Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Springs Post-acute during CMS and state inspections, most recent first.
Failure to Protect Resident Confidentiality: Surveyors observed an unattended EHR computer screen and a clipboard with resident names and PHI left open in a hallway. RT stated he had left both items exposed while visiting a resident, and the DON confirmed resident information should be kept private and confidential. The facility PHI policy required staff to protect information from unauthorized release or disclosure.
A resident with seizures, anemia, and g-tube dependence received ferrous sulfate, minocycline, and phenytoin together during a med pass, and the LVN restarted the enteral feeding pump immediately after giving the meds. The MAR showed ferrous sulfate and minocycline were given at the same time for multiple days, despite orders and facility policy addressing drug and food interactions and holding tube feedings around phenytoin.
Failure to Provide Ordered ROM, Splinting, and Complete Therapy Assessments: A resident with anoxic brain injury, functional quadriplegia, and contractures had physician orders for PROM to both arms and hand roll splints to both hands, but an RNA did not provide PROM to the wrists and hands or apply the ordered hand rolls during the session. The resident’s OT eval documented impaired hand ROM without objective goniometer measurements, and the PT eval for ROM decline and RNA training did not assess mobility. The DON and DOR stated the ordered ROM, splinting, objective measurement, and mobility assessment were expected.
RNA Failed to Apply Ordered Hand Roll Splints An RNA did not follow a resident’s physician-ordered hand roll splint program for a resident with anoxic brain injury, functional quadriplegia, contractures, and severe cognitive impairment. During an RNA session, the resident’s hands were in fists and the RNA provided PROM but did not apply the ordered hand rolls; instead, the RNA placed balls in the resident’s hands. The RNA stated she sometimes substituted towels, stress balls, gauze rolls, or items from home and modified the RNA program without notifying therapy or nursing, while the DOR, DSD, and DON confirmed RNAs were expected to carry out the order exactly and were not qualified to modify the program.
Controlled medication records were not accurately maintained for three residents: doses of an opioid/APAP pain medication, Hysingla ER, Hydrocodone/APAP, and Modafinil were documented on the MAR but not properly recorded on the CDR, creating mismatches with the medication cards. An RN supervisor confirmed the discrepancies, and an LPN also failed to sign the shift-change narcotic count sheet with the outgoing or covering nurse before taking possession of a med cart.
Pharmacist MRR did not identify clinically significant medication issues for three residents receiving phenytoin via G-tube. One resident received ferrous sulfate and minocycline together despite an interaction affecting absorption, while two residents had phenytoin orders without documented enteral feed-hold instructions. The DON and consultant pharmacist stated the interaction and feeding-related concerns were not documented in the monthly review records.
A resident with seizures, anemia, hemiplegia, and g-tube dependence had multiple medication administration errors during a pass. An LPN gave ferrous sulfate, multivitamin and minerals liquid, phenytoin suspension, and minocycline through the g-tube, but did not shake the phenytoin or multivitamin liquids before pouring, did not separate minocycline from ferrous sulfate, and restarted enteral feeding after phenytoin despite the facility’s enteral feed order and staff statements about holding feeds around Dilantin.
A facility failed to prevent significant med errors involving enteral meds for three residents. An LVN administered ferrous sulfate and minocycline together for one resident despite known interaction concerns, and phenytoin via g-tube was given without consistently holding tube feedings before and after administration for residents receiving Dilantin. The DON, consultant pharmacist, and dispensing pharmacist all acknowledged the interaction issues, and one resident had a low Dilantin level documented.
Failure to report a scabies outbreak and follow IPCP measures. Two residents had positive skin scrapings for scabies, but the IPN and DON stated the outbreak was not reported to the local health department when the second positive case occurred. The Housekeeping Supervisor reported no complete deep-cleaning log and no documentation that linens or belongings were bagged or deep cleaned. Two other residents with suspicious rashes were not placed on contact precautions despite the facility scabies policy requiring contact precautions for affected residents.
Delayed Response to GT Pump Alarms: Staff did not promptly respond when a resident’s GT pump alarmed and displayed a tube slip message. An LVN and RN walked past the room without checking the alarm, and no one entered for more than 20 minutes. The resident had multiple serious diagnoses, severe cognitive impairment, no speech, and was dependent on GT feeding, oxygen, trach care, and suctioning. The DON stated the pump needed to be attended right away because ongoing beeping meant the resident would not receive the correct feeding order and total volume delivery would be delayed.
A resident with a G-tube, severe cognitive impairment, and inability to make decisions was observed wearing a hand mitten restraint. The restraint was started as a least restrictive intervention, but the record lacked documentation of attempts to reduce it, and staff stated there were no documented episodes of the resident pulling at the G-tube or other methods tried to determine ongoing need. The DON and LVN noted the mittens were treated as restraints, yet monitoring and documentation were incomplete compared with facility policy.
Failure to Attempt Nonpharmacological Interventions Before PRN Ativan: A resident with intracerebral hemorrhage, respiratory failure with ventilator dependence, depression, anxiety, and moderately impaired cognition received PRN Ativan via G-tube on multiple days for anxiety-related restlessness and shortness of breath. The MAR showed nonpharmacological interventions were not attempted before administration, and the RN supervisor and DON confirmed that non-drug measures should be used before giving Ativan per facility policy.
Failure to provide daily activities. A resident with cerebral palsy, muscle weakness, contractures, and severely impaired cognition was dependent on staff for all ADLs, yet the Activities Director reviewed the resident's activity record and stated the resident did not have daily activities. The AD and DON acknowledged that activities are part of daily living and support cognition and quality of life.
A resident with anoxic brain damage and a persistent vegetative state was assessed as very high risk for pressure injury due to immobility, limited ROM, moist skin, and limited sensory perception. Staff observed overlapping, contracted toes on the left foot with visible pressure indentation, and both RN and LVN confirmed that a barrier or off-loading device should have been placed between the toes but was not. The DON stated contracted, overlapping toes require assessment and off-loading to prevent skin breakdown, and facility policy called for daily skin inspection, repositioning, support devices, and protective dressings for at-risk residents.
Missed Foley Catheter Care and Monitoring: A resident with a neurogenic bladder and indwelling catheter had repeated missed documentation for ordered catheter cleansing and drainage bag monitoring across several shifts. The physician’s order required every-shift catheter site care and assessment of urine characteristics and UTI signs, but the TAR showed multiple omissions. The RNS stated that if it was not documented, it was not done, and the DON acknowledged the importance of catheter care to prevent infection in a resident with a history of recurrent UTI.
A resident with chronic kidney disease and dependence on renal dialysis missed scheduled HD because of a transportation issue. The resident had severely impaired cognition and was dependent on staff for all ADLs. The RNS stated HD residents should not miss dialysis because it could cause fluid overload, and the DON also stated missing dialysis could cause fluid overload.
The facility failed to place a thermometer in the dry storage food area. The DM stated a thermometer was only needed when the room got too hot and said nothing in the room would be affected because there was no produce. The DON stated a thermometer should be in the dry storage room to monitor temperatures because certain foods have temperature requirements and could spoil. The facility policy required thermometers in all storage areas and frequent checks.
Trash Collection Area Not Kept Clean and Waste Containers Left Open: Two gray waste containers and one blue waste container were observed not fully closed in the designated trash collection area, and the floor had a used pair of gloves and black sticky residue. The DS stated the containers were full and not fully closed, and that the area should be kept clean to contain trash and prevent rodents or pests from digging through it. Facility policy stated the trash collection area must be kept clean and swept and washed down regularly.
Missing Hospital Discharge Summary in Resident Record: A resident with a left ulna fracture, anoxic brain damage, osteoporosis with pathological fracture, and severe cognitive impairment returned from the hospital after ED evaluation and splinting, but the GACH Discharge Summary was not in the EMR or readily accessible. RNS, MR, and DON confirmed the discharge summary was missing from the clinical record, even though it was needed to guide nursing care, orders, and follow-up after the hospital return.
A resident admitted under hospice care with severe protein calorie malnutrition, dementia, depression, and Parkinson's disease had severely impaired cognition and was dependent on staff for all ADLs. The hospice agreement stated the HHA would visit twice weekly, but the RNS confirmed documented evidence showed the visits did not occur twice a week. The DON stated hospice care was essential to meeting residents' comfort goals.
A resident with tracheostomy, G-tube, and respiratory failure received IV antibiotics for suspected pneumonia, but the infection screening evaluations did not document signs and symptoms meeting McGeer’s or Loeb’s Criteria. The IPN stated she follows those criteria for antibiotic stewardship, did not understand the “No IPC Case Triggered” notation, and did not see the Infection Analysis section when the form was initiated. The DON stated antibiotic stewardship is meant to ensure appropriate treatment and avoid unnecessary antibiotics, while the facility policy described monitoring antibiotic use but did not outline procedures for determining antibiotic appropriateness.
A resident with severe cognitive impairment and type 2 DM was started on Lantus insulin at bedtime per a new physician order, and the medication was administered throughout the month without notifying the resident’s responsible party (RP). The RP later learned of the new medication from the resident’s insurance company and reported feeling that her authority and right to participate in the plan of care were undermined. The DON confirmed there was no documentation of notification or discussion with the RP about the initiation of Lantus, despite facility policy requiring prompt notification of the resident’s representative for changes in medical care or treatments.
Failure to Recognize Suspected Scabies Outbreak: Five residents developed generalized itchy rashes and were diagnosed as unspecified dermatitis, yet each was placed on contact precautions and treated with ivermectin and permethrin as if for scabies. Records showed one resident had a dermatology differential that included scabies, another had scabietic nodules documented, and staff interviews confirmed the facility used scabies medications prophylactically without skin scraping or outbreak recognition. The IPN stated scabies are reportable when diagnosed, while the DON stated suspected cases were not reportable.
A resident with severe cognitive impairment and multiple diagnoses developed swelling and discoloration in the hand. Staff attempted to contact the primary physician but did not reach out to the medical director as required by facility policy, resulting in a 13-hour delay before medical orders were received.
A resident with severe cognitive impairment and multiple diagnoses sustained a non-displaced finger fracture of unknown origin. The LVN who received the x-ray results did not report the injury to CDPH, law enforcement, or the Ombudsman within the required two-hour window, and the DON was not informed until several hours later. Facility policy and regulations required immediate reporting of such incidents, but this was not followed.
A resident with multiple medical conditions and moderate cognitive impairment was subjected to a violation of their rights when a CNA, previously restricted from providing care to the resident due to a family complaint, entered the resident's room to care for the roommate. Despite facility policy and known conflicts, the CNA was assigned to the room, resulting in a failure to treat the resident with respect and dignity.
A resident with severe cognitive impairment and a history of falls was not consistently supervised according to their care plan, resulting in multiple falls, including an unwitnessed incident that led to hospitalization for head trauma. Staff were unfamiliar with the resident's routine after a room change, and communication lapses between activity and nursing staff contributed to the deficiency.
