, labeled, and dated when stored. During a concurrent observation and interview on 12/15/2025 at 8:14 a.m., one sweet and sour sauce container was observed with residue left outside the container, and the CK stated it was dirty and should be clean before being returned to the refrigerator. On 12/16/2025 at 11:12 a.m., the ice machine water filter was observed labeled as installed on 5/16/2025 and to be replaced on 11/16/2025; the DS stated it was supposed to be changed to ensure proper water filtration. During a concurrent observation, interview, and record review on 12/15/2025 at 8:31 a.m., chocolate milk and vanilla and chocolate ice creams in the residents' refrigerator were observed without resident names and dates, and the refrigerator temperature log was missing daily temperatures for 12/12/2025, 12/13/2025, and 12/14/2025.
Failure to Provide Advance Directive Information to Resident Representative
Penalty
Summary
The facility failed to provide a resident's representative with information regarding formulating an advance directive for Resident 16. Resident 16 was admitted on 1/30/2025 with diagnoses including anxiety disorder and history of falling. The resident's MDS dated 11/4/2025 indicated cognitive skills for daily decision making were intact and that the resident required partial to moderate assistance with ADLs. A review of Resident 16's H&P dated 1/30/2025 indicated the resident did not have the capacity to make health care decisions, but was able to decide for ADLs and make needs known. During a concurrent interview and record review on 12/18/2025, the SSD stated that the advance directive was offered to Resident 16, but the resident declined assistance. The SSD also stated that he should have offered assistance to Resident 16's responsible party regarding formulating an advance directive since Resident 16 had no capacity to make health care decisions.
Failure to Notify Physician of Bleeding Signs in Resident on Anticoagulants
Penalty
Summary
The facility failed to follow a physician order to notify the physician when a resident showed signs and symptoms of bleeding while receiving anticoagulant therapy. Resident 2 was admitted with diagnoses including ventricular fibrillation, myocardial infarction, and end stage renal disease, and the MDS indicated intact cognition and maximal assistance needed for ADLs. The care plan identified the resident as high risk for bleeding, bruising, and skin discoloration related to anticoagulant therapy and included interventions to monitor, document, and report signs and symptoms of bleeding. The order summary included clopidogrel 75 mg daily, Eliquis 2.5 mg twice daily, and an order to monitor for signs and symptoms of bleeding every shift and notify the physician if present. The MAR documented yes for signs and symptoms of bleeding on multiple shifts from 12/6/2025 through 12/16/2025, but progress notes and SBAR documentation did not show any bleeding assessment details or physician notification. RN 1 stated staff must notify the physician and document when bleeding signs are present, and LVN 1 stated staff needed to report any signs and symptoms of bleeding because the resident was high risk due to anticoagulant use.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of a resident’s discharge from the facility for one of three sampled residents. Resident 54 was admitted with diagnoses including difficulty walking, nicotine dependence, and anxiety disorder. The resident’s H&P indicated she had the capacity to make medical decisions, and the MDS indicated she could make herself understood, understand others, eat independently, and required partial assistance with ADLs. Resident 54 was discharged back to her home at an assisted living facility with her belongings and discharge instructions after completing IV antibiotic therapy. During interview and record review, the Social Services Director stated he gave the Notice of Transfer form to the resident but did not fax it to the Ombudsman because he had been advised by the DON that it was not necessary when the resident initiated the discharge. RN 3 stated the Ombudsman should have been notified just in case there was a concern. The facility policy stated that copies of notices of transfer are to be forwarded to the Ombudsman.
Coiled catheter tubing with impaired drainage
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter tubing was not coiled and that urine could flow freely into the drainage bag for one sampled resident. The resident was admitted with diagnoses including recurrent urinary tract infections, neurogenic bladder, and chronic kidney disease. The resident's H&P indicated the resident did not have the capacity to make decisions or needs known, and the MDS indicated the resident could sometimes make self-understood and sometimes understand others. The resident had an order for an indwelling catheter to a drainage bag due to neurogenic bladder, and the care plan included checking the tubing for kinks each shift. During observation, the resident was lying in bed with the catheter bag hanging on the side of the bed frame. The catheter tubing hung below the bed and had coils with a kink, and the coiled portion contained yellow liquid. An LVN observed the same condition and stated the tubing should be straight and without kinks so urine could drain into the bag, and that the resident had a history of UTIs. An RN later stated the tubing should not be coiled or kinked and should be below bladder level, and that coiling could lead to back flow and possible infection. The facility policy stated catheter care is provided to reduce infection risk and that tubing should be positioned lower than the body to facilitate drainage, and the catheter insert directions stated to maintain unobstructed free flow of the catheter and tubing.
