Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Earlwood during CMS and state inspections, most recent first.
A resident with complex medical conditions, including cirrhosis with ascites and esophageal varices, experienced several days of vomiting and 10/10 abdominal pain, repeatedly refusing medications due to fear of vomiting. Nursing staff delayed initiating a change-of-condition evaluation and did not develop a care plan for the vomiting and pain, and assessments of vomitus, abdominal status, and VS were incomplete or undocumented. The NP issued texted orders for Tylenol suppository, non-pharmacologic pain interventions, IV fluids, STAT labs, and immediate transfer to a GACH, but these orders were not consistently implemented, not entered into the EHR, and not documented, and STAT labs were delayed by about 13 hours. Despite ongoing symptoms and reports of reddish vomitus, the resident was not transferred until after vomiting blood and reporting severe esophageal pain, resulting in a prolonged delay between the NP’s initial transfer order and the actual hospital transfer.
A high‑fall‑risk resident with impaired mobility, fluctuating decision‑making capacity, and a history of repeated falls experienced two unwitnessed falls within hours, with the second causing a forehead laceration, skin tears, and bruising. Despite documented high risk and a change in condition after the first fall, staff did not update the fall care plan to include device‑based interventions such as a bed alarm, landing pads, or maintaining the bed in the lowest position, nor did they initiate more frequent rounding or closer supervision as required by facility policy. Nursing staff and the DON acknowledged that the facility’s accident‑investigation policy, which requires identifying causes and implementing pertinent interventions to prevent subsequent falls, was not followed. Separately, surveyors observed that the front door and three of four exit doors lacked active interior alarms, contrary to the facility’s security plan that calls for electronic alarm systems to address resident elopement risk.
Expired Ground Cracker Crumbs Left in Dry Storage: An open container of ground cracker crumbs was found in the kitchen dry storage area after its use-by date and remained available for food prep. A DA and DS stated the crackers should have been discarded, and the DS said he is responsible for checking storage daily to ensure expired items are removed. Facility policy required date marking and a 60-day usability period for cracker items.
A facility failed to follow infection control practices for multiple residents. A Foley catheter bag was left on the floor, a hydration bag and oxygen tubing/humidifier were left unlabeled, and an oxygen cannula was positioned incorrectly. In addition, an LPN used unclean medication trays and did not disinfect a B/P cuff or stethoscope before use on residents. The DON stated reusable equipment should be disinfected before and after use to prevent cross contamination.
Surveyors found that the facility transferred two residents to a GACH for reported declines in ADL status without documenting a clear medical necessity, monitoring, or reassessment. One resident with hemiplegia and ESRD had recently completed PT/OT with documented improvement and no recorded ADL decline or change of condition, yet was sent to the hospital for "decreased participation in ADLs" with a blank COC form and no documented in-house interventions. Another resident with dementia, CHF, and generalized weakness had a COC noting ADL decline and postural imbalance, but concurrent PT/OT notes showed active participation and improvement, and there were no labs, diagnostics, or monitoring documented between the COC and the hospital transfer. Staff interviews and record review confirmed that required documentation of specific unmet needs, facility attempts to meet those needs, and justification for transfer, as outlined in facility policy, was not present for either resident.
A resident with complex medical conditions, quadriplegia, and intact cognition experienced several days of vomiting and generalized pain rated 10/10, but staff did not timely initiate a change of condition process or develop a person-centered care plan with measurable interventions. Nursing notes documented repeated vomiting, a firm abdomen, and NPO status, yet there was no complete assessment of the vomitus, abdominal status, or vital signs for at least one episode, and the resident was not closely monitored as described by an LVN. An RN supervisor confirmed that the change of condition evaluation was delayed by two days, the physician notification lacked documented details, and the resident’s pain and vomiting were never incorporated into an individualized care plan, contrary to facility policy requiring an interdisciplinary, comprehensive care plan based on the resident’s assessment.
A resident with complex medical conditions, including cirrhosis with ascites, esophageal varices, quadriplegia, and chronic spinal disease, repeatedly reported severe abdominal and arm pain rated 10/10 along with several days of vomiting. Despite existing orders for routine pain monitoring, PRN acetaminophen, daily SL suboxone, and non-pharmacologic measures such as warm compresses, repositioning, and relaxation breathing, nursing staff did not complete required pain assessments, did not administer the ordered suboxone, and did not implement or document non-pharmacologic interventions. An RN supervisor failed to initiate a change-of-condition assessment, provide pharmacologic or non-pharmacologic pain relief, or transcribe NP text orders into the record or care plan, and an LVN acknowledged not assessing or documenting the resident’s pain or vital signs. No individualized pain management care plan was developed, and the facility’s pain management and documentation policies requiring systematic assessment, treatment, monitoring, and documentation of pain and changes in condition were not followed, resulting in the resident experiencing unrelieved severe pain and transfer to an acute care hospital.
A resident with multiple complex conditions, including cirrhosis with ascites and quadriplegia, experienced vomiting, pain, and abdominal discomfort, leading an NP to order STAT CBC, CMP, lipase, and lactate tests and to continue IV hydration. Despite the facility’s policy that STAT labs be called in immediately and completed within 4–6 hours, the labs were not drawn until about 13 hours after the order, and the RN Supervisor could not explain the delay, resulting in a failure to complete STAT laboratory testing as ordered.
Delayed Response to Call Lights: The facility failed to answer call lights in a timely manner for two residents who needed assistance with ADLs and other care needs. One resident with a history of falls, vertigo, and functional dependence reported waiting a long time at night and sometimes calling the nurses’ station on his cellphone when his call light was not answered. Another resident with a broken leg, urinary incontinence, emphysema, and oxygen dependence said staff took a long time to answer his call light. Staff interviews confirmed ongoing concerns about unanswered call lights, especially on evening and night shifts.
A resident with dementia, hemiplegia, hemiparesis after CVA, and DM was found to lack capacity to understand and make decisions, yet the facility did not provide evidence that the resident’s representative was informed of the right to complete an Advance Directive. The resident’s Advance Directive Acknowledgement Form showed refusal to sign, and both the MDSN and SW stated the resident could not understand the form and there was no documentation that it was offered to the responsible party.
A resident with intrahepatic bile duct carcinoma and a malfunctioning biliary drain was transferred to a GACH, but the facility did not provide a written bed hold notice to the resident or RP at the time of transfer. The RN supervisor and DON confirmed the notice was not given, even though facility policy required written information on bed-hold rights at transfer or within 24 hours for an emergency transfer.
A resident with bipolar disorder and paraplegia did not receive a Level II PASARR mental health evaluation after the MDS Nurse missed the bipolar diagnosis during review of the PASARR and medical record. The resident’s record showed the resident could make medical decisions, express wants, and understand others, and the MDS also listed bipolar disorder. The MDSN stated the missed diagnosis could result in mental health services and PASARR recommendations being overlooked, and the DON stated inaccurate pre-screening could affect care for behaviors and needed services.
Failure to Update Care Plan for Resolved Coccyx Pressure Injury: The facility did not revise the care plan for a resident with a resolved coccyx pressure injury when the treatment order changed to skin maintenance. The resident had impaired cognition, needed assistance with mobility and ADLs, and was at risk for pressure injuries. The TN and IPN stated no new care plan was created for the coccyx skin maintenance, and the DON confirmed the care plan should have been developed so staff would know the resident’s current care needs.
Food Not Palatable or Appetizing: Two residents reported that meals lacked flavor and that meat was dry and nearly caused vomiting. A test tray observed with the DS showed overcooked, mushy cauliflower, a hard biscuit, and a strong onion odor. The residents had significant neurologic and functional impairments, and the record showed one needed supervision or touching assistance with eating while the other required broader ADL support.
Failure to Document Resident Meal Preferences: A resident with severe protein malnutrition, hemiplegia, dysphagia, cerebral infarction, and DM was on a fortified pureed diet, but his dietary profile had no documented likes, dislikes, or food preferences. The resident requested a pureed grilled cheese sandwich, and the DS confirmed the request was known but not recorded in the chart.
Failure to Complete Ordered SLP Evaluation for Resident With Dysphagia: A resident with a hx of CVA and dysphagia was observed coughing after drinking water, and the physician ordered an SLP eval due to coughing during meals. The eval was not completed because the LNs did not communicate the order to rehab, and the RN supervisor, ST, DOR, and DON all confirmed the missed follow-through.
QAPI was not used effectively to identify resident care concerns such as falls, quality of care, and ineffective pain management. The ADM stated the facility was focusing on falls and call lights using a yellow star program for residents at high risk for falls, while also noting that corrective action plans were in progress and staff education would continue. The facility policy stated the QAPI program should be ongoing and address all systems and practices affecting residents, including clinical care, quality of life, resident choice, and safety.
Resident rooms failed to meet the required square footage per occupant in multiple-occupancy rooms. A Client Accommodations Analysis Form showed several rooms were occupied by two or four residents despite room sizes that did not provide at least 80 sq. ft. per resident. Surveyors observed that the room size did not interfere with care or privacy, and the facility's Homelike Environment policy stated residents should be provided a safe, clean, comfortable, and homelike environment.
The facility did not maintain indoor temperatures between 71 and 81°F, resulting in multiple residents with chronic conditions experiencing cold in their rooms and common areas. Despite complaints to staff, no corrective action was taken, and thermostats lacked a minimum temperature setting. The maintenance supervisor confirmed that heat was only activated manually after complaints, and staff were not trained to adjust thermostats, leading to ongoing discomfort for residents.
Failure to follow up on an oral surgery referral for a resident with Bechet’s disease, depression, and dementia. A dental note recommended referral for SRP and oral surgeon follow-up, but the resident was observed with decayed teeth and stated he wanted to see a dentist. The SSD acknowledged the recommendation should have been done right away, and the ADM stated there was a delay in care.
Failure to Honor Resident Food Preferences: A resident with Bechet’s disease, depression, and dementia had multiple documented food dislikes, but the meal ticket listed no dislikes and the lunch tray included items the resident disliked, including cranberry juice and broccoli. The DS stated the dislikes were entered incorrectly into the computer system, and the DON and ADM acknowledged the resident’s food preferences were not honored.