A resident with significant mobility impairments and requiring two-person assistance for turning was repositioned by a single CNA, resulting in a fracture of the left forearm. The incident occurred due to understaffing, as other CNAs and nurses were occupied with other duties. The resident, who had conditions such as anoxic brain damage and osteoporosis, was totally dependent on staff for bed mobility. Despite the care plan's requirement for two-person assistance, the CNA proceeded alone, leading to the injury.
The facility failed to provide necessary occupational and physical therapy services to residents with limited range of motion (ROM) and mobility issues. A resident with severe hypoxic ischemic encephalopathy and cerebral infarction did not receive recommended therapy services due to insurance denial, and inaccurate Joint Mobility Screens (JMS) were performed. Other residents did not receive timely evaluations or interventions, such as splints or therapy services, leading to preventable contractures and further decline in their conditions.
The facility failed to respond to call lights in a timely manner for three residents, leading to delays in care. One resident with polyneuropathy and paraplegia reported long wait times, while another with an amputated leg experienced up to 15-minute delays. A third resident with cord compression noted that staff sometimes promised to return but did not. Interviews and records confirmed the issue, despite facility policy requiring immediate response.
The facility failed to accurately code the use of restraints in the MDS for three residents. One resident with severe cognitive impairment had mittens applied, another with Parkinson's disease had mittens to prevent interference with medical devices, and a third with hemiplegia had a mitten to prevent pulling on a gastrostomy tube. These restraints were not documented in the MDS, as confirmed by the MDS Coordinator.
The facility failed to label and date opened food containers, including sandwiches and salads, in the refrigerator, as observed during a kitchen tour. Staff interviews confirmed the responsibility to date prepared foods to prevent serving unsafe food. The facility's policy requires all prepared foods to be labeled and dated, but this was not followed, risking residents' safety.
The facility failed to address unresolved quality deficiencies in restraint monitoring and documentation, as well as accurate resident assessment. A resident with significant medical needs had no documentation for the assessment and monitoring of physical restraints. The LVN admitted the lack of documentation, and the MDSC did not recognize hand mittens as restraints, leading to incorrect coding. The Administrator and DON acknowledged that these issues were identified in previous surveys but not effectively addressed.
The facility did not document COVID-19 vaccination status for all employees, including physicians and consultants, as required by their policy. The IPN was unaware of the need to obtain this information, and the DON confirmed that all staff should be included in the vaccination records. This oversight could potentially place staff and residents at risk for serious COVID-19 outcomes.
A long-term care facility failed to provide a usable call light for a resident with severe cognitive impairment and physical limitations, and another resident had a non-functional call light, leading to delayed care. The facility's policies require functional call systems, but these were not adhered to, impacting resident safety and communication.
A resident with cerebral infarction and legal blindness was not adequately protected from abuse after a verbal altercation with another resident. Despite intervention by an RN, the aggressive resident threw tissue boxes at the vulnerable resident. The facility failed to separate the residents as required, moving the aggressive resident to a room sharing a patio with the victim, contrary to policy.
A facility failed to assess, monitor, and document the use of hand mittens as a restraint for a resident with a G-tube. The resident, with a history of traumatic subarachnoid hemorrhage and hemiplegia, required dependent assistance and had impaired extremities. Despite orders for mitten use with specific release and skin check instructions, staff did not document monitoring in the MAR. Interviews revealed non-compliance with restraint monitoring protocols, contrary to facility policy requiring least restrictive use and documentation.
The facility failed to ensure accurate PASARR screenings for two residents with mental disorders, leading to potential inappropriate placement and unidentified specialized services. One resident with schizophrenia and another with schizoaffective disorder had screenings that did not reflect their mental health diagnoses. The MDS Coordinator and DON acknowledged the inaccuracies, which are against the facility's policy requiring accurate PASARR screenings for all admissions.
A facility failed to implement a comprehensive care plan for a resident with chronic respiratory failure, a tracheostomy, and a gastrostomy, who required bilateral hand mittens to prevent pulling at life-sustaining devices. The care plan did not address the use of hand mittens, despite the resident's dependency on staff for self-care and mobility. The MDS Coordinator and DON acknowledged the importance of care plans in preventing complications, which was not adhered to in this case.
A resident with limited mobility and a history of severe medical conditions was not transferred out of bed daily as required by their care plan. Despite the family's desire for daily transfers, the resident was observed lying in bed over several days. The facility's DON confirmed there was no care plan indicating the family's request for the resident to remain in bed, and the facility's policy required assistance with mobility for residents unable to perform activities of daily living independently.
A facility failed to obtain a podiatry consult for a resident with a thickened toenail on the left big toe. The resident, with conditions such as Down syndrome and chronic kidney disease, required podiatry care every two months, but the last visit was in September 2024. Observations confirmed the need for a podiatry consult, which was not scheduled, delaying necessary foot care.
A facility failed to monitor, assess, document, and discontinue an IV hep lock for a resident after completing IV therapy. The resident, at high risk for infection due to an immunocompromised status, experienced discomfort from the IV hep lock, which remained in place despite the completion of antibiotic therapy. Staff interviews revealed a lack of documentation and adherence to facility policy regarding IV site care and discontinuation.
A facility failed to change the Heat and Moisture Exchanger (HME) for a ventilator-dependent resident as scheduled, risking infection. The HME, part of the ventilator circuit, had not been changed since a specific date, contrary to the facility's policy of daily changes. The resident, with severe cognitive impairment and total dependence on staff, had a care plan indicating a risk of infection at the tracheostomy site.
A facility failed to provide Speech Therapy (SLP) services to a resident with severe brain injuries, as recommended by an SLP Evaluation and ordered by a physician. Despite the resident's need for intensive rehabilitation to assess oral intake safety, the facility did not conduct the necessary therapy or a new evaluation as ordered. The facility's policy required evaluations to be initiated within 72 hours of a physician's order, which was not followed.
A Physical Therapist (PT 2) at the facility provided therapy to a resident with an inactive license. The resident, admitted with multiple diagnoses including a tibia fracture and muscle weakness, required assistance for movement. The Director of Rehabilitation was unaware of the inactive status, and PT 2 mistakenly selected this option, leading to unauthorized practice.
A resident with chronic respiratory failure and other conditions was not offered the pneumococcal vaccine upon admission and readmission, contrary to facility policy. The resident, who lacked decision-making capacity and was dependent on others for care, was at increased risk due to their medical condition. The facility's policy requires vaccine assessment and offering within thirty days of admission, which was not adhered to in this case.
A resident with a history of serious medical conditions experienced a significant change in condition, including a high fever and elevated heart rate, but the facility failed to notify the physician as required. Despite multiple instances of vital signs exceeding the set parameters, the physician was not informed, leading to the resident's transfer to a hospital where they were diagnosed with septic shock and later passed away. Staff interviews revealed a lack of documentation and adherence to notification policies.
A resident with neuromuscular dysfunction of the bladder experienced a change in condition, including a high fever and elevated heart rate, which was not promptly assessed or reported to the physician by the facility staff. The lack of a specific care plan and failure to document vital signs led to a delay in transferring the resident to a hospital, where they were diagnosed with septic shock and later expired.
A facility failed to return a resident's funds to Social Security after discharge, as required by policy. The resident, with severe cognitive impairment, was transferred to a GACH and did not return. Despite this, the facility continued to receive Social Security funds and did not close the Resident Fund Management Service account, which had a balance of $11,649.00. The Business Office Manager did not refund the funds within three business days, as stipulated by the facility's policy.
A resident with severe cognitive impairment and high fall risk experienced multiple falls without revisions to their care plan, resulting in continued falls and injuries. Despite interdisciplinary team discussions to increase monitoring, the care plan was not updated, violating facility policies for comprehensive, person-centered care.
Failure to Protect Resident Confidentiality
Penalty
Summary
The facility failed to maintain resident confidentiality when RT 1 left an electronic health record (EHR) computer screen open and unattended in the hallway, along with a clipboard containing notes and a list of resident names and personal health information. During an observation on 4/20/2026 at 10:55 am, surveyors saw the unattended computer screen and clipboard displayed on a bedside table in the hallway with resident information fully exposed. During a concurrent observation and interview on 4/20/2026 at 11:00 am, RT 1 exited a resident's room and returned to the table with the computer and clipboard. RT 1 stated he had left to visit a resident and accidentally left both items open and unattended in the hallway, and acknowledged that he should have closed the computer screen and turned the clipboard over because both contained personal health information that must remain private and confidential. The DON later stated that resident information should always be kept private and confidential and that the computer screen and clipboard should not have been left open to public view. The facility's PHI policy stated that personnel with access to resident and facility information are responsible for ensuring it is managed and protected to prevent unauthorized release or disclosure.
Medication Orders Not Followed for Tube-Feed and Drug Interaction Timing
Penalty
Summary
Licensed staff failed to follow or clarify physician medication orders for three residents, including a resident with seizures, anemia, gastrostomy tube dependence, and respiratory/ventilator dependence. For one resident, the medication pass observation showed ferrous sulfate, multivitamins, phenytoin oral suspension, and crushed minocycline prepared together and then administered via g-tube during the same pass. The LVN turned off the enteral feeding pump, checked tube placement, gave an initial water flush, administered the medications, and immediately turned the feeding pump back on after administration. The resident’s orders included phenytoin via g-tube twice daily, ferrous sulfate daily with food, minocycline via g-tube twice daily for 14 days, and an enteral feed order to hold feeding one hour before and one hour after medications with drug/nutrient interaction such as phenytoin. The MAR showed ferrous sulfate and minocycline were administered together at the same scheduled time for 18 days. The DON stated ferrous sulfate and minocycline should not be given together because iron binds to minocycline, and the pharmacist stated the two medications should be separated because they affect each other’s absorption. The facility’s medication administration and enteral tube policies also addressed preventing medication or food interactions and holding tube feedings when indicated by the order.
