Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Gardens Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple health conditions did not receive their prescribed morning medications, which were left unattended on a meal tray in the hallway. Nursing staff signed the MAR indicating the medications were administered, despite not observing the resident take them. Facility policy required staff to witness medication ingestion and accurately document administration, which was not followed in this instance.
A resident with an indwelling catheter did not receive or have documented catheter care as ordered by the physician on several shifts, and two residents identified as candidates for bowel and bladder retraining did not have such programs initiated due to staff oversight of assessment forms. These deficiencies were confirmed through record review and staff interviews.
The facility did not post actual daily nurse staffing information, including the number of staff and hours worked, in a visible and prominent location as required. Instead, only projected staffing was displayed, and actual staffing data for previous days was not made accessible to residents or visitors, contrary to facility policy.
Two residents with Permacath catheters had their pre- and post-dialysis assessments inaccurately documented by nursing staff, who repeatedly recorded the presence of thrill and bruit—findings not possible with this type of access. Both a registered nurse and the DON confirmed the inaccuracy, and facility policy required precise documentation of dialysis care in the medical record.
A resident with an indwelling urinary catheter, cognitive impairment, and a need for staff assistance was observed to have their urinary catheter bag uncovered, contrary to facility policy and physician orders. Both an RN and the DON confirmed that catheter bags should be covered to maintain dignity, but this was not done for the resident.
A resident with dementia, depression, and a history of falls was found in bed with the call light on the floor and out of reach, despite a care plan requiring it to be accessible. Staff confirmed the call light was not within reach, and facility policy mandates that call lights be accessible to residents at all times.
A resident with intact cognition and multiple medical conditions had an advance directive on file, but facility staff failed to keep a current copy in the active clinical record. Both the SSD and DON confirmed the document was missing from the chart, despite facility policy requiring its presence for staff guidance.
A resident with multiple diagnoses and an indwelling catheter was admitted, but the baseline care plan developed within 48 hours did not address catheter care as required. Staff interviews and record reviews confirmed the omission, despite physician orders for catheter care and facility policy mandating comprehensive baseline care plans for all care areas.
A resident with diabetes, hypertension, and COPD was using a continuous glucose monitoring (CGM) system as ordered by a physician, but staff did not develop or implement a comprehensive, person-centered care plan to address the use and monitoring of the CGM sensor. Interviews with the MDSC and DON confirmed that no care plan with goals or interventions was created, despite facility policy requiring such plans for all residents.
A resident with type 2 diabetes did not receive proper monitoring or support for their continuous glucose monitoring (CGM) system, as staff failed to ensure the availability of sensor patches and did not apply or monitor the device as ordered. The resident independently applied the CGM sensors without staff assessment or documentation, and the admission assessment and care plan were incomplete and did not address the use of the CGM system.
An LVN left a bottle of vitamin C unattended and accessible on top of a medication cart while administering medications to a resident with diabetes, hypertension, and COPD. The bottle was not secured in the cart, making it easily accessible to other residents in the hallway, contrary to facility policy requiring medications to be stored securely and attended by authorized staff.
A resident with multiple medical conditions and cognitive impairment did not receive weekly weight monitoring as ordered by a physician. After an initial weight was recorded, staff failed to document the required weekly weight, missing one week before the next weight entry. Facility leadership confirmed the omission and acknowledged it was not in line with policy or physician orders.
A resident admitted after spinal fusion surgery retained a peripheral IV catheter without a physician order or ongoing need. Nursing staff did not assess or remove the IV upon admission, and facility records lacked documentation or indication for its use, contrary to facility policy requiring physician orders for IV therapy.
A resident with an order for continuous oxygen via nasal cannula was found with their oxygen tubing on the floor and the cannula not attached, contrary to physician orders and facility policy. An LVN confirmed the tubing was contaminated, and the DON acknowledged staff are required to follow oxygen administration orders.
Surveyors found that medications were disposed of in a manner that left them retrievable and that three medications were not properly documented with witness signatures on the Medication Disposition Record/Pass Log. Both a nurse and the DON confirmed that facility policy requiring non-retrievable disposal and dual nurse verification was not followed.
A resident with multiple medical conditions, who was dependent on staff for most ADLs but cognitively intact, had a baked custard left at the bedside for longer than four hours after lunch. Facility staff and dietary policy confirmed that leftover food should be removed within four hours, but this was not done, resulting in improper food handling and sanitation practices.
A resident with dementia and impaired cognition was made to sign her own consent forms for citalopram, influenza, and COVID-19 vaccines, despite lacking the capacity to make medical decisions. The facility failed to involve the Responsible Party (RP) as required by policy, placing the resident at risk. Staff interviews confirmed the oversight and acknowledged the need for RP involvement.
A resident with dementia and high fall risk was not reassessed for elopement risk after triggering exit alarms and wandering. The resident exited the facility without assistance, resulting in a fall and injuries. The facility failed to implement necessary safety measures, contributing to the incident.
A resident's medical records were incomplete due to the facility's failure to document physician orders for surgical wound treatment and urinary catheter drainage bag changes before performing these procedures. The resident, admitted with a spinal fusion, muscle weakness, and hypertension, had an indwelling catheter and a surgical wound. Despite these conditions, treatments were administered without documented orders, leading to inaccuracies in the clinical record. The facility's policies required immediate documentation of verbal orders, but delays were noted, potentially resulting in missed orders.
Two residents in the facility had incomplete care plans, leading to deficiencies in their care. One resident's care plan lacked specified frequency for neuro checks after an unwitnessed fall, while another resident's care plan did not include details about their urinary catheter care. These omissions were confirmed by staff and did not align with the facility's policy on comprehensive care plans.
A resident with an indwelling urinary catheter was not provided proper care as the catheter was not secured to the thigh, contrary to the care plan and facility policy. This oversight was observed during a survey, with the DON acknowledging the risk of dislodgement and infection due to improper securing.
A resident on enhanced barrier precautions was at risk due to a breach in infection control procedures by an RN. The RN failed to change gloves after touching unclean surfaces while performing wound treatment and changing a urinary catheter drainage bag. The facility's infection prevention policies were not adhered to, as confirmed by the DON.
The facility failed to implement comprehensive care plans for residents using psychotropic and anticoagulant medications, side rails, and urinary catheters. This lack of care plans led to unmonitored medication side effects, increased risk of falls, and potential health complications. The ADON and MDSC acknowledged these deficiencies, which were contrary to the facility's policies requiring person-centered care plans.
The facility failed to rotate injection sites for insulin administration for three residents, leading to potential adverse effects. Despite guidelines from insulin manufacturers, repeated injections were given in the same areas, risking complications such as lipodystrophy and poor medication absorption. The ADON confirmed the lack of site rotation for insulin and heparin injections.
The facility failed to properly document and reconcile controlled medications, with missing entries on audit forms for Medication Cart 2. Additionally, a resident did not receive their prescribed cholecalciferol oral liquid due to its unavailability in the medication cart. The facility's policy required timely reordering of medications, which was not followed, leading to a lapse in medication management.
