Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 Villa Del Rio during CMS and state inspections, most recent first.
Insufficient CNA staffing assignments were identified when two CNAs were placed on resident work assignments despite expired certification periods. The ADSD stated the uncertified NAs were not to provide direct resident care and were instead paired with another CNA, while the DON stated CNA workloads should be assigned equally and that one CNA should not have two resident work assignments because it could prevent attention to residents’ needs and create safety issues.
The facility failed to complete and document the annual performance evaluation for one sampled LVN. The nurse’s file did not contain evidence of annual evaluations, and the DON acknowledged there was no documentation that the evaluations had been completed for licensed nurses. Facility policy required performance evaluations after the probationary period and at least annually thereafter.
A staff member worked as an uncertified NA beyond the allowed 4-month period and performed direct resident care tasks while her CNA certification was not verified. She was assigned residents for many shifts and, according to interviews, helped with diaper changes, feeding, Hoyer lift transfers, and charting alongside a CNA. The ADSD and DON stated uncertified NAs were limited to supportive duties and should not provide direct care.
Missing Annual CNA Performance Evaluations: The facility failed to document annual performance evaluations for three sampled CNAs. Employee files for two CNAs lacked evaluations for multiple years after hire, and one CNA’s file lacked evaluations for several years. The ADSD and DON stated the evaluations should have been completed and documented, but no records were available in the employee files or DSD binder.
Unlabeled Open Food Items in Kitchen: Open containers of ground rosemary, ground dill weed, ground oregano, ground chili powder, and an open bag-in-box juice dispenser system were found without open dates during a kitchen tour. The DM stated unlabeled items may place residents at risk for foodborne illness and expired food products, and the DDM reviewed facility policy requiring food items to be appropriately labeled and dated.
Failure to Obtain Informed Consent and Explain Medications: Staff did not obtain informed consent for psychotropic meds for two residents, including an LPN/RN-reviewed case where one resident lacked decision-making capacity and another resident’s consent was obtained despite being unable to make medical decisions. Staff also administered routine meds to a resident without first telling the resident the medication names or indications, limiting the resident’s ability to participate in care and refuse treatment.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms: Surveyors found missing clocks in two residents’ rooms, two residents sleeping on bare mattresses without bed sheets, one resident’s bed without a headboard, and damaged drywall behind another resident’s headboard. Residents and staff stated the missing items and room conditions affected time awareness, comfort, and the homelike environment, and the facility’s policies required clean linens, functional furniture, and a safe, clean, comfortable setting.
A resident did not receive a scheduled antidepressant because the medication was not available in the cart or facility at the time of administration. In addition, an LPN failed to promptly document a lorazepam dose on the controlled drug record, and two medication Ekits containing controlled meds were found without shift-by-shift inventory reconciliation logs. The DON stated the facility’s policies required timely reordering, immediate documentation of controlled doses, and shift-change counts for controlled medications.
An LPN found an opened levalbuterol inhalation pouch without a date and an opened fluticasone with salmeterol Diskus that was expired in a medication cart. In the medication room, an LPN also found expired Afluria vaccine syringes and expired loperamide tablets stored with facility stock. The DON stated expired meds should be removed from use, and facility policy required opened inhalation products to be dated and outdated meds not to be administered.
Missing COVID-19 Vaccination Documentation: The facility failed to document COVID-19 vaccine administrations, refusals, and resident education for three residents with diagnoses including schizophrenia/schizoaffective disorder, COPD, diabetes, hypertension, and anxiety. The IPN stated he held vaccine clinics and provided vaccine information sheets, but did not keep records of prior/current doses or specific education in the medical record because he lacked CAIR2 access until recently.
A resident with Alzheimer’s disease, aphasia, and colostomy status had a colostomy bag assessed while lying in a shared room with another resident present, and no privacy curtain was installed between the beds. An LVN acknowledged the room lacked a privacy curtain and that the resident’s privacy was compromised during the procedure, despite facility policy requiring full visual privacy and resident rights protecting privacy during medical treatment and personal care.
Failure to establish a responsible party for a resident with severe cognitive impairment and inability to make medical decisions. The resident had metabolic encephalopathy, schizophrenia, and heart failure, and the record listed family emergency contacts, but the SSD and DON stated the family should have been contacted to serve as the resident’s RP for medication consent and other medical decisions.
Failure to Notify Physician and RP of Change in Condition: Staff did not notify the physician of two low BP readings for one resident with HTN, and did not document or report a bleeding forehead scab for another resident with cognitive impairment and multiple diagnoses. The LVN stated the low BP was not rechecked or reported, and the assigned LVN stated the bleeding scab was treated but not documented, despite policy requiring notification of the physician and resident representative when a change in condition occurs.
Failure to involve authorized representatives in NOMNC and ABN decisions: Two residents with impaired cognition and limited decision-making capacity had Medicare Part A coverage end, but the facility did not verify that the forms were completed by a conservator, public guardian, or other authorized RP. One resident’s forms were signed by the resident despite conserved status and fluctuating capacity, and the other resident’s forms reflected only a verbal decision even though the resident could not make medical decisions. Both RPs stated they were not notified or included.
Delayed Submission of Quarterly MDS Assessments: The facility failed to timely complete and submit quarterly MDS assessments for four residents. The affected residents had significant psychiatric and medical diagnoses, and each had moderately impaired cognition. The MDS nurse stated the assessments were submitted well after the required timeframe, with no documented explanation for the delays, and the DON acknowledged the facility should have identified and addressed the late submissions.
A resident with schizoaffective disorder, epilepsy, muscle weakness, and impaired cognition had documented fall risk and required staff assistance with multiple ADLs. After repeated falls, the fall care plan remained unchanged, with the same interventions listed despite the resident hitting the head and later striking the face against a wall. RN stated the fall plan was not updated with alternative interventions, and the MDS nurse stated no post-fall IDT meeting occurred to modify the plan of care.
Failure to Complete Ordered Monitoring Assessments: A resident with hypertension, depression, anxiety, schizophrenia, and schizoaffective disorder had physician-ordered monitoring for lung sounds, behavior changes, CNS adverse effects, bleeding, O2 sat, pain, and orthostatic BP. Review of the MAR with the DON showed the assessments were left blank and not done, and the DON stated the monitoring was intended to track behaviors and adverse effects of medications.
Failure to Supervise and Complete Ordered Orthostatic BP Checks: A resident with impaired cognition, epilepsy, and high fall risk had repeated falls and later showed bruising under one eye and scabs on the forehead, but nursing notes did not document the required visual checks. In addition, two residents had physician orders for weekly orthostatic BP monitoring, yet the ordered lying-and-sitting measurements were not completed or were charted incorrectly, and the DON confirmed the orders were not followed as written.
