Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Grove Post-acute Care Center during CMS and state inspections, most recent first.
A resident with encephalopathy, epilepsy, and HTN, and with severely impaired cognition and dependence for multiple ADLs, repeatedly refused showers and declined participation in activities, sometimes screaming when refusing care. A CNA reported these refusals but did not notify the charge nurse about the resident’s refusal to attend activities, and there was no documentation that activities were offered or refused over several days. Record review showed the resident had minimal group activity participation due to physical limitations and that assistance to and from activities had been identified as a needed intervention, but this intervention was not added to the activities care plan. The resident also lacked a care plan addressing refusal of care, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives, timeframes, and inclusion of services not provided due to the resident’s exercise of the right to refuse treatment.
A facility failed to follow its menu and standardized recipes for regular and therapeutic diets, affecting meals for many residents, including a resident with DM2, HLD, and HTN who was ordered NCS, consistent carb, cardiac, soft and bite sized, and thin liquids. During tray observations, the Dietary Supervisor found the cornbread lacked the expected chili flavor, and a cook stated he used boxed cornbread but forgot to add the chiles and sour cream. Staff stated the recipe was used to provide the right nutrients, calories, and flavor, and that the omission changed the taste of the food.
Advance Directive information and documentation were incomplete for three residents. One resident with DM, schizophrenia, and epilepsy had capacity to make decisions, but the ADAF did not show that written AD information or related rights were provided. Another resident with cancer, CVA, and atrial fibrillation had intact cognition and decision-making capacity, but the ADAF was incomplete and the latest form could not be found in the chart. A third resident with DM and parkinsonism had an AD noted on the ADAF, but staff could not locate a copy in the chart for ready reference.
Unsafe Room Conditions and Inaccurate Resident Clocks: A resident’s bed remote cord had exposed/frayed wires, another resident’s bathroom water measured below the facility’s stated range and remained lukewarm during observation, and two residents had room wall clocks that were not keeping correct time. The DON and other staff stated the equipment and water conditions were not in line with facility expectations, and residents reported the issues had persisted without being fixed.
A facility failed to ensure three residents were free from physical restraints when mid-siderails and a concave/bolstered bed were observed in use without the required physician orders, informed consent, restraint assessments, or care plans. Staff and the DON identified the devices as restraints, while RN review confirmed missing documentation and that one resident had an order for 1/4 side rails but was instead using mid-siderails. The residents had significant neurologic, mobility, and cognitive impairments, and the facility policy required restraint use only with the proper order and assessment.
The facility failed to ensure PRN lorazepam orders for two residents had stop dates and ongoing re-evaluation of need, including for residents on hospice/comfort care. It also failed to implement adverse-effect monitoring for a resident receiving Seroquel; the care plan called for monitoring for TCAP and other psychotropic complications, but the MDSC stated no such order was in place and the monitoring was not implemented.
Failure to Include Resident and Representatives in Care Plan Conferences: A resident with DM, dementia, and psychosis had moderately impaired cognition and needed substantial to maximal ADL assistance, yet the resident's emergency contacts said they were never notified or invited to care plan conferences or IDT meetings. The SSD stated there was no documentation of invites, emails, or phone calls, and no system in place for family notifications, despite conference notes showing attendance by the resident and responsible party.
The facility failed to follow insulin administration standards for two residents by not rotating SQ injection sites, with repeated use of the same abdominal areas documented for one resident and staff acknowledging the lack of rotation. The facility also failed to complete glucometer control solution testing correctly for a resident’s blood sugar check, with QA logs lacking recorded results and an LVN demonstrating a method that did not match the meter user guide. The DON stated the testing is intended to confirm the meter is functioning properly and accurately.
Pressure ulcer care was not provided as ordered for three residents with significant wounds and impaired function. A resident had a low air loss mattress in use without a physician order, two residents were observed on air mattresses set at incorrect settings for wound healing, and one resident’s wound vac ordered for continuous suction was found turned off and not functioning. The DON and treatment nurse acknowledged the mattress and wound vac issues.
Unlabeled urinals were observed in the rooms of three residents, including residents with urinary incontinence and toileting assistance needs. The TN and DON stated the urinals should have been labeled with the resident’s name, room number, and date provided to prevent switching, cross-contamination, and possible UTI, and the DON said staff did not follow the facility’s infection control protocol.
Failure to Rotate Insulin Injection Sites: Two residents receiving insulin had repeated subcutaneous injections documented in the same abdominal areas and, at times, the right arm instead of having sites rotated. RN and DON interviews confirmed that licensed staff did not follow the facility’s insulin administration policy, and the DON stated the repeated use of the same sites could cause skin integrity issues and lipodystrophy, affecting insulin absorption.
Medication storage and disposal practices were not followed on two med carts. An LPN kept lorazepam oral solution for two residents in a locked drawer without refrigeration labeling, stored topical meds in the same drawer as oral meds, and left a discontinued breathing treatment in a cart after a resident discharge. The DON and RPH stated the lorazepam required refrigeration and that discontinued meds should be removed from the cart right away.
A dietary service failed to serve hot and cold foods at proper temperatures during trayline and test tray observations, with puree turkey, puree cauliflower, and salad with dressing outside the facility’s stated ranges. The facility also did not follow the standardized cornbread recipe for regular and puree diets, as an LPN/cook used boxed cornbread and omitted chiles and sour cream, resulting in food that the DS described as lacking the expected flavor.
Puree diet/IDDSI level 4 foods were served with cauliflower and cornbread that did not hold shape and were weeping liquid. During trayline and test tray observation, the DS confirmed the food texture was not acceptable because fluid was separating from the food and stated puree items must hold their shape; the facility’s diet manual, recipes, and IDDSI guidance all required level 4 foods to be smooth, hold shape, and not separate.
Unsafe Kitchen Sanitation and Food Handling Practices: Kitchen observations found dust and dirt buildup on the walk-in refrigerator vent and racks, a soiled towel on the floor, cheese held above 41 F, no internal thermometer in the refrigerator, damaged food-contact surfaces including a peeling freezer rack, scratched cutting boards, and a discolored can opener. Staff also had hair exposed during food prep and trayline service, and QUAT sanitizer testing did not follow the test strip manufacturer’s instructions.
The facility had multiple infection control deficiencies involving an ice scooper stored in a mesh container instead of a closed container, a linen cart covered with a permeable mesh cover rather than a non-permeable cover, and a resident’s foam-padded side rails being cleaned with a disinfectant labeled for hard, non-porous surfaces. The IP, DON, and CSS identified the storage and cleaning practices during observation and record review, and facility policies and product labels did not match the observed practices.
Antibiotic Stewardship and Infection Surveillance Documentation Failures: The facility failed to complete required surveillance forms and the monthly infection surveillance log for two residents receiving antibiotics for UTI and pneumonia. Records reviewed by the DSD, IP, and DON showed the residents’ charts did not document the clinical signs and symptoms, mental status, or culture results needed to support the antibiotic orders, and the Surveillance Data Collection forms indicated the residents did not meet criteria for the antibiotics prescribed.
Call Light Not Kept Within Reach for High-Fall-Risk Resident: A resident with dementia, cerebral palsy, schizoaffective disorder, weakness, and poor coordination was totally dependent on staff and assessed as always disoriented, chair bound, and at high risk for falls. Although the care plan required the call light to be within reach, surveyors observed the call light cord wrapped around the bedside rail and resting on the floor, out of the resident’s reach, while CNAs entered and exited the room. The resident said she needed assistance and did not have a call light, and an LVN and the DON both confirmed it should have been within reach.
A resident with COPD, HIV, and DM received personal mail opened by the SSD instead of unopened and in private. The SSD opened the resident’s share of cost letter, addressed to the resident, to determine payment information for the facility, and the resident stated he was upset. The DON confirmed residents have the right to personal mail unopened and that staff should not open it without consent.
Failure to Provide Written NOMNC and SNF ABN Notices: The SSD did not provide completed written NOMNC and SNF ABN forms to two residents or their RPs when Medicare Part A coverage was ending. One resident had limited ability to understand and make decisions, while the other was cognitively able to understand and decide. In both cases, the forms were signed by the SSD only, had no resident or RP signature, and the SNF ABN options were left blank.
Failure to Protect Confidential Dietary Records: A dietary aide was observed discarding meal tickets with residents' names, room numbers, diet orders, and allergy information into the trash by the dishwashing area. The DS stated the tickets were routinely thrown in the trash and then taken to the dumpster, and the RD and DON acknowledged the tickets contained protected information and should be shredded or placed in a confidential disposal bin per facility policy.
A resident with DM, ESRD, and insulin use had blood sugar checked with a glucometer and received Humalog after a reading of 304. Surveyors found that QA logs for two glucometers lacked documented control results on reviewed dates, and staff stated the control testing should have had recorded results but could not locate them.
Medication Left at Bedside: A resident with major depressive disorder, GERD, dysphagia, and moderate cognitive impairment had a cream/ointment left in a medication cup on top of the bedside drawer despite no topical order on the chart and no MSA completed. The TN, RN, and DON all stated medications should not be left at the bedside because other confused residents could access and accidentally ingest them, and the resident’s care plan included an intervention to provide a safe environment.
A resident with DM and an order for insulin Lispro had insulin removed from the insulin e-kit, but staff did not ensure the e-kit was replaced within the facility’s 72-hour timeframe. An LVN stated the kit had been opened and the insulin needed replacement, while an RN said there was no e-kit log and did not know the replacement timeframe. The DON confirmed the kit should be replaced within 72 hours and that the facility did not have an e-kit log, despite the policy requiring replacement of opened kits or added doses within 72 hours.
Failure to Monitor Anticoagulant Therapy for Adverse Effects: The facility failed to ensure adequate monitoring for adverse effects for two residents receiving anticoagulants. One resident received rivaroxaban and another received warfarin sodium, but neither the OSR nor MAR included medication-specific monitoring orders for adverse effects. Although both care plans addressed bleeding and bruising risk with daily skin checks and reporting unusual bleeding, RN and DON interviews confirmed that monitoring orders for the anticoagulants themselves were not in place and the facility’s anticoagulation protocol was not followed.
A resident with gout, atrial fibrillation, and COPD refused Colace during a med pass, but the LVN documented the stool softener as given even though it was not administered. The resident had the capacity to make decisions, and the DON stated the inaccurate MAR entry was not objective, complete, or accurate.
Failure to Offer Pneumococcal Vaccine After Admission: A resident with UTI, DM2, and generalized weakness had a pneumococcal vaccine that was not up to date. Although the resident consented to receive the vaccine, the ADON stated a physician order had not been obtained and the vaccine had not been ordered from the pharmacy. The IP stated the vaccine was not offered on admission because it was not available in the facility, despite CAIR2 showing another dose was recommended and the facility policy requiring vaccines to be offered during admission.