Two residents who required assistance with personal care were found with call lights out of reach and in soiled incontinence briefs for extended periods. Staff interviews confirmed that call lights should always be accessible and that regular rounding was expected, but delays occurred due to competing duties. Both residents experienced discomfort and feelings of neglect as a result.
A resident with intact cognition and multiple medical conditions underwent two room changes without receiving written notice or providing consent, and the reasons for the moves were not properly documented in the medical record. The resident was not informed of his right to refuse the changes, and facility staff acknowledged that required procedures for notification and documentation were not followed.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a failure to meet the resident's individualized care needs.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
A resident with end stage renal disease and moderate cognitive impairment returned from a cardiology consultation without progress notes or care instructions being documented in the medical record. Facility staff were unaware of the appointment outcome, leading to a delay in scheduling a planned micro laryngoscopy. Required procedures for documenting and maintaining medical records were not followed.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure that a resident with pressure ulcers received appropriate care to promote healing, and failed to implement adequate preventive measures to protect residents at risk for developing new pressure ulcers.
A resident with a history of surgical aftercare, cancer, and GERD, who was at risk for malnutrition, experienced poor food intake and refused to be weighed on several occasions. Staff failed to notify the physician and RD as required, and inaccurately documented the resident's weight despite refusals. This lack of communication delayed the resident's evaluation and care, as confirmed by the RD and DON.
A resident with a history of tongue cancer and swallowing difficulties was not properly monitored for nutritional status, as required weights were not obtained or accurately documented, and declining food and supplement intake was not communicated to the RD or physician. Physician orders for a speech therapy evaluation were not implemented, and requests for a more appropriate diet were not addressed, resulting in a delay in evaluation and care.
The facility did not ensure its QAPI committee monitored whether interventions to address delays in resident care, such as staff in-services on timely call light response, were effective. Multiple grievances from residents about slow responses to call lights were documented, but the QAPI committee did not include this issue as a focus area or evaluate the impact of corrective actions, as confirmed by the ADM and DON.
A resident with dementia and a history of wandering eloped from the facility after being left unsupervised during dinner service. The resident, who wore a wander guard bracelet, was not visually monitored by the CNA, and no alarm was heard when the resident exited. The resident was later found offsite by a member of the public and returned to the facility. Staff interviews confirmed that the wander guard system alone does not prevent elopement and that direct supervision is required.
Two residents with significant medical histories experienced changes in condition, including hypotension and vomiting, but did not have their vital signs reassessed for several hours despite physician recommendations and facility policy. The DON confirmed that vital signs should have been checked every 15-30 minutes after such events.
A resident with COPD was given supplemental oxygen by nursing staff without a current physician's order, despite facility policy and staff acknowledgment that such an order is required. The resident reported using oxygen daily as needed, and staff provided it upon request, with limited documentation of oxygen saturation monitoring.
Nursing staff failed to demonstrate competency in administering oxygen to a resident with COPD, providing supplemental oxygen without a current physician's order and without adequate training on oxygen administration, monitoring, or titration. Facility in-service training did not address these critical areas, and documentation of oxygen saturation was insufficient.
Several residents were housed in rooms with sliding glass doors that could not be locked, and facility entrance doors were left unsecured at night, allowing unrestricted access. Staff and residents expressed concerns about safety, and cockroach infestations were observed in two residents' rooms, causing discomfort and distress. Facility policies required secure and sanitary conditions, but these were not upheld.
Multiple residents with chronic medical conditions were found to be living in rooms with sliding glass doors that could not be locked, and facility entry points were unsecured, allowing unrestricted access. Staff and residents expressed concerns about safety, and cockroach infestations were observed in resident rooms, with no effective follow-up on pest control measures.
Two residents with significant medical and cognitive needs were found with their beds placed against the wall and side rails up, restricting their movement. Staff, including LVNs and the DON, confirmed this setup is considered a physical restraint and requires a physician's order, which was not present. Facility policy states restraints should only be used for medical symptoms after alternatives have failed.
Two residents did not have their care plans updated after falls or to address bed placement against the wall, despite staff and policy indicating these actions were necessary. One resident with cerebral infarction and major depressive disorder required maximal assistance, while another with psychosis and epilepsy was dependent for care. Staff interviews and record reviews confirmed that care plans were not revised as required after incidents or changes in condition.
The facility's QAA and QAPI committee did not effectively monitor or analyze data on an increase in resident falls. The DON reported an uptick in falls and the need for new interventions, but was unable to locate the QAPI binder needed to address the issue after a change in administration. The facility's policy requires ongoing measurement and improvement of care outcomes, which was not followed in this instance.
Multiple live cockroaches were found in the shared room of two residents, both of whom reported feeling uncomfortable and unclean due to the infestation. A CNA confirmed the presence of cockroaches in resident drawers and walls. The Maintenance Director stated that several rooms had been treated for cockroaches but did not follow up to ensure effectiveness, and the DON acknowledged the unsanitary conditions.
Licensed nurses did not notify physicians or document a change of condition when four residents with significant medical histories missed their scheduled morning medications. Staff interviews and record reviews confirmed that required notifications and documentation were not completed, resulting in delayed evaluation and care.
On a day when a licensed nurse called off and another did not show up, the facility did not have enough nursing staff to administer scheduled medications on time. As a result, several residents with complex medical conditions did not receive their morning medications as scheduled, and one resident's cancer medication was repeatedly given late throughout the month. Residents reported distress and concern over the missed or delayed doses, and the DON acknowledged responsibility for staffing coverage.
Several residents did not receive their scheduled medications within one hour of the prescribed time, with some medications being omitted or administered several hours late. Residents with complex medical conditions, including stroke, hypertension, diabetes, and cancer, reported distress and concern over the delays. Staff interviews indicated that staffing shortages contributed to the failure to administer medications as required by facility policy.
Staff failed to perform hand hygiene between resident care and before entering or exiting rooms, with observations showing empty hand sanitizer dispensers in some rooms and none in hallways due to renovations. Both a CNA and an LVN acknowledged not following hand hygiene protocols, citing lack of supplies, while facility leadership confirmed awareness of the issue and the importance of hand hygiene per facility policy.
A resident with cancer and thrombocytopenia did not have required lab tests drawn before a scheduled oncology appointment due to a breakdown in communication and follow-up between the Social Services designee and nursing staff. This resulted in the cancellation of the resident's medical appointment.
The facility did not ensure that the designated IPN had completed the required specialized infection control training, as the IPN's certificate did not show completed hours and the correct certification could not be located. The DON was unaware of the certification issue, and the IPN did not meet the job description's experience and training requirements.
A resident did not receive proper documentation for Meclizine administration, and a care plan was not initiated for a new cough. The resident reported not always receiving medications and having to inform the nurse about the medication type and dosage. The facility's policies on medication administration and nursing documentation were not followed, leading to these deficiencies.
The facility failed to label opened food containers with open and use-by dates, including apple sauce, beef base, and chicken tenders, risking food-borne illnesses. Additionally, pork was improperly defrosted in standing water, contrary to safe defrosting procedures. Staff interviews confirmed these practices violated facility policies.
The facility failed to accommodate the needs of two residents, one with mobility issues due to insufficient room space and another unable to sleep due to a noisy roommate. Despite available beds, no room changes were offered, impacting their health and well-being.
Failure to Follow NP Orders and Respond Timely to Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered and needed treatment and care to a resident who experienced a significant change of condition, including prolonged vomiting and severe pain. The resident had multiple complex diagnoses, including alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia, and cervical spine disorders, and was dependent for all ADLs. According to progress notes, the resident had been vomiting for three days by 11/21 and reported generalized and abdominal pain rated 10/10, refused medications such as gabapentin and lactulose due to fear of vomiting, and was placed NPO except for sips of water. Despite these symptoms, there was no timely initiation of a change of condition (COC) evaluation or care plan to address the vomiting and pain, and nursing assessments (including description of vomitus, abdominal assessment, and vital signs) were either incomplete or undocumented. The facility did not follow the NP’s texted orders for pain management and transfer to the hospital, and did not document those orders in the medical record. On 11/21, the NP instructed via text to use a Tylenol suppository, warm compresses to the abdomen, and repositioning for the resident’s 10/10 abdominal and arm pain with three days of vomiting; these interventions were not documented as implemented. On 11/22 at 1:35 p.m., the NP texted an order to transfer the resident immediately to a GACH for MRI and further evaluation due to ongoing vomiting, 10/10 abdominal and arm pain, concern for dehydration, and possible esophageal varices. This transfer order was not entered into the EHR, not carried out, and not documented in the resident’s record. Instead, staff reported that the DON advised not to transfer the resident and to start IV fluids and STAT labs, and the NP later texted that if the DON was taking over the case, staff should follow the DON’s direction while completing IV hydration and STAT labs and monitoring the resident. The facility also failed to ensure timely completion of STAT laboratory tests and to follow its own policies on change in condition and transfer. The NP ordered STAT CBC, CMP, lipase, and lactate on 11/22 at 7:13 p.m., but IV fluids were not started until 8:00 p.m., and the STAT labs were not drawn until 8:00 a.m. the next day, approximately 13 hours after the orders were received, despite staff acknowledging that STAT labs should be completed within four hours. The COC evaluation for vomiting was not initiated until 11/22, two days after vomiting began, and there was no COC or care plan initiated for the resident’s 10/10 pain on 11/21. The facility’s transfer/discharge and change-in-condition policies required prompt physician notification and transfer when the resident’s needs could not be met in the facility, but the resident was not transferred until the evening of 11/23, after vomiting blood and reporting severe esophageal pain with red-colored vomitus. This sequence of inactions and delays resulted in a 30-hour delay in transfer from the time the NP first ordered immediate transfer on 11/22 at 1:35 p.m. Additional interviews and record reviews further demonstrated the deficiencies in assessment, monitoring, and documentation. CNAs reported observing multiple vomiting episodes and notifying licensed staff, with the resident complaining of nausea and worsening abdominal pain, while the resident continued to refuse medications due to fear of vomiting. LVN 3 acknowledged that there was no documented assessment of the vomitus (color, smell), abdominal status, or vital signs, and that no COC report or care plan was initiated, stating that lack of documentation meant the assessment was not done and that the resident was not closely monitored. RNS 3 confirmed that vomiting began on 11/20, that the COC was delayed until 11/22, that the NP’s transfer order on 11/22 was not entered into the EHR or carried out, and that the delay in following the NP’s orders placed the resident at risk for harm. The DON acknowledged that there was no COC initiated for vomiting until 11/22, no COC for the 10/10 pain on 11/21, and no care plan for vomiting and pain, despite facility policies requiring prompt response to significant changes in condition and transfer when the resident’s needs could not be met in the facility. The facility’s own policies titled “Change in a Resident’s Condition or Status” and “Transfer or Discharge” required prompt notification of the attending physician and resident/representative when there was a significant change in condition, and transfer when necessary for the resident’s welfare and when needs could not be met in the facility. The documented events show that although the NP was notified and issued orders for NPO status, pain interventions, IV fluids, STAT labs, and immediate transfer, these orders were not consistently implemented, documented, or acted upon in a timely manner. The resident ultimately was transferred to the hospital after vomiting blood and reporting severe pain, where she was treated for hematemesis, minimal esophageal varices, gastritis, and ascites requiring therapeutic paracentesis and blood transfusion. The deficiency centers on the facility’s failure to follow provider orders, to timely assess and respond to a clear change in condition, to complete STAT diagnostics promptly, to create and implement a person-centered care plan with measurable interventions, and to adhere to its own transfer and change-in-condition policies. These failures resulted in a 30-hour delay in transferring the resident to the GACH from the time the NP gave the transfer order on 11/22/2025 at 1:35 p.m.
