Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Rehabilitation Center Of Los Angeles during CMS and state inspections, most recent first.
Incomplete hemodialysis access orders were documented for two residents with severe cognitive impairment and dependent functional status. One resident’s OSR listed a right IJ HD catheter every shift, and another resident’s OSR listed a right chest permacath every shift. The TN said she did not handle HD orders, the RN supervisor could not explain the meaning of the right IJ HD catheter order, and the attending provider said the order was not a specific order they had issued beyond standard protocol orders.
A facility failed to provide reasonable accommodation for resident communication and call light access. One resident who had unclear speech and impaired cognition did not have a communication board at the bedside, another resident who spoke Spanish did not have the ordered Spanish communication board, and two residents had call lights on the floor and out of reach. A third resident could not activate the call light because it was not fully plugged in and the resident could not apply enough pressure to trigger the alarm; the DON stated the resident was not able to easily access and activate the call light.
Incomplete response to resident council call light grievances: Two residents raised ongoing concerns that call lights were not being answered promptly, and the facility’s grievance records repeatedly lacked the required investigation details, findings or conclusions, and confirmation status. Resident council minutes documented repeated complaints across multiple shifts, while the DON and SSD acknowledged the grievance documentation was incomplete and did not fully reflect the investigation process required by policy.
A resident with pneumonia-related antibiotic treatment had no care plan developed for the new IV ertapenem order, another resident with DM had a care plan for diabetes management but no documented diet education or diet noncompliance, and a resident on HD experienced repeated late transportation that shortened dialysis treatment. Interviews and record review showed missing documentation and failure to follow the HD transportation order, with the DON confirming the care plan gaps and late transport issue.
Improper LALM settings and nonfunctioning support surface: Three residents with pressure ulcer risk and skin/wound orders had LALM issues. One resident’s mattress was set for the wrong weight despite a higher documented weight and existing pressure injuries, while another resident’s LALM was found turned off and unplugged. A third resident also had a LALM order and care plan requiring the mattress to be in place, plugged in, and functioning properly.
Pureed Bread Served Lumpy on Pureed Diet Trays: The facility failed to provide 19 residents on pureed diets with bread prepared to IDDSI Level 4 standards. During tray line service, the pureed bread was observed to be lumpy, grainy, and not smooth, with small bread pieces and residue remaining in the mouth requiring chewing before swallowing. Cook1 stated the bread had not been processed long enough to become smooth, and the RD and ADS agreed the texture was not appropriate for a pureed diet.
Fortified diet orders were not followed for 18 of 112 meal trays during lunch tray line service. A dietary aide did not communicate the fortified diet orders on the tray cards to the cook, and the cook did not add any extra items such as melted butter, fortified soup, or power foods. The RD stated these diets were intended for residents at risk for wt loss and were to provide added calories across meals.
Undated and expired food items were found in the kitchen and a resident refrigerator, including frozen chicken with no label, expired chicken soup, raw chicken and beef stored beyond allowed timeframes, and nutrition shakes without thaw dates. The ADS stated several items were past use-by dates or stored too long, and staff acknowledged that thawed nutrition shakes required dating to track the 14-day limit. Undated food and beverages were also found in the resident refrigerator, and facility leaders stated these items required labeling and dating.
Inaccurate dialysis access documentation was found for two residents with ESRD who received dialysis. Nursing staff documented AV shunt checks for bruit and thrill on dialysis communication records even though one resident had a right upper chest IJ catheter and the other had a right upper chest permacath. The LPNs involved stated the entries were mistaken, and the DON confirmed the documentation was not accurate and did not reflect the residents' actual dialysis access.
Infection control practices were not maintained during g-tube and enteral feeding care for multiple residents. An LVN did not rinse a medication syringe after g-tube medication administration, a treatment nurse did not wear a gown during g-tube dressing care for a resident on EBP, and two residents’ enteral feeding tubes were left uncapped and open to air. The DON confirmed the syringe, PPE, and tube-handling practices did not match facility policy.
A resident who was not approved for safe self-administration of medications was observed unlocking a closet and retrieving an unsealed bottle of Vitamin C supplements from his room. Records showed no physician order or care plan for self-administration, and staff interviews confirmed that residents who did not pass the self-administration assessment were not allowed to keep medications at bedside or in the room. The DON stated the facility policy was not followed, and the policy required IDT determination before any medication could be self-administered.
A resident with quadriplegia, dementia, and total dependence on staff was observed in bed with her chest and abdomen exposed while the privacy curtain was open and staff passed by. CNA and RN staff confirmed the resident should have been covered, and the DON stated staff were expected to protect her privacy and dignity by drawing the curtain and securing her clothing.
A resident with severe cognitive impairment, hemiplegia, functional quadriplegia, and multiple chronic conditions was observed receiving morning care with the privacy curtain halfway open and the lower body exposed while a CNA left to get help. The resident’s call light was on the floor. RN and DON stated residents should be kept private during care, and the facility policy required staff to prevent exposure by closing curtains or doors and using clothing or draping.
A resident with epilepsy, aphasia, and impaired ability to communicate or make decisions had a PRN Ativan 2 mg IM order for seizures that lacked an end date. LVN, RN, and DON review confirmed the order had no end date, despite the facility policy limiting PRN psychotropic orders to 14 days.
A resident with acute and chronic respiratory failure and encephalopathy was transferred to the hospital for tachycardia and difficulty maintaining oxygen saturation. The facility completed an NPTD stating the resident’s needs could not be met, but the notice was not faxed to the LTC Ombudsman until later and no fax report was maintained in the medical record on the date of transfer, despite facility policy requiring prompt Ombudsman notification and documentation.
A resident’s MDS did not accurately document tobacco use. The resident was identified in the care plan, smoking risk assessment, and smoking list as a smoker, and the resident stated he smoked one cigarette daily, but the MDS indicated the resident did not use tobacco. The MDS LVN and DON both stated the assessment was inaccurate and should have reflected the resident’s smoking status.
Failure to Update Dialysis Care Plan: A resident with ESRD and dependence on dialysis had a care plan that still listed an older dialysis schedule and transportation pick-up time after the physician order changed. RN, MDS LVN, and DON all confirmed the care plan did not match the active order for dialysis T/Th/Sat and the updated transport time, leaving the plan inconsistent with the resident’s current care.
Failure to Rotate Subcutaneous Injection Sites: The DON, IPN, and RN verified that two residents received repeated subcutaneous injections in the same sites without rotation. One resident with DM received multiple Humalog injections in the same arm and abdomen areas despite an order to rotate sites, and another resident with DM and other significant diagnoses received repeated Enoxaparin, NPH insulin, and Humalog injections in the abdomen LLQ despite orders to rotate injection sites. The facility’s insulin administration policy stated injection sites should be rotated to reduce the risk of damaging skin tissue.
Failure to provide oral care for a dependent resident: A resident with quadriplegia, dementia, intellectual disabilities, gastrostomy, and contractures was assessed as severely cognitively impaired and dependent on staff for oral hygiene and other ADLs. During observation, the resident was found in bed with white opaque fluid coming from the mouth and onto the gown, and the IPN and DON both stated the resident needed total assistance with oral care and that staff should have wiped the resident's mouth.
A resident with larynx cancer, dysphagia, a G-tube, and unsafe oral intake had two Boost orders that did not specify the route of administration. Staff interviews showed the resident was drinking the Boost orally, despite being at increased aspiration risk, and the care plan did not include a focus for aspiration risk even though aspiration precautions were listed. The DON, RN, LVN, MDS nurse, and ST all confirmed the route should have been clarified and that no aspiration risk care plan was in place.
Uncapped Enteral Feeding Tubes Left Open to Air: Two residents with G-tubes were observed with enteral feeding tubes uncapped and open to air. One resident had dysphagia, hemiplegia/hemiparesis following CVA, DM2, reduced mobility, and EBP related to the gastrostomy tube; the care plan called for clean technique and tubing changes per policy. An LVN and RN acknowledged the infection control concern, and the DON stated the tube should have been capped when disconnected.
Oxygen Tubing and Humidifier Not Labeled or Dated: A resident receiving O2 via nasal cannula had tubing and a humidifier observed without a label or date. The LVN and RN verified the equipment was not labeled and dated, and the RN could not locate MAR documentation showing when it was last changed. The DON reviewed the facility policy requiring oxygen tubing and humidifiers to be changed weekly, and stated the equipment should have been labeled and dated.
A resident with ESRD and HD dependence experienced repeated late transportation for dialysis, including a late pickup that caused the HD session to be shortened. The case manager did not follow the physician’s pickup order, the EMT reported dispatch did not provide an exact pickup time, and the dialysis communication record lacked treatment start and end times. The DON stated the facility did not follow the resident’s dialysis care plan and that the shortened treatment was not communicated back to the facility.
Medication administration and controlled substance accountability were not maintained for three residents. An LVN gave pantoprazole via g-tube using apple sauce and water instead of following the manufacturer’s g-tube instructions, and two controlled medications were administered without accurate CDR documentation. The DON and LVN acknowledged the documentation and administration issues, and the facility policy required immediate controlled substance reconciliation and medication administration in accordance with guidelines.
A resident with a g-tube, GERD, and acute transverse myelitis received pantoprazole granules and mycophenolate mofetil suspension via g-tube at the same time, while the pantoprazole was mixed with applesauce rather than prepared per the product labeling. The LVN reported difficulty pushing the medications through the tube, and the consultant pharmacist did not treat the pantoprazole–mycophenolate interaction as requiring physician notification, despite manufacturer labeling and Micromedex identifying reduced MMF absorption concerns.
A resident with incomplete quadriplegia and intact cognition received PRN hydrocodone-acetaminophen outside the ordered pain parameters. MAR review showed multiple administrations of 2 tablets for pain scores that did not meet the severe-pain range, including scores of 0, 4, 5, and 6. The LVN, DON, and consultant pharmacist all identified that the resident should have received the ordered dose based on the documented pain level, and the resident was also receiving baclofen and pregabalin.
A resident with a g-tube, GERD, and moderately impaired cognition received pantoprazole delayed-release granules and mycophenolate mofetil suspension together during med pass, along with several other medications prepared for g-tube administration. The LPN mixed pantoprazole with applesauce and water before giving it via g-tube and stated she had difficulty pushing medications through the tube. The record also showed the two medications were scheduled at the same time, while manufacturer labeling and Micromedex identified a clinically relevant interaction between pantoprazole and mycophenolate mofetil and gave specific instructions for g-tube administration of pantoprazole.
A resident with incomplete quadriplegia and intact cognition had PRN hydrocodone-acetaminophen orders for moderate pain and severe pain, with a 3 g/day APAP limit and instructions to hold for RR <12. MAR review showed nurses repeatedly documented giving 2 tablets for pain scores that did not meet the severe-pain parameter, including scores of 0, 4, 5, and 6. LVN and DON interviews confirmed the doses did not follow the ordered pain scale, and the consultant pharmacist identified the administrations as medication errors.
Improper medication storage and labeling were found in multiple medication areas. An LPN and RN observed a resident’s lorazepam stored in a refrigerator that was above the manufacturer’s required temperature, a discontinued eye drop still kept in storage, a medication bottle with mismatched inside and outside labels, and two Humulin R vials without open dates. The DON and staff acknowledged the storage and labeling problems during the review.