A resident with parkinsonism, weakness, unsteady gait, impaired vision, and moderate cognitive impairment had a high fall risk and needed supervision with mobility and ADLs. Staff observed that the call light on one bed was not working, and the alternate call light provided had frayed/exposed wires. An LVN, RN, and DON all acknowledged that call lights should be functional and free of frayed wires, and the facility policy required the resident call system to remain functional at all times.
Failure to Notify Physician of PICC Site Bleeding: A resident with anemia, AFib, HF, and anticoagulant/antiplatelet use had fresh bleeding at a newly inserted PICC site after the procedure. An RN applied pressure until the bleeding stopped, but the event was not documented on SBAR/COC and the primary MD was not notified. The PICC RN remained charting at the nurses’ station, and the DON stated the incident should have been communicated to the provider for further orders.
Failure to develop and implement person-centered care plans for two residents with PICC lines and IV antibiotics. One resident had cellulitis, DM with foot ulcer, and a chronic foot ulcer; the other had pneumonia, heart failure, and UTI. Records showed PICC-related orders and IV therapy, but RN and DON stated no PICC care plans were in place to guide safe maintenance and management.
Daily staffing information was not updated at the reception desk and on the whiteboard, with postings still showing an older date during observations. RN 1 and the DSD confirmed the DSD was responsible for updating the postings, and the DON stated the facility policy required staffing numbers to be posted at the start of each shift for visitors and family members to see.
Excess Occupancy in Resident Room: A survey found one resident room with five beds, although only four residents were occupying it at the time. A CNA stated the room normally had five beds and reported no space issues, while the DON reviewed a waiver request for the five-bed capacity. Facility records showed the room measured 461.15 sq ft, and the facility policy and CA Title 22 required no more than four residents per room.
A resident with intact cognition and a history of joint replacement, depression, and anxiety reported to the SSD that a transportation company personnel inappropriately touched her face and made inappropriate comments. Although the SSD notified the DON and Administrator, the incident was not reported to the SSA until 27 days later, despite facility policy requiring reporting within two hours.
A resident with a history of depression and anxiety reported being inappropriately touched by transportation personnel. Following the report, neither licensed nurses nor social services documented any monitoring of the resident's psychological or psychosocial health, despite facility policy requiring such actions for residents with behavioral health needs.
A resident reported being verbally and physically abused by a CNA, but the facility failed to report the incident to the SSA within the required two-hour timeframe. The misunderstanding of the facility's policy by the DON and ADM led to the delay, as they believed incidents without bodily injury could be reported within 24 hours. The facility's policy was outdated and incorrectly interpreted, contributing to the deficiency.
A resident with a fracture, diabetes, and hypertension alleged abuse by a CNA, but the LVN failed to document this in the medical record. The DON confirmed the omission, which violated the facility's documentation policy, potentially leading to confusion in care.
A resident with dysphagia was served improperly prepared pureed food that did not meet IDDSI Level 4 standards, including bread soaked in milk, lumpy oatmeal, and non-pureed scrambled eggs. The dietary staff failed to follow recipes, posing a risk to the resident's safety.
The facility failed to properly dispose of garbage, with a kitchen trash can lacking a plastic liner and an overflowing dumpster not fully closed. These issues were acknowledged by the Dietary and Maintenance Supervisors as unacceptable due to potential pest attraction and germ spread, contrary to facility policies and the Food Code 2022.
A facility failed to ensure the Infection Preventionist (IP) was competent in managing a scabies outbreak. A resident diagnosed with scabies was removed from isolation prematurely, contrary to policy, risking the spread of infestation. The IP was unsure of the correct isolation duration and did not report the case to the state agency as required. The Director of Nursing highlighted the importance of IP competence in infection control to prevent transmission risks.
The facility failed to properly dispose of discontinued medications for three residents, did not label multidose medication bottles with open dates, and did not maintain accurate records for controlled substances. These deficiencies were observed during a survey, with staff acknowledging the lapses in following facility policies.
The facility failed to ensure kitchen staff were trained and evaluated for competency, leading to improper preparation and portioning of meals. Staff did not follow recipes for regular and puree diets, resulting in potential nutritional inadequacies for residents. The Director of Food Services acknowledged the lack of competency evaluations for staff.
The facility failed to adhere to the prescribed menu and portion sizes, affecting 62 out of 63 residents on regular and puree diets. The staff could not locate the menu spreadsheet, leading to incorrect portion sizes and deviations from the menu, such as serving plain scrambled eggs instead of puree baked Western omelet and regular cake instead of coffee cake. Incorrect scoop sizes were also used, potentially causing unintended weight changes among residents.
The facility failed to follow food preparation guidelines, resulting in a plain cake instead of coffee cake and incorrect portion sizes for a baked Western omelet. These deviations affected the taste, flavor, and presentation of the food, potentially leading to unplanned weight loss among residents.
The facility failed to maintain safe food storage and preparation practices, with expired and undated foods in the refrigerator, improper hand hygiene by staff, and unclean food preparation areas. These deficiencies could lead to contamination and illness among residents.
The facility did not designate a Medical Director (MD) for 12 months, lacking a job description or policy outlining the MD's responsibilities in coordinating medical care. Interviews revealed that while the MD was involved in resident care and attended quality assurance meetings, the absence of formal documentation could lead to confusion among staff regarding clinical decision-making and accountability.
The facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their clinical documentation. A resident with Alzheimer's disease did not have showers accurately documented, and their hygiene needs were not properly addressed. Another resident with hemiplegia was incorrectly documented as having received a shower when only a bed bath was provided due to equipment unavailability. These discrepancies highlight a failure to adhere to the facility's policy on accurate documentation.
The facility failed to implement effective infection control measures, including not following the water management plan to prevent legionella, maintaining a sanitary medication room, and ensuring proper contact isolation for a resident with scabies. Additionally, a resident was observed using a nasal cannula without a labeled date, increasing infection risk.
The facility failed to maintain the dignity of two residents by not ensuring proper feeding assistance and failing to provide a shower. A CNA stood over a resident while assisting with a meal, contrary to policy requiring sitting at eye level. Another resident, dependent on staff for showering, did not receive a shower due to insufficient slings for mechanical lifts, receiving a bed bath instead.
A facility failed to inform a resident and their representative about the right to formulate an advance directive upon admission. The resident, with fluctuating decision-making capacity due to developmental delay, had no advance directive noted in their records. Interviews with staff confirmed the absence of documentation offering an advance directive, despite the facility's policy requiring such information to be provided.
A resident with severe cognitive impairment and a history of infections did not receive a complete course of azithromycin due to the facility's failure to notify the physician about the unavailability of the medication. The prescribed doses were missed for three consecutive days, and the facility's staff did not follow the policy of informing the physician to obtain new orders.
Failure to Care Plan for Refusal of Care and Assistance With Activities
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s refusal of care and need for assistance with activities. The resident, originally admitted with encephalopathy, epilepsy, and essential hypertension, had an MDS dated 1/5/2026 indicating severely impaired cognitive function and dependence on staff for multiple ADLs, including oral care, toileting, bathing, lower body dressing, and personal hygiene. Observations on 2/19/2026 and 2/20/2026 found the resident in bed, either asleep or watching television. A CNA reported that on 2/19/2026 the resident initially refused a shower, sometimes screaming when refusing in the past, but was later convinced to shower. The CNA also stated the resident did not want to participate in activities on 2/19/2026 and 2/20/2026, and acknowledged not informing the charge nurse of the resident’s refusal to participate in activities. During concurrent interview and record review, an RN confirmed there was no documentation in the prior 72 hours that the resident had been offered or had refused activities, despite the expectation that such offers and refusals be documented and that residents have the right to decline. The RN also confirmed that the resident did not have a care plan addressing refusal of care. Review of an Activities-Quarterly/Annual Participation Review dated 1/5/2026 showed the resident had very little participation in group activities due to physical limitations and that new interventions were to include assistance to and from group activities. However, the resident’s activities care plan dated 3/31/2026 did not include the intervention that assistance would be provided to and from group activities. The facility’s policy on comprehensive person-centered care plans required measurable objectives, timeframes, and inclusion of services not provided due to the resident exercising the right to refuse treatment, but these elements were not reflected in the resident’s care plan related to refusal of care and activity participation.
Menu and Recipe Noncompliance Affecting Meal Quality
Penalty
Summary
The facility failed to follow the menu and did not meet the nutritional needs of 59 of 63 residents on regular and therapeutic diets, including a resident admitted with type 2 diabetes, hyperlipidemia, and essential hypertension. The resident’s record showed orders for a no added salt diet, consistent carbohydrate diet, cardiac diet, soft and bite sized texture, and thin liquids. During interview, the resident stated the food “sucks,” does not taste like anything, and reported having pancakes and rice for breakfast that tasted strange. On 12/1/2025, the daily cook’s spreadsheet for the winter menu listed regular diet cornbread with green chilis and puree diet puree cornbread. During a test tray observation, the Dietary Supervisor stated the regular cornbread was good but not flavorful and said she needed to check the recipe because the spreadsheet indicated green chili but there was no chili taste. During the puree tray observation, the Dietary Supervisor stated the puree cornbread tasted like regular bread and that boxed cornbread was used. On 12/2/2025, [NAME] 1 stated he made the cornbread from the box and forgot to add the chiles and sour cream, and that this affected the flavor and could lead residents to complain about it. The Dietary Supervisor stated staff follow standardized recipes so residents get the right nutrients, calories, and good flavors, and stated that forgetting the chili and sour cream changed the flavor and could result in residents not liking the food and not eating it. The facility’s Food Preparation policy required approved standardized recipes with specific ingredients, portions, methods, and time and temperature guidelines, and the recipe for cornbread with green chiles required boxed cornbread mix with canned green chilies and sour cream.
Advance Directive information and documentation were incomplete
Penalty
Summary
The facility failed to ensure residents’ rights to formulate an Advance Directive (AD) for three sampled residents. For Resident 2, the record showed the resident was admitted with diagnoses including DM, schizophrenia, and epilepsy, and later assessments indicated the resident could understand others, make himself understood, and had capacity to understand and make decisions. The resident’s Advance Directive Acknowledgement form indicated he did not have an AD, but the form was not completed to show that he was given written materials about the right to accept or refuse medical treatment, informed of the right to formulate an AD, told that an AD was not required to receive treatment, or informed that any executed AD would be followed. For Resident 11, the record showed the resident was readmitted with diagnoses including malignant neoplasm of the large intestine, CVA, and atrial fibrillation. The H&P and MDS indicated the resident had capacity to understand and make decisions, could make self understood, understood others, had intact cognition, and actively participated in assessment and goal setting. The resident’s ADAF dated 12/26/2014 did not specify that written materials about the right to accept or refuse medical treatment were provided, that the resident was informed of the right to formulate an AD, that the resident understood an AD was not required for treatment, or that any executed AD would be followed. Staff also could not locate the latest ADAF in the medical chart or electronic chart, and the SSD found the old form incompletely filled out. For Resident 59, the record showed the resident was admitted with diagnoses including type 2 DM, parkinsonism, and long-term insulin use. The H&P indicated the resident had capacity to understand and make decisions, and the MDS showed the resident could make self understood, usually understood others, had moderately impaired cognition, and the resident and family actively participated in assessment and goal setting. The ADAF indicated the resident had an AD, but staff could not find a copy of the AD in the medical chart. The SSD stated the facility had not been able to secure a copy from the resident or representative, that seven days was a reasonable time to obtain it, and that more than seven days had passed since follow-up for the copy to be placed in the chart.
