Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Palms Care Center during CMS and state inspections, most recent first.
Failure to Obtain Valid Consent for Psychotropic Medication: A resident with metabolic encephalopathy, DM II, and anemia was documented as moderately cognitively impaired and lacking decision-making capacity, while a Public Guardian appointment was pending. Despite this, the resident was given verbal consent for Depakote, a psychotropic medication ordered for mood disorder. RN, SSD, and DON stated consent should have been obtained through the IDT or bioethics committee because the resident did not have capacity and had no RR.
Late lunch service occurred when kitchen staff were still preparing the trayline after the scheduled lunch period had begun, with the first meal cart not leaving the kitchen until well after noon and the last trays not reaching residents until after 1:20 p.m. The DS stated a staff member became confused with the easy-to-chew menu and that the delay affected meal timing and food temperature, with residents potentially becoming angry, frustrated, or complaining about cold food.
Unsafe food storage and prep practices were observed in the kitchen. Food-contact surfaces and storage racks had chips, rust, cracks, and worn finishes; several storage areas and equipment shelves had dirt, dust, and food debris; and a dented can was stored with intact cans. A dietary aide wore jewelry while preparing food, pork chops were thawed with the water off, another aide did not wash hands when moving from dirty to clean tasks, sanitizer testing and dilution did not follow manufacturer directions, and the resident refrigerator/freezer area lacked proper temperature monitoring.
Improper Dumpster Covering and Garbage Disposal: The dumpster area was observed with trash on the surrounding floor, dry black liquid spills, and dry spills on the dumpster body. Two dumpsters were not completely covered, including one with a gap in the middle and another with more than a 3-inch gap. Staff stated the gaps could allow pests to enter the trash, and the facility policy required garbage containers to have tight-fitting lids and outside dumpsters to be kept closed and free of surrounding litter.
A facility failed to ensure that five residents were informed where to find the most recent survey results binder. During a resident council meeting, the residents stated they were unsure of the location, while the AD later pointed out the binder near Nurses Station B and the DON stated binders were placed in hallways across from nurses' stations. The residents had intact cognition or decision-making capacity, and several had significant medical conditions and varying levels of ADL dependence.
A resident’s wobbly headboard, another resident’s broken TV remote battery cover held with a rubber band, and two residents’ broken dresser drawers were observed in their rooms. Staff and the DON stated the items were unsafe or not homelike, and the residents’ records showed significant mobility and medical issues, including dementia, hemiplegia, weakness, falls, diabetes, and HTN.
The facility failed to develop and implement person-centered care plans for a resident with healing pressure injuries, a resident on continuous O2, and three residents receiving clonazepam, Plavix, and Hiprex. Staff stated the care plans were missing for these needs, including monitoring of affected skin areas, oxygen administration, and medication-related monitoring and adverse effects, despite the residents’ diagnoses, assessments, and active physician orders.
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents with DM2. Both residents had physician orders and care plan interventions directing site rotation, but the MAR/location records showed repeated injections in the same abdominal areas. The ADON acknowledged the repeated sites and stated the insulin administration policy was not followed; the DON stated repeated use of the same site can harden the skin and cause lipodystrophy with impaired absorption.
Surveyors found multiple unsafe environmental conditions in the LTC facility. A resident at risk for falls had a bed left high instead of in the lowest position, another resident’s bed was also left high without an order or care plan, and a floor mat was placed halfway under a bed instead of beside it. Surveyors also observed a bed remote on the floor, hand sanitizer left at a bedside, a wobbly headboard, unlocked chemical compartments on EVS carts, and an open A&D ointment package left at a resident’s bedside without documentation supporting self-medication.
Bed rail orders, assessments, consent, and care plans did not match for three residents. One resident with severe cognitive impairment and dependence for ADLs had half-length bed rails in use even though the order was for grab bars, and the assessment and care plan addressed grab bars only. Another resident with ESRD and DM had half-length bed rails in place even though the order was for quarter rails, and the consent lacked signatures. A third resident with dementia and an above-knee amputation had an order for half rails, but the consent, SRUA, and care plan all documented quarter rails instead.
Incomplete Staff Performance Reviews and ADL Training: The facility failed to ensure that a CNA had current ADL care training and that multiple nursing staff had annual performance evaluations. Record review and interviews showed the DSD could not confirm up-to-date competency or performance reviews for an RN, a TN, and two CNAs, and stated there was no established process to track when evaluations were due. The DON stated these evaluations are used to discuss performance, expectations, feedback, goals, and training needs.
Two residents with DM had insulin orders that required rotating injection sites, and both care plans included the same intervention. Review of the LARs showed repeated SQ insulin injections in the same abdominal areas instead of rotation. The ADON and DON stated the repeated site use did not follow the insulin administration policy and was considered a medication error.
Expired and unlabeled medications were found on two medication carts during observation with an LPN and the DON. On one cart, insulin pens, topical creams, and gels lacked open dates, and a clonazepam bubble pack remained in the cart past its expected use period. On another cart, a metoprolol tartrate bubble pack with an expired date was still present. The DON stated expired or questionable medications must be removed and that opened insulin pens and topical tubes must be dated.
Menu Portion Size Not Followed for Bratwurst: Staff served grilled bratwurst in 1.5 oz portions instead of the 3 oz portion listed on the menu for residents on a regular diet. The DS was observed cutting the bratwurst in half, and the RD and DS later observed half portions plated on residents' trays. The RD stated that serving under the portion size placed residents at risk for weight loss.
Food Served at Unsafe and Unappetizing Temperatures: A resident with HTN, chronic respiratory failure, and acute kidney failure was on a regular diet with set-up and clean-up assistance for meals and stated the facility did not keep food warm. During tray observations, the DS recorded hot items on regular and soft bite trays at 80 F to 90 F and said the delay in trayline caused the poor temperatures; the DS also stated residents could complain of cold food and not eat much. The facility policy required food to be served at a safe and appetizing temperature.
Soft Bite Sized Diet Served at Minced and Moist Texture: A resident diet service issue occurred when kitchen staff prepared meats for a prescribed SB6 diet at a minced and moist texture instead of the ordered soft bite sized texture. The DS tested meats with a fork pressure test, found they did not meet SB6 requirements, and directed staff to grind or blend them; the RD stated the kitchen was downgrading the diet rather than following the recipe. Facility policy and the diet manual required therapeutic diets to match the ordered texture.
Frayed or exposed wires were observed on bed remote controls in the rooms of five residents with varying cognitive and physical impairments. Staff and leadership stated the damaged remotes could cause electrical shock or electrocution, and the ADON acknowledged the facility did not follow care plans calling for a safe environment. The facility’s maintenance policy required equipment to be kept safe and operable, and the bed manual called for inspection of cords and components for damage or excessive wear.
Call lights were not kept within reach for two residents with cognitive impairment and fall risk concerns. One resident's call light was found on the floor, and another resident's call light was hanging off the bed; staff stated both residents would not have been able to call for assistance and could have fallen trying to reach the device. The residents had diagnoses and assessments showing severe cognitive impairment, need for assistance with ADLs, and fall risk.
A resident with dementia and severe cognitive impairment had an ADA showing an executed Advance Directive, but the actual document was not uploaded into the EHR and was not readily retrievable. The SSD and DON stated the copy was missing from the chart, despite the resident’s DPOA naming the son to make healthcare decisions if the resident became incapacitated, and the care plan noted the resident had an advance directive.
Missing Personal Property Not Documented or Investigated: A resident with CVA-related hemiplegia/hemiparesis and intact decision-making reported a missing [NAME] stick, but the AD only noted it in a personal notebook and did not document it in the chart. The item was not added to the resident inventory list, the facility did not keep a log for resident-purchased deliveries, and the required theft/loss investigation form could not be located.
A resident with psychosis, anxiety, auditory hallucinations, and moderate cognitive impairment was receiving Risperdal and PRN Lorazepam, but the record did not show current informed consent for Lorazepam and the Risperdal consent on file reflected an older 2 mg dose instead of the current 3 mg order. The ADON confirmed the missing and outdated consents, and the DON stated current informed consent was important for these psychotropic medications, especially given their black box warnings.
Failure to report an unwitnessed fall with injury of unknown origin: A resident with dementia, disorientation, and severely impaired cognition/vision was found on the floor next to the bed with a head bump, abrasion, and toe skin tear and was sent to the hospital. The SBAR and HN described the event as an unwitnessed fall with possible syncope, and the ADON, RN, DON, and ADM stated it was reportable under the SOM because the resident was confused, could not explain what happened, and had multiple unexplained injuries, but it was not reported to the state agency.
Failure to Submit New PASRR After Mental Health Diagnosis: A resident with dementia, unspecified psychosis, and mild neurocognitive disorder was later diagnosed by a psychologist with schizophrenia spectrum/psychotic disorder, but the facility did not submit a new PASRR Level I screening. The MDSC and DON stated that a new PASRR was needed after a new MD diagnosis, yet the resident’s prior PASRR had indicated no serious mental illness or suspected mental illness.
Failure to Update Fall Care Plan After Unwitnessed Fall: A resident with Parkinson’s, severe protein-calorie malnutrition, history of falls, incontinence, and severe cognitive impairment was found on the floor next to the bed with a head bump, abrasion, and toe skin tear. The SBAR documented the unwitnessed fall, but the fall care plan was not updated to reflect the event, and the DON and ADON stated it should have been revised to match the resident’s current status.
Failure to Monitor Healed Pressure Ulcer: A resident with a history of stage 2 and stage 3 pressure injuries had a care plan calling for affected areas to be checked each shift, but staff did not continue documented skin monitoring after the wound healed. The TN stated there was no physician order for ongoing skin checks and the last documented skin assessment was several days earlier, even though the resident’s buttocks were observed as dry, intact, and blanchable pink.
Unlabeled Oxygen Tubing: A resident receiving continuous O2 via nasal cannula was observed with tubing that had no date label showing when it was last changed. The resident had COPD, pneumonia, and acute respiratory failure with hypoxia, and the order/care plan required the cannula and tubing to be changed weekly with a name and date label. The LVN, ADON, and DON all stated the tubing should be labeled for infection control and to ensure it was not used longer than a week.
Delayed Pain Reassessment After PRN Opioid Administration: A resident with ESRD on hemodialysis, cellulitis, failure to thrive, and spinal stenosis had PRN hydrocodone-acetaminophen given for pain, but pain was not consistently reassessed within 30 to 60 minutes as the RN, DON, and facility policy described. The resident was alert and oriented, had pain related to a left upper arm AV fistula site, and expressed a desire for more consistent pain medication timing. The eMAR showed several doses followed by reassessments that occurred later than the expected timeframe.
Failure to implement fluid restriction and intake/output monitoring for a resident receiving HD. A resident with ESRD and intact cognition had a nutrition assessment recommending a 1200 ml daily fluid restriction, and the care plan included fluid restriction plus monitoring intake and recording every meal. However, RN stated there was no physician order or implementation for the restriction and no intake/output monitoring in place, despite the resident’s dialysis schedule and the facility’s ESRD care policy.
Pharmacy Services Failure for Outside Medication: A resident with pneumonia, pancreatic cancer, type II DM, and moderate cognitive impairment returned from an outside appointment with a new Rx for Zenpep, but the medication was found at the med cart with a label not generated by the facility pharmacy. The LVN stated there was no documentation of pharmacist notification or consultation and no care plan for the new medication; the DON confirmed outside medications must be reported, reviewed by pharmacy, properly labeled, and included in a comprehensive care plan.