Failure to Notify RP of Canceled Podiatry Appointment: A resident with COPD, DM, and dementia had an initial podiatry visit canceled because transportation was not arranged, but the SSC did not notify the RP or document the cancellation in social services notes. The RP later learned of the missed appointment after contacting the facility, and the resident was documented as having severely impaired cognition and no capacity to make decisions.
Medication was administered outside ordered parameters for two residents. One resident with atrial fibrillation, depression, dysphagia, and schizoaffective disorder received lisinopril and metoprolol even though the HR was below the ordered hold limit. Another resident with HTN and DM received Lantus when BG was below the hold parameter and losartan when SBP was below the hold parameter. The DON confirmed the medications should have been held, and the facility policy required meds to be given according to physician orders.
A facility failed to keep resident records accurate in three cases. One resident with schizoaffective disorder, epilepsy, and impaired cognition had bleeding forehead scabs observed and reported by CNA staff, but the chart lacked assessment, monitoring, and treatment documentation. Another resident with major depressive disorder and intracranial injury was listed as self-responsible on the Face Sheet even though the SSD stated she lacked decision-making capacity and had no RP. A third resident with COPD, anemia, and HTN was assigned to the wrong room in the EHR and physical chart, and nursing staff confirmed the room assignment error.
Arbitration Agreement Signed by Resident With Impaired Cognition: A resident with COPD, encephalopathy, bipolar disorder, and schizophrenia had documented fluctuating and severely impaired mental capacity, yet an arbitration agreement was signed with an X by the resident and not by the daughter identified as the emergency contact. The resident said he did not remember signing anything or know what the agreement was, while the daughter said she was not informed or present and believed he lacked the capacity to sign legal documents. The BOM said the agreement was explained and translated before signing, and the DON stated residents should have the capacity to understand legal documents before signing them.
A resident with ESRD, schizophrenia, overactive bladder, dementia, and nodular prostate had a room with a strong urine odor and flying insects observed around the bedside area. Staff reported the resident sometimes urinated on the floor or knocked over the urinal, and the HLS later found old urine pooled under the nightstand that had not been removed during routine cleaning. The IP stated visible bodily fluids should be cleaned immediately and not left for another department to address later.
A resident’s belongings were not listed on the inventory form after readmission, even though the resident had items including tote bags, a purse, and a cell phone. The resident had diagnoses including polyosteoarthritis and unspecified psychosis, with the H&P stating the resident could understand and make decisions and the MDS showing moderate cognitive impairment and assistance needs. CNA and LVN staff stated the belongings inventory should have been completed and updated, and the DON confirmed staff did not follow the facility policy requiring all personal items to be inventoried and documented.
Bed-Hold Notice Not Properly Documented and Resident Not Readmitted to First Available Bed: A resident with hemiplegia, hemiparesis, and no decision-making capacity was transferred to a GACH with a 7-day bed hold order. The facility did not obtain a signed bed-hold notice or provide written notice to the RP at transfer, despite policy requirements. When the resident was ready to return after the bed-hold period, the DON declined readmission due to acuity, even though the Admin stated the facility had the capacity, including an empty isolation room and ability to care for BiPAP and wound needs.
Facility Assessment Not Updated for Lack of RT Contract: The facility failed to update its Facility Assessment after it no longer had an active RT contract. The assessment still listed RT as a needed resource, while the Admin confirmed there was no contracted RT company in place and acknowledged the assessment should be updated annually and as needed.
A resident with schizophrenia, anxiety, and epilepsy left the facility after being observed agitated and pacing, and staff later found the resident missing during rounds. The AMA discharge process was not completed, with no documented physician notification, risk education, signed AMA form, discharge instructions, or confirmation that the resident understood the risks of leaving.
Delayed and Inaccurate Documentation of Resident Behavior: An LVN documented a resident’s alleged aggressive behavior several days after the event rather than at or near the time it occurred. The resident had schizophrenia, anxiety, and epilepsy, and the record described intact cognition and the ability to understand and be understood. Video review did not support the documented aggression, and the ADM, LVN, and DON all acknowledged the note was not timely and that resident behaviors, incidents, assessments, and interventions were expected to be documented accurately in the chart.
Two residents did not receive timely, physician-ordered care for fungal skin rashes. One resident with intact decision-making capacity and no cognitive impairment had standing orders for twice-daily cleansing and application of Triamcinolone cream, and later Nystatin powder plus Triamcinolone to breast, buttock, and perineal areas for candidiasis; TAR review and staff interviews confirmed multiple missed evening doses across two months. Another resident with pneumonia, epilepsy, and moderate cognitive impairment reported an itchy, red, raised groin rash, with documentation that the physician was called and staff were awaiting treatment orders, but records showed no successful physician contact or treatment orders in place until six days later. The DON confirmed that ordered treatments were not fully administered and that the delay in obtaining orders for the rash constituted a delay of care, contrary to facility policies on medication administration and change in condition.
A resident with dermatitis of the trunk and a history of cardiac arrhythmias had physician orders for daily topical ketoconazole and triamcinolone for 30 days, with a care plan goal that symptoms such as scaly, flaky, itchy, red skin would resolve within that period and a specified re-evaluation date. On observation, the resident still had a generalized rash and reported ongoing itchiness, yet review of progress notes showed no documented re-evaluation of the treatment or care plan on the target date. The treatment nurse and DON confirmed that the care plan was not reassessed or revised as required by facility policy, resulting in a failure to update the plan of care based on the resident’s ongoing skin condition.
A resident with muscle weakness, hypertension, and dependence for most ADLs and mobility was care planned to have a call light within reach, but surveyors found the call light not within reach and the resident unable to use it due to limited arm and hand movement. The resident reported not knowing where the call light was, being unable to press it, feeling powerless and ignored, and having to yell or wait for staff, including times when the resident was dirty and wanted to be cleaned. A CNA acknowledged she had not assessed whether the resident could use the call light and recognized that lack of access could lead to feelings of neglect and delayed care. The MDS nurse stated he was unaware the resident could not use the call light, despite facility policy requiring evaluation of each resident’s unique needs and provision of appropriate call system accommodations.
A resident with muscle wasting, atrophy, and lack of coordination was readmitted with a bilateral lower extremity rash documented in the progress notes. An LVN who completed the readmission observed the rash but did not notify the physician, did not complete a Change of Condition assessment, and did not initiate a care plan, resulting in the rash not being properly assessed or treated. This was inconsistent with facility policy requiring prompt physician notification for changes in a resident’s condition.
A resident with muscle weakness, hypertension, impaired decision-making capacity, and high dependence for ADLs received incontinence care from an LVN who failed to perform hand hygiene before donning gloves and did not remove contaminated gloves before applying a clean brief and touching the resident. The LVN cleaned the resident’s pubic area and buttocks, placed soiled towels on the bed, then immediately handled clean items and continued resident contact with the same gloves. The LVN acknowledged not following hand hygiene practices, despite facility policy requiring hand hygiene before applying and after removing PPE and before resident care.