Improper Storage of Eye Drops with Oral Medications
Penalty
Summary
The facility failed to store medications in accordance with manufacturer specifications, professional principles, and facility policy and procedures in one of two inspected medication carts, Medication Cart 1. During a concurrent observation and interview on 12/16/2025 at 10:18 a.m. with LVN 3, one eye drop solution was found stored in the same bin as sodium chloride oral tablet, glucosamine oral capsule, and oyster shell calcium oral tablets. LVN 3 stated that orally administered medications and eye drops should be stored separately in their own sections or bins, not together, to prevent errors in wrong route administration. During an interview on 12/16/2025 at 3 p.m. with the ADON, it was stated that internally administered medications, such as oral and intravenous medications, and externally administered medications, such as those for the eyes, ears, nose, and skin, should be stored separately to prevent wrong route administration, infections, and contamination. Review of the facility's Policy and Procedure titled Pharmaceutical Services - Labeling and Storage, last reviewed 1/28/2025, showed that externally used drugs in liquid, tablet, capsule, or powder form shall be stored separately from drugs for internal use.
Water Pitchers Placed on Floor by Resident Bedside
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a resident's water pitchers were observed on the floor beside the bed. Resident 16 was admitted on 1/30/2025 with diagnoses including anxiety disorder and history of falling. The resident's MDS dated 11/4/2025 indicated cognitive skills for daily decision making were intact and that the resident required partial to moderate assistance with ADLs. During an observation on 12/15/2025 at 11:15 a.m., two water pitchers were seen on the floor by Resident 16's bedside while the resident was in bed sleeping. During a concurrent observation and interview, the DSD/IPN confirmed the pitchers were on the floor and stated that residents' water pitchers are to be placed on a clean nightstand or bedside table, not on the floor. The DSD/IPN stated the floor is a dirty surface and that water pitchers placed there can become contaminated.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its Abuse Prohibition and Prevention Program policy for a resident who reported an allegation of emotional abuse by a Licensed Vocational Nurse (LVN). The resident, who was admitted with chronic obstructive pulmonary disease and generalized muscle weakness, reported that the LVN made derogatory comments, causing emotional distress. Despite the LVN being initially suspended, the Director of Nursing allowed the LVN to return to work with the condition of having another staff member present when caring for the resident. The resident and family members were not informed of this arrangement, and the resident expressed discomfort with the LVN's continued involvement in her care. The facility's administration acknowledged that the resident's preferences should have been accommodated, and the LVN should not have been assigned to the resident again. The facility's policy emphasizes the protection of residents' health, welfare, and rights, which was not upheld in this instance.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On November 3, 2024, at 7:00 a.m., a resident with severely impaired cognition due to dementia and psychosis was physically assaulted by their roommate, who threw a cup at them, resulting in a laceration on the forehead. The injured resident required emergency medical attention and was transferred to a hospital where they received sutures for the wound. The aggressive resident, who had intact cognition and a diagnosis of schizophrenia, reported that they threw the cup in response to being repeatedly called a racial slur by the injured resident. This incident was documented in the facility's records, including the Minimum Data Set (MDS) and Situation, Background, Assessment, Recommendation Report (SBAR), which detailed the events leading to the physical altercation and the subsequent medical treatment required by the injured resident. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed the occurrence of the physical abuse and the actions taken immediately following the incident. The facility's policy on abuse prevention and prohibition was reviewed, highlighting the residents' right to be free from abuse and the staff's responsibility to prevent such incidents. The report substantiates the abuse allegation based on the aggressive resident's admission of their actions and the facility's acknowledgment of the incident as physical abuse.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous insulin injection sites for a resident with diabetes mellitus. The resident, who was cognitively intact and required setup help with eating, was admitted to the facility with a diagnosis of diabetes. The care plan for the resident included an intervention to rotate insulin injection sites to prevent complications. However, the facility did not follow this intervention, as evidenced by the repeated administration of insulin in the same areas of the resident's abdomen. The review of the resident's medical records revealed multiple instances where insulin was administered in the same quadrant of the abdomen, contrary to the physician's orders and the facility's policy. The records showed that insulin was repeatedly injected in the left and right upper quadrants and the right lower quadrant of the abdomen over the course of a month. This practice was confirmed by interviews with the resident and nursing staff, who acknowledged the failure to rotate injection sites and the lack of education provided to the resident about the importance of site rotation. The Director of Nursing confirmed the deficiency, acknowledging that the facility's policy required the rotation of insulin injection sites to prevent skin damage and lipodystrophy. Despite the policy and the physician's orders, the nursing staff did not consistently rotate the injection sites, leading to a potential risk of adverse effects for the resident. The facility's policy on insulin administration, last reviewed shortly before the survey, emphasized the necessity of rotating injection sites to protect skin tissue.