Medication Administration Errors With Vitamin B12 and Miralax: An LVN administered medications for a resident with Parkinson’s disease, G-tube dependence, and dysphagia while the resident was observed in the room. The LVN identified that the ordered vitamin B12 dose did not match the in-house supply, and prepared Miralax by adding powder before measuring water to the 8 oz line, which did not follow the ordered method.
A resident with pressure ulcers, intact cognition, and an order for a specialty bed mattress had staff document monitoring of the mattress on multiple shifts even though the mattress was not actually in place during observation. An LVN stated she documented the mattress check without confirming placement, and the DON stated nurses should document only what they observe per physician orders.
Uncovered Mobile Linen Cart During Resident Care: CNA 4 brought a mobile linen cart to a resident’s room, removed the needed linen supplies, and left the cart uncovered and unattended while providing care. The CS, ADON, and DON stated the cart should have been covered after supplies were obtained to protect the linen from environmental contaminants and maintain infection control practices.
Antibiotic stewardship monitoring was not implemented for two residents. One resident received Hiprex for UTI prophylaxis with no documented end date, no recent UA/culture, and no specific monitoring for adverse effects or care plan for its use. Another resident received Amoxicillin-Pot Clavulanate for cellulitis, but staff stated there was no specific monitoring for adverse effects during the treatment period, despite the care plan calling for observation of adverse reactions and the DON stating monitoring should occur every shift.
Failure to Document Pneumococcal Vaccine Refusal and Reoffer Annually: A resident with a history of pneumonia, COVID-19, and intact cognition refused the pneumococcal vaccine, but the record lacked documentation that risks and benefits were explained. The IP and DON stated the refusal should have been documented and the vaccine should have been offered yearly, but it was missed for two seasons.
Failure to document COVID-19 vaccine refusal education: A resident with intact cognition and a history of malnutrition and prior antineoplastic chemotherapy refused the COVID-19 vaccine, but the IP could not find documentation that the risks and benefits of refusal were explained. The DON stated the refusal should have been documented and the vaccine offered yearly, consistent with facility policy requiring resident education on benefits, risks, and side effects before vaccination.
Pest Control Program Not Effective: A resident found a cockroach in the bathroom, and a dead cockroach was observed on the floor. The resident, who had intact cognitive skills and needed staff help with ADLs, said she was bothered by the pest issue and felt the facility should improve cleaning. RN and DON interviews confirmed staff are responsible for monitoring pests and that the facility has a pest control policy intended to keep the building free of insects and rodents.
The facility failed to follow its abuse P&P when two roommates had a physical altercation and staff did not immediately separate them. A resident with Parkinson’s disease, PVD, quadriplegia, intact cognition, and decision-making capacity reported that his roommate went through his nightstand, threw a bottle of lotion that struck his shin, and continued to manipulate the privacy curtain to look at him. CNAs and an RN acknowledged that they observed or were told about the incident, moved furniture such as the nightstand and bed, and continued to monitor both residents while they remained in the same room, and one CNA delayed reporting the allegation until later in the day. The DON stated that the abuse policy required immediate separation of residents and prompt reporting to the abuse coordinator, which did not occur in this case.
The facility failed to timely report an allegation of resident-to-resident physical abuse within the required two-hour timeframe. A resident with Parkinson’s disease, PVD, and quadriplegia, who was cognitively intact and dependent for ADLs, reported that a cognitively impaired roommate with schizophrenia went through his nightstand and threw a lotion bottle that struck his shin. CNAs became aware of the allegation during the morning, with one CNA observing the roommate at the nightstand and the curtain being repeatedly opened and closed, and both CNAs delayed reporting due to a busy morning and fear of reporting. An RN was informed of the concern but did not escalate or document it, and the Social Services staff did not report the allegation to external authorities until several hours after it was first made, contrary to the facility’s abuse reporting policy and the DON’s stated expectation for immediate reporting within two hours.
A resident with DM, dysphagia, schizophrenia, and severely impaired cognition exhibited a recurring behavior of opening and closing the room privacy curtain to see a roommate, but nursing staff did not document this behavior in progress notes or revise the care plan to address it. The MDS nurse confirmed that no care plan was initiated for the behavior, despite the expectation that nurses update care plans when new conditions or issues arise. An RN acknowledged observing the behavior and not documenting or care-planning it, and the DON stated that the behavior was not monitored each shift and that the care plan did not reflect the resident’s current needs, contrary to facility policy requiring ongoing assessment and care plan revision.
The facility failed to follow its abuse investigation policy by not timely interviewing a CNA who directly witnessed and responded to a physical altercation between two residents with cognitive impairments and significant medical conditions, including DM, HTN, prior rib fractures, and post-stroke sequelae. Documentation and staff interviews showed that one resident reported the other repeatedly entering his room, leading to a verbal dispute and a physical encounter involving a raised front-wheel walker, a fall against a wall, and a skin tear, while the other resident reported becoming tangled with the walker and accidentally striking the first resident. A housekeeper and the CNA both observed the confrontation and intervened, with the CNA assisting the resident to bed and serving as translator when an RN assessed him. Despite a written policy requiring interviews of all witnesses and involved staff, the DON did not initially recognize the CNA as a witness, did not obtain a written statement from her during the investigation, and only interviewed her several days later, acknowledging that the abuse policy was not followed.
A resident with multiple comorbidities and cognitive impairment developed a right forearm skin tear and left cheek abrasion after an altercation with another resident that led to a loss of balance and impact with a wall. The Treatment Nurse identified the new skin tear and abrasion but did not measure the wound, despite acknowledging that new skin changes should be measured to monitor progress. The DON confirmed that the lack of wound measurements left the medical record incomplete and was not consistent with the facility’s wound care and injury investigation P&Ps, which require documentation of wound size and detailed, objective descriptions of injuries.
A resident with moderate cognitive impairment was physically struck on the left cheek by another resident with severe cognitive impairment and a history of aggressive behavior. The incident occurred in a hallway and was witnessed by multiple staff, who confirmed that the aggressor reached out, grabbed the victim's arm, and punched her. Facility policy states residents must be free from abuse, and staff interviews and documentation confirmed the event as physical abuse.
A resident with rib fractures and heart disease experienced severe pain, as documented by staff and self-reported by the resident. Despite a physician's order for hydrocodone-acetaminophen for pain rated 4-10, there was no documentation that the medication was given when the resident reported a pain level of eight. Facility leadership confirmed the medication should have been administered as ordered.
A nurse administered sacubitril-valsartan to a resident with heart failure even though the resident's blood pressure was below the physician-ordered threshold for holding the medication. The medication was given despite clear instructions to withhold it for systolic blood pressure under 110 mmHg, as confirmed by documentation and nursing leadership interviews.
A resident with intact cognitive function and multiple health conditions reported to staff that her roommate had hit her legs. The allegation was communicated to a CNA, LVN, and RN, but was not reported to the Administrator or authorities as required by facility policy. Staff delayed reporting because they believed the accused resident was not capable of abuse, resulting in a delayed investigation and intervention.
A resident with multiple chronic conditions reported being physically abused by a roommate, but staff did not perform a body assessment or notify the physician as required by facility policy. Nursing staff and the DON later confirmed that these actions should have been taken immediately following the allegation, but were not completed, resulting in delayed care and monitoring.
A resident with a urostomy was not provided care in accordance with professional standards, as staff failed to notify the physician about cloudy urine with sediments, did not assess or document signs of UTI as required by the care plan, and did not record urine output in milliliters per physician order. These actions were confirmed by interviews and record reviews, revealing lapses in communication and documentation among nursing staff.
A resident with significant medical needs, including a urinary catheter, was observed with an uncovered urinary collection bag. Staff interviews revealed the cover was removed during care and not replaced, despite facility policy requiring dignity covers for such devices. Multiple staff acknowledged the oversight and its potential impact on the resident's psychosocial wellbeing.
A resident with a urostomy and complex medical history had cloudy urine with sediments observed by staff, but the CNA did not report these findings to the LVN as required by the care plan. The LVN only learned of the issue later and confirmed that such symptoms should have been reported to the physician. Facility leadership acknowledged that the care plan was not followed, resulting in a failure to provide timely notification to the physician about potential signs of UTI.
A resident with an indwelling urinary catheter did not have a dignity bag covering the catheter drainage bag, as required by the facility's policy. This was observed during a review and interview, where it was noted that the bag was exposed, potentially affecting the resident's sense of self-worth. The resident's care plan included an intervention to ensure the bag was covered, but it was not in place during the observation. The DON confirmed the necessity of the dignity bag for privacy.
Failure to Obtain Valid Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for Depakote, a psychotropic medication, from a resident who did not have the capacity to make decisions. Resident 1 was admitted with diagnoses including metabolic encephalopathy, DM II, and anemia, and the admission record showed that Public Guardian appointment was pending. The MDS dated 4/11/2026 indicated the resident’s cognitive functioning was moderately impaired, and the H&P dated 5/1/2026 stated that Resident 1 did not have the capacity to make decisions. The order summary showed a physician’s order for Depakote oral tablet delayed release 125 mg, given one tablet by mouth three times a day for mood disorder manifested by outburst, bursting, and inappropriate behavior. During a concurrent interview and record review, RN 1 reviewed the informed consent form for psychoactive medication dated 5/13/2026, which indicated Resident 1 provided verbal consent to receive Depakote. RN 1 stated that as of 5/1/2026, Resident 1 did not have the ability to make decisions for self. RN 1, the SSD, and the DON stated that because Resident 1 lacked decision-making capacity and did not have a RR, consent for treatment should have been obtained through the facility’s IDT or bioethics committee while the Public Guardian appointment was pending. The DON stated staff obtained consent from Resident 1 based on the assumption that being alert and able to answer questions meant the resident had capacity, and stated staff failed to review physician notes and correctly identify the resident’s decision-making capacity. The facility policies reviewed stated that residents without decision-making capacity and without effective family support would be referred to social services and that the IDT would evaluate psychotropic medication use and whether the resident or representative understood the intended benefit of the medication.
Late Lunch Service
Penalty
Summary
Meals were not served at the facility’s scheduled lunch time on 5/4/2026. During observation, kitchen staff were still taking temperatures of foods at 12:00 p.m., had only started dishing out the lunch trayline at 12:24 p.m., and did not deliver the first meal cart out of the kitchen until 12:41 p.m. The last meal cart left the kitchen at 1:15 p.m., and nursing staff were observed passing trays to residents at 1:21 p.m., with the last tray delivered at 1:25 p.m. During interview, the Dietary Supervisor stated that one staff member got confused with the easy-to-chew menu and that she should have stepped in earlier. The Dietary Supervisor also stated that meals should be on time so residents would not get angry, frustrated, and file a grievance, and that the delay affected food temperature and could lead residents to complain that the food was cold. The facility policy stated that residents are to receive meals at times comparable to typical community meal times or in accordance with resident needs, preferences, requests, and the plan of care, and that meals are to be served at scheduled times.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. Multiple food-contact and storage surfaces were observed with chips, cracks, rust, amber discoloration, or worn finishes, including racks in the walk-in refrigerator, shelves in the reach-in refrigerator and walk-in freezer, shelves in dry storage, resident trays, and a chopping board by the trayline. The Dietary Supervisor stated these conditions were not acceptable because smooth, cleanable surfaces are needed to prevent bacterial accumulation and cross-contamination. Facility policies and Food Code provisions cited in the report required food-contact surfaces to be smooth, free of cracks and chips, and maintained in good repair. Kitchen and storage areas were also observed with dirt, dust, and food debris. The bottom shelves of the reach-in refrigerator by the trayline had dried milk and debris, dry storage floors had dirt and dust, the canned goods storage area had dust and an apple sauce container, the scoop drawer had dirt and food debris, and the hallway reach-in freezer had dirt and vegetable debris. The Dietary Supervisor stated these areas needed to be cleaned to prevent cross-contamination and foodborne illness. One dented can was stored with non-dented cans in the dry storage area, and the Dietary Supervisor stated dented cans should be separated because of the risk associated with botulism. Food handling and sanitation practices were also observed to be out of compliance. A dietary aide wore a silver bracelet and rings while cutting potatoes, despite the facility policy and Food Code limiting jewelry during food preparation. Pork chops were being thawed in a sink with the water turned off and the water temperature at 74.5 F, while the Dietary Supervisor stated thawing required running water. Another dietary aide did not wash hands when moving from a dirty area to a clean area during dishwashing and instead used sanitizer from a red bucket. Staff also did not follow manufacturer instructions for sanitizer test strips or sanitizer dilution, and the posted sanitizer ratio did not match the manufacturer’s directions. In addition, the resident refrigerator/freezer area in Station B had no thermometer in the freezer, and the facility did not have freezer temperature information recorded on the log.