Unsafe Room Conditions and Inaccurate Resident Clocks
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by leaving a resident’s bed remote control cord with exposed and frayed wires. Resident 20 was admitted with paraplegia, muscle weakness, and lack of coordination, and records showed the resident had the capacity to understand and make decisions. During a concurrent observation and interview, the bed remote control cord was seen coiled on the left upper side rail with exposed/frayed wires. The Treatment Nurse stated the cord should not have exposed wires and that broken equipment should be reported immediately because it could create hazards. The DON later stated staff were responsible for identifying hazards during environment safety checks and that the facility’s Environmental Services Safety policy was not followed. The facility also failed to maintain Resident 55’s bathroom hot water within the stated temperature range. Resident 55 was admitted with cerebral infarction, aphasia, and unsteadiness on feet, and records indicated the resident had the capacity to understand and make decisions. The resident stated the bathroom water did not warm up enough for bathing and remained cold. During observation, the faucet was run for 5 to 10 minutes and the water temperature remained lukewarm. The Manager of Housekeeping, Linens, and Maintenance measured the water at 95 to 96 degrees F and stated the hot water should be 115 degrees F, noting the room’s distance from the boiler as a possible reason. The DON stated the water temperature should be within 105 to 120 degrees F and that staff should have reported the issue to Maintenance. The facility further failed to maintain accurate wall clocks in the rooms of Residents 19 and 69. Resident 19 was admitted with diagnoses including cerebral infarction affecting the left non-dominant side, anxiety disorder, and diabetes mellitus, and the MDS showed moderately impaired cognition with substantial/maximal assistance needed for ADLs; the physician note stated the resident had capacity to understand and make decisions. Resident 19 stated the wall clock had shown the wrong time since admission and that staff had not fixed it; the clock was observed reading 8:45 a.m. Resident 69 was admitted with diabetes mellitus, major depressive disorder, and a right arm fracture, and records showed moderately impaired cognition with substantial/maximal assistance needed for ADLs; the IMIE stated the resident had capacity to understand and make decisions. Resident 69 stated the clock was wrong and staff had not been able to fix it; the clock was observed reading 2:59. The Maintenance Supervisor stated room clocks should be working and batteries changed, and the DON stated room clocks should read the correct time for resident orientation and planning.
Unordered Bed Restraints Used Without Required Documentation
Penalty
Summary
The facility failed to ensure three sampled residents were free from the use of physical restraints unless needed for medical treatment. For Resident 62, the record showed admission with encephalopathy, epilepsy, and nontraumatic intracerebral hemorrhage, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severe cognitive impairment, dependence for mobility and ADLs, and highly impaired vision. During observation, the resident had mid-siderails on both sides of the bed and a mattress with built-in bolsters tucked under the sheet. Staff and the DON identified both the mid-siderails and the concave/bolstered bed as restraints, but the OSR did not show an order for either device, and there was no restraint assessment, informed consent, or care plan for their use. For Resident 11, the record showed diagnoses including hemiplegia, hemiparesis, and cerebrovascular disease. The H&P stated the resident had capacity to understand and make decisions, and the MDS indicated intact cognition with dependence to setup assistance for mobility and ADLs. The OSR contained an order for bilateral 1/4 side rails up in bed to aid mobility, positioning, and transfer, but during observation the resident had mid-siderails on both sides of the bed. Staff stated the mid-siderails were restraints because they restricted movement and could not be lowered by the resident. RN 1 stated there was no order for mid-siderails, no entrapment assessment, and no care plan for their use. For Resident 59, the record showed admission with parkinsonism, muscle weakness, and unsteadiness on feet. The H&P stated the resident had capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment, highly impaired vision, and dependence to supervision assistance for mobility and ADLs. The OSR did not show an order for mid-siderails, yet observation showed mid-siderails on both sides of the bed. Staff stated the mid-siderails were restraints, and RN 1 stated there was no order for mid-siderails, no assessment for entrapment, and no care plan for their use. The facility policy stated restraints require a physician order, informed consent, pre-restraint assessment, and care plan, and the DON stated the licensed staff did not follow the policy because the restraints were applied without the required elements.
Unnecessary psychotropic medication orders and missing adverse-effect monitoring
Penalty
Summary
The facility failed to ensure two residents receiving PRN lorazepam had psychotropic medication orders with an end date and ongoing re-evaluation of need. Resident 5 was admitted and later re-admitted with diagnoses including COPD with acute exacerbation, HIV, and DM, and was on hospice care. The resident’s record showed a PRN lorazepam oral concentrate order for shortness of breath, anxiety, and restlessness with no stop date. The MDSC stated lorazepam is a psychotropic medication with a high risk for adverse effects and that PRN psychotropics require routine physician evaluation and a stop date. The DON stated PRN psychotropic medications are ordered with a 14-day stop date and that even hospice residents receiving PRN psychotropics need a stop date. Resident 32 was admitted and later re-admitted with diagnoses including post procedural peritoneal adhesions, anxiety disorder, and joint pain. The resident’s record showed comfort care status and DNR/DNI status. The resident had a PRN lorazepam oral concentrate order for anxiety manifested by hyperventilating leading to SOB/fidgety, also with no end date. During interview, the MDSC stated lorazepam is a psychotropic medication with a high risk for adverse effects and that PRN psychotropics require routine evaluation. The DON stated PRN psychotropic medications are ordered with a 14-day stop date and that hospice status does not remove the need for a stop date. The facility also failed to monitor adverse effects for Seroquel for Resident 2. Resident 2 had diagnoses including vitamin D deficiency, schizophrenia, epilepsy, and dementia, and the record showed the resident could make self-understood and had the capacity to understand and make decisions. The order summary showed Seroquel 12.5 mg at bedtime for schizoaffective disorder manifested by auditory and visual hallucinations. The care plan included monitoring for psychotropic drug-related complications such as tardive dyskinesia, cognitive impairment, akathisia, and Parkinsonism, but the MDSC stated there was no order for TCAP monitoring and that the care plan to monitor adverse effects for Seroquel had not been implemented. The DON stated there should be an order for adverse effects monitoring for Seroquel, including TCAP, to identify adverse effects and adjust the medication accordingly.
Failure to Include Resident and Representatives in Care Plan Conferences
Penalty
Summary
The facility failed to ensure that Resident 29 was afforded the opportunity to participate in the development of the resident's care plan. Resident 29 was admitted on 2/21/2023 and readmitted on [DATE], with diagnoses including DM, dementia with other behavioral disturbances, and psychosis. The MDS dated 11/4/2025 indicated the resident's cognitive ability was moderately impaired and that the resident required substantial to maximal assistance with ADLs. A physician progress note dated 11/14/2025 stated the resident was able to make needs known but could not make medical decisions. The care plan report dated 7/18/2023 included encouragement of family involvement and inviting the resident's family to special events, activities, and meals. However, the resident's emergency contacts stated they had not been made aware of any care plan conferences or interdisciplinary team meetings and had not been invited to participate. The SSD stated there was no documentation of invites, emails, or telephone calls to the resident or representatives for care plan conferences, and that there was no system in place for such notifications. Although quarterly/annual care conference notes dated 2/7/2025, 5/6/2025, 8/5/2025, and 11/4/2025 indicated the resident and responsible party attended, both emergency contacts denied attending or being invited.
Insulin Site Rotation and Glucometer QA Failures
Penalty
Summary
The facility failed to ensure professional standards were met in insulin administration by not rotating subcutaneous injection sites for two sampled residents. One resident was admitted with type 2 DM, diabetic chronic kidney disease, and long-term insulin use, and the record showed repeated insulin lispro injections in the same abdominal areas, including the right lower quadrant and left lower quadrant on multiple administrations. RN 1 stated there were multiple instances where licensed staff did not rotate the insulin administration sites, and stated the facility’s electronic record showed where the last insulin dose had been given. The DON stated the insulin sites should have been rotated to prevent skin integrity issues such as bruising and scar tissue buildup, which she identified as lipodystrophy. A second resident was admitted with long-term insulin use, and the record showed an order for Novolin R insulin given subcutaneously before meals based on sliding scale blood sugars. The facility’s insulin administration policy stated injection sites should be rotated, preferably within the same general area, and the insulin manufacturer instructions also directed that injection sites be changed within the chosen area for each dose. The report identified that the licensed staff did not follow the facility’s insulin administration procedure for these residents. The facility also failed to perform glucometer control solution testing according to the user guide for one resident observed during a blood sugar check. During observation, an LVN obtained a blood glucose reading of 304 and administered Humalog insulin. Review of the glucometer QA logs showed control testing entries signed by an LVN on multiple dates, but the corresponding high and low results were not documented on the logs for some of those dates. LVN 3 stated he could not find the control results to confirm the documented QA log entries and stated he did not do the control solution testing on two of the dates. During demonstration, LVN 3 performed control testing by applying solution directly from the bottle to the test strip, which differed from the user guide instructions requiring the solution to be placed on a clean, dry, non-absorbent surface before touching the strip to the drop. The DON stated the control solution testing is done daily to ensure the meter is functioning properly and accurately.
Pressure ulcer care not provided as ordered
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for three sampled residents with existing pressure injuries. Resident 75 was admitted with multiple pressure ulcers, including unstageable wounds of the sacral region and buttocks and a stage 3 left heel ulcer. The resident’s care plan included a pressure relief/reduction mattress, and staff placed the resident on a low air loss mattress, but the order summary did not show a physician order for that mattress. During interview, the treatment nurse stated he was unable to obtain a physician order for the low air loss mattress and acknowledged that an order was important for safe use and to keep the physician informed of the treatment being provided. Resident 9 was admitted with a stage 3 sacral pressure ulcer, severe cognitive impairment, quadriplegia, and dependence for all ADLs. The physician ordered a low air loss mattress for wound management and ordered a Medela wound vac to the sacrum at 125 mmHg continuous suction. During observation, Resident 9 was in bed on the low air loss mattress with the comfort setting at 120-130, cycle time off, and therapy mode set at static. The mattress manual described comfort setting as controlling air pressure output and therapy mode options including static and alternating pressure. The treatment nurse stated the resident and another resident were on air mattresses set at incorrect settings. Resident 9’s wound vac was also observed turned off and not functioning even though the order was for continuous suction; the treatment nurse and wound care MD both stated it should not have been off. Resident 10 was admitted with an unstageable sacral pressure ulcer, severe cognitive impairment, and dependence for all ADLs. The physician ordered a low air loss mattress for pressure injury management, and the care plan directed use of the mattress at a setting between 70 and 105 pounds. During observation, Resident 10 was in bed on a micro air alternating pressure with low air loss mattress set at 3, which corresponded to 106-140 pounds. The treatment nurse stated Resident 9 and Resident 10 were on air mattresses set at incorrect settings and that this error put the residents at risk for further skin breakdown. The DON also stated that incorrect mattress settings and Resident 9’s wound vac being left off could cause further damage to skin integrity and worsen the wound.
