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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Village Care Center during CMS and state inspections, most recent first.
Unsafe window sealing and dirty fan affected resident environment. Two residents shared a room with a temporary portable AC that was attached to the window with loose painter's tape, and an LVN observed breeze coming through the gaps. An IP and ADON stated the seal should have been properly secured to prevent outside air from entering and to maintain room comfort. In a separate observation, a resident's electric desk fan had a moderate amount of gray dust on the front, back, and blades; a CNA identified the buildup as dust, and the ADON stated the fan should have been kept clean to support a homelike environment.
An LVN crushed and administered a resident’s oral meds with applesauce without a physician order, despite the resident’s dysphagia and the facility policy requiring written orders before crushing medications. In a separate event, an LVN administered senna to a resident on a dialysis day after the resident said he could not take it before leaving; the resident later said he did not refuse the dose and wanted the timing changed, but the physician was not notified about the request.
A pureed diet was not prepared according to the facility menu and recipe standards when the SLP directed the cook to add liquid thickener to blended food without using the measured substitute recipe. During trayline and dining observation, the food was runny, did not hold its shape, and was served to a resident with malnutrition, dementia, and other diagnoses. The RD, DS, SLP, and DON all stated the puree was not at the proper IDDSI Level 4 consistency and did not look appealing.
A resident on a pureed diet received a meal that was runny and did not hold its shape, and the same issue affected all residents on pureed diets observed by surveyors. The RD, DS, and DON all confirmed the puree consistency was not correct, with staff noting the food should be smooth, free of lumps, and hold its shape. The resident, who had dx including malnutrition, dementia, muscle weakness, and depression, ate only a small amount before indicating she did not want to continue.
Inaccurate Medication and Fluid Documentation: An LVN documented a resident’s request to delay senna for dialysis as a refusal instead of a timing request, another resident’s fluid intake was charted above the ordered restriction on the MAR, and Vancomycin was documented as given hours after the scheduled time despite staff stating it was administered on time. The records did not accurately reflect the residents’ care, medication timing, or ordered intake limits.
A facility failed to keep HVAC and related equipment in safe operating condition when one HVAC unit was out of service and portable AC units were placed in several resident rooms and other areas, including the rehab therapy room, DON office, activity office, and laundry room. Residents with COPD, pulmonary fibrosis, emphysema, CKD, and ESRD were observed with portable AC units in their rooms, with vents sealed using tape or foam, and residents reported rooms that were warm at times and cold at night.
Failure to assess bedside self-administration of medication: A resident with capacity to make decisions kept oxymetazoline HCl nasal spray on the bedside table and used it on his own, but the initial self-administration assessment said he did not want to self-administer and no further assessment was completed. Staff observed the nasal spray at bedside on multiple occasions, and an LVN confirmed there was no MD order authorizing self-administration or bedside storage. The DON and LVN stated staff should have identified the medication during rounds and completed the required assessment.
Advance Directive Discussion Not Documented: A resident with COPD, dementia, and anxiety disorder had severely impaired cognition and was documented as lacking capacity to make decisions, but the chart did not show that an AD was discussed or offered. The AHCD acknowledgement form was blank and did not indicate whether written information was provided, whether the resident refused, or why the form was not completed; the SSD and ADON both confirmed the documentation was incomplete.
Improper Use of Bedding as a Physical Restraint: A resident with dementia, muscle weakness, anemia, and ESRD was observed lying in bed with two pillows tucked under the fitted sheet on both sides. An LVN stated the pillows were being used for repositioning but should not be tucked under the sheet, and an RN and the DON confirmed there was no restraint order. Facility policy defined physical restraints as items the resident cannot easily remove that restrict movement and specifically identified tightly tucked sheets that prevent movement as an inappropriate restraint practice.
BiPAP Care Plan Not Followed for a Resident with COPD and OSA. A resident who used BiPAP nightly had a care plan and MD order directing staff to empty the water chamber, rinse it with warm water, and air dry it after use. During observation, the chamber still had water droplets inside, and the resident said staff had not cleaned the machine. An LVN stated the day shift cleans the BiPAP, but he had not cleaned it that day; the IP and ADON confirmed the cleaning and drying process was part of the resident’s care plan and was not implemented.
Care plan did not include ordered heel offloading intervention. A resident with a stage 1 pressure injury to the left foot had a physician order for heel protectors and pillow offloading, but the care plan only listed wound cleansing, ointment, and a foam dressing. During observation, a CNA did not place a pillow under the resident’s left foot, and the MDSC and DON stated the offloading intervention should have been included in the care plan.
Failure to provide ordered pressure ulcer care occurred when a resident with mild cognitive impairment, right-sided hemiplegia, and a stage 1 pressure injury to the left foot was repeatedly observed without the ordered pillow under the left foot. The physician ordered heel protectors and pillow offloading at all times except during showers and ADLs, but CNA and TN observations confirmed the pillow was not in place, despite staff stating it was needed to keep the heel offloaded and prevent worsening of the injury.
A resident’s oxymetazoline HCl nasal spray was left on a bedside table in a shared room and remained accessible even when the resident was out of the room, despite no order for self-administration and an AASAM indicating he did not want to self-administer meds. In a separate incident, another resident with dementia, prior fractures, and a history of falls was observed in bed without the ordered right-side floor mat in place while staff had temporarily moved it during feeding and failed to return it.
A resident with an indwelling urinary catheter was observed in bed with the drainage bag hanging on the side of the bed and the tubing forming a dependent loop with urine present in the tubing. An LVN stated the loop was preventing urine from flowing freely, and the DON/ADON confirmed catheter tubing should not be coiled or looped because it can block free flow and allow backflow. The resident had diagnoses including obstructive and reflux uropathy, and the physician’s order required the bag to stay below the bladder and the tubing to remain free of dependent loops and kinks.
A resident receiving GT feedings had a water flush bag left in use beyond the manufacturer’s 24-hour limit. The resident had dementia, severely impaired cognition, and required total assistance with ADLs. An LVN and the ADON both acknowledged the facility’s practice was to change water flush bags with the formula bags or after 48 hours, despite the manufacturer’s recommendation to limit use to 24 hours because of bacterial contamination concerns.
BiPAP cleaning and oxygen tubing handling were not followed for two residents. One resident’s BiPAP water chamber was observed with condensation despite an order to empty, rinse, and air dry it after use, and staff stated the machine was not cleaned as expected. Another resident receiving continuous O2 via NC was observed with tubing touching the floor, even though staff stated the tubing should be secured off the floor using a Velcro strap or stored in a plastic bag to prevent contamination.
Medication Crushing Without Physician Order: An LVN crushed and administered seven medications to a resident with COPD, dementia, dysphagia, and other diagnoses without a physician order to crush them, resulting in a 24.14% medication error rate during observation. The resident was on a pureed diet and dependent on staff for care, and the DON confirmed the facility requires a physician order before medications are crushed because altering a tablet may change its action on the body.
Failure to Serve Listed Food Preference: A resident with dysphagia, dementia, and failure to thrive was on a pureed diet with HPN and had a care plan to honor food preferences. During a dining observation, staff found that ice cream listed on the meal ticket was not served with the lunch tray, and RN and ADON confirmed the item was overlooked during tray inspection and was not provided as indicated.
A yellow bell pepper with white and gray discoloration was found in a green tray inside the walk-in refrigerator during a kitchen tour. The DS stated the pepper had signs of rotting and should have been discarded, and the DON stated that vegetables with signs of spoilage must be cut and properly washed or thrown away. The facility policy required produce to be fresh and free of wilting or spoilage.
A resident receiving hospice care with dementia, Parkinson’s disease, and encephalopathy had ordered CHHA services once weekly, but the HA did not visit on two scheduled occasions. The facility could not locate HA notes for those visits, and an RN visit note incorrectly indicated an HA evaluation was completed when the ADON later confirmed no such evaluation was done and the missed visits were not documented or followed up with the hospice provider.
Failure to Implement EBP for Resident with Left Foot Wounds: A resident with dementia, PVD, and two diabetic wounds on the left foot had wound care orders and was observed with the foot wrapped in gauze. The IP stated there was no physician order for EBP and no blue sticker next to the resident’s name, even though an EBP sign was posted outside the room. The ADON stated residents with draining wounds should have an EBP order, posted sign, and blue sticker so staff know to use proper PPE during high-contact care.
Inaccurate MDS Coding for Splint Use and Antibiotic Administration: A resident with hemiplegia, hemiparesis, contracture, and dementia had an MDS that did not correctly reflect restorative nursing splint use, even though RNA treatment records and observation showed bilateral knee splints were applied daily. Another resident’s MDS incorrectly indicated antibiotic use despite the order summary, discontinued orders, and acute hospital records showing no antibiotic was given. The MDSC and ADON identified both entries as coding errors and stated the MDS should reflect the resident’s actual clinical picture.
A resident with impaired cognition and multiple health issues was not promptly reported missing after leaving the facility with a family member. An LPN spent 30 minutes searching alone before notifying the RN, delaying the code pink response and resulting in the resident missing a prescribed insulin dose for elevated blood sugar. Facility policy required immediate action, which was not followed.
A facility failed to rotate insulin injection sites for a resident with diabetes, contrary to guidelines, risking adverse effects. Additionally, another resident on anticoagulant therapy lacked necessary monitoring for bleeding, as no physician's order was in place. These deficiencies were confirmed by staff and identified through interviews and record reviews.
The facility failed to maintain a safe environment, leading to potential accident hazards for several residents. A resident's path to the bathroom was obstructed, medications were left unattended, and fall risk assessments were inaccurately documented. Additionally, two residents had furniture placed on their floor mats, compromising safety. Staff interviews confirmed these deficiencies.
A LTC facility failed to provide adequate pharmaceutical services for five residents, leading to several deficiencies. Medications for a resident were not labeled with the complete date of opening, and another resident received pain medication against physician orders. Additionally, a resident's medication count was inaccurately documented, and potassium was administered with insufficient water. Lastly, a resident on heparin was not monitored for bleeding due to a lack of physician orders. These actions were against the facility's policies and procedures.