Improper Dumpster Covering and Garbage Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when the dumpster area outside the facility was observed with soiled gloves, paper and plastic cups on the surrounding floor and dry black liquid spills on the dumpster surroundings. During interview, Environmental Service staff stated the dumpster area was cleaned on a daily basis and also stated there was a space gap between the trash cover that could allow pests to get into the trash. The Dietary Aide stated kitchen trash and food trash were placed in the dumpster after every meal. During a concurrent observation with the Dietary Supervisor, Dumpster 1 was observed with a gap in the middle of the cover and Dumpster 2 had more than a three-inch gap, leaving both dumpsters not completely covered. The Maintenance Supervisor also observed dry spills on the dumpster body and stated the gaps between the covers were not okay because flies could go in the dumpster and potentially cause flies and rodents' infestation in the facility. The facility policy required garbage containers to have tight-fitting lids or covers and outside dumpsters to be kept closed and free of surrounding litter.
Residents Not Informed of Survey Results Location
Penalty
Summary
The facility failed to ensure that five sampled residents were informed of the location of the most recent survey results conducted by Federal or State surveyors. During a resident council meeting, Residents 36, 54, 75, 79, and 97 stated that they were unsure where to find the survey results. A concurrent observation showed a binder containing the most recent survey results located near the main entrance by Nurses Station B, and the DON later stated that the binders were located in hallways across from nurses' stations and that all residents must know where to locate them. Resident 36 was admitted and later readmitted with diagnoses including colon cancer, sepsis, and COPD. The H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated intact cognitive skills for daily decision making and independence with all ADLs. Resident 54 was admitted and later readmitted with diagnoses including spinal stenosis, Parkinson's disease, and PVD. The MDS indicated intact cognitive skills for daily decision making, with dependence for toileting, personal hygiene, showering, upper and lower body dressing, and footwear. Resident 75 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, and alcohol abuse; the MDS indicated intact cognitive skills for daily decision making, with dependence for toileting hygiene, showering, and footwear and partial/moderate assistance with oral and personal hygiene and upper body dressing. Resident 79 was admitted with diagnoses including a left fibula fracture, left ankle dislocation, and generalized muscle weakness; the H&P and MDS indicated intact judgment, insight, and cognitive skills, with independence in several ADLs and supervision or touching assistance with showering and upper body dressing. Resident 97 was admitted and later readmitted with diagnoses including right above-knee amputation, left below-knee amputation, DM, and generalized muscle weakness; the H&P indicated capacity to understand and make decisions, and the MDS indicated intact cognitive skills with partial/moderate assistance for toileting hygiene and lower body dressing and supervision or touching assistance with upper body dressing and personal hygiene.
Broken Furniture and Equipment in Resident Rooms
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by leaving broken or unsafe furniture and equipment in resident rooms. During observation and interview, Resident 31’s headboard was found wobbly and tilting toward the resident’s head. The resident had diagnoses including dementia, major depressive disorder, mood disorder, hypertension, and atrial fibrillation, and the record noted a history of falls and a need for a safe environment. Staff and leadership stated the loose headboard was unsafe and not homelike, but it remained unfixed at the time of observation. Resident 75’s TV remote control was observed with a broken battery compartment cover and a rubber band holding the batteries in place. The resident stated the remote had been in that condition for two to three weeks and that the issue had been reported to staff multiple times. The resident’s record showed diagnoses including hemiplegia, hemiparesis following cerebral infarction, hypertension, and alcohol abuse, and the resident required assistance with several activities of daily living. Staff confirmed the remote was broken and stated it did not promote a home-like environment. Resident 37 and Resident 49 each had a dresser with broken drawers in their room. In both rooms, staff observed that the drawers were not properly closing, and one drawer in each dresser belonged to the resident. Resident 37’s record included generalized muscle weakness, a history of falls, and difficulty walking, while Resident 49’s record included hemiplegia, type 2 diabetes mellitus, and essential hypertension. Staff stated the broken furniture was not promoting a homelike environment and that residents could not use the broken furniture.
Missing Comprehensive Care Plans for Skin Monitoring, Oxygen, and Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five sampled residents. For Resident 53, the record showed admission with diagnoses including hypertension, history of falling, cardiomyopathy, and atrial fibrillation. The MDS indicated the resident had intact cognitive skills for daily decisions, required partial to substantial physical assistance with ADLs, was at risk for pressure injuries, and had one stage 2 and two stage 3 pressure ulcers present on admission. The care plan identified monitoring of affected areas each shift and notifying the physician if breakdown occurred, but during observation and interview the Treatment Nurse stated the care plan to monitor the healed buttocks areas every shift was not implemented. The buttocks were observed as blanchable pinkish redness with dry, intact skin, and staff stated the resident had a history of pressure ulcer development and that lack of continuous monitoring could allow worsening before detection. For Resident 14, the record showed admission with diagnoses including other pulmonary embolism without acute cor pulmonale, generalized muscle weakness, and obesity class 2. The H&P and MDS indicated the resident had mental capacity, was alert and oriented, and had intact cognitive function, with dependence to partial assistance for several ADLs. The physician order summary included oxygen at 2 liters per minute via nasal cannula continuously, with titration to maintain oxygen saturation greater than 92%. During review, RN 1 was unable to find a care plan for oxygen administration and stated there was no care plan for oxygen. RN 1 stated the care plan should guide nurses in monitoring whether oxygen is effective and whether the physician needs to be notified, and the DON stated an OSR and care plan needed to be done for oxygen. For Resident 4, the record showed diagnoses including psychosis, anxiety disorder, and auditory hallucinations. The MDS indicated the resident usually could make self-understood and understand others, with moderate cognitive impairment, and was on a high-risk antipsychotic drug class. The OSR included clonazepam 0.6 mg by mouth daily for anxiety with monitoring for agitation. During review, the ADON stated there was no care plan for clonazepam use and that a care plan was important to outline the problem, goal, and interventions, and to communicate care needs to all healthcare providers. For Resident 31, the record showed diagnoses including paroxysmal atrial fibrillation, presence of a cardiac pacemaker, and GERD. The H&P indicated the resident did not have capacity to understand and make decisions, while the MDS indicated the resident had moderate cognitive impairment. The OSR included Plavix 75 mg daily for CVA prophylaxis, but staff stated there was no specific care plan for Plavix and that without one they would not be able to monitor serious adverse effects. For Resident 39, the record showed diagnoses including pneumonia, hemiplegia, and hemiparesis, with the H&P indicating capacity to make decisions and the MDS showing intact cognition and frequent incontinence of urine and stool. The OSR included Hiprex 1 gram twice daily for UTI prophylaxis, but staff stated there was no care plan developed and implemented for Hiprex use.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for two residents with diabetes mellitus. Resident 76 was admitted with diagnoses including DM2, adult failure to thrive, and dysphagia, and the record showed severe cognitive impairment and lack of decision-making capacity. The physician order for insulin aspart included instructions to rotate injection sites, and the care plan also directed site rotation. However, the April 2026 location of administration record showed repeated insulin injections in the abdomen, including multiple doses in the left upper quadrant and repeated doses in the right upper quadrant. Resident 39 was admitted with diagnoses including DM2, morbid obesity, and dysphagia, and the record showed intact cognition and ability to make decisions. The physician orders for insulin aspart and insulin glargine both directed that injection sites be rotated, and the care plan included an intervention to rotate the injection site. The April 2026 location of administration record showed repeated insulin glargine injections in the abdomen-left upper quadrant and repeated injections in the abdomen-right lower quadrant, as well as repeated insulin aspart injections in the abdomen-right lower quadrant. During interview and record review, the ADON stated the physician had ordered rotation of insulin administration sites and acknowledged that the residents’ location of administration records showed repeated sites. The ADON stated the facility’s insulin administration policy was not followed. The DON stated insulin sites should be rotated to avoid infection and trauma, and that frequent use of the same site hardens the skin and causes lipodystrophy, with impaired absorption and possible hypo/hyperglycemia.
Unsafe Resident Environment and Bedside Hazard Control Failures
Penalty
Summary
The facility failed to keep Resident 4’s bed in the lowest position. Resident 4 was admitted with diagnoses including hearing loss, contracture, and auditory hallucinations, and the admission/readmission data tool identified the resident as at risk for falls. The care plan included an intervention to keep the bed in the lowest position when the resident was not actively being repositioned. During observation, the bed was found in a high position and measured 27.5 inches from the floor to the mattress surface. Staff acknowledged the bed was high, and the ADON and DON stated the bed should have been kept at the lowest possible position. The facility also failed to keep Resident 29’s bed in the lowest position. Resident 29 had diagnoses including generalized muscle weakness, dementia, anxiety, and an acquired absence of the right leg above the knee. The resident’s records showed the resident required dependent supervision assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and the quarterly risk data collection tool identified the resident as at risk for falls. During observation, the bed was in a high position and measured 31 inches from the floor. RN and ADON interviews confirmed there was no physician order or care plan supporting a high bed position, and both stated the bed should have been kept at the lowest position possible. The facility failed to maintain several other resident environments and items as observed by surveyors. Resident 76’s floor mat was placed halfway under the bed instead of beside it, despite a care plan intervention to place a landing pad beside the bed. Resident 110’s bed remote control was found on the floor rather than within reach, even though the care plan called for a safe environment and reachable personal items. Resident 15 had a large bottle of hand sanitizer left at the bedside, and staff stated it should not be there because the resident had dementia and could ingest it. Resident 31’s headboard was observed tilting forward and wobbly, and staff stated it could fall on the resident’s head. In the hallway, two EVS carts had unlocked chemical compartments while unattended, and staff stated residents could access the chemicals. Resident 113 had an open package of A&D ointment on the nightstand at the bedside, and LVN staff stated there were no physician orders, care plan, or self-medication assessment to support medication being left there.