The facility failed to maintain functional ceiling-suspended privacy curtains in two shared rooms, resulting in inadequate visual privacy for two residents who required assistance with ADLs. One resident, with mental health and physical impairments and partial/moderate ADL dependence, had a curtain that was too short and did not close completely, allowing others to see the resident during care, as reported by a CNA. Another resident, with muscle weakness, hypertension, impaired decision-making capacity, and total ADL dependence, had a shortened curtain with tangled strings that did not provide sufficient privacy, as reported by an LVN. These conditions did not comply with the facility’s written policy requiring resident bedrooms to be equipped to assure full visual privacy with ceiling-suspended curtains around each bed in non-private rooms.
Nursing staff failed to follow professional standards when administering medications to three residents, including not identifying medications to residents with cognitive impairment, administering all medications at once without explanation, and crushing multiple medications together for administration via gastrostomy tube. Nurses acknowledged these practices did not align with facility policy, which requires explaining medications and administering them in accordance with professional standards.
Two residents were not provided with a safe, clean, and homelike environment due to unresolved maintenance issues, including a damaged bathroom door and a broken toilet seat. Staff were aware of these hazards but failed to document or report them according to facility procedures, resulting in ongoing risks to resident safety and comfort.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in residents receiving drugs without adequate justification or in a manner that could limit their functional abilities.
The facility did not complete or retain required background check documentation for multiple staff, including RNs, LPNs, a treatment nurse, and a CNA. Several employee files lacked background reports, some checks were delayed for years after hire, and some were incomplete or missing due to misplaced records after a change in ownership. The DSD and DON confirmed that background checks should have been done upon hire and that missing documentation was a failure to follow facility policy.
A resident with a history of COPD, hemiplegia, and aphasia was observed receiving G-tube feeding while lying with the head of bed at a 20-degree angle, below the required 30-45 degrees specified in both the care plan and facility policy. The LVN confirmed the improper positioning during the feeding, despite clear orders and protocols for enteral feeding safety.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with severe mental illness, impaired cognition, and a history of exit-seeking behavior was able to leave the facility through an unarmed exit door due to lack of staff supervision, failure to communicate elopement risk among staff, and failure to follow care plan interventions and facility policy regarding door alarms. The resident was not monitored as required, and staff were unaware of the resident's risks, leading to the resident's elopement and subsequent death offsite.
Staff did not ensure the shower room floor was dry and free of dirty linen after use, and the toilet was left uncleaned with visible soiling and no lid. Maintenance staff, a CNA, and the DON all confirmed these conditions did not meet infection control standards and violated facility policies for cleanliness.
Multiple Geri chairs and shower chairs were found to be broken or ripped, with missing cushions, exposed padding, and damaged parts, creating an unsafe and uncomfortable environment for residents. The Maintenance Supervisor and DON confirmed the deficiencies, and facility policies and equipment manuals required regular inspection and repair to ensure resident safety and comfort.
A resident with metabolic encephalopathy and type 2 DM had a care plan requiring monitoring of rash treatment effectiveness, but nursing staff did not document any monitoring after the care plan was established. The DON confirmed the absence of documentation, which was inconsistent with facility policy requiring comprehensive, measurable care plans.
A resident with metabolic encephalopathy and diabetes did not have their pain reassessed in a timely manner after receiving Norco for moderate to severe pain. On one occasion, pain was reassessed five hours after administration, and on another, there was no documentation of reassessment. The DON confirmed these lapses, which were not in accordance with facility policy.
A LVN failed to document the administration of a PRN dose of Hydrocodone-Acetaminophen for a resident with metabolic encephalopathy and diabetes, despite facility policy requiring immediate documentation on the MAR after medication administration. The nurse stated the omission occurred due to being called away to assist another resident.
The facility did not provide a refrigerator for storing food brought in by visitors for residents, leading to the disposal of leftover perishable food items. Staff and policy confirmed that only shelf-stable foods could be kept at the bedside, while foods requiring refrigeration were thrown out due to the absence of a dedicated storage option.
Multiple infection control deficiencies occurred, including the lack of Enhanced Barrier Precautions for residents with indwelling medical devices or MDROs, absence of a documented water management program, a resident consuming food from another's used tray, and a nurse failing to perform hand hygiene during wound care. These lapses were confirmed through observation, interviews, and record reviews.
Multiple residents received psychotropic medications without proper informed consent, including cases where residents lacked decision-making capacity or had appointed representatives who were not consulted. Consent forms were often incomplete, outdated, or missing entirely, and staff acknowledged that required procedures for obtaining and documenting informed consent were not followed.
The facility failed to accurately complete and document MDS assessments for several residents, including not reflecting therapeutic diets, dialysis status, language preferences, interpreter needs, and oral/dental conditions. These inaccuracies were identified through record review, observation, and interviews with residents, family, and staff, revealing that assessments did not match residents' actual health status or communication needs.
Insufficient CNA Staffing Assignments
Penalty
Summary
The facility failed to provide sufficient staffing when CNAs were assigned two resident work assignments. During record review, CNA 4’s personnel and certification records showed she was hired by the facility and had a Nurse Assistant Certification that was valid for a period of time, but the staffing assignment document showed CNA 4 had a resident work assignment for three shifts. In a phone interview, CNA 4 stated her certification expired and was later renewed, and that while her certification was expired she did not provide direct care to the residents assigned to her and instead assisted other nursing staff. The Assistant Director of Staff Development stated CNA 4 was assigned a resident work assignment but was partnered with another CNA near her assigned area and was instructed not to perform direct resident care. A similar situation was identified for CNA 5. Her personnel and certification records showed she was hired by the facility and had a Nurse Assistant Certification that was valid for a period of time, while the staffing assignment document showed she had a resident work assignment for 29 shifts. CNA 5 stated her certification expired and was later renewed, and that while it was expired she did not perform direct care and instead assisted other nursing staff and later activity staff. The ADSD stated CNA 5 was assigned a resident work assignment but was partnered with another CNA near her assigned area, and that the partnered CNA was assigned daily and not shown on the staffing sheet. The ADSD also stated uncertified nursing assistants could not perform direct resident care tasks, and the DON stated workloads should be assigned equally between CNAs and that one CNA should not be assigned two resident work assignments because it could prevent attention to residents’ needs and place residents at risk for falls and other safety issues.
Missing Annual Performance Evaluation for LVN
Penalty
Summary
The facility failed to conduct the annual performance evaluation for one sampled LVN, LVN 9. LVN 9’s Personal Action Form showed the nurse was hired on 3/29/2024, but the employee file did not contain documentation of an annual performance evaluation for 2025 or 2026. During interview, the ADSD stated that completed performance evaluations should be kept in the employee’s physical file or in a binder maintained by the DSD, and that annual evaluations were necessary to identify areas for improvement in resident care. The DON stated she was responsible for conducting annual performance evaluations for licensed nurses and acknowledged there was no documentation that the evaluations had been completed for the licensed nurses. The facility’s policy stated that a performance evaluation would be completed at the end of the 90-day probationary period and at least annually thereafter.
