Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Vista Nursing And Transitional Care Llc during CMS and state inspections, most recent first.
A resident with CKD on dialysis and sepsis was ordered oxycodone HCl 5 mg PRN for moderate pain, but the MAR showed it was given for pain rated 9/10 and 10/10. An LVN and the QA nurse stated staff administered the opioid outside the ordered pain range and did not obtain a new order for severe pain.
Medication cart 2 was found unclean and disorganized, with medication spills, sticky bottles, and sanitizer wipes mixed with medications. An LPN confirmed that a resident's Eliquis, fludrocortisone, and Midodrine remained stored in the cart after transfer to the GACH, and staff stated sanitizer wipes should not be kept with medications. The resident had CKD, was on renal dialysis, and was dependent for several ADLs.
A resident with CKD on dialysis and sepsis had Oxycodone administered, but nursing staff did not document the specific pain location in the MAR/administration notes. An LVN and the QA nurse confirmed the missing detail during record review, and the facility policy required adequate pain documentation in the medication record.
The facility failed to administer ordered meds within the prescribed time frame for two residents. One resident with glaucoma, HTN, neuropathy, and anticoagulant use had several meds, including eye drops, antihypertensive, anticoagulant, neuropathy, and muscle relaxant therapy, documented well after the scheduled times. Another resident with bipolar disorder, anemia, and DM II also had aspirin and divalproex doses given late. RN stated meds should be given within the scheduled window, and the facility policy required administration in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Water Management Program Not Implemented as Written: The facility failed to follow its IPC policy when the WMP was not carried out as written. The IP and MS stated the MS only checked hot water temperatures and did not check cold water temperatures or chlorine content, and the plan did not address emergency actions. Review of the Legionnaire’s Disease policy and Environmental Assessment Form showed required flowcharts and assessment sections were incomplete or blank.
Incomplete Flu and Pneumococcal Vaccine Documentation: The facility failed to properly complete influenza vaccine consent records for four residents, with missing LPN signatures on the consent forms. One resident with impaired cognition and total care needs also had no documented evidence that the pneumococcal vaccine was offered or administered, and the IP stated the pneumococcal record was missing. The facility’s policies required influenza refusals and pneumococcal assessments/offers to be documented in the medical record.
Incomplete COVID-19 vaccination documentation and screening: The facility lacked documented evidence of staff screening, education, offering, and current vaccination status for several employees, including the Administrator, a Dietary Aide, and the Head Cook. Two residents also had incomplete COVID-19 vaccine consent forms with missing eligibility screening sections; one resident had DM, a foot ulcer, cellulitis, and paraplegia, and the other had leukemia, DM, and keratitis.
Call lights were not kept within reach or matched to resident needs for four residents with significant cognitive and physical impairments. One resident with bilateral arm splints did not have an accessible call light or a pad call light, another had a pad call light on the floor, a third had the call light stuck under the mattress, and a fourth had the call light behind the headboard and out of reach. Staff and the DON stated the residents could not use the call lights as found.
Advance directive information was not properly provided or completed for three residents. One resident with ESRD and heart failure had no AHDAF found in the chart or old files, while two residents with severe cognitive impairment had incomplete AHDAFs that did not show whether they had an advance directive or wanted to formulate one. RN and MDSC interviews confirmed the SSD was responsible for providing the form, and the DON stated staff should have ensured the residents’ end-of-life wishes were documented.
Unordered Pillow Restraints: Staff placed pillows under the fitted sheet for three residents, and those pillows were identified by CNA, LVN, MDSC, and DON as restraints because the residents could not remove them and their movement in bed was restricted. One resident had schizophrenia, dementia, and epilepsy; another had dementia, functional quadriplegia, schizophrenia, and high fall risk; and a third had encephalopathy, hemiplegia, and severe cognitive impairment. The record reviews showed no physician order, informed consent, restraint assessment, or care plan for the pillow use.
The facility failed to ensure psychotropic medication orders were properly managed for two residents. One resident with mood disorder, GAD, and cognitive impairment received PRN alprazolam without documented informed consent, and another resident with severe cognitive impairment received PRN lorazepam without informed consent, without a stop date, and without a care plan. Staff and the DON confirmed the missing consent and, for the lorazepam order, the missing end date and care plan.
PASRR screenings were not completed or updated for residents with newly identified mental health diagnoses. The MDSC acknowledged overlooking new diagnoses of psychosis, depression, GAD, and major depressive disorder, and also failed to resubmit a Level I screening when the admission screening did not match the resident’s current condition. The DON stated the PASRR process should have been completed or corrected for these residents.
A facility failed to develop and implement care plans for two residents’ high-risk medications. One resident had Xarelto ordered for CVA prophylaxis and diagnoses including PVD, atherosclerotic heart disease, and peptic ulcer, while another resident had Alprazolam for anxiety and Aripiprazole for mood disorder with paranoia, along with mood disorder, GAD, and alcohol dependence. The MDSC and DON stated no care plans were in place for these medications, despite the facility policy requiring comprehensive person-centered care plans with measurable objectives and timetables.
Care plans were not reviewed and revised to include ordered LALM interventions for three residents with pressure injuries or pressure injury risk. Each resident had significant medical issues and cognitive impairment, and staff observed LALMs in use, but the care plans for pressure ulcer management did not list the LALM as an intervention. The MDSC and DON stated the care plans should have reflected the current physician orders.
Low Air Loss Mattresses Not Set by Resident Weight: Three residents with pressure injuries or high pressure injury risk had LALM orders for wound management, but staff observed the mattresses set at incorrect settings rather than according to each resident’s weight. The MDSC and DON stated the settings should have matched the residents’ weights, and the care plans did not include the LALM interventions for the affected residents.
A facility failed to keep floor mats free of furniture and equipment for three residents with significant cognitive and mobility impairments. Staff observed bedside tables, a nightstand, and an IV pole placed on top of mats intended to provide a soft landing surface, and the MDSC and DON stated that objects on the mats defeated their purpose.
A resident with a history of UTI and two other residents with significant cognitive impairment had foley catheters that were not properly managed. One catheter tubing had loops and was touching the floor, and two catheters lacked a leg strap or stat lock. The MDSC, LVN, CNA, and DON stated the tubing should be secured and kept off the floor to prevent pulling, trauma to the meatus, and infection, and the facility’s catheter care policy and related orders were not followed.
A resident with a PICC line had a dressing that lacked the date, time, and staff initials during observation. RN and DON stated PICC dressings should be changed every 7 days or as needed, and the facility policy required sterile dressings to be labeled with initials, date, and time.
Respiratory care was not maintained consistently for several residents with serious respiratory and medical conditions. Surveyors observed oxygen tubing, humidifiers, suction equipment, and nebulizer supplies that were undated, not changed per order or facility practice, stored on the floor, or mixed with another resident’s items. Staff and the DON stated the equipment should have been labeled, changed, and kept clean to prevent contamination and respiratory infections.
A resident with epilepsy and psychiatric diagnoses had ordered doses of divalproex sodium and levetiracetam documented as given on the MAR, but the same doses were still found in the blister packs during observation. An LVN, the MDSC, and the DON all confirmed that the MAR showed administration even though the medications appeared not to have been removed, and the facility policy required meds to be given as ordered and documented after administration.
Failure to Rotate Insulin Injection Sites: A resident with DM, encephalopathy, and severe cognitive impairment had orders for Novolin R and Lantus insulin with instructions to rotate injection sites, but the LAR showed repeated injections in the same arm and abdominal areas instead of rotation. The MDSC and DON stated the sites were not rotated, the care plan was not followed, and the facility considered this a medication error.
Missing Dietary Aide Competency Documentation: The facility failed to maintain a current competency and skills checklist for one dietary aide, with the employee file showing the last skills check completed in 2023 and no documentation for the following years. The DSD stated performance evaluations are important for competency and quality of care and confirmed the aide had not been evaluated to verify continued job performance. The dietary aide job description required compliance with policies and attendance at orientation, in-services, and meetings as required.
Incorrect Portioning During Tray Line Service: The Head [NAME] was observed serving mashed potatoes on the tray line using a size 8 scooper for residents assigned small portions, including residents on a level 4 IDDSI diet. The facility's menu spreadsheet indicated that mashed potatoes for the pureed diet required use of both a size 8 and a size 12 scooper for correct portioning, and the Head [NAME] stated the size 12 scooper was missing. The DS and RD stated staff should follow the spreadsheet and use accurate measurements for resident diets.
Unpasteurized eggs were found in the walk-in refrigerator and were used to serve sunny side up eggs to two residents, while the invoice did not show pasteurized eggs. Kitchen sanitation records were incomplete, including an ice machine log with entries far apart and a daily cleaning log without a month or year. Surveyors also observed condensation in the freezer and a thickener scoop left on top of its container with residue, rather than stored in a clean designated holder.
A resident with mood disorder, GAD, alcohol dependence, and moderate cognitive impairment had multiple pain medication entries on the MAR/MAAR where the documented time did not match the administration time for oxycodone and ibuprofen. The resident stated pain meds were given late most of the time. Staff gave conflicting explanations about the MAR columns, while the DON stated pain meds should be documented as soon as given and noted several entries were documented more than 30 minutes late.
Failure to Monitor Antibiotic Side Effects The facility did not document required monitoring for adverse effects for two residents receiving antibiotics. One resident received ciprofloxacin for a UTI, and although the care plan called for observation of side effects, the MDSC could not find documentation that monitoring occurred. Another resident received cephalexin, and progress notes did not show the required every-shift monitoring for adverse reactions during the antibiotic course. Staff interviews confirmed that monitoring and documentation were expected for residents on antibiotic therapy.
A resident receiving Xarelto for CVA prophylaxis was not monitored for adverse effects and had no care plan developed or implemented for anticoagulant use. The resident had PVD, atherosclerotic heart disease, and peptic ulcer, and the MDS showed moderate cognitive impairment and use of a high-risk anticoagulant drug class. The MDSC and DON both stated that monitoring and a care plan were important for safe anticoagulation therapy and communication among the care team.
Medication Cart 1 had multiple storage and labeling problems, including an opened glucose test strip vial without an open date, Megestrol Acetate Oral Suspension without an open date, a new Lantus pen mixed with opened insulin pens instead of being refrigerated, and sanitizing wipes stored with medications. The drawer also had medication spills and sticky bottles, and the DON confirmed the items should have been dated, refrigerated as indicated, and kept separate from non-medication supplies.
A resident with moderate protein-calorie malnutrition, metabolic encephalopathy, and dysphagia reported that the food was not tasty and bland. During tray observations, the meat patty lacked flavor, the fries were dry and unseasoned, the vegetables were overcooked and mushy, and later the chicken and soup were also described as tasteless. CNA reported the resident typically ate only 25-50% of meals and usually drank protein shakes, but refused one that day.
A resident admitted with multiple fractures, including sacral, rib, scapular, and vertebral fractures, and prescribed PRN Hydrocodone-Acetaminophen for severe pain did not have these conditions or pain management needs addressed in the comprehensive care plan. The MDS documented moderately impaired cognition and need for moderate assistance with ADLs, yet the care plan omitted interventions for fracture care and pain control. An LVN and the DON acknowledged that the care plan was not comprehensive and did not reflect the resident’s existing conditions as required by facility policy.