A resident with ESRD and HD dependence experienced repeated late transportation to dialysis, including one trip where the ambulance arrived late and the return was also delayed. The resident reported the dialysis center had the resident sign paperwork because the treatment was shortened, and records showed the HD session was cut short by 24 minutes due to late arrival. Staff interviews confirmed the CM did not follow the ordered pickup time, and the LVN was unaware the treatment had been shortened.
Call Light Out of Reach for Resident with Dementia and Mobility Impairment: A resident with dementia, reduced mobility, muscle weakness, and a history of falls had a care plan calling for the call light to be within reach and for staff to anticipate toileting needs. During observation, the resident's call light was found on the floor and out of reach, and an LVN confirmed it was not accessible.
Two residents dependent on staff for daily care, including those with chronic respiratory and neurological conditions, experienced significant delays in staff response to the call system, with one reporting waits of up to half an hour and another stating it could take a couple of hours. Staff interviews confirmed awareness of the expectation for immediate response, but cited competing demands and short staffing as contributing factors. These delays led to residents feeling neglected, anxious, and unsafe.
The facility did not maintain required competency documentation for a registry LVN and a regular CNA assigned to two residents with complex medical needs. The LVN's file lacked a full skills checklist and performance evaluation, and the CNA's file was missing a skills checklist. Leadership could not confirm completion of these requirements, and the facility's own policy mandates such documentation for all staff, including agency personnel.
A resident who was fully dependent on staff and had a nephrostomy tube experienced multiple episodes of tube dislodgement, resulting in repeated hospital transfers for invasive procedures. Care plans lacked specific interventions to prevent dislodgement, and staff interviews indicated that improper handling during care likely contributed to the incidents. Unlicensed staff did not receive targeted training on nephrostomy tube care, and the facility's policies were not effectively implemented to prevent recurrence.
Two residents with severe cognitive impairment and ventilator dependence were placed in hand mittens to prevent accidental removal of tubing, with physician orders requiring removal and assessment of skin and circulation every two hours. However, staff only documented these checks every shift and did not include details about skin condition or circulation, contrary to orders and facility policy. Interviews confirmed a lack of consistent documentation and monitoring, resulting in a deficiency related to the use of physical restraints.
Three residents did not receive care according to professional standards: two residents with diabetes received insulin injections repeatedly in the same site without rotation, contrary to physician orders and facility policy, and another resident with end-stage renal disease and hypertension did not have their significantly elevated blood pressure reassessed or reported to a physician in a timely manner. Staff interviews and record reviews confirmed these failures in medication administration and monitoring.
Nursing staff failed to rotate insulin injection sites as ordered for two residents with diabetes, resulting in repeated use of the same sites. A discrepancy was found between the inventory and accountability record for a resident's oxycodone, due to a documentation error that was not corrected. Additionally, the Cubex drug dispensing record did not match the eMAR for a resident's Norco administration, as the nurse failed to document the dose after being called away.
Kitchen staff were unable to correctly demonstrate and verbalize proper dishwashing and QUAT sanitizer testing procedures, including incorrect use of the preparation sink, failure to air dry equipment, and not following manufacturer guidelines for sanitizer concentration testing. These practices had the potential to cause cross-contamination and foodborne illness among medically compromised residents.
Staff served 4 oz portions of BBQ pork instead of the prescribed 3 oz to 83 residents on regular texture diets, as confirmed by direct observation and review of facility records. The Registered Dietitian stated that this failure to follow the menu and portion guidelines resulted in meals not meeting the intended nutritional needs.
The facility did not consistently prepare or present food in a palatable, attractive, or properly textured manner, as observed with pureed cabbage that did not hold its shape, dry pork barbecue, and overcooked vegetables. Two residents with complex medical needs reported that the food was unappetizing and poorly prepared, and staff confirmed that food quality and presentation did not meet facility guidelines.
Surveyors identified multiple deficiencies in kitchen operations, including unclean equipment and storage areas, improper cold food holding temperatures, use of damaged trays and chopping boards, incorrect dishwashing and sanitizing procedures, and failure to maintain proper refrigerator temperatures. Staff did not consistently follow facility policies or manufacturer guidelines, resulting in unsanitary conditions and increased risk of food contamination for residents.
Surveyors found that food brought in by family and visitors for residents was not consistently stored at the required temperature of 41°F or below, as shown by refrigerator logs and staff interviews. Multiple days showed temperatures above the safe limit, and staff were unclear about the correct temperature range, affecting over a hundred medically compromised residents who stored food in the refrigerator.
Two dumpsters were found overflowing, uncovered, and surrounded by spilled food and trash, with both the Dietary Supervisor and Housekeeping Supervisor confirming the unsanitary conditions and failure to follow facility policy and Food Code requirements for proper garbage disposal and storage.
Two residents with severe cognitive impairment and complex medical conditions did not have comprehensive care plans developed or implemented for critical needs, including rectal tube management, edema, and pressure ulcers. Staff interviews and record reviews confirmed the absence of these care plans, with documentation lapses attributed to issues in the electronic medical record system and care plan management processes.
A resident with hypertensive chronic kidney disease and end stage renal disease did not receive a prescribed dose of furosemide during a morning med pass because an LVN withheld the medication due to the resident's scheduled dialysis later that day. Facility staff and the DON confirmed there was no clear instruction on which medications to hold or when, leading to a significant medication error.
A deficiency occurred when an LVN repeatedly left keys on top of an unattended medication cart while administering medications to a resident in the Subacute unit. The DON confirmed that these keys provide access to both medication carts and narcotic drawers, and facility policy requires secure storage of drugs accessible only to authorized personnel. The practice of leaving keys unattended did not comply with these requirements.
A resident with dementia and high fall risk experienced multiple falls, including one resulting in a shoulder fracture, due to inadequate supervision and failure to implement a person-centered care plan. Despite being identified as high risk, the facility did not provide necessary fall prevention measures such as supervision, padded mats, or a bed alarm. Family members and staff noted the lack of effective monitoring and communication regarding fall prevention strategies.
A resident with multiple health conditions was not allowed to return to the LTC facility after hospitalization, despite available isolation beds. The facility cited the need for a single isolation room, but records showed vacant beds. The resident's family was informed that a previous complaint affected the readmission, causing emotional distress.
A resident identified as a high fall risk experienced three unwitnessed falls within a month due to the facility's failure to implement its Fall Management Program. Despite being dependent on staff for orientation and ambulation, the resident attempted to self-ambulate and turn off their bed alarm. The facility's inadequate supervision and delayed response to the resident's call light contributed to the falls, highlighting the need for more effective interventions such as assigning a sitter.
A facility failed to document background checks and license information for staff assigned to a resident with severe medical conditions, increasing the risk of abuse. Despite the resident's dependency and cognitive impairment, the required documentation for the CNA and LVN was missing, contrary to the facility's abuse prevention policy.
Incomplete Hemodialysis Access Orders
Penalty
Summary
The facility failed to provide clear and concise medical orders for two sampled residents with hemodialysis access orders. One resident was admitted with diagnoses including displaced intertrochanter fracture of the right femur, bacteremia, and type 2 DM, and the MDS showed severely impaired cognition and dependent functional abilities. The resident’s OSR listed a right intrajugular hemodialysis catheter every shift. Another resident was admitted with diagnoses including hypoxia and toxic encephalopathy, and the MDS showed severely impaired cognition and dependent functional abilities. That resident’s OSR listed a right chest permacath every shift. During interview, the Treatment Nurse stated she only cared for residents and wounds and did not handle hemodialysis-related orders, which she said were managed by the RN supervisor. The RN supervisor stated there were 10 hemodialysis residents on the floor and that hemodialysis residents were cared for and charted on by the RN supervisor on shift, but he was unable to explain the meaning of the order "Right IJ HD Catheter every shift" and said he had not encountered that type of order before. The attending provider for one resident stated nursing staff enter standing admission orders under the provider’s name and said they were unsure of the meaning of the order, adding that it was not a specific order they had issued beyond standard protocol orders and that the only interpretation they could infer was that the right IJ catheter should be flushed every shift. The facility policy on physicians’ orders stated orders must be complete and accurate and include enough description to ensure clarity of the physician’s plan of care.
Communication Boards and Call Light Access Not Provided
Penalty
Summary
The facility failed to provide reasonable accommodation for resident communication needs and call light access for multiple sampled residents. Resident 1 was admitted with diagnoses including paralytic syndrome, senile degeneration of the brain, DM2, muscle weakness, dysphagia, a suicide attempt, and schizoaffective disorder. The record showed Resident 1 had the capacity to make decisions, usually could make himself understood and understand others, had unclear speech, and had moderately impaired cognition. During observation, Resident 1 was trying to communicate by mumbling and did not have a communication board at the bedside. CNA 5 stated he could sometimes figure out what Resident 1 was trying to say and would get a communication board. Resident 1 nodded yes when asked if he wanted one, and LVN 7 stated it would be better if Resident 1 had a means of communicating directly instead of staff guessing what he needed. The DON reviewed the facility policies and stated the facility should have provided Resident 1 with a communication board. Resident 93 was admitted with rhabdomyolysis, transverse myelitis, and hemiplegia affecting the left side of the body. The resident needed touching assistance with ADLs and was identified as high risk for falls. The care plan included an intervention for the call light to be within reach and answered promptly. During observation, Resident 93 was sitting upright in bed with a basin on his lap and yellowish brown fluid on his chin, mouth, chest, and bed linens. Resident 93 stated the call light did not work and asked for help cleaning up the vomit. RNA 1 pressed the call light and it did not alarm, and MS 1 found the cord was not fully plugged into the wall socket. After the cord was pushed in, Resident 93 still could not activate the call light, and LVN 6 stated Resident 93 could not apply enough pressure to activate the alarm. The DON stated the resident was not able to easily access and activate the call light and that staff should have assessed residents who could not use a standard call light due to functional limitations. Resident 185 was admitted with DM2, hyperlipidemia, chronic kidney disease, CHF, and hypertension. The care plan identified the resident as a Spanish speaker and included an intervention to provide a Spanish communication board at bedside. The MDS showed severe cognitive impairment and dependence or assistance with multiple ADLs. During observation, Resident 185 was lying in bed watching a Spanish language TV channel, and no Spanish communication board was present at the bedside. CNA 4 stated Resident 185 spoke Spanish and did not have a communication board at bedside. RN 3 and the DON both stated the resident should have had a communication board at bedside and that the care plan indicated one was needed. Resident 104 and Resident 138 also had call lights not within reach during observation; Resident 104’s call light was on the floor and the resident stated it had fallen earlier and no one came to help retrieve it, while Resident 138’s call light was observed on the floor during morning care.