Failure to Provide Ordered ROM, Splinting, and Complete Therapy Assessments
Penalty
Summary
The facility failed to provide appropriate care to maintain and/or improve ROM and mobility for one resident with significant ROM and mobility concerns. The resident had diagnoses including anoxic brain injury, functional quadriplegia, and contractures, and the MDS indicated severely impaired cognition, dependence in multiple ADLs, and functional limitations in ROM in both arms and both legs. The resident also had physician orders for RNA to provide PROM exercises to both arms five times a week and to apply hand roll splints to both hands for six hours five times a week. During an observed RNA session, the resident was sitting in a geri-chair with both elbows bent and resting on the chest, both wrists bent, and both hands positioned in fists. RNA 1 provided PROM to the resident’s shoulders and elbows and to both legs, but did not assist with PROM to both wrists and hands and did not apply hand roll splints to both hands as ordered. RNA 1 stated she forgot, later returned to provide ROM to the wrists and hands, and initially placed yellow balls in the resident’s hands instead of the ordered hand rolls. RNA 1 later obtained rolled gauze and placed it in the resident’s hands. RNA 1 stated she often used rolled towels, stress balls, or gauze rolls depending on what was available, despite the order specifying hand roll splints. The resident’s OT evaluation documented impaired ROM of both hands, but the limitations were not objectively measured with a goniometer. The PT evaluation was completed for a new onset of ROM decline and to re-establish a maintenance program with RNA training for safe handling, but it did not include an assessment of the resident’s mobility. The DOR and DON stated that ROM limitations should have been objectively measured, that PT evaluations should include mobility assessment, and that RNAs were expected to carry out ordered PROM and splinting as written.
RNA Failed to Follow Ordered Hand Roll Splint Program
Penalty
Summary
The facility failed to ensure that a Restorative Nursing Aide (RNA) was competent to provide RNA services for one resident with physician-ordered hand roll splints. The resident had diagnoses including anoxic brain injury, functional quadriplegia, and contractures, and the Minimum Data Set showed severely impaired cognition, dependence for multiple activities of daily living, and functional limitations in range of motion in both arms and both legs. The resident’s order summary included an order for RNA to apply hand rolls to both hands for six hours, five times a week. During observation of an RNA session, the resident was seen sitting in a geri chair with both elbows bent, both wrists bent, and both hands positioned in fists. The RNA assisted with passive range of motion to the resident’s shoulders, elbows, and legs, but did not apply hand roll splints to both hands as ordered. Instead, after the ROM exercises, the RNA placed a yellow ball into each hand. Earlier, the resident had also been observed in bed with both elbows bent and resting on the chest while holding a ball in each hand. In interview, the RNA stated she understood the order called for hand roll splints, but described hand rolls as rolled gauze and said she had not applied them because she forgot. She also stated she sometimes used rolled towels, soft stress balls, gauze rolls, or items brought from home in place of the ordered hand rolls, and that she did so without notifying the DOR or nursing. The RNA stated she thought these items were more appropriate for hand hygiene and odor, but also acknowledged that RNAs were supposed to follow the order exactly and were not qualified to modify the RNA program. The DOR, DSD, and DON each confirmed that hand rolls were cylindrical splints ordered by therapy, that gauze rolls, towels, and balls were not appropriate substitutes, and that RNAs were not qualified to modify the RNA program; only PT or OT could modify it. The facility policy and the RNA job description also stated that staff were to provide competent care and refer questions or concerns about treatment plans to therapy.
Controlled Medication Documentation and Shift Count Errors
Penalty
Summary
The facility failed to ensure safe medication administration and accurate accountability of controlled medications for three residents during controlled medication storage inspection and record review. For one resident admitted with chronic pain, low back pain, and leg pain, the April 2026 MAR showed Oxycodone with Acetaminophen 5 mg/325 mg was administered, but the CDR did not document the removal of that dose. The CDR showed a last removal time and remaining quantity that did not match the medication card, creating a controlled medication discrepancy. The LVN stated the removal should have been documented on the CDR so the remaining amount would be accurate. For a second resident admitted with diagnoses including aftercare following joint replacement surgery, osteomyelitis, rheumatoid arthritis, and muscle spasm, the MAR showed administration of Hysingla ER 20 mg and Hydrocodone with Acetaminophen 10 mg/325 mg, but the CDR did not reflect the removal of those doses. The CDR and medication cards showed different remaining quantities for both medications, creating discrepancies. The LVN stated the doses were not written down on the controlled drug record and that failing to document could lead to inaccurate documentation and miscommunication about what the facility had on hand. For a third resident with narcolepsy and moderately impaired cognitive skills, the MAR showed Modafinil 100 mg was administered, but the CDR did not show when a dose was removed for administration. The CDR quantity remained listed as 14 of 14 tablets while the medication card showed 13 tablets remaining, creating another discrepancy. A registered nurse supervisor reviewed the physician orders, CDR, MAR, and medication cards for these residents and confirmed the discrepancies, stating that the licensed nurses must count the medication and document the time controlled medications are given. In a separate finding, an LVN did not sign the shift change narcotic count sheet in the presence of the outgoing or covering nurse before taking possession of MedCart 3 on Station 2, and another LVN stated there was no licensed nurse present when the cart was taken over and the narcotics were not counted together.
Pharmacist MRR Did Not Identify Medication Interactions or Enteral Feeding Issues
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review that included the medical chart and identified clinically significant medication issues for three residents receiving phenytoin via gastrostomy tube. Resident 54 had diagnoses including seizures, epilepsy, anemia, and dependence on respiratory status. The April 2026 medication orders included phenytoin, ferrous sulfate, and a short course of minocycline, and the MAR showed ferrous sulfate and minocycline were administered together at the same scheduled time for 18 days. During interviews, the consultant pharmacist stated the two medications should have been separated because they affect each other’s absorption, and the dispensing pharmacist stated the interaction was not detected because ferrous sulfate was not listed in the resident’s profile. Resident 97 had diagnoses including seizures, epilepsy, and gastrostomy tube dependence. The April 2026 orders included enteral feeding instructions to hold feeds one hour before and after medications with drug-nutrient interactions and phenytoin suspension three times daily. A review of the resident’s phenytoin level showed a low result of 7.0 mcg/ml, and the DON stated there was no parameter on the order to hold enteral feeding before and after phenytoin administration. Resident 76 also had diagnoses including seizures, coma, and gastrostomy tube dependence, and had an active phenytoin order in April 2026. The DON stated there was no order to hold enteral feeding before and after phenytoin administration for this resident. The facility’s consultant pharmacist MRR binder listed Residents 54, 97, and 76 among residents reviewed, but it did not show recommendations for enteral feeding and phenytoin instructions or identify the interaction between ferrous sulfate and minocycline for Resident 54. The DON stated there was no documentation that the pharmacist consultant made recommendations for phenytoin administration via g-tube during the monthly regimen reviews for January, February, and March 2026. The facility policy stated the consultant pharmacist’s responsibilities included reviewing the medical chart and medication profile to identify drug interactions and documenting resident-specific irregularities in the active record and reporting them to the DON, Medical Director, and attending physician.
Medication Administration Errors With Enteral Feeding and Drug Compatibility
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. During a medication administration observation, four medication errors were identified out of 25 opportunities, resulting in an overall medication error rate of 16 percent and affecting one of six residents observed during the pass. The errors involved one resident with a history of seizures, anemia, hemiplegia affecting the right dominant side, gastrostomy tube dependence, and respiratory/ventilator dependence, who was documented as rarely or never understood and lacking capacity to understand and make decisions. During the medication pass, the LVN prepared ferrous sulfate liquid, multivitamins with minerals liquid, phenytoin oral suspension, and minocycline for administration through the resident’s g-tube. The LVN poured the ferrous sulfate, multivitamin, and phenytoin doses into medication cups without shaking the phenytoin oral suspension or the multivitamin and minerals liquid before pouring. The minocycline tablets were crushed and placed into a medication cup. The LVN then administered the medications separately through the g-tube and restarted the enteral feeding pump after the medication pass. During interview and record review, the LVN stated he was not sure whether the g-tube feeding should be started immediately after phenytoin administration and acknowledged that he forgot to shake the phenytoin oral suspension and multivitamin and minerals liquid before pouring them. The DON stated that enteral feeding must be held one hour before and one hour after phenytoin administration, and that this information was not included on the physician order or prescription label. The consultant pharmacist stated enteral feeding should be held one to two hours before and after phenytoin administration for better absorption and effectiveness. The dispensing pharmacist stated the resident’s minocycline should not be given together with ferrous sulfate. The facility policy required consideration of medication and food interactions, and the enteral tube medication policy addressed compatibility with feeding tube formula and manufacturer-specified timeframes.
Medication Administration Errors with Enteral Feeds and Drug Interactions
Penalty
Summary
The facility failed to prevent significant medication errors for three residents receiving enteral medications. During a medication pass observation, an LVN prepared and administered multiple medications for one resident, including ferrous sulfate liquid, multivitamins with minerals, phenytoin oral suspension, and crushed minocycline tablets. The resident had diagnoses including seizures, anemia, hemiplegia, and dependence on respiratory status, and the record showed the resident lacked the capacity to understand and make decisions. The resident’s care plan included seizure precautions and treatment for infection, and the physician orders included both phenytoin via g-tube and minocycline for 14 days. The resident was administered ferrous sulfate and minocycline together at the same scheduled medication time for 18 days. The DON stated there was a potential interaction between ferrous sulfate and minocycline and that they should not be given together because iron binds to minocycline. The consultant pharmacist and dispensing pharmacist both stated that minocycline and ferrous sulfate should be separated because they affect each other’s absorption. The resident’s MAR documented the concurrent administration of both medications during the identified period. The facility also failed to ensure enteral feedings were held before and after phenytoin administration for three residents receiving Dilantin via g-tube. For one resident, the LVN restarted the feeding pump after giving phenytoin and stated he was not sure whether feeding should be started immediately after administration. The DON stated the feeding must be held one hour before and one hour after phenytoin, but that this instruction was not included on the physician order or prescription label. For two other residents, the records showed active phenytoin and enteral feeding orders, and the DON stated there was no order to hold feedings before and after phenytoin administration. One resident’s Dilantin level was documented as low at 7.0 mcg/ml. The facility’s policy and a drug reference reviewed by the DON stated that phenytoin absorption is reduced with tube feeding and that feeds should be held around administration.
Failure to Report Scabies Outbreak and Follow IPCP Measures
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents with suspected and confirmed scabies. Resident 87 had a positive skin scraping for sarcoptes scabiei on 1/20/26, and Resident 66 later tested positive for scabies on 2/25/26 after having a rash with severe itching and a dermatology visit that documented a generalized itchy, red, scaly rash with sleep disruption. The dermatologist prescribed ivermectin and permethrin cream for Resident 66, and the line listing reflected the positive scabies results within the incubation period described by the facility. During interview, the Infection Preventionist Nurse stated the facility did not report the outbreak to the local health department because there were not yet two positive residents to qualify as an outbreak, and acknowledged the report should have been submitted when the second resident tested positive. The DON stated that two positive cases within the incubation period constituted an outbreak and that the facility failed to report the positive case identified in 02/2026. The DON also stated the agency should have been notified so it could visit the facility and ensure appropriate measures were being taken to contain the spread of infection. The facility also did not maintain the environmental cleaning and isolation measures described in its scabies policy. The Housekeeping Supervisor stated there was no complete log of deep cleaning for rooms occupied by affected residents or for shower rooms, no documentation that linens or personal belongings of Residents 66 and 87 had been bagged or deep cleaned, and no additional deep-cleaning procedures were performed beyond the regular schedule. In addition, Resident 36 and Resident 39 had rashes and were evaluated for suspected scabies, but the record review and interview showed no documented contact precautions when the rashes were identified. The facility policy stated affected residents should remain on contact precautions and that residents with typical scabies should be placed on contact precautions during treatment.