A resident with schizoaffective disorder, bipolar disorder, depression, and generalized anxiety disorder, and with documented behavioral issues such as aggression and yelling, was transferred to a GACH on a 5150 psychiatric hold for danger to others and later readmitted. Despite GACH records noting verbal aggression, agitation, labile mood, inability to contract for safety, and suicidality, the resident’s comprehensive care plan was not revised after the hospital stay to address the transfer, the 5150 hold, or the readmission. An LVN confirmed the omission during record review, and the DON acknowledged that the care plan should have been updated with new approaches and interventions, contrary to facility policy requiring care plan revision after significant changes in condition and hospital readmission.
Surveyors found that two residents with multiple fractures and moderately impaired cognition did not receive the prescribed opioid doses for severe pain. Review of MARs showed that on multiple occasions, nursing staff administered lower-dose oxycodone and hydrocodone-acetaminophen regimens that were ordered for moderate pain, even though the residents reported severe pain levels. An LVN acknowledged these were medication errors, and the DON confirmed that staff are required to follow prescriber orders, pain scales, and the facility’s medication administration policy, which mandates verification of the right dose before giving medications.
A resident with COPD, emphysema, and hypertensive heart disease experienced documented SOB over multiple consecutive days, with nursing notes repeatedly recording respiratory complaints and observations but no evidence of physician notification. Despite a care plan directing staff to assess respiratory status and notify the MD as indicated, the change in condition was not communicated until the resident developed severe SOB requiring EMS activation and transfer to an acute care hospital, where low oxygen saturation and several days of worsening symptoms were documented. This failure occurred despite facility policy requiring MD notification for significant changes in condition and for situations necessitating hospital transfer.
Two residents did not receive ordered topical medications and wound care as prescribed. One resident with multiple chronic conditions and moderately impaired cognition had physician orders for daily-shift Nystatin powder to abdominal folds for MASD and Mupirocin 2% ointment to both legs for cellulitis; review of the TAR with an RN showed no licensed staff initials for these treatments on two morning shifts, and the RN confirmed there was no documented evidence they were administered. Another resident with paraplegia and a stage 4 sacral pressure ulcer had detailed daily-shift sacral wound care orders involving Dakin’s solution, collagen, hydrocolloid, and foam dressings; the TAR similarly lacked licensed staff initials for two morning shifts, and the RN stated there was no documentation the treatment was completed. Facility policy required medications, including topical treatments, to be administered as prescribed and recorded on the TAR.
A resident with heart failure, epilepsy, COPD, and moderately impaired cognition, who depended on staff for multiple ADLs, experienced vomiting and an O2 saturation of 76% on room air, leading to transfer to an acute care hospital. Despite this significant change in condition, the resident’s comprehensive care plan was not revised to address the vomiting and desaturation, contrary to facility policy requiring the IDT to review and update care plans after significant changes or hospital stays. An RN confirmed that the care plan was not updated and that it serves as the essential guide for staff monitoring and care.
A resident with a history of liver disease and alcohol dependence left the facility AMA after being placed on a one-on-one sitter, but did not receive discharge instructions or information about the risks and benefits of leaving in their preferred language of Spanish. The AMA form was signed in the presence of two RNs who could not communicate in Spanish, resulting in the resident not being fully informed as required by facility policy.
A resident with a history of aggression physically assaulted another cognitively impaired resident, causing injury and pain. Despite prior documented aggressive incidents, there was no evidence of psychiatric evaluation or consistent monitoring, and required follow-up interventions were lacking. Staff confirmed the abuse and facility policies mandated protection from such incidents.
A resident with a history of alcoholic cirrhosis, malnutrition, and alcohol dependence left the facility AMA after being placed on one-on-one supervision. The resident's preferred language was Spanish, but discharge instructions and the AMA form were only provided in English, and staff present could not translate. As a result, the resident left without fully understanding the risks and benefits of leaving AMA.
A resident with schizoaffective disorder and dementia received PRN Haloperidol without an end date or required 14-day re-evaluation, and staff did not monitor or document behavioral symptoms to justify continued use. This failure did not comply with facility policy for antipsychotic medication management.
A resident was readmitted with a new indwelling catheter, but the care plan was not updated to include goals or interventions for catheter care. The omission was confirmed by an RN during record review and interview, despite facility policy requiring care plan updates after significant changes or readmission. The resident had multiple diagnoses and required maximal assistance with daily activities.
A resident with multiple chronic conditions and severe cognitive impairment experienced a significant change in condition with abnormal vital signs. Facility staff did not assess the resident's blood glucose level at the time, despite policy and professional standards requiring this assessment during such events. The omission was acknowledged by nursing staff and resulted in incomplete evaluation during the resident's acute episode.
A resident with severe cognitive impairment and multiple medical conditions was admitted with a new indwelling catheter, but staff failed to place orders for catheter care or monitoring, and there was no documentation of care or assessment as required by facility policy.
A resident with COPD, acute respiratory failure, and dementia did not receive prescribed continuous oxygen therapy or regular spO2 monitoring as ordered. Staff failed to reconnect the nasal cannula and turn on the oxygen concentrator after care, and documentation for oxygen administration and spO2 checks was missing for several shifts, contrary to facility policy.
Two residents with complex medical needs did not have discharge planning included in their person-centered care plans, despite facility policy and staff acknowledgment that social services are responsible for this process. Both the MDS assessments and interviews with the DON confirmed the absence of discharge planning interventions, which is required by facility policy and the Social Services Director's job description.
A resident with multiple chronic conditions requested transfer closer to family, and the Social Services Director engaged in discussions and outreach to potential facilities. However, there was no documentation in the medical record of these communications or actions, contrary to facility policy requiring all services and care planning activities to be recorded.
A resident with multiple medical conditions and total dependence on staff for care was found to have their call light on the floor and out of reach, contrary to their care plan and facility policy. Staff confirmed the importance of keeping the call light accessible, and facility policy required it to be within reach when the resident is in bed.
A resident with multiple respiratory diagnoses was found with her oxygen nasal cannula inside her mouth instead of her nose, despite a physician's order for continuous oxygen via nasal cannula. Staff interviews confirmed the importance of proper placement and adherence to orders, but the deficiency occurred when the device was not correctly positioned, resulting in the resident not receiving oxygen as prescribed.
A resident with depressive disorder, hypertension, and anxiety disorder was found to be living in a room and restroom that were not clean or homelike, with visible residue, rust, and broken fixtures. Both an LVN and the DON confirmed the lack of cleanliness, which did not meet facility policy for maintaining a sanitary and comfortable environment.
Three residents with various medical conditions and decision-making capacity were not provided with written information about their right to formulate an Advance Directive upon admission. Staff interviews and record reviews confirmed that required documentation and discussions did not occur, and the facility's process for informing residents about ADs was not followed.
The facility failed to obtain informed consent and properly monitor the use of psychotropic medications for several residents, including not documenting behavioral indications, adverse effects, or end dates for PRN orders. Staff did not follow required procedures for consent and ongoing evaluation, and behavior monitoring documentation was missing for multiple months for two residents receiving antipsychotic and antianxiety medications.
Pain medication given outside ordered pain level
Penalty
Summary
The facility failed to address the pain level of one resident by not following the physician’s order for pain management. The resident was admitted with diagnoses including chronic kidney disease, dependence on renal dialysis, and sepsis. The resident’s MDS showed dependence for toileting hygiene, showers, upper and lower body dressing, putting on and taking off footwear, and personal hygiene, and the H&P documented that the resident had capacity to understand and make decisions. The active order for oxycodone HCl 5 mg was written to be given every 4 hours as needed for moderate pain rated 4 to 6. The MAR showed the resident received oxycodone 5 mg for pain rated 10 out of 10 on one occasion, and for pain rated 10 out of 10 and 9 out of 10 on another date. During interview and record review, the LVN stated staff administered oxycodone for pain levels of 9 and 10 despite the order being for moderate pain, and stated nursing staff should have contacted the physician to clarify the order or obtain a new order for the reported pain level. The QA nurse stated staff should have contacted the physician for a PRN order for severe pain and that the medication ordered for moderate pain was used to treat severe pain.
Medication Cart Not Kept Clean and Resident Medications Left Stored After Transfer
Penalty
Summary
Medication storage in medication cart 2 was not maintained in a clean and organized condition, and Resident 1's medications were left stored in the cart after the resident was transferred to the GACH. During observation, the left bottom drawer of medication cart 2 contained medication spills, sticky medication bottles, and a container of sanitizer wipes mixed with medications. The right bottom drawer contained Resident 1's Eliquis 5 mg tablet, fludrocortisone 0.1 mg tablet, and Midodrine HCL 10 mg tablet, along with a container of sanitizer mixed with the medications. Resident 1's record showed diagnoses of chronic kidney disease, dependence on renal dialysis, and sepsis. The MDS indicated the resident was dependent for toileting hygiene, showers, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The H&P stated the resident had capacity to understand and make decisions. Staff interviews confirmed that nursing staff were responsible for keeping medication carts clean and organized, that Resident 1's medications remained in the bottom right drawer while the resident was transferred to the GACH, and that sanitizer wipes should not be stored with medications. The facility policy stated nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Inaccurate Pain Documentation in Medication Record
Penalty
Summary
Nursing staff failed to accurately document the location of a resident’s pain when administering Oxycodone. The resident was admitted with chronic kidney disease, was dependent on dialysis, and had sepsis. The resident’s MDS indicated dependence for toileting hygiene, showers, upper and lower body dressing, footwear, and personal hygiene, and the H&P stated the resident had capacity to understand and make decisions. During interview and record review, an LVN and the QA nurse reviewed the resident’s administration notes and MAR and stated that the location of pain was not documented in the medical record when Oxycodone was given. They stated that the specific body site affected by pain should be documented so staff can assess whether the medication effectively treated the resident’s pain. The facility’s Pain Assessment and Management policy required documenting the resident’s reported level of pain with adequate detail and recording the assessment information in the resident’s medication record.