Incomplete Response to Resident Council Call Light Grievances
Penalty
Summary
The facility failed to ensure grievances and recommendations voiced through Resident Council meetings were acted upon and responded to for two residents who attended a meeting with the nurse surveyor. The deficiency involved repeated resident council concerns about delayed response to call lights that were not fully investigated or documented in the grievance process as required by the facility’s policy. Resident 75 was admitted with diagnoses including dysarthria, cerebral infarction, and DM. The resident’s MDS dated 2/6/2026 indicated intact cognition for daily decision-making and dependence on staff for ADLs including bed mobility, transfers, eating, walking in the room, dressing, toileting, and personal hygiene. Resident 147 was originally admitted in 2015 and re-admitted later with diagnoses including COPD, CKD, and generalized muscle weakness. The resident’s H&P dated 11/3/2025 indicated capacity to understand and make decisions, and the MDS indicated moderately impaired cognition with varying levels of assistance needed for ADLs. Resident Council Minutes documented repeated complaints about long call light wait times on multiple shifts, including concerns raised about the 11 PM-7 AM shift, the 3 PM-11 PM and 11 PM-7 AM shifts, and the 3 PM-11 PM shift. Corresponding grievance/complaint resolution reports showed entries such as grievance received, 1:1 in-service started, managers notified, or education needed, but several reports lacked a summary of pertinent findings or conclusions, and one report was blank in that section. During the resident council meeting on 5/11/2026, Resident 75 and Resident 147 stated the facility had been made aware of call light delays and that the issue remained ongoing and unresolved. Facility leadership reviewed the records and stated the grievance documentation was incomplete because it did not include the full investigation, the findings or conclusion, whether the grievance was confirmed, and the corrective action taken.
Missing care plans and failed implementation for pneumonia, diabetes education, and hemodialysis transportation
Penalty
Summary
Resident 4 did not have a comprehensive care plan developed for pneumonia-related antibiotic use after the resident developed a fever and tachycardia and then received an order for Ertapenem Sodium 1 gram IV daily for pneumonia for 10 days. The record review showed the resident had diagnoses including gastrostomy tube dependence, chronic respiratory failure, and ventilator dependence, and the DON confirmed that when a resident started an antibiotic medication, nursing staff had to develop a care plan for the diagnosis of the antibiotic use. The review found that a care plan for antibiotic use and a care plan for pneumonia were missing when the antibiotic was ordered. Resident 169 had diagnoses including essential hypertension, type 2 DM, CKD stage 4, PVD, and a right 3rd toe ray amputation. The resident’s MDS showed cognitive intactness and that Spanish was the primary language. During observation, the resident stated he was supposed to have food low in sugar but was served sweet juice and ice cream and had too many finger sticks and insulin injections. The chart review and interviews found a care plan intervention for diabetes management, including meal planning and education, but there was no documentation that the resident was educated on diet or that noncompliance with the diet was documented. The SBAR also did not show documentation of diet noncompliance or education. Resident 190 had diagnoses including acute respiratory failure with hypoxia, ESRD, and dependence on hemodialysis. The resident stated transportation for HD was repeatedly late, including on one occasion when the ambulance arrived late and the dialysis session was shortened, and on another occasion when the resident was still waiting for transportation and no one had informed him of the delay. The CM who scheduled transportation stated the HD start time was 9:30 a.m. with a pick-up time of 8:30 a.m. or 9:00 a.m., but did not know the physician’s order required an 8:15 a.m. pick-up time. The record included an AMA form showing the dialysis treatment was shortened by 24 minutes because of the late arrival, and the DON stated the CM did not follow the resident’s care plan or order for dialysis transportation.
Improper LALM settings and nonfunctioning support surface
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards and physician orders for three residents who were on low air loss mattresses (LALMs) for skin and wound management. Resident 1 was admitted with multiple diagnoses including paralytic syndrome, senile degeneration of the brain, diabetes mellitus type 2, muscle weakness, dysphagia, and schizoaffective disorder, and had an unstageable sacral ulcer, bilateral knee wounds, bilateral toe wounds, a right arm skin tear, a right groin skin fold wound, and an occiput pressure sore. Resident 1’s care plan and physician order called for use of a LALM, and the care plan also directed staff to regularly check the mattress inflation to ensure correct pressure and airflow. During observation, Resident 1’s LALM was set for a weight of 120 pounds, while the resident’s EMR showed a weight of 155 pounds. The IPN and RN verified the resident’s weight, and the RN stated the mattress should have been set according to the resident’s weight and that the resident’s sacrococcyx pressure injury could be negatively affected if the mattress was not set correctly. The DON also stated the mattress should have been set based on the resident’s weight. The facility’s policy required staff to follow the manufacturer’s guidelines, and the manufacturer’s manual instructed staff to determine the resident’s weight and set the control knob to that weight setting. Resident 9 was admitted with diagnoses including gastrostomy, respiratory failure, and metabolic encephalopathy. The resident was identified as being at risk for pressure ulcer development, had impaired cognition for daily decision-making, and was dependent on staff for ADLs. The care plan required the LALM to be in place, plugged in, functioning properly, and maintaining the correct level and airflow, and the physician order called for a LALM every shift for skin and wound management. Resident 4 was re-admitted with diagnoses including gastrostomy, chronic respiratory failure, and ventilator dependence, and was also identified as being at risk for pressure ulcers, dependent on staff for ADLs, and ordered to use a LALM for skin management every shift. During observation, Resident 4’s LALM machine was turned off and unplugged from the wall outlet, and RN 2 stated it should have been turned on. TX 1 stated the LALM should have been plugged in and turned on to reduce pressure to the skin. The facility’s policy and the mattress manual both indicated support surfaces should be used according to manufacturer instructions, and the manual stated the mattress and control unit should be checked to ensure the system is operating correctly.
Pureed Bread Served Lumpy on Pureed Diet Trays
Penalty
Summary
The facility failed to ensure that 19 residents on pureed diets received bread prepared in a form that met their individual needs and was consistent with IDDSI Level 4 pureed standards. During tray line service for lunch, pureed bread on the steam table was observed to be lumpy and not smooth. Kitchen staff stated they used a robot coupe to make the pureed bread and added butter and milk, then pulsed the machine only a couple of times until it was mixed. During a concurrent interview and taste test with the ADS, Cook1, and the RD, the bread was observed to have a lumpy texture with small pieces of bread and was not smooth. The bread was described as grainy, with residue remaining in the mouth and requiring chewing before swallowing. Cook1 stated the bread looked minced and lumpy because it had not been left in the food processor until smooth, and acknowledged that pureed food had to be smooth and that improper preparation could cause swallowing problems for residents on pureed diets. The facility recipe for Pureed Bread or Roll directed staff to pulse bread in a food processor until a fine consistency and add only enough liquid to achieve a smooth consistency.
Fortified Diet Orders Not Followed During Meal Service
Penalty
Summary
The facility failed to provide fortified diets for 18 of 112 meal trays that required them. During lunch tray line service, meal trays marked for fortified diets received the same food as trays without fortified diet orders. A dietary aide did not communicate the fortified diet orders written on the meal tray cards to the cooks, and the cook did not add any additional food items to the trays. The dietary aide stated fortified diets were meant to add extra calories for residents who were losing weight, but acknowledged that the fortified diets were not communicated to the cook and that no one received anything extra. The cook confirmed that fortified diets were supposed to include added items such as melted butter, but none was added during the lunch service because the dietary aide did not read out the fortified diet orders. The registered dietitian stated fortified diets were recommended for residents at risk of weight loss and required an additional 500 calories per day spread over three meals, with options such as melted butter over vegetables and starches, high protein and calorie mashed potatoes, or creamy soup. Facility guidelines also stated that fortified foods were to be provided within the specifications of the diet order and that fortified enhanced power foods were intended to increase calories and/or protein in meals.
Undated and Expired Food Stored in Kitchen and Resident Refrigerator
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen when multiple food items were found stored without required dates or beyond their allowed storage periods. During observation, three bags of frozen chicken were in the reach-in freezer with no date or label, and the Assistant Dietary Supervisor stated the chicken had been removed from its original packaging and should have been marked with the date it was opened or delivered. In the walk-in refrigerator, an open container of chicken tortilla soup was found with a use-by date of 5/9/2026 and was identified as expired and left in storage. Five bags of thawed raw chicken with a use-by date of 5/6/2026, three logs of ground beef with a use-by date of 5/10/2026, and two large bags of marinated beef chunks with a use-by date of 5/8/2026 were also observed in the walk-in refrigerator. The ADS stated the chicken and ground beef had been stored longer than 5 days, the chicken was past the use-by date, and the marinated beef was staff food that should not have been stored in the facility refrigerator. Nutrition shakes stored in the kitchen were also not dated after thawing. Two boxes of chocolate-flavored nutrition shakes and one box of strawberry-flavored nutrition shakes were found in the walk-in refrigerator with no thaw date, even though the manufacturer’s instructions stated the shakes were to be used within 14 days of thawing. The ADS stated the shakes had been delivered frozen and then stored in the refrigerator, but staff did not know when they had been thawed because no thaw dates were present. The ADS acknowledged the shakes were dairy based and stated residents could get sick if they received expired shakes. A resident refrigerator located in the first-floor utility room also contained undated items. One thawed nutrition shake, one renal nutrition supplement, and one soda were observed with no date or label. The ADS stated the nutrition shake was from the facility and was only good for 14 days once thawed, while the ADON stated all food and beverages stored in the resident refrigerator had to have a date and label indicating discard within 2 days. The DSD stated nursing staff were expected to label and date leftovers placed in the resident refrigerator, and that undated food could make residents sick.
Inaccurate Dialysis Access Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two sampled residents, both of whom had ESRD and received dialysis. Resident 14 was admitted with ESRD and dependence on renal dialysis, was cognitively intact, and had a right upper chest IJ catheter for dialysis. Resident 190 was also admitted with ESRD and dependence on renal dialysis, was cognitively intact, and had a right upper chest permacath for dialysis access. Resident 14's Dialysis Communication Records dated 5/5/2026, 5/7/2026, and 5/9/2026 documented that an AV shunt was checked for bruit and thrill, even though the resident had a catheter and not an AV fistula or AV shunt. During interview, LVN 13 stated she mistakenly documented bruit and thrill checks on Resident 14's records and acknowledged that the documentation was not accurate. The DON later reviewed the records and stated the documentation showing AV shunt checks was not accurate because Resident 14 had a right upper chest IJ catheter and bruit and thrill are only checked with an AV fistula or AV shunt. Resident 190's Dialysis Communication Records dated 5/8/2026, 5/11/2026, and 5/13/2026 also documented that an AV shunt was checked for bruit and thrill, while the resident's access was a dialysis catheter and later identified in the order summary as a right-side chest permacath. LVN 2 stated she mistakenly documented the AV shunt assessment and did not mean to document that bruit and thrill were checked. The DON reviewed these records and stated the documentation was not accurate, that Resident 190 had a right upper chest permacath, and that the records could mislead nurses to perform an assessment or intervention that was not appropriate for the resident.