Delayed Response to GT Pump Alarms
Penalty
Summary
The facility failed to reasonably accommodate resident needs when staff did not respond in a timely manner to gastrostomy tube (GT) pump alarms for 2 of 8 sampled residents, including a resident admitted with chronic respiratory failure with hypoxia, gastrointestinal hemorrhage, dysphasia following cerebral infarction, hypertension, anemia, diabetes mellitus, and BPH. The resident’s MDS indicated no speech, rarely or never understood, sometimes understands, highly impaired vision, severely impaired cognitive skills for daily decision making, impaired ROM on both sides, dependence with ADLs, incontinence, oxygen therapy, tracheostomy care, and suctioning. Physician orders directed GT feeding of Glucerna 1.5 at 65 ml/hr for 18 hours via pump and to monitor GT patency every shift. During observation, the resident’s GT pump was audibly alarming and displayed “tube slip detected, remove and reload cassette.” Staff were observed walking past the room without entering to check on or respond to the alarm, and more than 20 minutes after the alarm was first noted, no staff had entered the room to address it. When an LVN later entered the room, she stated she could not tell whether the tube was loose and that the machine did not indicate whether the tubing was dislodged or clogged. The care plan identified the resident as at risk for altered nutritional status related to GT feeding and directed feeding and flushes as ordered at the proper rate and volume. The DON stated the GT pump needed to be attended right away and that if it kept beeping without attention, the resident would not receive the correct feeding order and there would be delayed total volume delivery.
Improper Monitoring and Reassessment of Hand Mitten Restraint
Penalty
Summary
The facility failed to ensure that one sampled resident was assessed and monitored properly for the use of hand mittens. Resident 67 was observed in bed with a soft hand mitten on the left hand. The resident was admitted with diagnoses including a G-tube, hemiplegia, hemiparesis affecting the right dominant hand, and anxiety disorder. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment and dependence on all ADLs. The restraint records showed that hand mittens were initiated as the least restrictive intervention and were intended as a trial period instead of Ativan. The quarterly restraint assessment documented that Resident 67 continued to try to pull out the G-tube, but there were no attempts documented to reduce the hand mitten restraint over the past quarter and the mitten continued to be used. During interview and record review, LVN 8 stated hand mittens were considered restraints, that Resident 67 had not had any episodes of pulling out the G-tube or dislodgements, and that there was no documentation of monitoring episodes of him pulling at the tube. LVN 8 also stated other methods had not been tried to determine whether the mittens were still needed. The DON stated restraints restrict resident mobility and that licensed staff used visual checks to determine continuation of the hand mittens, but there was no documentation or tally marks of Resident 67 trying to pull out the G-tube. The facility policy required restraints to be used only after other alternatives failed, with ongoing re-evaluation documented, and required residents in restraints to be observed at least every 30 minutes with documentation of the resident's condition and the episode leading to restraint use. The policy also required documentation of the effectiveness of the restraint, observation, range of motion, and repositioning flow sheets.
Failure to Attempt Nonpharmacological Interventions Before PRN Ativan
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 8, received nonpharmacological interventions before PRN Ativan was administered. Resident 8 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, acute and chronic respiratory failure with ventilator dependence, depression, and anxiety disorder. The resident’s MDS dated 3/23/2026 indicated moderately impaired cognition and dependence on staff for activities of daily living. Resident 8’s order listing showed Ativan 0.5 mg via G-tube was ordered every 6 hours PRN for anxiety manifested by restlessness leading to shortness of breath/hyperventilation. The MAR for 4/1/2026 through 4/22/2026 showed the resident received PRN Ativan on six days, and the MAR indicated nonpharmacological interventions were not attempted before administration. During interview and record review, the RN Supervisor stated nonpharmacological measures were not attempted prior to giving Ativan and should be attempted before administration to prevent unnecessary use. The DON stated non-pharmacological interventions for behavior prior to medication use were to prevent use of Ativan because the medication has undesirable side effects. The facility policy on Psychotropic Medication Use stated non-pharmacological interventions are used unless contraindicated to minimize the need for medications when possible.
Failure to Provide Daily Activities
Penalty
Summary
Provide activities to meet all resident's needs. Based on interview and record review, the facility failed to ensure one of one resident received daily activities appropriate to the resident's needs. Resident 88 was admitted with diagnoses including cerebral palsy, muscle weakness, and contractures of the left and right knee. The resident's MDS dated 2/4/2026 indicated severely impaired cognition and dependence on staff for all ADLs. During a concurrent interview and record review on 4/21/2026, the Activities Director reviewed Resident 88's Activities Point of Care Report for March and April 2026 and stated the resident did not have daily activities. The Activities Director acknowledged that residents should receive daily activities to support brain stimulation and promote quality of life. During a later interview, the DON stated activities are a part of residents' daily living that can stimulate cognition. The facility policy titled Activity Program stated activities are provided to support the well-being of residents.
Failure to Off-Load Overlapping Toes for a Resident at Very High Risk for Pressure Injury
Penalty
Summary
The facility failed to ensure that Resident 41, who was assessed as being at very high risk for pressure ulcer development, had a pressure-relieving barrier placed between the overlapping toes of the left foot as indicated by facility policy. Resident 41 was admitted with anoxic brain damage, acute respiratory failure with hypoxia, and a persistent vegetative state, and the MDS showed dependence in oral hygiene, toileting, bathing, dressing, personal hygiene, rolling, and transfers, along with functional limitations in range of motion in both arms and both legs. The Braden Scale dated 3/5/2026 identified Resident 41 as very high risk for pressure ulcer development due to completely limited sensory perception, very moist skin, complete immobility, and concerns for friction and shearing. During observation on 4/20/2026, Resident 41 was lying in bed with both legs straight, curved inward, and hyperextended at the knees, with both feet pointing downward. The second toe on the left foot was positioned on top of the big toe, creating an overlap, and RN 1 confirmed the overlap and a visible indentation on the big toe caused by direct pressure from the overlapping toes. RN 1 stated the toes required staff to physically separate and consistently reposition them to prevent pressure, and that a barrier or ointment should have been placed between the overlapping toes but was not. LVN 2 also confirmed the contractures and overlapping toes, noted visible indentation from pressure, and stated the area should have been off loaded with a barrier device between the toes to prevent pressure ulcers and skin breakdown. The DON stated contracted, overlapping toes placed residents at high risk for pressure ulcer development and should be assessed by Rehab, nursing, and/or the physician to ensure the pressure between the toes was off-loaded, monitored, and treated appropriately. The facility policy on prevention of pressure injuries stated staff were to inspect skin daily, reposition residents, provide support devices as needed, and use facility-approved protective dressings for at-risk individuals.
Missed Foley Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident with an indwelling foley catheter received catheter cleansing and catheter drainage bag monitoring as ordered to help prevent recurrent UTI. Resident 94 was admitted with diagnoses including COPD, DM, and VUR, and the record showed she had a neurogenic bladder with an indwelling catheter in place. Her H&P indicated she had the capacity to understand and make decisions, and the MDS indicated intact cognitive status, moderate assistance with self-care, and maximal assistance with mobility. The physician’s order required cleansing the indwelling catheter site with soap and water, rinsing, and patting dry every shift, along with monitoring the catheter drainage bag every shift for urine color, consistency, odor, hematuria, bladder distention, burning, and sensation, with documentation of signs or absence of signs and symptoms of UTI. Review of the TAR showed missed documentation for catheter cleansing and drainage bag monitoring on multiple shifts across February, March, and April 2026, including missed entries on the night shift of 2/19/2026, evening and night shifts on 3/8/2026, night shift on 3/26/2026, and night shift on 4/5/2026. During observation, Resident 94 was in bed watching television and stated she had a catheter placed after hospitalization and could not walk to the restroom. The RNS reviewed the TAR and stated there was missing documentation for cleansing and monitoring on some dates and that if it was not documented in the TAR, it was not done. The RNS also stated the resident had a history of UTI and had received antibiotics for UTI in the past. The DON stated the importance of monitoring and providing indwelling catheter care was to prevent infection and acknowledged that staff should have been following the physician’s orders to monitor and provide catheter care to prevent UTI.
Missed Hemodialysis Due to Transportation Issue
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for one resident receiving hemodialysis. Resident 10 was recently re-admitted with diagnoses including chronic kidney disease and dependence on renal dialysis. The resident's MDS dated 2/5/2026 indicated severely impaired cognition and dependence on staff for all ADLs. The resident had an order dated 1/13/2026 to receive hemodialysis at an outpatient dialysis center on Tuesday, Thursday, and Saturday. During interview and record review, the facility's SBAR and initial COC/alert charting and skilled documentation showed the resident missed hemodialysis on 1/27/2026 because there was an issue with transportation. The RNS stated HD residents should not miss dialysis because it could cause fluid overload, and the DON stated missing dialysis could cause fluid overload. The facility policy for ESRD care indicated residents with ESRD would be cared for according to currently recognized standards of care.
Missing Thermometer in Dry Storage Area
Penalty
Summary
The facility failed to ensure a thermometer was placed in the dry storage food area. During a concurrent observation and interview, the Dietary Manager stated the current storage room temperature was 72 degrees Fahrenheit and said the facility did not need a thermometer in the dry storage room, explaining that when the room gets too hot they would place a thermometer there and take the temperature. The Dietary Manager also stated nothing in the storage room would be affected because there was no produce. In a later interview, the Director of Nursing stated a thermometer should be in the dry storage room so the facility could monitor the temperature because certain foods have temperature requirements and could spoil if the room temperature was not maintained. Review of the facility policy titled, Storage of Food and Supplies, dated 2023, indicated thermometers should be placed in all storage areas and checked frequently, with a recommended temperature of 50 degrees Fahrenheit to 85 degrees Fahrenheit and corrective action if dry food storage goes over 85 degrees Fahrenheit.
Trash Collection Area Not Kept Clean and Waste Containers Left Open
Penalty
Summary
The facility failed to ensure exterior waste disposal containers were fully closed and the designated trash collection area was kept clean and free of black sticky residue. During an observation of the trash collection area located on the left side of the facility, two of three gray waste disposal containers and one blue waste container were not fully closed, and the floor had a used pair of gloves and black sticky residue. During a concurrent observation and interview, the Dietary Supervisor stated the waste disposal containers were full and not fully closed, a used pair of gloves was on the floor, and the floor had black sticky residue. The Dietary Supervisor also stated that keeping the waste disposal containers fully closed and the waste disposal area clean was important to contain trash and prevent rodents or pests from digging through the trash and potentially entering the facility. Review of the facility policy titled Garbage and Trash indicated the trash collection area is a potential feeding ground for vermin and rodents and must be kept clean, and that the area must be swept and washed down on a regular basis.