Late Medication Administration for Two Residents
Penalty
Summary
The facility failed to administer medications as ordered for two residents. Resident 1 was admitted with diagnoses including glaucoma, idiopathic peripheral autonomic neuropathy, HTN, and long-term anticoagulant use. The record showed Resident 1 had capacity to understand and make decisions, intact cognitive functioning, and required varying levels of assistance with personal care. Active orders included brimonidine tartrate ophthalmic solution for glaucoma, amlodipine for HTN, apixaban for CVA prophylaxis, gabapentin for neuropathy, and methocarbamol for muscle spasms. Review of Resident 1’s MAAR showed multiple medications were given later than the scheduled 9 a.m. or 1 p.m. times, including amlodipine, apixaban, methocarbamol, gabapentin, and brimonidine tartrate. Examples included 9 a.m. medications documented as administered at 10:26 a.m., 10:31 a.m., 10:32 a.m., and 10:32 a.m., and 1 p.m. medications documented as administered at 3:39 p.m. During interview, RN 1 stated medications should have been administered within the scheduled time and that staff have one hour before and one hour after the scheduled time to administer medications. Resident 2 was admitted with diagnoses including bipolar disorder, anemia, and type 2 DM. The record showed Resident 2 had capacity to understand and make decisions and intact cognitive functioning. Active orders included aspirin for CVA prophylaxis and divalproex sodium for bipolar disorder. Review of the MAAR showed aspirin and divalproex sodium scheduled for 9 a.m. were administered at 11:35 a.m. and 11:05 a.m., and a 6 p.m. divalproex sodium dose was administered at 8:46 p.m. RN 1 stated these medications should have been administered within the scheduled time, and the facility policy stated medications are to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Water Management Program Not Implemented as Written
Penalty
Summary
The facility failed to ensure staff followed its Infection Prevention Control Policy to prevent the spread of infection when the Water Management Program was not implemented as written. During a concurrent interview and record review with the Infection Preventionist and Maintenance Supervisor, the facility’s Water Management Program 2026 Committee document was reviewed and identified that the committee meeting was conducted on 1/2/2026. The Infection Preventionist stated that he and the Maintenance Supervisor were responsible for the water management plan, and that the purpose of water management was to prevent legionella in the facility. The Infection Preventionist stated he was not responsible for implementation because he was not the one checking temperatures, and the Maintenance Supervisor stated he checked only the hot water temperature. The Maintenance Supervisor stated he did not check cold water temperatures or chlorine content for any water sources. The Infection Preventionist and Maintenance Supervisor also stated the plan provided did not address what to do in an emergency. Review of the facility’s Legionnaire’s Disease policy showed the facility was to determine risk areas using a Building Water System Process Flowchart, implement controls, and identify control locations using a Control Area Monitoring Flowchart, with preventive maintenance plans for each control area. Review of the Environmental Assessment Form showed multiple sections were blank, including who completed the assessment, the total rooms and number of buildings, and buildings with supplemental disinfection.
Incomplete Flu and Pneumococcal Vaccine Documentation
Penalty
Summary
The facility failed to ensure influenza vaccination consent forms were properly completed for four sampled residents. For Resident 15, who had diagnoses including type II DM with foot ulcer, immunodeficiency, and atherosclerotic heart disease, the MDS showed moderately impaired cognitive skills for daily decisions and maximal assistance needed for ADLs, but the Flu Vaccination Record Consent dated 2/24/2026 was missing the signature of the licensed nurse who obtained and verified the consent. For Resident 51, admitted with DM with foot ulcer, cellulitis of the left lower limb, and paraplegia, the Flu Vaccination Record Sheet dated 1/28/2026 was also missing the licensed nurse signature. For Resident 50, admitted with leukemia and DM, the Flu Vaccination Record Sheet dated 10/23/2025 did not indicate a licensed nurse signature who obtained and witnessed the consent. Resident 28, admitted with displaced fracture of the fourth cervical vertebra and fracture of nasal bones, had moderately impaired cognitive skills for daily decisions and required maximal assistance with ADLs. The Flu Vaccination Record for this resident was missing the licensed nurse signature, and during interview the Infection Preventionist stated Resident 28 refused the flu vaccine in 9/2025. The IP also stated he did not recall whether the pneumococcal vaccine was offered because it was not in the medical record, and that consents and vaccine records were missing for Resident 28. The facility’s policy titled Influenza Vaccine stated residents without contraindications would be offered the influenza vaccine annually and refusals would be documented on the informed consent and placed in the medical record. The Pneumococcal Vaccine policy stated residents are offered pneumococcal vaccines, assessed for eligibility prior to or upon admission, and offered the vaccine series within 30 days of admission unless medically contraindicated or already vaccinated. During record review, Resident 15’s pneumococcal consent showed the vaccine was administered six days after the consent was signed, and the IP stated vaccines should be administered as soon as possible after consent is signed so any signs and symptoms can be related to the vaccine. For Resident 28, the IP stated the pneumococcal vaccine was not documented in the medical record.
Incomplete COVID-19 vaccination documentation and screening
Penalty
Summary
The facility failed to provide documented evidence of employee COVID-19 screening, education, offering, and current vaccination status for all staff. During a concurrent interview and record review, the Infection Preventionist reviewed the staff roster vaccination list and found the sections for the Administrator, Dietary Aide 1, and the Head Cook were blank. The Infection Preventionist stated he did not have the Administrator, Dietary Aide 1, and Head Cook's records. The facility policy titled, Corona virus Disease (COVID-19)-Vaccination of Staff, dated October 2022, indicated staff are required to be fully vaccinated for COVID-19 unless exempted by law. The facility also failed to ensure COVID-19 vaccine screening was completed for two sampled residents. Resident 51 was admitted with diagnoses including type two DM with foot ulcer, cellulitis of the left lower limb, and paraplegia, and the MDS indicated intact cognitive skills for daily decisions and partial moderate assistance with ADLs. Resident 51's COVID-19 Vaccine Consent Form contained a missing screening section for vaccine eligibility, and the Infection Preventionist stated the form was not filled out. Resident 50 was admitted with diagnoses including leukemia, DM, and keratitis, and the MDS indicated moderately impaired cognitive skills for daily decisions and moderate assistance with ADLs. Resident 50's COVID-19 Vaccine Consent Form also had a missing screening section for vaccine eligibility, and the Infection Preventionist stated the form was not filled out. The facility policy titled, Coronavirus Disease (COVID-19)-Vaccination of Residents, indicated residents are screened for contraindications to the vaccine, medical precautions, and prior vaccination before being offered the vaccine.
Call Lights Not Kept Within Reach or Properly Matched to Resident Needs
Penalty
Summary
The facility failed to ensure that call lights were within reach and that the appropriate type of call equipment was provided for four sampled residents. The deficiency was identified through observation, interview, and record review and involved Residents 20, 34, 63, and 66. The report states that the failure had the potential to result in delayed care and services, possible injury, and inability for the residents to summon staff for assistance or adjust their beds for comfort as needed. Resident 20 had diagnoses including contracture of muscle, generalized anxiety disorder, and dementia, with records showing fluctuating capacity to understand and make decisions, severe cognitive impairment, dependence for mobility and ADLs, and orders for bilateral elbow splints and bilateral wrist/hand splints. The care plan included an intervention that the call light would be within reach at all times. During observation, the call light cord was not accessible and was found at the back of the curtain. Staff stated the resident could not use the regular call light because of the splints and that a special pad call light should have been assessed for and provided. Resident 34 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, other lack of coordination, and contracture of the left hand, with records showing no capacity to understand and make decisions, severe cognitive impairment, and dependence to moderate assistance with mobility and ADLs. During observation, the pad call light was on the floor on the right side of the bed. Staff stated the resident would not be able to call for help if the call light was not within reach. Resident 63 had diagnoses including metabolic encephalopathy, other lack of coordination, and hypotension, with records showing no capacity to understand and make decisions, severe cognitive impairment, and dependence to needing setting-up assistance with mobility and ADLs. During observation, the call light was stuck under the mattress near the head of the bed and was not accessible until staff removed it. Resident 66 had diagnoses including visual loss in both eyes, lack of coordination, and protein-calorie malnutrition, with records showing severely impaired cognition, inability to understand and make needs known, impairment of both upper extremities, and substantial to total assistance with all ADLs. The resident was also identified as high risk for falls. During observation, the call light was not within reach and was behind the headboard down to the floor. Staff stated the resident was unable to reach it because of weakness in both upper extremities, and the DON stated the call light should have been accessible at all times.
Advance Directive Information Not Provided or Completed for Three Residents
Penalty
Summary
The facility failed to inform and provide written information to adult residents about the right to accept or refuse medical or surgical treatment and, at the resident’s option, to formulate an advance directive. The deficiency involved three sampled residents and centered on the Social Services Director’s responsibility to ensure the advance healthcare directive acknowledgment form was provided and completed. The facility’s own policy stated that, prior to or upon admission, the Social Services Director or designee inquires about any written advance directive and provides written information concerning the right to refuse or accept treatment and to formulate an advance directive. Resident 8 was admitted with diagnoses including end stage renal disease, dependence on renal dialysis, and hypertensive heart disease with heart failure. The resident’s history and physical indicated the resident had capacity to understand and make decisions, and the MDS later indicated the resident could make self-understood and understand others with moderate cognitive impairment. During record review, RN 1 could not find the advance healthcare directive acknowledgment form in the electronic record, physical chart, or old files. RN 1 stated the form was important to ensure advance healthcare directive information was provided to the resident or representative. The MDSC stated it was the primary responsibility of the SSD to ensure the form was provided, and the DON stated staff should have offered it so the resident’s end-of-life wishes would be followed. Resident 42 was admitted and later readmitted with diagnoses including sepsis, acute respiratory failure with hypoxia, and secondary malignant neoplasm of bone. The history and physical indicated fluctuating capacity to understand and make decisions, and the MDS showed the resident usually could make self-understood and understand others, had severe cognitive impairment, and had family participating in assessment and goal setting. RN 1 found the acknowledgment form incomplete because it did not indicate whether the resident had an advance directive or was interested in formulating one. Resident 5 was admitted and later readmitted with diagnoses including COPD, encephalopathy, and dementia. The history and physical indicated cognitive impairment, and the MDS showed the resident rarely to never could make self-understood and understand others and had severe cognitive impairment, with family participating in care planning. RN 1 also found this resident’s acknowledgment form incomplete for the same reason. In both cases, the MDSC stated the SSD was responsible for ensuring the form was provided and that the facility’s advance directive policy was not followed.
Unordered Pillow Restraints
Penalty
Summary
The facility failed to ensure residents were free from the use of physical restraints unless needed for medical treatment. For Resident 20, the record showed diagnoses including schizophrenia, dementia, and epilepsy, and the resident had fluctuating capacity, severe cognitive impairment, and dependence for mobility and ADLs. During observation, a pillow was found tucked under the sheets on the right back side of the resident. The CNA and LVN stated the pillow should not be tucked under the sheets because the resident could not remove it easily and it limited repositioning in bed. The MDSC also stated the tucked pillow was a restraint. Resident 20’s record did not show an order for restraint pillows tucked under the sheets, and the record review identified no informed consent, restraint assessment, or care plan for the use of the pillow as a restraint. The MDSC stated that before applying a restraint, the facility should have a physician’s order, informed consent, a restraint assessment, and a care plan, and that these elements were not present in the OSR. The DON stated the tucked pillow was a restraint and should have had those required elements documented. For Resident 57, the record showed diagnoses including dementia, functional quadriplegia, schizophrenia, adult failure to thrive, and lack of coordination, with severely impaired cognition and high fall risk. During observation, two pillows were tucked under the fitted sheet on both sides of the bed. CNA 2, CNA 1, LVN 1, the MDSC, and the DON all stated that pillows tucked under the fitted sheet restricted the resident’s movement, could not be removed by the resident, and were considered a restraint. The record review showed no physician’s order for placing the pillows under the fitted sheet, and the same restraint requirements were identified as missing. For Resident 2, the record showed diagnoses including other toxic encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and other lack of coordination. The resident had severe cognitive impairment and required maximal assistance with mobility and ADLs. During observation, pillows were tucked under the fitted sheet on both sides of the bed. CNA 6 stated there should not be pillows under the fitted sheet because it restricts movement and is considered a restraint. The MDSC and DON stated there was no physician’s order, the resident could not remove the pillows, and placing the pillows under the fitted sheet restricted mobility and was considered a restraint.