The facility failed to ensure that the drug regimen for two residents was free from unnecessary medications. One resident's order for apixaban lacked a specific medical condition, while another resident receiving heparin was not monitored for adverse effects. These omissions were identified by the MDS Coordinator and the ADON, who confirmed that the facility's policy requiring specific clinical conditions for medication orders and monitoring for adverse effects was not followed.
The facility failed to manage and monitor psychotropic medication regimens for several residents, leading to deficiencies in their care. One resident received lorazepam without a 14-day limit or specific behavior monitoring, while another was given buspirone without documented behavior monitoring. Additionally, residents on quetiapine and citalopram lacked appropriate physician's orders for monitoring target behaviors and adverse effects, risking unnecessary medication use and adverse effects.
The facility failed to rotate injection sites for insulin and heparin in three residents, leading to potential adverse effects. The ADON confirmed repeated injections in the same areas, contrary to guidelines and facility policy.
The facility failed to ensure kitchen staff followed dress code policies, leading to potential cross-contamination. Observations revealed unlabeled and improperly stored food items, including moldy produce, and unsanitary kitchen conditions with grease and debris build-up. Staff acknowledged the risks of foodborne illnesses due to these deficiencies.
A LTC facility failed to maintain an effective infection control program, as evidenced by an LVN not sanitizing a blood pressure cuff between residents, not wearing appropriate PPE for a resident under enhanced precautions, and failing to change a BIPAP mask weekly. Additionally, mechanical lift slings were reused without washing, and nasal cannulas were not labeled with change dates, increasing infection risk.
A resident with Alzheimer's and acute kidney failure was found without a privacy cover on their urinary catheter bag, compromising their dignity. The facility's policy requires such covers to enhance residents' well-being. Both a CNA and the ADON acknowledged the oversight.
A facility failed to assist a resident with formulating an Advance Directive (AD) upon admission, as required by policy. The resident, with type 2 diabetes and intact cognition, did not have documented evidence of AD discussion during care conferences. Interviews confirmed the oversight, highlighting the importance of discussing ADs to respect residents' medical care preferences.
A resident at risk for pressure ulcers was found to have their low air loss mattress (LALM) set incorrectly, not according to their weight as per the manufacturer's guidelines. Despite the resident weighing 195 pounds, the LALM was set to a range of 660 to 750 pounds. Facility staff confirmed the importance of setting the LALM to the resident's weight to prevent skin breakdown and discomfort.
A resident without authorization for self-administration of medications was found with multiple medications left unattended in their room. Staff failed to remove these medications despite being aware of the facility's policy against leaving medications at the bedside. The resident, who required assistance with personal care and had no assessment for self-administration, was at risk of accidental ingestion or overuse.
The facility failed to provide proper catheter care for two residents, resulting in potential infection risks. One resident's catheter tubing was kinked, and the bag was on the floor, while another resident's catheter bag was placed on the floor during a transfer. Staff acknowledged these practices increased infection risks, contrary to facility policy.
A resident receiving IV Sodium Chloride for hypercalcemia had their medication bag and tubing unlabeled, contrary to facility policy. This oversight was confirmed by an LVN and the ADON, who noted the risks of administering unlabeled medication. The facility's policy requires medication containers to be changed every 24 hours and administration sets every 72 hours, but without labels, these protocols could not be followed.
Two residents had bed rails installed without proper assessment or informed consent. Despite policies requiring risk assessment and consent, the facility failed to follow these procedures, leading to potential safety risks.
A facility failed to ensure a nurse had the necessary skills for administering medications via a gastrostomy tube (GT). The nurse used a syringe and slow push method instead of the required gravity method, potentially causing discomfort or dislodging the GT. The nurse lacked a skills checklist and had not attended relevant training, highlighting a gap in staff competency assessment.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. A resident did not receive prescribed cholecalciferol and fluticasone due to their unavailability in the medication cart. The ADON confirmed this omission as an error, aligning with the facility's policy on medication errors.
During a survey, a facility was found to have five unpackaged and unlabeled albuterol nebules in a medication cart, which were not stored according to policy. An LVN admitted to not knowing the owner of the nebules and stated they should have been discarded. The DON confirmed that the facility's medication storage policy was not followed, emphasizing the importance of proper labeling to prevent medication errors.
A facility failed to maintain accurate clinical records when an LVN documented the administration of cholecalciferol to a resident, despite not having the medication available. The resident, admitted with gastrostomy status and retention of urine, had a physician's order for daily cholecalciferol via gastrostomy tube. The ADON confirmed the inappropriateness of documenting unadministered medications, as it can cause potential issues for the resident.
The facility failed to properly explain the arbitration agreement to residents, leading to confusion and lack of awareness about their rights to rescind the agreement. Residents and their representatives signed the agreement without understanding its implications, and the Admissions Director did not inform them of the 30-day rescission option.
The facility failed to screen eight visitors and three staff members for COVID-19 during an outbreak, as required by their policy and public health guidelines. Observations and interviews revealed missing temperature entries and unanswered screening questions, with staff acknowledging the lapses in procedure.
The facility failed to accommodate a room change request for a resident with Alzheimer's disease, despite available rooms and complaints from other residents. The request was communicated but not acted upon, potentially impacting the resident's well-being.
Medications Left Unattended and Incorrectly Documented as Administered
Penalty
Summary
A deficiency occurred when a resident, who was moderately impaired in thought process and dependent on staff for activities of daily living, did not receive their prescribed morning medications as required. The resident had diagnoses including hypertension, osteoarthritis, and pulmonary embolism, and was prescribed medications such as Eliquis, multivitamins, Coenzyme Q10, losartan potassium, and metoprolol. On the day of the incident, a medication cup containing five medications was observed left on top of the resident's breakfast tray, which was parked unattended in the hallway. Both a Licensed Vocational Nurse and a Registered Nurse confirmed the presence of the medication cup and stated that the nurse responsible should have observed the resident taking all medications to ensure proper administration. Despite the medications not being administered, the Medication Administration Record (MAR) was signed by the nurse, indicating that the medications had been given. Interviews with nursing staff and the Director of Nursing confirmed that the MAR should not have been signed unless the medications were actually administered and observed to be ingested by the resident. Facility policy also required staff to observe residents after medication administration to ensure the full dose was taken, and to document any partial ingestion. The failure to follow these procedures resulted in a significant medication error for the resident.
Failure to Provide Catheter Care and Bowel/Bladder Retraining
Penalty
Summary
The facility failed to provide proper care and services for a resident with an indwelling catheter by not administering catheter care as ordered by the physician. The resident, who had diagnoses including urinary retention and a history of urinary tract infection (UTI), required catheter care every shift, including cleansing the area and monitoring for signs of infection. Documentation revealed that on three specific shifts, there was no evidence that licensed nurses provided or documented the required catheter care or monitoring for redness, irritation, swelling, or symptoms of UTI. Both the MDS Coordinator and the Director of Nursing confirmed that the care was not documented and acknowledged that licensed nurses are required to implement physician orders and document the care provided. Additionally, the facility did not implement a bowel and bladder retraining program for two residents who were identified as candidates for such a program upon admission. Both residents had assessments indicating they could comprehend and follow instructions and were suitable for retraining programs. However, after the initial 72-hour assessment period, the staff failed to review the Bowel and Bladder Assessment forms when determining the need for retraining, resulting in neither resident being started on a program. Interviews with the MDS Coordinator and a registered nurse confirmed that the assessments were overlooked, and the required programs were not initiated as per facility policy. The facility's policies and procedures required that catheter care be documented in the resident's medical record, including assessment data and the resident's response to care, and that a toileting program be established within four days of admission for eligible residents. In these cases, the required documentation and program initiation did not occur, as confirmed by staff interviews and record reviews.