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring of a resident receiving apixaban, an anticoagulant medication, for potential side effects. The resident, who had a history of epilepsy, acute kidney failure, atrial fibrillation, and dementia, was dependent on staff for all activities of daily living and had severely impaired cognition. The physician's orders required monitoring for signs and symptoms of bleeding, such as bruising, which was not accurately documented in the Medication Administration Record (MAR) despite being noted in the SBAR communication tool. During interviews, both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged the lack of documentation in the MAR regarding the resident's bruising. The facility did not have a specific policy for monitoring anticoagulant side effects but followed the manufacturer's guidelines, which emphasized the importance of evaluating and reporting unusual bleeding. The failure to document the bruising in the MAR could hinder the ability to inform the physician of all side effects, potentially affecting the resident's care.
Excessive Dose of Duloxetine Administered Due to Medication Error
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic drugs by administering an excessive dose of duloxetine, contrary to the physician's order. Resident 10, who was diagnosed with major depressive disorder, was prescribed duloxetine 20 mg daily following a Gradual Dose Reduction (GDR) recommendation by the facility's consultant pharmacist. However, due to an error, the resident continued to receive 30 mg of duloxetine, which was the previous dosage before the GDR. The error was discovered during a medication administration observation when a Licensed Vocational Nurse (LVN) noticed that the bubble pack contained duloxetine 30 mg instead of the prescribed 20 mg. The LVN confirmed that the resident had been receiving the incorrect dosage for 21 days, as indicated by the count of medication in the bubble pack. The Director of Nursing (DON) acknowledged that the pharmacy had delivered the wrong dosage and that the licensed nurses failed to verify the medication against the physician's order, leading to the administration of the incorrect dose. The facility's policy and procedure for medication administration require a triple check of the five rights (right resident, right drug, right dose, right route, and right time) to prevent such errors. However, this protocol was not followed, resulting in a significant medication error. The facility's policy also mandates that medication errors should not exceed a five percent error rate, emphasizing the importance of adherence to proper medication administration procedures.
Medication Error: Incorrect Duloxetine Dosage Administered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering an incorrect dose of duloxetine. Resident 10, who was diagnosed with major depressive disorder, difficulty in walking, and type two diabetes mellitus, was prescribed duloxetine 20 mg once a day starting from May 16, 2024, following a Gradual Dose Reduction recommendation by the facility's consultant pharmacist. However, due to an error, the resident continued to receive duloxetine 30 mg instead of the prescribed 20 mg. The error was discovered during a medication administration observation on November 5, 2024, when a Licensed Vocational Nurse (LVN) noticed that the bubble pack contained duloxetine 30 mg instead of the prescribed 20 mg. The LVN confirmed that the resident had been receiving the incorrect dose for 21 days, as evidenced by the count of medication in the bubble pack. The Director of Nursing (DON) confirmed that the pharmacy had delivered the incorrect dosage and that the licensed nurses had failed to verify the medication against the physician's order, resulting in a medication error. The facility's policy and procedure on medication errors and administration emphasize the importance of verifying the five rights of medication administration, including the right dose. Despite these guidelines, the licensed staff did not adhere to the policy, leading to the administration of an excessive dose of duloxetine to Resident 10. This oversight had the potential to expose the resident to adverse reactions due to overmedication.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. A single sausage patty was found unwrapped and exposed on top of an open box containing an unsealed bag of the same sausage patties in Freezer 1. This was acknowledged by a staff member who discarded the exposed sausage patty and the entire box. Additionally, an undated bottle of Gatorade belonging to a staff member was found in Refrigerator 2, which was against the facility's policy of not allowing personal food or drinks in the kitchen refrigerator. The bottle was subsequently discarded by the staff member. Further observations revealed that shelves intended for clean trays were stained and covered with crumbs and dust. Two plastic bins holding clean utensils were also found with reddish food residue and crumbs, placed on dusty shelves. The Dietary Supervisor confirmed that the kitchen staff do not clean over the weekend, and he is responsible for cleaning on Mondays. The facility's policies on food storage and cleaning schedules were reviewed, indicating that food should be stored in airtight containers and that a routine cleaning schedule should be maintained, which was not adhered to in this instance.