Unnecessary Psychotropic Medication Use Without Consent, Stop Date, or Care Plan
Penalty
Summary
The facility failed to ensure the drug regimen was free from unnecessary psychotropic medications for two residents by not obtaining informed consent, and in one case by not having a stop date or care plan for a PRN psychotropic order. For Resident 46, the record showed admission with diagnoses including mood disorder, generalized anxiety disorder, and alcohol dependence. The H&P stated the resident had the capacity to understand and make decisions, while the MDS indicated the resident could make self-understood and understand others but had moderate cognitive impairment and was receiving antipsychotic and antianxiety medications. The OSR showed an order for alprazolam 0.5 mg by mouth every six hours as needed for anxiety manifested by constant complaints of pain for 30 days. During concurrent review, the MDSC stated there was no informed consent on the use of alprazolam and that PRN psychotropic medications were only good for 14 days. The DON stated licensed staff should have obtained informed consent from the resident or responsible party for alprazolam and that informed consent was important so the risks and benefits were explained and the resident could agree or disagree with the treatment. The facility policy on psychoactive medication informed consent stated informed consent is to be obtained for each resident’s psychoactive medication, and the psychotropic medication use policy stated residents will not receive medications that are not clinically indicated and that PRN psychotropic orders are limited to 14 days. For Resident 66, the H&P indicated cognitive impairment, and the MDS showed severely impaired cognition, inability to understand and make needs known, and substantial to total assistance with ADLs. The OSR showed an order for lorazepam 1 mg by mouth every six hours as needed for anxiety manifested by excessive worrying and screaming. The record review found no documented informed consent, no stop date for the PRN lorazepam, and no care plan developed and implemented for its use. The MDSC and DON both stated the PRN lorazepam should have had an end date, informed consent should have been obtained from the resident and/or responsible party, and a care plan should have been developed and implemented for the medication. The facility’s care plan and psychotropic medication policies stated comprehensive person-centered care plans are to be developed and implemented and that PRN psychotropic medications are limited to 14 days unless the prescriber documents rationale and duration.
PASRR screenings were not updated for residents with new mental health diagnoses
Penalty
Summary
The facility failed to ensure PASRR screening and resident review were completed for residents with newly identified mental disorders, and failed to ensure a new PASRR Level I Screening was submitted when an existing screening contained a discrepancy. The deficiency involved three residents and was identified through record review and staff interviews with the MDSC and DON. For one resident, the record showed admission and later readmission with new diagnoses of GAD, depression, and psychosis. The H&P documented fluctuating capacity to understand and make decisions, and the MDS showed severe cognitive impairment, use of antipsychotic and antidepressant medications, and family participation in care planning. The resident’s PASRR, completed before the new diagnoses, indicated no SMI and no functional limitations in the prior 6 months. During interview, the MDSC stated a resident review should have been completed for the new mental health diagnoses and acknowledged overlooking the diagnoses; the DON stated another PASRR assessment should have been performed. For a second resident, the record showed admission and readmission with diagnoses of psychosis, depression, and GAD. The MDS showed moderate cognitive impairment and antidepressant use, and the prior PASRR indicated that a level II mental health evaluation was not required. The MDSC stated the resident’s new diagnoses should have triggered a resident review for PASRR and acknowledged overlooking the mental illness diagnoses. The DON stated another PASRR assessment should have been completed for the new diagnoses. For the third resident, the admission record and H&P documented major depressive disorder and GAD, and the MDS also reflected major depressive disorder, GAD, and psychotropic medication use. The PASRR Level I Screening completed at admission indicated no serious mental disorder, no suspected mental illness, and no psychotropic medications. The MDSC stated the screening should have been resubmitted to reflect the resident’s current diagnoses because the admission screening did not match the resident’s condition, and stated that without a new Level I Screening the resident would not be evaluated and would not receive the appropriate treatment and referral as needed. The DON stated the MDSC was responsible for ensuring the PASRR Level I Screening was accurate upon admission and resubmitted when there was a discrepancy.
Missing Care Plans for Anticoagulant and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 11’s use of Xarelto, an anticoagulant ordered for cerebrovascular accident prophylaxis. Resident 11 was admitted to the facility with diagnoses including peripheral vascular disease, atherosclerotic heart disease, and peptic ulcer. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment and use of a high-risk anticoagulant drug class. During interview and record review, the MDS Coordinator reviewed Resident 11’s OSR and care plans and stated there was no care plan developed and implemented addressing the resident’s use of Xarelto. The MDS Coordinator stated the care plan was important to ensure safe use of Xarelto, to communicate to all healthcare providers, and to ensure monitoring for adverse effects and consistent interventions to meet the goals of therapy. The DON also stated it was important for Resident 11 to have a care plan for Xarelto to ensure safe use and that the goal of anticoagulant therapy was to prevent bleeding. The facility also failed to develop and implement a care plan for Resident 46’s use of psychotropic medications, Alprazolam and Aripiprazole. Resident 46 was admitted with diagnoses including mood disorder, generalized anxiety disorder, and alcohol dependence. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment and use of high-risk antipsychotic and antianxiety medication classes. The OSR showed orders for Alprazolam for anxiety and Aripiprazole for mood disorder with paranoia, and the MDS Coordinator stated there was no care plan addressing these medications. The MDS Coordinator and DON stated the lack of a care plan predisposed the resident to adverse effects and uncoordinated care among healthcare providers.
Care plans were not updated to include ordered low air loss mattress interventions
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team for three residents with pressure injuries or pressure injury risk. For each of the three sampled residents, the record showed an order for a low air loss mattress (LALM) for wound management, but the corresponding care plan did not include the LALM as an intervention. The deficiency involved Residents 42, 5, and 71, whose care plans were not updated to reflect the current physician-ordered treatment. Resident 42 was admitted and later readmitted with diagnoses including sepsis, acute respiratory failure, and malignant neoplasm of the bone. The resident’s assessment showed severe cognitive impairment, dependence for mobility and ADLs, and a stage 3 pressure injury over a bony prominence with pressure injury treatment in place. The order summary report showed an order for a LALM for wound management, and staff observed the resident on a LALM in the room. However, the care plan titled for stage 3 pressure ulcer or potential pressure ulcer development, last revised on 5/12/2026, did not include the LALM intervention. The MDSC stated the LALM was not added to the care plan and that the care plan should have been updated to reflect current treatment. Resident 5 was admitted and later readmitted with diagnoses including COPD, encephalopathy, and dysphagia. The MDS showed severe cognitive impairment, dependence to partial assistance with mobility and ADLs, and a stage 1 pressure injury with pressure reducing devices and pressure injury care. The OSR showed an order for a LALM for wound management during every shift, and staff observed the resident on a LALM. The care plan titled for stage 3 pressure injury extending to the right buttocks did not include the LALM intervention. Resident 71 was admitted and later readmitted with diagnoses including fracture of the neck and left femur, encephalopathy, and gastrostomy. The resident’s assessment showed no capacity to understand and make decisions, severe cognitive impairment, dependence to partial assistance with mobility and ADLs, and risk for pressure injuries. The OSR showed an order for a LALM for wound management, and staff observed the resident on a LALM. The care plan titled documented pressure ulcer did not include the LALM intervention. In each case, the MDSC and DON stated the care plan should have been updated to reflect the physician’s order for LALM.
Low Air Loss Mattresses Not Set by Resident Weight
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice when low air loss mattresses were not set according to each resident’s weight for three sampled residents. Resident 42 was admitted and later readmitted with diagnoses including sepsis, acute respiratory failure, and malignant neoplasm of the bone. The resident’s assessments showed severe cognitive impairment, dependence for mobility and ADLs, a stage 3 pressure injury over the sacro coccyx, and high risk for further pressure injuries. The OSR included an order for a low air loss mattress for wound management, but the care plan did not include the mattress as an intervention. During observation, Resident 42’s low air loss mattress was found set past 350 on the machine. LVN 1 stated the mattress should be set according to the resident’s weight. The MDSC reviewed the records and stated the resident’s current weight was 146 lbs and that the mattress should have been set according to that weight. The MDSC also stated the care plan should have been updated to reflect the current treatment order. The DON later stated the mattress should have been set according to the resident’s current weight and that the care plan should have been updated to reflect the physician’s order for the low air loss mattress. Resident 5 had diagnoses including COPD, encephalopathy, and dysphagia, with severe cognitive impairment and dependence for mobility and ADLs. The resident had a stage 1 pressure injury over a bony prominence, was at risk for further pressure injuries, and had an OSR order for a low air loss mattress for wound management every shift. The resident’s weight was 124 lbs, but during observation the mattress was set to 300 and static. LVN 1 stated the mattress should be set according to the resident’s weight. The MDSC stated the mattress should have been set according to the resident’s weight and that the care plan did not include the low air loss mattress intervention. The DON stated the mattress should have been set according to the resident’s current weight and the care plan should have been updated to reflect the physician’s order. Resident 71 had diagnoses including fracture of the neck and left femur, encephalopathy, and gastrostomy, with severe cognitive impairment and dependence for mobility and ADLs. The resident was at risk for pressure injuries, had a very high risk Braden score, and had an OSR order for a low air loss mattress for wound management. The resident’s weight was 118 lbs, but during observation the mattress was set at 250, alternating. LVN 1 stated the mattress should be set according to the resident’s weight. The MDSC stated the mattress should have been set according to the resident’s weight and that the care plan titled documented pressure ulcer did not include the low air loss mattress intervention. The DON stated the mattress should have been set according to the resident’s current weight and the care plan should have been updated to reflect the physician’s order.
Floor mats obstructed by furniture and equipment
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards for three sampled residents by allowing equipment or furniture to be placed on top of floor mats intended to serve as soft landing surfaces. The report states that floor mats were observed with bedside tables, nightstands, and an IV pole for a feeding pump positioned on top of them, which defeated the purpose of the mats as described by staff and management. Resident 1 was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with circulatory complications, and lack of coordination. The resident’s H&P stated the resident did not have the capacity to make decisions, and the MDS indicated severe cognitive impairment and dependence or partial/moderate assistance with mobility and ADLs. During observation, the resident’s bedside table and nightstand were on top of the floor mat in the room. A CNA stated the mat would not serve its purpose if the table and nightstand remained on it, and the MDSC and DON both stated that placing furniture or equipment on the mat defeated its purpose and could cause injury. Resident 34 was admitted and readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, other lack of coordination, and contracture of the left hand. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment and dependence or moderate assistance with mobility and ADLs. During observation, the resident was lying in bed with a bedside table on top of the floor mat on one side and part of the mat under the bed. A CNA stated there should be no furniture placed on the floor mat, and the MDSC and DON stated the mat was intended to provide a soft landing surface and that objects on it defeated that purpose. Resident 71 was admitted and readmitted with diagnoses including fracture of the neck and left femur, encephalopathy, and epilepsy. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment, dependence to partial assistance with mobility and ADLs, and a fall since admission/entry or reentry prior to assessment with injury. The resident’s order summary did not indicate an order for a floor mat, although the fall risk evaluation identified the resident as at risk for falls and the care plan included interventions related to seizure activity and removing obstacles to ensure a safe environment. During observation, the resident’s floor mat had an IV pole for a feeding pump on top of it. An LVN stated there should be no equipment or furniture on top of the mat, and the MDSC and DON stated the mat was meant to provide a soft landing surface and that placing objects on it defeated its purpose.