Failure to Implement Adequate Fall Prevention and Door Alarm Safety Measures
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and provide adequate supervision and fall prevention measures for a high‑risk resident, as well as failure to maintain active door alarms. The resident, identified as having a history of falls, impaired balance, unsteady gait, difficulty walking, and end‑stage renal disease, was dependent or required substantial to maximal assistance for most ADLs, including toileting, transfers, and walking. The resident’s assessments and care plans documented high fall risk, fluctuating capacity to understand and make decisions, and a history of repeated falls. Existing fall care plans focused on a clutter‑free environment, call light use, close monitoring, and toileting schedules, but did not include specific device‑based interventions such as bed alarms, landing pads, or other enhanced safety measures. On one evening, the resident experienced an unwitnessed fall at approximately 9 p.m. after being last seen in the room around 6:30 p.m. CNA and LVN interviews and the change‑of‑condition documentation indicated the resident was found on the floor, with no apparent injuries and unable to explain what happened. Despite this fall and the resident’s known high‑risk status, the care plan titled “Unwitnessed Fall” was not updated to add interventions such as a bed alarm, landing pads, keeping the bed in the lowest position, or increased monitoring. Staff interviews, including from the LVN, RN supervisor, and DON, confirmed that no new fall‑prevention interventions were added after the first fall, and that frequent rounding (e.g., hourly checks) and closer supervision were not implemented. CNA and LVN staff also stated that the resident frequently attempted to get up without assistance and required constant help with toileting, yet monitoring was described as every two hours at best, and not hourly following the change in condition. Approximately four hours after the first fall, around 1 a.m., the resident sustained a second fall, again while attempting to go to the bathroom, resulting in a one‑inch laceration to the left forehead, skin tears to the left elbow, forearm, and hands, and generalized bruising and scabs noted on hospital evaluation. The facility’s policy on Accidents and Incidents‑Investigating and Reporting required prompt investigation, collection and evaluation of information to determine the cause of falls, and identification of pertinent interventions to prevent subsequent falls, including trying various interventions until falling reduced or stopped. Interviews with nursing staff and the DON confirmed that these policy expectations were not met for this resident, as underlying causes were not fully addressed and additional interventions were not implemented between the first and second falls. A separate but related deficiency involved the facility’s failure to ensure that the front door and three of four emergency exit doors had active alarms when accessed from inside the building. Observations with the RN supervisor and a CNA showed that the front door could be pushed open without an alarm and that alarms on three exit doors were not activated, including a door used by staff to transport linens. Staff interviews, including with the RN supervisor, CNA, and the Administrator, confirmed that these doors should have been alarmed from the inside as part of the facility’s security plan to address resident elopement risk and interior building security. The facility’s Security Plan policy referenced the use of electronic alarm systems and resident‑specific security needs, including risk for elopement, but the observed lack of active alarms on these doors did not conform to that plan.
Expired Ground Cracker Crumbs Left in Dry Storage
Penalty
Summary
The facility failed to follow its food handling and storage policy by leaving an open container of ground cracker crumbs in the dry storage room after its expiration date. During a concurrent observation and interview in the kitchen dry storage room, the container was seen with an opened date of 10/11/2025 and a use-by date of 11/12/2025, yet it remained available for use in food preparation. Dietary Aid 1 stated that open ground crackers can only be used for one month after the opened date and that the crackers should have been removed and discarded after the expiration date but were not. During an interview, the Dietary Supervisor stated the expired ground cracker crumbs should have been discarded and that he is responsible for checking the storage area daily, Monday through Friday, to ensure no expired items remain and all expired products are discarded. The Dietary Supervisor also stated that if expired ground crackers were used, residents could become ill, experience diarrhea, and in severe cases the situation could be life-threatening. Review of the facility’s Food Life Reference sheet dated 12/2/22 showed that cracker items such as saltine and graham crackers have a usability duration of 60 days, and the Food storage Dry Goods policy dated 2/2023 stated storage areas will be neat, arranged for easy identification, and date marked as appropriate.
Infection control lapses with catheter care, unlabeled equipment, and unclean reusable items
Penalty
Summary
The facility failed to follow infection prevention and control practices for six sampled residents during observations, interviews, and record review. Resident 11 had a Foley catheter bag observed on the floor in the room. During the same observation, a CNA stated the bag should not be on the floor because it could lead to a bladder infection and urine flow obstruction, and the bag was then lifted and secured to the bed rail. The resident’s record showed diagnoses including irritable bowel syndrome, alcoholic cirrhosis of the liver with ascites, secondary esophageal varices without bleeding, quadriplegia, and contractures, and the MDS indicated intact cognition with dependence for multiple ADLs. Resident 2 had a water bag for hydration observed hanging in an infusion pump without a date and time label. The LVN stated the bag should be dated and runs for 24 hours, and that labeling helps other nurses know when to replace it and prevents contamination. Resident 2’s record showed diagnoses including type 2 DM and contractures of both lower extremities, and the MDS indicated severe cognitive skills for daily decision making with dependence for multiple ADLs. Resident 15 was observed receiving oxygen through a nasal cannula positioned in the mouth instead of the nostrils, and the tubing and humidifier were not labeled with the date and time of setup. The LVN stated the tubing and humidifier should be dated and that the cannula should be correctly placed in the nostrils. The resident’s record showed diagnoses including dysphagia and Alzheimer’s disease. The facility also failed to disinfect reusable equipment before use. LVN 1 was observed giving medications to Resident 1 and Resident 82 on medication trays that had not been disinfected first. LVN 1 was also observed taking blood pressures for Resident 45 and Resident 82 with a B/P cuff and stethoscope that had not been disinfected prior to use. LVN 1 stated she did not disinfect the medication tray, B/P cuff, or stethoscope before using them and should have done so to prevent the spread of infection. The DON stated that any time staff use medical equipment on residents it should be disinfected before and after use to prevent spread of infection through cross contamination. The records for Resident 1, Resident 45, and Resident 82 showed diagnoses including HTN, anemia, dementia, heart failure, atrial fibrillation, chronic kidney disease, anxiety, and other conditions, with varying levels of cognitive status and assistance needs documented in the MDS.