Missing Hospital Discharge Summary in Resident Record
Penalty
Summary
The facility failed to ensure the General Acute Care Hospital (GACH) Discharge Summary for one sampled resident was in the medical record and readily accessible. Resident 3 was initially admitted to the facility on 12/26/2022 and re-admitted on 2/13/2025 with diagnoses including a left ulna fracture, anoxic brain damage, and osteoporosis with pathological fracture. The resident’s MDS dated 2/17/2026 indicated severely impaired cognitive skills for daily decision making, dependence in oral hygiene, toileting, bathing, dressing, personal hygiene, rolling, and transfers, and functional limitations in ROM in both arms and both legs. The resident’s GACH ED Note dated 2/8/2025 showed the resident was transferred to the hospital from the facility for evaluation of a left forearm fracture sustained while staff tried to move the resident in bed. The ED note indicated the resident could return to the facility after a splint was placed on the left arm and recommended follow-up with the primary care physician/Orthopedics in seven to 10 days after discharge. During interview and record review, RNS 3 confirmed the resident’s GACH Discharge Summary for the hospital return was missing from the clinical record and stated it was supposed to be in the EMR but was not. The MR also confirmed the GACH Discharge Summary was missing from the resident’s clinical record and stated it had to be obtained from the hospital. The DON stated a licensed nurse was responsible for accepting the resident’s paperwork, implementing new physician orders, and scheduling follow-up appointments when a resident returned from the hospital, and stated the resident’s GACH Discharge Summary was needed to know what care to provide upon re-admission. The facility’s policies stated current medical records were to be filed and maintained, and documentation in the medical record was to be objective, complete, accurate, and facilitate communication among the interdisciplinary team.
Hospice aide visits were not provided as scheduled
Penalty
Summary
The facility failed to ensure that hospice services were provided as arranged for one of two hospice residents, Resident 13. Resident 13 was recently re-admitted with diagnoses including severe protein calorie malnutrition, dementia, depression, and Parkinson's disease. The MDS dated 3/3/2026 indicated the resident's cognition was severely impaired and that the resident was dependent on staff for all ADLs. The hospice admission agreement dated 2/18/2026 stated that the hospice aide would make visits twice a week, and the active order summary indicated Resident 13 was admitted under hospice care. During a concurrent interview and record review on 4/22/2026, the RNS stated the HHA was supposed to visit twice a week and that documented evidence showed the HHA did not visit twice a week. During an interview on 4/23/2026, the DON stated that hospice care was essential to ensuring residents' comfort goals were met.
Antibiotic Screening Not Completed Appropriately Before Treatment
Penalty
Summary
The facility failed to ensure that one sampled resident was screened appropriately before antibiotic treatment was started. Resident 31 was admitted with diagnoses including tracheostomy, gastrostomy, and acute and chronic respiratory failure. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severe cognitive impairment, dependence on all ADLs, and impairments in both upper and lower extremities. Resident 31’s IV MAR showed treatment with Zosyn 3.375 gram/50 mL every 6 hours for 7 days for pulmonary infiltrate in the left middle and lower lung field, with the course starting 4/4/2026 and ending 4/10/2026. The Infection Screening Evaluation dated 4/3/2026 documented a current active diagnosis of infection and a chest x-ray showing new infiltrates consistent with pneumonia, but it did not identify signs and symptoms meeting McGeer’s or Loeb’s Criteria. A later Infection Screening Evaluation dated 4/16/2026 documented a current active diagnosis of infection, respiratory rate greater than 25 breaths per minute, and new or increased cough with productive purulent sputum, but it also did not indicate signs and symptoms meeting McGeer’s or Loeb’s Criteria. During interviews, the IPN stated antibiotic stewardship is used to monitor residents on antibiotics, ensure the correct antibiotic is used for the indication, and advocate for discontinuation or change when not needed. The IPN stated she follows McGeer’s Criteria to determine the need for antibiotics and said the screening evaluations did not meet McGeer’s or Loeb’s Criteria. She also stated she did not know what the “No IPC Case Triggered” notation meant and did not see the Infection Analysis section indicating whether the screening met criteria when the form was initiated. The DON stated antibiotic stewardship is intended to ensure residents meet criteria for appropriate treatment and avoid unnecessary antibiotics. The facility policy titled Antibiotic Stewardship stated antibiotics will be prescribed and administered under the guidance of the facility’s antibiotic stewardship program and that the purpose of the program is to monitor antibiotic use, but the policy did not describe procedures for identifying appropriateness for antibiotic use.
Failure to Notify Responsible Party of New Insulin Medication
Penalty
Summary
The facility failed to notify the responsible party (RP) when a resident was started on a new insulin medication, Lantus, resulting in a violation of the RP’s right to be informed and involved in treatment decisions. The resident’s face sheet showed admission with diagnoses including cerebral infarction, metabolic encephalopathy, and type 2 DM. The resident’s H&P dated 8/29/2025 documented that the resident did not have the capacity to understand and make decisions, and the MDS dated 8/14/2025 indicated severe cognitive impairment with the resident rarely or never able to understand and be understood by others. A physician’s order dated 12/8/2025 directed that the resident receive Lantus 16 units subcutaneously at bedtime for type 2 DM, to be held if blood sugar was less than 150. The MAR for 12/2025 showed that Lantus was administered at 9 p.m. from 12/8/2025 through 12/31/2025. During a telephone interview, the RP stated she learned from the resident’s insurance company that Lantus had been started, and she expressed anger that the facility had not informed her of the new medication, stating that the facility undermined her authority and right to contribute to the resident’s plan of care and that she felt distrustful toward the facility. In an interview, the DON stated that review of the medical record revealed no documentation that the RP was notified when Lantus was added and confirmed there was no record of any discussion with the RP regarding Lantus prior to its initiation. The facility’s P&P titled “Change in Resident’s Condition or Status,” dated 5/2022, required prompt notification of the resident, attending physician, and representative of changes in the resident’s medical/mental condition or status and stated that a nurse or healthcare provider would inform the resident of any changes in medical care or nursing treatments, regardless of the resident’s current condition.
Failure to Recognize and Control Suspected Scabies Outbreak
Penalty
Summary
The facility failed to implement infection control measures to prevent a scabies outbreak for five sampled residents who were treated prophylactically for suspected scabies. Residents 1 through 5 each had generalized or spreading rashes, itching, and skin findings documented as unspecified dermatitis, and each was placed on contact precautions for a rash of unknown origin. Their records showed treatment with ivermectin and permethrin, medications commonly used for scabies, despite the diagnosis being documented as unspecified dermatitis. Resident 1 had a generalized eczematous rash that was evaluated by the NP and dermatology, with orders for contact precautions and repeated courses of ivermectin and permethrin. Resident 2 had a body-wide itchy, red, scaly rash for weeks with difficulty sleeping, and the dermatology differential diagnosis included scabies, dyshidrotic eczema, pruritus, and pediculosis corporis; the resident was also placed on contact precautions and treated with ivermectin and permethrin. Resident 3 developed pimple-like eruptions on the thighs and trunk extending to the generalized body, with itching, warmth, and scant serous exudate, and was placed on contact isolation with ivermectin and permethrin ordered. Resident 4 had a generalized rash with redness, scant serous drainage, and warmth to touch, was placed on contact isolation, and received ivermectin and permethrin. Resident 5 had a rash throughout the body that was itchy, red, scaly, and present for weeks, with difficulty sleeping at night due to itching; the dermatology note documented scabietic nodules and erythematous eczematous patches, and the diagnosis included scabies, contact dermatitis, and dyshidrotic eczema. Interviews showed staff understood the residents were being treated as suspected scabies cases, but the facility did not recognize or manage the situation as a scabies outbreak. CNA 1 stated she gave a shower with special soap and cream for scabies to residents in the room, and LVNs stated residents with unspecified dermatitis were placed on contact precautions and treated with permethrin and ivermectin because the rash origin was unknown. The IPN stated scabies are reported to the health department right away when diagnosed, that skin scraping can be ordered if scabies are suspected, and that no testing for scabies was done before administering scabies medication. The DON stated residents diagnosed with unspecified dermatitis were given permethrin and ivermectin prophylactically and that suspected scabies were not reportable, only confirmed cases. The dermatologist stated unspecified dermatitis could be possible scabies or eczema and that it is standard for the facility to isolate, report, and test residents with suspected scabies. The facility policy titled Scabies Identification, Treatment and Environmental Cleaning stated its purpose is to treat residents infected with and sensitized to Sarcoptes scabiei and prevent spread to other residents and staff.
Failure to Timely Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a significant change in condition for a resident who developed swelling and discoloration of the left fourth and fifth fingers. The resident, who had diagnoses including Alzheimer's disease, schizophrenia, and Parkinson's disease, was severely cognitively impaired and dependent on staff for daily activities. Documentation showed that staff observed the swelling and discoloration, and initial attempts were made to contact the resident's physician, but there was no immediate response. Follow-up calls and texts were made, but the physician did not respond until approximately 13 hours after the initial observation. Facility policy required staff to contact the medical director if the primary physician could not be reached within 30 minutes, but this protocol was not followed. Interviews with nursing staff and the DON confirmed that the medical director was not contacted as required, resulting in a delay in obtaining medical orders for the resident's condition. The facility's job descriptions and policies emphasized timely physician notification and the use of alternate physicians when the primary was unavailable, but these procedures were not adhered to in this instance.
Failure to Timely Report Fracture of Unknown Origin
Penalty
Summary
The facility failed to report a fracture of unknown origin for a resident to the California Department of Public Health (CDPH), law enforcement, or the Ombudsman as required. The resident, who had diagnoses including Alzheimer's disease, schizophrenia, and Parkinson's disease, was severely cognitively impaired and dependent on staff for daily activities. The resident was found to have swelling and discoloration of the left hand, and subsequent x-ray results confirmed a non-displaced fracture of the fifth finger. Despite the absence of documentation explaining how the injury occurred, the results were not reported to the required authorities within the mandated two-hour timeframe. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) who received the x-ray results did not notify the appropriate agencies immediately, and the Director of Nursing (DON) only became aware of the incident several hours later. Facility policies and job descriptions reviewed during the investigation clearly stated the requirement to report suspected abuse, neglect, or injuries of unknown origin immediately, defined as within two hours. The failure to report the incident in a timely manner delayed the initiation of an investigation and did not comply with both facility policy and regulatory requirements.