Two residents in a facility experienced significant medication errors. One resident with diabetes received insulin injections without proper site rotation, contrary to professional standards and facility policy. Another resident was given heparin without the route of administration being specified in the physician's order, leading to 102 instances of administration without clarification. Staff acknowledged these errors, which were identified through interviews and record reviews.
The facility failed to maintain safe food storage and preparation practices, with unmonitored storage room temperatures and expired or unlabeled food items found in the kitchen. Staff interviews confirmed the importance of proper labeling and temperature monitoring to prevent foodborne illnesses, as outlined in the facility's policies.
The facility failed to maintain infection control by not cleaning Prostat bottles on medication carts and lacking knowledge of legionella indicators. LVNs admitted to not cleaning sticky Prostat bottles, violating policy. The Maintenance Director and Infection Preventionist were unaware of biofilm, crucial for legionella prevention, compromising the water management program.
A resident with severe cognitive impairment was exposed during care when a CNA failed to fully close the privacy curtain, breaching the facility's dignity and privacy standards. Interviews confirmed the importance of maintaining privacy to protect residents' self-esteem and self-worth.
The facility failed to obtain written informed consent for two residents before administering antidepressants, violating their rights to make informed decisions. One resident, with severely impaired cognitive skills, did not have their representative's consent documented for bupropion use. Another resident, with moderate cognitive impairment but decision-making capacity, did not have their consent documented for venlafaxine use. The facility's policy requires written consent before administering psychotherapeutic medications, which was not followed in these cases.
The facility failed to ensure call lights were within reach for two residents, both at high risk for falls and requiring substantial assistance. Despite care plans and physician orders indicating the need for accessible call lights, staff did not comply, leaving one resident's call light on the floor and another's out of reach. Observations confirmed these deficiencies, which could delay care and services.
The facility failed to inform two residents about their right to formulate an advance directive, violating their rights. One resident, with conditions like cardiomyopathy, was not offered information about advance directives upon admission. Another resident, unable to make medical decisions, had no documentation of advance directive discussions with their representative. The facility's policy requires providing such information and documenting decisions, which was not followed.
A facility failed to notify a resident's representative of a low iron level, violating the policy for changes in condition. The resident, with multiple diagnoses, had a lab result indicating low iron, but no SBAR was completed, and the family was not informed. The DON confirmed the need for an SBAR and care plan, which were not done.
A facility failed to maintain the confidentiality of a resident's medical records when an LVN left an EHR open and unattended. The incident involved a resident with a history of TIA, hypertension, and hyperlipidemia. The LVN acknowledged the oversight, and the DON confirmed the requirement to minimize screens to protect resident information.
A facility failed to provide a safe and homelike environment for a resident by not replacing a torn floor mat, which was part of the resident's fall prevention plan. The resident, who had severe cognitive impairment and required total assistance with daily activities, was affected by this deficiency. The facility's policy emphasized the importance of maintaining a clean and safe environment, and staff were responsible for reporting any equipment in disrepair.
A resident's bed was positioned against the wall, restricting movement without proper documentation or consent. Despite the resident's ability to make decisions, there was no restraint assessment, informed consent, or care plan. Staff were unaware of the rationale, and the facility's policy on restraint use was not followed, posing potential risks to the resident.
The facility failed to timely develop comprehensive care plans for two residents. One resident, readmitted with a heparin order, had a care plan initiated nearly a month late, while another resident with low iron levels had no care plan for monitoring anemia or addressing iron supplementation risks. These deficiencies could delay necessary care and treatments.
A facility failed to update a resident's care plan after a physician increased the dosage of bupropion and changed insulin orders. The care plan, last updated months prior, did not reflect these changes, potentially delaying necessary care. Interviews with staff confirmed the oversight, highlighting the importance of updating care plans to guide medication administration and ensure all staff are aware of current care plans.
A resident with hemiplegia and malnutrition was not consistently provided with meal assistance as ordered by the physician. Despite requiring significant help and cueing to eat, the resident's need for assistance was not reflected in staff assignments, leading to minimal food intake. Observations and staff interviews confirmed the lack of adherence to facility policies on meal assistance.
A resident with multiple diagnoses, including hemiplegia and epilepsy, had a low iron level detected in lab results. Despite notifying the NP and initiating treatment with ferrous sulfate, the facility failed to create an SBAR to document and monitor the resident's condition. Interviews with staff confirmed the necessity of an SBAR for such changes, as per facility policy.
A resident with a history of hemiplegia and malnutrition was not provided with necessary meal assistance, leading to inadequate food intake. The facility failed to notify the resident's MD when the resident consumed less than 50% of meals on multiple occasions, contrary to the care plan. Staff interviews revealed inconsistencies in communication and documentation, posing a risk of malnutrition and delayed care.
A facility failed to conduct necessary behavioral IDT meetings for a resident on Seroquel and escitalopram, despite multiple behavioral episodes. The resident, with diagnoses including dementia and depression, had care plans requiring medication discussions, but no IDT meetings with the psychiatrist were documented. Facility staff confirmed the lack of documentation and the importance of these meetings for medication adjustments.
A facility failed to act on a pharmacist's recommendation for a TSH blood draw for a resident on amiodarone, and did not identify irregularities in another resident's anticoagulant regimen. The first resident did not have a TSH test ordered or conducted, and the second resident received heparin without clarifying discrepancies in the physician's order and medication label. The facility's medication regimen review policy was not followed, leading to potential risks for the residents.
A facility failed to obtain informed consent for a resident when increasing the dosage of bupropion, a psychotropic medication. The resident, with impaired cognitive skills and lacking decision-making capacity, had their medication increased without the necessary consent, contrary to facility policy. Interviews with facility staff confirmed the oversight, emphasizing the importance of adhering to protocols for resident rights and medication administration.
Two medication errors resulted in a 7.69% error rate at an LTC facility. An LVN gave a resident potassium chloride with insufficient water, against physician orders. Another LVN administered heparin without clarifying the order, which lacked a specified route. Both errors were confirmed through staff interviews and policy reviews.
A facility failed to follow the prescribed menu and meet the nutritional needs of a resident at nutritional risk due to adult failure to thrive. The resident's care plan required adherence to a diet and consideration of food preferences. A delivery issue led to a substitution of corn for green beans, which the resident disliked and refused to eat. The Dietary Supervisor acknowledged the error, and the Registered Dietitian confirmed the substitution but was unaware of the resident's refusal, potentially affecting the resident's intake.
A resident's medical records contained inaccurate documentation of blood pressure, leading to potential confusion in care. The MAR showed a blood pressure of 18/62 instead of the correct 118/62, affecting medication administration. Interviews with staff highlighted the importance of accurate documentation, as per facility policy.
A facility failed to involve a resident or their representative in the initial IDT meeting for hospice care planning, despite the resident's severe cognitive impairment and need for substantial assistance. This oversight, confirmed by staff interviews, contradicted the facility's policy and had the potential to delay necessary hospice services.
A resident receiving vancomycin for pneumonia was not monitored for side effects as required by the facility's policy. Despite the medication being administered, there was no documentation of monitoring in the MAR, Progress Notes, or Daily Skilled Medicare Charting. Interviews with staff confirmed the deficiency in following the facility's antibiotic stewardship and infection surveillance policies.
Unsafe window sealing and dirty fan affected resident environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when it did not ensure that the window area around a temporary portable AC was well sealed for two residents. Resident 8 had diagnoses including COPD, obstructive sleep apnea, and convulsions, and Resident 1 had diagnoses including pulmonary fibrosis, emphysema, and bipolar disorder. Resident 1 stated the portable AC had been provided because the room became warm, especially near the laundry room, but the room also became cold and the unit had not been turned on. Resident 8 stated the room could get warm on hot days, but it had been cold recently and the portable AC had not been used lately. During a concurrent observation and interview, the portable AC in the shared room for Residents 8 and 1 was observed attached to the window with blue painter's tape. The LVN stated the tape was loose and could feel breeze coming in through the window, and stated the window should be well sealed with no gaps because it defeats the purpose of regulating the room temperature with the portable AC. The IP stated the seal was maintained by maintenance and needed to be properly secured to prevent outside air from entering, noting that the room temperature may be affected and that hot air keeps coming in and defeats the purpose of cooling the room. The ADON also stated the seal was intended to prevent outside air from entering and that fluctuations in air temperature made the room uncomfortable and did not support a homelike environment. The facility also failed to maintain the cleanliness of Resident 50's electric desk fan. Resident 50 had diagnoses including Parkinson's disease, dementia, and anxiety disorder, and the resident had moderately impaired cognition and required total assistance with all ADLs except supervision or touching assistance with eating. During observation, the fan had a moderate amount of gray streaks on the front and back panels and on the fan blades. A CNA stated the gray streaks were dust and that maintenance was responsible for cleaning the fan. The ADON later reviewed a photograph of the fan and stated it had a lot of gray dust on the front and back panels, that maintenance was responsible for keeping electric fans and resident equipment clean, and that the fan should have been kept clean because the resident could inhale dust particles and it was not providing a homelike environment.
Medication Administration Errors Involving Crushed Medications and Senna Timing
Penalty
Summary
The facility failed to provide pharmaceutical services for two residents during medication administration observations and record review. For one resident with COPD, HTN, unspecified dementia, major depression, metabolic encephalopathy, malnutrition, and dysphagia, the record showed orders for multiple oral medications, including amlodipine, ascorbic acid, memantine, a multivitamin with minerals, oyster shell calcium/vitamin D, rifaximin, and sertraline. During the 9 a.m. medication pass, an LVN stated the resident was on a pureed diet and crushed the medications with applesauce before administering them. A later review of the physician orders showed there was no order to crush the medications, and the LVN stated she had assumed such an order existed. The DON reviewed the facility policy and stated a physician order is required before crushing medications. The DON also stated that not all medications can be crushed and that altering a tablet may change its action on the body. The facility policies reviewed stated medications are to be administered as prescribed in accordance with written physician orders and that medications shall be crushed only when appropriate and safe to do so, consistent with physician orders. The policy also stated the MAR or other documentation must indicate why it was necessary to crush the medication. For a second resident with CKD, ESRD, and left shoulder pain, the physician ordered sennosides 8.6 mg, two tablets by mouth twice a day on Monday, Wednesday, and Friday for bowel management, with instructions to hold for loose stools. During medication administration, an LVN prepared and administered the senna, and the resident stated he could not take it because he had dialysis that day. The resident later stated he did not refuse the medication and explained that on dialysis days he does not take it before leaving because he cannot go anywhere for four hours. The LVN later stated he should have notified the physician about the resident’s request to change the timing of the senna and acknowledged he did not document the risks and benefits accurately.