Improper Foley Catheter Securement and Tubing Placement
Penalty
Summary
Residents with indwelling urinary catheters did not receive catheter care as outlined in the facility’s policies and physician orders. The report identified three sampled residents with catheter-related deficiencies: one resident had catheter tubing with loops and the tubing was touching the floor, and two residents had catheters that were not secured with a leg strap or stat lock. The facility’s policy stated that catheter tubing and drainage bags should be kept off the floor and that catheters should remain secured with a securement device to reduce friction and movement at the insertion site. Resident 42 was admitted and later readmitted with diagnoses including sepsis, UTI, acute cystitis, and hematuria. The resident’s record showed fluctuating decision-making capacity, severe cognitive impairment, and dependence for toileting hygiene. During review and interview, the MDSC stated the catheter tubing should not have loops and urine should go directly to the bag. The MDSC also stated the resident’s catheter care plan was not followed and that the tubing loops and contact with the floor created a potential for UTI due to possible backflow of urine. The DON stated the tubing should not have loops or touch the floor because of ascending infection risk. Resident 5 had diagnoses including type 2 DM, obstructive and reflux uropathy, and encephalopathy, and the MDS showed severe cognitive impairment with substantial assistance needed for toileting hygiene. The physician order required checking anchor placement every shift, and the care plan stated the resident should remain free from catheter-related trauma. During observation, the resident’s urinary catheter did not have a leg strap or stat lock. The LVN and MDSC stated a securement device was needed to prevent tugging and pulling that could cause trauma to the meatus and serve as a portal of entry for infection, and the DON stated the catheter should always have a securement device in place. Resident 1 was admitted with diagnoses including metabolic encephalopathy, type 2 DM with circulatory complications, and infection and inflammatory reaction due to an indwelling urethral catheter. The resident lacked decision-making capacity and had severe cognitive impairment with dependence or partial/moderate assistance for mobility and ADLs. During observation, the resident’s foley catheter did not have a securement device such as a stat lock or leg strap. The CNA and MDSC stated the catheter lacked the securement device needed to prevent pulling, irritation, and tearing of the urinary meatus, and the DON stated the catheter should have had a stat lock to keep it in place and prevent trauma.
PICC Dressing Lacked Required Documentation
Penalty
Summary
The facility failed to ensure proper documentation for a resident’s PICC line dressing. Resident 80 was admitted with diagnoses including sepsis, lack of coordination, and essential hypertension, and the history and physical noted the resident had the capacity to understand and make decisions. During a concurrent observation and interview, the resident was found to have a PICC line in the right upper arm, and the dressing did not have the date, time, or staff initials documented. During interviews, RN 1 stated PICC dressing changes should be done every seven days or as needed, and that if the dressing does not have the date, time, and initials, it should be changed because staff would not be able to verify when it was changed. The DON stated the PICC dressing needs to be changed every seven days or as needed to prevent infection, and if the dressing does not have the date, time, and initials, it needs to be changed immediately. The facility policy for Central Venous Catheter Care and Dressing Changes stated sterile dressings should be labeled with initials, date, and time.
Respiratory Equipment Not Properly Changed, Labeled, or Stored
Penalty
Summary
Respiratory care was not provided in accordance with physician orders and facility practice for six sampled residents. The report states that the facility failed to ensure oxygen tubing, humidifiers, suction equipment, and nebulizer supplies were properly changed, labeled, stored, and kept off the floor or away from other residents’ belongings. Surveyors observed multiple instances of respiratory equipment that was undated, improperly stored, or not maintained as required. For one resident with ESRD, dialysis dependence, and hypertensive heart disease, the nasal cannula tubing was found stored in a clear plastic bag dated 5/11/2026, and staff stated it should have been changed on 5/9/2026 per physician order. For another resident with pneumonia, sepsis, and acute respiratory failure with hypoxia, surveyors observed a suction setup with a canister nearly full of whitish secretions that had no label, a Yankauer with suction tubing without a change date, and oxygen tubing on the floor without a date. Staff stated these items should have been labeled and replaced to prevent respiratory infections. A resident with COPD, encephalopathy, and dysphagia had oxygen tubing touching the floor, and the clear plastic bag for the tubing was dated 5/11/2026 even though the order required weekly changes. Another resident’s drawer contained a nebulizer mask and tubing labeled with another resident’s last name and no date. A resident with CHF and morbid obesity had nasal cannula tubing and humidifier without any indication of when they were last changed, and the respiratory TAR did not show the scheduled change was completed. A resident with pneumonia, COPD, and acute respiratory failure had nasal cannula tubing on the floor, and staff stated it should not have been there and needed to be changed. The facility’s infection prevention and control policy was also reviewed and stated it was intended to help maintain a safe, sanitary, and comfortable environment and prevent transmission of diseases and infections.
Medication Administration Not Documented Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate administration of ordered medications for one resident. Resident 48 had diagnoses including epilepsy, schizophrenia, and major depressive disorder, and the record also noted cognitive impairment. Physician orders included divalproex sodium 250 mg twice daily for schizoaffective disorder, bipolar type, and levetiracetam 500 mg twice daily for seizure control. A review of the May 2026 MAR showed the resident’s 9 a.m. doses of divalproex sodium and levetiracetam on 5/13/2026 and 5/17/2026 were documented as given with check marks and nurse initials. However, during observation of medication administration and review of the resident’s blister packs with LVN 2, those doses were still present in the blister pack. LVN 2 stated that if the medications remained in the blister pack, it could mean they were not given, and that nurses are supposed to administer the medication before signing the MAR. During follow-up interview and record review, the MDS Coordinator confirmed that the blister packs showed the 9 a.m. doses remained in place while the MAR indicated administration. The DON stated medications are to be given as ordered, the MAR signed after administration, and if a medication is not administered there should be a note explaining why. The facility policy also stated medications are to be administered in a safe and timely manner, within 1 hour of the prescribed time unless otherwise specified, and the MAR should be initialed after giving each medication.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that one sampled resident with type 2 diabetes mellitus was free from significant medication errors related to insulin administration. Resident 5 was admitted with diagnoses including type 2 diabetes mellitus, encephalopathy, and dysphagia, and the MDS dated 3/11/2026 indicated the resident rarely to never could make self understood or understand others and had severe cognitive impairment. The resident had orders for Novolin R insulin with a sliding scale and Lantus insulin at bedtime, and both orders directed staff to rotate the injection site. The Location of Administration Report for 4/2026 showed repeated insulin injections given in the same areas rather than being rotated. Lantus was administered multiple times to the left arm and then repeatedly to the right arm, and Novolin R was administered multiple times to the left arm and then repeatedly to the abdomen, including several injections in the right upper quadrant and left lower quadrant. During interview and record review on 5/20/2026, the MDS Coordinator stated there were multiple instances where insulin administrations were not rotated and that the care plan intervention to administer medication as ordered was not followed. During interview on 5/21/2026, the DON stated the resident's insulin administration sites should have been rotated to prevent lipodystrophy and cutaneous amyloidosis and stated that injecting insulin on sites of lipodystrophy could result in hypo/hyperglycemia. The facility's insulin administration policy required injection sites to be rotated, and the medication error policy defined medication errors as administration not in accordance with physician orders, manufacturer specifications, or accepted professional standards. The HPI for both Lantus and Novolin R also stated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.
Missing Dietary Aide Competency Documentation
Penalty
Summary
The facility failed to ensure that one of two sampled dietary aides had a current specific competency and skills checklist completed for 2024 and 2025. During a concurrent interview and record review on 5/21/2026 at 10:00 a.m. with the DSD, the employee file for DA 1 was reviewed and there was no documentation showing a current skills checklist for 2024 or 2025. The DSD stated the last skills check in the file was completed in 2023 and that the last in-service skills checklist was also not found in the file. During the interview on 5/21/2026 at 10:10 a.m., the DSD stated that performance evaluations are important for competency and quality of care and that it was her responsibility to make sure performance evaluations were done timely. The DSD also stated that when the skills checklist is not completed, it means the employee was not evaluated to make sure they could still perform the job properly. The dietary aide job description, dated 03/2021, stated that dietary aides comply with company and departmental policies and procedures and attend orientation, in-services, and meetings as required. The facility assessment, dated 3/1/2026 to 3/1/2027, identified staff competency training review and training topics for staff based on condition, equipment use, therapy schedule/assistance, special skills, resident rights, baseline care plan, comprehensive care plan, resident record/care plan copies, and therapy schedules and transport training.
Incorrect Portioning During Tray Line Service
Penalty
Summary
The facility failed to ensure the Head [NAME] used the correct scoopers during tray line service for residents on small-portion diets, including residents on a level 4 International Dysphagia Diet Standardization Initiative diet. During an observation of the tray line on 5/18/2026 at 11:57 a.m., the Head [NAME] was observed serving mashed potatoes from the steam table using a size 8 scooper, which holds 4 fluid ounces, as each tray moved down the line. The potatoes were portioned directly from the pan, and the Head [NAME] continued serving in the same manner for all residents assigned to receive the small portion. A review of the facility's [NAME] Spreadsheet Spring Menu for week 4, dated 5/18/2026, showed that mashed potatoes prepared for the level 4 pureed diet required use of two scoopers, a size 8 and a size 12, to ensure correct portioning. During interview, the Head [NAME] stated the spreadsheet listed the measurements and scoopers to use during tray line and acknowledged that the size 12 scooper was missing. The Dietary Supervisor stated staff should use the correct scooper based on the spreadsheets, and the Registered Dietitian stated measuring portions is important so residents who need fewer calories receive accurate food measurements.