Uncertified NA Worked Beyond Allowed Period and Performed CNA Duties
Penalty
Summary
The facility failed to ensure that one staff member who worked as an uncertified nursing assistant (NA) did not exceed the allowed 4-month period of NA employment and did not perform duties reserved for certified staff. The staff member was initially hired to the housekeeping department, later moved to the nursing department, and then worked as both a certified nursing assistant (CNA) and an uncertified NA from 5/1/2023 through 7/31/2024. The facility’s staffing assignment document showed the staff member had resident work assignments for 130 shifts during that period, but the employee file did not show a Nurse Assistant Certification. During interview, the staff member stated she completed a CNA program and began working as an NA shortly afterward while waiting for her certification card to arrive, but the certification never appeared. She stated that while waiting, she worked with another CNA and performed resident care tasks together, including changing residents’ diapers and clothing, passing meal trays, assisting with feeding, assisting with Hoyer lift transfers, and documenting in residents’ charts. The Assistant Director of Staff Development stated the staff member’s certification was not properly processed and that uncertified NAs should only perform limited tasks such as answering call lights and relaying information to certified staff. The ADSD and DON both stated NAs were allowed to work only for a four-month period while their certification was processed and verified, and that uncertified NAs should not perform direct resident care tasks after that period. The ADSD stated uncertified NAs could not assist with feeding, transfers, or charting, and the DON stated that having an NA perform CNA tasks placed residents at risk for quality of care and safety issues. The facility’s job descriptions also showed NAs were limited to supportive duties, meal tray distribution to residents who could feed themselves, housekeeping support, and transporting residents only after certified staff had safely transferred them to a wheelchair.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for three of three sampled CNAs, identified in the report as CNA 4, CNA 5, and CNA 6. Review of CNA 4’s Personal Action Form showed hire on 5/6/2022, but the employee file did not contain documentation of an annual performance evaluation from 2023 through 2026. Review of CNA 5’s Personal Action Form showed hire on 3/7/2022, but the employee file did not contain documentation of an annual performance evaluation from 2023 through 2026. Review of CNA 6’s Personal Action Form showed hire on 1/19/2018, but the employee file did not contain documentation of an annual performance evaluation from 2018 through 2026. During interview, the Assistant Director of Staff Development stated she recalled performance evaluations were completed, but there was no documentation of their completion and that evaluations should be in the employee’s physical file or in a binder kept by the DSD. The DON stated the DSD was responsible for conducting annual performance evaluations for the CNAs and that there was no documentation showing the evaluations were completed.
Unlabeled Open Food Items in Kitchen
Penalty
Summary
The facility failed to ensure that open containers of ground rosemary, ground dill weed, ground oregano, ground chili powder, and an open bag-in-box juice dispenser system were labeled with an open date. During an initial kitchen tour, the Dietary Manager observed these items without open dates, and stated that unlabeled items may place residents at risk for foodborne illness and expired food products. During later interview and record review, the District Dietary Manager reviewed the facility policy and procedure titled, Receiving, revised 2/2023, which indicated that all food items will be appropriately labeled and dated. The District Dietary Manager stated these errors may place residents at risk for foodborne illness, cross-contamination, poor food quality, and unsafe meal service.
Failure to Obtain Informed Consent and Explain Medications
Penalty
Summary
The facility failed to honor residents’ right to be informed of and participate in their treatment by not obtaining informed consent for psychotropic medications for two residents and by not providing medication names and indications before administration to a third resident. The report states that these deficiencies involved Residents 5, 34, and 150 and were identified through observation, interview, and record review. Resident 5 had diagnoses including Parkinson’s disease, schizophrenia, and diabetes mellitus, and the H&P noted fluctuating capacity to understand and make decisions. The MDS described moderately impaired cognition and dependence for toileting and bathing, with supervision needed for eating. Physician orders included Olanzapine 5 mg every 12 hours and Trazadone Hydrochloride 50 mg at bedtime for inability to sleep. During record review, staff found that informed consents were not obtained for either medication. An LVN and an RN both stated informed consents should have been obtained for Resident 5’s psychotropic medications and that residents had the right to know what medications they were taking, the indication for the medication, and be involved in their own care. Resident 34 had diagnoses including major depressive disorder and intracranial injury. The admission record described the resident as self-responsible, while the MDS showed moderately impaired cognition and substantial assistance needed with several activities. The H&P stated the resident could make needs known but could not make medical decisions. A physician ordered Celexa 10 mg daily for major depressive disorder, and the MAR showed the first dose was given on 9/14/2025. During interview and record review, the SSD stated Resident 34 did not have the capacity to make medical decisions and had no family to serve as RP, and that the IDT made medical decisions after the probate referral was denied. RN 2 stated informed consent must be obtained from an individual with medical decision-making capability, and the resident’s verification of informed consent for Celexa had been obtained from Resident 34 even though RN 2 stated she was not self-responsible and could not make an informed decision. The DON stated Resident 34 did not have the capacity to understand the risks associated with taking Celexa. For Resident 150, the MAR showed orders for amlodipine, multivitamins with minerals, and cholecalciferol. During observation, an LVN administered these medications orally but did not tell the resident the names of the medications or their indications before the resident swallowed them. In interview, the LVN stated she failed to inform Resident 150 of the names and indications of the medications prior to administration. The LVN also stated the facility’s policy required residents to be informed because they had the right to be involved in their care and treatment and to make choices such as refusing a specific medication.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six sampled residents by not ensuring basic room conditions and furnishings were present or maintained. Surveyors observed that two residents did not have clocks in their rooms, two residents were sleeping on mattresses without bed sheets, one resident’s bed did not have a headboard attached, and one resident’s wall behind the headboard had damaged, cracked, and crumbling drywall with exposed, peeling material. The facility’s own policies stated that residents would be provided a safe, clean, comfortable, and homelike environment, clean bed linens, and functional furniture appropriate to resident needs and preferences. Resident 89 had diagnoses including schizoaffective disorder, diabetes mellitus, and anxiety, and the MDS indicated moderately impaired cognitive skills and a need for supervision with ADLs. During observation, no clock was present in the room, and the resident stated staff had purposely removed the clocks so she would not know the time for scheduled smoke breaks. An LVN later confirmed there was no clock in the room and stated the resident depended on a clock to determine when it was time for designated smoke breaks, adding that access to a clock was a resident’s right and supported awareness of the smoke break schedule. Resident 15 had diagnoses including bipolar disorder, dementia, and schizoaffective disorder, and the MDS indicated moderate cognitive impairment with setup or clean-up assistance needed for ADLs. During observation, no clock was present in the room, and the resident stated a working wall clock would help track the time during the day. An LVN stated residents should have a working wall clock to ensure a homelike environment and later stated staff were responsible for placing requests for missing clocks or repairs. The DON stated maintaining a homelike environment helped residents feel safe, comfortable, respected, and promote dignity. Resident 48 had diagnoses including encephalopathy, epilepsy, and schizophrenia, with MDS findings of moderately impaired cognitive skills and supervision needed for ADLs. During observation, the resident was sleeping on a mattress without a bed sheet and later stated the bed had not had sheets the day before and it made him feel cold. Resident 133 had diagnoses including dementia, diabetes, and cataracts, with severely impaired cognitive skills and partial to moderate assistance needed for ADLs. The resident was also observed sleeping on a mattress without a bed sheet. A CNA stated she had removed the soiled linens, cleaned the mattresses, and air-dried them earlier that morning, and that the bed linens should have been replaced immediately. Resident 78 had diagnoses including DM, anemia, and schizophrenia, and the record indicated the resident could make needs known but could not make medical decisions. The MDS indicated intact cognitive function and the need for setup or clean-up assistance with ADLs. During observation, the resident was lying in a bed without a headboard. An LVN stated residents should have headboards attached to their beds to ensure a homelike environment, and another LVN stated staff were responsible for maintenance requests for missing or damaged equipment. Resident 30 had diagnoses including COPD, DM, and dementia, with no capacity to understand and make decisions and severely impaired cognitive skills. Surveyors observed damaged, cracked, and crumbling drywall with exposed, peeling material behind the resident’s headboard. A CNA stated the wall was damaged and could cause injury if not repaired promptly, and the MS stated damaged drywall should be reported through the communication book and that delays could increase injury risk and negatively affect cleanliness, comfort, and the homelike environment.