Bed rail orders, assessments, consent, and care plans did not match
Penalty
Summary
The facility failed to ensure the safe and appropriate use of bed rails for three residents. The report states that the facility did not follow physician orders, did not complete the required bed rail assessments, and did not develop care plans that matched the bed rail use documented for the residents. The deficiencies were identified during survey review of the accidents care area and involved Resident 1, Resident 7, and Resident 29. For Resident 1, the resident was admitted with acute respiratory failure with hypoxia, sepsis, type II DM, and dementia, and had a BIMS score of 3 indicating severe cognitive impairment. The resident was dependent for oral care, toileting, personal hygiene, upper and lower body dressing, and footwear. During observation, the resident was in bed with bilateral half-length bed rails elevated, and CNA 8 stated the rails were always kept elevated to prevent falls. The ADON reviewed the record and stated the physician order was for bilateral grab bars to assist with turning and repositioning and as an enabler, but the facility had applied half-length bed rails instead. The ADON also stated the side rail utilization assessment was completed for grab bars rather than half-length bed rails, and the care plan addressed grab bars only and did not address half-length bed rails. For Resident 7, the resident was admitted with metabolic encephalopathy, type II DM, and ESRD, and the H&P stated the resident had the capacity to understand and make a decision. The resident required substantial to maximal assistance with toileting hygiene, showering, and lower body dressing. During observation, the resident was lying in bed with bilateral half-length bed rails elevated, and CNA 7 stated the resident was afraid of falling and requested the rails be elevated when in bed. The ADON reviewed the record and stated the physician order was for quarter bed rails on both sides of the bed for turning and repositioning, but the informed consent for physical restraint and side rails did not contain the resident’s or representative’s signatures. For Resident 29, the resident had generalized muscle weakness, unspecified dementia without behavioral disturbance, and an acquired absence of the right leg above the knee. The H&P stated the resident had capacity to make decisions, and the MDS indicated intact cognitive function and the ability to make self-understood and understand others, with dependent to supervision assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The OSR ordered half side rails on both sides of the bed for turning and repositioning, but the consent form documented quarter side rails, the side rail utilization assessment documented quarter length side rails, and the care plan was written for quarter length side rails. During observation, the bed had a rail on the right middle side and another rail on the left upper side, and CNA 7 stated the size of the rail on the right side was unknown while the left upper rail was a grab bar. The ADON stated the care plan, consent, and assessment did not match the physician order.
Incomplete Staff Performance Reviews and ADL Training
Penalty
Summary
The facility failed to ensure that nursing staff had complete performance reviews and required training. During interview and record review, the Director of Staff Development reviewed five employee files and found that CNA 1’s ADL care training for toileting hygiene and shower/bathing had last been completed on 10/31/2024. The DSD stated that CNA 1 also assists nursing staff and should have ADL care training. The facility assessment, revised 08/1/2025, indicated that the facility conducts an audit of all direct care staff competencies before the end of 2025 and that competency training for staff continues as an annual standard of practice. The DSD stated that performance evaluations are conducted annually or whenever retraining is necessary, and that the DON or ADON oversees evaluations for licensed nursing staff while the DSD ensures they are completed. Record review showed RN 1’s last annual performance review was 11/18/2024 with none completed for 2025 or 2026, TN 1’s last annual performance review was 11/11/2024 with none completed for 2025 or 2026, CNA 1 did not receive an annual performance evaluation, and CNA 2’s last performance review was 1/16/2025 with none for 2026. The DSD stated there was no established process to track which staff were due for evaluations and acknowledged the need for improvements in tracking to ensure continuity. The DON stated that performance evaluations are intended to discuss staff performance and expectations, provide feedback, set goals, and offer recommendations for training and improvement.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that two residents receiving insulin were free from significant medication errors because subcutaneous insulin injections were not rotated as ordered. For Resident 76, the record showed diagnoses including type 2 DM, adult failure to thrive, and dysphagia. The resident’s orders included insulin aspart with instructions to rotate injection sites, and the care plan also directed site rotation. However, the April 2026 LAR showed repeated injections in the same abdominal areas, including multiple doses in the LUQ and repeated doses in the RUQ. For Resident 39, the record showed diagnoses including type 2 DM, morbid obesity, and dysphagia. The resident had orders for insulin aspart before meals and at bedtime and insulin glargine twice daily, both with instructions to rotate injection sites. The care plan likewise included an intervention to rotate the injection site. The April 2026 LAR showed repeated insulin glargine injections in the LUQ and repeated insulin aspart injections in the RLQ, rather than rotation among sites. During a concurrent interview and record review, the ADON reviewed the orders, LARs, and care plans for both residents and stated the repeated administration sites meant the facility’s insulin administration policy and procedure was not followed. The ADON stated not rotating insulin administration sites was considered a medication error. The DON also stated that insulin sites should be rotated to avoid infection and trauma, that frequent use of the same site can harden the skin and cause lipodystrophy, and that administering insulin into lipodystrophic tissue can impair absorption and may cause hypo/hyperglycemia.
Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
The facility failed to ensure safe pharmaceutical storage and labeling on two medication carts. On Station A Middle medication cart, a concurrent observation with LVN 2 found a Novolog Flexpen, a Lantus Solostar, a tube of Anecream 5%, a tube of triamcinolone 0.1%, and two tubes of diclofenac sodium 1% topical gel that were not labeled with an open date. The same cart also contained a clonazepam 0.5 mg bubble pack that had been prescribed and filled on 1/30/2026 for 14 days of use but had not been removed from the cart. LVN 2 stated the unlabeled medications could be used beyond recommended timeframes and that the clonazepam remained in the cart beyond the expected completion date. On Station B medication cart, a concurrent observation with LVN 3 and the DON found a metoprolol tartrate 25 mg bubble pack with an expiration date of 1/30/2026 still in the cart. LVN 3 stated the label printer may have been an issue, and the DON confirmed the expiration date on the bubble pack. The DON stated expired or questionable medications must be removed from the cart immediately and that questionable labels must be verified and reconciled with the pharmacist. The facility policy titled Medication Labeling and Storage, dated 1/28/2026, stated discontinued, outdated, or deteriorated medications are to be handled through the dispensing pharmacy and that opened multi-dose containers are to be dated and discarded within 28 days unless otherwise specified.
Menu Portion Size Not Followed for Bratwurst
Penalty
Summary
The facility failed to follow the menu and did not meet nutritional needs when staff served grilled bratwurst in a portion smaller than the menu specified. The Spring 2026 menu spreadsheet dated 5/4/2026 listed grilled bratwurst at 3 oz for residents on a regular diet, along with buttered new potatoes, sauerkraut, a wheat roll, margarine, an oatmeal raisin cookie, and water. During observation on 5/4/2026 at 11:12 a.m., the Dietary Supervisor was seen cutting the grilled bratwurst in half on a yellow chopping board. During a concurrent observation and interview on 5/4/2026 at 12:26 p.m., the Registered Dietitian and Dietary Supervisor observed half portions of bratwurst plated on residents' plates. The Dietary Supervisor stated the portion size was one half because the recipe called for it to be cut in half. Random portions were weighed on the facility scales and both measured 1.5 oz. The Registered Dietitian stated that if the bratwurst was under the portion size it placed residents at risk for weight loss. The facility's policies stated that menus must meet nutritional needs and indicate standard portions, food service staff must be trained in proper weights and measures, standardized recipes shall be used, and the grilled bratwurst recipe listed a suggested portion size of 3 oz and instructed staff to serve 3 oz per portion.
Food Served at Unsafe and Unappetizing Temperatures
Penalty
Summary
The facility failed to prepare food by methods that conserved temperature when hot foods were not served hot. During a review of Resident 53’s record, the resident was admitted on 4/15/2026 with diagnoses including essential HTN, chronic respiratory failure, and acute kidney failure. The MDS dated 4/20/2026 indicated the resident understood others and could make self understood, and needed set-up and clean-up assistance when eating. The order recap showed the resident was ordered a low fat, low cholesterol, no added salt, regular texture, thin consistency diet with a 1500 ml fluid restriction. In interview, Resident 53 stated the facility needed a hot box to keep food warm because the food was not kept warm and it would make a difference to receive food warm. During a concurrent test tray observation, the Dietary Supervisor took temperatures of regular diet items and stated the grilled bratwurst was 80 F, buttered new potatoes were 90 F, and sauerkraut was 82 F. On the soft bite size diet tray, the DS took temperatures and stated the minced and moist pork chop was 83 F, the soft bite sized new potatoes were 80 F, and the soft bite sized sauerkraut was 82 F. The DS stated the food temperatures were not good because of a delay in trayline, that hot food usually comes out at 110 to 115 F, and that residents could complain of cold food and would not eat much as a potential outcome. The facility’s Food and Nutrition Services policy stated residents are to receive nourishing, palatable, well-balanced diets and that food trays will be inspected to ensure food appears palatable and attractive and is served at a safe and appetizing temperature.
Soft Bite Sized Diet Served at Minced and Moist Texture
Penalty
Summary
The facility failed to ensure residents ordered a soft bite sized level 6 diet received food prepared in the prescribed texture. The menu spreadsheet for Spring 2026 showed that residents on the soft bite sized diet were to receive items such as soft bite grilled bratwurst with gravy, soft bite buttered new potatoes, soft bite sauerkraut, puree bread, margarine, and a puree sugar cookie. During food preparation observations, the Dietary Supervisor chopped the grilled bratwurst, then performed a fork pressure test and determined it did not pass, instructing staff to grind it. Later, the Dietary Supervisor tested pork chops, stated they did not pass the fork test for the soft bite sized diet because they could not be cut using a fork, and said they would be blended to minced and moist texture instead. During interviews, the Dietary Supervisor stated the easy-to-chew meats did not pass the fork pressure test and were made as minced and moist texture instead. The Registered Dietitian stated serving minced and moist food to soft bite sized diet was acceptable from a safety perspective, but the kitchen staff were not following the recipe and were downgrading the diet instead of providing soft bite sized foods. The facility policy stated therapeutic diets are prescribed by the attending physician or delegated dietitian, diet orders should match food service terminology, and mechanically altered diets must specify the texture modification. The facility diet manual defined soft and bite sized texture as soft, tender, and moist with no separate thin liquid, and the standardized pork chop recipe directed that SB6 portions be chopped cooked regular portions.