Pureed Diet Preparation Did Not Follow Menu or Recipe Standards
Penalty
Summary
The facility failed to follow the menu and did not meet the nutritional needs of residents on a pureed diet when the SLP instructed the cook to add liquid thickener to blended food without using the measured recipe for substitutes. The report states this affected twelve out of twelve residents on a pureed diet and involved the facility’s IDDSI Level 4 pureed food preparation process. The deficiency was identified during observation, interview, and record review in the trayline area while pureed food was being prepared for lunch. Resident 12 was admitted with diagnoses including malnutrition, muscle weakness, dementia, and depression, and the H&P stated the resident did not have the capacity to understand and make decisions. The facility’s diet order listed Resident 12 on a pureed diet. During the trayline observation, the SLP performed a fork drip test and directed the CK to add more liquid thickener to the blended food when the consistency was not to her liking. The CK added liquid thickener with a pump, and after the SLP left the kitchen, the pureed food later appeared runny and did not hold its shape. The lunch menu for that day included tarragon chicken, oven roasted potatoes, green beans with red bell peppers, broccoli salad, and tropical fruit mold. The facility’s pureed food recipes specified measured amounts for pureed meats, vegetables, and starches, with stabilizer options listed if needed. During dining observation, Resident 12 was served runny brown, green, and light yellow food and ate only a spoonful of pudding, part of the brown food, and thickened red juice before gesturing that she no longer wished to continue eating. The RD, DS, SLP 2, and DON all stated the pureed food did not have the proper consistency, did not hold its shape, and did not look appealing, and the facility policy stated pureed food should be smooth, free of lumps, hold its shape, and not weep.
Pureed Diet Meals Served Runny and Failed to Hold Shape
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet individual needs when 12 of 12 residents on a pureed diet received meals that were runny and did not hold their shape. The deficiency was identified through observation, interview, and record review during trayline and dining observations, where the pureed food was seen as watery, flat, and not maintaining the expected puree consistency. The facility policy for IDDSI Level 4 pureed diet stated the food should be smooth, free of lumps, hold its shape, and not weep. Resident 12 was admitted with diagnoses including malnutrition, muscle weakness, dementia, and depression, and the H&P stated the resident did not have the capacity to understand and make decisions. The resident was ordered a pureed diet. During the lunch observation, the resident’s tray contained runny brown, green, and light yellow food, and the resident ate only a small amount of the food before indicating by gesture that she no longer wished to continue eating. Staff interviews confirmed the meal did not meet the intended puree consistency. The RD stated the pureed diet served at lunch did not reach the adequate consistency of the ideal puree blend and did not hold its shape. The DS stated pureed food should be smooth, free of lumps, not runny or hard, and should hold its shape, and noted that liquid thickener had been added to the blended food. The DON also stated the pureed lunch was runny, did not hold its shape, and did not look appealing to residents.
Inaccurate Medication and Fluid Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving senna for bowel management. The resident had chronic kidney disease, ESRD, pain in the left shoulder, and was documented as cognitively intact and able to understand and make decisions. During medication administration, the resident told the LVN that he could not take senna because he had dialysis that day and explained that he did not want to take it before leaving because he would be gone for several hours. The LVN documented the interaction as a refusal and recorded that risks and benefits had been explained, although the explanation was not observed. The resident later stated that he did not refuse the medication and that staff normally offers it after dialysis. The LVN later stated the resident’s statement should have been clarified as a request to change the timing of the medication, not a refusal, and that the documentation did not accurately reflect the resident’s request. The facility also failed to accurately document fluid intake for a resident with ESRD, CHF, muscle weakness, and impaired decision-making capacity. The resident had a fluid restriction of 800 mL per 24 hours, with specific amounts assigned across meals and shifts. On the date reviewed, the MAR showed fluid intake entries that totaled 1,280 mL for the 24-hour period, including an entry of 800 mL for the night shift when the LVN later stated that only 50 mL should have been documented for that shift. RN 1 confirmed that the documentation exceeded the ordered restriction and that LVN staff were responsible for monitoring and documenting fluid restriction. The LVN later stated the 800 mL entry was an error and that the documentation was meant to reflect only the shift amount. The facility further failed to accurately document the administration time of Vancomycin for a resident with hemiplegia, hemiparesis, a history of falls, and hypertension. The resident had an order for Vancomycin IV at 5:00 p.m. for 14 days, but the MAR documented the dose as given at 9:09 p.m. RN 1 stated there was no documentation explaining the delay or indicating loss of IV access. RN 4 stated she gave the medication around 5:00 p.m. and that the 9:09 p.m. entry was a documentation error. The ADON also stated the medication was documented past the scheduled time and that the record did not accurately reflect the administration time.
HVAC Unit Out of Service With Portable AC Units Used in Multiple Resident and Facility Areas
Penalty
Summary
The facility failed to maintain electrical and resident care equipment in safe operating condition when one HVAC unit was not working and portable AC units were used in multiple areas of the building. The deficiency involved resident rooms 36, 37, 38, and 39, as well as the rehabilitation therapy room, the DON's office, the activity staff office, and the laundry room. The report states the HVAC unit had been out of service since 9/10/2025, and portable AC units were installed in the affected areas with vents sealed using tape or adhesive foam. Resident 8 had diagnoses including COPD, obstructive sleep apnea, and convulsions. The resident was able to make needs known and understand others, but required staff assistance with eating, oral hygiene, toileting, bathing, dressing, hygiene, and mobility. During observation, a portable AC was seen in the resident's room with the exhaust pointed outside the window, and the resident stated the room could get warm on hot days and had been very cold at night recently, so the AC had not been used lately. Resident 1 had diagnoses including pulmonary fibrosis, emphysema, and bipolar disorder. The resident was cognitively intact, had capacity to understand and make decisions, and had received oxygen therapy while in the facility. The resident stated the portable AC was present because the room had been warm during hot weather and was next to the laundry room, but the room also got cold so the AC had not been turned on. Resident 7 had diagnoses including CKD, ESRD, and left shoulder pain, was cognitively intact, and required assistance with dressing, footwear, personal hygiene, and ambulation. During observation, a portable AC with a vent taped to the window was present in the room, and the resident stated staff operated the unit and did not remember when it was placed there.
Failure to Assess Bedside Self-Administration of Nasal Spray
Penalty
Summary
The facility failed to perform a medication self-administration assessment for a resident who kept oxymetazoline HCl nasal spray at the bedside for self-administration. The resident was admitted with diagnoses including heart failure, depression, and hypertension, and the H&P stated he had the capacity to understand and make decisions. The MDS indicated he was able to understand others and make himself understood, and he required varying levels of assistance with daily care tasks. The resident's admission/readmission initial assessment for self-administration of medications indicated he did not want to self-administer medications and no further assessment was completed. During observation, the nasal spray was seen sitting on the resident's bedside rolling table, and the resident stated he used it whenever he needed it for allergies and had been using it for about a month in the evenings for a stuffy nose. The medication remained at bedside during later observation, including when the resident was out of the room and no staff were present. Staff interviews and record review showed the resident did not have a physician's order for oxymetazoline HCl nasal spray or an order allowing self-administration. An LVN stated the facility process required a physician order authorizing self-administration and said the resident should not have been self-administering or storing the medication at bedside without that order. The LVN and DON stated staff should have identified the medication during rounds, removed it, notified the physician, and completed a self-administration assessment, but this did not occur.
Advance Directive Discussion Not Documented
Penalty
Summary
The facility failed to ensure Resident 21’s medical record documented that the formulation of an advance directive was discussed. Resident 21 was admitted with diagnoses including COPD, dementia, and anxiety disorder. The admission H&P stated the resident did not have the capacity to understand and make decisions. The MDS dated 2/1/2026 indicated severely impaired cognition, that the resident was sometimes able to understand others and make needs known, and that the resident’s advance directive was not completed. The Advance Healthcare Directive Acknowledgement Form was undated, blank, and did not show whether an advance directive was offered or discussed, whether written information was provided, or why the information was not provided, offered, or discussed. During interview, the SSD stated the form was blank and did not indicate whether the resident had previously formulated an AD, was provided information, refused information, or was unable to sign. The SSD also stated the resident did not have a representative and the facility was in the process of obtaining public guardianship. The ADON stated the form should have been completed to show that the AD was discussed and offered, written information was provided, or the reason it was not completed.
Improper Use of Bedding as a Physical Restraint
Penalty
Summary
The facility failed to ensure that one resident was treated with respect and dignity, including the right to be free from physical restraints, when two pillows were found tucked under the fitted sheet on both sides of the bed for Resident 64. Resident 64 was admitted on 1/15/2026 and later readmitted, with diagnoses including muscle weakness, unspecified dementia, anemia, and end-stage renal disease. The resident's H&P dated 4/26/2026 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 4/29/2026 indicated the resident did not have the capacity to understand others or make self-understood. Resident 64's MDS also indicated substantial or maximal assistance was needed for personal hygiene, dressing, and repositioning, and that the resident was dependent on staff for bathing and all other ADLs. The care plan for falls and injuries included an intervention to assess and anticipate the resident's needs, including food, thirst, toileting, comfort level, body positioning, and pain. During an observation on 5/04/2026, Resident 64 was lying on the right side in bed with eyes closed, and pillows were observed tucked under the fitted sheet on both sides of the bed. During a concurrent observation and interview, an LVN stated the pillows were being used for repositioning and should be placed over, not tucked under, the fitted sheet, and stated that pillows tucked under the fitted sheet are considered a restraint because they restrict movement. An RN and the ADON both stated the resident did not have an order for restraints and explained that restricting a resident's movement with an item the resident cannot remove is a form of restraint. The facility policy also defined physical restraints and specifically listed tucking sheets so tightly that a bed-bound resident cannot move as an inappropriate practice.