Failure to Honor Resident's Right to Dignity and Self-Determination
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) entered the room of a resident who had previously requested not to receive care from that CNA, following a complaint from the resident's family member. Despite an agreement that the CNA would not be assigned to provide care to this resident, the CNA entered the resident's room to provide care to the roommate and closed the curtain for privacy. Staffing records confirmed that the CNA was assigned to the roommate, not the resident in question, but the Director of Nursing (DON) acknowledged that, due to the known conflict and complaints, the CNA should not have been assigned to the room at all. The resident involved had multiple medical conditions, including hemiplegia, hemiparesis, acute respiratory failure, diabetes mellitus, asthma, and post-traumatic stress disorder (PTSD). The resident's cognitive skills were moderately impaired, and they were dependent on staff for all activities of daily living. The facility's policy stated that residents have the right to be treated with respect, kindness, and dignity, and to participate in decision-making regarding their care. The failure to honor the resident's request and the facility's own policy resulted in a violation of the resident's rights.
Plan Of Correction
F550 Resident Rights/Exercise of Rights 1. How corrective actions will be accomplished for those residents found to have been affected by the deficient practice. • Resident 1 remains in the facility and has no complaints/issues about his CNA. • CNA 1 will no longer be assigned to resident '1's roommate and cannot enter room since 08/02/2025. • Resident 1's care plans were reviewed and updated according to his needs. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken. • The Administrator, DON, and Social Services Director (SSD) randomly interviewed alert and oriented residents to address any concerns/issues regarding their CNA, ensuring they are treated with respect, kindness, and dignity, and participate in decision-making regarding their care; no concerns/issues were brought up. • There were no other residents affected by this deficient practice. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. 3. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not occur. Systemic changes will be achieved through in-service education and corrective action monitoring utilizing the facility quality assurance process. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. • The RN supervisor and charge nurse will review the assignment sheet every shift to ensure that staff who have issues with the resident will not be assigned to the resident's room and cannot enter the room. Any findings will be corrected immediately and reported to the DSD and DON for follow-up and corrections for future pre-assigned assignment sheets. • The RN supervisor will randomly observe staff daily when providing care to the residents to ensure residents are treated with respect, kindness, and dignity, and that staff comply with resident care plans. Any findings will be corrected immediately and reported to the DON for follow-up and corrective actions. • Department Heads will conduct daily room rounds and interview the residents regarding any concerns/issues regarding their CNA, ensuring they are treated with respect, kindness, and dignity, and participate in decision-making regarding their care. Immediate correction will be carried out upon notice of issues/concerns. Any findings during their room rounds will be discussed in the stand-up meeting for corrective actions and follow-up. • The DSD or designee will continue to provide in-service education regarding Resident Rights. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator and/or DON shall implement, monitor, and evaluate this Plan of Correction. The SSD or designee will recapitulate findings related to Resident Rights issues at the monthly QAA meeting for further evaluation, recommendation, and/or appropriate improvement actions. If it is determined that we have accomplished the objectives in the Plan of Corrections above and the results are successful, then the facility will consider the matter resolved. The QAA Committee will continue to review until the deficiency has been proven resolved for two consecutive months and/or advised by the QAA Committee.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure staff familiarity with a resident assessed as high risk for falls. The resident, who had severe cognitive impairment and was dependent on staff for most activities of daily living, experienced multiple falls, including an unwitnessed fall that resulted in hospitalization for head trauma. The facility's care plan and interdisciplinary team (IDT) interventions specified that the resident should not be left unattended in a wheelchair, and that staff should escort or endorse the resident between locations. However, these interventions were not consistently implemented, particularly after the resident was moved to a new room with unfamiliar caregivers. Observations and interviews revealed that staff were not always aware of or adhering to the resident's fall prevention interventions. On one occasion, the resident was found unsupervised in the hallway after wheeling himself from the activity room, contrary to the care plan. Staff interviews indicated that communication between activity and nursing staff was primarily verbal and not documented, leading to lapses in supervision. Additionally, there were no visible indicators in the resident's environment to alert staff to the high fall risk, and staff monitoring intervals may not have been sufficient given the resident's condition. The facility's policies required that interventions be communicated to all relevant staff, implemented consistently, and re-evaluated after each fall. Despite these requirements, the resident continued to experience falls, including in situations where new caregivers were unaware of the resident's routine. The lack of consistent supervision, inadequate communication, and failure to reassess and adjust interventions after each fall directly contributed to the resident's repeated falls and subsequent injury.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident who required two-person assistance for turning and repositioning in bed was not turned and repositioned by one person, resulting in an injury. On February 8, 2025, a certified nursing assistant (CNA 1) turned and repositioned the resident alone, despite the care plan indicating the need for two-person assistance. This action led to the resident sustaining an acute fracture of the distal shaft of the left forearm, necessitating transfer to a general acute care hospital for further evaluation and treatment. The resident, who had been admitted with diagnoses including anoxic brain damage, osteoporosis, and muscle contractures, was totally dependent on staff for bed mobility. The Minimum Data Set (MDS) indicated that the resident had functional limitations and impairments in both upper and lower extremities, placing them at risk for injury. Despite these conditions, CNA 1 proceeded to turn the resident alone due to the unavailability of other staff members, resulting in a loud cracking sound from the resident's left arm during the process. Interviews with staff revealed that the subacute unit was understaffed, leading to situations where CNAs had to perform tasks alone that required assistance. The director of nursing confirmed that the care plan required two-person assistance for the resident's safety, and the director of rehabilitation emphasized the need for careful handling due to the resident's stiffness and contractures. The facility's policy on turning residents also highlighted the importance of reviewing care plans for special needs, which was not adhered to in this case.
Failure to Provide Necessary Therapy Services for Residents with ROM Limitations
Penalty
Summary
The facility failed to provide necessary occupational and physical therapy services to several residents with limited range of motion (ROM) and mobility issues. Resident 76, who had a history of severe hypoxic ischemic encephalopathy and cerebral infarction, was identified as needing occupational therapy for contracture prevention and physical therapy for ankle limitations. Despite these evaluations, the resident did not receive the recommended skilled therapy services due to a denial from the health insurance. The facility also failed to perform accurate quarterly Joint Mobility Screens (JMS) for Resident 76, which inaccurately reported full ROM despite documented limitations. Resident 48 did not receive an occupational therapy evaluation after a decline in elbow ROM was identified, and the facility applied elbow extension splints without professional assessment. Similarly, Resident 61 did not receive an OT evaluation before the application of a right elbow extension splint, and the facility failed to identify ROM decline in the resident's left hand and ankle. Resident 68, who was admitted to hospice care, did not receive passive range of motion (PROM) exercises for the arms and legs as required. The facility's failure to provide restorative nursing aide (RNA) services as ordered for Resident 54 further exemplifies the systemic issue of inadequate care. Interviews with staff and family members revealed that the facility did not provide necessary interventions, such as splints or therapy services, due to insurance denials, and there was a lack of documentation and follow-up on identified ROM limitations. The facility's policies did not require insurance authorization for interventions to prevent ROM loss, yet these services were not provided, leading to preventable contractures and further decline in residents' conditions.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that call lights for three residents were answered in a timely manner, resulting in a delay of care and services. Resident 34, who was admitted with polyneuropathy, muscle weakness, and paraplegia, required varying levels of assistance with activities of daily living (ADLs) and reported long wait times for call light responses. Resident 45, with a diagnosis of acquired absence of the left leg below the knee and osteomyelitis, also experienced delays in call light responses, with wait times reported up to 15 minutes. Resident 82, suffering from cord compression and reduced mobility, similarly reported that call lights were not answered promptly, and sometimes staff would promise to return but failed to do so. Interviews with the residents and staff, including the Infection Prevention Nurse and the Director of Nursing, confirmed the issue of untimely responses to call lights. The facility's Resident Council Minutes also documented complaints about the delayed response to call lights. The facility's policy and procedure on answering call lights, which was revised in September 2022, stated that call lights should be answered immediately to meet the residents' needs. However, the observations and interviews indicated that this policy was not being followed, leading to the deficiency in care provided to the residents.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, specifically in the Minimum Data Set (MDS) Section P regarding restraints and alarms. Resident 80, who was admitted with severe cognitive impairment and dependent on all activities of daily living, had mittens applied as a restraint, which was not documented in the MDS. The MDS Coordinator confirmed the oversight during an interview, acknowledging that the MDS was not coded to reflect the use of mittens as restraints. Resident 296, admitted with conditions including Parkinson's disease and chronic respiratory failure, was also found to have hand mittens applied to prevent interference with life-sustaining devices. However, the MDS did not indicate the use of restraints. During an observation, Resident 296 was seen with mittens on both hands, and the MDS Coordinator confirmed that mittens should have been coded as restraints, as they restrict movement and cannot be easily removed by the resident. Similarly, Resident 86, who had a traumatic subarachnoid hemorrhage and hemiplegia, was observed with a mitten on the left hand to prevent pulling on a gastrostomy tube. The MDS did not reflect this restraint use, and the MDS Coordinator admitted to not realizing that mittens are considered restraints. The facility's policy requires comprehensive assessments, and the Resident Assessment Instrument manual specifies that mittens are categorized as limb restraints, which should have been accurately documented in the MDS.
Failure to Label and Date Food Containers
Penalty
Summary
The facility failed to ensure that food containers, once opened, were labeled with an open date and a use-by date, which is a violation of professional standards for food storage and safety. During an initial tour of the kitchen, several items in the refrigerator, including wrapped turkey sandwiches, a large jar of pickle relish, prepared fruit cups, and prepared salads, were found without preparation or use-by dates. This oversight was confirmed during an interview with Dietary Aide 1, who acknowledged that staff are responsible for dating prepared foods to prevent serving potentially unsafe food to residents. Further interviews with staff, including [NAME] 1 and the Dietary Supervisor, reinforced the importance of labeling and dating food items to avoid serving expired or potentially harmful food to residents. The facility's undated policy on labeling and dating of foods requires all prepared foods to be covered, labeled, and dated, either individually or in bulk. The lack of adherence to this policy could lead to residents consuming food that is unsafe, as food should be discarded after three days to prevent bacterial growth.
Failure to Address Quality Deficiencies in Restraint Monitoring and Documentation
Penalty
Summary
The facility failed to identify and address unresolved quality deficiencies, particularly in the areas of assessment, monitoring, and documentation of physical restraints, as well as accurate resident assessment with documentation. These deficiencies were noted during previous surveys but were not corrected through the Quality Assessment and Assurance (QAA) process. The report highlights the lack of effective corrective actions and the absence of documentation in the Quality Assurance Performance Improvement (QAPI) binder regarding these issues. A specific case involved a resident admitted with traumatic subarachnoid hemorrhage, hemiplegia, and generalized muscle weakness, who required dependent assistance for daily activities. The resident's Medication Administration Records (MAR) lacked documentation for the assessment and monitoring of left-hand mitten physical restraints. The Licensed Vocational Nurse (LVN) acknowledged the absence of documentation and stated that the physician's order was not transcribed to the MAR, and no follow-up was conducted. The LVN emphasized the importance of assessing and monitoring restraints every two hours to prevent injury. Further interviews revealed that the Minimum Data Set Coordinator (MDSC) did not recognize hand mittens as physical restraints, leading to incorrect coding in the resident matrix. The Administrator admitted that the issues were identified in previous surveys but were not effectively addressed in QAPI meetings. The Director of Nursing (DON) confirmed that the assessment and monitoring orders for the mitten were not carried out correctly, and these issues were not resolved through the QAA/QAPI committee meetings.