Frayed Bed Remote Wires Left in Residents’ Rooms
Penalty
Summary
The facility failed to maintain electrical and patient care equipment in safe operating condition for five sampled residents by allowing bed remote controls to remain in disrepair with frayed or exposed wires. During observations, Resident 76, Resident 31, Resident 2, Resident 15, and Resident 49 each had a bed remote control that showed frayed wiring near the control pad or exposed inner wires. For Resident 49, the LVN immediately removed the remote from the resident’s reach and notified maintenance after observing the exposed wires. The affected residents had diagnoses and assessments showing varying levels of cognitive impairment and need for assistance. Resident 76 had diagnoses including dementia, disorientation, and adult failure to thrive, and the H&P stated the resident did not have capacity to make decisions. Resident 31 had diagnoses including atrial fibrillation, dementia, and major depressive disorder, and the H&P stated the resident did not have capacity to understand and make decisions. Resident 2 had diagnoses including cognitive communication deficit, dementia, and aphasia, with the H&P stating the resident was awake, alert, oriented, and had capacity. Resident 15 had diagnoses including dementia, major depressive disorder, and psychosis, and the H&P stated the resident did not have capacity to understand and make decisions. Resident 49 had diagnoses including hemiplegia, type 2 diabetes mellitus, and hypertension, and the MDS showed dependence for several activities of daily living and moderate cognitive impairment. Each resident’s care plan or related documentation included expectations for a safe environment or functional adaptive equipment. The facility’s staff and leadership acknowledged during interviews that frayed or exposed wires on bed remote controls should not be present because they can cause electrical shock or electrocution. The ADON stated the facility did not follow the care plans related to providing a safe environment, and the DON stated maintenance was responsible for the equipment, while staff should also report hazards. The facility policy stated maintenance was responsible for keeping buildings and equipment safe and operable, and the bed manufacturer’s manual instructed inspection of bed components and electrical cords for damage, chafing, cuts, or excessive wear.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents who were identified as needing assistance and who had fall risk concerns. Resident 10 was admitted with diagnoses including hypertension, history of falling, seizures, and atrial fibrillation. The MDS dated 04/19/2026 indicated severe cognitive impairment and that the resident required extensive physical assistance for ADLs. The care plan for risk for falls, revised on 4/23/2026, directed staff to ensure the call light was within reach and to encourage use of it for assistance as needed. During a concurrent observation and interview on 5/04/2026, Resident 10's call light was observed on the floor, and an LVN stated it should always be within reach because it allows residents to call for staff assistance. Resident 88 was admitted with diagnoses including type 2 diabetes mellitus with other specified complication, generalized muscle weakness, and hypotension. The H&P dated 11/7/2025 stated the resident did not have capacity to make decisions, and the MDS dated 2/24/2026 indicated severe cognitive impairment, dependence to partial/moderate assistance with mobility and ADLs, and ability to usually make self-understood and understand others. The QRDCT dated 2/24/2026 identified the resident as at risk for falls. During a concurrent observation and interview on 5/4/2026, the resident's call light was observed hanging off the right side of the bed, and a CNA stated the resident would not have been able to call for assistance because the call light was out of reach. RN 1 and the DON stated the call light should always be within reach and that the resident could have fallen trying to reach it.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of Resident 15’s executed Advance Healthcare Directive was uploaded into the electronic health record and readily available for staff to review and honor. Resident 15 was admitted in 2017 and readmitted in 2018 with diagnoses including dementia, major depressive disorder, and cognitive communication deficit. The record also showed that the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment with the resident and family participating in care planning. The resident’s Advance Directive Acknowledgement, dated 8/25/2019, indicated that an Advance Directive had been executed, but the actual document could not be found in the electronic healthcare record. The care plan identified that the resident had an advance directive and included an intervention to offer assistance if the resident wished to execute one or more directives. During interview and record review, the ADON stated the SSD should have followed up on the ADA and that the purpose of the ADA was to honor the resident’s wishes when the resident could not decide for self. The SSD stated that the resident’s DPOA identified the son as the person to decide in the resident’s best interest regarding healthcare if she became incapacitated. The SSD also stated he remembered an IDT discussion with the son regarding the resident’s advance directive, but could not remember whether the advance directive package had been turned into the facility. The SSD stated the copy was not in the chart and was not readily available, and the DON stated the SSD was responsible for obtaining the executed Advance Healthcare Directive so it would be readily available in the chart for staff to implement.
Missing Personal Property Not Documented or Investigated
Penalty
Summary
The facility failed to ensure Resident 75 was free from misappropriation of personal property when the resident’s [NAME] stick went missing and was not promptly addressed. Resident 75 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hypertension, and alcohol abuse. The resident’s MDS dated 3/12/2026 indicated intact cognitive skills for daily decision making, dependence with toileting hygiene, showering, and footwear, and partial/moderate assistance with oral and personal hygiene and upper body dressing. During an interview, Resident 75 stated the [NAME] stick had been missing for about one week and that he reported it to the Activities Director, but had not received follow-up or a response. The Activities Director stated Resident 75 reported the missing item and that she documented the concern in her personal notebook and relayed it to Social Services, but she did not document the incident in the resident’s medical record. She also stated the [NAME] stick had not been added to the Resident Inventory List and that the facility did not maintain a log for delivered packages or resident-purchased items. Social Services stated facility protocol required immediate investigation and completion of a Theft and Loss Investigation Report when notified of a missing item, and that if the item was not located within three to five days, the resident would be reimbursed or the facility would replace it; however, the form could not be located and the incident was not documented in the medical record. The facility policy stated residents’ personal belongings are inventoried and documented upon admission and updated as necessary, and that complaints of misappropriation or mistreatment of residents’ property are promptly investigated.
Missing Current Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure Resident 4’s drug regimen was free from unnecessary psychotropic medications by not having current informed consent for Lorazepam and Risperdal. Resident 4 was admitted with diagnoses including psychosis, anxiety disorder, and auditory hallucinations, and the MDS dated 4/27/2026 indicated the resident usually could make self-understood and understand others, had moderate cognitive impairment, and was receiving a high-risk antipsychotic medication. The record showed an order for Risperdal 3 mg by mouth at bedtime for psychosis and an order for Lorazepam 0.5 mg by mouth every six hours as needed for anxiety. The informed consent on file for Risperdal was dated 11/14/2025 and reflected a 2 mg dose, which did not match the current 3 mg order. The record also did not contain an informed consent for Lorazepam. During interview and record review, the ADON stated there was no informed consent for Lorazepam and that the Risperdal consent was from the previous admission. The ADON stated the new Risperdal dosage was 3 mg and the old consent was for 2 mg. The DON stated it was important to have current informed consents for these medications, especially because they had black box warnings, and that informed consent honors the resident’s right to agree or disagree with the proposed treatment.
Failure to Report Unwitnessed Fall With Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an alleged injury of unknown origin was reported immediately, and no later than 2 hours after the allegation was made, for one sampled resident who was found on the floor with a right lateral head bump, abrasion, and a right lateral great toe skin tear and was transferred to the hospital. The resident had diagnoses including dementia, disorientation, and adult failure to thrive, and the H&P stated the resident did not have the capacity to make decisions. The MDS indicated the resident had severely impaired cognition, severely impaired vision, and required assistance with mobility and ADLs. The SBAR form documented that the resident was found on the floor next to the bed in a side-lying position on the right side holding the bed control, was confused at baseline, and had no change in LOC noted. The SBAR also documented a small bump and abrasion to the right lateral head and a small skin tear to the right lateral great toe, with transfer to a GACH. A Health Facility Note described the event as an unwitnessed fall to the floor due to possible syncope and noted minor injuries including a small bump/abrasion to the right lateral head, redness to the left forehead, and a small skin tear to the right great toe. During interview and record review, the ADON and RN stated the incident was reportable under the SOM because the fall was not observed, the resident was confused and could not recount what happened, and multiple injuries were noted. They stated the facility’s policies titled Accidents and Incidents- Investigating and Reporting and Unusual Occurrence Reporting were not followed because the incident was not reported to the state agency. The ADM and DON also stated the unwitnessed fall should have been reported because nobody witnessed it and the multiple injuries could not be explained, and they stated the failure to report the unwitnessed fall constituting an injury of unknown origin predisposed the resident to suspected abuse that was not detected.
Failure to Submit New PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a new PASRR Level I screening for one resident after the resident was diagnosed by a psychologist with other specified schizophrenia spectrum and other psychotic disorder. The resident had originally been admitted on 9/4/2025 and later readmitted, with diagnoses that included dementia with behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and mild neurocognitive disorder due to a known physiological condition with behavioral disturbances. A review of the resident’s MDS dated 4/14/2026 showed moderate cognitive impairment, with the ability to make self-understood and understand others, and the resident required maximal to supervision assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident’s PASRR Level I screening dated 9/2/2025 stated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and had not been prescribed psychotropic medications. The psychological evaluation and consultation dated 9/8/2025 documented a diagnosis of other specified schizophrenia spectrum and other psychotic disorder. During interview, the MDS Coordinator stated that the resident’s admission record showed unspecified psychosis and that a new PASRR was needed when a new diagnosis of mental illness was made after admission, but no new PASRR had been done for the resident. The DON also stated that if a resident was diagnosed with an MD or ID after admission, a new PASRR Level I should have been submitted.
Failure to Update Fall Care Plan After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that Resident 76’s comprehensive care plan was reviewed and revised by an interdisciplinary team to reflect an unwitnessed fall on 12/3/2025. Resident 76 was admitted on 6/9/2023 and readmitted on 8/4/2025 with diagnoses including difficulty walking, muscle weakness, and lack of coordination. The H&P dated 8/5/2025 indicated the resident did not have the capacity to make decisions. The MDS dated 2/20/2026 indicated the resident usually could make self understood and usually understand others, had severe cognitive impairment, and was dependent to needing partial assistance with mobility and ADLs. The ADT dated 12/5/2025 indicated the resident was at risk for falls. The SBAR communication form dated 12/3/2025 documented that the resident was found on the floor next to the bed in a side-lying position on the right side holding the bed remote control, confused as baseline, with a small bump and abrasion to the right lateral head and a small skin tear to the right great toe. The care plan titled, "The resident is at risk for Falls related to diagnosis of Parkinson's, severe protein-calorie malnutrition, history of falls, incontinence, history of getting up and ambulate without asking or calling for assistance, trying to function beyond his capabilities," initiated on 8/5/2024, did not reflect the actual fall that occurred on 12/3/2025. During interview, the ADON and DON stated the care plan was not updated with the resident’s current unwitnessed fall and that it should have been updated to reflect the resident’s current status.
Failure to Monitor Healed Pressure Ulcer
Penalty
Summary
The facility failed to monitor and assess a healed pressure ulcer on the affected site for one sampled resident. The resident was admitted with diagnoses including hypertension, history of falling, cardiomyopathy, and atrial fibrillation. The MDS dated 04/20/2026 indicated the resident’s cognitive skills for daily decisions were intact, that the resident required partial to substantial physical assistance with ADLs, and that the resident was at risk for developing pressure injuries. The MDS also indicated the resident had one stage 2 pressure ulcer and two stage 3 pressure ulcers that were present on admission. The care plan for possible wound recurrence of resolved left lateral buttock stage 2 pressure injury, left buttock stage 3 pressure injury, and right buttock stage 3 pressure injury, initiated on 04/30/2026, included a goal to keep the skin intact by monitoring affected areas each shift and notifying the physician if breakdown occurred. During interview and observation, the treatment nurse stated the buttocks were blanchable pinkish redness with dry, intact skin, but also stated there was no physician order for monitoring the skin after the wound healed and the last documented skin assessment was on 4/27/2026. The treatment nurse, RN, and DON all stated that healed pressure injuries should continue to be monitored and documented, and the facility policy on prevention of pressure injuries required ongoing monitoring, reporting, documenting skin changes, and regular assessment of intervention effectiveness.
Unlabeled Oxygen Tubing
Penalty
Summary
The facility failed to ensure that respiratory care was provided in accordance with professional standards of practice for one resident who was receiving continuous oxygen therapy via nasal cannula. The resident was admitted with diagnoses including COPD, pneumonia, and acute respiratory failure with hypoxia, and the record indicated the resident had decision-making capacity and intact cognition. The resident’s orders included oxygen at 2 liters per minute via nasal cannula continuously and a weekly change of the oxygen nasal cannula with a name and date label. During a concurrent observation and interview, the resident’s oxygen tubing was observed without a label showing the date it was last changed. The LVN stated the tubing should be labeled with the date it was changed for infection control purposes. The ADON and DON both stated the oxygen tubing should be labeled with the date it was last changed, that it was changed every Sunday, and that labeling was needed to ensure it was not used longer than a week and to support infection control. The facility policy also stated the oxygen cannula and tubing should be changed every seven days or as needed.