Failure to Assess, Document, and Justify Hospital Transfers for ADL Decline
Penalty
Summary
The deficiency involves the facility’s failure to ensure that transfers and discharges to a general acute care hospital (GACH) were medically necessary, properly assessed, and appropriately documented for two residents. For Resident 33, who had hemiplegia and hemiparesis following a cerebral infarction, contractures, end stage renal disease, muscle wasting, and atrophy, the care plan called for monitoring conditions that might contribute to ADL decline and referring to rehabilitation therapy if a decline was noted. Physician progress notes in October documented no decline in responsiveness or new confusion and instructed staff to call 911 for acute medical symptoms. Nursing notes on 12/8/2025 documented that Resident 33 was alert, oriented, able to make needs known, and refused a doctor-ordered transfer to the hospital for “further evaluation related to decrease in participation in ADLs,” with risks and benefits explained. There was no nursing documentation of an actual ADL decline or change of condition prior to the transfer. Therapy records for Resident 33 showed that from late September through 12/10/2025, the resident received PT and OT and made gains. The OT discharge summary documented that the resident met goals for washing the face with assistance and had a Modified Barthel Index current level of functioning score of 19, exceeding the target of 18, and was discharged from OT on 12/10/2025 with documented gains. PT notes on 12/10/2025 showed improved knee extension and active participation in therapeutic exercises, and the PT discharge summary indicated discharge from PT on that date. The MDS dated 12/18/2025 showed the resident could express wants and understand verbal content, was dependent for several ADLs, used a wheelchair, and had received PT and OT in the last seven days. Interviews with the DOR and DON confirmed that Resident 33 had improved, exceeded therapy goals, and did not have a documented decline; both stated there was no medical necessity or reason for the hospital transfer, and the DOR stated that a decrease in ADLs is not a hospital diagnosis. The COC form dated 12/11/2025 was reported as blank, and LVN 5 stated there was no documentation of a change in ADLs or interventions to prevent hospitalization. Despite the lack of documented ADL decline, Resident 33 was transferred to the GACH on 12/11/2025. The GACH face sheet listed chief complaints of end stage renal disease and elevated lipase, and hospital physician notes documented intermittent abdominal pain, intact sensation, and stable neurological status, with radiology showing nonspecific bowel gas. Facility nursing notes on readmission from the GACH indicated the resident was admitted there for abdominal pain, diagnosed with end stage renal disease and elevated lipase, and received dialysis. Resident 33 reported being transferred for three days with the expectation of receiving therapy, repeatedly asking at the hospital why she was there, and not receiving therapy after returning. Facility staff interviews (CNA 8, LVN 5, RNS 3, DOR, and DON) consistently showed that the stated reason for transfer was decreased participation in ADLs, but there was no supporting documentation of a change of condition, no documented attempts to address ADL issues in-house, and no completed COC form documenting symptoms or interventions. For Resident 44, who had dementia, congestive heart failure, generalized muscle weakness, and bipolar disorder, the MDS indicated intact cognition and a need for partial/moderate assistance with bed mobility and lower body dressing. A COC form dated 8/27/2025 documented a decline in ADL status starting that day, with noticeable regression in physical and postural control and physician notification. The transfer form dated 8/29/2025 stated the resident was transferred to the GACH due to decline in ADL status and noted postural imbalance with right-sided leaning, raising concerns for musculoskeletal weakness or neurological involvement. However, OT treatment encounter notes on 8/26/2025 and 8/27/2025 documented that the resident actively participated and was compliant with skilled interventions, and PT encounter notes on 8/26/2025 and 8/28/2025 indicated improvement and no ADL decline. During record review and interviews, LVN 1, the DOR, the DON, and the MDS nurse confirmed that therapy documentation for Resident 44 showed no decline in mobility or ADLs and that the resident had improved before discharge to the GACH. The MDS nurse and LVN 1 stated there were no laboratory tests or diagnostic tests ordered by the physician in response to the COC on 8/27/2025 and before the transfer on 8/29/2025. They also stated there was no documentation that the resident was monitored or that the resident was not doing well due to ADL decline between the COC date and the transfer date, and no documentation that the resident required transfer to the hospital. The DON stated she could not recall why the resident was discharged to the hospital and acknowledged that not monitoring, reassessing, and documenting the necessity of transfer after a COC had the potential to result in an inappropriate discharge. The facility’s undated policy and procedure titled “Transfer or Discharge” required that when a transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility, the physician must document the specific needs that cannot be met, the facility’s attempts to meet those needs, and the receiving facility’s services available to meet those needs. In the cases of Resident 33 and Resident 44, the survey findings showed that the facility did not document medical necessity for transfer, did not complete or fully document COC forms, did not document monitoring or reassessment after reported changes in ADL status, and did not document attempts to meet the residents’ needs before transferring them to the GACH. These omissions led to the deficiency that residents were transferred without evidence that their needs were assessed or that the facility attempted to meet those needs prior to discharge.
Failure to Develop and Implement Person-Centered Care Plan for Resident With Vomiting and Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan with measurable interventions when a resident experienced ongoing vomiting and severe generalized pain. The resident, who had intact cognitive skills for decision-making, was dependent for all major ADLs and had significant medical conditions including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia with contractures, and cervical spine disorders with myelopathy and spinal stenosis. Despite these complex conditions, when the resident began vomiting and reporting generalized pain rated 10/10, the facility did not timely initiate a change of condition process or create a care plan addressing these acute symptoms. Record review showed that the resident’s vomiting began on 11/20/25 and continued for several days, with documentation on 11/21/25 that the resident had been vomiting for three days, had a firm abdomen, and was placed NPO except for sips of water. Another note the same day documented that the resident had been vomiting throughout the day. However, there was no documented assessment of the vomitus (such as color or smell), no detailed abdominal assessment, and no vital signs recorded in connection with at least one of the vomiting episodes. The LVN on the 3 p.m. to 11 p.m. shift stated the resident vomited twice during his shift, that the first episode contained food, and that he did not observe the second episode, which was assessed by the RN supervisor. He acknowledged there was no documentation of a full assessment and stated that without documentation, the assessment was not done, and that the resident was not closely monitored. Further review and interview with the RN supervisor confirmed that although vomiting started on 11/20/25, the change of condition evaluation was not initiated until 11/22/25. The change of condition form indicated the resident was unable to eat or drink adequately and had nausea and vomiting starting on 11/20/25, with decreased appetite and inability to keep food down, and that the primary care physician was notified, but without documented date, time, or recommendations. The RN supervisor stated that the resident’s pain and vomiting were not care planned and acknowledged that a person-centered care plan with measurable interventions should have been created and implemented when the symptoms began. This failure occurred despite a facility policy requiring the interdisciplinary team to develop an individualized comprehensive care plan based on the resident’s assessment, to guide treatment and care tailored to each resident’s needs.
Failure to Assess, Treat, and Document Severe Pain for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management for a resident who repeatedly reported severe pain. The resident had multiple significant diagnoses, including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia with contractures, and cervical disc disorder with myelopathy and spinal stenosis. Physician orders dated 6/9/25 directed staff to monitor the resident’s pain every shift using a 0–10 scale, administer acetaminophen 325 mg (two tablets) every six hours as needed for mild pain, and document non-pharmacologic interventions such as repositioning, relaxation breathing, and massage. An additional order dated 11/14/25 prescribed daily sublingual suboxone for pain management. The resident’s MDS showed intact cognition and total dependence on staff for mobility and ADLs. On 11/21/25 at 2:59 p.m., nursing progress notes documented that the resident complained of severe pain rated 10/10 and had been vomiting for three days. Text messages between the RN supervisor and the NP that day showed the RN reporting sharp, stabbing abdominal and arm pain rated 10/10 and asking for pain management options. The NP responded with orders to use Tylenol suppository if available, warm compresses to the abdomen, and repositioning to reduce discomfort. Despite this, the pain assessment record showed no pain assessment documented on 11/21/25 after the 10/10 pain complaint, and the MAR for 11/21/25–11/22/25 indicated the resident did not receive suboxone as ordered. The RN supervisor later acknowledged there was no documentation of a pain assessment, no pharmacologic or non-pharmacologic interventions provided on 11/21/25, and that the NP’s text orders for non-pharmacologic interventions were not transcribed into the record or care plan. Additional interviews and record reviews confirmed further lapses. A CNA reported the resident complained of severe abdominal pain on 11/22/25 and that a licensed nurse was notified, but there was no corresponding documentation of assessment or interventions. An LVN stated that on 11/21/25 the resident complained of abdominal pain, but he did not assess the pain’s location, level, or characteristics, did not obtain or record vital signs, did not document the complaint, and did not initiate monitoring despite recognizing this as a change of condition. The resident later reported that she experienced severe abdominal pain with vomiting blood starting on 11/20/25, that she was only given low-dose Tylenol which did not relieve her pain, and that staff refused to give her the sublingual pain medication for several days. The facility’s pain management and charting/documentation policies required systematic identification, assessment, treatment, evaluation of pain, development of an individualized IDT care plan, monitoring of effectiveness, documentation of non-pharmacologic interventions, and documentation of all services and changes in condition. These requirements were not followed for this resident, resulting in unaddressed severe pain and lack of an individualized pain management care plan. The facility also failed to develop and implement an individualized care plan addressing the resident’s pain, despite ongoing pain complaints and existing orders for both pharmacologic and non-pharmacologic interventions. The RN supervisor confirmed that no care plan was created to address the resident’s pain and that the NP’s text orders for warm compresses, relaxation breathing, and repositioning were not incorporated into the care plan or progress notes. Pain assessments documented around the incident showed pain levels of 7/10 on 11/19/25 at 11:15 p.m., 0/10 on 11/21/25 at 4:42 a.m., 0/10 on 11/22/25 at 3:47 a.m., 0/10 on 11/23/25 at 4:15 a.m., and 8/10 on 11/23/25 at 7:35 p.m., but there was a clear gap on 11/21/25 after the documented 10/10 pain complaint. The combination of missing assessments, failure to administer ordered pain medication, failure to provide ordered non-pharmacologic measures, lack of documentation of NP orders, and absence of an individualized pain care plan constituted the deficient practice. The deficient practices resulted in the resident experiencing severe sharp, stabbing arm and abdominal pain rated 10/10 for approximately 48 hours, requiring evaluation and treatment at a general acute care hospital. The resident reported feeling very stressed and frustrated and described the pain as the worst she had ever experienced. The RN supervisor acknowledged that failure to address the resident’s pain could affect the resident mentally and physically and potentially elevate blood pressure. The facility’s own policies on pain management and charting/documentation, which required comprehensive assessment, treatment, monitoring, and documentation of pain and changes in condition, were not followed in this case.
Failure to Complete STAT Laboratory Tests Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion of STAT laboratory tests as ordered for one resident. The resident had multiple complex medical conditions, including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices without bleeding, quadriplegia with contractures, and cervical disc disorder with myelopathy and spinal stenosis, and was dependent for most activities of daily living. A physician order dated 11/22/25 at 5:40 p.m. directed STAT laboratory tests, including a CBC, CMP, lipase, and lactate. Text messages reviewed between the NP and the RN Supervisor on the evening of 11/22/25 showed that the NP confirmed the plan to continue IV hydration and complete the STAT labs after being informed that the DON had advised not to transfer the resident to a hospital and instead start IV fluids and STAT labs due to vomiting, pain, and abdominal discomfort. Record review and interview with the RN Supervisor revealed that the STAT labs were not drawn until 8:00 a.m. on 11/23/25, approximately 13 hours after the orders were received, despite the RN Supervisor acknowledging that STAT labs were supposed to be completed within four hours. The lab report confirmed collection at 8:00 a.m., receipt at 10:35 a.m., and reporting at 12:50 p.m. on 11/23/25. The facility’s laboratory services policy stated that when there is a STAT order, staff must immediately call the lab, clearly mark the requisition as STAT, and that the goal is to complete STAT orders within a 4–6 hour timeframe. The delay in obtaining the ordered STAT labs for this resident constituted the cited deficiency.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for two sampled residents. Resident 28 was admitted with diagnoses including repeated falls, vertigo, muscle wasting, and atrophy. His MDS indicated he could express ideas and understand others, but he was dependent on nursing staff for showering, dressing, putting on and taking off shoes, sitting, and lying down, and needed supervision or touching assistance with eating, oral hygiene, bathing, and personal hygiene. His care plan directed staff to encourage him to use the call light for assistance. Resident 61 was admitted with diagnoses including a broken left leg, urinary incontinence, emphysema, and dependence on supplemental oxygen. His MDS indicated he could express ideas and understand others, but he was dependent on nursing staff for dressing and putting on and taking off shoes, needed substantial to maximal assistance with sitting, standing, lying down, and transferring, and needed setup or clean-up assistance with eating, oral hygiene, and personal hygiene. His care plan also directed staff to encourage him to use the call light for assistance. During interviews, Resident 28 stated he had to wait a long time at night for assistance and sometimes called the nurses’ station on his cellphone when his call light was not answered. Resident 61 stated the nurses took a long time to answer his call light. CNA 9 stated CNAs on the night shift do not answer call lights and that the facility had conducted an in-service training about two weeks earlier to ensure call lights were within residents’ reach. CNA 9 stated call lights should be answered promptly for needs such as pain management, water, or incontinent pad changes. The DSD stated the facility continued to receive reports and concerns about call lights not being answered during the evening and night shifts and that in-service training was being conducted to address the issue. LVN 7 stated she had heard complaints about call lights not being answered promptly, that Resident 28 had to call the nurses’ station for assistance because the call light was not answered, and that call lights should be answered within minutes to determine whether a resident was in pain or having breathing difficulties. The facility policy titled Answering the Call Light stated its purpose was to ensure timely responses to residents’ requests and needs.