Unlabeled Urinals for Three Residents
Penalty
Summary
The facility failed to ensure that the urinals used by three residents who were incontinent of bladder were labeled with the resident’s name, room number, and the date the urinal was provided. During a concurrent observation and interview, Resident 11’s urinal was seen hanging on the left side rail in the room without any label. The Treatment Nurse stated the urinal should be labeled to prevent switching of urinals among residents and cross-contamination that could cause infections such as UTI. The Director of Nursing later stated the urinal should have been labeled for infection control and that the date helps staff monitor how long the resident has been using it because urinals are replaced weekly. Resident 42’s record showed diagnoses including benign prostatic hyperplasia and urge incontinence, and the MDS indicated the resident was dependent on toileting hygiene and always incontinent of urine and bowels. Resident 42’s urinal was also observed hanging on the left side rail without a label. The Treatment Nurse gave the same explanation that labeling was needed to prevent switching of urinals and cross-contamination. The DON stated the staff did not follow the facility’s infection control protocol. Resident 15’s record showed diagnoses including hemiplegia, hemiparesis, and benign prostatic hyperplasia, and the MDS indicated the resident required supervision with toileting hygiene and was always continent of urine. Resident 15’s urinal was likewise observed hanging on the left side rail without the resident’s name, room number, or date provided. The DON stated the urinal should have been labeled for infection control and that the staff did not follow the policy titled Infections-Clinical Protocol.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that two residents receiving insulin were free from significant medication errors by not rotating subcutaneous insulin administration sites. For Resident 6, the record showed an admission diagnosis of type 2 DM with diabetic chronic kidney disease and long-term insulin use. The resident’s orders included Insulin Lispro by sliding scale before meals and at bedtime. The Location of Administration Report showed repeated insulin injections given in the same abdominal areas on multiple occasions, including the LLQ, LUQ, RUQ, RLQ, and right arm, with several consecutive doses documented in the same site before moving to another site. For Resident 4, the record showed a diagnosis of long-term insulin use and an order for Novolin R by sliding scale before meals. The Location of Administration Report showed repeated injections in the same abdominal areas, including the RUQ, LLQ, and LUQ, with later doses also given in the right arm. During the concurrent interview and record review, RN 1 stated there were multiple instances where licensed staff did not rotate the insulin administration sites for both residents and stated that the electronic record showed where the last insulin dose had been given. RN 1 stated the staff were probably in a hurry and were ignoring the administration instructions, and stated that failing to rotate insulin sites can lead to skin trauma, bruising, and lipodystrophy. The DON stated the insulin sites should have been rotated to prevent skin integrity issues and scar tissue buildup, identified as lipodystrophy, and stated that this buildup affects insulin absorption and can cause hypo or hyperglycemia. The facility’s policy required insulin injection sites to be rotated, preferably within the same general area, and the manufacturer’s instructions for Insulin Lispro also directed site rotation to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.
Medication Storage and Disposal Errors on Two Med Carts
Penalty
Summary
The facility failed to ensure safe handling and storage of medications on two medication carts. On Med Cart 3, opened bottles of lorazepam oral solution for two residents were stored in the locked controlled-medication drawer without refrigeration instructions on the labels, even though the manufacturer specifications required refrigeration at 36°F to 46°F and discarding opened bottles after 90 days. The registered pharmacist stated the medication must be refrigerated at all times because otherwise its efficacy is reduced, and the DON stated improper storage could affect the medication and make it ineffective for treating anxiety. Med Cart 3 also contained Resident 18’s diclofenac gel and lidocaine cream in the same drawer as routine orally administered medications. LVN 1 stated these external-use medications were kept in the medication cart drawer with oral bubble-pack medications because the nurse administering them was not the treatment nurse. The facility’s policies stated orally administered medications are to be kept separate from externally used medications and that external-use medications are to be stored separately from other medications. On Med Cart 1, Resident 74’s ipratropium/albuterol solution remained in the cart after the resident had been discharged. LVN 2 stated the resident had been discharged and the medication should have been removed from the cart. The DON stated discontinued medications should be removed right away and should not remain in the cart to prevent inadvertent use by other residents. The facility policy stated discontinued or discharged residents’ medications are to be marked discontinued and destroyed, and medications are to be removed from the medication cart immediately upon receipt of a discontinue order.
Food Temperature and Recipe Preparation Deficiencies
Penalty
Summary
The facility failed to prepare and serve food at temperatures that conserved flavor and temperature during lunch service. During trayline observation, puree turkey was measured at 136 F. During test tray observations, puree cauliflower was measured at 105 F and salad with dressing was measured at 46 F. The Dietary Supervisor stated food needed to be at the right temperatures, with the acceptable range being 135 F for hot food and 41 F for cold food during tray distribution, and stated residents would not want to eat food that was cold. The facility’s policies and standardized recipes required food to be prepared by methods that conserve nutritive value, flavor, and appearance, and to be served at recommended temperatures. The policy for Meal Service stated the goal is to serve cold food cold and hot food hot, with suggested delivery temperatures including salads at 45 F or less and vegetables at 120 F or more. The standardized recipes for pureed meats and vegetables directed that they be served on trayline at 160 F to 180 F, and the salad recipe directed that it be served at 41 F or less. The facility also failed to follow the standardized cornbread recipe for all diets. The regular diet spreadsheet listed cornbread with green chilis, and the puree diet spreadsheet listed puree cornbread. During test tray observation, the Dietary Supervisor stated the cornbread was not flavorful and needed to check the recipe because there was no chili taste. The puree cornbread tasted like regular bread and was made from a box. The cook stated he made the cornbread from the box but forgot to add the chiles and sour cream, and stated that not adding those ingredients affected the flavor and that residents would not eat it and complain about it.
Puree Diet Foods Failed to Hold Shape
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet/IDDSI level 4 received puree cauliflower and puree cornbread that did not hold their shape on the plate and were weeping liquid. During trayline observation, the puree food was seen looking flat on the residents’ plates. During the puree test tray observation and interview with the Dietary Supervisor, the supervisor stated the puree cauliflower and puree cornbread had fluid separating and coming from the plate cover, and stated this was not okay because it changed the food texture. The Dietary Supervisor stated puree food must hold its shape on the plate and that the puree cauliflower and puree cornbread were not holding their shapes. The supervisor also stated residents could choke if there was fluid coming out of the puree foods. The facility’s diet manual and recipes for IDDSI level 4 foods stated the finished pureed item should be smooth, free of lumps, hold its shape, and should not weep, and the IDDSI guideline stated level 4 pureed food should hold shape on the plate and liquid must not separate from solid.
Unsafe Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During the initial kitchen tour, the walk-in refrigerator vent had dust and dirt buildup, two silver racks in the walk-in refrigerator had dust and dirt buildup, and a soiled, wet towel was on the floor. The Dietary Supervisor stated the vent should be clean so it could circulate air, the racks needed cleaning because dirt buildup could contaminate food, and the towel should have been disposed of after use because it could spread bacteria to food. Food storage temperatures were also not maintained as observed. Shredded jack cheese in the walk-in refrigerator was 44.5 F and shredded cheddar cheese was 43.5 F and 44.1 F. The Dietary Supervisor stated the walk-in refrigerator was maintained at 41 F and below to avoid danger zone temperatures and stated both cheeses were in the danger zone and had to be disposed of because bacteria could grow in them. The refrigerator also had no internal thermometer, and the Dietary Supervisor stated they only checked the outside gauge and did not place an additional thermometer inside to measure the warmest area of the unit. Kitchen equipment and food-contact surfaces were observed in poor condition. The black rack in the walk-in freezer had peeling paint and dirt accumulation, the green and brown chopping boards had scratches, and the can opener blade and body had amber discoloration. Staff hair was not fully covered during food preparation and trayline service, with hair sticking out from hats and hairnets. In addition, the QUAT sanitizer testing process did not follow the manufacturer’s instructions: the test strip was dipped for 10 seconds instead of the instructed 10 seconds noted by the aide and 20 seconds stated by the Dietary Supervisor, the solution temperature was 63 F, and the manufacturer’s instructions required the testing solution to be between 65 F and 75 F. The Dietary Supervisor stated the manufacturer’s guidelines should be followed to ensure the sanitizer concentration was read correctly.
Infection Control Deficiencies With Ice Scoop Storage, Linen Cart Covering, and Cleaning of Porous Side Rails
Penalty
Summary
The facility failed to maintain an infection prevention and control program in several observed areas. During an observation and interview, two ice carts were found with ice scoopers placed in a mesh material container, and later one cart was observed with the ice scooper missing from the container. The Infection Preventionist stated the scooper should have been placed in a storage container after use because it was already contaminated when staff touched the handle, and that storing it in a permeable sack was not appropriate because it could be exposed to dust and contaminants in the environment. The facility policy for Ice Procedures stated a covered plastic or stainless container will be used to hold the scoop and that the scoop is not to be left in the ice at any time. The facility also failed to protect clean linens during transport and storage. A linen cart in the hallway had a breathable, permeable mesh cover rather than a non-permeable cover, and the Infection Preventionist stated the cover was not protecting the linens from contaminants. The Infection Preventionist stated the linen cart cover should have been non-permeable to protect the linens from dust and other bacteria dispersed in the environment. The facility policy for Laundry and Bedding, Soiled stated clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. Resident 29’s upper bilateral side rails were padded with foam tube noodles, and staff were observed cleaning the porous padding with DC 1. Housekeeping staff stated they used DC 1 wipes on the foam pads, while the Infection Preventionist and DON reviewed the product information and stated DC 1 and DC 2 were designed for hard, non-porous surfaces. The CSS stated DC 2 was used for porous surfaces such as pillows, cloth chairs, and foam side rails, but the product label and SDS reviewed by the facility indicated DC 2 was also for hard, non-porous inanimate surfaces. The SDS for DC 1 and DC 2 identified eye irritation and other exposure precautions, and the DON stated the foam tube covering the side rails could absorb the chemicals and be harmful to residents when they come in contact with them or ingest them.