Missed medication dose and controlled substance accountability failures
Penalty
Summary
The facility failed to ensure Rexulti was available for a resident with depressive disorder and self-isolation when the 9 a.m. dose was due. During a concurrent observation and interview, an LVN was preparing several medications for the resident, but Rexulti was not available in Medication Cart 3 or elsewhere in the facility for administration. The LVN stated the medication should be readily available for timely administration and that the resident’s dose was missed because the medication had not been obtained in advance. The facility also failed to properly document and reconcile controlled medications. During an observation in Medication Cart 2, a discrepancy was identified for a resident prescribed lorazepam 1 mg every 12 hours for anxiety. The Controlled Drug Record showed one tablet missing from the bubble pack, while the pack contained 11 tablets and should have contained 12 based on the last documented administration. The LVN stated one dose had been administered but was not signed off on the Controlled Drug Record, and acknowledged that the facility’s policy required each controlled medication dose to be documented immediately after administration. In addition, two medication Ekits containing controlled medications in the medication room were observed without accountability logs showing inventory reconciliation at each shift change for July 2026. One Ekit was stored in the refrigerator and labeled [NAME].REF-49, and another was stored at room temperature and labeled S20. The DON stated controlled medication Ekits should be counted and reconciled at every shift change, and that the Ekits in the medication room were not accounted for with an inventory count on an accountability log at each shift change during the month.
Expired and Unlabeled Medications Found in Cart and Medication Room
Penalty
Summary
Medication storage and labeling practices were not followed for inhalation medications in Medication Cart 2. During observation with an LVN, an opened levalbuterol inhalation foil pouch for one resident was found at room temperature without an open date, and the LVN stated she did not know when it had been opened. An opened fluticasone with salmeterol Diskus for another resident was also found at room temperature and was identified as expired based on the date the foil pouch had been opened. The LVN stated both medications were considered expired and should have been removed from the cart. Expired medications were also found in the medication room during observation with another LVN. Fifteen Afluria influenza vaccine syringes for facility stock were stored in the refrigerator even though the manufacturer expiration date had passed, and sixteen loperamide tablets were stored in the medication cabinet with an expiration date of 4/2026. The LVN stated both the expired vaccines and tablets needed to be removed from use and placed in a designated disposal area to prevent accidental use. During interview, the DON stated expired medications should be removed from use and placed in the expired medication bin to be disposed of, and that expired medications lose potency and may not work properly. The DON stated licensed nurses failed to remove the expired Afluria syringes, loperamide tablets, and the expired fluticasone with salmeterol Diskus from use, and also failed to label the opened levalbuterol pouch with a date when it was first opened. Facility policies reviewed stated outdated medications and containers without labels are to be destroyed, expired medications are not to be administered, and certain inhalation products require date opened labeling and shortened beyond-use dating after opening.
Missing COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain documentation of COVID-19 vaccination records and vaccine offerings for three sampled residents. Resident 47 was admitted and later readmitted with diagnoses including schizophrenia disorder, COPD, and anxiety, but the resident’s immunization report dated 7/15/2026 did not show prior COVID-19 vaccine administrations or refusals. Resident 101 was admitted and later readmitted with diagnoses including schizoaffective disorder, diabetes, and anxiety, and the immunization report also did not document prior COVID-19 vaccine administrations or refusals. Resident 146 was admitted and later readmitted with diagnoses including hypertension, schizoaffective disorder, and anxiety, and the immunization report likewise did not document prior COVID-19 vaccine administrations or refusals. During interview, the Infection Prevention Nurse stated it was not his practice to maintain records of current and previous COVID-19 vaccine administrations in the residents’ medical records because he did not have access to CAIR2 until recently, although he had been employed since 11/2024. He stated he held clinics for COVID-19 vaccination in the facility but did not maintain documentation of the vaccinations or the specific education provided, even though he provided the COVID-19 medication information sheets to residents and responsible parties. The facility’s COVID-19 Vaccination policy stated residents would be offered vaccination when supplies were available unless medically contraindicated, already immunized, or refusing, and that the medical record would include documentation of education, each dose administered, or refusal/medical contraindication.
Failure to Maintain Privacy During Colostomy Assessment
Penalty
Summary
The facility failed to ensure privacy curtains were installed and privacy was maintained for one resident during assessment of a colostomy bag filled with stool. During a concurrent observation and interview, an LVN assessed the resident’s colostomy bag in a shared room while another resident was present in the adjacent bed, and no privacy curtain was in place between the two residents. The LVN stated the room did not have a privacy curtain installed and acknowledged that privacy was compromised during the procedure. The resident involved had diagnoses including Alzheimer’s disease, aphasia following cerebral infarction, and colostomy status. The resident’s MDS indicated severely impaired cognition and need for partial assistance with toileting hygiene and showering. The facility’s policy stated that resident bedrooms would be equipped to assure full visual privacy, including ceiling-suspended curtains around each bed in non-private bedrooms, and its resident rights policy stated residents had a right to personal privacy and confidentiality, including during medical treatment and personal care.