Failure to Inform Representative About Advance Directive Rights
Penalty
Summary
The facility failed to inform and provide evidence that Resident 24’s representative was informed of the right to formulate an Advance Directive. Resident 24 was admitted and readmitted with diagnoses including dementia, hemiplegia, hemiparesis following a cerebral infarction, and diabetes mellitus. The resident’s H&P dated 1/17/2025 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 11/14/2025 indicated severely impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, dressing, and personal hygiene. During review of the Advance Directive Acknowledgement Form dated 12/23/2025, the MDS Nurse stated the resident refused to sign but did not have the capacity to understand what she was signing due to cognitive impairment, and that the form should have been documented as offered to the responsible party. The Social Worker also stated there was no documentation that the Advance Directive was offered to the responsible party in the Social Services Quarterly Assessment, and confirmed the resident lacked the capacity to sign or understand the form. The facility policy stated residents are to be given the opportunity to make decisions regarding their health care and that the choice not to complete the Advance Directive form is to be recorded in the medical record.
Failure to Provide Written Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to Resident 13 or the resident’s representative at the time of transfer to a General Acute Care Hospital. Resident 13 had been admitted to the facility, was later readmitted with diagnoses including intrahepatic bile duct carcinoma and mechanical complication of a bile duct prosthesis, and had moderately impaired cognitive skills with partial/moderate assistance needed for bed mobility, transfers, and dressing per the MDS dated 11/14/2025. During review of the transfer record, Resident 13 was transferred to the hospital on 11/6/2025 because of a malfunctioning biliary drain. In interviews, the RN Supervisor stated a bed hold notice is provided to the resident and ordered by a physician when a resident is transferred to the hospital, and the DON stated there was no written bed hold notice provided before transfer or discharge. The DON also stated licensed nurses can obtain a verbal physician order for a 7-day bed hold and then give the written notice to the resident or representative. The facility policy titled Bed-Holds and Returns stated residents or representatives are to be provided written information regarding state bed-hold policies at the time of transfer or within 24 hours if the transfer is an emergency.
PASARR Level II evaluation not completed for resident with bipolar disorder
Penalty
Summary
The facility failed to ensure that one sampled resident with a diagnosis of bipolar disorder had a Level II PASARR evaluation completed. Resident 7’s admission record showed the resident was admitted with diagnoses including bipolar disorder and paraplegia. The physician progress notes dated 11/25/2025 indicated the resident had the capacity to make medical decisions, and the MDS dated 11/27/2025 indicated the resident could express ideas and wants, understand others, and needed varying levels of assistance with transfers, toileting, showering, dressing, and shoes. The MDS also listed bipolar disorder as a diagnosis. During the concurrent interview and record review on 1/8/2026, the MDS Nurse reviewed Resident 7’s Notice of PASARR Level I Screening Results dated 11/21/2025, which indicated a Level II mental health evaluation was not required for serious mental illness. The MDS Nurse stated she reviewed the PASARR and medical records for inaccuracies and reviewed the resident’s medication list and diagnoses, but missed the diagnosis of bipolar disorder. The MDS Nurse stated that appropriate services for mental illness and recommendations from the PASARR could be missed. The DON stated that if the pre-screening was not documented accurately, the resident may not receive appropriate care for behaviors and necessary services. The facility policy stated that all admissions must have the appropriate PASARR completed.
Failure to Update Care Plan for Resolved Coccyx Pressure Injury
Penalty
Summary
The facility failed to revise, review, and update the care plan for one sampled resident with a pressure injury risk, specifically Resident 13, addressing the resident’s coccyx pressure injury. Resident 13 was initially admitted to the facility and later readmitted with diagnoses including intrahepatic bile duct carcinoma and mechanical complication of the bile duct prosthesis. The resident’s MDS dated 11/14/2025 indicated moderately impaired cognitive skills, partial/moderate assistance with bed mobility, transfers, and dressing, substantial/maximal assistance with toilet hygiene and bathing, and risk for developing pressure injuries. During interview and record review, the Treatment Nurse stated the care plan was not created or changed when the physician order for the coccyx pressure injury treatment was changed to skin maintenance after the pressure injury resolved. The Infection Preventionist Nurse stated the pressure injury care plan was resolved on 12/30/2025 and no care plan was created for skin maintenance of the coccyx. The DON stated the care plan should have been developed to address skin maintenance for the coccyx so all staff caring for the resident would know the plan. The facility policy stated assessments are ongoing and care plans are reviewed and revised as the resident’s condition changes.
Food Not Palatable or Appetizing
Penalty
Summary
The facility failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature for two sampled residents. Resident 33 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, contractures of both legs, ESRD, muscle wasting, and atrophy. The record showed the resident was self-responsible and able to express wants and ideas, but required nursing assistance for several activities of daily living. During interview, Resident 33 stated the food had no flavor. Resident 79 had diagnoses including hemiplegia and hemiparesis following cerebral infarction and DM. The record showed the resident had capacity to understand and make decisions and needed varying levels of assistance with ADLs, including supervision or touching assistance with eating. During interview, Resident 79 stated the meat was always dry and the food almost made her vomit. During observation of a test tray with the Dietary Supervisor, the cauliflower was overcooked and mushy, the biscuit was hard, and the meal had a strong, overpowering onion odor. The Dietary Supervisor stated complaints had been received about food being served too cold and acknowledged that unappetizing food could result in weight loss and inadequate meal intake.
Failure to Document Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that Resident 77 was assessed for meal preferences, including likes and dislikes. Resident 77 was admitted and later readmitted with diagnoses including severe protein malnutrition, hemiplegia, dysphagia, cerebral infarction, and diabetes mellitus. The H&P noted fluctuating capacity to understand and make decisions, and the MDS showed the resident was dependent on nursing staff for toileting, showering, lower body dressing, sitting, standing, and transferring. The physician order summary indicated a fortified pureed diet with thin consistency and a large portion diet. During interview, Resident 77 stated he had just started a pureed diet and wanted a pureed grilled cheese sandwich, and said he had asked dietary staff about it. In a concurrent interview and record review, the Dietary Supervisor reviewed the resident’s Dietary Profile and found no documentation of likes, dislikes, or additional comments regarding food preferences. The Dietary Supervisor stated he was aware of the request for a pureed grilled cheese sandwich, but the preference was not documented and should have been recorded in the resident’s chart. He also stated the resident’s diet had been changed to pureed and that the resident could have a pureed grilled cheese sandwich.
Failure to Complete Ordered SLP Evaluation for Resident With Dysphagia
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 42, received a speech language pathology evaluation after a physician ordered it on 12/10/2025 because the resident was coughing during meals. During observation on 1/5/2026, Resident 42 was seen lying in bed with the head of the bed elevated to 30 degrees and drinking water; after a few sips, the resident coughed and took several seconds to clear the airway. Record review showed the resident had been admitted and readmitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and dysphagia following cerebral infarction. The resident’s MDS dated 10/2/2025 indicated intact cognition and set-up or clean-up assistance with eating. The care plan initiated on 12/10/2025 identified risks for altered nutritional and hydration status and aspiration related to dysphagia and CVA, with interventions including supervising and assisting with meals as needed. The physician order dated 12/10/2025 at 10:13 p.m. directed an SLP evaluation due to coughing during meals, but interviews with the RN Supervisor, Speech Therapist, Director of Rehabilitation, and DON confirmed the evaluation was not completed because licensed nurses did not communicate the order to the rehab department.
QAPI Program Not Effectively Addressing Resident Care Concerns
Penalty
Summary
The facility failed to ensure its Quality Assessment/Quality Assurance and Performance Improvement (QA/QAPI) program was used effectively to identify resident care concerns, including falls, quality of care, and ineffective pain management. During interview, the Administrator stated the facility's QA/QAPI was currently focusing on falls and call lights through a yellow star program that identified residents at high risk for falls and involved investigating why residents were falling. The Administrator also stated that corrective action plans were in progress and that the facility would emphasize resident care concerns such as falls, quality of care, and pain management, while continuing staff education, especially for newly hired staff. Review of the facility's QAPI policy showed the program was intended to be ongoing and address all systems and practices affecting residents, including clinical care, quality of life, resident choice, and safety.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that four resident rooms measured at least 80 square feet per resident in multiple-occupancy rooms. A Client Accommodations Analysis Form dated 11/14/2025 showed that room [ROOM NUMBER] measured 142 sq. ft. and was occupied by two residents, room [ROOM NUMBER] measured 154 sq. ft. and was occupied by two residents, and room [ROOM NUMBER] and room [ROOM NUMBER] measured 295 sq. ft. and were occupied by four residents. During the recertification survey observation from 1/5/2026 to 1/8/2026, surveyors noted that the square footage of the resident rooms did not interfere with the care and services provided by staff, and there were no negative observations related to the adequacy of space for nursing care or residents' privacy. The facility's policy titled Homelike Environment, revised 2/2021, stated that all residents are provided with a safe, clean, comfortable, and homelike environment emphasizing comfort, independence, personal needs, and preferences.