Infection Control Lapses During G-Tube Care and Enteral Feeding
Penalty
Summary
The facility failed to maintain infection control practices for four sampled residents involving gastrostomy tube care and enhanced barrier precautions. The cited issues included a nurse not rinsing a medication syringe after administering crushed medications through a g-tube for a resident with acute transverse myelitis, GERD, and impaired cognition; a treatment nurse not wearing a gown during g-tube dressing care for a resident on enhanced barrier precautions; and two residents’ enteral feeding tubes being left uncapped and open to air. For the first resident, LVN 5 prepared nine medications for g-tube administration, entered the room, and placed the medications on the bedside cart without disinfecting the cart. After checking tube placement and using a 60 mL syringe to check residual volume, the nurse removed the syringe, pushed a few droplets of residual liquid onto the bedside cart while handling the medications, administered the medications through the g-tube, and then placed the syringe back in the syringe bag without rinsing or cleaning it. The nurse later stated the residual droplets created a risk of infection and that the syringe should have been rinsed to keep it clean and patent. The DON stated the syringe should have been cleaned and disinfected, and the facility policy required the syringe used for medication instillation to be rinsed and stored in a clean manner. For the second resident, who had a g-tube, respiratory failure, metabolic encephalopathy, impaired cognition, and an order for enhanced barrier precautions, the room signage indicated staff were to wear gloves and a gown for high-contact care activities. During observed g-tube dressing care, TX 2 was not wearing a gown and stated the gown had been forgotten. The DON stated the treatment nurse should have been wearing gloves and gowns during wound care to prevent infections. For the third and fourth residents, both with enteral feeding tubes and orders for enhanced barrier precautions, the tubes were observed uncapped and open to air during concurrent observations. Staff verified the tubes were uncapped and stated the residents could be at risk for infection if the uncapped tubes were connected. The DON stated the tubes should have been capped if disconnected for infection control, and the facility policies required clean technique and proper handling of enteral feeding systems.
Resident Kept Vitamin C in Room Without Self-Administration Approval
Penalty
Summary
The facility failed to ensure that one sampled resident who was determined not to be a candidate for safe self-administration of medications did not self-administer Vitamin C kept in the resident’s room. The resident was readmitted with diagnoses including pneumonia, larynx cancer, and a gastrostomy. The admission H&P stated the resident had the capacity to understand and make decisions, but the facility’s Self Administration of Medication Assessment indicated the resident was not a candidate for safe self-administration of medications, no physician orders to self-administer medications were obtained, and no care plan for self-administration was implemented. Additional records showed the resident had severe dysphagia, was to remain NPO with enteral feeding, and later ENT records stated clearance for oral intake was to be determined by speech therapy based on swallow evaluation. The MDS later indicated the resident was cognitively intact and needed touching assistance with ADLs. The Order Summary Report did not show any physician orders for self-administration of medications, and the Care Plan Report did not include any focus, goal, or interventions for self-administration of medications. During observation and interview, the resident used a key to unlock the closet and retrieve an unsealed bottle of Vitamin C supplements and stated he took one supplement by mouth every other morning. Staff interviews indicated CNA 6 was unaware whether the resident kept medications at bedside, LVN 11 stated residents who did not pass the self-administration assessment were not allowed to keep medications at bedside or in the room, and AA 1 stated it was not okay for the resident to keep medications in the closet. The DON reviewed the facility policy and stated it was not followed; the policy stated a resident may only self-administer medications after the IDT has determined which medications may be self-administered.
Resident left exposed with curtain open
Penalty
Summary
The facility failed to maintain dignity and respect for one sampled resident when Resident 83 was observed lying in bed with the gown bunched up around the upper chest and neck, leaving the abdomen and chest exposed while the privacy curtain was pulled open. Staff were observed passing by the room during the observation. Resident 83 was a [AGE]-year-old woman admitted with diagnoses including quadriplegia, hemiplegia, hemiparesis, gastrostomy, bed confinement status, dementia, unspecified intellectual disabilities, and contractures of both shoulders and hands. Her MDS dated 5/1/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. During the concurrent observation, CNA 3 confirmed the curtains were open and the resident’s chest was exposed, then pulled down the gown to cover her chest and stated she should have been covered and provided privacy to maintain dignity. RN 3 stated that if staff passed by and noted a resident was exposed, they should have covered the resident and provided privacy using the curtain, and that Resident 83 should have been covered to maintain privacy and dignity. The DON stated Resident 83 could not verbalize needs and was totally dependent on staff for care, and that staff were expected to protect her privacy and dignity by drawing the curtain, covering her with the gown and blanket, and securing her clothing. Facility policies on dignity, respect, privacy, and confidentiality stated residents are to be treated with dignity and that staff should prevent exposure by pulling privacy curtains or closing doors and providing clothing or draping to prevent public view.
Failure to Maintain Resident Privacy During Morning Care
Penalty
Summary
The facility failed to ensure Resident 138’s privacy curtain was completely closed during morning care, and the resident’s lower body was exposed while Certified Nursing Assistant 1 provided care. Resident 138’s admission record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, functional quadriplegia, type 2 diabetes mellitus with hyperglycemia, cognitive communication deficit, essential hypertension, acute and chronic respiratory failure with hypoxia, and muscle weakness. The resident’s MDS dated 04/12/2026 indicated severely impaired cognitive skills for daily decision-making, memory problems with short-term and long-term memory, and the need for extensive staff assistance with ADLs including personal hygiene, toileting hygiene, dressing, bathing, transfers, and mobility. During the observation on 05/13/2026 at 9:08 a.m., the privacy curtain was halfway open, the lower part of Resident 138’s body was exposed, and CNA 1 left the resident partially exposed while going to obtain assistance from another CNA. The resident’s call light was also observed on the floor. During interviews, RN 1 stated residents should be provided privacy during care and said, "If I were him, I would be upset." The DON stated that leaving a resident exposed during morning care may place the resident at risk for emotional distress, embarrassment, humiliation, loss of dignity, anxiety, and psychological discomfort. The facility policy titled Privacy and Confidentiality, revised 03/2023, stated residents have the right to personal privacy during personal care and that staff shall prevent exposure of body parts by pulling privacy curtains or closing doors and providing clothing or draping to prevent public view.
PRN Ativan Order Lacked Required End Date
Penalty
Summary
The facility failed to ensure that one sampled resident, who was admitted and later readmitted with diagnoses including epilepsy, aphasia, type 2 DM, muscle weakness, dysphagia, and essential HTN, had an end date for a PRN Ativan order. The resident’s MDS indicated no speech and that he rarely could make himself understood or understand others, and the H&P stated he did not have the capacity to understand and make decisions. During record review and interviews with LVN 9, RN 3, and the DON, the resident’s order summary showed Ativan 2 mg IM PRN for seizure with a start date but no end date. The facility’s policy on psychoactive medications stated PRN psychotropic drugs shall be limited to 14 days, and staff verified that the order did not have an end date and should have been limited to 14 days.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for one sampled resident who was transferred to the hospital on 5/11/2026. Resident 3 had been admitted on 3/14/2026 and re-admitted on 4/3/2026 with diagnoses including acute and chronic respiratory failure and encephalopathy. The resident’s MDS dated 3/18/2026 indicated intact cognition for daily decision-making and that the resident was mostly dependent on staff for ADLs. The H&P dated 4/6/2026 stated the resident had the capacity to understand and make decisions. Resident 3’s RTR dated 5/11/2026 indicated transfer to GACH due to tachycardia and difficulty maintaining adequate oxygen saturation levels. The NPTD dated 5/11/2026 stated the discharge was necessary because the resident’s needs could not be met by the facility. During record review, the NPTD fax report showed the notice was faxed on 5/13/2026 at 11:18 AM, and the MRA stated no fax report was completed or maintained in the medical record on the date of transfer. The DON stated it was best practice to notify the LTC Ombudsman by fax as soon as possible when a resident was transferred and that the fax report should have been maintained in the resident’s medical record. The facility policy required that when a resident was temporarily transferred on an emergency basis to an acute care facility, notice be provided to the resident and representative, a copy be forwarded to the Ombudsman, and evidence maintained that the notice was sent.
Inaccurate MDS Tobacco Use Assessment
Penalty
Summary
The facility failed to ensure Resident 57’s MDS accurately reflected the resident’s tobacco use. Resident 57 was admitted with diagnoses including spondylosis, type 2 DM, diverticulosis, muscle weakness, and a history of falling. The resident’s Care Plan Report identified the resident as a smoker, noted risk for injury, non-compliance, and respiratory illness, and documented that the resident was informed of the facility’s smoking guidelines and given instructions on safe smoking. A Smoking Risk Assessment also identified the resident as a smoker. The MDS for Resident 57, however, indicated the resident was cognitively intact but did not currently use tobacco. The facility’s Resident Smoking List identified Resident 57 as a smoker, and during interview the resident stated he smoked one cigarette daily. The MDS LVN and the DON both stated the MDS was inaccurate and should have indicated that the resident used tobacco. The facility’s Resident Assessment policy stated the facility conducts a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity.
Failure to Update Dialysis Care Plan
Penalty
Summary
The facility failed to update and revise the ESRD and dialysis care plan for one resident after the resident’s dialysis transportation pick-up time changed. The resident was admitted with diagnoses including ESRD and dependence on renal dialysis, and the care plan dated 11/14/2025 identified a goal to remain free of complications related to renal disease or dialysis with an intervention to assist with coordination of the dialysis schedule as ordered. The care plan listed dialysis every Tuesday, Thursday, and Saturday with transportation pick-up at 1:15 PM. A physician order dated 5/5/2026 changed the resident’s dialysis schedule to three times weekly on Tuesday, Thursday, and Saturday at 12:15 PM, with transportation pick-up at 11:30 AM. During interviews and record review, RN 3, the MDS LVN, and the DON all stated the care plan did not reflect the resident’s active physician orders and should have been revised to match the current dialysis schedule. The DON stated the care plan still reflected a previous physician order and did not match the care the resident was to receive.
Failure to Rotate Subcutaneous Injection Sites
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration by not rotating subcutaneous injection sites for two residents. Resident 80 was admitted with diagnoses including type 2 DM, local infection of the skin and subcutaneous tissue, and long-term current use of insulin. The resident’s MDS and H&P indicated he could understand others, make himself understood, and make decisions. His care plan included giving diabetes medication as ordered by the physician. A review of Resident 80’s Location of Administration Report showed repeated Humalog injections were given in the left arm and then the abdomen LLQ without rotation. The report documented Humalog administered in the left arm on multiple occasions, followed by injections in the abdomen LLQ on consecutive days. The resident’s order summary included Humalog to be given subcutaneously before meals and at bedtime for DM2 with instructions to rotate injection sites. The IPN, RN 4, and DON all verified that the injection sites were not rotated and stated the nurses did not follow the physician order or the facility’s insulin administration policy, which stated injection sites should be rotated to reduce the risk of damaging skin tissue. Resident 186 was admitted with diagnoses including epilepsy, aphasia, type 2 DM, muscle weakness, dysphagia, and essential HTN. The resident’s MDS indicated unclear speech and limited ability to make himself understood or understand others, and the H&P stated he did not have capacity to understand and make decisions. His Location of Administration Report showed repeated Enoxaparin, NPH insulin, and Humalog injections were given in the abdomen LLQ without rotation. The order summary included Enoxaparin 40 mg subcutaneously daily with instructions to rotate the injection site, Humalog before meals and at bedtime with rotation, and NPH insulin every 8 hours with rotation. The IPN, RN 4, and DON verified the injections were not rotated and stated the facility nurses did not follow the physician orders for Enoxaparin and insulin.