Failure to Establish a Responsible Party for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to determine the responsible party for Resident 9, a resident with metabolic encephalopathy, schizophrenia, and heart failure whose cognition was severely impaired and who was dependent on staff for oral hygiene, toileting, bathing, upper and lower body dressing, and putting on and taking off footwear. The resident’s admission record listed two family members as emergency contacts, and the History and Physical stated that the resident could make needs known but could not make medical decisions. During interview, the Social Services Director stated that because Resident 9 was unable to make medical decisions, the resident’s sister and son should have been contacted to see if one of them wanted to serve as the resident’s responsible party. The Director of Nursing also stated that Resident 9 required a responsible party to consent for medications and make other medical decisions. The facility policy stated that when a resident is declared incompetent or incapable of understanding rights, the resident’s surrogate and/or representative is to be advised of the resident’s rights and responsibilities.
Failure to Notify Physician and Responsible Party of Changes in Condition
Penalty
Summary
The facility failed to notify the physician and responsible party of changes in condition for two residents. One resident had a history of metabolic encephalopathy, schizophrenia, and hypertension, and the record showed blood pressure readings of 86/43 and 71/40. The care plan directed staff to monitor vital signs, assess for hypotension, and notify the physician, but the electronic health record did not show that the physician was notified of either hypotensive reading. During interview, the LVN stated the 71/40 reading was not the resident’s usual blood pressure, was not rechecked, and was not reported to the physician. For the second resident, the record showed diagnoses including schizoaffective disorder, epilepsy, muscle weakness, muscle wasting, and lack of coordination, and the resident lacked the capacity to understand and make decisions. Progress notes and SBAR notes from the period reviewed did not document scattered, circular scabs on the forehead. During observation, the resident was noted to have a blue to purple discoloration under the left eye and several small scattered scabs across the forehead. A CNA stated one of the forehead scabs began bleeding during a shower and was reported to the assigned LVN. The assigned LVN stated she treated the affected areas but did not document her assessment or the interventions provided. She also stated a change of condition note should have been documented to alert the physician, responsible party, and licensed nursing staff and to obtain appropriate orders. The DON stated that if nursing staff had assessed and treated the bleeding scab, the responsible party should have been notified and the physician consulted. The facility policy on notification of changes required prompt consultation with the physician and notification of the resident’s representative when there was a change requiring notification.
Failure to Involve Authorized Representatives in Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to verify that the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) forms were signed by someone with decision-making capability when Medicare Part A coverage ended for two residents. One resident was admitted and readmitted with diagnoses including anemia, schizophrenia, and HTN, and the record showed the resident was conserved, had fluctuating capacity to understand and make decisions, and had moderately impaired cognition. The resident’s NOMNC and ABN forms were signed by the resident, even though the Social Services Director stated the resident did not have the capacity to understand or make informed medical decisions and that the conservator should have been contacted to complete the forms. For the second resident, the record showed diagnoses including schizophrenia, DM, and COPD, and the resident’s responsible party was a public guardian. The History and Physical stated the resident could make needs known but could not make medical decisions, and the MDS showed moderately impaired cognition with supervision needed for toileting, bathing, and dressing. The resident’s NOMNC and ABN forms indicated the resident refused to sign but made a verbal decision, and the last covered date for Medicare Part A skilled services was documented in the record. During interviews, both responsible parties stated they had not been notified that Medicare Part A services had ended and said they should have been included in the decision-making process. The Social Services Director stated he should have contacted the resident’s RP to complete the NOMNC and ABN forms, and the Administrator stated facility staff should notify and involve conservators and public guardians when Medicare Part A coverage ends so an informed decision can be made. The facility policy stated the NOMNC is issued to the resident or representative when Medicare covered services are ending, and another policy stated the facility will seek a health care decision from a representative when the resident is determined to be incompetent in accordance with state law.
Delayed Submission of Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed and submitted within the required federal timeframe for four sampled residents. The quarterly MDS assessments for Residents 44, 46, 47, and 75 were initiated but were not submitted until well after the required submission deadline. During interview and record review, the MDS nurse stated that quarterly MDS assessments must be completed and electronically submitted within the required ARD completion timeframe and that these assessments were not submitted within the required timeframe. Resident 44 had diagnoses including schizophrenia, dementia, COPD, bipolar disorder, and diabetes, and the MDS indicated cognition was moderately impaired. The quarterly MDS was initiated on 5/17/2026 but was not submitted until 7/15/2026, which the MDS nurse stated was 45 days late. Resident 46 had diagnoses including diabetes, schizoaffective disorder, and hyperlipidemia, and the MDS indicated cognition was moderately impaired. The quarterly MDS was initiated on 5/14/2026 but was not submitted until 7/13/2026, which was stated to be 46 days late. Resident 47 had diagnoses including bipolar disorder, schizophrenia, COPD, and insomnia, and the MDS indicated cognition was moderately impaired. The quarterly MDS was initiated on 3/12/2026 but was not submitted until 4/27/2026, stated to be 32 days late. Resident 75 had diagnoses including schizoaffective disorder, psychosis, and hypertensive heart disease, and the MDS indicated cognition was moderately impaired. The quarterly MDS was initiated on 5/18/2026 but was not submitted until 7/10/2026, stated to be 39 days late. The MDS nurse stated there was no documented explanation or justification in the medical records for the delayed submissions, and the DON stated the facility should have identified and addressed the delays.
Fall Care Plan Not Revised After Repeated Falls
Penalty
Summary
The facility failed to revise a fall care plan after a resident fell, leaving the resident’s plan of care unchanged after subsequent fall events. Resident 135 was admitted and later readmitted to the facility with diagnoses including schizoaffective disorder, epilepsy, muscle weakness, muscle wasting, and lack of coordination. The resident’s MDS indicated moderately impaired cognition, and another assessment showed the resident required staff supervision for eating, dressing, personal hygiene, transfers, and walking. The H&P stated the resident lacked the capacity to understand and make decisions, and fall risk evaluations dated 6/22/2026 and 6/30/2026 identified the resident as at risk for falls. The record showed that Resident 135 fell on 6/30/2026, hitting the back of the head and bleeding, and then fell again on 7/13/2026 after leaning forward in the wheelchair and striking the face against a wall. Review of the care plans titled Actual Fall dated 6/30/2026 and 7/1/2026 showed both plans indicated the resident fell backwards while ambulating and both contained the same interventions, with no change after the second fall. RN 1 stated the facility’s practice was to update fall care plans with alternative interventions, but she did not ensure different interventions were implemented after the second fall. The MDS nurse stated a post-fall IDT meeting was important to collaborate on the plan of care and modify fall interventions, and that such a meeting should occur within 72 hours after a fall; however, no post-fall IDT occurred after the resident’s falls.