Antibiotic Stewardship and Infection Surveillance Documentation Failures
Penalty
Summary
The facility failed to implement its antibiotic stewardship and infection prevention and control processes for two residents by not completing required Surveillance Data Collection forms and by not fully documenting the monthly Infection Prevention and Control Surveillance Log. For one resident, the record showed a physician order for ciprofloxacin for UTI, but the Surveillance Data Collection form for residents with UTIs without an indwelling catheter had no check marks showing that the resident met the criteria for antibiotic use. The Infection Prevention and Control Surveillance Log for the month did not indicate the resident’s signs and symptoms of UTI, mental status, or culture result. The resident’s record included diagnoses of dementia, enterocolitis due to C. diff, and schizophrenia, and the H&P and MDS showed impaired cognition and dependence for ADLs. For the second resident, the record showed a physician order for ceftriaxone for community acquired pneumonia that was later changed to Augmentin. The Surveillance Data Collection form for respiratory tract infections showed check marks for a chest radiograph demonstrating pneumonia or a new infiltrate and for low oxygen saturation, but the Infection Prevention and Control Surveillance Log did not indicate the resident’s signs and symptoms of respiratory infection or pneumonia, mental status, or culture result. The resident’s record included diagnoses of pneumonia, dementia, and psychosis, and the H&P and MDS showed the resident was unable to make medical decisions, had severely impaired cognition, and required extensive assistance with ADLs. During interviews, the DSD, IP, and DON reviewed the records and stated the Infection Prevention and Control Surveillance Log and nurses’ notes did not show clinical signs and symptoms for either resident. They also stated the Surveillance Data Collection forms indicated that both residents did not meet criteria for the antibiotics ordered. The IP stated she did not notify the physician that the residents did not meet criteria for the antibiotics, and the DON stated the physician should have been notified when the criteria were not met. The facility policy for antimicrobial stewardship stated the IP was responsible for infection surveillance and MDRO tracking, including review of whether a culture was obtained before ordering an antibiotic and whether the antibiotic was changed during treatment.
Call Light Not Kept Within Reach for High-Fall-Risk Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of a resident’s needs and preferences by not keeping the call light within reach for a resident who was totally dependent on staff for eating, mobility, dressing, bathing, toileting, and oral and personal hygiene. The resident had diagnoses including unspecified dementia, cerebral palsy, schizoaffective disorder, muscle weakness, and lack of coordination, and the H&P stated the resident did not have the capacity to understand and make decisions. The resident’s MDS indicated she was sometimes able to make herself understood and sometimes able to understand others, and the fall risk assessment identified her as always disoriented, chair bound, requiring assistance with elimination, and at high risk for falls. The resident’s care plan for risk for falls and injury, initiated for deconditioning, balance problems, and history of falls, included interventions to ensure the call light was within reach and to encourage use of the call light for assistance as needed. During observation, the resident was awake in bed and the call light cord was wrapped around the left bedside rail and resting on the floor, out of reach. The resident stated she needed assistance and did not have a call light. Subsequent observations showed the call light remained on the floor and out of reach when a CNA entered and exited the room, and when another CNA entered to describe the resident’s magnetic clip alarm. The LVN stated the resident was a high fall risk, used the call light every now and then, and should always have it within reach; the LVN then observed that the call light was on the floor and not within reach. The DON stated the call light should always be within reach and that staff should assess the environment each time they enter a resident’s room, and acknowledged the facility’s policy and plan of care were not followed.
Personal Mail Opened Without Resident Privacy
Penalty
Summary
The facility failed to ensure a resident’s personal mail was received unopened and with privacy. Resident 5 was admitted on 3/27/2025 and later re-admitted with diagnoses including COPD with acute exacerbation, HIV, and DM. The resident’s MDS dated 11/12/2025 indicated he was able to make himself understood and understand others, while also requiring substantial staff assistance for bathing, partial assistance with toileting and personal hygiene, and supervision with eating. His H&P dated 11/4/2025 stated he could make his needs known but could not make decisions. His care plan included interventions to encourage him to verbalize his needs, concerns, and feelings and to offer support and reassurance. During Resident Council, Resident 5 stated he received his mail opened. He later stated he had an issue with the SSD because the SSD opened his personal mail regarding financial payments to the facility. The SSD stated that within the last month, the SSD opened Resident 5’s personal share of cost letter, which was addressed to the resident and not the facility, because the SSD needed to know the resident’s share of cost for payment to the facility. The SSD acknowledged the resident was upset and stated the letter could have been requested as a facility copy instead of opening the resident’s personal mail. The DON reviewed the facility policy and stated residents have the right to receive personal mail unopened and that staff should not open a resident’s personal mail without consent; the DON confirmed the SSD did not follow facility policy when opening the resident’s mail.
Failure to Provide Written Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide in writing the completed Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) for two sampled residents when Medicare Part A services were ending with benefit days remaining. For Resident 10, the record showed admission on 6/11/2024 and a most recent re-admission with diagnoses including UTI, sacral pressure ulcer, and cerebral palsy. The MDS dated 11/24/2025 indicated the resident was rarely or never able to understand others and rarely or never able to make herself understood, and the H&P dated 12/3/2025 stated the resident did not have the capacity to understand and make decisions. Resident 10’s SNF Beneficiary Protection Notification Review form indicated the facility initiated discharge from Medicare Part A services before benefit days were exhausted, with the last covered day listed as 9/30/2025. The NOMNC, signed by the SSD on 9/26/2025, documented verbal consent but had no resident or RP signature. The SNF ABN, also signed by the SSD on 9/26/2025, stated the resident no longer met Medicare Part A guidelines for skilled nursing care and rehab services, but none of the listed options were selected and there was no resident or RP signature. The SSD stated the forms were not provided in writing to the resident or RP and that there was no documented evidence of who was notified. For Resident 72, the record showed admission on 9/9/2025 with diagnoses including fracture of the upper end of the right femur, dysphagia, and schizophrenia. The MDS indicated the resident was usually able to understand others and able to make herself understood, and the H&P dated 9/17/2025 stated the resident had the capacity to understand and make decisions. The SNF Beneficiary Protection Notification Review form showed Medicare Part A discharge was initiated before benefit days were exhausted, with the last covered day listed as 10/5/2025. The NOMNC signed by the SSD on 10/2/2025 had no resident or RP signature, and the SNF ABN signed by the SSD on 10/2/2025 was not completed with any option selected and also had no resident or RP signature. During interview, the SSD stated the facility calls or speaks to residents or RPs in person and does not provide the written forms, and the DON stated the forms were not provided in writing to Resident 10 or 72 or their RPs.
Failure to Protect Confidential Dietary Records
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when dietary meal tickets containing protected health information were discarded in the trash instead of being secured for shredding. During observation on 12/1/2025 at 8:15 a.m., a dietary aide was seen throwing residents' meal tickets into the trash by the dishwashing area. The meal tickets contained residents' names, room numbers, diet orders, and food allergy information. During interviews, the Dietary Supervisor stated the current process was to throw the menu tickets in the trash and then take the trash to the dumpster outside, and acknowledged that the tickets contained residents' names and other protected information. The Registered Dietitian stated a new policy was being started for the menus to be thrown away in a confidential bin because the current practice was to throw them in the dumpster. The DON stated he was not aware kitchen staff throwing menus with residents' names was a privacy issue and stated shredding the menu ticket is the best way to protect resident privacy. Facility policy required safeguarding resident confidentiality and stated dietary tray cards were to be placed in an assigned bin for disposal in a shredder service bin, not in the garbage bin used for food and trash waste.
Glucometer QA Logs Lacked Documented Control Results
Penalty
Summary
The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one sampled resident with DM, ESRD, and long-term insulin use. The resident’s record showed orders for scheduled insulin lispro and sliding-scale insulin, and the care plan identified goals of no complications related to DM with interventions to administer diabetes medication as ordered and monitor for side effects and effectiveness. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident required assistance with multiple ADLs. During observation, an LVN checked the resident’s blood sugar with a glucometer and obtained a reading of 304, then prepared and administered 8 units of Humalog to the resident’s left arm. During interview and record review, staff reviewed the glucometer QA logs for GLM 1 and GLM 2 and found that control testing results were not documented on certain dates. An LVN stated there should be a result recorded when control testing was done, and another LVN stated the night shift performed daily control testing but could not find the control results on the reviewed dates. The report stated the facility failed to ensure GLM 1 and GLM 2 were working properly by performing calibration or checks as instructed by the manufacturer or the facility.
Medication Left at Bedside
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards when a cream/ointment was left at the bedside of Resident 52 in a medication cup on top of the resident’s drawer. Resident 52 was admitted on 5/30/2025 with diagnoses including major depressive disorder, GERD, and dysphagia. The resident’s H&P dated 6/2/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 9/10/2025 indicated the resident could make self-understood and understand others and had moderate cognitive impairment. The resident’s OSR dated 12/4/2025 did not show any order for topicals, and the care plan included an intervention to ensure/provide a safe environment related to the resident’s communication problem and Spanish language barrier. During a concurrent observation and interview on 12/1/2025, the Treatment Nurse observed the cream/ointment left at the bedside and stated there should be no medications left at the bedside because it could be accessed by confused residents and accidentally ingested, causing potential poisoning. During a concurrent interview and record review, the RN confirmed there was no order for a topical medication on the chart and no medication self-administration assessment had been completed. The RN also stated medications should not be left at the bedside because other confused residents could get a hold of them and accidentally ingest them, causing chemical poisoning. The DON later stated licensed staff should not have left a medication at the bedside and that doing so was against facility policy.
Insulin E-Kit Not Replaced Within Required Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services for one sampled resident by not ensuring the insulin emergency kit was replaced within 72 hours after use, according to the facility’s policy and procedure. Resident 73 was admitted with diagnoses including DM, COPD, and long-term use of insulin, and had an order for insulin Lispro injection solution 100 unit/mL to be given by sliding scale before meals and at bedtime for DM. During observation and interview, LVN 1 stated the insulin e-kit had been opened and insulin Lispro had been taken out for Resident 73, and that the medication needed to be replaced, but he did not know how soon the e-kit had to be replaced. LVN 1 also stated the e-kit contained a slip with the original and yellow copy documenting what was removed and that both copies go back to the pharmacy. During interview, RN 1 stated the facility did not have an e-kit log to document what was taken from the insulin e-kit and did not know when the e-kit should be replaced. The DON stated the e-kit is replaced within 72 hours once opened and that the facility does not have an e-kit log. The DON also stated the licensed nurse who removed the medication should keep the yellow copy of the e-kit slip and return the white copy to the insulin emergency drug kit. The facility policy titled Emergency Pharmacy Service and Emergency Kits stated that opened kits are replaced with sealed kits within 72 hours of opening, or replacement doses are added within 72 hours of opening.