Failure to Provide Oral Care for a Dependent Resident
Penalty
Summary
The facility failed to provide necessary oral care for Resident 83, who was dependent on staff for oral hygiene. Resident 83 was admitted with diagnoses including quadriplegia, hemiplegia, hemiparesis, gastrostomy, bed confinement status, dementia, unspecified intellectual disabilities, and contractures of both shoulders and hands. The MDS dated 5/1/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The care plan dated 4/9/2026 identified the resident as needing assistance with multiple ADLs and included an intervention to assist with maintaining good personal hygiene every shift and as needed. During observation on 5/11/2026, Resident 83 was lying in bed with white opaque fluid coming from the mouth and onto the upper part of the gown, and the mouth and lips were covered in the fluid. The IPN stated the resident needed oral care, that oral care was to be performed as needed, and that the resident was confused and dependent on staff for care. The DON later stated the resident could not verbalize needs, was totally dependent on staff, and needed total assistance with oral care; the DON also stated staff should have wiped the resident's mouth and that keeping the mouth clean was important to maintain dignity. The facility policy stated staff would assist dependent residents with oral hygiene and other ADLs as necessary.
Failure to Clarify Boost Route and Implement Aspiration Risk Care Plan
Penalty
Summary
The facility failed to provide care and services to prevent aspiration for one resident with diagnoses including larynx cancer, dysphagia, and a gastronomy tube. The resident’s admission record showed readmission with these diagnoses, and the history and physical noted the resident had capacity to understand and make decisions. A speech-language pathologist discharge summary stated oral intake was not safe and that the resident needed ENT follow-up for further evaluation. Later records showed severe dysphagia, continued NPO status with enteral feeding, and ENT records indicating clearance for oral intake was to be determined by speech therapy based on swallow evaluation. The resident’s order records contained two separate Boost supplement orders, including an order for Boost three times a day and another order to acknowledge diet as followed on Boost supplement TID and enteral feeding. The orders did not specify the route of administration. During interview, an LVN stated the Boost orders should have been clarified to determine whether the supplement was to be given orally or through the G-tube, and stated the resident could aspirate if he drank Boost. An RN stated the resident would drink the Boost supplement and was at increased risk for aspiration when consuming it orally. The resident also stated he drank the Boost supplements and that nurses did not administer them through the G-tube. The resident’s care plan did not include a focus for risk for aspiration, although aspiration precautions were listed under special instructions. Staff interviews confirmed there was no current aspiration risk care plan, and multiple staff stated one should have been in place because of the resident’s dysphagia and aspiration risk. The speech therapist stated the resident was high risk for aspiration due to left vocal cord paralysis and could choke or develop aspiration pneumonia from drinking the Boost supplement. The DON stated the route for the Boost orders should have been clarified and that there was no care plan for risk for aspiration.
Uncapped Enteral Feeding Tubes Left Open to Air
Penalty
Summary
The facility failed to maintain G-tube care for two sampled residents by leaving enteral feeding tubes uncapped and open to air. Resident 175 was admitted and later readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, muscle weakness, type 2 DM, acquired absence of part of the digestive tract, and reduced mobility. The resident’s care plan identified enteral feeding through a feeding tube, risk for aspiration, dehydration, weight fluctuation, nausea and vomiting, abdominal distention, diarrhea, constipation, and intolerance to feeding related to dysphagia, and included interventions to use clean techniques and change tubing per policy or as ordered. The resident also had EBP related to the gastrostomy tube, and the record indicated the resident had no speech, rarely or never could make himself understood, rarely or never understood others, and did not have capacity to understand and make decisions. During observation, Resident 175’s enteral feeding tube was found uncapped and open to air. In a concurrent interview, the LVN stated the tube was uncapped and that the resident could be at risk for infection if staff connected the uncapped tube to the resident, and stated she would need to change the enteral tube feeding system. In a separate interview, RN 3 stated there could be an infection control issue if the resident’s enteral feeding tube was uncapped and left open to air. Resident 186 was also observed with an enteral feeding tube uncapped and open to air. During the observation and interview, the LVN stated the tube was uncapped and that the resident could be at risk for infection if staff connected the uncapped enteral feeding tube to the resident, and stated she would need to change the enteral tube feeding system. The DON later stated the facility should have capped Resident 186’s enteral feeding tube if the enteral feeding had been disconnected for infection control. The facility’s policies on infection prevention and enteral feeding safety were reviewed during the investigation.
Oxygen Tubing and Humidifier Not Labeled or Dated
Penalty
Summary
Resident 80 was admitted to the facility on 2/16/2026 and readmitted on 5/9/2026 with diagnoses including type 2 DM, local infection of the skin and subcutaneous tissue, heart failure, anemia, and long-term current use of insulin. The resident’s MDS dated 2/22/2026 indicated the resident could understand others and make himself understood, and the H&P dated 4/14/2026 also indicated the resident had the ability to understand and make decisions. The resident was receiving oxygen therapy, and the physician order summary dated 5/13/2026 showed an order for oxygen at 2 liters per minute via nasal cannula for SOB/wheezing, with the oxygen tubing to be changed every 7 days on Sunday mornings and as needed. During a concurrent observation and interview on 5/11/2026 at 1:27 PM, Resident 80’s nasal cannula tubing and humidifier were observed missing a label and date, and LVN 4 verified they were not labeled and dated. During a later concurrent observation and interview the same day with the IPN and RN 4, the nasal cannula tubing and humidifier were again observed without a label and date. RN 4 stated the facility documented when the tubing and humidifier were changed on the MAR, but she could not locate documentation showing when they were last changed. RN 4 stated she could not guarantee the tubing and humidifier had been changed on Sunday because the current equipment was not labeled and dated. The IPN stated the nasal cannula tubing and humidifier needed to be changed for infection control. During interview and record review on 5/14/2026, the DON reviewed the facility’s Oxygen Therapy policy, which stated oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen are for single resident use only and will be changed weekly and when visibly soiled. The DON stated the facility should have put a label and date on Resident 80’s nasal cannula tubing and humidifier.
Late Dialysis Transportation and Poor Communication
Penalty
Summary
The facility failed to implement the care plan for a resident who required hemodialysis and had diagnoses including acute respiratory failure with hypoxia and end stage renal disease with hemodialysis dependence. The resident’s MDS showed intact cognition with a BIMS score of 14 and significant assistance needs for daily activities. The resident stated there had been repeated problems with transportation for dialysis, including late ambulance pickup and late return to the facility, and said the dialysis center had him sign paperwork because his treatment was shortened. On 5/13/2026, the resident was still in his room waiting for transportation for HD and stated he was running late again and had not been told anything. The EMT stated dispatch provided pickup and destination information but not an exact pickup time. The case manager stated the resident’s HD start time was 9:30 a.m. with a pickup time of 8:30 a.m. or 9:00 a.m., but did not know the physician’s order dated 4/29/2026 specified an 8:15 a.m. pickup time. The case manager also stated the resident was being late and the HD time would be shortened. Record review showed the dialysis communication record did not include the time HD started and ended, and the LVN stated the facility usually notifies the dialysis center if transportation is late but was not aware the resident’s dialysis was cut short. An AMA form dated 5/11/2026 documented the dialysis treatment was shortened by 24 minutes from the prescribed 195 minutes because the resident arrived late. The DON stated the case manager did not follow the resident’s care plan or order for dialysis transportation, and that the facility should have communicated with the case manager and dialysis center when the resident was late and should have been alerted when the dialysis treatment was cut short.
Medication Administration and Controlled Substance Documentation Errors
Penalty
Summary
Safe medication administration was not ensured for a resident with a g-tube, GERD, and moderately impaired cognition when pantoprazole granules were administered in a manner that did not match the manufacturer’s instructions or the physician’s order. The order summary directed Protonix oral packets 40 mg to be given via g-tube twice daily and stated to mix the granules with apple sauce, while the manufacturer’s labeling for g-tube administration instructed that the packet contents be placed in a catheter-tip syringe and mixed with apple juice. During observation, an LVN prepared pantoprazole with apple sauce, then added water, and administered it via g-tube after other medications. The LVN stated she had been giving the medication with apple sauce and needed to look up the package insert or ask a supervisor. The DON reviewed the labeling and stated the instructions called for apple juice, acknowledged that the medication had been given with apple sauce and water, and stated there was a risk of g-tube clogging and that some granules might not be delivered. Accurate accountability of controlled medications was not maintained for a resident with generalized muscle weakness and no capacity to understand and make decisions when hydrocodone-acetaminophen was administered but not documented on the controlled drug record/count sheet. The resident had an order for hydrocodone-acetaminophen 10-325 mg via g-tube twice daily for pain management. During inspection of Station 4 Medication Cart 1, the bubble pack, the facility’s controlled drug record, and the eMAR were reviewed together. The bubble pack contained 21 tablets, the controlled drug record showed 22 tablets remaining with the last dose documented the prior day, and the eMAR showed a dose documented as given that morning. The LVN stated she forgot to document the medication in the book after administering it and acknowledged that controlled medications should be documented in the count sheet to maintain a record of administration and prevent misuse. Accurate accountability was also not maintained for another resident with epilepsy and status epilepticus when lacosamide was administered but not reflected correctly on the controlled drug record. The resident had an order for lacosamide 50 mg, two tablets every 12 hours for seizure control, and the bubble pack label indicated lacosamide 100 mg, one tablet every 12 hours. During the same inspection of Station 4 Medication Cart 1, the bubble pack contained 51 tablets, the controlled drug record showed 52 tablets remaining with the last dose documented the prior evening, and the eMAR showed two tablets documented as administered that morning. The LVN stated she was supposed to sign the book after removing the medication from the bubble pack and then document in the eMAR after administration. The facility policy required controlled substances to be entered immediately upon removal from controlled storage, including the date, time, amount removed, amount remaining, and nurse signature, and required medications to be administered in accordance with state and federal guidelines and the right time and route.
Pharmacy review failed to address pantoprazole and mycophenolate issues
Penalty
Summary
The facility failed to ensure monthly drug regimen review addressed medication irregularities for one sampled resident who had a history of acute transverse myelitis, GERD, and a g-tube. The resident’s MDS indicated moderately impaired cognition and dependence on staff for multiple ADLs. The resident’s MAR showed pantoprazole granules and mycophenolate mofetil suspension were both administered via g-tube at the same scheduled time, and the order summary reflected pantoprazole 40 mg packets mixed with applesauce and given via g-tube twice daily, along with Cellcept suspension 200 mg/mL given via g-tube twice daily. During observation of medication administration, an LVN prepared pantoprazole granules and mycophenolate mofetil suspension for administration through the g-tube. The LVN stated she had difficulty administering medications by gravity and needed to push the plunger slightly to help the medications pass through smoothly. Pantoprazole was observed being mixed in applesauce and then with water before administration via g-tube, and the LVN administered the pantoprazole at the end because of the granules. The LVN also stated that Cellcept was thick and that the medications were hard to push through, and that the resident was gassy. The manufacturer’s labeling for pantoprazole granules indicated that for patients with a gastrostomy tube, the packet contents should be administered using a catheter-tip syringe with apple juice, and that no granules should remain in the syringe. The labeling also identified mycophenolate mofetil as a drug dependent on gastric pH for absorption and stated pantoprazole can reduce absorption of mycophenolic acid. Micromedex identified the interaction between pantoprazole and mycophenolate mofetil as major and warned that concurrent use may reduce mycophenolic acid exposure and decrease efficacy. The consultant pharmacist stated the interaction was only cautionary and did not require physician notification, and the DON stated the pharmacist discussed the interaction with the QA nurse and considered it not severe. The facility did not provide lab values for mycophenolate mofetil levels, and the record showed the medications were administered concurrently via g-tube before the interaction was clarified.