Failure to Post Actual Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, including the actual number of staff and hours worked, was posted in a visible and prominent location as required. During an observation and interview with the Director of Staff Development (DSD), it was found that only projected staffing information for the current day was posted at the nursing station, rather than the actual staffing data for previous days. The DSD confirmed that the actual staffing information for the previous two days was not posted. Further interviews revealed that the Director of Nursing (DON) stated that daily staffing information is placed at the nursing station and that residents, families, and visitors could ask staff about the number of nursing personnel providing direct care. However, review of the facility's policy indicated that actual staffing numbers and hours worked for each shift must be posted within two hours of the beginning of each shift in a prominent location. The facility did not follow this policy, resulting in the required information not being readily accessible to residents and visitors.
Inaccurate Dialysis Assessment Documentation for Residents with Permacath Catheters
Penalty
Summary
The facility failed to ensure accurate completion of pre- and post-dialysis assessments for two residents who were dependent on dialysis and had Permacath catheters in place. Both residents had complex medical histories, including type 2 diabetes, muscle weakness, and end-stage renal disease, and were dependent on staff for activities of daily living. Documentation in their medical records repeatedly indicated that a thrill and bruit were present at the dialysis access site, which is not possible with a Permacath catheter. Record reviews showed that for multiple dates, nursing staff checked off the presence of thrill and bruit on both pre- and post-dialysis assessment forms for these residents. During interviews, a registered nurse and the DON confirmed that this documentation was inaccurate, as Permacaths do not produce a thrill or bruit. The facility's policy required accurate documentation of dialysis care, including the use of the Pre/Post Dialysis form, and maintaining this information in the resident's medical record. The inaccurate charting of assessment findings was acknowledged by both the registered nurse and the DON, who stated that licensed nurses should not have documented the presence of thrill and bruit for residents with Permacaths. This failure to accurately assess and document the residents' dialysis access sites resulted in the maintenance of incorrect medical information in the residents' records.
Failure to Cover Urinary Catheter Bag with Privacy Bag
Penalty
Summary
A resident with a history of urinary retention, urinary tract infection, and falls was admitted to the facility and had an indwelling urinary catheter in place. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for substantial to moderate staff assistance with activities of daily living, including toileting and hygiene. Physician orders required staff to check the placement of the indwelling catheter every shift. During an observation, it was noted that the resident's urinary catheter bag was not covered with a privacy (dignity) bag, as required by facility policy. Both a registered nurse and the Director of Nursing confirmed that catheter bags are required to be covered to promote resident dignity, and acknowledged that the resident's catheter bag was not covered at the time of observation. The facility's policy on dignity specifically prohibits practices that compromise resident dignity and directs staff to assist residents in keeping urinary catheter bags covered.
Call Light Not Accessible to Resident with High Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to ensure that the call light was within reach of a resident who had been admitted with diagnoses including dementia, depression, and a history of falls. The resident's care plan specifically required that the call light and personal belongings be placed within her reach to minimize fall risk and ensure her ability to request assistance. During an observation, the resident was found lying in bed with the call light on the floor, unable to locate or reach it. The resident attempted to search for the call light but was unsuccessful. Certified Nursing Assistant 1 confirmed during the observation that the call light was not within the resident's reach and acknowledged that it should always be accessible. The Director of Nursing also stated that call lights are required to be accessible to residents at all times. Review of the facility's policy indicated that call lights must be within easy reach of residents while in bed. The failure to follow these procedures resulted in the resident's inability to call for help when needed.
Failure to Maintain Resident's Advance Directive in Clinical Record
Penalty
Summary
Facility staff failed to maintain a current copy of a resident's advance directive in the active clinical record, despite documentation indicating that the resident had executed such a directive. The resident, who had diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, and major depressive disorder, was assessed as having intact cognition and the capacity to make decisions. During record review, it was found that while the Advance Directive Acknowledgement Form indicated the existence of an advance directive, the actual document was not present in the resident's chart. Interviews with the Director of Social Services and the Director of Nursing confirmed that the advance directive should have been kept in the resident's active chart to guide staff in honoring the resident's wishes. The facility's policy also required that a copy of any executed advance directive be maintained in the resident's medical record and be readily retrievable by staff. The absence of the advance directive in the clinical record constituted a failure to ensure the resident's wishes regarding medical treatment were accessible to facility staff.
Failure to Address Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the baseline care plan did not address the resident's indwelling catheter, despite the resident having diagnoses including type 2 diabetes mellitus, obstructive uropathy, reflux uropathy, and benign prostatic hyperplasia. The resident required varying levels of assistance for activities of daily living and had a physician's order for catheter care, including cleansing and monitoring for signs of infection every shift. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the baseline care plan was incomplete and did not include interventions for the indwelling catheter. The facility's policy required a baseline care plan to be developed within 48 hours of admission, addressing all care areas and necessary nursing interventions. The omission was acknowledged by staff, who stated that the baseline care plan must be thorough to meet the resident's immediate care needs.
Failure to Develop Care Plan for Resident's Continuous Glucose Monitoring System
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident who was using a continuous glucose monitoring (CGM) system. The resident, admitted with diagnoses including type 2 diabetes mellitus, hypertension, and COPD, had intact cognitive skills and was prescribed hypoglycemic medication. Physician orders specified the application of a CGM sensor every 14 days for continuous blood sugar monitoring. Despite this, there was no care plan created to address the use, monitoring, or management of the CGM sensor. Interviews with the MDS Coordinator and the Director of Nursing confirmed that licensed nurses did not develop a care plan with goals and interventions for the resident's CGM sensor. Both acknowledged that the absence of such a care plan meant there were no documented strategies to ensure the sensor was applied properly or functioning as intended. Review of facility policy indicated that a comprehensive, person-centered care plan with measurable objectives and timeframes should have been developed and implemented for each resident, but this was not done for the resident in question.
Failure to Monitor and Support Resident's Continuous Glucose Monitoring System
Penalty
Summary
The facility failed to provide necessary care and services for a resident with type 2 diabetes by not monitoring the resident's continuous glucose monitoring (CGM) system and not ensuring that CGM sensor patches were available for application as ordered by the physician. Documentation showed that on multiple occasions, the required CGM sensor patches were not available in the facility, and staff did not apply the sensors as ordered. Instead, the resident independently applied the CGM sensor patches every 14 days without staff assistance, despite not having requested self-administration of medication. Licensed staff did not monitor the placement or functionality of the CGM system, and the Director of Nursing was unaware of the resident's use of the CGM sensor until it was observed during the survey. Additionally, the facility did not complete the resident's Admission/Readmission Screen and Baseline Care Plan form accurately upon admission. The assessment was left incomplete and unsigned, and it did not address the resident's use of a CGM system. The lack of a comprehensive, person-centered care plan meant that there were no documented goals or interventions for monitoring the resident's CGM sensor, as required by facility policy. The MDS Coordinator confirmed that the absence of a complete assessment and care plan could result in a lack of necessary care and services for the resident. Interviews with nursing staff revealed that the physician's order for the CGM sensor was received and processed, but no additional order for monitoring the device was obtained. Staff acknowledged that the resident's ability to self-administer the CGM sensor was not properly assessed, and the facility did not ensure the availability of sensor patches. Facility policies reviewed indicated that all services and changes in resident condition should be documented, and that comprehensive, person-centered care plans should be developed and implemented for each resident.