BiPAP Care Plan Not Implemented
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving BiPAP therapy. The resident had diagnoses including COPD, obstructive sleep apnea, and convulsions. The resident’s H&P indicated the resident could make needs known but could not make medical decisions, and the MDS showed the resident could make self understood, understand others, and was dependent on staff for multiple activities of daily living, including oral hygiene, toileting, bathing, dressing, personal hygiene, mobility, and eating. The MDS also indicated that a non-invasive mechanical ventilator was used while the resident was in the facility. The physician order for BiPAP directed staff to empty the distilled water chamber at the end of each treatment, rinse with warm water, and air dry in the morning. The care plan for the resident on BiPAP at bedtime included the intervention to empty the BiPAP distilled water chamber at the end of each treatment, rinse with warm water, and air dry. During observation, the BiPAP water chamber was seen with water droplets inside. The resident stated he used the BiPAP every night, that staff removed it in the morning, and that staff had not cleaned the BiPAP machine, adding that his wife had spoken to staff about cleaning it. During interview, LVN 1 stated the night shift changes the BiPAP equipment and the day shift cleans the BiPAP machine, and also stated the water chamber should not have condensation and must be dry. LVN 1 stated he did not clean the resident’s BiPAP machine that day. The Infection Preventionist stated cleaning and air drying the BiPAP after each use is intended to prevent respiratory infection build-up of microorganisms. The ADON stated the care plan was not implemented when the BiPAP was not rinsed and air dried and condensation remained in the water chamber.
Care plan did not include ordered heel offloading intervention
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident 49 to reflect the physician’s order to offload the left foot for a stage 1 pressure injury. Resident 49 was readmitted with diagnoses including metabolic encephalopathy, right-sided hemiplegia, and dysarthria following a cerebral infarction, and the MDS dated 4/23/2026 indicated mild cognitive impairment, dependence for several ADLs, and a stage 1 pressure ulcer on the left foot upon readmission. The physician’s active order dated 4/20/2026 directed heel protectors to the left foot at all times and use of pillows to offload the heel for pressure reduction, but the care plan dated 4/21/2026 only included cleansing the left heel stage 1 pressure injury, applying vitamin A&D ointment, and covering with a silicone foam dressing every day shift for 21 days. During observation on 5/6/2026, CNA 1 did not place a pillow under Resident 49’s left foot and stated the resident was supposed to have a pillow under the left foot so it would not touch the bed. The MDSC stated the pillow should have been included in the care plan per the physician’s order, but it was not, and that missing information in the care plan may lead staff to miss required interventions. The DON stated the pillow should be on the left heel at all times except when the resident is being cleaned, that the pillow is used as an offloading device to protect the skin, and that if the intervention is not in the plan of care, it is possible that the intervention is not being provided.
Failure to Offload Left Foot Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for Resident 49, who was admitted and later readmitted with metabolic encephalopathy, right-sided hemiplegia, and dysarthria following a cerebral infarction. The Minimum Data Set indicated mild cognitive impairment and dependence for several activities of daily living, and it also identified a stage 1 pressure ulcer on the left foot upon readmission. The physician’s active order dated 4/20/2026 directed that heel protectors be used on the left foot at all times and that pillows be used to offload the heel for pressure reduction every shift for left heel pain, with removal allowed only during showers and ADLs. During observations on 5/04/2026, 5/05/2026, and 5/06/2026, Resident 49 was seen without a pillow under the left foot. During the 5/06/2026 observation, CNA 1 stated the resident should have a pillow under the left foot to keep it offloaded from the bed and stated the pressure ulcer could worsen if the wound came into contact with the bed. TN 1 stated the resident receives treatment for the stage 1 pressure injury, that pillows are used as heel protectors, and that without the pillow the resident was at risk for further skin breakdown and worsening of the pressure ulcer. The DON stated the physician’s order required the pillow to be on the left foot at all times except when the resident was being cleaned, and that if the pillow was not there, the pressure injury could worsen.
Unattended Medication at Bedside and Missing Fall Mat
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents when oxymetazoline HCl nasal spray was left unattended and available for self-administration in a shared room for one resident. The resident had diagnoses including heart failure, depression, and hypertension, and the history and physical stated he had the capacity to understand and make decisions. The minimum data set indicated he could understand others and make himself understood, but he required supervision for eating, partial assistance for oral hygiene, and was dependent on staff for toileting and bathing. An admission/readmission assessment for self-administration of medications indicated the resident did not want to self-administer medications and no further assessment was completed. During observation, the nasal spray was seen sitting on the resident’s bedside rolling table while he was in the room, and later it remained on the bedside table and was visible from the hallway while the resident was not in the room and no staff were present. The resident stated he used the nasal spray whenever he needed it and had been using it for about a month in the evenings for a stuffy nose. A CNA stated she did not notice the nasal spray when she was in the room and did not know why the resident needed it. An LVN reviewed the physician orders and stated there was no order for the nasal spray or for self-administration, and that without an order the resident should not have been self-administering or storing it at bedside. The DON stated the facility had a process for self-administration assessments and that medications should not have been left at bedside. The facility also failed to ensure the right-side floor mat was in place while another resident was in bed and unattended. That resident had diagnoses including unspecified dementia, a displaced fracture of the base of the left femur, fractures of the mandible and left humerus, UTI, muscle weakness, lack of coordination, and a history of falling. The history and physical stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident was rarely or never able to understand others or make herself understood and had a fall in the month before admission resulting in fracture. The care plan and physician order summary both included bilateral floor mats for prevention of injury from falls. During observation, the resident was lying in bed unattended while the floor mat on the right side was found propped on its side against the bathroom door and wall, with an unoccupied chair at the bedside and no mat in place. The same condition was observed again later, with the resident still in bed and unattended. A CNA stated another CNA had moved the chair and floor mat while feeding the resident and had forgotten to put the mat back. Another CNA stated she had placed the mat against the door while feeding the resident and did not put it back because the other CNA was going to continue feeding. An LVN stated the resident had an order for a fall mat because she was at high risk for falls and that the mat should always be in place when the resident was in bed and no staff were in the room. The DON stated the mat was fine to remove temporarily, but it had to be put back in place, and that the facility’s policy was not followed.
Dependent Loop in Urinary Catheter Tubing
Penalty
Summary
The facility failed to ensure appropriate catheter care for Resident 28, who was admitted with diagnoses including obstructive and reflux uropathy, lack of coordination, and generalized muscle weakness. The resident’s H&P indicated he had the capacity to understand and make decisions, and the MDS indicated intact cognition and an indwelling urinary catheter. The physician’s order required the drainage bag to be kept below the bladder and the tubing to remain free of dependent loops and kinks, with monitoring for signs and symptoms of possible urinary infection each shift. During observation, Resident 28 was found lying in bed asleep with the urinary drainage bag hanging on the side of the bed frame and the catheter tubing forming a dependent loop with urine present in the tubing. LVN 6 stated the loop was preventing urine from flowing freely into the bag and noted urine in the loop with some white sediments. The ADON stated staff are supposed to ensure the tubing is not coiled or looped because it prevents urine from flowing freely and can back flow. The facility policy on urinary catheter care stated the purpose is to prevent CAUTIs and directed staff to keep the catheter and tubing free of kinks and position the drainage bag lower than the bladder at all times.
Tube Feeding Water Flush Bag Not Changed per Manufacturer Guidance
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident receiving enteral feeding when the water flush bag was not changed according to the manufacturer's recommendations. Resident 73 had diagnoses including dementia, gastrostomy, and hypertension, and the record indicated the resident lacked capacity to understand and make decisions, had severely impaired cognition, was unable to make needs known, required total assistance with ADLs, and received GT feeding. The resident's physician orders included continuous tube feeding via GT and water flushes through the GT. The care plan for tube feeding directed staff to change the administration set and monitor for signs and symptoms of dehydration, nausea, vomiting, diarrhea, reflux, and constipation. During observation, the resident's water flush bag was seen dated 5/3/2026 at 1:45 p.m. On interview, an LVN stated the water flush bags were changed with the feeding formula bags when finished or 48 hours after start of infusion, and acknowledged the manufacturer's recommendation for the water flush bag was not to use the feeding set for more than 24 hours. The LVN stated she did not know the water flush bags could not be used for more than 24 hours and that the facility practice was to change them with the feeding formula bags. The ADON also stated the manufacturer's recommendation was not to use the feeding sets for greater than 24 hours because of the risk of bacterial contamination and overall system accuracy, but the facility practice was to change the water flush bags when the formula bags were finished or no more than 48 hours from when the formula bag was started. The facility's policy referenced hang times and administration set changes, but the observed water flush bag remained in use beyond the manufacturer's recommended time.
BiPAP Cleaning and Oxygen Tubing Handling Not Followed
Penalty
Summary
Respiratory care was not provided in accordance with physician orders and facility policy for two residents reviewed for respiratory care. One resident had diagnoses including COPD, obstructive sleep apnea, and convulsions, and was dependent on staff for multiple activities of daily living. The physician order directed staff to empty the BiPAP distilled water chamber at the end of each treatment, rinse it with warm water, and air dry it in the morning. The resident’s care plan also included the BiPAP cleaning and drying intervention. During a concurrent observation and interview, the resident’s BiPAP water chamber was observed with water droplets inside. The resident stated he used the BiPAP every night and that staff removed the machine in the morning, and he stated staff had not cleaned the BiPAP machine. A nurse later stated the night shift changes the BiPAP equipment and the day shift cleans the machine, and that the water chamber is not supposed to have condensation and has to be dry. The Infection Preventionist stated cleaning the BiPAP after each use and air drying it is intended to prevent respiratory infection and microorganism buildup, and the ADON stated the care plan was not implemented when the BiPAP was not rinsed and air dried and condensation remained in the chamber. A second resident had diagnoses including COPD, CHF, and dementia, lacked capacity to make decisions, had severely impaired cognition, was totally dependent for all ADLs, and received continuous oxygen therapy via nasal cannula. During observation, the resident was asleep in bed with oxygen at 2 liters per minute via NC, and the tubing was observed touching the floor. Staff stated the tubing should be kept off the floor by placing extra tubing in the plastic storage bag on the oxygen concentrator or by using a Velcro strap to secure it to the side rail. Staff further stated the Velcro strap should have been in place, that the tubing should not touch the floor at any time, and that the floor was dirty and could contaminate the tubing. The facility’s oxygen administration policy stated oxygen tubing shall be stored in a designated plastic bag, and the infection prevention policy described maintaining a safe, sanitary, and comfortable environment and preventing transmission of infections.