Unsafe egg use and poor kitchen sanitation documentation
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. During an initial kitchen observation, unpasteurized grade AA eggs were found in the walk-in refrigerator on the lowest shelf with an open date, and the Head Cook stated those eggs were used that morning to serve sunny side up eggs to two residents, including a resident whose record showed intact cognitive skills, no swallowing disorder, and a therapeutic diet. The Dietary Supervisor stated the eggs had been ordered as pasteurized, but the invoice reviewed for the supplier order did not indicate pasteurized eggs. The Dietary Supervisor also stated that unpasteurized eggs must be cooked to 165 degrees Fahrenheit to kill salmonella, and the Registered Dietitian stated that eggs that are not pasteurized could contain harmful bacteria and can cause Salmonella. Kitchen sanitation logs were not kept up to date or fully dated. The ice machine log showed entries dated 12 days apart, and the daily cleaning schedule posted on the bulletin board was not labeled with a month and year. Staff interviews confirmed that the logs were expected to be completed at the beginning of shifts and that the daily cleaning schedule was supposed to be done daily. The Dietary Supervisor stated the logs needed complete documentation and that without a date or year staff would not know when cleaning was done. The Registered Dietitian stated the kitchen logs needed to be completed daily, weekly, or monthly as scheduled to maintain sanitation. Additional kitchen observations showed condensation in the vegetable freezer, and the Dietary Supervisor stated maintenance was responsible for preventing condensation because ice crystals can prevent circulation for cooling. At the food preparation table, the scoop for thickened liquid was left on top of the container and had white residue. Staff stated the scoop should be kept in a separate cup or holder and not left on the container lid. The Dietary Supervisor stated the scoop should be cleaned after each use and returned to a designated area, and that the scoop in dry storage had no date showing when it was last cleaned. The facility policy and procedure for sanitation and for refrigerators and freezers stated food contact surfaces and utensils are to be cleaned and sanitized, and that supervisors inspect refrigerators and freezers for excess condensation and other maintenance needs.
Delayed and Inaccurate Documentation of Pain Medication Administration
Penalty
Summary
The facility failed to maintain Resident 46’s medical record in a complete and accurately documented manner for pain medication administration. Resident 46 was admitted with diagnoses including mood disorder, generalized anxiety disorder, and alcohol dependence. The resident’s H&P stated she had the capacity to understand and make decisions, and the MDS indicated she could make herself understood and understand others, though she also had moderate cognitive impairment. The resident’s record included orders for ibuprofen 400 mg for pain level 1-3 and oxycodone 5 mg and 10 mg for moderate and severe pain. A review of the MAAR showed multiple pain medication administrations where the documented time did not match the administration time. Examples included oxycodone 5 mg documented later than the administration time, oxycodone 10 mg documented later than the administration time on several occasions, and ibuprofen documented later than the administration time on multiple occasions. During interview, Resident 46 stated her pain medications were given late most of the time, but she could not recall specific details, dates, times, or which nurses were involved. Staff interviews and record review showed differing explanations for the MAAR time entries. LVN 2 stated pain medication should be documented as soon as it is given and identified the third column as reassessment, not administration, but could not provide evidence because the MAR had no time stamps for reassessment. The MRD and MDSC stated the third column was documented time and the last column was who gave the medication, while the DON stated pain medications should be documented as soon as given and that a 30-minute allowance is afforded, but several instances exceeded 30 minutes. The facility’s policies stated medications are to be administered in a safe and timely manner and documented after administration, and pain should be reassessed every 30 to 60 minutes after onset until relief is obtained.
Failure to Monitor Adverse Effects During Antibiotic Therapy
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not documenting monitoring for adverse effects for two residents receiving antibiotic therapy. One resident was admitted with diagnoses including UTI, neuromuscular dysfunction of the bladder, and a punctured abdominal wall wound. The resident’s H&P indicated capacity to understand and make decisions, and the MDS showed the resident could make self-understood and understand others, with moderate impaired cognition and use of a high-risk drug class antibiotic. For this resident, the OSR showed an order for Ciprofloxacin HCl 500 mg by mouth every 12 hours for UTI for 7 days. The care plan, initiated for antibiotic therapy related to UTI and risk for adverse reaction, included an intervention to observe for side effects or adverse reactions and call the MD once noted. During interview and record review, the MDSC stated the chart contained the ciprofloxacin order and care plan, but he could not find documentation showing monitoring for adverse effects of the medication. The MDSC stated there was no documentation to support that the monitoring was being done, and the DON stated the resident should have had monitoring for adverse effects to prevent harmful effects and allow physician intervention. A second resident was admitted with diagnoses including visual loss in both eyes, lack of coordination, and protein-calorie malnutrition. The H&P noted cognitive impairment, and the MDS showed severely impaired cognition, inability to understand and make needs known, and substantial to total assistance with ADLs. The resident received cephalexin by telephone order, 7500 mg, one tablet by mouth every 6 hours for 7 administrations until finished. The care plan directed staff to administer medication as ordered, monitor vital signs, and observe for side effects every shift, but progress notes from the listed shifts did not document monitoring for adverse side effects during the antibiotic course. Staff interviews confirmed that licensed nurses were expected to monitor residents on antibiotics every shift and document it in the progress notes, and the DON stated this monitoring was important so staff could detect adverse effects and notify the physician.
Failure to Monitor Xarelto Use and Develop Care Plan
Penalty
Summary
The facility failed to ensure that one resident's drug regimen was free from unnecessary drugs by not monitoring for adverse effects related to Xarelto use and by not developing and implementing a care plan for the medication. Resident 11 was admitted with diagnoses including PVD, atherosclerotic heart disease, and peptic ulcer, and the record showed the resident had the capacity to understand and make decisions, with moderate cognitive impairment noted on the MDS. The resident was ordered Xarelto 10 mg by mouth daily for CVA prophylaxis and was identified as receiving a high-risk anticoagulant drug class. During the record review and interview with the MDSC, the OSR, care plans, and progress notes were reviewed, and the MDSC stated there was no monitoring for adverse effects and no care plan developed and implemented for the use of Xarelto. The MDSC stated that monitoring for adverse effects helps the physician provide safe anticoagulation therapy and that the care plan is important to ensure safe use of Xarelto and to communicate interventions to healthcare providers. The DON also stated that monitoring for adverse effects and developing and implementing a care plan were important for safe use of Xarelto. The DON stated the number one goal of anticoagulant therapy was to prevent bleeding to residents and stated that the failure of licensed staff to monitor for adverse effects and to develop and implement a care plan on the use of Xarelto had predisposed the resident to its unsafe use and possibly bleeding. The facility policy on anticoagulation required assessment for signs or symptoms related to adverse drug reactions, and the care plan policy required a comprehensive, person-centered care plan with measurable objectives and timetables for each resident.
Medication Cart Storage and Labeling Deficiency
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in Station 1 Medication Cart 1. During a concurrent observation and interview, surveyors found one opened vial of glucose test strips with no date opened, a bottle of Megestrol Acetate Oral Suspension without an open date, one new Lantus pen mixed with opened insulin pens, and a container of sanitizing wipes mixed in with medications. The bottom left fourth drawer also had medication spills, and the medication bottles in the drawer were sticky. LVN 1 stated the glucose test strip vial should have been dated when opened and that the strips are good for 28 days after opening. LVN 1 also stated the Megestrol Acetate Oral Suspension should have an open date, the new Lantus pen should not have been mixed with opened pens and should have been kept in the refrigerator, and the sanitizing wipes should not have been stored with medications. LVN 1 further stated the dirty drawer and medication spills could contaminate medications. The DON stated the glucose test strips should be open dated and are only good for 28 days, the Megestrol Oral Suspension should have an open date and is good for 30 days once opened or until the expiration date, whichever comes first, and a new Lantus pen should be refrigerated to preserve potency. The DON also stated disinfectant wipes should not be mixed with medications and medication cart drawers should be clean and spill-free to prevent contamination of other medications.
Meals Were Not Palatable or Flavorful for a Resident With Malnutrition and Dysphagia
Penalty
Summary
The facility failed to ensure that Resident 33 received palatable and flavorful meals consistent with the resident’s preferences and nutritional needs. Resident 33’s records showed diagnoses including moderate protein-calorie malnutrition, metabolic encephalopathy, and dysphagia. The MDS dated 2/18/2026 indicated the resident had severe cognitive impairment, could make self-understood and understand others, and required dependent to moderate assistance with mobility and ADLs. During an interview, Resident 33 stated she did not like the food because it was not tasty. During a food tray taste test, the meat patty lacked flavor and was bland, the french fries were dry and unseasoned, and the mixed vegetables were overcooked and mushy. On a later observation, Resident 33 stated the chicken did not have flavor and she did not like the soup because it was bland and tasteless; she said she did not want to eat the food anymore and only wanted to eat the ice cream. CNA 5 stated the resident ate about 25% of lunch and normally ate about 25-50%, and also normally drank protein shakes but refused one that day. The Dietary Supervisor stated flavor is important for residents to enjoy meals and that Resident 33 liked protein shakes and sweet foods. Facility job descriptions stated meals were to be prepared and served as palatable and appetizing in appearance.
Failure to Care Plan for Fractures and Pain Management
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident admitted with multiple fractures and pain management needs. The resident was admitted with diagnoses including a nondisplaced zone II sacral fracture, multiple left rib fractures, a displaced fracture of the scapular body, and other fractures of the fourth and fifth vertebrae. The History and Physical documented that the resident had capacity to understand and make decisions, while the MDS assessment showed moderately impaired cognitive functioning and a need for moderate assistance with oral hygiene, toileting hygiene, toilet transfers, showers, and personal hygiene. A physician’s order dated shortly after admission prescribed Hydrocodone-Acetaminophen 5-325 mg, two tablets by mouth every four hours as needed for severe pain. During an interview and concurrent record review, an LVN confirmed that the resident’s care plan did not address the resident’s fractures or pain management, despite these documented conditions and orders. The LVN stated that the care plan is the guide for staff interventions and that failure to include pain management and fracture care could lead to staff mistakes and delayed care. The DON also stated that the care plan should have addressed all existing conditions and acknowledged that the resident’s care plan was not comprehensive. Review of the facility’s policy on comprehensive, person-centered care plans showed that it required development and implementation of a care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, derived from a thorough assessment and reflecting recognized standards of practice, which was not done for this resident’s fractures and pain management.
Failure to Revise Behavioral Care Plan After Psychiatric Hospitalization and Readmission
Penalty
Summary
The facility failed to revise a resident’s comprehensive care plan following a significant change in condition and readmission from a general acute care hospital (GACH) on a 5150 psychiatric hold. The resident, originally admitted on 12/18/2024 and later readmitted, had diagnoses including schizoaffective disorder, bipolar disorder, depression, and generalized anxiety disorder. A Minimum Data Set dated 3/16/2026 showed moderately impaired cognitive functioning, with the resident independent in eating, oral hygiene, toileting hygiene, and ambulation. A care plan created on 3/11/2026 identified behavior problems such as aggression, hitting staff, kicking objects, yelling, and cursing. On 3/16/2026 at 2:01 p.m., a progress note documented that the resident was transferred to GACH for psychiatric evaluation on a 5150 hold due to aggressive behavior toward staff and refusal of medications. GACH records from 3/16/2026 indicated the resident was admitted on a hold for danger to others and being gravely disabled, with documented verbal aggression, irritability, agitation, labile mood, inability to contract for safety, and endorsement of suicidality. During a concurrent interview and record review on 4/14/2026, an LVN confirmed that the resident’s care plan did not address the transfer to GACH on a 5150 hold or the subsequent readmission. In an interview on 4/15/2026, the DON stated that the care plan should have been revised after readmission to provide new approaches and interventions to prevent recurrence of previous problems and to manage the resident’s behavior. The facility’s policy on comprehensive person-centered care plans, last reviewed on 2/26/2026, required that care plans be revised when there is a significant change in condition and when a resident is readmitted from a hospital stay, which did not occur in this case.