Failure to Maintain Required Indoor Temperatures for Residents
Penalty
Summary
The facility failed to maintain indoor temperatures within the required range of 71 to 81 degrees Fahrenheit for all sampled residents, as evidenced by observations and interviews. On the day of the survey, temperatures in resident rooms, hallways, and the activity room were recorded between 66 and 69 degrees Fahrenheit. Multiple residents reported feeling cold during both day and night, and several stated that they had notified staff about the low temperatures, but no corrective action was taken. In some cases, residents attempted to mitigate the cold themselves, such as by covering vents with blankets. Residents affected by the deficiency included individuals with chronic medical conditions such as COPD, rheumatoid arthritis, heart failure, hemiplegia, and atrial fibrillation. These residents required varying levels of assistance with activities of daily living and were cognitively able to communicate their discomfort. Despite their complaints, staff did not resolve the temperature issues, and the cold persisted in their rooms and common areas. Facility staff interviews revealed that thermostats were programmed only with a maximum cooling set point and lacked a minimum heating set point. The maintenance supervisor confirmed that heat was turned on manually only when complaints were received, and staff were not trained to adjust thermostats independently. The facility's policy required temperatures to be maintained within the specified range, but this was not consistently implemented, resulting in prolonged periods of cold for residents.
Failure to Follow Up on Dental Specialist Recommendation
Penalty
Summary
The facility failed to ensure that one sampled resident was seen by an oral surgeon after a dental progress note dated 7/1/2025 recommended follow-up with an oral surgeon for referral for scaling and root planing. Resident 1’s admission record listed diagnoses including Bechet’s disease, depression, and dementia, and the H&P dated 1/17/2025 indicated the resident was alert and oriented. The MDS dated 10/17/2025 indicated the resident’s cognition was intact and that substantial to maximal assistance was needed with ADLs. During a concurrent observation and interview on 11/20/2025, Resident 1’s teeth showed signs of decay and the resident stated he would like to see a dentist. The Social Services Director stated she was made aware by the resident’s sister that the resident needed to see an oral surgeon and acknowledged the recommendation from 7/1/2025, stating it should have been done right away. The Administrator stated staff were expected to follow up on dental recommendations within 72 hours after receiving them and stated there was a delay in care for Resident 1. The facility policy on appointments stated it would assist residents in contacting specialty providers and in scheduling appointments and transportation.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that Resident 1’s food preferences were honored. Resident 1 was admitted with diagnoses including Bechet’s disease, depression, and dementia, and the record showed the resident was alert and oriented with intact cognition. The dietary assessment listed multiple food dislikes, including cranberry juice, alfredo sauce, broccoli, bell peppers, eggs, fish, tuna, greens, macaroni and cheese, mashed potatoes, hot cereal, peas, salad dressing, and spinach. On review of the meal ticket, Resident 1 was documented as having no food dislikes. During lunch observation, Resident 1’s tray contained cranberry juice, chicken stroganoff, and broccoli. The Dietary Supervisor stated the resident’s dislikes had been entered incorrectly into the computer system and that the resident should not have received those foods because they were disliked items. The DON and Administrator both stated that the resident’s food preferences were not honored, and the facility policy required meals to be consistent with resident preferences as reflected on the tray card.
Failure to Ensure Call Light Accessibility and Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, both of whom required assistance with activities of daily living. One resident, who was dependent for toileting hygiene and bathing due to diagnoses including dysphagia and heart failure, was observed lying in bed with the call light placed behind the bed, out of reach. The resident's incontinence brief was found to be wet and soiled, and staff acknowledged that it had been that way since the previous shift. The certified nurse assistant (CNA) responsible stated she had intended to change the resident after breakfast but was delayed due to attending to other residents. Another resident, who required supervision or touching assistance for personal care due to diagnoses including type 2 diabetes mellitus and atrial fibrillation, was also found lying in bed with the call light out of reach. This resident's incontinence brief was similarly observed to be wet and soiled. The CNA assigned to this resident stated that she had not yet rounded on the resident because she was distributing breakfast trays and assisting with feeding. The resident reported feeling neglected and uncomfortable due to prolonged periods without staff checking on her or changing her brief. Interviews with staff, including a licensed vocational nurse (LVN) and the director of nursing (DON), confirmed that call lights are expected to be within reach at all times to allow residents to request assistance promptly. Facility policy also requires call lights to be accessible from the bed and other locations. Staff acknowledged that failure to provide timely incontinence care and to ensure call light accessibility could result in residents remaining unattended and in soiled conditions for extended periods, compromising their dignity and delaying care.
Failure to Obtain Consent and Document Room Changes
Penalty
Summary
The facility failed to obtain written consent and provide proper documentation in the medical record prior to making room changes for a resident with intact cognition and multiple medical diagnoses, including type 2 diabetes mellitus, GERD, and muscle weakness. The resident experienced two room changes within the same month, and in both instances, there was no evidence in the clinical record that written notice was given or that the resident consented to the moves. The Room Change Forms indicated the moves occurred, but either lacked a documented reason or did not serve as a substitute for written consent or proper notification. Interviews with the resident revealed that he was not informed of the reasons for the room changes, was not asked for his consent, and was unaware that he could refuse the changes. The social worker acknowledged that it was her responsibility to obtain consent and document the process but admitted to forgetting to do so. The DON confirmed that the facility's process requires informing the resident or responsible party, obtaining consent, and providing notification prior to any room change, none of which were documented for this resident. The facility's policy also requires timely advance notice and documentation of room changes, which was not followed in these cases.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's care or condition.
Failure to Maintain and Document Medical Records Following Outside Consultation
Penalty
Summary
The facility failed to ensure that a resident who attended an outside cardiology consultation returned with progress notes and care instructions that were available in the resident's medical record. The resident, who had end stage renal disease and moderate cognitive impairment, was scheduled for a micro laryngoscopy for vocal cord lesion removal. Physician's orders indicated the need for a cardiology clearance prior to surgery, and the resident had an appointment with a cardiologist. However, upon review, there was no documentation in the medical record of the consultation note or care instructions following the cardiology appointment. Interviews with facility staff revealed that the Social Services Director was initially unaware if the resident attended the appointment and only later obtained the cardiology notes after contacting the cardiologist's office. The Director of Nursing, upon not finding the cardiology note in the medical record, assumed the appointment had not occurred and scheduled another cardiology appointment, resulting in a delay in the planned surgery. Facility policy required that orders and follow-up appointments be documented in the electronic record and that medical records be maintained appropriately, but these procedures were not followed in this instance.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents with existing pressure ulcers did not consistently receive the necessary interventions to promote healing. Additionally, preventive strategies to protect residents at risk for developing pressure ulcers were not adequately carried out, as required by care standards.
Failure to Notify Physician and Dietician of Resident's Poor Intake and Refusal to be Weighed
Penalty
Summary
The facility failed to notify a resident's physician and registered dietician (RD) when the resident exhibited poor food intake and refused to be weighed, as required by facility policy and the resident's care plan. The resident, who had a history of surgical aftercare, malignant neoplasm of the tongue, and gastro-esophageal disease, was identified as being at risk for malnutrition. Documentation showed that the resident was not meeting nutritional needs, consuming only about 53% of meals, and had a poor appetite. The care plan specifically instructed staff to monitor intake, weigh the resident as ordered, and alert the physician and RD to any decline in intake. Despite these instructions, the resident refused to be weighed on multiple occasions, but staff documented the same weight as previous entries, which did not accurately reflect the resident's status. Additionally, the resident's poor meal consumption was not communicated to the RD or physician. The RD confirmed that she was not notified of the resident's refusal to be weighed or the ongoing poor intake, and stated that this lack of communication delayed her ability to reassess and revise the nutritional care plan. The DON also acknowledged that the nursing staff should have notified the RD and physician of these changes, and that the failure to do so resulted in a delay in evaluation and care for the resident. Facility policy required immediate notification of the resident, physician, and representative in the event of significant changes in the resident's condition, including nutritional status. The failure to follow these policies and care plan interventions led to a delay in the resident's evaluation and care, with the potential for the resident to become malnourished and lose weight, as directly stated in the report.
Failure to Monitor and Address Resident's Nutritional Status and Dietary Needs
Penalty
Summary
A deficiency occurred when the facility failed to accurately and consistently assess and monitor the nutritional status of a resident who was at risk for malnutrition. The resident, who had a history of tongue cancer, surgical aftercare, and gastro-esophageal disease, was admitted with difficulty swallowing and a poor appetite. Despite physician orders for regular weight monitoring and a speech therapy (ST) evaluation, the facility did not ensure these orders were carried out. The resident's weights were not properly obtained or documented, with staff entering a weight value even when the resident refused to be weighed, resulting in inaccurate records. Additionally, the resident's declining food and supplement intake was not communicated to the Registered Dietician (RD) or physician as required. The resident's care plan identified her as being at nutritional risk and included interventions such as monitoring intake, offering alternate food choices, and alerting the RD and physician to any decline in intake. However, these interventions were not effectively implemented. The resident and her responsible party repeatedly requested a different diet due to her difficulty chewing and swallowing, but these requests were not addressed, and the resident was not evaluated for an appropriate diet. The RD was not notified of the resident's poor intake or refusal to be weighed, and the ST evaluation was never completed. There was also no evidence of an interdisciplinary team (IDT) meeting to address the resident's nutritional risk, despite facility policy requiring such collaboration. Interviews with facility staff, including the RD, DON, and Director of Rehabilitation, confirmed that there was a lack of communication and follow-through regarding the resident's nutritional needs. The resident reported feeling weak and unhealthy due to inadequate nutrition and an inappropriate diet. Facility policies required weekly weights after admission, comprehensive care planning, and IDT involvement when care was refused or requested, but these were not followed. The failure to monitor, document, and communicate the resident's nutritional status and to implement physician orders led to a delay in evaluation and care, placing the resident at risk for malnutrition and weight loss.