Failure to Document COVID-19 Vaccination Status for All Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, including physicians and consultants, which was identified during an interview and record review with the Infection Prevention Nurse (IPN). The IPN was unaware of the requirement to obtain COVID-19 immunization status for physicians and consultants. Additionally, during an interview with the Director of Nursing (DON), it was stated that all staff, including board members, licensed practitioners, lab, and hospice personnel, should be included in the vaccination records. The facility's policy and procedure, revised in October 2022, indicated that all staff, regardless of their role or contact with residents, should be vaccinated against COVID-19. This lack of documentation had the potential to place staff and residents at risk for serious outcomes related to COVID-19.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident had a call light they could use, and another resident had a working call light, resulting in a delay of care and services. Resident 80, who was admitted with severe cognitive impairment and was dependent on all activities of daily living, had a mitten on their right hand and was unable to move their left hand. Despite having a push button call light placed on their chest, Resident 80 was unable to use it due to their physical limitations. The Infection Prevention Nurse acknowledged that Resident 80 would benefit from an adaptive call light. Resident 30, who had intact cognitive skills but required assistance with various activities, was observed to have a non-functional call light. Despite signaling for help, the call light did not activate, and Resident 30, who had a tracheostomy and was unable to vocalize, mouthed that they had been trying to get assistance for almost an hour. The Registered Nurse Supervisor and Maintenance Supervisor confirmed the importance of a working call light for residents who cannot verbalize their needs, and the Maintenance Supervisor noted that the call light for Resident 30 was not working and needed replacement. The facility's policies and procedures indicated that assistive devices and equipment should be provided to ensure resident safety and independence, and that call lights should be answered immediately. However, the facility failed to adhere to these policies, as evidenced by the non-functional call light for Resident 30 and the inappropriate call light setup for Resident 80. The Director of Nursing emphasized the necessity of a working call light for residents to communicate their needs, especially in emergencies.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect Resident 50 from physical and verbal abuse by not adequately separating them from Resident 197 after a verbal altercation. Resident 50, who has cerebral infarction, muscle weakness, and legal blindness, was involved in a conflict with Resident 197, who has essential hypertension and anxiety disorder. The altercation began when Resident 197 refused to close the patio door despite freezing temperatures, leading to a verbal argument with Resident 50. Despite the intervention of Registered Nurse 2 (RN 2) to calm the situation, Resident 197 later threw two tissue boxes at Resident 50, which was not immediately addressed by relocating Resident 197 to a non-adjacent room. The facility's policy requires staff to separate residents involved in altercations and make necessary changes to care plans. However, after the incident, Resident 197 was moved to a room that shared a common patio with Resident 50, failing to ensure their separation. Interviews with staff, including RN 2, Licensed Vocational Nurse 4 (LVN 4), and the Director of Nursing (DON), revealed that the facility did not follow its policy to prevent further interactions between the two residents, thereby placing Resident 50 at risk for further abuse and feelings of insecurity.
Failure to Monitor and Document Restraint Use
Penalty
Summary
The facility failed to properly assess, monitor, and document the use of hand mittens as a physical restraint for a resident who was at risk of pulling out a gastrostomy tube. The resident, who was admitted with a traumatic subarachnoid hemorrhage, hemiplegia on the right side, and generalized muscle weakness, required dependent assistance for daily activities and had impaired upper and lower extremities on one side. Despite having an order to apply a hand mitten on the left hand with specific instructions for release and skin checks, the facility did not document the necessary monitoring and assessment. During observations, the resident was seen with a hand mitten on the left hand, which was intended to prevent the removal of the G-tube. However, there was no documentation in the Medication Administration Records (MAR) regarding the monitoring and assessment of the mitten use, as the staff failed to transcribe the physician's order to the MAR. Interviews with the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) revealed that the staff did not follow the protocol for monitoring the restraint every two hours, which is crucial to prevent injury. The facility's policy on the use of restraints emphasizes that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully. The policy also requires that restraints be the least restrictive and used for the shortest time necessary, with ongoing re-evaluation and documentation. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and monitoring of the resident's hand mitten, which was considered a restraint due to its restriction of movement.
Inaccurate PASARR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASARR) for two residents, which is a federal requirement to ensure individuals with mental disorders are placed in appropriate facilities. Resident 11 was admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, and essential hypertension. However, the PASARR screening inaccurately indicated that Resident 11 did not have a mental disorder, despite the diagnosis of schizophrenia. The MDS Coordinator confirmed that the PASARR and Minimum Data Set (MDS) were not accurate, which could lead to inappropriate placement and unidentified specialized services for the resident. Similarly, Resident 33 was admitted with a diagnosis of schizoaffective disorder, bipolar type, but the PASARR screening also failed to reflect this mental disorder. The MDS Coordinator acknowledged the inaccuracy in the PASARR and emphasized the importance of correct screening to meet the resident's needs. The Director of Nursing confirmed that the PASARR should be accurate and completed as required by law. The facility's policy and procedure on admission criteria, revised in 2019, mandates Level I PASARR screening for all admissions and readmissions, screening all residents for mental disorders per the PASARR process.
Failure to Implement Comprehensive Care Plan for Resident with Hand Mittens
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident 296, who was admitted with significant medical conditions including chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy. The resident was noted to have bilateral hand mittens applied to prevent pulling at life-sustaining devices, as per an order dated 10/25/2024. However, the comprehensive care plan dated the same day did not address the use of these hand mittens, which was a necessary intervention for the resident's safety and well-being. Observations and interviews revealed that the care plan lacked specific measures to address the resident's use of hand mittens, despite the resident's dependency on staff for all self-care and mobility activities. The MDS Coordinator acknowledged the absence of a care plan for the hand mittens and emphasized the importance of care plans in monitoring and preventing complications. The Director of Nursing also highlighted the role of care plans in addressing residents' needs and diagnoses. The facility's policy on comprehensive, person-centered care plans requires measurable objectives and timeframes, which were not met in this instance.
Failure to Transfer Resident Out of Bed Daily
Penalty
Summary
The facility failed to provide adequate services to a resident with limited range of motion and mobility by not transferring the resident out of bed daily. The resident, who had a history of severe hypoxic ischemic encephalopathy, cerebral infarction, cerebral edema, and required attention to a G-tube, was observed lying in bed on multiple occasions over several days. The care plan for the resident indicated the need for assistance during transfers using a mechanical lift with two to three persons and to apply a helmet when out of bed. However, the resident was not transferred out of bed regularly, as observed during the survey. Family members of the resident expressed their desire for the resident to be transferred out of bed daily, contradicting the facility staff's claim that the family wanted the resident to remain in bed. The family stated that they had only requested the resident to be transferred out of bed on specific occasions, such as when the weather was nice. The facility's Director of Nursing confirmed that there was no care plan indicating the family's request for the resident to remain in bed, and acknowledged that generally, residents are not kept in bed every day. The facility's policy on supporting activities of daily living indicated that care and services should be provided for residents unable to carry out these activities independently, with the consent of the resident and in accordance with the care plan. Despite this policy, the facility did not adhere to the care plan for the resident, resulting in the resident remaining in bed and not being transferred to a Geri chair as needed for comfort and postural support.
Failure to Obtain Podiatry Consult for Resident's Foot Care
Penalty
Summary
The facility failed to obtain a podiatry consult for a resident who was noted to have a thickened toenail on the left big toe. The resident, who was admitted with diagnoses including Down syndrome, chronic kidney disease, and reduced mobility, was dependent on staff for all activities of daily living. The resident's medical records indicated a need for podiatry care every two months for conditions such as mycotic and hypertrophic nails. However, the last podiatry visit was recorded in September 2024, and no subsequent visit was scheduled to address the resident's foot condition. During an observation, the resident's left foot was found to have a thickened and dirty toenail, which was confirmed by the Restorative Nurse Assistant and the Infection Prevention Nurse. The facility's policy on foot care, which emphasizes maintaining mobility and foot health, was not adhered to, as the necessary podiatry consultation was not arranged. This oversight resulted in a delay of needed foot care services for the resident.
Failure to Discontinue IV Hep Lock Post-Therapy
Penalty
Summary
The facility failed to properly monitor, assess, document, and discontinue a peripheral intravenous (IV) hep lock site for a resident after the completion of IV therapy. Resident 42, who was admitted with a right foot open wound, sepsis, and diabetes mellitus, was at high risk for infection due to an immunocompromised medical status. Despite the completion of IV antibiotic therapy on January 15, 2025, the IV hep lock remained in place, wrapped loosely with gauze, causing discomfort to the resident. The resident expressed confusion about the presence of the IV hep lock, as they had not received IV antibiotics since the previous month. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse Supervisor (RNS), revealed a lack of documentation regarding IV site care and the discontinuation of the IV hep lock. The Director of Nursing (DON) confirmed that the IV hep lock should have been removed after the completion of therapy to prevent infection. The facility's policy indicated that peripheral catheters should be removed at the completion of therapy, yet this was not adhered to, as evidenced by the absence of documentation and the continued presence of the IV hep lock.
Failure to Change Respiratory Equipment as Scheduled
Penalty
Summary
The facility failed to ensure the timely change of a Heat and Moisture Exchanger (HME) for a ventilator-dependent resident, identified as Resident 40. The HME, which is part of the ventilator circuit and provides humidification to tracheostomy residents, was observed to have not been changed since 1/17/25, despite the facility's policy requiring daily changes. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN) and a Respiratory Therapist (RT), who stated that the HME should be changed twice a day to prevent clogging with secretions. Resident 40, who was readmitted to the facility with multiple diagnoses including anoxic brain damage, ventilator dependence, and hemiplegia following a cerebrovascular accident, was noted to have severely impaired cognitive skills and was totally dependent on staff for all activities of daily living. The resident's care plan highlighted a potential for infection related to the tracheostomy site, with a goal to keep the stoma site clear of infection. The failure to change the HME as scheduled had the potential to harbor microorganisms in the respiratory equipment, increasing the risk of infection for Resident 40.