PRN opioid given outside ordered pain parameters
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs when hydrocodone-acetaminophen was administered outside the parameters of the physician’s orders. The resident had diagnoses including incomplete quadriplegia and a history of physical injury and trauma, and the record indicated the resident had decision-making capacity and intact cognition. The physician orders included pain monitoring every shift and two PRN hydrocodone-acetaminophen orders: 1 tablet for moderate pain (4-6) and 2 tablets for severe pain (7-10), both with a maximum acetaminophen limit of 3 g/day and instructions to hold if RR was less than 12 and call the MD. Review of the MAR showed multiple administrations of hydrocodone-acetaminophen 7.5-325 mg, 2 tablets, when the documented pain scores did not meet the severe-pain parameter. In April 2026, the medication was documented as given six times for pain scores of 6, 0, 0, 0, 0, and 4. In May 2026, it was documented as given four times for pain scores of 0, 6, 5, and 6. These entries showed that the 2-tablet dose was administered even when the resident’s pain level was below the ordered range for severe pain. During interview and record review, the LVN stated the resident had two hydrocodone-acetaminophen orders and that giving 2 tablets for pain level 6 instead of 1 tablet exceeded the intended dosing and could increase acetaminophen exposure. The LVN also stated the resident was receiving baclofen and pregabalin, which increased the risk for respiratory depression. The DON stated the resident needed reassessment for pain and that the nurse should have followed the physician orders and given 1 tablet instead of 2 tablets for pain level 6. The consultant pharmacist stated that when nurses gave 2 tablets instead of 1 tablet for the different pain scale, it was considered a medication error. The facility policies stated medications must be administered in accordance with orders and that opioids should be selected and dosed according to professional standards of practice.
Medication Administration Error Involving G-Tube Pantoprazole and Mycophenolate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication pass for one sampled resident. Resident 7 had diagnoses including acute transverse myelitis in demyelinating disease of the central nervous system, GERD, and attention to a gastrostomy tube. The resident’s MDS indicated moderately impaired cognition and dependence on staff for multiple ADLs, and the resident’s eating function was not attempted due to medical condition or safety reasons. During medication administration observation, LVN 5 prepared multiple medications for administration via g-tube, including pantoprazole delayed-release granules and mycophenolate mofetil oral suspension, both scheduled for the same time. LVN 5 crushed several tablets, dissolved them in water, and prepared pantoprazole by mixing the packet in applesauce and then water at bedside before giving it via g-tube. LVN 5 stated it was difficult to administer medications by gravity and that she sometimes had to push the plunger to help medications pass through smoothly. She also stated she usually administered Protonix at the end because of the granules. The resident’s orders showed pantoprazole 40 mg via g-tube twice daily and Cellcept 500 mg via g-tube twice daily. The report states the facility did not provide lab values for mycophenolate mofetil levels. LVN 5 later stated she found the interaction between pantoprazole and mycophenolate and believed they should not be given together because pantoprazole could lower mycophenolate levels. The DON stated the pharmacist had discussed the interaction with the QA nurse and considered it not severe, and the consultant pharmacist stated it was only a cautionary interaction and did not require physician notification. Manufacturer labeling for pantoprazole directed administration via g-tube using apple juice, not applesauce, and identified reduced absorption of mycophenolate mofetil as a clinically relevant interaction. Micromedex identified the interaction as major and noted that concurrent use may reduce mycophenolic acid exposure and decrease efficacy. The facility’s medication administration and unnecessary drugs policies required medications to be administered in accordance with physician orders and state and federal guidelines.
Medication Error With PRN Hydrocodone-Acetaminophen
Penalty
Summary
The facility failed to ensure one resident was free from a significant medication error involving hydrocodone-acetaminophen. The resident had diagnoses including incomplete quadriplegia and a history of physical injury and trauma, and was documented as having intact cognition and the capacity to understand and make decisions. The resident’s physician orders included pain monitoring every shift and two separate PRN hydrocodone-acetaminophen orders: 1 tablet every 4 hours as needed for moderate pain rated 4-6, and 2 tablets every 4 hours as needed for severe pain rated 7-10, with a maximum of 3 grams of acetaminophen per day and instructions to hold if respiratory rate was less than 12 and call the MD. Review of the MAR showed that licensed nurses documented administration of 2 tablets of hydrocodone-acetaminophen on multiple occasions when the recorded pain score did not meet the ordered severe-pain parameter. During the April MAR review, the 2-tablet dose was given for pain scores of 6, 0, 0, 0, 0, and 4. During the May MAR review, the 2-tablet dose was given for pain scores of 0, 6, 5, and 6. These administrations were documented by two different licensed nurses and did not match the physician’s ordered pain scale parameters. During interview and record review, LVN 9 stated there were two hydrocodone-acetaminophen orders and that giving 2 tablets instead of 1 tablet for pain level 6 was a medication error. LVN 9 also stated the resident was receiving baclofen and pregabalin, which increased the risk for respiratory depression, and noted the acetaminophen exposure could exceed the 3-gram daily limit. The DON stated the nurse should have assessed pain and followed the physician orders by giving 1 tablet instead of 2 tablets for pain level 6, and acknowledged the risk of acetaminophen and liver toxicity as well as the need to monitor for respiratory depression and respiratory distress. The consultant pharmacist stated that when nurses gave 2 tablets instead of 1 tablet for a different pain scale, it was considered a medication error.
Improper medication storage and labeling
Penalty
Summary
Medication storage and labeling were not maintained in accordance with manufacturer specifications and facility policy in the Station 3 Medication Room and in two medication carts. During observation and interview, Resident 1’s lorazepam oral concentrate 2 mg/mL was found in the medication refrigerator while the thermometer read 60 F, even though the manufacturer required refrigeration at 36 F to 46 F. The resident’s record showed diagnoses including generalized anxiety disorder and palliative care, and the MAR showed the lorazepam had been administered twice during the review period. Staff stated the medication refrigerator was reading high temperatures and that the lorazepam should have been removed with the other medications because the refrigerator was not working properly. Resident 119’s discontinued ciprofloxacin HCl ophthalmic solution 0.3% was still stored in a cabinet in the Station 3 Medication Room with the resident’s name on the container. The physician order for the eye drops had ended, and the MAR showed the medication had been administered earlier in the year, but there was no active order for it at the time of review. Staff stated the ciprofloxacin had been discontinued but could not identify the discontinuation date, and the medication had not been discarded from the medication storage area. In Station 4 Medication Cart 1, Resident 23’s Rocklatan ophthalmic solution bottle had an outside label with the resident’s name and Rocklatan, but the inside label and medication were for olopatadine drops. In the Controlled Care Unit Medication Cart on Floor 2, Resident 130’s and Resident 96’s Humulin R vials were found without open dates. The facility’s policy required medications to be stored according to manufacturer recommendations, discontinued or deteriorated medications to be removed and destroyed, and insulin to be labeled with an open date when not refrigerated. The DON and nursing staff acknowledged that the insulin needed proper dating and that the wrong medication could be given if staff relied on the outside label alone.
Late Dialysis Transportation Resulted in Shortened Treatment
Penalty
Summary
The facility failed to ensure transportation to and from outside laboratory services was not late for a resident who depended on hemodialysis. Resident 190 was admitted with acute respiratory failure with hypoxia and end stage renal disease with hemodialysis dependence. The resident’s MDS showed intact cognition with a BIMS score of 14, and the resident required varying levels of assistance with activities of daily living, including dependence for transfers, toileting, and showering. During interview, Resident 190 stated that transportation for dialysis had been late on multiple occasions. The resident reported that on one occasion the ambulance arrived one hour late for pickup and 45 minutes late for return to the facility, and that the dialysis center had the resident sign paperwork because the treatment was shortened. On another day, the resident was still waiting in the room for transportation and stated the dialysis time was being shortened because of the delays. EMT 1 stated dispatch provided pickup and destination information but not an exact pickup time. Record review showed the facility arranged transportation for a 9:30 a.m. dialysis start time with pickup at 8:30 a.m. or 9:00 a.m., while the physician’s order dated 4/29/2026 indicated pickup time of 8:15 a.m. The dialysis communication record and AMA form dated 5/11/2026 showed the resident’s dialysis treatment was shortened by 24 minutes from the prescribed 195 minutes due to arriving late. Staff interviews showed the CM did not know the ordered pickup time, the LVN was not aware the treatment had been cut short, and the DON stated the CM did not follow the resident’s care plan or order for dialysis transportation.
Call Light Out of Reach for Resident with Dementia and Mobility Impairment
Penalty
Summary
The facility failed to ensure that Resident 85's call light was within reach. Resident 85 was admitted with diagnoses including HTN, history of falling, GERD, difficulty walking, reduced mobility, muscle weakness, and dementia. The care plan identified Resident 85 as being at risk for falls and included interventions for the call light to be within reach, to encourage use of the call light for assistance as needed, and to maintain a safe environment with a working and reachable call light. Another care plan noted bowel and bladder incontinence and the need to anticipate toileting needs. The H&P stated Resident 85 did not have the capacity to understand and make decisions. The MDS indicated Resident 85 was dependent on staff for toileting hygiene, showering/bathing, putting on and taking off shoes, and tub/shower transfer, and needed partial/moderate assistance for bed mobility. During a concurrent observation and interview, Resident 85's call light was observed lying on the floor and out of reach. The LVN verified the call light was on the floor and out of Resident 85's reach and stated he would sanitize it and place it within reach so the resident could ask for help if needed. The facility policy stated the resident call system shall be accessible to the resident while in bed or other sleeping accommodations and that the facility is equipped to allow residents to call for staff assistance from the bedside, floor, or toileting facilities.
Failure to Respond Timely to Resident Call System
Penalty
Summary
The facility failed to ensure that two of four sampled residents received care in accordance with professional standards by not answering the resident call system in a timely manner. One resident, who was dependent on staff for most activities of daily living due to chronic respiratory failure, mobility issues, and generalized anxiety disorder, reported that call lights sometimes went unanswered for half an hour or more, leading to feelings of unsafety, frustration, and anxiety. Direct observation confirmed a delay of seven minutes in responding to this resident's call light. Staff interviews acknowledged that call lights should be answered immediately, but the assigned CNA was unaware of the call due to assisting other residents at the time. Another resident, with diagnoses including metabolic encephalopathy, COPD, and chronic kidney disease, also required significant assistance and reported that call lights often took a couple of hours to be answered. This resident stated that staff frequently cited short staffing as the reason for delays and expressed feelings of neglect. The facility's policies require prompt response to call systems and provision of care based on comprehensive assessments, but these standards were not met, as evidenced by resident reports, staff interviews, and direct observation.