Failure to Monitor Anticoagulant Therapy for Adverse Effects
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs by not ensuring adequate monitoring for adverse effects related to anticoagulant therapy. One resident was admitted with diagnoses including epilepsy, heart failure, and GERD, and had intact cognition and capacity to make decisions. The resident’s order summary included rivaroxaban 20 mg by mouth in the evening for DVT prophylaxis, but the order summary and MAR did not include monitoring for adverse effects related to rivaroxaban. The care plan addressed risk for bleeding and spontaneous bruising with daily skin inspection and reporting unusual bleeding or bruising, but no medication-specific monitoring order was present. A second resident was admitted with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, and long-term use of anticoagulants, and also had capacity and intact cognition. The resident’s order summary included warfarin sodium 7 mg by mouth in the evening for DVT prophylaxis, but the order summary and MAR did not include monitoring for adverse effects related to warfarin sodium. The care plan again addressed risk for bleeding and spontaneous bruising with daily skin inspection and reporting unusual bleeding or bruising, but there was no order for warfarin-specific monitoring. During interview, RN 1 stated there was no order for monitoring for adverse effects for rivaroxaban on one resident and no order for warfarin sodium on the other resident. The DON stated licensed staff should have obtained orders for monitoring for adverse effects for both anticoagulants and stated the medications could not be treated the same because each had more potent chemicals and different adverse effect concerns. The DON also stated the failure to monitor for adverse effects of rivaroxaban and warfarin sodium could potentially lead to severe bleeding that could lead to death, and stated the facility’s Anticoagulation-Clinical Protocol was not followed. The facility policy required physician collaboration with nursing staff and monitoring for possible complications in individuals being anticoagulated, and the provided prescribing information for both medications included bleeding warnings.
Inaccurate MAR Documentation for Refused Stool Softener
Penalty
Summary
The facility failed to maintain accurate medical records for one resident when docusate sodium (Colace) was documented as administered even though the resident refused the medication. The resident had diagnoses including gout, atrial fibrillation, and COPD, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS indicated the resident could understand others and make self-understood, and required assistance with toileting hygiene. The order was for docusate sodium 250 mg by mouth daily for constipation, to be held for loose stools. During medication administration, the resident told the LVN he did not want Colace and stated he had a bowel movement. The LVN observed the refusal, did not place the medication in the cup, and later stated he completed the medication pass. When the MAR was reviewed later that day, the LVN stated he had marked the medication as given even though it was not administered, and said it should have been documented as refused. The DON stated the resident has the right to refuse medications and that inaccurate documentation of a stool softener could affect the resident's bowels and result in a delay in care. The facility policy required documentation to be objective, complete, and accurate.
Failure to Offer Pneumococcal Vaccine After Admission
Penalty
Summary
The facility failed to follow its policy and procedure for flu and pneumococcal vaccine administration by not offering the pneumococcal vaccine to one sampled resident. Resident 59 was admitted with diagnoses including UTI, type 2 DM, and generalized muscle weakness. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident was able to understand and make needs known, though also noted moderately impaired cognition and extensive assistance needs with ADLs. The MDS further indicated the resident’s pneumococcal vaccine was not up to date. Record review showed Resident 59 had a pneumococcal vaccination consent form indicating consent to receive the vaccine. During interview, the ADON reviewed the consent form and stated the resident gave consent, but a physician order had not yet been obtained and the medication had not been ordered from the pharmacy. The ADON admitted there was a delay in pneumococcal vaccine administration. The facility’s Pneumonia Vaccine Log showed the resident last received a pneumonia vaccine on 6/15/2019 and another dose was recommended. Review of CAIR2 with the Infection Preventionist showed the resident last received pneumococcal conjugate vaccine 13 on 6/15/2019, with a recommendation for another pneumococcal conjugate vaccine dated 6/15/2020. The IP stated she was responsible for offering the vaccine upon confirmation from the resident, family members, or CAIR2, but did not offer it on admission because the vaccine was not available in the facility. The DON stated the facility’s policy is to offer pneumonia vaccines to residents over the applicable age upon admission and that the IP is responsible for ensuring the vaccine is offered, consented, and administered after physician orders are obtained.
Nonfunctional Call Light and Frayed Cord Observed in Resident Room
Penalty
Summary
The facility failed to maintain electrical resident care equipment in safe operating condition for one of six sampled residents, Resident 59. Resident 59 was admitted on 11/12/2025 with diagnoses including parkinsonism, muscle weakness, and unsteadiness on feet. The resident’s H&P dated 11/14/2025 indicated the resident had the capacity to understand and make decisions. The MDS dated 11/24/2025 indicated the resident could make self-understood and usually understand others, had highly impaired vision, moderately impaired cognition, and was dependent to needing supervision assistance with mobility and ADLs. The FRA dated 11/13/2025 identified the resident as high risk for falls, and the care plan for Parkinson’s included an intervention to monitor for fall risks. During a concurrent observation and interview on 12/1/2025 at 9:43 a.m., Resident 59’s call light on Bed A was observed attached to the wall panel but not working, and the alternate call light provided from Bed B had frayed/exposed wires on the cord. LVN 4 stated the Bed A call light was not functioning and the Bed B call light had frayed/exposed wires. RN 1 stated staff should check call lights for functionality and there should be no frayed wires, and that the non-functioning wall panel on Bed A should have been reported and the Bed B call light should not have been provided. The DON stated it was everyone’s responsibility to ensure call lights were working and that staff should inspect the resident environment for safety during rounds. The facility’s Call System, Residents policy stated the resident call system remains functional at all times and is routinely maintained and tested, and the Hazardous Areas, Devices and Equipment policy stated malfunctioning or poorly maintained equipment is a hazard.
Failure to Notify Physician of PICC Site Bleeding
Penalty
Summary
The facility failed to inform the resident’s physician when Resident 75 had bleeding from a newly inserted PICC line insertion site on the right upper arm. Resident 75 was admitted with diagnoses including iron deficiency anemia, atrial fibrillation, and heart failure. The record also showed the resident was receiving aspirin and dabigatran and had orders to monitor for bleeding every shift related to aspirin, dabigatran, and enoxaparin use. The resident’s history and physical indicated the resident could make needs known but could not make medical decisions, and the MDS reflected moderate cognitive impairment. On 9/30/2025, a contracted PICC RN inserted the PICC line for IV antibiotic administration. RN 1, the RN supervisor, stated that around 2 p.m. she observed fresh blood around the PICC dressing at the insertion site. She placed 4x4 gauze over the site and applied pressure for 15 minutes until the bleeding stopped. RN 1 stated the PICC RN was aware of the bleeding and remained in the facility charting at the nurses’ station, but the incident was not documented as an SBAR/COC and the primary physician was not notified. During interviews, RN 1 stated she should have documented the incident and completed an SBAR/COC so the resident representative and primary physician would be informed and the physician could give further orders if needed. The PICC CNO stated the PICC RN was expected to be the primary person to control the bleeding because he inserted the line and was still in the facility. The DON stated licensed staff should have documented the PICC bleeding incident on the SBAR/COC notes to capture what happened and allow the primary provider to manage the incident through new orders.
Failure to Develop Person-Centered Care Plans for PICC Line Management
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents who had PICC lines and were receiving IV antibiotics. Resident 37 was admitted with cellulitis of the left lower limb, type 2 DM with foot ulcer, and a non-pressure chronic ulcer of the left foot. The record showed the resident had the capacity to understand and make decisions, and the MDS indicated intact cognition, was on a high-risk antibiotic, had IV medications, and had IV access. The OSR included orders for PICC dressing changes, injection cap changes, arm circumference measurements, and measurement of the PICC insertion site to hub. During observation on 12/1/2025, Resident 37 was seen with a PICC line and a dressing dated 11/26/2025. The treatment nurse stated the PICC line was being used for IV antibiotics. During interview and record review, RN 1 stated there were orders for PICC maintenance and management, but no care plan had been developed and implemented for the resident’s PICC line. RN 1 stated a person-centered care plan was important to ensure safe use of the PICC line and to prevent infection, and stated the lack of a care plan predisposed the resident to infection and substandard PICC care. Resident 75 was admitted with pneumonia, heart failure, and UTI. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated the resident could make self-understood, usually understood others, had moderate cognitive impairment, and was on a high-risk antibiotic. The OSR included an order for insertion of a PICC line catheter for IV antibiotic administration by a contracted company. RN 1 and the DON stated there were orders for PICC maintenance and management, but no care plan had been developed and implemented for the resident’s PICC line, and that the care plan should have communicated goals and interventions for safe PICC use.
Daily Staffing Information Not Updated
Penalty
Summary
The facility failed to ensure nurse staffing information was posted and updated on a daily basis. During observations on 12/1/2025 at 7:30 a.m. and again at 8:28 a.m., the staffing information posted at the reception desk and on the whiteboard next to the activity room entrance was still dated 11/28/2025. During a concurrent observation and interview at 8:46 a.m., RN 1 reviewed photographs of the whiteboard and daily staffing posting dated 11/28/2025 and stated the Director of Staff Development (DSD) was responsible for updating the whiteboard and posting the paper at the reception desk. RN 1 stated the posting should have been updated because visitors and family members would not be aware of the number of staff working for the day and might think there would not be enough staff to provide resident care. During interview, the DSD stated he was responsible for changing the daily staffing posting and acknowledged the information for Saturday through Monday was not updated timely and was changed when he arrived at the facility. The DON later stated he was aware the daily staffing posting had not been changed since 11/28/2025 and confirmed the facility policy required the posting to be updated at the start of each shift.
Excess Occupancy in Resident Room
Penalty
Summary
The facility failed to meet the requirement for no more than four residents per room in room [ROOM NUMBER], which was observed to contain five beds during a facility tour. At the time of the observation, four residents were occupying the room. The surveyor noted that the residents had adequate space to move freely, and nursing staff had enough space to safely provide care, with room for beds, hanging curtains, side tables, dressers, and resident care equipment. During interview, a CNA stated the room normally had five beds but currently had four residents, and reported there were no issues with room space and staff could safely perform care and ADLs without issue. The DON reviewed a facility letter requesting a waiver for the five-bed capacity in room [ROOM NUMBER], stating each bed would allow for 92.23 sq ft of space and that residents had freedom of movement and safety was not jeopardized. The facility's Client Accommodation Analysis form showed the room measured 14 ft 6 inches by 31 ft 6 inches, equaling 461.15 sq ft, and the facility policy and California Code of Regulations Title 22 both stated resident rooms must provide privacy and no more than four residents per room.
Failure to Timely Report Alleged Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of visitor-to-resident sexual abuse to the State Survey Agency (SSA) within the required timeframe. A resident, who had diagnoses including aftercare following joint replacement surgery, major depressive disorder, and anxiety disorder, and was assessed as having intact cognition and decision-making capacity, reported to the Social Services Director (SSD) that a transportation company personnel inappropriately touched her face and made inappropriate comments. This report was made to the SSD on 7/3/2025, who then notified the Director of Nursing (DON) and the Administrator (ADM). Despite the facility's policy requiring that any allegation of abuse be reported to the SSA within two hours, the Abuse Coordinator did not report the incident until 27 days after the initial allegation. Interviews confirmed that the DON and SSD were aware of the policy and the requirement for timely reporting. The delay in reporting the allegation constituted a failure to follow established procedures for abuse reporting.