Medication Crushing Without Physician Order
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. During a Medication Administration Task, 7 errors were observed out of 29 total opportunities, resulting in an error rate of 24.14 percent for one sampled resident. The errors occurred when an LVN crushed and administered seven medications to the resident without a physician's order during the 9 a.m. medication pass. The resident involved had diagnoses that included COPD, HTN, unspecified dementia, major depression, metabolic encephalopathy, moderate protein-calorie malnutrition, and dysphagia. The resident's H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident rarely or never understood others or could make himself understood and was dependent on staff for eating, toileting, bathing, personal and oral hygiene, dressing, and mobility. The care plan included interventions to adjust the diet for chewing, swallowing, or eating issues and to give medications as ordered. During observation, the LVN stated the resident was on a pureed diet and that she would crush the medications and administer them with applesauce. She crushed amlodipine, ascorbic acid, memantine, multivitamin with minerals, oyster shell calcium/vitamin D, rifaximin, and sertraline, then administered them. In a follow-up interview and record review, the LVN stated she assumed there was an order to crush the medications, but the physician orders did not include such an order. The DON stated the facility process required a physician's order before crushing medications and that not all medications can be crushed because altering the tablet may change its action on the body. The facility policy stated medications are administered in accordance with written physician orders and that medications shall be crushed only when appropriate and safe to do so, consistent with physician orders.
Failure to Serve Listed Food Preference
Penalty
Summary
The facility failed to ensure Resident 43 received a food preference listed on the meal ticket when ice cream was not served with the lunch tray. Resident 43 was originally admitted on 8/21/2025 and readmitted on 4/23/2026 with diagnoses including dysphagia, adult failure to thrive, and dementia. The H&P dated 4/24/2026 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 4/29/2026 indicated severely impaired cognition, rarely or never understanding and making needs known, and total dependence on staff for all ADLs. The order summary dated 5/1/2026 showed a regular diet with pureed texture and thin liquids, along with high protein nourishment sugar free three times daily. The care plan for unavoidable weight loss, initiated on 4/9/2026 and revised on 5/4/2026, included interventions to honor resident preferences and provide supplements as ordered to help the resident consume at least 50% of meals two to three times a day. The meal ticket for 5/4/2026 indicated to add ice cream. During dining observation on 5/4/2026, RN 3 stated the meal ticket indicated ice cream, but it was not served in the lunch tray and had been overlooked during tray inspection before distribution. RN 3 stated the diet list is compared with the resident's meal tray and meal ticket to ensure all listed items are served, and that the ice cream should have been provided to assist with increased intake when eating a food preference. The ADON later reviewed the meal ticket, meal served, physician orders, care plan, and dietary/nutritional progress note, and stated the photograph did not show ice cream was served even though the meal ticket indicated it, and that the resident should have received it as listed.
Spoiled Produce Left in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when a yellow bell pepper with white and gray discoloration was observed inside a green tray in the walk-in refrigerator. During the tour, the Dietary Supervisor stated that vegetables and other food items are checked regularly and acknowledged that the yellow bell pepper should have been discarded because it had signs of rotting and could no longer be used. During interview, the DON stated that vegetables and other food items are inspected every day and that vegetables with signs of spoilage can be cut and properly washed or must be thrown away. The facility policy titled, General Receiving of Delivery of Food and Supplies, stated that food deliveries are to be inspected for proper handling, labeling, temperature, and appearance, and that produce is to be fresh and free of wilting or spoilage.
Missed Hospice Aide Visits and Inaccurate RN Documentation
Penalty
Summary
Necessary hospice care was not provided consistently for a resident receiving hospice services. The resident was admitted with diagnoses including dementia, Parkinson’s disease, and encephalopathy. The record also indicated the resident had the capacity to understand and make decisions, could make self understood and understand others, and required staff assistance with ADLs and mobility. The resident was admitted to hospice under routine level of care, and the hospice order specified Certified Home Health Aide services once per week for 12 weeks. Record review and interviews showed the hospice aide did not visit on 2/13/2026 and 2/20/2026, and the facility could not locate hospice aide notes for those dates. The RN Visit Note dated 2/13/2026 indicated that a hospice aide evaluation of care was completed, but the ADON stated the hospice aide report and addendum received later showed no HA evaluation was done by the RN. The ADON also stated there was no documentation that the missed hospice aide visits were noted and followed up with the hospice provider.
Failure to Implement EBP for Resident with Left Foot Wounds
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident 89 by not ensuring there was a physician's order for Enhanced Barrier Precautions (EBP) related to the resident's left foot wounds and by not ensuring the EBP sign was posted outside the resident's room. Resident 89 was admitted with diagnoses including dementia, absence of the left great toe, and peripheral vascular disease, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS showed moderately impaired cognition and significant assistance needs with ADLs. Resident 89 had physician's orders for a left medial heel diabetic wound and a left lateral plantar foot diabetic wound, both requiring cleansing, topical treatment, dressings, and wrapping with gauze bandage roll. During observation, the resident was seen in bed with the left foot wrapped in gauze bandage roll, and the resident stated he was diabetic and had two wounds on his left foot for a few months. The Infection Preventionist stated the resident had diabetic wounds on the left foot, but there was no physician's order to place the resident on EBP and no blue sticker next to the resident's name at the door. The EBP sign was observed outside the room, but the blue round sticker identifying the resident as requiring EBP was not present next to the resident's name. The ADON stated that residents with indwelling devices and draining wounds should have a physician's order for EBP, an EBP sign posted, and a blue round sticker next to the resident's name so staff would know to use proper PPE during high-contact activities. The ADON also stated she was aware that Resident 89 did not have the physician's order and did not have the blue round sticker identifying EBP status.
Inaccurate MDS Coding for Splint Use and Antibiotic Administration
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for a resident with hemiplegia, hemiparesis following cerebral infarction, contracture of the left hand muscle, and dementia. The resident’s physician ordered restorative nursing staff to apply bilateral knee splints daily for 4 hours or as tolerated, and an observation showed an RNA applying the splints to both knees while stating the resident was to wear them 7 days a week for 4 hours and had been tolerating them. However, the MDS Coordinator reviewed the March 2026 RNA treatment record and the MDS assessment dated 3/30/2026 and stated the assessment should have been coded for 7 days because the resident received the splints every day and had no missed treatments. The MDS Coordinator stated the splint coding was incorrect and that a modification would be submitted. The Assistant DON stated the MDS is a legal document that transmits to CMS and should accurately show how the resident is treated, including the bilateral knee splint application. The facility’s RAI Manual stated that splint or brace assistance includes a scheduled program of applying and removing a splint or brace and should be reviewed for each activity throughout the 24-hour period. The facility also failed to ensure an accurate MDS transmission for a resident admitted with alcohol use, generalized muscle weakness, and lack of coordination. The resident’s most recent admission MDS indicated the resident was taking an antibiotic with an indication for use, but the Order Summary Report did not show any physician order for an antibiotic. The MDS Coordinator reviewed the order summary, discontinued or completed orders, and acute hospital records and stated the resident did not receive an antibiotic during hospitalization or while in the facility, identifying the entry as a coding error. The ADON stated that if the EHR or hospital records did not indicate antibiotic use, it should not have been coded on the MDS assessment.
Failure to Immediately Initiate Missing Resident Protocol
Penalty
Summary
The facility failed to immediately initiate its missing resident protocol, known as 'code pink,' when a resident with multiple complex medical conditions was discovered missing. The resident, who had moderately impaired cognition and required assistance with daily activities, was last seen in their room with a family member. After a blood sugar check revealed a high reading, a nurse received an order to administer insulin. When the nurse returned to the resident's room to give the medication, the resident and the family member were gone. Instead of immediately reporting the resident as missing and calling code pink, the nurse spent approximately 30 minutes searching the facility alone before notifying the charge nurse. Only then was code pink announced and a broader search initiated, including contacting the administrator, DON, and police. Security footage later showed the resident and family member leaving the facility during this time frame. The delay in following the facility's policy for missing residents resulted in the resident missing a prescribed dose of insulin for elevated blood sugar. Interviews with staff confirmed that the code pink should have been called as soon as the resident was found missing, and that the delay was not in accordance with facility policy. The facility's own policies require immediate action and notification when a resident is suspected missing.
Deficiencies in Insulin Administration and Anticoagulant Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of care in the administration of insulin for a resident with type 2 diabetes mellitus. The resident, who had severely impaired cognition and required total assistance with activities of daily living, was not receiving insulin injections with proper site rotation. The insulin was repeatedly administered in the same areas of the abdomen, contrary to the manufacturer's guidelines and facility policy, which require rotation to prevent adverse effects such as bruising, lipodystrophy, and cutaneous amyloidosis. Both the Licensed Vocational Nurse and the Assistant Director of Nursing acknowledged that the insulin administration sites were not rotated as required. Additionally, the facility failed to implement appropriate monitoring for a resident receiving anticoagulant therapy with heparin. The resident, who also had severely impaired cognition and required total assistance with daily activities, did not have a physician's order for monitoring signs and symptoms of bleeding, which is crucial for residents on anticoagulant therapy. The Registered Nurse and the Assistant Director of Nursing confirmed the absence of such an order and acknowledged that monitoring should have been in place to prevent complications related to anticoagulant use. The facility's policies and procedures for insulin administration and anticoagulant therapy were not followed, leading to deficiencies in care. The lack of adherence to these protocols posed potential risks to the residents, as the insulin administration sites were not rotated, and there was no monitoring for bleeding in a resident on anticoagulant therapy. These failures were identified through interviews and record reviews conducted by the surveyors.