Unattended Medication Bottle Left Accessible on Medication Cart
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed preparing morning medications for a resident with diagnoses including type 2 diabetes mellitus, hypertension, and COPD. During the medication pass, the LVN removed a bottle of vitamin C from the medication cart, dispensed a tablet, and left the bottle unsecured on top of the cart before entering the resident's room to administer medications. The bottle of vitamin C was left unattended and easily accessible to other residents in the hallway. The LVN later acknowledged leaving the vitamin C bottle outside the medication cart, stating that medications should not be left unattended and accessible to residents. The Director of Nursing confirmed that the bottle should not have been left on the cart, as it allowed unsupervised access to medications. Facility policies reviewed indicated that medications must be stored securely and only accessible to authorized personnel, with medication carts locked or attended at all times.
Missed Weekly Weight Monitoring for Resident
Penalty
Summary
The facility failed to follow a physician's order to conduct weekly weights for a resident who was admitted with diagnoses including type 2 diabetes, muscle weakness, and metabolic encephalopathy. The resident was dependent on staff for activities of daily living and had cognitive impairments, as documented in the admission records and assessments. The physician's order, dated 4/21/2025, specified that the resident's weight should be monitored weekly for 30 days. However, a review of the weight records showed that after an initial weight was recorded on 4/22/2025, the next weight was not documented until 5/4/2025, with no weight recorded on 4/29/2025 as required by the order. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that the weekly weight was missed and acknowledged that this was not acceptable practice. The facility's policy on weighing and measuring residents, last reviewed on 1/20/2025, emphasizes the importance of regular weight monitoring as an indicator of nutritional status. The failure to obtain and document the weekly weight as ordered resulted in a deficiency related to the monitoring of the resident's nutritional status.
Failure to Assess and Remove Unnecessary IV Catheter
Penalty
Summary
The facility failed to provide care and services that meet professional standards of quality by not assessing the continued need for a peripheral intravenous (IV) catheter for a resident who was admitted after spinal fusion surgery. Upon admission, the resident had an IV in place on the back side of her right lower arm, but there was no physician order or indication for IV fluids or medications. The resident expressed that she did not know why the IV had not been removed and found it annoying, though it was not painful. The admission and skin evaluation records did not document the presence of an IV, and the electronic medical record also lacked any order or indication for its use. Nursing staff, including a registered nurse and the Director of Nursing, confirmed that the IV should have been identified and removed upon admission, as there was no ongoing need for it. The facility's policy required physician orders for initiating IV therapy, specifying details such as dose, frequency, duration, and diagnosis, none of which were present for this resident. The failure to remove the unnecessary IV upon admission constituted a lapse in following professional standards and facility policy.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified when a resident who had a physician's order for continuous oxygen at two liters per minute via nasal cannula was observed with their oxygen tubing on the floor and the cannula not attached to their nose. The tubing was found under the resident's body, with one end connected to the oxygen concentrator, and the other end not in use. This observation was confirmed by a Licensed Vocational Nurse, who acknowledged that the tubing was contaminated and not in accordance with professional standards of practice. The resident involved had a history of right femur fracture, aphasia, and urinary tract infection, and was assessed as able to make needs known but unable to make medical decisions. Facility policy required the nasal cannula to be properly placed in the resident's nose and secured, and CDC guidelines indicated that floors can become rapidly contaminated. The Director of Nursing confirmed that staff are required to implement physician orders for oxygen administration and acknowledged the potential for infection if tubing contacts the floor and for desaturation if the cannula is not attached.
Improper Medication Disposal and Incomplete Documentation
Penalty
Summary
The facility failed to ensure proper disposal and documentation of medications in accordance with federal regulations and facility policy. During an observation in the medication room, a pharmaceutical waste bin was found to contain a mixture of unopened and unused medications in their original manufacturer packaging, as well as loose, intact tablets and capsules. The registered nurse present confirmed that medications were disposed of without rendering them non-retrievable, as required by policy, since no liquid was poured over them to prevent retrieval. This left the medications in a form that could be easily accessed and reused. Additionally, a review of the Medication Disposition Record/Pass Log revealed that three disposed medications—Vancomycin oral suspension, Nystatin powder, and Naloxone spray—were not documented with the required verifying signatures of two licensed nurses. Both the registered nurse and the Director of Nursing confirmed that these medications were not logged or witnessed as per policy. The facility's policy requires that all destroyed medications be entered on the disposition form with date, resident's name, medication details, and signatures of witnesses, which was not followed in these instances.
Failure to Remove Leftover Food from Resident Room Within Required Timeframe
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices when a resident's leftover food was not removed from the bedside after four hours. Specifically, a resident with diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, and major depressive disorder, who was cognitively intact but dependent on staff for most activities of daily living, had a baked custard left on the bedside table for an extended period. The resident reported that the custard had been in the room for a couple of days, and staff confirmed it was served during lunch the previous day. Facility policy, as reviewed with the Dietary Supervisor, requires that leftover food not be stored in resident rooms for more than four hours due to the lack of temperature control and the risk of foodborne illness. Observations and interviews with nursing and dietary staff confirmed that the custard was not removed within the required timeframe, and the policy was not followed. The failure to remove the food in a timely manner created a situation where the resident could have consumed contaminated food.
Failure to Obtain Proper Consent for Resident with Impaired Cognition
Penalty
Summary
The facility failed to ensure that the Responsible Party (RP) or Resident Representative (RR) signed consent forms for a resident with a history of dementia and moderately impaired cognition. The resident, who was unable to make medical decisions, was made to sign her own consent forms for the administration of citalopram, an influenza vaccine, and a COVID-19 vaccine. This action was contrary to the facility's policy, which requires a surrogate decision-maker to be identified when a resident lacks the capacity to make informed decisions. The resident's admission record indicated diagnoses including Parkinson's disease, generalized muscle weakness, and a neurocognitive disorder with Lewy bodies. Despite these conditions, the resident signed the consent forms in the presence of a registered nurse, without the involvement of the RP. The facility's policy mandates that informed consent should be obtained from the RP when a resident is determined to lack decision-making capacity, which was not adhered to in this case. Interviews with facility staff, including the Director of Nursing and the Director of Staff Development, revealed that the RP was not notified prior to the administration of the medications and vaccines. The staff acknowledged that the resident did not have the capacity to sign the consent forms and that the RP should have been contacted to provide consent. The facility's failure to follow its own policies and procedures for obtaining informed consent placed the resident at risk for making healthcare decisions without proper understanding or authorization.