Delayed Pain Reassessment After PRN Opioid Administration
Penalty
Summary
The facility failed to effectively manage pain for one sampled resident by not consistently reassessing pain within one hour after administering hydrocodone-acetaminophen oral tablets. Resident 12 was admitted with diagnoses including ESRD with hemodialysis dependence, cellulitis, failure to thrive, and spinal stenosis. The resident’s admission record and H&P indicated swelling, blistering, and pain at the left upper extremity AV fistula site, and the resident was documented as alert, oriented, and having mental capacity to make decisions. Resident 12’s orders included acetaminophen 325 mg, hydrocodone-acetaminophen 5-325 mg for moderate pain, and hydrocodone-acetaminophen 10-325 mg for severe pain. The care plan for acute pain directed that pain relief be expressed or managed through proper medication administration, monitoring and documenting side effects and effectiveness, anticipating pain relief needs, and responding promptly to complaints of pain. During observation and interview, Resident 12 stated a desire for more consistent pain medication timing and described being confined to bed as affecting his control over care and well-being. Review of the eMAR showed multiple instances where hydrocodone-acetaminophen was administered and pain reassessment occurred later than the facility’s stated 30 to 60 minute timeframe for oral pain medication. Examples included reassessments at 3:00 a.m. after a 12:24 a.m. dose, at 10:21 a.m. after a 7:53 a.m. dose, and at 11:24 p.m. after a 9:46 p.m. dose. RN 1 stated pain should be reassessed within 30 minutes to one hour after oral medication, and the DON stated reassessment should occur within 30 minutes to an hour and that delayed reassessment may leave residents in pain. The facility policy titled Pain Assessment and Management stated acute pain or worsening chronic pain should be evaluated every 30 to 60 minutes after it begins and reassessed as needed until relieved.
Failure to Implement Fluid Restriction and Intake/Output Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with ESRD who was dependent on hemodialysis. The resident was admitted with diagnoses including ESRD with dependence on hemodialysis, cellulitis, failure to thrive, and spinal stenosis. The MDS indicated the resident’s cognitive skills for daily decisions were intact and that the resident required supervision to moderate physical assistance with ADLs. The H&P noted the resident was admitted due to swelling, blistering, and pain at the left upper extremity AV fistula site, and also stated the resident had mental capacity to make decisions. The resident’s OSR showed dialysis was scheduled every Monday, Wednesday, and Friday. A nutrition assessment recommended a 1200 ml daily fluid restriction, and the care plan included a 1200 ml fluid restriction and monitoring intake and recording every meal. During interview and record review, RN 1 stated there was no physician order or implementation for the fluid restriction and that no implementation of intake and output monitoring existed, despite the care plan. RN 1 and the DON both stated that fluid restriction and monitoring intake and output were necessary for dialysis residents, and the facility policy stated the resident’s comprehensive care plan would reflect needs related to ESRD/dialysis care.
Pharmacy Services Failure for Outside Medication
Penalty
Summary
The facility failed to accurately and safely provide pharmaceutical services for Resident 93 by not notifying the pharmacist for review and proper labeling of a medication brought in from an outside appointment before it was administered, and by not incorporating the medication into the resident’s care plan. Resident 93 was admitted with diagnoses including pneumonia, malignant neoplasm of the pancreas, and type II DM, and the MDS dated 3/12/2026 indicated moderate cognitive impairment and dependence with toileting hygiene, showering, lower body dressing, and putting on/taking off footwear. During a concurrent observation, interview, and record review, a bottle of Zenpep 25,000-79,000-105,000 units with a name tag for Resident 93 was present at the Station B medication cart, and the label did not originate from the facility’s pharmacy. LVN 3 stated the resident had returned from an outside doctor’s appointment with the new prescribed medication, but there was no documentation in the progress notes of pharmacist notification or consultation regarding the medication. LVN 3 also stated there was no care plan documented for Zenpep. The DON stated medications received from outside sources must be reported to the physician, evaluated by the facility pharmacy, and properly labeled prior to administration, and that a comprehensive care plan must be developed and implemented for safe medication management.
Medication Administration Errors With Vitamin B12 and Miralax
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with 2 medication errors out of 25 total opportunities for an overall error rate of 8% during medication administration for one resident. The resident had a history of Parkinson’s disease, gastrostomy, and dysphagia, and was severely impaired in daily decision making and dependent for several activities of daily living. During observation of medication administration, an LVN prepared vitamin B12 via G-tube and Miralax for the resident while the resident was in the room. For the vitamin B12 order, the LVN reviewed the eMAR and stated the physician’s order was for vitamin B12 1000 mcg one tablet via G-tube daily, but the in-house supply available was vitamin B12 500 mcg, which did not match the ordered dosage. For Miralax, the LVN prepared 17 gram oral packet medication by pouring the powder into the cup first and then adding water up to the 8 oz line, even though the order directed that the powder be dissolved in 8 oz water. The DON stated that physician orders must match the available medication dosage and that the prescribed amount of fluid should be measured first before adding powder. The facility policy defined a medication error as preparation or administration not in accordance with physician orders, manufacturer specifications, or accepted professional standards.
Inaccurate Documentation of Specialty Mattress Placement
Penalty
Summary
The facility failed to accurately document the placement of a low air loss mattress for Resident 53. Resident 53 was admitted with diagnoses including hypertension, history of falling, cardiomyopathy, and atrial fibrillation. The MDS dated 04/20/2026 indicated the resident’s cognitive skills for daily decisions were intact, he required partial to substantial physical assistance with ADLs, was at risk for pressure injuries, and had one stage 2 and two stage 3 pressure ulcers present on admission. The H&P stated that Resident 53 had the capacity to understand and make decisions. The physician ordered a specialty bed mattress on 4/16/2026 with instructions to monitor placement and function every shift. The MAR showed licensed staff documented monitoring of the mattress on multiple shifts between 4/16/2026 and 5/6/2026. However, during observation on 5/06/2026, Resident 53 did not have a LAL mattress in place and stated he had been refusing it because of his experience with it. During interview and record review, LVN 2 stated she had documented monitoring the mattress during her shifts without checking whether it was actually in place, and after inspecting the bed stated the LAL mattress was not in place. RN 1 stated nurses should document what occurred or was present, and the DON stated nurses should document what they observe as per physician orders and not record information that was not present.
Uncovered Mobile Linen Cart During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program when a mobile linen cart was left uncovered after CNA 4 removed the needed linen supplies during resident care. During an observation on 5/4/2026 at 10:25 a.m., CNA 4 brought the mobile linen cart to Room A, opened it, and obtained the supplies needed for the resident. The cart was then left open facing the resident’s room while CNA 4 provided care without replacing the cover. During a concurrent observation and interview on 5/4/2026 at 10:26 a.m., the CS stated the mobile linen cart was uncovered and unattended, and said CNA 4 should have replaced the cover after getting the supplies to prevent contamination of the linen from external contaminants. CNA 4 stated she should have placed the cover back to prevent the linen from being exposed to environmental contaminants. The ADON later stated CNA 4 should have replaced the cover to protect the linens from environmental contaminants, and the DON stated the cart should have been covered after getting all needed supplies to protect the linen from contaminants that can cause the resident to get sick.
Antibiotic Stewardship Monitoring Not Implemented
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two sampled residents by not ensuring required duration and monitoring elements were in place for antibiotic use. The report states that the facility’s policy required complete antibiotic orders, including a start and stop date or number of days of therapy, and that residents receiving medication were to be monitored for adverse consequences. Surveyors found that these expectations were not met for Resident 39 and Resident 2. Resident 39 was admitted with diagnoses including pneumonia, COPD, and acute respiratory failure, and was documented as having the capacity to make decisions and intact cognition. The resident had an order for Hiprex 1 gram by mouth twice daily for UTI prophylaxis. During interview and record review, the ADON stated the medication had an indefinite duration, there was no latest UA and culture found, no MD documentation of prolonged use, no specific monitoring for adverse effects, and no care plan for its use. The DON stated the Hiprex use should have had an end date and monitoring for adverse effects. Resident 2 was admitted with diagnoses including UTI, cellulitis of the right lower limb, and sepsis, and was documented as alert, awake, oriented, and having capacity to understand and make decisions. The resident had an order for Amoxicillin-Pot Clavulanate 875-125 mg every 12 hours for cellulitis for 4 days. The care plan included administering antibiotic therapy as ordered and observing for adverse reactions, but during interview the ADON stated there was no specific monitoring for adverse effects from 3/31/2026 to 4/4/2026. The DON stated monitoring for adverse effects should have occurred every shift, and both the ADON and DON stated the antibiotic should have been monitored for adverse effects.
Failure to Document Pneumococcal Vaccine Refusal and Reoffer Annually
Penalty
Summary
The facility failed to offer the pneumococcal vaccine yearly after a resident refused the immunization on 10/11/2023. Resident 54 was admitted on 5/25/2020 and readmitted on 11/20/2025 with diagnoses including pneumonia, adult failure to thrive, and a personal history of COVID-19. The resident’s H&P dated 11/21/2025 indicated the resident was alert and oriented x3, had tremors, and had the capacity to make decisions. The MDS dated 1/28/2026 indicated the resident could make self-understood and understand others, had intact cognition, and was up to date with pneumococcal vaccine. During review of the immunization record, the resident was documented as refusing the pneumonia vaccine on 10/11/2023. In a concurrent interview and record review, the IP stated there was no documentation showing the refusal was accompanied by explanation of the risks and benefits, and stated the refusal should have been documented because it is vital for safety and prevention. The IP also stated the vaccine should have been offered yearly and that the facility missed offering it for 2024 and 2025. The DON stated the refusal should have been documented to show the risks and benefits were explained and that the vaccine should have been offered yearly.
Failure to Document COVID-19 Vaccine Refusal Education
Penalty
Summary
The facility failed to document the explanation of the risks and benefits of refusing the COVID-19 vaccine for one of five sampled residents, Resident 36. Resident 36 was admitted on 7/19/2024 and readmitted on 2/16/2026 with diagnoses including protein-calorie malnutrition and a personal history of antineoplastic chemotherapy. The resident’s H&P dated 9/5/2024 indicated the resident had the ability to understand and make decisions, and the MDS dated 4/20/2026 indicated the resident could make self-understood and understand others and had intact cognition. The MDS also indicated the resident’s COVID-19 vaccination was up to date. The Immunization Record showed the resident refused the COVID-19 vaccine on 10/17/2025. During interview and record review, the Infection Preventionist stated the resident refused the vaccine on 7/23/2024 and 4/2/2025 but could not find documentation showing the risks and benefits of refusal were explained. The DON stated the IP should have documented the refusal to ensure the risks and benefits of refusing the vaccine were explained to the resident, and that the vaccine should have been offered yearly. The facility policy stated residents are to be offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, and that education regarding benefits, risks, and potential side effects is to be provided before the vaccine is offered.
Pest Control Program Not Effective
Penalty
Summary
An effective pest control program was not maintained when a dead cockroach was found on the bathroom floor in the room of one resident. The resident’s admission record showed diagnoses including hypertension, acute pancreatitis, and acute kidney failure. The resident’s MDS dated 04/21/2026 indicated that her cognitive skills for daily decisions were intact and that she required supervision to moderate physical assistance from staff for ADLs, including toileting hygiene and showering/bathing. During a concurrent observation and interview on 5/4/2026 at 10:55 a.m., the resident stated she had found a cockroach in the bathroom, and one dead cockroach was observed on the bathroom floor. She stated that she was bothered by pest issues and that the facility should improve its cleaning practices. RN 1 stated that all staff are responsible for visually monitoring for pests and that pests indicate poor facility hygiene and may require thorough cleaning. The DON stated that the maintenance supervisor oversees pest control and that pests can harm residents, create infection control issues, cause distress, and spread disease-causing bacteria through cross-contamination. The facility’s Pest Control policy, reviewed 01/28/2026, stated that an ongoing program is in place to keep the building free of insects and rodents.