Failure to Administer Correct Opioid Doses for Severe Pain
Penalty
Summary
Surveyors identified a deficiency in medication administration related to opioid pain management for two residents. For Resident 1, who was admitted with multiple fractures including a displaced cervical vertebra and nasal bone fracture and had moderately impaired cognition, the physician ordered oxycodone 10 mg by mouth every four hours as needed for severe pain (7–10/10) and oxycodone 5 mg every four hours as needed for moderate pain (4–6/10). Review of the March MAR showed that on three separate dates, at evening administration times, nursing staff documented administering only 5 mg of oxycodone when Resident 1 reported severe pain at a level of 8/10. During interview, LVN 1 acknowledged that the 10 mg dose should have been given for severe pain and that giving the 5 mg dose instead was a medication error with the potential for unrelieved pain. For Resident 3, who was admitted with multiple traumatic fractures including sacral, rib, scapular, and vertebral fractures and also had moderately impaired cognition, the physician ordered hydrocodone-acetaminophen 5-325 mg, one tablet every six hours as needed for moderate pain (4–6/10), and two tablets every four hours as needed for severe pain (7–10/10), with a maximum daily acetaminophen limit. Review of the April MAR showed that on two separate mornings, nursing staff documented administering only one 5-325 mg tablet when Resident 3 reported severe pain at levels of 8/10 and 10/10. LVN 1 confirmed that the single-tablet dose was ordered for moderate pain and that two tablets should have been administered for severe pain, identifying these as medication errors. The DON stated that licensed staff are expected to follow prescriber orders, the pain scale, and residents’ reported pain levels when administering pain medications. The facility’s “Administering Medications” policy, last reviewed in February, directed that medications be administered safely, timely, and as prescribed, and required the individual administering medications to check the label three times to verify the right resident, medication, dosage, time, and route before administration. Despite these requirements, the documented administrations for both residents did not match the ordered dosages for the reported severe pain levels, resulting in the cited deficiency for failure to ensure residents were free from significant medication errors.
Failure to Notify Physician of Resident’s Ongoing Shortness of Breath
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s primary physician of a significant change in respiratory status over several days. The resident was admitted with COPD, emphysema, and hypertensive heart disease and had moderate cognitive impairment, requiring partial to moderate assistance with activities of daily living. The resident’s care plan for impaired gas exchange and ineffective airway clearance related to COPD included interventions to assess respiratory function, monitor for respiratory changes, and notify the physician as indicated. Progress notes documented that, beginning on 2/7/2026, the resident experienced shortness of breath, initially while lying flat, and then on subsequent days continued to report and exhibit shortness of breath. These respiratory symptoms were documented on 2/7, 2/8, 2/9, 2/10, and 2/11, but there was no documentation or evidence that the resident’s physician was notified of this ongoing change in condition. Facility nursing staff, including an LVN and an RN, later acknowledged that the resident’s shortness of breath had been present since 2/7/2026 and that the physician should have been notified during that period. On 2/12/2026 at 3:26 a.m., an SBAR was completed identifying a COPD exacerbation with severe shortness of breath, and an order was entered at 4:34 a.m. to transfer the resident to an acute care hospital. Emergency medical services documented that the resident reported having shortness of breath for the past five days without help and was found to have an oxygen saturation of 82% on room air when picked up from the facility. The hospital emergency department record indicated the resident presented with progressively worsening shortness of breath over six days. The facility’s own policy on change in a resident’s condition required nursing staff to notify the attending physician when there was a significant change in the resident’s physical condition or a need to transfer the resident to a hospital, which did not occur during the days when the resident’s shortness of breath was repeatedly documented.
Failure to Administer and Document Ordered Topical Treatments and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and professional standards of practice for two residents. For one resident with depression, cirrhosis, heart failure, and COPD, the admission record showed the resident was readmitted in January 2026 and had moderately impaired cognition, with dependence on staff for personal hygiene, toileting hygiene, and lower body dressing. Physician orders included daily-shift topical Nystatin powder to abdominal folds for MASD starting 1/28/2026, and Mupirocin 2% ointment to both legs for cellulitis starting 1/29/2026. Review of this resident’s February 2026 Treatment Administration Record (TAR) with an RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials in the TAR boxes for the ordered Mupirocin ointment treatments to the left and right legs, and no licensed staff initials for the ordered Nystatin powder to the abdominal folds. The RN stated there was no documented evidence that these treatments were administered as ordered on those dates and times and acknowledged that failure to administer the treatments as ordered had the potential to negatively affect the resident’s care and potentially cause wound deterioration, infection, or delay of wound healing. For a second resident admitted with paraplegia, a stage 4 sacral pressure ulcer, and sacral osteomyelitis, the H&P indicated intact decision-making capacity, and the care plan for pressure ulcers directed staff to provide wound care per treatment orders. Physician orders dated 1/23/2026 specified a multi-step daily-shift sacral/coccyx stage 4 pressure ulcer treatment, including cleansing with Dakin’s solution, application of a collagen dressing cut to wound shape, application of a hydrocolloid dressing, and coverage with abdominal pads and Mepilex foam. Review of this resident’s February 2026 TAR with the RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials documenting completion of the ordered sacral pressure ulcer treatment. The RN stated there was no documented evidence the treatment was done and that failure to administer the treatment as ordered had the potential to cause complications such as infection and deterioration of the pressure ulcer. The facility’s medication administration policy, revised 1/2026, stated that medications are to be administered safely, timely, and as prescribed, and that topical medications used in treatments are to be recorded on the TAR.
Failure to Update Care Plan After Resident Desaturation and Vomiting Episode
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident after a significant change in condition involving desaturation and vomiting. The resident was admitted with diagnoses of heart failure, epilepsy, and COPD, and had moderately impaired cognitive functioning, requiring staff assistance for toileting hygiene, toilet transfers, showers, and lower body dressing. On review of the resident’s MDS and admission records, these needs and conditions were documented. The facility’s policy required that the comprehensive, person-centered care plan, which includes measurable objectives and timetables to meet physical, psychological, and functional needs, be reviewed and updated when there is a significant change in condition or when a resident is readmitted from a hospital stay. On a specific date, an SBAR Communication Form documented that the resident experienced an episode of vomiting and an oxygen saturation of 76% on room air, and was transferred to a general acute care hospital for further evaluation. During an interview and concurrent record review, an RN confirmed that the resident’s care plan had not been updated to address the episode of vomiting and desaturation. The RN stated that the care plan is an essential guide for staff to provide monitoring to ensure the resident’s condition does not deteriorate and acknowledged that the failure to update the care plan had the potential to delay care and monitoring for the resident.
Failure to Provide Discharge Instructions in Resident's Preferred Language
Penalty
Summary
The facility failed to provide a resident with discharge instructions in the resident's preferred language of Spanish when the resident left the facility Against Medical Advice (AMA). The resident, who had a history of alcoholic cirrhosis with ascites, protein calorie malnutrition, and alcohol dependence, was sometimes able to understand and be understood by others, with Spanish documented as the preferred language. On the day of the incident, the resident expressed a desire to leave after being placed on a one-on-one sitter following an alleged physical abuse incident with another resident. The resident signed an AMA form, which was witnessed by two RNs, neither of whom could speak or translate Spanish. The review of facility records and interviews confirmed that the AMA form and related discharge instructions were not provided in Spanish, and the resident did not receive information about the risks and benefits of leaving AMA in a language he understood. Facility policies require that residents be informed of their rights and responsibilities and be supported in exercising those rights, including being informed in a manner they can understand. The failure to provide instructions in the resident's primary language resulted in the resident not being fully informed to make an appropriate decision regarding leaving the facility AMA.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another in the hallway. On the morning of the incident, one resident, who had a documented history of verbal and physical aggression, stood up from his wheelchair, grabbed another resident, pinned them against a door, struck their head against the door, and punched them in the face. This resulted in the victim sustaining redness and pain to the left eye, with a pain rating of three out of ten. The incident was witnessed by both a CNA and an LVN, who confirmed the aggressive actions and the use of racial slurs during the altercation. The resident who committed the abuse had a care plan in place for aggression, which included monitoring behavior every shift. However, records revealed multiple prior incidents of aggressive behavior, including several change in condition (COC) events related to aggression in the months leading up to the incident. Despite these documented behaviors, there was no evidence of a psychiatric evaluation or consistent 72-hour monitoring following previous aggressive episodes. Additionally, progress notes did not indicate social services visits after aggressive incidents, suggesting a lack of follow-up and intervention. The victim of the abuse had severe cognitive impairment and a history of encephalopathy, major depressive disorder, and generalized anxiety disorder. The facility's own policies required protection of residents from abuse by anyone, including other residents. Interviews with staff and review of facility policies confirmed that the actions constituted both physical and verbal abuse, and that the facility failed to ensure the safety and well-being of the residents involved.
Failure to Provide Discharge Instructions in Resident's Preferred Language
Penalty
Summary
The facility failed to provide a resident with discharge instructions in their preferred language, Spanish, when the resident chose to leave the facility against medical advice (AMA). The resident, who had a history of alcoholic cirrhosis with ascites, protein calorie malnutrition, and alcohol dependence, was admitted with ongoing needs for long-term care. The Minimum Data Set indicated that the resident's preferred language was Spanish and that communication abilities were sometimes limited. On the day of discharge, the resident expressed a desire to leave after being placed on one-on-one supervision following an alleged incident of physical abuse with another resident. The resident informed staff of plans to go to a hotel, though no specific destination was provided. The resident had an active physician order allowing passes out of the facility for up to four hours. When the resident signed the AMA form, both registered nurses present were unable to communicate in Spanish or provide a translated version of the discharge instructions. Facility policies required that residents be informed of their rights and responsibilities and that discharge planning should address individual needs and preferences, including language. Despite these policies, the facility did not ensure the resident received information about the risks and benefits of leaving AMA in a language the resident could fully understand, resulting in the resident leaving without adequate comprehension of the implications.
Failure to Re-Evaluate PRN Psychotropic Medication and Monitor Behavioral Symptoms
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medication and chemical restraints for one resident by not providing ongoing re-evaluation of the need for PRN Haloperidol. The order for Haloperidol, prescribed for schizoaffective disorder, did not include an end date as required, and the medication was not limited to a 14-day period before re-evaluation by a physician. Additionally, there was no documented monitoring of the resident's behavioral manifestations related to schizoaffective disorder to determine the continued need for the medication. The resident involved had diagnoses including COPD, schizoaffective disorder, and unspecified dementia, with severely impaired cognitive functioning and required maximal assistance with daily activities. The facility's own policy required that antipsychotic medications be prescribed at the lowest possible dosage for the shortest period, with PRN orders not to be renewed beyond 14 days without physician evaluation and documentation. These requirements were not followed, as confirmed by staff interviews and record reviews.