Failure to Provide Speech Therapy Services as Ordered
Penalty
Summary
The facility failed to provide Speech Therapy (SLP) services to a resident, identified as Resident 76, in accordance with the SLP Evaluation recommendations and physician orders. Resident 76, who had a history of severe hypoxic ischemic encephalopathy, cerebral infarction, and cerebral edema, was admitted to the facility with a tracheostomy tube and required gastrostomy tube feeding. The SLP Evaluation, dated August 6, 2024, recommended intensive acute rehabilitation to stimulate pharyngeal abilities and assess the safest level of oral intake, but the facility did not provide these services. The facility also failed to conduct a new SLP Evaluation as ordered by the physician on January 23, 2025. Despite the physician's order for a Speech Therapy evaluation and treatment for possible oral intake, the SLP did not complete the evaluation within the required timeframe. The Director of Rehabilitation acknowledged that the SLP did not complete the documentation in response to the physician's order, and the facility's policy did not require health insurance authorization prior to providing further intervention. During interviews and record reviews, it was revealed that the facility did not have documentation of therapy services being provided to Resident 76 after the initial SLP Evaluation. The Director of Nursing confirmed that the facility's Rehabilitation Policy and Procedures required the evaluation process to be initiated within 72 hours of the physician's order, which was not adhered to in this case.
Inactive License for Physical Therapist
Penalty
Summary
The facility failed to ensure that one of its Physical Therapists (PT 2) had a current and active license to provide physical therapy treatment. This deficiency was identified when PT 2 was observed providing therapy to Resident 90, despite PT 2's license being inactive. Resident 90 had been admitted with several diagnoses, including a displaced fracture of the left tibia, right foot drop, difficulty in walking, and muscle weakness. The resident's Minimum Data Set (MDS) indicated impairments in range of motion in both legs and a dependency on assistance for various movements. PT 2 was scheduled to provide treatment to eight residents, including Resident 90, while holding an inactive license. The Director of Rehabilitation (DOR) was unaware of PT 2's inactive license status until it was reviewed during the survey. The DOR acknowledged that it was both their responsibility and the therapist's responsibility to ensure that the therapist had an active license. PT 2 was also unaware that their license had been placed in an inactive status, which was confirmed by the Physical Therapy Board of California (PTBC). The PTBC stated that PT 2 had mistakenly selected the option to change their license to inactive, which prohibited them from practicing. This oversight resulted in PT 2 providing therapy without a valid license, potentially affecting other residents requiring physical therapy treatment.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to Resident 29 upon their admission and readmission, as required by the facility's policy. Resident 29, who was admitted with chronic respiratory failure with hypoxia, traumatic brain injury, and seizures, did not have the capacity to understand and make decisions, as indicated in their history and physical assessment. The Minimum Data Set assessment further noted that Resident 29 was rarely or never understood and was dependent on others for self-care activities. Despite these vulnerabilities, the pneumococcal vaccine was not offered to Resident 29 or their responsible party, as confirmed by the Infection Prevention Nurse during an interview. The Director of Nursing acknowledged that the facility's policy is to offer vaccines, including the pneumococcal vaccine, on the day of admission or the following day. However, this procedure was not followed for Resident 29. The facility's policy, revised in March 2022, states that residents should be assessed for vaccine eligibility prior to or upon admission and offered the vaccine within thirty days unless contraindicated. The failure to offer the vaccine to Resident 29, who had a tracheostomy and was receiving oxygen, increased the risk of the resident acquiring pneumococcal disease.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced a significant change in condition. The resident, who had a history of acute respiratory failure, bronchopneumonia, seizures, hemiplegia, and neuromuscular dysfunction of the bladder, exhibited vital signs that were outside the parameters set by the physician for sepsis prevention. Despite having a temperature of 103.8°F and a heart rate of 130 bpm, the licensed nurses did not notify the physician as required by the resident's care plan. The report details multiple instances where the resident's vital signs exceeded the thresholds for physician notification, including elevated temperatures and heart rates on several occasions. The failure to notify the physician of these changes in condition resulted in the resident developing an altered level of consciousness and low blood pressure, leading to their transfer to a general acute care hospital. The resident was diagnosed with septic shock and passed away 13 hours after admission to the hospital. Interviews with facility staff revealed that the physician was not informed of the resident's critical condition, and nonpharmacological interventions were attempted without success. The staff acknowledged that the physician should have been notified, and documentation of the resident's condition and interventions was lacking. The facility's policies and procedures for notifying physicians of clinical problems and changes in resident status were not followed, contributing to the deficiency.
Removal Plan
- License Nurse 1 was educated by the DON regarding Change of Condition policy and procedure focusing on immediate notification of the physician as it relates to quality of care.
- In-service education was commenced by the DON and Quality Staff Registered Nurse to all licensed nurses regarding physician notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention.
- In-service education was commenced by the DON and/or designee regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing urinary tract infection/sepsis and other areas that accurately reflects resident's conditions and care.
- Competency Skills Check for licensed nurses was commenced by DON and Quality Staff Registered Nurse regarding assessing residents' change in conditions, identifying symptoms of infection/sepsis and of change of condition, assess, monitor and implement needed interventions based on residents' change of condition, recognizing symptoms of urinary tract infection and including elevated temperature, hematuria, abdominal pain, and low back pain, and compliance with recognizing, evaluating and monitoring.
- The facility checked Situation, Background, Assessment, Recommendation/Change of Condition. All 161 SBAR/COC showed that medical doctor was notified on a timely manner.
- In-service education was commenced by the DON and/or designee regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care.
- In-service education was commenced regarding Physician Notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention. 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff received the in-service on Physician Notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention.
- Competency Skills Check regarding change of condition was commenced by DON and Quality Staff Registered Nurse. Competency Skills Check regarding change of condition was conducted to 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff.
Failure to Monitor and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to ensure timely assessment and monitoring of a resident who experienced a change in condition, which included a high fever and elevated heart rate. The Licensed Vocational Nurse (LVN) did not assess or document the resident's vital signs after the initial recording of a temperature of 103.8°F and a heart rate of 130 bpm. The resident's physician was not notified of these critical changes, and nonpharmacological interventions were attempted without success. The lack of documentation and failure to notify the physician contributed to a delay in transferring the resident to a general acute care hospital (GACH). The resident, who had a history of neuromuscular dysfunction of the bladder, was not provided with a care plan addressing this condition, which could have included interventions to prevent urinary tract infections and sepsis. Despite the resident's severe cognitive impairment and dependency on staff for mobility, the facility did not have a specific care plan in place to manage the resident's condition effectively. This oversight, combined with the failure to monitor and document the resident's vital signs, resulted in a significant delay in addressing the resident's deteriorating condition. The resident was eventually transferred to the GACH, where they were diagnosed with septic shock and expired shortly after admission. Interviews with facility staff revealed that the primary care physician was not informed of the resident's critical condition, and there was a general lack of adherence to the facility's policy for notifying physicians of significant changes in resident status. The facility's failure to act promptly and follow established protocols contributed to the resident's decline and eventual death.
Removal Plan
- License Nurse 1 was educated by the DON regarding Change of Condition policy and procedure focusing on immediate notification of the physician as it relates to quality of care.
- In-service education was commenced by the DON and Quality Staff Registered Nurse to all licensed nurses regarding physician notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention.
- In-service education was commenced by the DON and/or designee regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care.
- Competency Skills Check for licensed nurses was commenced by DON and Quality Staff Registered Nurse regarding assessing residents' change in conditions, identifying symptoms of infection/sepsis and of change of condition, assess, monitor and implement needed interventions based on residents' change of condition, recognizing symptoms of urinary tract infection and including elevated temperature, hematuria, abdominal pain, and low back pain, and compliance with recognizing, evaluating and monitoring.
- The facility checked Situation, Background, Assessment, Recommendation/Change of Condition. All 161 SBAR/COC showed that medical doctor was notified on a timely manner.
- In-service education was commenced regarding Physician Notification of the Change of Condition including but not limited to vital signs that are out of range for the sepsis prevention. 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff received the in-service on Physician Notification of the Change of Condition including but not limited to vital signs that are out of range for the sepsis prevention.
- Competency Skills Check regarding Change of Condition was commenced by DON and Quality Staff Registered Nurse. Competency Skills Check regarding Change of Condition was conducted to 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff.
Failure to Return Resident Funds After Discharge
Penalty
Summary
The facility staff failed to return funds to Social Security after a resident was discharged, as required by the facility's policy. The Business Office Manager (BOM) did not refund the resident's funds within three business days, as stipulated in the facility's Policy and Procedure (P&P) titled Links Healthcare Resident Trust Policy. The resident, who had severe cognitive impairment and lacked decision-making capacity, was transferred to a General Acute Care Hospital (GACH) due to oxygen desaturation and did not return to the facility. Despite this, the facility continued to receive Social Security funds for the resident and did not close the Resident Fund Management Service (RFMS) account, which had a balance of $11,649.00 as of January 2025. The deficiency was identified through interviews and record reviews, revealing that the facility did not adhere to its policy of refunding resident trust funds within three business days of discharge. The BOM stated that the account was not closed because the facility anticipated the resident's return, although the Director of Nursing (DON) confirmed that the resident had not returned since the transfer in September 2024. The resident's family member had been requesting the funds since the discharge, but the facility failed to comply with its policy, resulting in the continued holding of the resident's funds.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after multiple falls, which resulted in continued falls and injuries. The resident, who was admitted with diagnoses including metabolic encephalopathy, unspecified dementia, and end-stage renal disease, had a care plan indicating a risk for falls due to poor safety awareness, unsteady gait, balance problems, and poor endurance. Despite these risks, the care plan was not updated following falls on specific dates, leading to further incidents. The resident experienced a fall on a specified date, resulting in a questionable fracture of the right scapula, although a subsequent X-ray showed no fracture. The resident was assessed as high risk for falls, but the care plan was not revised to address this increased risk. Another fall occurred on a later date, where the resident was found in a sitting position on the floor with moderate pain, yet again, the care plan was not updated to reflect new interventions or precautions. A third fall resulted in a skin tear and discoloration to the resident's head, and once more, the care plan remained unchanged. The Director of Nursing confirmed that the care plan interventions had not been revised despite discussions in interdisciplinary team meetings to increase monitoring and visual checks. The facility's policies and procedures require that care plans be comprehensive and person-centered, reflecting changes in the resident's condition, but these were not followed, leading to the deficiency.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 7,001 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Norwalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Studebaker Healthcare Center | 0.7 mi | ★★★★★ | 46 | 0 |
| Intercommunity Healthcare & Rehabilitation Center | 1 mi | ★★★★★ | 3 | 0 |
| Norwalk Skilled Nursing & Wellness Centre, Llc | 1.4 mi | ★★★★★ | 4 | 0 |
| Southland | 1.6 mi | ★★★★★ | 33 | 0 |
| Villa Del Sol Post Acute | 1.7 mi | ★★★★★ | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.