Failure to Implement Abuse Policy by Not Immediately Separating Roommates After Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse policy and procedure requiring immediate protection of a resident following an allegation of physical abuse. One resident with Parkinson’s disease, PVD, quadriplegia, intact cognition, and documented decision-making capacity reported that his roommate went through his nightstand during the early morning hours and threw a bottle of moisturizer that struck his shin, followed by additional objects thrown in his direction. The resident stated that the roommate had repeatedly opened and closed the privacy curtain to look toward his side of the bed and that he felt uncomfortable and unable to defend himself. Despite this, the resident reported that he and his roommate were kept in the same room and were not separated until later that day. Staff interviews confirmed delays and incomplete protective actions after the allegation. CNA 4 reported entering the room after hearing voices, learning from the resident that the roommate had thrown a bottle of lotion that hit his shin, and observing the roommate with the nightstand drawer open and the privacy curtain being repeatedly opened and closed. CNA 4 stated she removed the lotion from the bed, returned it to the nightstand, and reported the incident to RN 1. RN 1 acknowledged that the resident expressed concern about the roommate taking items from his nightstand and stated that she asked CNA 4 to help move the nightstand closer to the resident to keep it away from the roommate’s reach, but she did not separate the roommates, and both remained in the same room. Additional information from CNA 2 showed further delay in reporting and action. CNA 2 stated that during breakfast the same morning, the resident told her that the roommate had taken items from his nightstand and thrown something at him while the roommate was still in the room sleeping. CNA 2 reported that she did not notify the Social Services Assistant until approximately 2 p.m. due to a busy morning and that she continued to monitor both residents in the same room, despite the resident expressing that he did not feel safe and feared harm from his roommate. The DON stated that staff were required by the abuse policy to immediately separate residents after such an allegation and report it to the abuse coordinator, and acknowledged that this did not occur. The resident’s care plan, initiated after the allegation, included an intervention to ensure immediate safety by separating the resident from the alleged source if indicated, underscoring that the required immediate separation had not been implemented at the time of the incident.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of physical abuse within two hours as required by policy. Resident 1, admitted with Parkinson’s disease, peripheral vascular disease, and quadriplegia, had intact cognition and decision-making capacity and was dependent for ADLs. Resident 2, admitted with diabetes mellitus, dysphagia, and schizophrenia, had severely impaired cognition per MDS but was noted in the H&P as able to understand and make decisions. On 4/10/2026, Resident 1 reported that Resident 2 went through his belongings in the nightstand and threw a bottle of lotion that struck his shin. CNA 4 stated that after returning from break on 4/10/2026, she heard voices from the shared room, entered, and Resident 1 reported that Resident 2 had thrown a bottle of lotion that landed on his right shin. CNA 4 observed Resident 2 with the nightstand drawer open and the privacy curtain repeatedly opened and closed, removed the lotion bottle from Resident 1’s bed, and reported the incident to RN 1. RN 1 acknowledged that Resident 1 expressed concern about Resident 2 taking items from his nightstand and stated she asked CNA 4 to help move the nightstand closer to Resident 1, but she did not report the allegation to anyone else or document it in a progress note. Separately, CNA 2 reported that during breakfast on 4/10/2026, Resident 1 told her that his roommate had taken items from his nightstand and thrown something at him, and that Resident 1 stated he did not feel safe sharing a room with his roommate. CNA 2 stated she delayed reporting this to the Social Services Assistant until approximately 10 a.m. due to a busy morning and feeling scared to report the incident. The SSA stated that CNA 2 reported the concern around 11 a.m., that she then spoke with Resident 1 before lunch, and that she reported the allegation to the Director of Social Services around 11:30 a.m., but the report to outside authorities was not made until 2 p.m. The DON confirmed awareness of the physical altercation and stated that allegations of physical abuse should be reported immediately, but no later than two hours after the allegation is made, consistent with the facility’s abuse reporting policy requiring immediate reporting to state licensing and the ombudsman within two hours of an allegation involving abuse.
Failure to Revise Care Plan for Resident Behavior
Penalty
Summary
The facility failed to revise and update a comprehensive care plan to address a resident’s identified behavior. Resident 2 was admitted with diagnoses including diabetes mellitus, dysphagia, and schizophrenia. An MDS dated 4/12/2026 documented that the resident’s cognition was severely impaired and that the resident required maximal assistance with ADLs, while an earlier H&P indicated the resident could understand and make decisions. Staff observed that Resident 2 repeatedly opened and closed the privacy curtain in the shared room to see the roommate, but this behavior was not added to the resident’s care plan. During interviews and record reviews, the MDS nurse stated that nursing staff failed to initiate a care plan for Resident 2’s curtain-opening behavior and confirmed that nurses are responsible for initiating and revising care plans whenever a new condition or issue arises. RN 1 acknowledged that the resident liked to play with the curtain to see the roommate and admitted she did not document this behavior in progress notes or update the care plan. The DON stated that licensed nurses are expected to document any changes in condition and create a nursing progress note every shift, and that Resident 2’s curtain behavior was not documented or monitored each shift. The DON further stated that the care plan was not updated to reflect the resident’s current needs, despite the facility’s policy requiring ongoing assessment and revision of care plans as resident information and conditions change.
Failure to Interview Key Witness in Resident-to-Resident Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy and procedure by not thoroughly investigating an allegation of resident-to-resident physical abuse involving two residents. One resident, admitted with multiple right rib fractures, DM, and HTN, had an H&P indicating lack of capacity to understand and make decisions and an MDS showing moderately impaired cognitive skills. Progress notes and an SBAR documented that this resident reported another resident repeatedly entering his room, leading to an altercation in which he raised his walker in defense, lost his balance, hit the wall, and sustained a right forearm skin tear. The other resident, admitted with sequelae of cerebral infarction, generalized muscle weakness, and difficulty walking, had an H&P indicating capacity to make decisions but an MDS showing severely impaired cognitive skills, and his SBAR documented his account of a verbal altercation escalating when the first resident raised a front-wheel walker, resulting in him becoming tangled with the walker, being hit in the chest, and accidentally hitting the other resident in the face. Multiple staff accounts confirmed that an altercation occurred and that staff intervened. A housekeeper reported seeing the first resident holding his walker up in the air in front of the second resident and stated she separated them before the administrator entered the room. A CNA reported hearing the housekeeper scream for help, observing both residents trying to fight, seeing the first resident attempt to hit the second resident with his walker, and seeing the second resident with his right fist raised attempting to punch but not making contact. This CNA stated she remained in the room with the administrator, assisted the first resident to sit on the bed, and helped calm him. An RN later reported that when she responded to the room, the CNA was present beside the first resident, who was seated on the bed, and that she spoke with the first resident using the CNA as a translator. The facility’s abuse, neglect, exploitation, or misappropriation reporting and investigating policy required that the individual conducting the investigation interview any witnesses to the incident and staff members on all shifts who had contact with the resident during the period of the alleged incident. The DON stated she was not aware that the CNA had responded to the incident and therefore did not initially interview the CNA or obtain a written statement, even though she had obtained statements from other staff including the housekeeper, RN, LVNs, and other CNAs. The DON acknowledged that the allegation between the two residents occurred on a specific date and that the CNA was not interviewed until several days later, that the abuse policy was not followed, and that it was important to interview all staff who were involved in the incident to verify what they observed.
Failure to Measure and Document New Skin Tear per Wound Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s skin condition was assessed and documented according to professional standards of practice and facility policy, resulting in an incomplete medical record. The resident was admitted with diagnoses including multiple right rib fractures, diabetes mellitus, and essential hypertension, and had documented cognitive impairment and lack of decision-making capacity. A skin assessment dated 2/5/2026 showed the resident had a right outer forearm skin tear and a left cheek abrasion following an altercation in which another resident entered the room, the resident raised a walker in defense, lost balance, and hit the wall. An SBAR communication form documented the incident and the resulting right forearm skin tear and left cheek abrasion. During interview, the Treatment Nurse stated he performed the skin check on 2/5/2026, noted the right forearm skin tear and left cheek abrasion with minimal bleeding, but did not measure the skin tear and acknowledged he does not measure skin issues all the time, despite stating that measurements should be done with any new skin changes to track improvement. The DON confirmed the Treatment Nurse should have measured the skin tear and that, without measurements, the facility would not know if the skin tear was getting better or worse or if treatment was effective, and that the medical record was incomplete and facility policy was not followed. Review of the facility’s Wound Care policy required that all assessment data, including wound size, be recorded, and the Investigating Resident Injuries policy required objective, sufficiently detailed descriptions, including dimensions of injuries, which were not documented in this case.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck her on the left cheek while both were in the hallway. The incident occurred as one resident was wheeling herself in her wheelchair and was approached by another resident, who was being pushed by a CNA. The aggressor resident reached out, grabbed the victim's left arm, and punched her on the left cheek. Multiple staff members, including CNAs and nurses, witnessed or were immediately informed of the event, and documentation confirmed the physical contact and the resident's report of being hit. The resident who was struck had a history of transient cerebral ischemic attack, unspecified encephalopathy, and generalized muscle weakness. Her cognitive skills for daily decisions were moderately impaired, and she required moderate assistance for activities such as toileting and showering. The aggressor resident had diagnoses including metabolic encephalopathy, diabetes mellitus, and generalized muscle weakness, with severely impaired cognitive skills and no capacity to make decisions. Staff interviews and records indicated that the aggressor resident had a known history of aggressive behaviors, including previous incidents directed at staff. Facility policy and procedure documents, as reviewed with the Director of Nursing and other staff, clearly state that residents have the right to be free from abuse, including physical abuse by other residents. Staff interviews consistently identified the incident as abuse, regardless of the aggressor's cognitive status or the absence of physical injury. The event was substantiated by witness statements, resident reports, and facility documentation, confirming that the resident was not protected from physical abuse as required by facility policy.
Failure to Administer Ordered Pain Medication for Resident with Severe Pain
Penalty
Summary
A resident with multiple rib fractures, a history of falls, and hypertensive heart disease with heart failure was admitted to the facility and had a physician's order for hydrocodone-acetaminophen to be administered every four hours as needed for moderate to severe pain (pain level 4-10). The resident's Minimum Data Set indicated occasional pain at a level of six out of ten, and the Medication Administration Record documented a pain level of eight out of ten on a specific date. However, there was no documentation that the ordered pain medication was administered at that time. Interviews with the resident confirmed ongoing severe pain, particularly when being moved or turned, and that pain medication provided only short-term relief. The Assistant Director of Nursing and the Director of Nursing both acknowledged that the nurse should have administered the pain medication as ordered and that there was no documentation of administration or follow-up. Facility policies reviewed indicated that medications are to be administered according to prescriber orders and that pain should be addressed with appropriate interventions.