Failure to Monitor and Document Psychosocial Well-being After Alleged Incident
Penalty
Summary
Licensed nurses and social services staff failed to monitor and document the psychological and psychosocial well-being of a resident following the resident's report of being inappropriately touched by transportation company personnel. The resident, who had diagnoses including major depressive disorder and anxiety disorder, reported the incident to the Social Services Director (SSD), but there was no documented evidence in the resident's progress notes that any follow-up monitoring occurred after the allegation. The SSD confirmed that she did not document any follow-up visits and acknowledged that if monitoring was not documented, it was considered not to have happened. The Director of Nursing (DON) also confirmed that neither licensed nurses nor social services documented any monitoring of the resident's psychological and psychosocial health after the incident was reported. The facility's policy required assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect, but this was not followed in this case. The lack of documentation and monitoring occurred despite the resident's intact cognition and known mental health diagnoses.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe to the State Survey Agency (SSA). The incident involved a resident who was admitted with diagnoses including an unspecified fracture of the right femur, diabetes mellitus, and essential hypertension. On the day following the resident's admission, a family member reported to a Licensed Vocational Nurse (LVN) that a Certified Nursing Assistant (CNA) had verbally abused the resident and grabbed their forearm. The family member subsequently called 911 and local law enforcement, who arrived and spoke with the involved parties. However, the facility did not report the incident to the SSA and Ombudsman until the following day, exceeding the two-hour reporting requirement. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed a misunderstanding of the facility's policy regarding the reporting of abuse allegations. The DON and ADM believed that incidents without bodily injury could be reported within 24 hours, contrary to the facility's policy, which mandates reporting to the SSA, local law enforcement, and the Ombudsman within two hours for all abuse allegations, regardless of injury. The facility's policy, last reviewed in January 2025, was found to be outdated and incorrectly interpreted by the ADM, contributing to the delay in reporting the incident.
Failure to Document Abuse Allegation in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to a deficiency in documentation. The resident was admitted with diagnoses including an unspecified fracture of the right femur, diabetes mellitus, and essential hypertension. On the day following admission, the resident allegedly informed a family member of verbal and physical abuse by a Certified Nursing Assistant (CNA). However, this allegation was not documented in the resident's Change of Condition (COC) or Progress Notes by the Licensed Vocational Nurse (LVN) responsible for the resident's care. The Director of Nursing (DON) confirmed that the LVN did not document the abuse allegation, which was a failure to adhere to the facility's policy and procedure for charting and documentation. The facility's policy requires that all services, changes in condition, and incidents involving residents be documented to facilitate communication among the healthcare team. The lack of documentation in this case could lead to confusion in care and inaccurate medical records, as the DON emphasized the importance of accurate documentation for communication and ensuring the medical record reflects actual events.
Failure to Provide Proper Pureed Diet
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for a resident on a pureed diet. The resident, who had a diagnosis of dysphagia, was served food that did not meet the International Dysphagia Diet Initiative (IDDSI) Level 4 standards. Specifically, the resident was given bread soaked in milk, oatmeal with lumps, and scrambled eggs that were not smooth and pureed, which did not comply with the required texture for a pureed diet. The deficiency was identified during an observation and interview with the dietary staff, where it was revealed that the cook did not follow the recipe for pureed foods. The dietary supervisor confirmed that the cook failed to blend the foods as required, resulting in the resident receiving food that was not safe for their swallowing difficulties. The registered dietitian and speech-language pathologist both emphasized the importance of adhering to the IDDSI Level 4 standards to prevent potential harm to residents with swallowing impairments. The resident involved had a history of swallowing problems and was on a pureed diet as per physician's orders. The facility's policy and procedures required that pureed foods be smooth, free of lumps, and meet specific testing requirements, which were not followed in this instance. The failure to adhere to these standards posed a risk of choking and aspiration for the resident.
Removal Plan
- The Registered Dietitian (RD) provided an in-service to [NAME] 2, [NAME] 3, and Dietary Aide 1 (DA 1) regarding food preparation of IDDSI Level 4 foods.
- The RD provided an in-service and competency test to the Dietary Supervisor (DS) regarding puree food consistency to meet IDDSI Level 4 standards. The DS provided supervision to the dietary staff to ensure a blender was used on pureed foods for dinner service to meet IDDSI Level 4 standards. The RD verified the DS's competency through return demonstration and the RD acknowledged the DS to be competent in providing in-services to the dietary staff.
- The DON assessed Resident 214 for signs and symptoms of respiratory distress and for presence of food particles in the oral cavity and there were no issues found.
- The DON provided an in-service to Licensed Vocational Nurse 1 (LVN 1) on food texture and consistency based on IDDSI Level 4 standards. The DON verified LVN 1's competency through return demonstration by observing and verbalizing the correct texture of puree diets using IDDSI Level 4 standards.
- The Infection Preventionist (IP) and the Minimum Data Set Coordinator (MDSC) checked all residents receiving pureed food to ensure proper consistency and texture for lunch and dinner meals. The licensed nursing staff will continue to check meal trays for breakfast, lunch, and dinner on an ongoing basis for proper puree consistency and texture of food.
- The DS checked the puree food items for proper texture and consistency per IDDSI Level 4 standards using the spoon tilt test and fork drip test. The DS will continue this process until six (6) months.
- The ADM, the RD, and the DS examined the process of food preparation and food distribution for all residents on puree diet to ascertain and confirm food items that did not pass IDDSI Level 4 standards would not be given to the residents and will be remade.
- The DON assessed the residents on puree diet for signs and symptoms of respiratory distress and ensured aspiration precautions were maintained for the residents on puree diet. The DON reviewed and revised the care plans as necessary.
- The Speech Language Pathologist (SLP) assessed the residents on pureed diet for signs and symptoms of respiratory distress and aspiration.
- The SLP provided an in-service to the dietary staff and the nursing staff on the risk of eating food that was not properly pureed per physician's order, choking hazards, what signs and symptoms to monitor, and what consistency and texture of a pureed diet should look like.
- The RD provided an in-service and competency test to [NAME] 1, [NAME] 2, DA 1, DA 2, and DA 3 on how to puree foods following the recipes and IDDSI Level 4 standards. The RD provided an in-service to six (6) of seven (7) dietary staff. [NAME] 4 was scheduled to attend an in-service.
- A qualified RD will be supervising the DS for a period of one (1) month or until such time the RD determined the DS to be competent to supervise the workflow of the dietary staff and kitchen. At such time, if it is determined that the DS is not competent, the ADM will replace the DS with a qualified and competent DS.
- A Spanish version of the menu and recipe will be obtained by the ADM as soon as applicable.
- The RD provided another in-service to the licensed nursing staff on testing the puree diet per IDDSI Level 4 standards.
- The DS or licensed nurse will test the pureed foods on the menu per IDDSI Level 4 standards with a fork and spoon tilt test after the in-service training. The in-service training and competency test started. Training would continue until all licensed nursing staff and dietary staff have been completed.
- The assigned designee for testing the puree foods will be the Station 2 charge nurse when the DS is not available such as on weekends, holidays. The 11 p.m. to 7 a.m. shift Station 2 charge nurse will be in-charge for breakfast, the 7 a.m. to 3 p.m. shift Station 2 charge nurse for lunch, and the 3 p.m. to 11 p.m. Station 2 charge nurse for dinner.
- A pureed food adherence tool titled Puree Texture Checklist was used for breakfast to ensure food on the menu are prepared using a blender per IDDSI standards. The Puree Texture Checklist will be used for breakfast, lunch, and dinner including weekends and holidays.
- The RD checked the snacks for the residents on puree diets which included blended yogurt, apple sauce, and pudding. No other snacks would be provided by staff to residents on puree diet except snacks approved by the RD.
- The RD will conduct weekly Quality Assurance (QA) rounds in the kitchen to monitor meal tray accuracy including pureed food texture based on IDDSI Level 4 standards. The results of the audit will be presented to the Quality Assessment and Assurance (QAA) committee monthly and at a minimum of quarterly for further action planning and monitoring as necessary. The benchmark for compliance will be 100 percent (%) for a period of three (3) months.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. Specifically, a trash can in the kitchen was found without a plastic liner, which the Dietary Supervisor acknowledged was necessary to prevent contamination. Additionally, one of the two dumpsters outside the facility was observed to be overflowing and not completely closed, which the Dietary Supervisor and Maintenance Supervisor both stated was unacceptable due to the potential attraction of pests and the spread of germs. The facility's policies and procedures, as well as the Food Code 2022, emphasize the importance of proper trash disposal to prevent contamination and pest attraction. The policies require that trash bins be emptied regularly to avoid overfilling, and that receptacles be covered with tight-fitting lids. The observed deficiencies in trash disposal practices had the potential to attract pests and spread infection among the facility's residents.
Infection Control Deficiency in Scabies Management
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) was competent in implementing the infection control program, specifically in managing a scabies outbreak. Resident 52, who was admitted with diagnoses including unspecified dementia, muscle weakness, and hypertension, was identified as having scabies mites through a diagnostic test. Despite this, the resident was removed from isolation before the completion of treatment or confirmation that they were scabies-free, contrary to the facility's policy. The IP admitted to not knowing the correct duration for scabies isolation and acknowledged that the resident was still undergoing treatment and experiencing symptoms. The facility's policy required maintaining contact precautions until treatment was complete or the resident was confirmed to be scabies-free. However, Resident 52's isolation was discontinued prematurely, and the room lacked necessary transmission-based precautions and personal protective equipment. The IP's lack of adherence to the policy posed a risk of spreading the infestation to other residents and staff. The Director of Nursing emphasized the importance of the IP's competence in infection control to prevent improper isolation and transmission risks. Additionally, the facility failed to report the scabies case to the state agency as required by their policy on unusual occurrence reporting. The IP did not report the incident, mistakenly believing that a single case did not warrant reporting. The facility's policy mandated reporting unusual occurrences that affect the health, safety, or welfare of residents, employees, or visitors to the state agency within 48 hours. The IP's uncertainty about the reporting process further highlighted the deficiency in the facility's infection control practices.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not properly disposing of medications discontinued by the physician for three residents. During an observation, it was found that medications belonging to Residents 25, 63, and 64 were not destroyed as per facility policy. These medications were left in bins beside the refrigerator in the medication room instead of being placed in the incinerator for destruction. The Director of Nursing confirmed that discontinued medications should be disposed of in the incinerator to prevent unauthorized access. Additionally, the facility did not adhere to its policy of labeling multidose medication bottles with the open date. Observations revealed that several medications in the medication carts and medication room were not labeled with the date they were opened. This oversight was acknowledged by the staff, who confirmed that the facility policy requires all opened medication bottles to be dated to ensure proper tracking and usage. Furthermore, the facility failed to maintain accurate records for controlled substances. Specifically, the narcotic sheet for Resident 63's pregabalin was not signed after administration, leading to a discrepancy in the medication count. The staff acknowledged that the narcotic sheet should be signed immediately after removing the medication from the bubble pack to ensure accurate documentation and prevent potential drug diversion.