Facility Fails to Prevent Accident Hazards and Ensure Proper Supervision
Penalty
Summary
The facility failed to ensure a safe environment for several residents, leading to potential accident hazards. Resident 23's pathway to the bathroom was obstructed by a roommate's wheelchair, which could have caused a fall. Despite being identified as at risk for falls, the resident's care plan was not adequately followed, as staff did not ensure an unobstructed path to the bathroom. Interviews with staff confirmed the obstruction and the potential risk it posed to the resident. Resident 92's medications, including acetaminophen and enoxaparin, were left unattended on top of a medication cart by LVN 4. This practice posed a risk of the medications being taken by another resident or person. The facility's policy requires that medication carts be kept closed and locked when out of sight, which was not adhered to in this instance. Interviews with LVN 4 and the DON confirmed the lapse in protocol and the potential risk involved. The facility also failed to accurately document Resident 95's fall risk assessment after a fall, which could have led to inappropriate interventions. The resident's fall risk score was inaccurately lowered, despite the resident's continued risk factors. Additionally, Residents 297 and 32 had floor mats with furniture placed on top, compromising the mats' effectiveness in reducing fall impact. Staff interviews confirmed that such placement could lead to injury, as the furniture could become unstable and fall on the residents.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for five residents, leading to several deficiencies. For Resident 25, the facility did not label the Trelegy inhaler and two over-the-counter medications with the complete date, including the year, when they were opened. This oversight was observed during a medication administration review, and both the Director of Staff Development and the Director of Nursing acknowledged the importance of including the year to maintain medication efficacy and prevent errors. The facility's policy requires that all medications be properly labeled with the complete date of opening. Resident 32 received Norco, a pain medication, despite having a pain level of zero, which was against the physician's order that specified administration only for severe breakthrough pain with a level of seven to ten. This was confirmed through a review of the Medication Administration Record and interviews with the Director of Staff Development and the Director of Nursing, who emphasized the necessity of following physician orders for medication administration. Additionally, Resident 41's Medication Count Sheet for clonazepam was inaccurately documented, showing discrepancies in the number of tablets recorded versus the actual count. The Assistant Director of Nursing highlighted the importance of accurate documentation for controlled substances. For Resident 58, the facility did not adhere to the physician's order to administer potassium with a full glass of water, instead providing only two ounces. This was acknowledged by the Licensed Vocational Nurse and the Director of Nursing, who stated that a full glass is necessary to prevent stomach upset. Lastly, Resident 2 was not monitored for signs and symptoms of bleeding while on heparin, an anticoagulant, due to the absence of a physician's order for such monitoring. Both the Registered Nurse and the Assistant Director of Nursing recognized the need for monitoring orders to prevent complications. The facility's policies on medication administration and anticoagulant protocols were not followed, leading to these deficiencies.
Medication Administration Errors in Insulin and Anticoagulant Use
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving insulin administration and anticoagulant use. In the first case, a resident with type 2 diabetes mellitus and severely impaired cognition received insulin injections without proper rotation of the administration sites. The Licensed Vocational Nurse (LVN) and Assistant Director of Nursing (ADON) confirmed that the insulin administration sites were not rotated according to standards of practice, which could lead to adverse effects such as bruising and skin conditions. The facility's policy and manufacturer's guidelines emphasized the importance of rotating injection sites to prevent such issues. In the second incident, another resident with dementia and severely impaired cognition was administered heparin, an anticoagulant, without the route of administration being specified in the physician's order. The medication label indicated a different route than what was documented in the Medication Administration Record (MAR). Despite the discrepancy, the heparin was administered 102 times without clarification from the physician. The LVN, Registered Nurse (RN), and ADON acknowledged the error, noting that the medication should have been held until the order was clarified. The facility's policy required that medications be administered according to the prescriber's orders, including the correct route. Both incidents highlight a failure to adhere to professional standards and facility policies regarding medication administration. The lack of proper site rotation for insulin injections and the administration of heparin without confirming the correct route represent significant medication errors. These deficiencies were identified through interviews and record reviews, with staff acknowledging the deviations from established protocols.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During an observation tour, it was noted that temperatures were not checked on specific dates for the dry storage room, which is crucial for maintaining food safety. Additionally, several food items, including corn flakes, breadcrumbs, beans, and cheese, were found with expired use-by dates and were not discarded as required. Furthermore, some food items such as lentils, Lays chips, and soy sauce were not properly labeled with received, open, or use-by dates, which is necessary to ensure that food is consumed safely and not past its expiration. Interviews with staff, including a kitchen staff member and the Dietary Supervisor, confirmed that all foods should be labeled with received, open, and use-by dates to prevent the consumption of expired items. The Dietary Supervisor emphasized the importance of tracking storage room temperatures to prevent bacterial growth that could lead to foodborne illnesses. The facility's policy and procedures also require all food items to be labeled and dated, and corrective actions to be taken if storage room temperatures exceed 85°F. These deficiencies had the potential to result in harmful bacterial growth and cross-contamination, posing a risk of foodborne illness to residents.
Infection Control Deficiencies in Medication Handling and Legionella Management
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by the mishandling of Prostat bottles on medication carts. During observations, it was noted that Prostat bottles on two medication carts were sticky and had dried brown drippings on the sides. Licensed Vocational Nurses (LVNs) acknowledged the bottles were not cleaned after use, which is against the facility's policy that requires reusable equipment to be cleaned or disinfected after each use. The Director of Staff Development and the Director of Nursing confirmed that staff should clean medication bottles to prevent cross-contamination. Additionally, the facility's Maintenance Director and Infection Preventionist were unable to identify signs of legionella, a severe form of pneumonia, as outlined in the facility's Legionella Water Management Program. The Maintenance Director admitted to not knowing what biofilm was, which is crucial for identifying potential legionella growth in the water system. The Infection Preventionist, who provided training to the Maintenance Director, also did not know what biofilm was, indicating a gap in knowledge and training regarding legionella prevention. Interviews with the Director of Staff Development and the Administrator revealed that the Maintenance Director was responsible for inspecting the facility for stagnant water and selecting water samples for legionella testing. However, the lack of knowledge about biofilm and other signs of legionella growth compromised the effectiveness of the water management program. The facility's policy emphasizes the importance of preventing, detecting, and controlling water-borne contaminants, but the staff's inability to identify key indicators of legionella growth represents a significant deficiency in infection control practices.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident, identified as Resident 13, during care. Resident 13, who has severe cognitive impairment and requires extensive assistance with activities of daily living, was exposed when Certified Nursing Assistant 5 (CNA 5) did not fully close the privacy curtain while providing care. This incident occurred during a morning observation when CNA 5 was distracted by a conversation with the Charge Nurse and neglected to ensure the curtain was fully closed, leaving the resident's buttocks exposed. Interviews with CNA 5, the Director of Staff Development (DSD), and the Director of Nursing (DON) confirmed that the facility's policy requires staff to maintain resident privacy by fully closing privacy curtains during care. Both the DSD and DON acknowledged that CNA 5's failure to close the curtain was a breach of the facility's dignity and privacy standards, which are designed to protect residents' self-esteem and self-worth. The facility's policy emphasizes the importance of promoting and protecting resident privacy during personal care and treatment procedures.
Failure to Obtain Informed Consent for Antidepressant Use
Penalty
Summary
The facility failed to obtain written verification of informed consent for two residents, which violated their rights to make informed decisions regarding their treatment. Resident 32, who was admitted with diagnoses including metabolic encephalopathy, generalized muscle weakness, and depression, was found to have severely impaired cognitive skills. Despite this, the facility did not document the consent of Resident 32's representative for the administration of bupropion, an antidepressant. The Assistant Director of Nursing (ADON) acknowledged that the informed consent was incomplete and emphasized the importance of having a completed consent form to ensure the resident representative's right to be informed. Similarly, Resident 76, admitted with conditions including gastroenteritis, colitis, depression, and generalized weakness, had moderately impaired cognitive skills but retained the capacity to make decisions. The facility failed to document Resident 76's consent for the administration of venlafaxine, another antidepressant. The Registered Nurse (RN) and ADON both confirmed that the informed consent was not completed before the medication was administered, which was against the facility's policy. The facility's policy on informed consent for psychotherapeutic medications requires a written consent signed by the resident or their representative, along with a healthcare professional's signature, before treatment. This policy was not adhered to in the cases of Residents 32 and 76, as their informed consents were incomplete, and medications were administered without proper documentation of consent. The Director of Nursing (DON) stated that incomplete informed consent is not valid, and medication should not be administered without it.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs and preferences of two residents by not ensuring their call lights were within reach. Resident 1, who was admitted with diagnoses including dementia, gait abnormalities, and muscle weakness, was found to have a call light on the floor, out of reach. Despite having a care plan and physician's order indicating the call light should be within reach due to a high risk of falls, staff did not comply with these directives. During an observation, a Licensed Vocational Nurse confirmed the call light was not properly positioned, which could prevent the resident from calling for assistance. Similarly, Resident 77, who also had dementia and was at high risk for falls, had a call light placed on the upper left side of the bed, not within reach. This resident required substantial assistance with activities of daily living and had limited upper extremity movement, making it difficult to activate the call light. The care plan and physician's order also specified that the call light should be within reach, but this was not adhered to by the staff. An observation confirmed the call light was not accessible, and the Licensed Vocational Nurse acknowledged the oversight. The facility's policy and procedure on answering call lights, which was last reviewed in January 2025, clearly stated that call lights should be within easy reach of residents when they are in bed or confined to a chair. However, the staff failed to follow this policy, resulting in a deficiency that could delay care and services for the residents involved.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide two residents, Resident 20 and Resident 84, with the option to formulate an advance directive, which is a legal document that outlines a person's wishes regarding medical treatment if they are unable to communicate. Resident 20 was admitted with conditions such as cardiomyopathy and COPD and had the capacity to understand and make decisions. However, the Social Services Director (SSD) did not offer or provide information about formulating an advance directive during the admission process, which is a requirement according to the facility's policy. The Director of Nursing (DON) confirmed that the admission department should initiate the conversation about advance directives, and the SSD should follow up, but this was not done for Resident 20. Resident 84, who was admitted with conditions including hemiplegia and encephalopathy, had a representative due to their inability to make medical decisions. The facility's records showed no evidence of an advance directive or acknowledgment of one in Resident 84's medical records. The Health Information Director (HID) and SSD confirmed that there was no documentation indicating that Resident 84's representative was informed about the option to formulate an advance directive. The SSD acknowledged that this oversight could lead to the resident's rights not being respected, as there was no paper form of the resident's after-life wishes. The facility's policy and procedure on advance directives, last reviewed in January 2025, states that residents should be provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive upon admission. If a resident is incapacitated, this information should be provided to their legal representative. The policy also requires that any decision regarding advance directives be documented in the resident's medical record. However, this policy was not followed for Residents 20 and 84, leading to a violation of their rights.