Infection Control Lapse in Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices when a Licensed Vocational Nurse (LVN) did not wash hands between administering medications via a gastrostomy tube and giving an insulin injection to a resident. During an observation, the LVN was seen administering medications through the G-tube and then preparing to give an insulin injection without performing hand hygiene in between these tasks. The LVN acknowledged the lapse in hand hygiene when questioned by the surveyor, admitting that hands should have been washed after administering the G-tube medications and before donning gloves for the injection. The resident involved, identified as Resident 32, had a medical history that included anemia, colon cancer, and vascular dementia, and lacked the capacity to understand and make decisions. The facility's policy on medication administration, last reviewed shortly before the incident, clearly stated the requirement for good hand hygiene, including washing hands before and after direct contact with residents and when administering medications via enteral tubes. The Director of Nursing confirmed that handwashing was necessary for infection control after administering medications through a gastrostomy tube.
Failure to Develop Person-Centered Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 14, who was admitted with diagnoses including unspecified dementia, repeated falls, dysphagia, and depression. The resident's Minimum Data Set (MDS) indicated severe impairment in cognitive skills and dependence on staff for daily activities. The resident's preferred language was Armenian, and an interpreter was needed for communication with healthcare staff. However, the care plan did not specify the resident's language needs, which is crucial for effective communication. During observations, it was noted that Resident 14 did not have a communication board or device available, which was necessary due to the resident's inability to understand English. Certified Nursing Assistant 1 (CNA 1) confirmed the communication barrier and the absence of a communication board at the resident's bedside. The MDS Coordinator acknowledged the oversight in developing a person-centered care plan that addressed the resident's specific language needs, which was a critical component for ensuring the resident's ability to communicate requests, needs, or concerns. The facility's policy on developing comprehensive care plans emphasizes the need for person-centered, culturally competent plans that address residents' medical, physical, mental, and psychosocial needs. However, the care plan for Resident 14 did not reflect these requirements, as it failed to incorporate the resident's language preferences and communication needs, leading to a deficiency in providing adequate care for the resident.
Failure to Provide Communication Device in Preferred Language
Penalty
Summary
The facility failed to provide a communication device or board in the preferred language of a resident, identified as Resident 14, who was admitted with diagnoses including unspecified dementia, repeated falls, dysphagia, and depression. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependence on staff for daily activities, with a preferred language of Armenian. Despite this, the care plan did not specify the resident's language needs, and no communication board was initially provided. Observations and interviews revealed that Resident 14, who primarily speaks Armenian and has limited English proficiency, did not have access to a communication board or device in his language. A Certified Nursing Assistant (CNA) confirmed the absence of such a device and acknowledged the necessity for a communication board for non-English speaking residents. The MDS Coordinator admitted to not developing a person-centered care plan that addressed the resident's specific language needs, resulting in the lack of a communication board until it was noted by the surveyor. The Director of Nursing (DON) confirmed the requirement for providing communication devices to non-English speaking residents in their primary language. The deficiency was identified as the failure to provide a communication board or device in Armenian for Resident 14, which could hinder effective communication and timely care delivery.