Failure to Prevent Resident Elopement and Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a history of dementia, high fall risk, and wandering behavior. The resident, admitted on 12/30/2024, had diagnoses including Parkinson's disease, generalized muscle weakness, and neurocognitive disorder with Lewy bodies. Despite being assessed as high risk for falls, the resident was not reassessed for elopement risk after triggering the exit door alarm twice on 12/31/2024 and exhibiting wandering behavior on 1/1/2025. On 1/2/2025, the resident managed to walk two steps outside the facility's exit door without staff assistance or an assistive device, resulting in a fall. The resident sustained injuries, including a comminuted nasal bone fracture and fractures in the right hand, requiring transfer to a general acute care hospital. The facility's failure to reassess the resident's elopement risk and implement appropriate interventions, such as a wander or elopement alarm, contributed to the incident. Interviews with facility staff revealed that the resident was known to wander and had previously set off the exit door alarm. However, there was no documentation of increased monitoring or reassessment for elopement risk. The facility's policies and procedures for safety and supervision were not adequately followed, as the resident's care plan did not include necessary interventions to prevent elopement and ensure safety.
Incomplete Documentation of Physician Orders
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented, leading to deficiencies in the care provided. Specifically, the facility did not document the physician's order for surgical wound treatment in the resident's clinical record before performing the treatment. Additionally, the order to change the resident's indwelling urinary catheter drainage bag was not documented prior to the change being made. These omissions resulted in inaccurate information in the resident's clinical record. The resident in question was admitted with diagnoses including a fusion of the spine, muscle weakness, and essential hypertension. The resident had an indwelling catheter and a surgical wound, as indicated in the Minimum Data Set. Despite these conditions, the facility staff performed surgical wound treatments and changed the urinary catheter drainage bag without documented physician orders. This lack of documentation was confirmed during interviews and record reviews with nursing staff, who were unable to provide the necessary physician orders for the treatments administered. The facility's policies required that verbal orders be recorded immediately in the resident's chart by the person receiving the order. However, there was a delay in entering the physician's orders into the resident's clinical records, with one order being entered more than seven hours after it was given. This delay in documentation had the potential to result in missed orders, as acknowledged by the Director of Nursing. The facility's failure to adhere to its own policies on documentation and order entry contributed to the deficiencies observed in the resident's care.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. For Resident 1, who was admitted with diagnoses including Parkinson's disease, type 2 diabetes mellitus, and essential tremors, the care plan did not specify the frequency of neuro checks following an unwitnessed fall. This omission was identified during a review of the resident's care plan and confirmed by a Licensed Vocational Nurse, who acknowledged that the care plan was incomplete. Resident 2, admitted with conditions such as fusion of the spine, muscle weakness, and essential hypertension, also had an incomplete care plan. The care plan for Resident 2's indwelling urinary catheter did not specify critical details such as the date of the last catheter change, frequency, size, and type of catheter. Additionally, the care plan lacked information on the catheter drainage bag change and surgical wound treatment. This was confirmed during a review with an LVN, who noted the care plan was not specific or individualized. The facility's policy on comprehensive person-centered care plans, dated earlier in the year, mandates that care plans include measurable objectives and timetables to meet residents' needs. However, the care plans for both residents did not adhere to this policy, placing them at risk for not receiving necessary services and assistance, potentially leading to infection and injury.
Failure to Secure Urinary Catheter Leads to Deficiency
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling urinary catheter, specifically by not securing the catheter tubing to the resident's thigh. This deficiency was identified for one of five sampled residents, who was admitted with diagnoses including spine fusion, muscle weakness, and essential hypertension. The resident's care plan, initiated shortly after admission, indicated a high risk for complications such as urinary tract infections and included interventions to prevent tension on the urinary catheter by securing it with a leg strap. During an observation, the resident was found with the urinary catheter improperly secured, allowing movement through the statlock device on the resident's thigh. A registered nurse, responsible for changing the urinary catheter drainage bag, was unable to secure the catheter properly. The Director of Nursing confirmed that the catheter should have been secured to prevent dislodgement and potential trauma or infection. The facility's policy on urinary catheter care emphasized the importance of securing the catheter to reduce friction and movement at the insertion site.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to infection control procedures during the care of a resident, identified as Resident 2, who was on enhanced barrier precautions due to having an indwelling urinary catheter and a lower back surgical incision. The resident was admitted with diagnoses including fusion of the spine, muscle weakness, and essential hypertension. The care plan for the resident indicated a high risk for developing complications such as urinary tract infections, necessitating strict adherence to enhanced barrier precautions. During an observation, RN 1 was seen performing wound treatment and changing the urinary catheter drainage bag for Resident 2 without changing gloves after touching unclean surfaces. RN 1 did not change gloves after removing the resident's soiled wound dressing and continued to handle the urinary catheter and drainage bag with the same gloves. Additionally, RN 1 placed alcohol pad packets on the resident's bed, which was not a clean working area, and touched the basin under the bed with gloved hands before handling the new drainage bag. Interviews with RN 1 and the Director of Nursing (DON) confirmed that gloves should have been changed after each treatment and after touching soiled surfaces to prevent potential infections. The facility's policies on infection prevention and control, as well as the use of personal protective equipment, were not followed, as evidenced by RN 1's actions during the care of Resident 2.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in their care. For one resident, there was no care plan for the use of buspirone, a psychotropic medication prescribed for anxiety. The absence of a care plan meant that the resident's behavior and medication effectiveness were not monitored, potentially leading to unnecessary medication administration and increased risk of altered cognition and falls. The Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator (MDSC) both acknowledged the lack of a care plan and its implications for the resident's health and safety. Another deficiency involved the failure to create care plans for residents using anticoagulant medications. One resident was prescribed apixaban, and another was on rivaroxaban, both without corresponding care plans to monitor for side effects such as bleeding and bruising. The MDSC and ADON highlighted the importance of these care plans in identifying risks and guiding staff in providing appropriate interventions. Without these plans, residents were at risk of health complications due to unmonitored medication side effects. Additionally, the facility did not develop care plans for the use of side rails and urinary catheters for certain residents. Two residents had side rails on their beds without care plans to prevent entrapment, and two others had indwelling urinary catheters without care plans to prevent urinary tract infections. The ADON confirmed the absence of these care plans and emphasized their necessity in ensuring resident safety and proper care. The facility's policies and procedures required comprehensive, person-centered care plans, but these were not followed, resulting in the identified deficiencies.