Failure to Complete Ordered Monitoring Assessments
Penalty
Summary
The facility failed to complete ordered assessments for one resident on 6/13/2026. Resident 38 was admitted and later readmitted to the facility with diagnoses including hypertension, depression, anxiety disorder, schizophrenia, and schizoaffective disorder. The resident’s MDS dated 6/9/2026 indicated moderately impaired cognition and need for substantial assistance with toileting, bathing, lower body dressing, and footwear. The H&P dated 6/2/2026 stated the resident had the capacity to understand and make decisions. Physician orders dated 6/2/2026 directed staff to monitor lung sounds, anxiety, depression, schizoaffective disorder, schizophrenia, CNS adverse effects, dehydration/hypotension/dizziness/confusion/muscle cramps, bleeding, oxygen saturation, pain, tardive dyskinesia/cognitive impairment/akathisia/parkinsonism every shift, and orthostatic blood pressure every Saturday. Review of the MAR with the DON showed that on 6/13/2026 these assessments were left blank and were not done. The DON stated the empty areas on the MAR indicated the assessments were not done and that the purpose of the monitoring was to track behaviors and adverse effects of medications.
Failure to Supervise a High-Fall-Risk Resident and Follow Orthostatic BP Orders
Penalty
Summary
The facility failed to ensure adequate supervision and visual checks for a resident with schizoaffective disorder, epilepsy, muscle weakness, muscle wasting, lack of coordination, and impaired cognition. The resident’s records showed he required staff supervision for eating, dressing, personal hygiene, transfers, and walking, and his fall risk evaluations identified him as at risk for falls. His care plan included visual checks and monitoring every shift, assistance with bed mobility and transfers as indicated, and maintaining a safe environment. The record also documented multiple falls and head injuries, including a witnessed fall with bleeding and an unwitnessed fall with bleeding to the back of the head. On 7/13/2026, the resident was observed with a blue to purple discoloration under his left eye and several small scabs scattered across his forehead. A concurrent review of nursing progress notes from 7/5/2026 through 7/12/2026 showed no documentation that visual monitoring had been performed before the discoloration and scabs were identified. The MDS nurse stated the resident required visual monitoring every 15 minutes because he was more prone to falls. The DON stated staff usually conducted head count rounds every two hours, but supervisory checks should have been performed and documented more frequently for this resident, who had poor safety awareness and was at risk for falls. The facility also failed to follow physician orders for orthostatic blood pressure monitoring for two residents. One resident had orders dated 3/14/2026 for weekly orthostatic blood pressure checks every Saturday evening in lying and sitting positions, with notification of the physician if the systolic difference was 20 mmHg or greater. The Weights and Vitals Summary for May, June, and July 2026 did not show the ordered orthostatic blood pressures were obtained on any of the listed Saturdays, and the LVN confirmed there was no documentation that the assessments were completed. Another resident had a physician order dated 5/22/2026 to monitor orthostatic blood pressure every Saturday in lying and sitting positions and notify the physician for differences of 20 mmHg or greater. On 6/13/2026, the registry LVN stated he overlooked the order and documented the same blood pressure for both positions instead of performing orthostatic monitoring. The DON stated orthostatic blood pressure monitoring was different from regular blood pressure readings and that failure to perform it could miss a change in condition requiring intervention.
Failure to Notify RP of Canceled Podiatry Appointment
Penalty
Summary
The facility failed to inform Resident 30’s responsible party when the resident’s initial podiatry appointment was canceled because transportation was not available. Resident 30 was admitted and later readmitted to the facility and had diagnoses including COPD, DM, and dementia. The history and physical dated 9/29/2025 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 5/3/2026 indicated cognition was severely impaired and that the resident required supervision or touching assistance for all attempted mobility activities in and out of bed. During a telephone interview, the responsible party stated the Social Services Coordinator did not notify her about the missed podiatry appointment or provide updates, and that she learned about the transportation issue only after contacting the facility about a week later. Social services notes from 5/18/2026 to 6/18/2026 did not include an entry showing the appointment was canceled or that the responsible party was informed because transportation was unavailable. The Social Services Director stated it was important to document appointments and follow-up measures in social services progress notes, and the facility policy required social services staff to schedule, coordinate, and document medical appointments and to record missed or delayed appointments with the reason and care coordination details involving the attending physician and responsible party.
Medication Given Outside Ordered Parameters
Penalty
Summary
The facility failed to follow physician-ordered medication parameters for two residents when administering antihypertensive and insulin medications. Resident 12 had diagnoses including atrial fibrillation, major depressive disorder, dysphagia, and schizoaffective disorder, and the H&P stated the resident could make needs known but could not make medical decisions. Physician orders required lisinopril 20 mg daily to be held if systolic blood pressure was less than 110 mmHg or heart rate was less than 60 beats per minute, and metoprolol 25 mg daily to be held if systolic blood pressure was less than 120 mmHg or heart rate was less than 60 beats per minute. Resident 12’s MAR showed that on 6/13/2026 the resident’s heart rate was 51 beats per minute, yet lisinopril and metoprolol were both administered at 9:00 a.m. During interview and record review, the LVN and DON stated licensed nurses are responsible for reviewing and following blood pressure and heart rate parameters before giving these medications, and that medications should be held when vital signs are outside the ordered limits. The facility policy stated medications are to be administered in accordance with written prescriber orders. Resident 9 had diagnoses including hypertension and type 2 diabetes mellitus, and the H&P stated the resident could make needs known but could not make medical decisions. Physician orders required Lantus 12 units daily to be held if blood glucose was less than 120 mg/dL and losartan potassium 25 mg daily to be held if systolic blood pressure was less than 120 mm Hg. The MAR showed Lantus was administered when blood glucose was 112 mg/dL on 6/13/2026 and 113 mg/dL on 6/20/2026, and losartan potassium was administered when systolic blood pressure was 119 mm Hg on 6/24/2026. The DON stated these medications should not have been administered under those conditions, and the facility policy stated medications were to be given in accordance with physician orders.