Failure to Ensure Staff Competency Documentation for Nursing and CNA Staff
Penalty
Summary
The facility failed to ensure that both a registry nurse (LVN) and a regular CNA assigned to two residents had the necessary competencies documented in their employee files. For the LVN, who was assigned to a resident with Type 2 Diabetes, chronic kidney disease, and obesity, there was no full skills checklist or performance evaluation in the employee file. The Director of Staff Development (DSD) and Director of Nursing (DON) could not confirm whether the required documentation existed or was completed, and the LVN himself was unaware of any abuse training or skills checklist being completed through the facility or the registry. The only documentation provided was a nephrostomy training checklist and a vague orientation verification, which was acknowledged by facility leadership as insufficient and not specific to the facility. For the CNA, who was assigned to a resident with hemiplegia, cerebral infarction, and urinary incontinence, the employee file also lacked a skills checklist. The DSD noted that the CNA had a history of sleeping on the job, but no documentation of competency was available in the file. The Assistant Director of Nursing (ADON) was unable to provide information on when or how often performance evaluations or skills checklists were completed, indicating a lack of oversight in ensuring staff competency. A review of the facility's policy indicated that the administrator is responsible for verifying that agency and contract staff have documentation of competencies and skills to care for the resident population. However, the facility did not have the required documentation for the LVN and CNA, resulting in a failure to ensure that staff had the appropriate competencies to care for residents as required by facility policy.
Failure to Prevent Recurrent Nephrostomy Tube Dislodgement
Penalty
Summary
The facility failed to provide necessary care and services to prevent the recurrent dislodgement of a nephrostomy tube for a resident who was completely dependent on staff for all activities of daily living. The resident, who had significant medical conditions including chronic respiratory failure, anoxic brain damage, cardiac arrest, and quadriplegia, experienced multiple episodes where the nephrostomy tube became dislodged, resulting in repeated transfers to a general acute care hospital for invasive procedures. The care plans reviewed did not include specific interventions aimed at preventing the dislodgement of the nephrostomy tube, despite the resident's high risk and history of such incidents. Staff interviews revealed that the resident was unable to move or pull out the nephrostomy tube independently, and the likely cause of dislodgement was attributed to staff actions during care activities such as turning, repositioning, and bathing. Several staff members, including CNAs, LVNs, and RNs, acknowledged witnessing the tube dislodged on multiple occasions and indicated that the tube could be easily hidden under skin folds or not properly secured during care. The facility's policy and procedure for nephrostomy care required checking the placement and integrity of the tube, but there was no evidence that unlicensed staff received competency training specific to nephrostomy tube care. Documentation and interviews indicated that the care plans were updated after each incident but continued to lack preventive interventions for tube dislodgement. The repeated failure to implement effective measures to secure the nephrostomy tube and ensure staff competency in its care led to ongoing complications for the resident, including multiple hospitalizations and exposure to further medical risks.
Failure to Document Required Monitoring and Release of Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the improper use of physical restraints, specifically hand mittens, by not documenting the required release of the mittens and monitoring for skin breakdown and impaired circulation every two hours as ordered by physicians. For one resident with severe cognitive impairment and dependence on ventilator support, physician orders and care plans specified that a hand mitten should be applied to prevent accidental removal of tubing, with removal every two hours for assessment of skin and circulation. However, documentation was only completed every shift, not every two hours, and did not include details about the resident's skin condition or circulation. Staff interviews confirmed a lack of clarity on where or how to document these assessments, and the Director of Nursing acknowledged that the documentation was insufficient and did not meet the required frequency or detail. A second resident, also with severe cognitive impairment and ventilator dependence, had similar orders for the use of a right-hand mitten with checks for skin integrity and circulation every two hours. The Medication Administration Record showed check marks indicating tasks were performed, but there was no descriptive documentation of the resident's skin condition or circulation. Staff interviews revealed that nurses were expected to document any changes in condition, but there was no routine documentation of the required assessments. Observations confirmed that the hand mitten was in use and that, while the resident's skin appeared intact at the time of surveyor review, the required documentation was not present in the records. The facility's policy on physical restraints emphasized the need for ongoing monitoring and documentation to minimize risks such as skin breakdown and impaired circulation. Despite this, both residents' records lacked the necessary documentation to demonstrate that the hand mittens were being released and that skin and circulation were being assessed at the required intervals. This failure to follow physician orders and facility policy constituted a deficiency in the care provided to these residents.
Failure to Rotate Insulin Sites and Reassess High Blood Pressure
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for three residents. Two residents with diabetes mellitus received insulin injections without proper rotation of injection sites, despite physician orders and facility policy requiring site rotation to prevent tissue damage. Medication Administration Records (MARs) showed repeated administration of insulin in the same arm over multiple days for both residents, and interviews with nursing staff and the Director of Nursing confirmed that injection sites were not rotated as required. Additionally, a resident with end-stage renal disease and hypertension did not receive timely reassessment or appropriate follow-up after a significantly elevated blood pressure reading. The resident's blood pressure was recorded as 194/86, but the assigned nurse did not recheck the blood pressure or notify the physician, citing workload as the reason for not following up. The resident expressed concern and requested transfer to the emergency room, and subsequent interviews with nursing leadership confirmed that the nurse did not follow established protocols for managing elevated blood pressure. Facility policies and procedures reviewed during the survey specified the need for rotating insulin injection sites and prompt response to changes in resident condition, including notification of the physician and reassessment. Staff interviews and record reviews confirmed that these protocols were not followed for the affected residents, resulting in deficiencies related to medication administration and monitoring of significant changes in condition.
Medication Administration and Documentation Deficiencies
Penalty
Summary
Nursing staff failed to rotate insulin injection sites as ordered for two residents with type 2 diabetes. For one resident, insulin was repeatedly administered in the left arm over consecutive administrations, and for another, injections were frequently given in the same abdominal quadrants, as documented in the electronic medication administration record (eMAR). The facility's infection preventionist confirmed that the records showed consecutive injections at the same sites, contrary to physician orders and facility policy requiring site rotation. A discrepancy was identified in the inventory and accountability record for a resident receiving oxycodone for pain management. During a medication count, the number of tablets present did not match the count sheet, and a review revealed a duplication error on the count sheet that was not corrected or noted by the nurse. The director of nursing acknowledged the error was due to a failure to document the correction. Additionally, the Cubex automated drug dispensing system's activity record did not match the eMAR for another resident receiving Norco for pain. The Cubex system showed a tablet was dispensed, but there was no corresponding documentation in the eMAR. The director of nursing stated that the nurse forgot to document the administration after being called away to attend to another resident. The facility's documentation policy did not specify procedures for medication administration documentation.
Failure to Ensure Dietary Staff Competency in Dishwashing and Sanitizer Testing Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were regularly trained and evaluated for competency in dishwashing procedures, as evidenced by staff being unable to correctly demonstrate and verbalize the process for checking quaternary ammonium compound (QUAT) sanitizer concentration and proper dishwashing techniques. During observation, a dietary aide washed a mixer in the three-compartment sink, followed the wash, rinse, and sanitize process, but then rinsed the mixer with water in the preparation sink, which is designated exclusively for food preparation. The dietary aide acknowledged this was a mistake, as the final step should have been air drying, not rinsing with water, to prevent chemical contamination. The dietary supervisor was unsure about the correct duration for dipping items in the sanitizer and incorrectly stated that spraying with water after sanitizing would be acceptable. Further observations revealed that both dietary aides and the dietary supervisor did not follow the manufacturer's guidelines for QUAT sanitizer concentration testing. Staff demonstrated incorrect procedures by dipping test strips for 15-20 seconds instead of the required 10 seconds and did not check the solution temperature as specified by the manufacturer. The dietary supervisor confirmed that these deviations could result in inaccurate readings and improper sanitization, potentially leading to cross-contamination. Review of facility policies, job descriptions, and competency checklists showed that while staff were deemed competent in some areas, there was no specific verification of competency for air-drying procedures or adherence to the correct sanitizer testing protocol. The report notes that these deficient practices had the potential to result in harmful bacterial growth and cross-contamination, which could lead to foodborne illness in 133 of 206 medically compromised residents who received food and ice from the kitchen. The findings were based on direct observation, staff interviews, and review of facility policies, job descriptions, and relevant food safety codes.
Failure to Follow Menu Portion Sizes for BBQ Pork
Penalty
Summary
The facility failed to follow its established menu and portion guidelines for residents on regular texture diets by serving 4 ounces of BBQ pork instead of the prescribed 3 ounces. This was identified through a review of the facility's daily spreadsheet, which specified a 3-ounce portion, and confirmed by direct observation and weighing of the portions served, which consistently exceeded the specified amount. Staff interviews revealed that the incorrect portioning occurred because a different staff member was responsible for cutting and serving the BBQ pork, and the Registered Dietitian confirmed that the menu and portion sizes were not being followed as required. Further review of the facility's standardized recipe and policies confirmed that the correct portion size should have been 3 ounces. The facility's policy mandates that menus are to be developed and prepared to meet residents' nutritional needs, including providing food in the correct amount, type, and consistency. The Registered Dietitian stated that serving incorrect protein portions could alter the nutritional content of the meals, resulting in the menu no longer meeting the intended nutritional needs of the residents.
Failure to Prepare and Present Palatable, Attractive, and Properly Textured Food
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved flavor, appearance, and appropriate texture, as evidenced by multiple observations and interviews. During lunch service, pureed cabbage did not hold its shape on the plate and appeared flat, which was confirmed by the Dietary Supervisor, who stated that pureed foods should be creamy, smooth, and able to hold their shape. The Dietary Supervisor acknowledged that the dietary staff did not achieve the required presentation, making it difficult to serve and potentially decreasing residents' appetites. Additionally, the pork barbecue served was observed to be dry, and the vegetables were overcooked and olive green in color, which affected their palatability and appearance. Two residents with significant medical histories, including end stage renal disease and type 2 diabetes mellitus, were specifically identified as being affected by these deficiencies. Both residents were on specialized diets requiring careful attention to nutritional content and food preparation. One resident reported that the vegetables served were overcooked and fell apart, while the other stated that the food did not look appetizing or taste good. Observations confirmed that the pork barbecue was dry due to being left in the oven too long, and the vegetables were not visually appealing. Review of the facility's policies and procedures indicated that food should be prepared to maintain nutritive value, appearance, and resident satisfaction, with specific guidelines for vegetable cookery and pureed foods. However, the observed practices did not align with these policies, as food was not consistently prepared or presented in a palatable or attractive manner. The failure to follow established guidelines for food preparation and presentation was directly observed and confirmed by staff interviews and resident feedback.