Failure to Monitor Effectiveness of Interventions for Timely Resident Care
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee monitored interventions related to delays in resident care, specifically regarding timely response to call lights. Multiple grievance reports documented concerns from residents about delays in receiving assistance after activating call lights. These grievances were noted on several occasions, with residents expressing dissatisfaction with the timeliness of care and customer service. Despite these documented concerns, the facility's QAPI committee did not include call light response or customer service as areas of focus in their most recent program reviews. While the Director of Nursing (DON) provided in-service education to staff on the importance of timely call light response, there was no system in place to evaluate whether these interventions were effective in improving response times or overall resident care. Interviews with the Administrator and DON confirmed the absence of a monitoring or evaluation process for these corrective actions. The facility's policy and procedure for the QAPI program outlined responsibilities such as collecting and analyzing performance data, identifying and monitoring facility systems, and evaluating performance improvement projects. However, the actual practice did not align with these responsibilities, as the QAPI committee did not track or assess the effectiveness of interventions implemented to address the identified delays in resident care.
Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a documented history of elopement and wandering behaviors was able to leave the facility unsupervised and without staff knowledge. The resident, who had diagnoses including Parkinson's disease, dementia, and muscle weakness, was assessed as being at risk for elopement. The care plan for this resident included interventions such as engaging in purposeful activity, identifying triggers and patterns for wandering, and ensuring close monitoring in common areas or during activities. Additionally, a wander guard bracelet was ordered and was to be checked for placement every shift. On the day of the incident, the resident was served dinner in the hallway and was left unsupervised while the CNA distributed dinner trays to other residents. The CNA did not maintain visual confirmation of the resident's location and did not inform other staff that she would be unable to monitor the resident directly. At some point, the resident left the facility through an unknown door, and the wander guard alarm did not alert staff to the resident's exit. The absence of an alarm and lack of direct supervision allowed the resident to leave the premises undetected. The resident was found offsite by a member of the public, who contacted emergency services and the facility. The resident was subsequently returned to the facility. Interviews with staff, including the DON and ADM, confirmed that the wander guard system is a monitoring tool and does not prevent elopement, emphasizing that staff supervision and monitoring are essential. The facility's own policies and product documentation also indicated that close personal surveillance is necessary in addition to monitoring equipment.
Failure to Monitor Residents After Change in Condition
Penalty
Summary
The facility failed to monitor and reassess two residents after a change in their medical condition. For one resident with a history of left femur fracture and hypertension, the resident experienced vomiting, sweating, hypotension, and tachycardia. The physician was notified and recommended continued monitoring, and 911 was called, but the resident initially refused transfer. The resident had another episode of vomiting several hours later and was then transferred to a hospital. During the six-hour period between the initial episode and the transfer, there was no reassessment of vital signs documented. For another resident with diagnoses of congestive heart failure and end stage renal disease on dialysis, the resident was found to have low blood pressure. The physician was notified and recommended blood pressure checks every thirty minutes for three times. However, there was no documentation of vital sign reassessment for approximately six hours until 911 was called and the resident was transferred. The Director of Nursing confirmed that vital signs should have been reassessed every 15-30 minutes after a change in condition, even without a physician order.
Oxygen Administered Without Physician Order
Penalty
Summary
A resident with a diagnosis of chronic obstructive pulmonary disease (COPD) was administered supplemental oxygen without a current physician's order. The resident's admission and assessment records indicated a need for supervision and assistance with daily activities, but there was no active order for oxygen administration after the previous order was discontinued. Despite this, the resident reported using 2 liters per minute of oxygen daily as needed, and nursing staff provided oxygen upon the resident's request. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that a physician's order is required for oxygen administration, specifying the amount and monitoring parameters. The facility's policy also mandates verification of a physician's order before administering oxygen. However, documentation and staff statements revealed that oxygen was given to the resident without such an order, and oxygen saturation was only documented twice after the order was discontinued.
Failure to Ensure Nursing Staff Competency in Oxygen Administration
Penalty
Summary
Licensed nursing staff failed to demonstrate competency in administering oxygen to a resident with chronic obstructive pulmonary disease (COPD). The resident was admitted and readmitted with a diagnosis of COPD and required supplemental oxygen. However, after the physician's order for oxygen was discontinued, nursing staff continued to provide oxygen to the resident upon request, without a current physician's order specifying the amount or monitoring requirements. Documentation showed that oxygen saturations were only recorded twice after the order was discontinued. The nurse involved could not recall receiving training on oxygen administration, oxygen orders, or monitoring. Interviews with facility leadership revealed that the in-service training provided to nursing staff did not cover essential topics such as validating physician orders for oxygen, monitoring requirements, or titration of oxygen. The Director of Nursing acknowledged that staff should be trained and in-serviced on these aspects to ensure proper use of oxygen. The facility's policy on in-service training stated that staff should demonstrate competency in training topics, but this was not reflected in the training provided regarding oxygen administration.
Failure to Maintain Secure, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. Three residents were housed in rooms with sliding glass doors that were broken, off track, and unable to be locked from the inside, allowing open access from outside the facility. The gates and fences surrounding the facility were also broken or missing locks, and the front and back entrance doors were found unlocked or ajar during nighttime hours, with no staff present or alarm systems in place. Staff and residents expressed concerns about safety, with several stating that anyone could enter the facility or their rooms without restriction. Additionally, the rooms of two residents were found to be infested with cockroaches. During an inspection, cockroaches were observed running from behind furniture and inside air fresheners. Both residents reported feeling dirty and uncomfortable due to the infestation, and staff confirmed the presence of cockroaches in resident rooms and drawers. The Maintenance Director acknowledged that pest control treatment had been performed in several rooms previously but admitted there was no follow-up to determine its effectiveness. The facility's own policies and job descriptions require maintaining a safe, secure, and sanitary environment, including ongoing pest control and ensuring that all doors and grounds are secure. Despite these requirements, the facility did not maintain functional locks on resident room doors, failed to secure the facility entrances, and did not effectively address pest infestations, directly impacting the residents' dignity, mood, and right to a homelike and safe environment.
Failure to Ensure Safe, Secure, and Clean Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. Resident rooms with sliding glass doors facing the outside were found to be open, unable to close, or unable to lock, leaving the rooms unsecured. The gates and fences surrounding the facility were broken or missing locks, and the front and back doors to the facility were observed to be unlocked or ajar, with no staff present or alarm system in place. Staff and residents expressed concerns about safety due to these unsecured entry points, and the Maintenance Director confirmed awareness of the broken doors and lack of locks. Residents affected by these deficiencies included individuals with intact cognition and various medical conditions such as diabetes mellitus, peripheral vascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, osteoarthritis, anxiety, and congestive heart failure. These residents required varying levels of assistance with activities of daily living. Both residents and their caregivers voiced concerns about the inability to secure their rooms, with personal belongings left vulnerable and a general sense of insecurity due to the facility's lack of physical security measures. Additionally, the facility failed to maintain a clean and pest-free environment in resident rooms. Multiple cockroaches were observed in the rooms of two residents, including inside personal items such as air fresheners and nightstand tables. Staff confirmed the presence of cockroaches and noted that previous pest control treatments had not been followed up to ensure effectiveness. Facility policies required ongoing pest control and maintenance of a clean, sanitary environment, but these were not upheld, as evidenced by the continued presence of pests and lack of follow-up.
Use of Bed Placement as Physical Restraint Without Proper Authorization
Penalty
Summary
Two residents were found to have their beds positioned against the wall, with the opposite side rails raised, effectively restricting their freedom of movement. Both residents had significant medical histories, including cerebral infarction, major depressive disorder, psychosis, and epilepsy. Assessments indicated that one resident had moderately intact cognition and required maximal assistance with transfers, while the other had intact cognition but was dependent on staff for dressing, toileting, and bathing. Observations confirmed that the beds were placed against the wall, and this setup was verified by staff during interviews. Staff, including two LVNs and the Director of Nursing, acknowledged that placing a bed against the wall is considered a form of physical restraint, which restricts resident movement and could potentially cause injury. Facility policy requires that restraints only be used for medical symptoms and after other alternatives have been tried unsuccessfully, with a physician's order. In these cases, there was no indication that such orders or alternative measures were in place, leading to the deficiency.
Failure to Revise and Individualize Care Plans After Falls and Bed Placement
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives, timeframes, and interventions for two residents. Specifically, the care plan for one resident was not reviewed or revised after each incident of falling, despite the resident experiencing multiple falls. Additionally, care plans for both residents did not address the placement of their beds against the wall, which staff identified as a necessary communication tool and a form of restraint that should be care-planned. Interviews with nursing staff and the Director of Nursing confirmed that care plans should be updated after falls and when beds are positioned against the wall, but this was not done. Resident records indicated that one resident had a history of cerebral infarction and major depressive disorder, requiring maximal assistance with transfers, while the other had diagnoses of psychosis and epilepsy and was dependent on staff for dressing, toileting, and bathing. Facility policy required ongoing assessment and revision of care plans when residents' conditions changed, and specifically called for care plans to address the use of restraints. The failure to update and individualize care plans as required was confirmed through record review and staff interviews.
Failure to Monitor and Address Increase in Resident Falls
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to monitor, review, and analyze data related to performance improvement issues, specifically regarding an increase in resident falls. During an interview, the DON acknowledged that there had been an increase in falls and that new interventions for fall prevention were needed, but also stated that the QAPI binder, which would address the increase in falls, could not be located following a change in administration. A review of the facility's QAPI policy indicated that the program is intended to measure care outcomes and implement performance improvement projects, but these processes were not effectively carried out in relation to the issue of falls. This lack of monitoring and analysis by the QAA and QAPI committee resulted in a failure to identify and address systemic issues related to resident falls, as required by facility policy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain a consistent and effective pest control program, as evidenced by the presence of multiple live cockroaches in the shared room of two residents. During an observation, one resident moved his nightstand and air freshener, revealing multiple cockroaches both running and inside the air freshener. Both residents expressed discomfort and dissatisfaction with the ongoing cockroach issue, stating it made them feel dirty and creepy. A CNA confirmed seeing cockroaches in resident drawers and coming out of the walls, validating the residents' complaints. The Maintenance Director acknowledged that 23 rooms had been treated for cockroaches previously but admitted there was no follow-up to determine if the treatment was effective. The Director of Nursing also recognized that the presence of cockroaches was unsanitary and could make residents feel gross. The facility's pest control policy requires an ongoing program to keep the building free of insects and rodents, and the maintenance director's job description includes ensuring the facility is maintained to protect the health and safety of residents. Despite these policies, the observed infestation and lack of follow-up contributed to the deficiency.