Failure to Notify Resident Representative of Low Iron Level
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding notifying a resident's representative of a change in condition. Specifically, the facility did not promptly inform the representative of a resident who had a laboratory result indicating a low iron level. This oversight was identified for one of the two sampled residents, referred to as Resident 50, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, epilepsy, and hypertension. The resident's fluctuating capacity to understand and make decisions was noted, and the family member was designated as the resident representative. On January 23, 2025, Resident 50's lab results showed an iron level of 49 micrograms per deciliter, which is below the normal range. Despite this significant finding, there was no Situational Background Assessment and Recommendation (SBAR) completed, which is a structured communication tool used to report changes in a resident's condition. The Health Information Director confirmed the absence of an SBAR for the low iron result. The Minimum Data Set Coordinator Nurse also noted that an SBAR should have been completed to ensure proper interventions, monitoring, and communication with the resident's family. The Director of Nursing confirmed that the low iron level represented a change in the resident's condition that required an SBAR and subsequent care planning. However, no follow-up orders for labs or care plans were created, and the family was not informed of the change in condition. This failure to notify the family violated the resident representative's right to be informed, as outlined in the facility's policy and procedure for changes in a resident's condition or status.
Failure to Maintain Resident Record Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN 4) left an electronic health record (EHR) open and unattended. This incident involved Resident 92, who was admitted to the facility with a history of transient ischemic attack, hypertension, and hyperlipidemia. During a random observation, LVN 4 was seen standing outside Resident 92's room with the EHR open to the medication administration records. LVN 4 then walked away to Nurse Station 2, leaving the EHR open and unattended. In an interview, LVN 4 acknowledged leaving the EHR open and unattended, recognizing the risk of unauthorized access to Resident 92's personal information. The Director of Nursing (DON) confirmed that staff are required to minimize computer screens when leaving them unattended to protect resident information. The facility's policy on confidentiality and personal privacy, last reviewed in January 2025, mandates the protection and safeguarding of resident confidentiality and personal privacy, limiting access to authorized staff and business associates.
Failure to Maintain Safe and Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for a resident, identified as Resident 32, by not ensuring that the resident's floor mat was in proper condition. The floor mat, which was located on the right side of the resident's bed, had a torn lower right corner. This issue was identified during an observation and interview with a treatment nurse, who acknowledged the damage and stated that the maintenance department would be notified to replace the mat. The resident's care plan included the use of a floor mat as an intervention to prevent falls, and the physician's order required the mat to be monitored every shift for proper positioning and placement. Resident 32 had been admitted to the facility with diagnoses including muscle wasting, dementia, and generalized muscle weakness, and required total assistance with activities of daily living. The resident's cognitive abilities were severely impaired, necessitating a safe and supportive environment. The facility's policy on providing a homelike environment emphasized the importance of maintaining a clean, safe, and functioning environment for residents. The Assistant Director of Nursing confirmed that any equipment in disrepair should be reported immediately to ensure residents are provided with a safe and homelike environment.
Failure to Document and Assess Restraint Use
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 20, was free from the use of physical restraints without proper documentation and consent. Resident 20 was admitted with diagnoses including cardiomyopathy, chronic obstructive pulmonary disease, and generalized muscle weakness. Despite having the capacity to understand and make decisions, as indicated in the Internal Medicine Initial Evaluation, the resident's bed was positioned with the right side against the wall, which restricted their freedom of movement. This setup was not accompanied by an informed consent, a restraint assessment, or a care plan, which are necessary to ensure the safety and appropriateness of such an arrangement. Observations and interviews revealed that the resident was unaware of the reason for the bed's positioning and expressed a preference for it not to be so close to the wall. Staff members, including a Certified Nursing Assistant and a Licensed Vocational Nurse, were also unsure of the rationale behind the bed's placement. The MDS Coordinator confirmed the absence of required documentation, such as a restraint assessment and informed consent, which are crucial for evaluating the necessity and safety of restraints. The facility's policy on the use of restraints emphasizes that they should only be used for the safety and well-being of residents and after other alternatives have been tried unsuccessfully. The Director of Nursing acknowledged the lack of documentation and stated that the resident's preference was noted in a physician's order. However, the absence of a comprehensive assessment and care plan meant that the facility did not adhere to its own policy, which requires ongoing re-evaluation and documentation of restraint use. This deficiency had the potential to restrict the resident's freedom of movement and posed risks of physical and psychosocial harm.
Failure to Timely Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan in a timely manner for Resident 2, who was readmitted with a physician's order for heparin, an anticoagulant. Despite the order being dated 12/27/2024, the care plan addressing the use of heparin was not initiated until 1/21/2025. This delay was acknowledged by both the Registered Nurse and the Assistant Director of Nursing, who stated that care plans should be initiated as soon as a physician's order is received to ensure all staff are aware of the necessary interventions to prevent delays in care and treatment. Additionally, the facility failed to develop a comprehensive care plan for Resident 50, who was admitted with conditions including hemiplegia and epilepsy. On 1/23/2025, Resident 50's laboratory results indicated low iron levels, and a physician's order for ferrous sulfate was issued. However, no care plan was created to monitor for signs and symptoms of anemia or to address the risk of constipation associated with iron supplementation. Both the Minimum Data Set Coordinator Nurse and the Director of Nursing confirmed the absence of a care plan for this condition, emphasizing the importance of care plans in directing treatment and addressing health changes. The facility's policy and procedure on comprehensive person-centered care plans, last reviewed in January 2025, requires that such plans be developed within seven days of completing the required comprehensive assessment. The policy also mandates that care plans include measurable objectives and timeframes to meet residents' needs. The deficiencies in care planning for Residents 2 and 50 had the potential to delay necessary care and treatments, as the facility did not adhere to its own policy guidelines.
Failure to Update Care Plans for Medication and Insulin Changes
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as Resident 32, after a physician increased the dosage of bupropion, a medication used to treat depression. The care plan, which was last updated in September 2023, did not reflect the change made in December 2024 when the dosage was increased from 100 mg to 150 mg. Interviews with the Assistant Director of Nursing (ADON), Director of Staff Development (DSD), and Minimum Data Set Nurse (MDSC) revealed that the care plan should have been updated to guide nurses on medication administration, but this was not done. Additionally, the facility did not update Resident 32's care plan for diabetes management to reflect current physician orders for insulin administration. The care plan, last revised in February 2023, did not include updated interventions for insulin types and dosages as ordered by the physician. The ADON acknowledged that the care plan should have been updated to ensure all staff were aware of the resident's current plan of care, which is crucial for preventing delays in necessary services. The facility's policy and procedure on care plans, last reviewed in January 2025, emphasizes the need for care plans to be comprehensive, person-centered, and updated as the resident's condition changes. However, the facility failed to adhere to this policy, resulting in care plans that did not accurately reflect the resident's current medical orders and interventions. This deficiency had the potential to delay the provision of necessary care and services to Resident 32.
Failure to Provide Meal Assistance to Resident
Penalty
Summary
The facility failed to provide necessary assistance with meals to Resident 67, who was diagnosed with hemiplegia, hemiparesis, moderate protein calorie malnutrition, and anemia. The resident was admitted and readmitted with these conditions, requiring a mechanical soft diet and feeding assistance at all times as per physician's orders. Despite these orders, the facility did not consistently provide the required assistance, as evidenced by multiple observations and interviews. Observations revealed that Resident 67 was often left without assistance during meals, leading to minimal food intake. On one occasion, the resident's food tray was left untouched, and on another, the resident consumed only two bites of breakfast. Interviews with staff and family members confirmed that Resident 67 required significant assistance and cueing to eat, yet the resident's name was not consistently listed on the staff assignment sheets as needing meal assistance. The Director of Nursing acknowledged that the resident required feeding assistance at all times, as per the physician's order, and that failure to provide this assistance could result in the resident not eating. The facility's policies on activities of daily living and dining assistance were not adhered to, as they state that residents unable to carry out these activities independently should receive necessary services to maintain good nutrition. This deficiency had the potential to lead to weight loss and further health complications for Resident 67.
Failure to Create SBAR for Resident's Low Iron Level
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when an SBAR was not created for a resident who experienced a change of condition due to low iron laboratory results. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, epilepsy, and hypertension, had a laboratory result indicating a low iron level of 49 ug/dL, which was below the normal range. Despite the laboratory results being communicated to the Nurse Practitioner and new orders for ferrous sulfate being carried out, the required SBAR was not created to document and monitor the resident's condition. Interviews with the Health Information Director, the Minimum Data Set Coordinator Nurse, and the Director of Nursing confirmed that an SBAR should have been created to address the resident's low iron level. The facility's policy and procedures indicated that changes in a resident's condition should be promptly documented and communicated to the relevant parties. The absence of an SBAR meant that the resident's condition was not adequately monitored, which could have included observing for symptoms such as fatigue, tarry stools, skin color changes, and bleeding.