Failure to Update Care Plan for Resident with New Indwelling Catheter
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was readmitted with a new indwelling catheter. Upon review, it was found that the care plan did not reflect the presence of the catheter or include goals and interventions necessary for its care. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, and required maximal assistance with activities of daily living. The Minimum Data Set indicated severely impaired cognitive functioning, and the resident was unable to make medical decisions independently. During an interview and record review, a registered nurse confirmed that the care plan was not updated upon the resident's readmission, despite the facility's policy requiring care plan revisions after significant changes in condition or readmission from a hospital stay. The lack of an updated care plan meant that staff did not have documented guidance to monitor or address the resident's catheter care, which was necessary to meet the resident's physical and functional needs as outlined in the facility's policy.
Failure to Assess Blood Glucose During Change in Condition
Penalty
Summary
Facility staff failed to assess a resident's blood glucose level during a significant change in condition, despite the presence of abnormal vital signs including low blood pressure, elevated heart rate, increased respiratory rate, low oxygen saturation, and a mild fever. The last recorded blood glucose measurement for the resident was from a week prior to the incident. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, with severely impaired cognitive functioning and a need for maximal assistance with daily activities. During the change in condition, the facility's policy required staff to gather all relevant and pertinent information, including blood glucose levels, before notifying a healthcare provider. However, the staff did not obtain a current blood glucose reading at the time of the event. This omission was acknowledged by the registered nurse, who stated that assessing blood glucose is necessary during such events to rule out related complications. The failure to follow professional standards and facility policy resulted in the resident not receiving appropriate assessment and care during a critical change in condition.
Failure to Provide and Document Indwelling Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received proper care and monitoring. Upon admission, the resident had a new indwelling catheter, but staff did not place an order for catheter care or monitoring. Record review confirmed there was no documentation of catheter care or monitoring, and staff interviews revealed that the omission was recognized by both an LVN and an RN. The staff acknowledged that they did not monitor the resident for signs and symptoms of catheter complications, nor did they track intake and output as required. The resident in question had multiple diagnoses, including COPD, acute respiratory failure, and severe cognitive impairment, and required maximal assistance with activities of daily living. Facility policy required observation for catheter complications and documentation of catheter care, including assessment data and urine characteristics. However, these procedures were not followed, and there was no record of catheter care being provided or monitored for this resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure, and dementia. The resident required continuous oxygen therapy via nasal cannula at a prescribed flow rate, as well as regular monitoring of peripheral oxygen saturation (spO2) every shift, per physician orders. The care plan also specified returning the resident to their usual oxygen delivery method after meals and administering medications as ordered. During an observation, the resident was found lying in bed with the nasal cannula disconnected and wrapped around the oxygen concentrator, which was turned off. A Licensed Vocational Nurse (LVN) confirmed that the resident was not connected to oxygen and stated that staff should have ensured the oxygen was properly administered after providing care. A Registered Nurse (RN) also acknowledged that staff failed to administer oxygen as ordered, which could result in low oxygen levels and respiratory decline for the resident. Record review revealed that the Medication Administration Record (MAR) lacked staff initials for several shifts, indicating that both oxygen administration and spO2 monitoring were not documented as completed on multiple occasions. Facility policies required staff to check oxygen equipment for proper function and to administer medications, including oxygen, as prescribed and in a timely manner. These actions and omissions led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Develop and Implement Discharge Planning in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing discharge planning for two residents. For one resident admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and atrial fibrillation, the Minimum Data Set (MDS) indicated substantial assistance was needed for activities of daily living. Despite the Social Services Director stating that discharge planning begins at admission and involves identifying the resident's discharge preferences and necessary resources, a review of the resident's care plan revealed no focus, goal, or intervention related to discharge planning. The Director of Nursing confirmed the absence of discharge planning in the care plan and acknowledged its importance for ensuring a safe and organized discharge process. Similarly, another resident admitted with seizures, hypertension, and depression, and assessed as requiring varying levels of assistance with daily activities, also lacked a care plan addressing discharge planning. The resident's MDS and medical history indicated the capacity to make decisions, yet the care plan did not include any discharge planning components. The Director of Nursing again confirmed that social services are responsible for this aspect of care planning and that its omission could lead to disorganized and stressful discharges. A review of the facility's policies and procedures confirmed that comprehensive, person-centered care plans with measurable objectives and timetables are required for each resident, and that social services staff are responsible for transitions of care, including discharge planning. The job description for the Social Services Director also specified responsibilities for discharge-planning services, such as referrals, follow-up arrangements, and post-discharge care plans. Despite these documented requirements, the facility did not ensure that discharge planning was included in the care plans for the two residents reviewed.
Failure to Document Social Services Discharge Planning Communications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the communications and actions taken by social services regarding the resident's discharge planning. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and major depressive disorder, expressed a desire to be transferred to a location closer to family. The resident reported that discussions about discharge planning with facility staff had occurred weeks prior, and was open to various locations near her desired area. During interviews and record reviews, the Social Services Director confirmed ongoing communication with contacts at potential receiving facilities and discussions with the resident about discharge options. However, there was no documentation in the resident's medical record reflecting these communications or actions. The Director of Nursing also confirmed the absence of any progress notes or records of discharge planning discussions in the electronic medical record. This lack of documentation was not in accordance with the facility's own policies and procedures, which require all services and progress toward care plan goals to be documented.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
The facility failed to ensure that the call light for one resident was accessible and within reach, as required by the resident's care plan and facility policy. The resident had significant medical conditions, including lumbar spondylosis, neuropathy, and respiratory failure, and was dependent on staff for activities such as eating, toileting, personal hygiene, and dressing. The care plan specifically identified the resident as being at risk for falls and required that the call light be kept within reach to allow the resident to request assistance as needed. During an observation, the call light was found on the floor behind the resident's bed, out of reach. Staff interviews confirmed that the call light should be accessible to the resident at all times, and the facility's policy required the call light to be within reach when the resident is in bed. The deficiency was identified through direct observation, staff interviews, and review of the resident's records and facility policies.
Failure to Ensure Proper Placement of Oxygen Nasal Cannula
Penalty
Summary
A deficiency occurred when a resident with diagnoses of congestive heart failure, pleural effusion, and respiratory failure, who was dependent on staff for all activities of daily living, was observed with her oxygen nasal cannula improperly placed inside her mouth while she was sleeping. The resident's care plan required continuous oxygen via nasal cannula, and the physician's order specified oxygen at 2 liters per minute for shortness of breath, with the option to increase up to 5 liters if necessary. During the observation, a CNA acknowledged the importance of proper nasal cannula placement and stated that if it was found out of place, the charge nurse should be notified to address the issue. Further interviews with nursing staff and the DON confirmed that professional standards of practice require checking the placement of the nasal cannula during routine room checks and that the facility's policy specifies the nasal cannula should be placed approximately one-half inch into the resident's nose. The staff confirmed that the doctor's order for oxygen must be followed as written. The failure to ensure the nasal cannula was properly placed in the resident's nose resulted in the resident not receiving oxygen as prescribed.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and homelike environment for one resident by not ensuring the cleanliness of the resident's room and restroom. Observations revealed black residue on the floor and window frame, white residue at the bottom of the window, a dark red coating on the soap dispenser, and a broken metal door upon entering the restroom. The soap dispenser was found to be rusty, and the metal door frame at the bottom of the bathroom door was separating from the door. Additionally, the window and the edge of the sliding door were noted to be dirty and dusty. These findings were confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged the room was not clean or homelike. The resident involved had diagnoses of depressive disorder, hypertension, and anxiety disorder, and was assessed as having intact cognitive functioning with a need for moderate assistance in personal hygiene and dressing. Facility policy required a clean, sanitary, and orderly environment, with regular cleaning of housekeeping surfaces and prompt cleaning of visibly soiled areas. The failure to adhere to these standards resulted in the resident not being provided with a clean and homelike environment, as required by facility policy.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to ensure that three residents were provided with written information regarding their right to formulate an Advance Directive (AD) upon admission, as required by facility policy and federal regulations. For each of the three residents reviewed, there was no documented evidence that the AD was discussed or that the AD Acknowledgment form was completed. Interviews with the Social Services Director (SSD) and nursing staff confirmed that the process for providing and documenting this information was not followed for these residents. One resident with diagnoses including end stage renal disease, diabetes, dementia, and sepsis was admitted and re-admitted to the facility. The resident was assessed as able to understand and make decisions, but the Social Service History and Initial Assessment Form was incomplete, and there was no documentation that the AD was discussed or that written information was provided. The SSD and nursing staff confirmed that the required AD Acknowledgment form was not completed, and the facility process was not followed. A second resident with hemiplegia, hemiparesis following a stroke, and anxiety disorder, and a third resident with anxiety disorder, bipolar disorder, neuropathy, and psychosis, were both found to have the capacity to understand and make decisions. However, neither had documentation in their records that the AD was discussed or that written information was provided. The SSD and RN confirmed that the AD Acknowledgment forms were not completed for these residents, and that the facility's process for informing residents about their rights regarding ADs was not followed.
Failure to Obtain Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as evidenced by multiple deficiencies in the administration, monitoring, and documentation of such medications for three residents. For one resident with a history of hemiplegia, hemiparesis, depression, and anxiety, the facility did not obtain informed consent prior to administering certain psychotropic medications, specifically diazepam and duloxetine. The resident reported not being informed about the medications being administered, and staff interviews confirmed that the required consent process was not followed, contrary to facility policy and procedure. Additionally, the facility did not provide ongoing re-evaluation of the need for psychotropic medications for this resident, as there was no documented monitoring for measurable behaviors or adverse effects related to bupropion, diazepam, or duloxetine. Orders for PRN diazepam lacked specific, measurable behavioral manifestations and did not include an end date, both of which are required by facility policy to ensure appropriate use and regular reassessment of high-risk medications. Staff interviews confirmed that these omissions could result in the administration of unnecessary medications and potential harm to the resident. For another resident with dementia and anxiety disorder, the facility failed to monitor for measurable behaviors and adverse effects of Risperdal for a specified period and did not complete required behavior summary side effect documentation for several months for both Risperdal and Klonopin. The lack of behavior monitoring and documentation was acknowledged by staff, who stated that such monitoring is necessary to evaluate medication effectiveness and to support gradual dose reduction. These failures were in direct violation of the facility's policies regarding psychotropic medication use, monitoring, and resident rights.
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What surveyors actually found near you
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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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Illustrative
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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) |
|---|---|---|---|---|
| Vineland Post Acute | 0.2 mi | ★★★★★ | 22 | 0 |
| Providence St Elizabeth Care Center | 1.3 mi | ★★★★★ | 33 | 2 |
| Four Seasons Healthcare & Wellness Center, Lp | 2 mi | ★★★★★ | 24 | 0 |
| All Saints Healthcare Subacute | 2.2 mi | ★★★★★ | 36 | 1 |
| Sherman Village Hcc | 2.8 mi | ★★★★★ | 17 | 0 |
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