Deficiency in Kitchen Staff Training and Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in food preparation and portion control. Specifically, staff did not follow recipes and portion sizes for both regular and puree diets. For instance, a staff member failed to prepare coffee cake according to the recipe, omitting key ingredients like brown sugar and coffee, which affected the taste and flavor, potentially leading to residents not eating the food. Additionally, the facility did not adhere to the prescribed methods for preparing puree diets. Observations revealed that bread soaked in milk contained whole chunks, scrambled eggs were not smooth, and oatmeal had lumps, all of which were served to residents on puree diets. The staff also used incorrect scoop sizes for portioning, leading to larger portions than intended, which could result in unplanned weight gain. The Director of Food Services admitted that there was no competency evaluation for the staff member responsible for these errors prior to the incident. The facility's policies and procedures required the use of standardized recipes and portion control, but these were not followed, leading to potential nutritional inadequacies for the residents.
Failure to Follow Menu and Portion Sizes
Penalty
Summary
The facility failed to follow the prescribed menu and meet the nutritional needs of 62 out of 63 residents on regular and puree texture diets. On the morning of December 29, 2024, the staff member responsible for meal preparation was unable to locate the menu spreadsheet, which is essential for determining the appropriate food and portion sizes for each diet. The absence of this spreadsheet led to the use of meal tickets that did not specify portion sizes, potentially resulting in inaccurate food servings and unintended weight changes for the residents. Additionally, the facility did not prepare the puree baked Western omelet as required for residents on the puree diet, instead serving plain scrambled eggs that did not meet the necessary texture or nutritional content. This deviation from the menu could lead to residents not receiving the correct number of calories and nutrients, potentially causing weight loss due to the altered taste and missing ingredients. Furthermore, the facility failed to prepare the coffee cake as specified, serving regular cake without the necessary toppings, which could affect the residents' willingness to eat and result in unplanned weight loss. The facility also used incorrect scoop sizes for serving portions, with a #10 scoop used instead of the required #12 scoop for puree eggs and bread soaked in milk. This error in portion control could lead to residents receiving more food than intended, potentially causing unplanned weight gain. The Dietary Supervisor acknowledged these discrepancies and the importance of adhering to the menu and portion sizes to prevent nutritional imbalances among residents.
Failure to Follow Food Preparation Guidelines
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance during breakfast service. Specifically, a staff member did not follow the recipe for coffee cake, resulting in the preparation of a plain cake instead. The staff member omitted the brown sugar and coffee topping, which affected the taste and flavor of the cake. This deviation from the recipe was acknowledged by the dietary supervisor, who confirmed that the coffee cake recipe did not include coffee as an ingredient and that brown sugar should have been mixed with the wet and dry ingredients. The failure to follow the recipe could lead to residents not eating the food, potentially resulting in unplanned weight loss. Additionally, the facility did not adhere to the specified portion sizes for the baked Western omelet. Instead of cutting the omelet into the prescribed 3x2 1/2 inch servings, a #10 scoop was used, which did not meet the portion size requirements. The dietary supervisor noted that the use of a scoop instead of cutting the omelet affected the presentation, making it less appetizing for residents. This failure to follow the facility's policy and procedure on food preparation could lead to residents not consuming the food, further risking unplanned weight loss.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Expired hotdog and hamburger buns were found in the kitchen refrigerator, and undated foods were stored in the refrigerator. Staff members had placed personal food items in the facility refrigerator, which is against the facility's policy. The Dietary Supervisor and Director of Nursing acknowledged that these practices could pose a risk of contamination and illness to residents. Additionally, the facility did not maintain proper hand hygiene practices. A dietary aide was observed touching a paper towel dispenser button after washing her hands and returning to work without re-washing her hands. This action was contrary to the facility's handwashing procedures and could lead to contamination of food and utensils, potentially causing illness among residents. The facility also failed to maintain cleanliness in food preparation areas. Ice crystals were observed on the walk-in freezer's ceiling, and dust and dirt were found on canned food racks, refrigerator gaskets, and the kitchen hood. A dented can was stored with non-dented cans, and expired sanitizer test strips were in use. These conditions could lead to cross-contamination and foodborne illnesses among residents, as acknowledged by the Dietary Supervisor.
Facility Lacks Designated Medical Director and Documentation of Responsibilities
Penalty
Summary
The facility failed to designate a Medical Director (MD) for a period of 12 months, from December 30, 2023, to December 30, 2024. This deficiency was identified during interviews and record reviews, where it was revealed that the facility did not have a job description or policy outlining the MD's responsibilities in coordinating medical care. The Administrator acknowledged that the facility's license did not list a Medical Director and that an application had not been submitted to the State Agency. Although there was a physician agreement in place since April 1, 2020, it did not specify the MD's role in organizing and coordinating physician services and other professional services related to resident care. Interviews with the MD and the Director of Nursing (DON) indicated that the MD was involved in resident care, attended quality assurance meetings, and provided oversight of clinical practices. However, the lack of formal documentation of the MD's responsibilities could lead to confusion among staff regarding clinical decision-making and accountability. The Administrator admitted uncertainty about how the absence of a job description or policy could impact the quality of care, but recognized that having such documentation could be beneficial.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their clinical documentation. For Resident 33, the facility did not accurately document the provision of showers from December 23 to December 29, 2024. The resident, who has Alzheimer's disease and severely impaired cognitive skills, was dependent on staff for activities of daily living, including bathing. Despite the care plan indicating the need for showers twice a week, the documentation showed daily bed baths instead. Additionally, the resident's fingernails were observed to be long and chipped, indicating a lack of proper hygiene care, which was not reported to the charge nurse or documented in the communication binder. In the case of Resident 39, the facility inaccurately documented a bed bath as a shower on December 27, 2024. Resident 39, who has hemiplegia and requires a mechanical lift for showering, reported not being showered for a week due to the unavailability of a sling. CNA 3 confirmed that the resident refused a shower due to the lack of an extra sling and received a bed bath instead. However, the documentation incorrectly indicated that a shower was provided, which was acknowledged as inaccurate by the Director of Nursing. The facility's policy on charting and documentation requires that records be objective, complete, and accurate. However, the discrepancies in documentation for both residents highlight a failure to adhere to these standards. The Director of Staff Development and the Director of Nursing both acknowledged the inaccuracies and the importance of accurate documentation for communication and continuity of care. These failures in documentation could lead to potential risks for the residents, as accurate records are essential for ensuring appropriate care and interventions.
Infection Control Deficiencies in Water Management, Medication Room, and Resident Care
Penalty
Summary
The facility failed to implement effective infection control measures, as evidenced by several deficiencies. Firstly, the facility did not adhere to its water management plan to prevent legionella growth. The Maintenance Supervisor (MS) admitted to not having a standard for legionella prevention and had never conducted a risk assessment as required by the facility's policy. The water temperatures recorded from October to December 2024 were consistently at 110 degrees Fahrenheit, which is within the range prone to legionella growth. The MS also failed to document water temperatures in the shower rooms, which are critical control points for legionella prevention. The Infection Preventionist (IP) and the Director of Nursing (DON) acknowledged the lack of proper monitoring and documentation, which are essential for ensuring resident safety. In another instance, the facility did not maintain a sanitary environment in one of the medication rooms. During an observation, a donut wrapped in a paper towel was found on top of a drainage kit box, which violates the facility's policy that prohibits food in medication rooms. The Licensed Vocational Nurse (LVN) and the DON confirmed that food should not be present in medication rooms to prevent infection. Additionally, the facility failed to maintain appropriate contact isolation for a resident diagnosed with scabies. The resident was initially placed on contact isolation, but it was discontinued before the completion of treatment and without confirming that the resident was scabies-free. The IP and DON acknowledged that the resident should have remained in isolation until treatment was complete or a negative scrape test confirmed the absence of scabies. This oversight posed a risk of spreading the infection to other residents and staff. Furthermore, another resident was observed using a nasal cannula without a labeled date, which is against the facility's policy of changing and dating nasal cannulas weekly to prevent infection. The DON confirmed that the lack of a date on the nasal cannula could lead to infection risks.
Failure to Maintain Resident Dignity and Provide Adequate Care
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, Resident 33 and Resident 39, as observed during a survey. For Resident 33, a Certified Nursing Assistant (CNA 4) was observed standing over the resident while assisting with feeding during a meal. This action was contrary to the facility's policy, which requires CNAs to sit at eye level with residents to ensure dignity and respect. The Director of Staff Development and the Director of Nursing confirmed that CNAs are expected to sit while assisting residents with meals to maintain their dignity and safety. Resident 33, who was admitted with Alzheimer's disease, major depressive disorder, and bipolar disorder, was dependent on staff for activities of daily living, including eating. Despite the resident's cognitive impairments, the facility's care plan indicated the need for one staff member to assist with eating, which was not adhered to in a manner that respected the resident's dignity. For Resident 39, the facility failed to provide a shower as required by the resident's care plan. Resident 39, who had hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for showering. The facility lacked sufficient slings for the mechanical lifts needed to shower the resident, resulting in the resident receiving a bed bath instead. The Director of Nursing acknowledged the issue, stating that the lack of slings was a problem and that it was a resident's right to have a shower if requested, as it is part of their dignity.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident and their responsible party about the right to formulate an advance directive upon admission. This deficiency was identified during a review of the resident's admission records, which showed that the resident was admitted with diagnoses including pneumonia, muscle weakness, and cerebral palsy. The resident had fluctuating capacity to understand and make decisions due to developmental delay. Despite these conditions, there was no advance directive noted in the resident's medical records, and interviews with facility staff confirmed that no documentation existed to show that an advance directive was offered to the resident or their representative. Interviews with the Medical Records Director, Social Services Director, and Director of Nursing revealed that the facility did not have any documentation indicating that an advance directive was offered to the resident or their representative. The Director of Nursing acknowledged that the Social Services Director should have documented the offer of an advance directive, especially since the resident was under court-ordered conservatorship. The facility's policy requires that residents and their legal representatives be provided with information regarding advance directives upon admission, but this was not adhered to in this case.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify the physician that azithromycin, an antibiotic prescribed for a resident with end-stage renal disease and a history of infections, was unavailable for three consecutive days. This resulted in the resident receiving an incomplete course of the medication, as the prescribed doses on specific dates were not administered. The resident was admitted with severe cognitive impairment and was dependent on staff for all activities of daily living, making it crucial for the facility to manage medication administration effectively. The Medication Administration Record indicated that the azithromycin was not given on the specified dates, and the facility's Infection Preventionist confirmed that the medication was not documented as administered. The Director of Staff Development and the Director of Nursing acknowledged that the Licensed Vocational Nurses should have informed the physician about the unavailability of the medication to obtain new orders. The facility's policy required notifying the physician when there was a significant alteration in the resident's medical treatment, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sylmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Astoria Healthcare Center | 0.9 mi | ★★★★★ | 24 | 2 |
| Maclay Healthcare Center | 1.1 mi | ★★★★★ | 58 | 1 |
| Mountain View Conv Hosp | 1.2 mi | ★★★★★ | 41 | 0 |
| Ararat Nursing Facility | 1.6 mi | ★★★★★ | 25 | 1 |
| Providence Holy Cross Med Ctr D/p Snf | 1.6 mi | ★★★★★ | 17 | 2 |
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