Failure to Discard Discharged Resident's Medication
Penalty
Summary
The facility failed to properly discard a medicated ointment belonging to a resident who had been discharged. The resident, who had been diagnosed with congestive heart failure and dementia, was originally admitted and later readmitted to the facility before being discharged. Despite the discharge, the resident's Preparation H ointment, which was prescribed for hemorrhoids, was found in the treatment cart during an inspection. The Director of Nursing acknowledged that the ointment should have been removed and discarded following the resident's discharge, as per the facility's policy. The policy mandates that unused medications should be removed from storage and destroyed if they remain in the facility after a resident's discharge. However, the ointment was still accessible in the treatment cart, indicating a lapse in following the established procedures for medication disposal.
Failure to Provide Fortified Diet as Ordered
Penalty
Summary
The facility failed to meet the nutritional needs of Resident 12 by not providing a fortified diet as ordered by the physician. Resident 12, who has a history of dysphasia, anorexia, unspecified dementia, and schizophrenia, was admitted with a physician's order for a pureed, fortified, and large portioned diet with moderately thick consistency fluids. Despite this order, the resident's lunch tray did not include the required fortified components, specifically mashed potatoes with gravy, which was confirmed by the Dietary Supervisor and another staff member. During an observation and interview, the Dietary Supervisor acknowledged that the lunch tray provided to Resident 12 was not fortified as per the physician's order. The Registered Nurse (RN) responsible for checking the food trays admitted to not confirming whether the meal was fortified, despite the physician's order for a fortified diet due to the resident's risk for weight loss. The Registered Dietician also confirmed that the resident's diet order was for fortified large portion meals and emphasized the importance of following the physician's order to prevent further weight loss. The Director of Nursing (DON) stated that the facility is required to serve meals based on the residents' physician orders and acknowledged that Resident 12 was not provided with the fortified diet as ordered. The facility's policy and procedure documents indicate that they are supposed to provide a diet that meets each resident's nutritional and dietary needs, but this was not adhered to in the case of Resident 12, leading to a deficiency in meeting the resident's nutritional requirements.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical abuse, resulting in an altercation between two residents. On 3/10/2024, a Certified Nurse Assistant (CNA) witnessed Resident 2 punch Resident 1 in the stomach, followed by Resident 1 punching Resident 2 in the face. This incident led to Resident 2 sustaining skin abrasions on the forehead, nose bridge, and nose crease, which required first aid and daily wound treatments. Both residents were diagnosed with mental health disorders, with Resident 1 having schizoaffective disorder and Resident 2 having bipolar disorder, schizophrenia, and psychosis. The Minimum Data Set (MDS) assessments indicated that Resident 1 had moderately impaired cognition and required supervision for various activities, while Resident 2 had intact cognition and required moderate assistance with mobility and supervision for other activities. The incident was documented in the Change of Condition (COC) forms for both residents, indicating the physical aggression and the resulting injuries. Resident 2's Wound Assessment Report detailed the specific injuries and the prescribed treatment, which included cleansing with Normal Saline and applying Triple Antibiotic Ointment. Interviews with both residents revealed that they recalled the altercation, although Resident 1 did not remember the exact date. The facility's surveillance video confirmed the physical altercation, showing Resident 2 punching Resident 1 first, followed by Resident 1 retaliating with multiple punches to Resident 2's face. Staff members, including CNA 2 and a Licensed Vocational Nurse (LVN), intervened to separate the residents. The facility's policy on abuse and resident-to-resident altercations, last reviewed on 2/27/2024, emphasized the residents' right to be free from abuse and neglect. However, the facility failed to prevent the physical abuse between Resident 1 and Resident 2, resulting in emotional distress and physical injuries. Interviews with the Administrator (ADM) and the Director of Nursing (DON) confirmed that the video recording validated the occurrence of physical abuse between the two residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Van Nuys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Valley Health Care Center | 0.7 mi | ★★★★★ | 25 | 1 |
| Valley Palms Care Center | 1.2 mi | ★★★★★ | 11 | 0 |
| Valley Village Care Center | 1.3 mi | ★★★★★ | 27 | 0 |
| California Healthcare And Rehabilitation Center | 1.7 mi | ★★★★★ | 43 | 0 |
| Berkley Post-acute | 1.7 mi | ★★★★★ | 8 | 0 |
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