Widespread Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and sanitation. Kitchen equipment and areas, including reach-in freezers and refrigerators, were found with dirt buildup, dried spills, and food debris. The Dietary Supervisor confirmed that cleaning schedules were not adequately followed, resulting in unsanitary conditions that could lead to physical contamination. Additionally, food items such as tuna salad and turkey slices were stored above the required cold holding temperature, and dented cans were found mixed with non-dented cans in the emergency food supply, contrary to facility policy and food safety standards. Further deficiencies were noted in the maintenance and use of kitchen equipment and utensils. All resident trays used for meal service were cracked and chipped, and chopping boards were observed with scratches and chips, making them difficult to clean and increasing the risk of cross-contamination. Pans were stacked wet while air drying, and staff were observed rinsing sanitized equipment with water, which negated the sanitizing process. Staff also failed to follow manufacturer guidelines for testing the concentration of the QUAT sanitizer, using incorrect timing and not checking solution temperature, which could result in improper sanitization of food contact surfaces. Refrigerator temperature logs showed that food was stored at temperatures above the recommended maximum of 41°F, with staff unaware of the correct danger zone for food safety. The facility's policies and procedures were not consistently followed, and staff demonstrated a lack of understanding of proper food safety practices during interviews. These actions and inactions led to multiple deficiencies in food safety and sanitation, as directly observed and documented by surveyors.
Improper Storage Temperatures for Resident Food from Outside Sources
Penalty
Summary
The facility failed to ensure that food brought in from outside sources for residents was stored at a safe temperature of 41 degrees Fahrenheit or below, as required by both facility policy and the 2022 Food Code. During a review of refrigerator temperature logs, it was found that the food refrigerator on Station 4 had recorded temperatures of 42 F on multiple dates throughout March. Licensed Vocational Nurses (LVNs) interviewed were not fully aware of the correct temperature range for safe food storage, with one LVN stating the acceptable range was 36 F to 46 F, which is inconsistent with facility policy and regulatory standards. The facility's policies and procedures clearly state that refrigerated food must be kept at 41 F or below, and that food brought in by family or visitors should be stored safely for no more than 48 hours. The deficiency was identified through observation, interview, and record review, revealing that 133 out of 206 medically compromised residents who store food in the resident refrigerator were potentially affected. The temperature logs and staff interviews confirmed that the refrigerator was not consistently maintained at the required temperature, and staff were not fully knowledgeable about the danger zone for foodborne bacterial growth. This lapse in maintaining proper food storage temperatures and staff awareness directly led to the deficiency cited by surveyors.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse as required, as observed during a survey. Two out of four dumpsters were found overflowing with trash, not completely covered when not in use, and the surrounding area was littered with food spillage, used gloves, and soiled paper cups. The Dietary Supervisor acknowledged that the dumpsters needed to be completely covered to prevent rodents from accessing the trash and noted that their proximity to the kitchen posed a potential hazard. The Housekeeping Supervisor also confirmed that the trash bins were full, not closed, and the area was contaminated with food splatters and used gloves. A review of the facility's policies and procedures indicated that garbage and refuse containers should be maintained in good condition, kept covered, and the storage area should be kept sanitary to prevent pest harborage. The Food Code 2022 further requires that outside receptacles have tight-fitting lids or covers and that garbage storage areas be kept clean to minimize odors and prevent attracting pests. The observed conditions did not meet these requirements, as the dumpsters were not properly covered and the surrounding area was not kept clean.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with complex medical needs. For one resident with anoxic brain damage, pressure ulcers, and reduced mobility, the facility did not create a care plan addressing the use and management of a rectal tube. Documentation showed that the rectal tube became dislodged, and although the medical doctor was notified and orders were given to discontinue the tube, there was no care plan in place to guide staff in monitoring or caring for the rectal tube. Interviews with the treatment nurse, MDS nurse, and DON confirmed the absence of a rectal tube care plan and acknowledged that such a plan should have been developed to ensure proper care and infection control. For another resident with anoxic brain damage, chronic kidney disease, pressure ulcers, and muscle weakness, the facility did not develop care plans for the resident's edema or pressure ulcer. The resident experienced significant weight loss attributed to fluid loss from edema and was receiving Lasix. Despite ongoing wound care and weekly assessments, staff could not locate care plans for either the edema or the pressure ulcer. The treatment nurse and MDS nurse both confirmed the lack of these care plans and stated that the absence of such plans could result in improper monitoring of the resident's conditions. The deficiency was further compounded by issues with the facility's electronic medical record system, where previous care plans were closed upon the resident's readmission, and new care plans were not properly created or updated. The MDS nurse and DON both acknowledged that the process of closing and reopening care plans led to the omission of necessary care plans for the resident's current conditions. The facility's own policy required the development of person-centered comprehensive care plans to address each resident's medical, physical, and psychosocial needs, which was not followed in these cases.
Significant Medication Error Due to Unclear Orders on Dialysis Days
Penalty
Summary
A licensed vocational nurse (LVN) failed to administer a prescribed dose of furosemide to a resident with hypertensive chronic kidney disease and end stage renal disease. During a morning medication pass, the LVN withheld the furosemide, stating it was due to the resident's scheduled dialysis appointment in the afternoon. The resident's physician's order specified furosemide 40 mg by mouth twice daily for hypertension, but there was also a separate order allowing medications to be held on dialysis days without specifying which medications or the timing relative to dialysis sessions. Interviews with staff revealed that there was no clear guidance on which medications should be held or when, particularly if dialysis was scheduled for later in the day. The Director of Nursing (DON) stated that all morning medications should be given if the resident is present in the facility unless otherwise specified, and that nurses should clarify with the physician if there is any uncertainty. The facility's policy required medications to be administered according to physician orders, but this was not followed in this instance, resulting in a significant medication error.
Unattended Medication Cart Keys Lead to Drug Storage Deficiency
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) was observed leaving keys on top of an unattended medication cart in the Subacute unit. On two separate occasions, the LVN unlocked the medication cart, placed the keys on top, and then left the cart unattended while administering medications to a resident inside a room. During one observation, a housekeeping staff member confirmed that the nurse was inside the room while the keys remained on the cart in the hallway. The LVN later acknowledged that the keys should have been kept in their pocket rather than left on the cart. The Director of Nursing (DON) confirmed that the keys used by nurses open both the medication carts and the narcotic drawers, and stated that keys should not be left on top of unattended carts. A review of the facility's policy indicated that drugs should only be accessible to designated personnel and that storage methods must prevent access by other patients. The observed practice of leaving keys unattended on the cart did not align with these requirements, resulting in a deficiency related to the secure storage of drugs and biologicals.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide a safe and accident-free environment for a resident who was assessed as a high fall risk due to impaired gait, mobility, and a diagnosis of dementia. The resident experienced multiple falls, including one that resulted in a minimally displaced acute acromion fracture. The facility did not provide adequate supervision or implement a person-centered care plan to prevent falls, as required by their Fall Management Program policy. The resident's care plan included interventions such as placing the call light within reach and encouraging the resident to use the call bell for assistance. However, the resident was too confused to be oriented to the call light and did not know how to use it. Despite being identified as a high fall risk, the facility did not have orders for supervision, padded mats, or a bed alarm prior to the falls. The resident's fall risk assessment indicated a score of 14, classifying them as high risk, yet the necessary fall prevention protocols were not initiated or documented on the care plan. Interviews with staff and family members revealed that the facility did not adequately monitor the resident or modify the care plan to prevent falls. The Director of Nursing acknowledged that the resident was found on the floor and likely broke their acromion during one of the falls. Family members expressed concerns about the facility's failure to protect the resident from falls and the lack of communication regarding fall prevention measures. The facility's policy required monitoring the effectiveness of interventions and modifying the care plan as necessary, which was not done in this case.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return to the nursing home following hospitalization, which was a violation of their policy. The resident, who had a history of chronic respiratory failure, dysphagia, generalized muscle weakness, type 2 diabetes, encephalopathy, and cerebrovascular accident with paraplegia, was transferred to a general acute care hospital (GACH) on multiple occasions. Despite being ready for discharge back to the skilled nursing facility (SNF) on several dates, the facility did not permit the resident to return, citing the unavailability of a single isolation room. The facility's census records indicated that there were vacant isolation beds available on several occasions, yet the resident was not readmitted. The Director of Admissions and other staff members stated that the resident required a single isolation room and could not be cohorted with other residents. The facility's policy stated that residents should be permitted to return to their previous room if available or to an available bed in the location they previously resided, but this was not adhered to in this case. Interviews with the facility's staff and the resident's family member revealed that the family member was informed that the resident could not return due to a previous complaint filed against the facility. This situation caused emotional distress and confusion for the resident's family member, who preferred the resident to return to the same facility. The facility's actions were inconsistent with their policy of permitting residents to return after hospitalization or therapeutic leave.
Failure to Implement Fall Management Program for High-Risk Resident
Penalty
Summary
The facility failed to implement its Fall Management Program for a resident identified as a high fall risk, resulting in three unwitnessed falls within a 30-day period. The resident, who was dependent on staff for orientation and ambulation, experienced falls on three separate occasions, each requiring a transfer to an acute general care hospital for a CT scan to rule out head injuries. The resident's medical history included hemiplegia, hemiparesis, and altered mental status, which contributed to their high fall risk. The resident's care plan, which was intended to minimize the risk of injury from falls, included interventions such as anticipating and meeting the resident's needs. However, the resident was found attempting to self-ambulate and turn off their bed alarm, indicating that the interventions were not effectively preventing falls. Interviews with staff revealed that the resident was forgetful and non-compliant, often attempting to get up unassisted despite being provided with a urinal and a bed alarm. The facility's failure to provide adequate supervision and timely response to the resident's call light contributed to the falls. On one occasion, the resident's call light went unanswered for an hour while a family member was on a FaceTime call, during which the resident attempted to go to the bathroom and fell. Staff interviews indicated that the resident might benefit from having a sitter, as all other measures had failed to prevent falls. The facility's policy on adequate supervision was not effectively implemented, leading to the repeated incidents.
Failure to Document Staff Background Checks and Licenses
Penalty
Summary
The facility failed to ensure that the assigned staff for one of the residents, who had severe medical conditions, had the necessary background checks and license information documented in their employee files. The resident, who was admitted with serious diagnoses including traumatic subdural hemorrhage, persistent vegetative state, and chronic respiratory failure, was found to have a fracture in the left humerus. Despite the resident's severe cognitive impairment and total dependency on staff for care, the facility did not have the required documentation for the certified nurse assistant and licensed vocational nurse assigned to the resident, which increased the risk of abuse. The facility's policy on abuse prevention required checking with licensing boards and registries before hiring and annually thereafter, but this was not adhered to. During interviews, both the licensed vocational nurse and certified nurse assistant assigned to the resident reported not observing any signs of bruising or pain, and the resident's family was actively involved in the resident's care. However, the lack of documented background checks and license verification for these staff members was a significant oversight, as confirmed by the facility administrator during the survey.
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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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westlake Convalescent Hospital | 0 mi | ★★★★★ | 4 | 0 |
| Bonnie Brae Skilled Nursing | 0.1 mi | ★★★★★ | 9 | 0 |
| Angels Nursing Health Center | 0.2 mi | ★★★★★ | 13 | 0 |
| Mid-wilshire Health Care Cntr | 0.4 mi | ★★★★★ | 35 | 0 |
| Pih Health Good Samaritan Hospital D/p Snf | 0.6 mi | ★★★★★ | 3 | 0 |
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