Failure to Provide Adequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to provide adequate nutritional care for a resident, identified as Resident 67, who was at risk of malnutrition and dehydration. The resident, who had a history of hemiplegia, hemiparesis, moderate protein-calorie malnutrition, and anemia, was not provided with the necessary assistance during meals on multiple occasions. Specifically, the resident was not assisted with meals on two consecutive days, which contributed to the resident consuming less than 50% of their meals on several occasions. This lack of assistance was contrary to the resident's care plan, which indicated the need for meal assistance due to swallowing safety concerns. Additionally, the facility failed to notify the resident's medical doctor when the resident consumed less than 50% of their meals for two consecutive meals on multiple dates. The facility's policy required that the medical doctor be informed in such cases to potentially adjust the resident's care plan, including orders for laboratory tests, fluids, diet changes, or medications. The failure to report these instances to the medical doctor posed a risk of weight loss and malnutrition for the resident, which could affect their overall health, including skin integrity, hydration, and consciousness levels. Interviews with staff and family members revealed inconsistencies in the facility's communication and documentation practices. The resident's need for meal assistance was not consistently reflected in staff assignments, leading to a lack of support during meals. Staff members acknowledged the oversight and indicated that the resident's meal consumption should have been reported to the medical doctor as per the care plan. The Director of Nursing confirmed that the lack of reporting and assistance could result in a delay in care, highlighting the facility's failure to adhere to its policies and procedures regarding nutritional support and monitoring.
Failure to Conduct Behavioral IDT Meetings for Medication Review
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident, identified as Resident 78, by not conducting a behavioral interdisciplinary team (IDT) meeting regarding the use of Seroquel and escitalopram. Resident 78 was admitted with diagnoses including toxic encephalopathy, unspecified dementia, and depression. The care plans for antidepressant and psychotropic medication use required discussions with the physician and family about the ongoing need for these medications. However, the facility did not document any IDT meetings with the psychiatrist to review the resident's medication use. The resident's psychoactive summary sheet indicated multiple behavioral episodes over two months, yet there was no evidence that these behaviors were discussed in the behavior management meetings. The facility's policy required periodic reviews of the relevance of each resident's medications and monitoring for improvement in target symptoms, but this was not documented for Resident 78. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed the lack of documentation and the importance of IDT meetings to adjust medication dosages appropriately. The facility's policy on psychotropic/antipsychotic medications emphasized the need for gradual dose reduction and behavioral interventions unless clinically contraindicated. Despite this, the facility did not conduct the necessary IDT meetings to evaluate the effectiveness of Resident 78's medications. The failure to hold these meetings and document discussions with the psychiatrist potentially compromised the resident's care and the ability to adjust medications based on behavioral changes.
Failure to Act on Pharmacist Recommendations and Medication Irregularities
Penalty
Summary
The facility failed to act upon the recommendations of the consultant pharmacist for a resident reviewed for unnecessary medications and medication regimen review. The resident, who was taking amiodarone for atrial fibrillation, did not have a thyroid stimulating hormone (TSH) blood draw ordered or conducted, despite the consultant pharmacist's recommendation. The MDS Coordinator confirmed that there was no TSH blood draw ordered from December 2024 to February 2025, and there was no documentation that the medication regimen review was relayed to the resident's physician. Another deficiency was identified when the facility failed to identify and report irregularities in the drug regimen for a resident using anticoagulants. The resident's physician's order and medication administration record did not match the heparin label, and the medication was administered without clarifying the discrepancy with the physician. The registered nurses involved acknowledged the error and stated that the medication should have been held until clarification was obtained. The consultant pharmacist and registered nurses involved in the medication regimen review process did not identify or report the irregularities in the residents' medication regimens. The facility's policy and procedure for medication regimen reviews were not followed, leading to potential risks for the residents involved.
Failure to Obtain Informed Consent for Psychotropic Medication Dosage Increase
Penalty
Summary
The facility failed to obtain informed consent for a resident when the dosage of bupropion, a medication used to treat depression, was increased. The resident, who was admitted with diagnoses including metabolic encephalopathy, generalized muscle weakness, and depression, was found to have severely impaired cognitive skills and lacked the capacity to make decisions. Despite this, the facility increased the resident's bupropion dosage from 100 mg to 150 mg without obtaining the necessary informed consent, as required by the facility's policy. Interviews with the Assistant Director of Nursing, Director of Staff Development, and Director of Nursing confirmed that informed consent should have been obtained with any increase in psychotropic medication dosage. The facility's policy mandates that written informed consent be recorded in the resident's medical record before initiating treatment with psychotherapeutic drugs. The failure to obtain informed consent for the increased dosage of bupropion was acknowledged by the facility staff, highlighting a lapse in adhering to the established protocol for resident rights and medication administration.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69 percent. This was due to two medication errors affecting two residents. The first error involved a Licensed Vocational Nurse (LVN) administering potassium chloride to a resident with only two ounces of water, contrary to the physician's order which specified a full glass of water. This resident had a history of Parkinson's Disease, hypokalemia, and essential hypertension. The LVN acknowledged the mistake and the Director of Nursing confirmed that the facility's policy required adherence to physician orders. The second error involved another LVN administering heparin to a resident without clarifying the physician's order, which did not match the medication label. The resident had a history of encephalopathy, complete atrioventricular block, and dementia. The physician's order lacked a specified route of administration, and the LVN failed to consult with a registered nurse or physician before proceeding. The Assistant Director of Nursing noted that the LVN should have clarified the order, as the route of administration is a critical component of medication safety. Both errors were observed during medication administration and were confirmed through interviews with nursing staff and a review of facility policies. The facility's policy on medication administration emphasized the importance of following prescriber's orders and verifying the correct medication details before administration. These deficiencies highlighted lapses in following established procedures, potentially leading to adverse effects for the residents involved.
Failure to Follow Menu and Meet Nutritional Needs
Penalty
Summary
The facility failed to adhere to the prescribed menu and did not meet the nutritional needs of a resident, identified as Resident 38, who was at nutritional risk due to a diagnosis of adult failure to thrive. The resident's care plan required adherence to a diet as ordered and consideration of food preferences. On a specific date, the facility's menu included green beans as part of the dinner meal, but due to a delivery issue, spinach was initially substituted. However, when spinach ran out, corn was served instead without prior approval from the Registered Dietitian (RD) and without considering Resident 38's dislike for corn. The Dietary Supervisor (DS) acknowledged the substitution error and the lack of communication regarding Resident 38's food preferences. The RD confirmed the substitution of corn for spinach but was unaware of the resident's refusal to eat corn, which could affect the resident's food intake. The facility's policies required that any menu deviations be documented and that residents' likes and dislikes be considered when making substitutions, which was not followed in this instance.
Inaccurate Documentation of Blood Pressure in Resident's MAR
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, identified as Resident 20, which led to potential confusion in care. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and unspecified cardiomyopathy. A discrepancy was found in the resident's medical records, specifically in the Medication Administration Record (MAR) for January 2025. The MAR indicated that a Licensed Vocational Nurse (LVN) administered Sacubitril-Valsartan with a documented blood pressure of 18/62, which was inaccurate. The LVN later stated that the correct blood pressure should have been documented as 118/62. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the LVN should have rechecked the blood pressure and corrected the documentation. The facility's policy on charting and documentation, last reviewed in January 2025, requires that documentation in the medical record be objective, complete, and accurate. The inaccurate documentation could have led to improper administration of medication, as the physician's order specified holding the medication for systolic blood pressure less than 110.
Failure to Involve Resident in Hospice Care Planning
Penalty
Summary
The facility failed to ensure necessary care was provided consistently for a resident reviewed for hospice services. The deficiency involved the lack of documented evidence that the resident and/or their representative was involved during the initial interdisciplinary team (IDT) meeting for admission to discuss the hospice plan of care. This oversight had the potential to negatively affect the resident's physical comfort and psychosocial well-being by delaying or lacking necessary hospice care and services. The resident in question was originally admitted to the facility and later readmitted with diagnoses including Parkinson's disease, dementia, and osteoarthritis. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a need for substantial assistance with activities of daily living. Despite receiving hospice services, there was no indication that the resident or their representative participated in the IDT meeting, which is crucial for developing a comprehensive care plan. Interviews with facility staff, including the Social Services Director and the Assistant Director of Nursing, confirmed that the IDT meeting did not include the resident or their representative. The facility's policy and procedure emphasized the importance of involving the resident and their representative in care planning, yet this was not adhered to in this case, leading to the deficiency.
Failure to Monitor Antibiotic Use and Side Effects
Penalty
Summary
The facility failed to monitor a resident for the use of vancomycin, an antibiotic, which could have led to unidentified side effects. The resident, who was admitted with diagnoses including metabolic encephalopathy, pneumonia, and unspecified cardiomyopathy, was prescribed vancomycin intravenously every 12 hours for pneumonia. Despite the administration of the medication being documented, there was no recorded monitoring for side effects or effectiveness in the Medication Administration Record, Progress Notes, or Daily Skilled Medicare Charting during specific shifts. Interviews with the Infection Preventionist, Director of Staff Development, and Director of Nursing revealed that the facility's policy required antibiotic monitoring every shift, with documentation in the Progress Notes and other records. However, this monitoring was not performed as required, and the facility's policies on antibiotic stewardship and infection surveillance were not followed. The lack of documentation and monitoring was acknowledged by the staff, highlighting a deficiency in the facility's adherence to its own procedures for antibiotic use and monitoring.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Hollywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Palms Care Center | 1 mi | ★★★★★ | 11 | 0 |
| Grand Valley Health Care Center | 1.2 mi | ★★★★★ | 25 | 1 |
| The Care Center On Hazeltine, Llc | 1.3 mi | ★★★★★ | 12 | 0 |
| Four Seasons Healthcare & Wellness Center, Lp | 1.8 mi | ★★★★★ | 21 | 0 |
| Sherman Village Hcc | 2.1 mi | ★★★★★ | 14 | 0 |
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