Failure to Notify Physician and Document Change of Condition After Missed Medications
Penalty
Summary
The facility failed to notify physicians when four residents did not receive their scheduled 9:00 a.m. medications on a specific date. Licensed nurses did not document a change of condition (COC) or inform the residents' physicians about the missed doses, as required by facility policy. This lack of notification and documentation was confirmed through interviews with nursing staff, who acknowledged that such actions should have been taken to ensure proper monitoring and care. The residents involved had significant medical histories, including conditions such as cerebral infarction, atrial fibrillation, hypertension, pancytopenia, malignant neoplasm, thrombocytopenia, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, myocardial infarction, and chronic obstructive pulmonary disease. Each resident's medication administration record indicated that the scheduled morning medications were not administered, and there was no evidence of physician notification or COC documentation in the records. Interviews with staff, including LVNs, the facility pharmacist, and the Director of Nursing, confirmed that the standard procedure when medications are missed is to notify the physician and document the event as a COC. The facility's job descriptions and policies also require reporting of medication errors and changes in condition to the appropriate parties. However, these procedures were not followed in this instance, resulting in a delay of evaluation, care, treatment, and monitoring for the affected residents.
Failure to Provide Sufficient Nursing Staff Resulting in Missed and Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on a specific day when one licensed nurse called off and another was a no call no show, resulting in the inability to administer scheduled medications to multiple residents at the designated times. This staffing shortage directly led to four residents not receiving their scheduled 9:00 a.m. medications, as documented in their Medication Administration Records (MARs). Additionally, one resident's medication for breast cancer was administered late on multiple occasions throughout the month, as shown in the Administration Details Report. Resident records reviewed indicated that the affected individuals had significant medical histories, including conditions such as stroke, atrial fibrillation, hypertension, pancytopenia, malignant neoplasm, thrombocytopenia, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, myocardial infarction, and chronic obstructive pulmonary disease. These residents required moderate assistance with activities of daily living and had intact cognition. Interviews with the residents confirmed that medications were not administered on time, with some reporting delays of several hours and expressing concern and distress over the missed or late doses. The Director of Nursing (DON) acknowledged responsibility for managing the licensed nurse schedules and stated that she should have covered the shift when the staffing shortage occurred. Facility policy and the DON's job description both require ensuring sufficient and competent staffing to meet resident needs, but these requirements were not met on the day in question, resulting in the observed deficiency.
Failure to Administer Medications Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications for four out of five sampled residents were administered within one hour of their scheduled administration times, as required by the facility's policy and procedures. Specifically, multiple residents did not receive their prescribed morning medications on time, with some medications being omitted entirely on certain days. Medication Administration Records (MARs) and Administration Details Reports showed that scheduled medications, including critical drugs for conditions such as atrial fibrillation, hypertension, diabetes, and cancer, were either not given or administered several hours late. Residents affected by these delays had significant medical histories, including diagnoses such as stroke, atrial fibrillation, hypertension, diabetes mellitus, peripheral vascular disease, cancer, and chronic obstructive pulmonary disease. Interviews with residents confirmed that medications were often given late, sometimes not until several hours after the scheduled time, and in some cases, not at all. Residents expressed concern, frustration, and distress over the missed or delayed medications, emphasizing the importance of timely administration for their health conditions. Staff interviews revealed that the delays and omissions were partly due to staffing shortages, with the Director of Nursing acknowledging responsibility for ensuring coverage when licensed staff were absent. Licensed nurses and the facility pharmacist confirmed the risks associated with missed or delayed administration of medications, particularly those for blood pressure, blood thinning, and seizure control. The facility's policy clearly stated that medications must be administered within one hour of the prescribed time, and the Director of Nursing's job description included monitoring medication passes to ensure compliance.
Failure to Maintain Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain proper infection control practices when a CNA and an LVN did not perform hand hygiene between resident care and before entering or exiting resident rooms. Observations revealed that two out of four resident rooms lacked hand sanitizing gel in the dispensers, and there were no hand sanitizing gel dispensers in the hallways due to ongoing renovations. Both the CNA and LVN admitted to not performing hand hygiene, citing empty dispensers as the reason, but acknowledged the importance of hand hygiene in preventing the spread of infection. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that staff were educated on the importance of hand hygiene and the facility's policy required hand hygiene before and after resident care, as well as before entering and after exiting resident rooms. The Infection Prevention Nurse was aware of the lack of hand sanitizing gel in some rooms due to a back order and stated that staff were instructed to wash their hands at the nurses' station. The facility's policy emphasized that hand hygiene products and supplies should be readily accessible to encourage compliance.
Failure to Obtain Ordered Laboratory Tests Resulting in Missed Medical Appointment
Penalty
Summary
The facility failed to obtain laboratory tests as ordered by a medical doctor prior to a resident's scheduled appointment. A resident with a history of malignant neoplasm of the right breast, bone involvement, and thrombocytopenia was admitted to the facility and required laboratory tests before an upcoming oncologist appointment. The resident's Minimum Data Set indicated intact cognition and a need for moderate assistance with toileting and dressing. The Social Services designee reported that she was responsible for notifying the RN to arrange laboratory draws for residents. She informed the RN that the resident required laboratory tests for the upcoming appointment, but the RN left early that day, and the SSD did not follow up to ensure the tests were completed. As a result, the laboratory tests were not drawn, leading to the cancellation of the resident's oncologist appointment.
Infection Preventionist Lacked Required Training and Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Prevention Nurse (IPN) had completed the required specialized training in Infection Control and Prevention. Record review showed that the IPN's certification, dated 12/30/2024, was from CDC Train but did not indicate the hours completed. During interviews, the IPN stated she began working at the facility as a new graduate licensed nurse in November 2024 and had been serving as the IPN since February 2025. She was unable to locate the correct Infection Preventionist certificate and believed the CDC Train certificate was sufficient. The Director of Nursing (DON) was unaware that the IPN had the incorrect certification and acknowledged the importance of having a full-time IP nurse with the correct credentials. The facility's job description for the Infection Preventionist required at least two years of clinical experience and appropriate training, which was not met in this case.
Failure to Document Medication and Initiate Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care as per physician orders and the resident's preferences and goals. Specifically, the facility did not document the administration of Meclizine, a medication for dizziness, on the Medication Administration Record (MAR) for two instances. This lack of documentation was confirmed by interviews with the Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), who acknowledged that if a medication is not signed on the MAR, it is considered a medication error. The resident reported not always receiving medications and having to inform the nurse about the medication type and dosage needed. Additionally, the facility did not initiate a plan of care or document a change of condition when the resident developed a new onset of cough. The resident reported coughing since the week of admission, and although cough medicine was administered, there was no documentation of the cough or monitoring for it. The LVNs confirmed that the cough was not recorded on the MAR, and a care plan was not initiated, which is necessary for following interventions to care for the resident. The facility's policies on administering medications and nursing documentation emphasize the importance of proper documentation and monitoring, which were not adhered to in this case.
Food Safety and Defrosting Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and dating of opened food containers, which included an open container of apple sauce, beef base, and frozen chicken tenders stored in a Ziploc bag. During interviews, the Dietary Aide and Dietary Manager confirmed that all opened food containers must have an open date and a use-by date to prevent the use of expired food, which could lead to food-borne illnesses. The Director of Nurses also emphasized the importance of labeling to ensure food freshness and prevent bacterial growth. Additionally, the facility did not follow safe defrosting procedures for pork, as it was left in a bowl of standing water in the sink. The Cook and Dietary Manager acknowledged that cold water must be running on the meat during defrosting to prevent it from reaching the temperature danger zone where bacteria can grow. The Director of Nurses reiterated the necessity of proper defrosting methods to avoid bacterial contamination. The facility's policies and procedures require safe food handling and proper labeling, which were not adhered to in these instances.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the individual needs and preferences of two residents, leading to deficiencies in their care. Resident 37, who has conditions such as diabetes mellitus, hyperlipidemia, and hydronephrosis, expressed concerns about the insufficient space in his room. The limited space hindered his mobility, access to his closet, and the ability to move his wheelchair comfortably, especially when staff provided care to his roommate. Despite his complaints, no room change was offered, and the Maintenance Supervisor confirmed the room's inadequate size. Resident 179, diagnosed with heart failure, weakness, angina pectoris, and acute kidney failure, reported being unable to sleep due to the noise from his roommate. Despite informing staff members and the issue being discussed in an Interdisciplinary Team Meeting, the concern was not addressed, and no room change was provided. The facility had available beds, but the Social Service Director cited room availability as a reason for not transferring the resident. The facility's policies on accommodating individual needs and providing a homelike environment were not adhered to, as evidenced by the failure to address the residents' concerns. The Director of Nursing acknowledged that insufficient living space and noise could negatively impact the residents' health and psychosocial well-being. The facility's census showed available beds, contradicting the reason given for not accommodating the residents' requests for room changes.
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Illustrative
What surveyors actually found near you
We read the 4,864 citations issued within 25 miles in the last 12 months — including the 22 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Driftwood Healthcare Center | 0 mi | ★★★★★ | 2 | 0 |
| Providence Little Co Of Mary Transitional Care Ctr | 0.1 mi | ★★★★★ | 17 | 0 |
| Torrance Care Center West, Inc | 0.2 mi | ★★★★★ | 7 | 0 |
| Bay Crest Care Center | 0.6 mi | ★★★★★ | 49 | 1 |
| Del Amo Gardens Care Center | 1.1 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.