Failure to Rotate Injection Sites for Insulin Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided care in accordance with professional standards by not rotating subcutaneous insulin administration sites for three of the five sampled residents. This practice was observed during a review of insulin use, where it was found that repeated injections were administered in the same area, contrary to the guidelines provided by insulin manufacturers. The failure to rotate injection sites can lead to adverse effects such as lipodystrophy, bleeding, and bruising. Resident 34, who was admitted with type 2 diabetes mellitus, received insulin injections without proper site rotation. The resident's care plan indicated the need for insulin administration as ordered, yet the Location of Administration Report showed repeated use of the same injection sites over a period of time. The Assistant Director of Nursing (ADON) confirmed that the administration sites were not rotated, which could lead to poor absorption of insulin and insufficient blood sugar control. Similarly, Resident 11, who was receiving heparin for deep vein thrombosis prophylaxis, also experienced repeated injections at the same sites. The ADON acknowledged the lack of site rotation, which is necessary to prevent complications such as bleeding and irritation. Resident 5, with a history of type 2 diabetes and transient cerebral ischemic attack, also had insulin injections administered without proper site rotation. The ADON confirmed the repeated use of the same sites, which could potentially lead to adverse effects as outlined in the insulin manufacturer's guidelines.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of controlled medications, as observed during a review of Medication Cart 2. The Controlled Substance / MAR Change of Shift Audit forms from 5/13/2024 to 6/2/2024 showed multiple missing entries, including signatures from oncoming and outgoing charge nurses and indications of whether the narcotic counts were correct. Licensed Vocational Nurse 2 (LVN 2) confirmed that the facility protocol required both nurses to count narcotics and sign the form at every shift change. The Director of Nursing (DON) stated that the facility policy was not followed, which could lead to medication going missing and delays in care. Additionally, the facility failed to administer medication to a resident, identified as Resident 249, who was admitted with a gastrostomy tube and required cholecalciferol oral liquid for nutritional support. On 6/5/2024, LVN 2 was unable to find the resident's medication in the cart, preventing administration. The Assistant Director of Nursing (ADON) acknowledged that residents would not receive the intended effects of their medications if not administered and emphasized the importance of timely reordering medications. The Operations Manager (OM) noted that the facility did not stock the liquid form of cholecalciferol, only tablets that could not be crushed. The facility's policy on Medication and Treatment Orders, last reviewed on 1/15/2024, required that medications be reordered from the pharmacy at least three days before the last dose to ensure availability. The failure to follow this policy resulted in the resident not receiving their prescribed medication, highlighting a lapse in the facility's medication management system.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that the drug regimen for two residents was free from unnecessary medications. For Resident 196, the facility did not provide an adequate indication for the use of apixaban, an anticoagulant medication. The resident was admitted with diagnoses including a fracture of the sacrum, hypertension, and atrial fibrillation. However, the physician's order for apixaban only stated it was for a blood thinner, without specifying the medical condition it was intended to treat, such as atrial fibrillation. This omission was identified during a review by the MDS Coordinator and the Assistant Director of Nursing, who acknowledged that the facility's policy requiring a specific clinical condition for medication orders was not followed. For Resident 11, the facility failed to monitor for adverse effects of heparin, another anticoagulant medication. The resident was admitted with conditions including atrial fibrillation, heart failure, and gastritis, and was receiving heparin for deep vein thrombosis prophylaxis. The order for heparin did not include instructions for monitoring adverse effects, such as bleeding and bruising, which are critical for patient safety. The Assistant Director of Nursing confirmed that the order lacked necessary monitoring instructions, which are essential to detect and report any adverse effects to the physician. The facility's failure to provide adequate indications for medication use and to monitor for adverse effects could lead to significant health risks for the residents. The facility's policy and procedures require that medication orders include the clinical condition being treated and that residents are monitored for potential adverse effects, but these protocols were not followed in the cases of Residents 196 and 11.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to manage and monitor the medication regimens of four residents, leading to deficiencies in promoting their highest practicable mental, physical, and psychosocial well-being. For one resident, the facility did not limit the PRN order for lorazepam to a 14-day duration, nor did it identify specific behaviors to monitor, as required by policy. This oversight was acknowledged by the Assistant Director of Nursing (ADON), who confirmed that the physician's order lacked necessary details to prevent unnecessary medication use. Another resident was prescribed buspirone for anxiety without documented monitoring of behavioral manifestations, such as restlessness leading to shortness of breath. The ADON and Director of Nursing (DON) both noted the absence of documentation for monitoring the resident's behavior, which is crucial for evaluating the medication's effectiveness and ensuring the resident's safety. The facility's policy mandates monitoring for efficacy and adverse consequences, which was not adhered to in this case. Additionally, the facility did not ensure appropriate physician's orders for monitoring target behaviors and adverse effects for residents receiving quetiapine and citalopram. One resident was given quetiapine without informed consent or proper documentation of the diagnosis and monitoring requirements. Similarly, another resident was prescribed citalopram without orders to monitor target behaviors and side effects. These lapses in medication management and monitoring placed residents at risk for adverse effects and unnecessary medication use.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of subcutaneous injections. For Resident 34, the facility did not rotate the injection sites for insulin administration, as evidenced by repeated injections in the same area of the abdomen over a period of time. This practice was confirmed by the Assistant Director of Nursing (ADON) during a review of the Medication Administration Record (MAR), who acknowledged that the sites should have been rotated to prevent adverse effects such as bruising and poor absorption of the medication. Similarly, Resident 5 experienced a lack of rotation in the administration of insulin injections. The MAR indicated that insulin was repeatedly administered in the same areas of the abdomen, which was again confirmed by the ADON. The failure to rotate injection sites was contrary to the manufacturer's guidelines and the facility's policy, which both emphasize the importance of site rotation to prevent complications like lipodystrophy. Resident 11 also suffered from improper medication administration practices, with repeated heparin injections in the same abdominal areas. The ADON confirmed that the sites were not rotated as required, which could lead to issues such as bleeding and irritation. The facility's policy and the manufacturer's guidelines for heparin administration both stress the necessity of rotating injection sites to avoid adverse reactions.
Deficiencies in Kitchen Hygiene and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to the dress code, which prohibits wearing excessive jewelry while handling food. During observations, a dietary aide and a dishwasher were seen wearing long, dangling necklaces and other jewelry that were not covered, contrary to the facility's policy and the Food Code 2017. The dietary manager confirmed that the policy was in place to prevent cross-contamination and infection control issues, as jewelry could potentially touch or fall into food. The facility also failed to properly label and store food items in the kitchen. Several opened food containers, including garlic spread, strawberry spread, and peeled garlic, were found unlabeled in the walk-in refrigerator. Additionally, mold was observed on blueberries, and produce was stacked unsafely to the ceiling, posing a risk of falling and contamination. Staff admitted that labeling and dating food items were necessary to prevent foodborne illnesses and that eating personal food in the kitchen could lead to cross-contamination. Furthermore, the kitchen equipment and utensils were not maintained in a clean condition. Observations revealed grease, dirt, and debris build-up on the oven, hood, stove, fryer, steam table, and floors. Cutting boards were stored while still wet, which could lead to bacteria and mold growth. The dietary manager acknowledged the unsanitary conditions and the potential for foodborne illnesses due to the lack of cleanliness in the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. One significant issue involved a Licensed Vocational Nurse (LVN) who did not sanitize a reusable blood pressure cuff between uses on multiple residents. This oversight occurred with three residents, all of whom had various health conditions, including immunodeficiency and respiratory issues, which increased their vulnerability to infections. The LVN admitted to not cleaning the cuff due to being rushed, which was against the facility's policy requiring disinfection of such equipment between uses. Another deficiency was observed when the same LVN failed to don appropriate personal protective equipment (PPE) while providing care to a resident under enhanced barrier precautions. The resident had a urinary catheter and a gastrostomy tube, necessitating the use of gloves and a gown to prevent contamination. The LVN only wore gloves, neglecting to wear a gown, which could have exposed both the resident and the LVN to potential infections. This was contrary to the facility's policy on enhanced barrier precautions, which mandates the use of full PPE during high-contact care activities. Additional issues included the failure to change a resident's bilevel positive airway pressure (BIPAP) machine facemask weekly, as required by the facility's policy, and the improper handling of mechanical lift slings, which were used on multiple residents without being washed. Furthermore, nasal cannulas for two residents were not labeled with the date of the last change, making it difficult to ensure they were replaced weekly as per the facility's infection control policy. These practices increased the risk of cross-contamination and infection among residents.