Failure to Follow Physician's Order for Blood Pressure Parameters in Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) administered sacubitril-valsartan to a resident despite a physician's order to hold the medication if the resident's systolic blood pressure (SBP) was below 110 mmHg. On the date in question, the resident's blood pressure was recorded at 109/77 mmHg, yet the medication was still given. The resident had a history of multiple rib fractures, falls, and hypertensive heart disease with heart failure. The medication order specifically instructed staff to withhold sacubitril-valsartan for SBP less than 110 mmHg or heart rate less than 60 beats per minute. Record reviews confirmed that the medication was administered contrary to the physician's order, and this was acknowledged by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. Facility policy required medications to be administered as prescribed, including verification of vital signs when necessary. Documentation in the Medication Administration Record (MAR) and progress notes indicated that the medication was given despite the resident's blood pressure being below the specified threshold.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
Facility staff failed to report an allegation of physical abuse in a timely manner after a resident, who had intact cognitive functioning and a history of anxiety disorder, multiple sclerosis, and chronic pain syndrome, reported being hit on the legs by her roommate. The incident was first disclosed by the resident to a Certified Nurse Assistant (CNA), who then informed a Licensed Vocational Nurse (LVN), and subsequently a Registered Nurse (RN). Despite the resident's clear statements to multiple staff members on the night of the incident, the allegation was not immediately reported to the facility's Administrator or to the required authorities as outlined in the facility's abuse reporting policy. Interviews with staff confirmed that the CNA, LVN, and RN were all made aware of the resident's claim that her roommate had hit her legs. The RN acknowledged that the resident's statement constituted an allegation of physical abuse and should have been reported immediately to the Administrator, who also served as the Abuse Coordinator. The Director of Nursing (DON) and the Administrator both stated that the facility's policy required immediate reporting of suspected abuse, defined as within two hours, but this protocol was not followed. Instead, the staff delayed reporting, and the investigation was not initiated until several days later when the resident informed the Administrator directly. Facility records and interviews revealed that staff did not report the allegation because they believed the accused resident was not capable of such behavior. This decision was made despite the facility's policy, which mandates reporting all suspicions of abuse regardless of staff assumptions. The failure to report the incident promptly resulted in a delay in investigation and intervention, as confirmed by the facility's own documentation and staff statements.
Failure to Assess and Notify Physician After Resident Abuse Allegation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who reported an allegation of physical abuse by another resident. On the evening of the incident, the resident informed a CNA that her roommate had hit her legs. The CNA relayed this information to an LVN, who then spoke with the resident and confirmed her complaint of pain in her legs. Despite this, there was no documentation that a body assessment was performed or that the physician was notified at the time of the allegation. Record reviews showed that the resident had a history of anxiety disorder, multiple sclerosis, and chronic pain syndrome, and was dependent on staff for several activities of daily living. The resident was cognitively intact and able to communicate her needs and experiences. The care plan and SBAR forms indicated that the resident was at risk for emotional distress related to the abuse allegation, but there was no evidence that an assessment or physician notification occurred immediately following the report of abuse. Interviews with nursing staff and the DON confirmed that facility policy required immediate assessment and physician notification in the event of an abuse allegation, which was not followed in this case. The facility's own investigative summary noted that staff failed to report the allegation because they believed the accused resident was not capable of such behavior. This failure to follow protocol resulted in a delay in care and monitoring for the resident who reported the abuse.
Failure to Notify Physician and Document Urostomy Care
Penalty
Summary
A deficiency occurred when a resident with a urostomy did not receive care consistent with professional standards, the care plan, and physician orders. The resident, who had multiple complex diagnoses including multiple sclerosis, bladder cancer, and a history of acute pyelonephritis, was observed to have cloudy urine with white sediments in the urinary tubing. Despite this, staff failed to notify the physician of these abnormal findings, as required by both the resident's care plan and facility policy. Certified Nursing Assistant (CNA) observed the cloudy urine but did not report it to the Licensed Vocational Nurse (LVN), and the LVN only became aware of the issue after being informed later. The Director of Nursing (DON) and other staff confirmed that the physician should have been notified immediately about the abnormal urine appearance. Additionally, the facility failed to assess, monitor, and document the resident for signs of urinary tract infection (UTI) as indicated in the care plan. The care plan specifically required monitoring for symptoms such as pain, burning, blood-tinged urine, cloudiness, changes in urine output, and other signs of infection. However, review of the resident's progress notes and other documentation revealed that there was no consistent monitoring or documentation of these signs and symptoms. The Director of Staff Development (DSD) acknowledged that nurses did not document assessments of urine color, odor, or presence of sediments every shift, as required by policy. Furthermore, the facility did not follow the physician's order to monitor and document the resident's urine output in milliliters (ml) every shift. Instead, documentation in the Medication Administration Record (MAR) only indicated the number of times the resident urinated, not the actual volume, which was contrary to the physician's explicit instructions. The DSD and DON both confirmed that this failure to document urine output in ml could result in unrecognized urine retention. Facility policy also required accurate measurement and documentation of input and output, which was not followed in this case.
Plan Of Correction
F 691 F 691a. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice On 4/30/25, LVN 1 immediately called MD to notify him of Resident 1 urinary tubing sediments and cloudy urine. ADON placed an order in PCC for monitoring of foley catheter output for Resident 1 on 05/01/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken ADON reviewed all other residents with foley catheter on 4/30/25 and noted no change of condition indicated, therefore, no notification to MD was required. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25 F 691 F 691. b&c How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice DON performed one-to-one in-service to LVN 1 on 4/30/25 regarding proper documentation of monitoring urine output in milliliters as well as documentation and proper assessment of the quality of the output. DON also reviewed the importance of following physician order. DON also reviewed facility policy and procedure "Urinary Catheter Care" with LVN 1 on 4/30/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken ADON reviewed all other residents in the facility with foley catheter on 4/30/25 and found no other signs of UTI related to catheter care. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding proper documentation of urine output in milliliter (ml-unit of volume) as well as facility policy and procedure "Urinary Catheter Care". DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding appropriate documentation of foley catheter including quality and quantity of urine output in ml (ml-unit of volume) as well as policy and procedure "Urinary Catheter Care". How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON and/or designee to conduct random reviews of residents weekly with foley catheter to verify appropriate documentation including quality (sediments/hematuria/cloudiness) and quantity of urine output in ml (ml-unit of volume) and any change of condition(s). Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for 3 months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25
Failure to Maintain Resident Dignity by Not Covering Urinary Collection Bag
Penalty
Summary
A deficiency occurred when staff failed to maintain a resident's dignity by not ensuring the resident's urinary collection bag was covered with a privacy bag. The resident, who had multiple diagnoses including multiple sclerosis, bladder cancer, and acute pyelonephritis, required maximum assistance for daily activities and had a urinary catheter or urinary ostomy. During an observation, the urinary collection bag was found hanging on a bedside drawer handle without a dignity cover. Staff interviews confirmed that the cover had been removed during care and was not replaced, and that staff were aware the bag should be covered for privacy. The facility's policy required that urinary catheter bags be covered to promote resident dignity and self-esteem. Multiple staff members, including a CNA, LVN, and the DON, acknowledged that the urinary collection bag should have been covered and that its absence could affect the resident's psychosocial wellbeing. The failure to provide the dignity cover was confirmed through observation, staff interviews, and review of facility policy.
Plan Of Correction
Residents rights/Exercise of Rights How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: CNA 1, on 04/30/2025, immediately placed a dignity bag on Resident 1's urinary collection bag. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Infection Control Nurse, on 4/30/25, completed a facility audit of all residents with foley catheter with dignity bag and found no other deficiencies noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: DON performed one-to-one in-service on 4/30/25 to CNA 1 and LVN 1 regarding placement of dignity bag to cover resident urine collection bag; and facility policy and procedures for Dignity and Infection Control. DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding placement of dignity bag over residents' urine collection bags as well as the facility policies for Infection Control and Dignity. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Managers and staff will perform facility room rounds using the facility tool entitled "Resident Centered Care Room Rounds Report" Monday to Friday to verify all foley catheters' urine collection bags have a dignity bag in place. On weekends, the Manager of the Day or designee will perform these room rounds to verify all appropriate dignity bags are in place. The Director of Nursing will collect and review room rounds data weekly and will report audit findings to the Quality Assurance Committee monthly for three months for review and evaluation. The Director of Nursing and/or Administrator will determine if continued auditing and monitoring are recommended after three months. Completion Date 5/22/25 F 550 F 550 Develop/Implement Comprehensive Care Plan
Failure to Implement Person-Centered Care Plan for Urostomy Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan for a resident with a urostomy, as required by federal regulations. The resident, who had diagnoses including multiple sclerosis, a malignant neoplasm of the bladder, and acute pyelonephritis, was admitted with a care plan intervention to monitor, record, and report signs and symptoms of urinary tract infection (UTI) to the physician. The care plan specifically listed symptoms such as cloudy urine, presence of sediments, and other indicators of infection that should prompt physician notification. On the day of the incident, observations revealed that the resident's urinary tubing contained cloudy urine with white sediments. The Assistant Director of Staff Development confirmed these findings and stated that the Certified Nursing Assistant (CNA) should have reported this to the Licensed Vocational Nurse (LVN). However, the CNA admitted to noticing the cloudy urine but did not report it to the LVN. The LVN only became aware of the issue after being informed later and acknowledged that such findings are possible signs of infection and should be reported to the physician without delay. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that the care plan was not followed, as the physician was not notified about the abnormal urine findings. The facility's policy required that any abnormalities in urine output, such as sediments or changes in color, be reported to the physician. The failure to follow the care plan and notify the physician as required constituted the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 4/30/35, Treatment Nurse immediately replaced urostomy tubing and bag for Resident 1. The care plan was updated by LVN 1 on 4/30/25, and the physician was notified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Infection Control Nurse on 4/30/25 completed a facility audit of all residents with Foley catheter to check for sedimentation and cloudiness in the output. Additionally, IP Nurse verified all care plans were in place for all residents with Foley catheter on 4/30/25. All residents with Foley Catheter have care plans in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: DON performed one-to-one in-service on 4/30/25 to CNA 1 regarding prompt reporting of any cloudy urine or sediment present in the urinary tubing and catheter bag to the LVN. DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding prompt reporting to MD of any cloudy urine, sediment, blood in urine, and/or change in condition. Additionally, DON reviewed the facility policy and procedure "Comprehensive Person-Centered Care Plans". DON performed licensed staff in-service to LVNs and RNs on 4/30/25, 5/1/25, and 5/2/25 regarding prompt reporting to MD of any cloudy urine, sediment, blood in urine, and/or change in condition. Additionally, DON reviewed the facility policy and procedure "Comprehensive Person-Centered Care Plans". How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Medical records department to audit care plans weekly for three months for residents with Foley catheter, to ensure care plan is being followed. Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for three months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25
Failure to Provide Dignity Bag for Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received proper care and services by not providing a dignity bag to cover the catheter drainage bag. This oversight was observed during a record review and an interview with a Licensed Vocational Nurse, where it was noted that the resident's catheter drainage bag was exposed and lacked a dignity bag. The facility's policy and procedure on dignity, which was last reviewed in January 2025, mandates that urinary catheter bags should be covered to promote the resident's sense of well-being and self-esteem. The resident, admitted on February 25, 2025, had a diagnosis of cerebral infarction and was using a Foley catheter for urinary retention due to benign prostatic hyperplasia. The care plan for the resident, initiated on February 26, 2025, included an intervention to ensure the catheter drainage bag was covered. However, during an interview, a Certified Nursing Assistant mentioned that the dignity bag was present before a lunch break, but it was not in place during the observation. The Director of Nursing confirmed that the dignity bag should have been used to protect the resident's privacy, as its absence could negatively impact the resident's psychosocial well-being.
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Nursing homes near N Hollywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Valley Health Care Center | 0.6 mi | ★★★★★ | 26 | 1 |
| Valley Village Care Center | 1 mi | ★★★★★ | 30 | 0 |
| The Care Center On Hazeltine, Llc | 1.2 mi | ★★★★★ | 12 | 0 |
| All Saints Healthcare Subacute | 1.8 mi | ★★★★★ | 36 | 1 |
| Four Seasons Healthcare & Wellness Center, Lp | 2.6 mi | ★★★★★ | 24 | 0 |
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