Failure to Provide Privacy Cover for Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity and respect of Resident 249 by not providing a privacy cover for the resident's urinary catheter bag. This deficiency was identified during an observation and interview with Certified Nursing Assistant 3 (CNA 3) in the resident's room, where it was noted that the urinary catheter bag was uncovered. CNA 3 acknowledged that a privacy cover should have been provided to promote the resident's dignity. Resident 249 was admitted to the facility with diagnoses including Alzheimer's disease, acute kidney failure, and retention of urine, and had an order for an indwelling Foley catheter. The facility's policy on dignity, last reviewed in January 2024, mandates that residents be cared for in a manner that enhances their well-being and self-esteem, explicitly stating that urinary catheter bags should be covered. The Assistant Director of Nursing (ADON) confirmed that the urinary catheter bag should have had a privacy cover to ensure the resident's dignity and respect.
Failure to Assist Resident with Advance Directive Formulation
Penalty
Summary
The facility failed to offer assistance with formulating an Advance Directive (AD) to a resident or their representative upon admission. This deficiency was identified during a review of advance directive care for one of the two sampled residents. The resident, admitted with type 2 diabetes mellitus, was noted to have intact cognition and required varying levels of assistance with activities of daily living. Despite this, there was no documented evidence that the AD was discussed with the resident or their representative during the care conference meeting. Interviews with the Social Services Director (SSD) and the Assistant Director of Nursing (ADON) confirmed the absence of documentation regarding the discussion of ADs. The SSD acknowledged the importance of discussing ADs to ensure the healthcare team is aware of the resident's medical care preferences. The facility's policy, last reviewed in January 2024, mandates that the SSD or designee inquire about the existence of any written AD prior to or upon admission and provide written information about the right to refuse or accept medical treatment and to formulate an AD.
Improper LALM Setting for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident by not setting the low air loss mattress (LALM) according to the manufacturer's guidelines. The resident, who was admitted with conditions including type two diabetes mellitus and a transient cerebral ischemic attack, was at risk for pressure ulcers and required a pressure-reducing device for the bed. Despite the resident's weight being documented as 195 pounds, the LALM was set to a weight range of 660 to 750 pounds, which was not in accordance with the resident's actual weight. Observations and interviews with facility staff, including a Certified Nursing Assistant, the Director of Staff Development, a Treatment Nurse, and the Assistant Director of Nursing, confirmed that the LALM should be set to the resident's weight to prevent skin breakdown and discomfort. The incorrect setting of the LALM had the potential to increase pressure on the resident's skin, potentially leading to the reopening of existing pressure ulcers. The manufacturer's guidelines also indicated that the mattress should be adjusted according to the resident's weight and comfort.
Failure to Prevent Unattended Medications
Penalty
Summary
The facility failed to ensure that medications were not left unattended and readily available to residents, specifically for one resident who was not authorized to self-administer medications. This deficiency was identified during observations and interviews with staff and the resident. The resident, who was admitted with multiple diagnoses including a fracture, hypertension, and immunodeficiency, did not have an assessment or physician's order for self-administration of medications. Despite this, medications were found on the resident's nightstand and bedside table. During observations, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) were present in the resident's room but did not remove the medications. The LVN initially mistook the medication bottles for shampoo and did not investigate further, while the CNA was unsure of the purpose of the medications and did not remove them. The resident stated that the medications belonged to her and that sometimes the nurses helped her take them, indicating a lack of consistent supervision and adherence to the facility's medication policies. The facility's policies require that medications should not be left at the bedside unless the resident is assessed and authorized to self-administer them. The Assistant Director of Nursing (ADON) and a Treatment Nurse confirmed that the resident did not have the necessary assessment or physician's order for self-administration. The presence of medications at the bedside posed a risk of accidental ingestion or overuse, as the resident had an order for a similar topical medication that could lead to overuse if both were applied.
Inadequate Catheter Care Leading to Potential Infection Risks
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to potential risks of catheter-associated urinary tract infections (CAUTI). For Resident 249, the urinary catheter tubing was observed to be kinked, and the catheter bag was touching the floor. This was noted during an observation with a Certified Nursing Assistant (CNA), who acknowledged that the catheter bag should be kept off the floor for infection control and that the tubing should be free of kinks to allow urine to flow freely. The Assistant Director of Nursing (ADON) confirmed that the catheter should be kept off the floor to prevent ascending infections and that the tubing should be inspected frequently to prevent backflow of urine, which could result in infection. Similarly, Resident 40's indwelling catheter bag was placed on the floor by a Physical Therapist (PT) during a transfer from a wheelchair to a bed. The PT admitted to placing the bag on the floor to expedite the transfer, acknowledging the increased risk of infection. The ADON reiterated that staff must adhere to standards of practice by keeping the catheter bag off the floor to prevent UTIs, which could lead to confusion, falls, and rehospitalization. The facility's policy on catheter care, last reviewed in January 2024, emphasizes the importance of keeping catheter tubing and drainage bags off the floor to prevent infections.
Failure to Label IV Medication Bag and Tubing
Penalty
Summary
The facility failed to properly label the intravenous (IV) medication bag and tubing for a resident, which could lead to complications in medication administration. The resident, who was admitted with conditions including malignant neoplasm of the breast, secondary malignant neoplasm of bone, chronic kidney failure, and hypercalcemia, was receiving Sodium Chloride 0.9% intravenously as per the physician's order. However, during an observation, it was noted that the IV medication bag and tubing were not labeled with essential information such as the resident's name, medication details, start time, and the person who administered it. The lack of labeling was confirmed during an interview with a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), who acknowledged the potential dangers of administering unlabeled medication. The facility's policy requires that medication containers be changed every 24 hours and administration sets for continuous infusion every 72 hours, but without proper labeling, adherence to these protocols could not be ensured. This oversight had the potential to increase the resident's risk for complications such as bacterial growth in the tubing and incorrect medication administration.
Failure to Assess Entrapment Risk and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to properly assess the risk of entrapment and obtain informed consent before installing bed rails for two residents. Resident 11 was admitted with diagnoses including age-related osteoporosis, dementia, and abnormal posture. Despite the resident's inability to make medical decisions, the facility did not conduct an assessment for entrapment risk or obtain informed consent before installing a half side rail on the resident's bed. Observations confirmed the presence of the side rail, and the Assistant Director of Nursing acknowledged the absence of necessary assessments and consents. Similarly, Resident 20, admitted with conditions such as lack of coordination and syncope, also had a half side rail installed without prior assessment or informed consent. The resident's medical records did not indicate any order for side rail placement, and the Assistant Director of Nursing confirmed the lack of required documentation and assessments. Observations of the resident's room confirmed the presence of the side rail. The facility's policy on bed safety and bed rails, last reviewed in January 2024, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The policy outlines a comprehensive assessment process to determine the risk of entrapment, which was not followed in these cases. The facility's failure to adhere to its own policies and procedures resulted in the installation of bed rails without proper assessment and consent, posing potential risks to the residents.
Deficiency in GT Medication Administration Competency
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) had the necessary competencies and skills to care for residents' needs, specifically in administering medications via a gastrostomy tube (GT). During an observation, LVN 2 was seen administering water through a resident's GT using a syringe and a slow push method, contrary to the facility's policy which requires medications to be administered via gravity. This method of administration was not in line with the resident's care plan and had the potential to cause discomfort or dislodge the GT. The Director of Staff Development confirmed that LVN 2 did not have a skills checklist for GT medication administration and had not attended the last in-service training on this topic. The facility's policy requires medications to be administered via gravity, and the Assistant Director of Nursing emphasized the importance of staff being competent in this procedure to prevent potential harm to residents. The deficiency was identified through observation, interviews, and record reviews, highlighting a gap in staff training and competency assessment related to GT medication administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of eight percent. This was observed during a survey where two medication errors occurred out of 25 opportunities. The errors affected one resident, who did not receive their prescribed medications, cholecalciferol and fluticasone, as ordered by their physician. The resident, who was admitted with conditions including gastrostomy status and retention of urine, was supposed to receive these medications for nutritional support and to relieve nasal symptoms due to oxygen use. During the observation, an LVN was unable to administer the medications because they were not available in the medication cart. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that not administering the medication as ordered constitutes an error. The facility's policy defines medication errors as any preparation or administration of drugs not in accordance with physician's orders, including omissions and wrong timing.
Unlabeled Albuterol Nebules Found in Medication Cart
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services during an inspection of a medication cart. Specifically, five unpackaged and unlabeled albuterol nebules were found in the bottom right drawer of Medication Cart 2. The Licensed Vocational Nurse (LVN) present during the observation acknowledged that the nebules were not in a labeled box, were not labeled to identify the resident to whom they belonged, and were not labeled with an opened date. The LVN admitted to not knowing the owner of the unlabeled nebules and stated that they should have been discarded instead of stored in the cart. This oversight had the potential to result in medication being administered to the wrong resident or the use of expired medication. The Director of Nursing (DON) reviewed the facility's policy and procedure regarding medication storage and confirmed that the proper process was not followed. According to the policy, nebules should be kept enclosed in a foil packet and labeled when opened. The DON emphasized the importance of removing and disposing of unlabeled medications to prevent medication errors. The facility's policy mandates that all drugs and biologicals be stored in the packaging, containers, or other dispensing systems in which they are received, and only the issuing pharmacy is authorized to transfer medication between containers. The failure to adhere to these procedures resulted in the deficient practice observed during the survey.
Inaccurate Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident during medication administration. Specifically, a Licensed Vocational Nurse (LVN) documented the administration of cholecalciferol, a Vitamin D supplement, to a resident when it was not actually administered. This error was identified during a review of the Medication Administration Record (MAR) for the resident, who had been admitted with diagnoses including gastrostomy status and retention of urine. The physician's order required the administration of cholecalciferol via gastrostomy tube once daily for nutritional support. During an interview, the LVN admitted to mistakenly marking the medication as administered, despite not having the medication available on that day. The Assistant Director of Nursing (ADON) confirmed that documenting medications as administered when they were not is inappropriate, as it can lead to potential problems for the resident. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication initialing the MAR after each administration.
Failure to Properly Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained to residents in a manner they could understand, leading to confusion and lack of awareness about their rights. Specifically, Resident 246's representative, Family Member 1, signed the arbitration agreement without knowing it could be rescinded within 30 days. The representative was not fully informed about the agreement's implications and was unaware that signing it was not a condition for admission. Similarly, Residents 4 and 40 signed the arbitration agreement without understanding its content or the option to rescind it within 30 days. Both residents had moderately impaired cognition and required varying levels of assistance with activities of daily living. Despite this, they were not adequately informed about the arbitration process or their rights to withdraw from the agreement. Interviews with the Admissions Director and Assistant Director of Nursing revealed that the arbitration agreement was part of the admission packet and signed electronically. However, the Admissions Director admitted to not explaining the rescission option to residents or their representatives. The facility's policy required clear communication about the right to withdraw from the agreement, which was not adhered to, resulting in the deficiency.
Failure to Screen Visitors and Staff for COVID-19 During Outbreak
Penalty
Summary
The facility failed to screen eight of ten sampled visitors and three of ten sampled staff for COVID-19 during a period from 4/23/2024 to 4/26/2024 while the facility was experiencing a COVID-19 outbreak. Observations on 4/29/2024 revealed that the front desk was unattended, and the Visitor and Employee Daily Monitoring Log had missing temperature entries and unanswered COVID-19 screening questions. Interviews with staff confirmed that the required screening procedures were not consistently followed, despite the facility's policy and the outbreak notification from the Los Angeles County Department of Public Health mandating such measures. The Infection Preventionist and the Director of Nursing acknowledged the lapses in screening, with the DON stating that they could not enforce compliance among visitors. The facility's policy required all employees and visitors to check their temperature and answer screening questions to prevent the spread of COVID-19. However, the logs reviewed indicated that these procedures were not adhered to, potentially compromising the health and safety of residents and staff during the outbreak.
Failure to Accommodate Room Change Request
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 4's needs and preferences when Family Member 1 (FM 1) requested a room change. Resident 4, who was admitted with diagnoses including cerebrovascular disease, pneumonitis, and Alzheimer's disease, did not have the capacity to make decisions. FM 1, the responsible party, requested a private room three weeks prior due to complaints from other residents about FM 1 staying in the room. Despite the request being communicated to the Admission Coordinator (AC) and mentioned in a standup meeting, no action was taken to move Resident 4, even though there were vacant rooms available during the requested period. The Assistant Director of Nursing (ADON) and the Administrator (ADM) were not aware of FM 1's request, and the facility's policy indicated that room changes should consider resident preferences, which was not adhered to in this case. Interviews with staff revealed that Resident 8, who was Resident 4's roommate, also requested a room change due to discomfort with FM 1 sleeping in the room. The AC acknowledged the request but cited a lack of vacant rooms at the time, although records showed that rooms were available. The ADON admitted that the room change should have been made when rooms were vacant, and the ADM stated that room changes are based on clinical needs rather than resident or family requests. This lack of communication and failure to act on the room change request potentially impacted the psychosocial well-being of Resident 4 and other residents involved.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Northridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Gardens Convalescent Hospital | 1 mi | ★★★★★ | 28 | 0 |
| Casitas Care Center | 1.2 mi | ★★★★★ | 19 | 0 |
| Rinaldi Convalescent Hospital | 2.3 mi | ★★★★★ | 42 | 0 |
| Granada Hills Convalescent | 2.3 mi | ★★★★★ | 19 | 0 |
| The Rehabilitation Center Of North Hills | 3 mi | ★★★★★ | 8 | 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.