Inaccurate medical record documentation for wound care, decision-making status, and room assignment
Penalty
Summary
The facility failed to keep Resident 135’s medical record accurate by not documenting an assessment, monitoring, or treatment note for bleeding scabs on his forehead. Resident 135 was admitted and later readmitted to the facility with diagnoses including schizoaffective disorder, epilepsy, muscle weakness, muscle wasting, and lack of coordination. His MDS indicated moderately impaired cognitive skills for daily decision making, and his H&P stated he lacked the capacity to understand and make decisions. Review of progress notes and SBAR notes from June 2026 through 7/12/2026 showed no documentation that he had developed scattered, circular scabs on his forehead, even though on 7/13/2026 he was observed with a blue to purple discoloration under the left eye and several small round scabs scattered across his forehead. CNA 7 stated one of the scabs began bleeding during a shower and that she reported it to LVN 8, and LVN 8 stated she administered treatment but agreed a change-of-condition note should have been documented. The facility also failed to keep Resident 34’s admission Face Sheet accurate. Resident 34’s record showed diagnoses of major depressive disorder and intracranial injury, and her H&P stated she could make her needs known but could not make medical decisions. Her MDS indicated moderately impaired cognition and substantial assistance with several activities of daily living. During review with the SSD, the Notice of Probate Referral showed that a legal guardian had been denied, and the SSD stated Resident 34 did not have capacity to make medical decisions and had no family to serve as responsible party. Despite this, the Face Sheet identified Resident 34 as self-responsible. The SSD stated this was not accurate and that the interdisciplinary team should have been listed as her responsible party. The facility also failed to assign Resident 3 to the correct room in the electronic record and physical chart. Resident 3’s record listed diagnoses including COPD, anemia, and HTN, and his MDS showed moderate cognitive impairment with dependence on staff for personal hygiene, toileting, and bathing. His H&P stated he was able to make decisions for activities of daily living. During observation, he was seen in one room bed assignment, but his admission record and physical chart identified him as assigned to a different bed in the same room. LVN 1 confirmed the room assignment was incorrect, and LVN 2 stated she had accidentally assigned him to the wrong bed on readmission because both beds were empty. The DON stated nursing staff should ensure documentation, including room assignments, was accurate.
Arbitration Agreement Signed by Resident With Impaired Cognition
Penalty
Summary
The facility failed to ensure that an Arbitration Agreement was executed through an appropriate and informed decision-making process for Resident 32. Resident 32 had diagnoses including COPD, encephalopathy, bipolar disorder, and schizophrenia. The resident’s H&P dated 5/21/2024 indicated fluctuating capacity to understand and make decisions, and the MDS dated 9/27/2024 indicated the resident’s mental capacity was severely impaired and that the resident was partially dependent on staff for activities of daily living. The arbitration agreement dated 10/14/2024 showed an X in the resident signature and initial areas, with two signatures from the BOM in the facility representative area. During interview, Resident 32 stated he did not remember signing any documents and did not know what an arbitration agreement was. Resident 32’s daughter stated she was present at the original admission, did not remember signing or being informed about an arbitration agreement, was not present when the document was signed on 10/14/2024, and stated her father did not have the mental capacity to sign legal documents. The BOM stated the arbitration agreement had been explained to Resident 32 and translated into Spanish by the SSD before the resident signed it, and that no legal documents from the original admission could be located, so admission and legal documents had to be re-discussed with the resident. The DON stated residents are expected to have the mental capacity to understand the purpose and legal implications of documents before signing them, and that when a resident lacks capacity, legal documents such as arbitration agreements should be reviewed with and signed by the resident’s legally authorized representative or responsible party rather than the resident.
Urine Contamination Left Uncleaned in Resident Room
Penalty
Summary
The facility failed to follow its Infection Prevention and Control measures for one sampled resident by not identifying, cleaning, and disinfecting urine contamination in the resident’s room. Resident 7 was admitted and later readmitted to the facility and had diagnoses including ESRD, schizophrenia, overactive bladder, dementia, and nodular prostate. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident required supervision for toileting hygiene and cleaning assistance for eating. During observation, Resident 7’s room had a very strong urine odor and flying insects were seen around the bedside table and nightstand. Housekeeping staff stated the odor remained after cleaning and mopping the room. CNA staff stated the resident sometimes urinated on the floor or knocked over the urinal, allowing urine to seep under the nightstand and bed. The Housekeeping and Laundry Supervisor later moved the nightstand and observed a puddle of yellow-colored fluid on the floor underneath it, identifying it as old urine that had not been removed during routine room cleaning and noting the nightstand had absorbed the urine due to prolonged exposure. The Infection Preventionist stated visible bodily fluids should be cleaned immediately upon discovery and that staff should not leave urine on the floor for another department to clean later.
Blank belongings inventory for resident on readmission
Penalty
Summary
The facility failed to ensure one resident’s belongings were listed in the resident belongings inventory on readmission. Resident 1 was admitted and later readmitted to the facility, with diagnoses including polyosteoarthritis and unspecified psychosis not due to a substance or known physiological condition. The resident’s H&P indicated the resident was able to understand and make decisions, while the MDS dated 5/20/2026 indicated moderate cognitive impairment and the need for partial/moderate assistance with some ADLs and substantial/maximal assistance for transfers. During observation on 7/10/2026, Resident 1 was seen with a wheelchair, two tote bags, a black purse, and a cell phone. Review of the chart showed the resident’s Belongings List was blank. CNA 1 stated the inventory list should be completed on admission and updated when new items are brought in. LVN 2 stated resident belongings should have been inventoried by CNAs and LVNs upon admission, and if the resident refused, that should have been documented in the nursing progress notes; LVN 2 also stated the blank belongings list was unacceptable because the resident had belongings at the facility. The DON stated staff did not follow the facility’s policy when the resident’s belongings were not listed in the inventory list, and the facility policy required all resident personal items to be inventoried at admission and documented in the medical record.
Bed-Hold Notice Not Properly Documented and Resident Not Readmitted to First Available Bed
Penalty
Summary
The facility failed to follow its Bed Hold Notice policy by not providing written bed-hold information to a resident and/or the resident representative at the time of transfer to the hospital, and by not keeping a signed and dated copy of the notice in the resident's record. The policy stated that written information about bed-hold periods, the resident's right to return to the next available bed, and the conditions for return would be provided as part of the admission packet and at the time of transfer or therapeutic leave. For the resident involved, the Bed Hold Notification dated 4/28/2026 did not include a signature from the resident or responsible party confirming receipt of the facility's bed-hold policy. Resident 1's record showed diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side. The resident's H&P dated 11/4/2025 indicated the resident did not have the capacity to understand and make decisions. The MDS dated 3/21/2026 showed the resident was dependent on staff for ADLs such as eating and bathing, required substantial to maximal assistance for rolling, and was dependent for changing positions from sitting to lying. Resident 1 was transferred to a GACH and had a seven-day bed hold order. The facility census on 6/17/2026 showed 16 empty rooms available. Email communication between the BOM and the hospital case manager showed the hospital was ready to send the resident back on 6/17/2026, but the DON determined the resident could not be readmitted due to high acuity. During interviews, the Admin stated the resident was returning with a BiPAP machine and that the facility had the capacity to care for residents using BiPAP, and later stated the facility had an empty isolation room and could have readmitted the resident on 6/17/2026.
Facility Assessment Not Updated for Lack of RT Contract
Penalty
Summary
The facility failed to implement its policy and procedure titled Facility Assessment when it did not update the assessment after it no longer had a contracted Respiratory Therapy (RT) company. The facility assessment, dated 1/27/2026, still indicated RT as a resource needed by the facility, even though the Administrator stated during interview that there was no active RT contract in place and that it was not appropriate to include RT in the assessment without one. During concurrent interview and record review on 6/26/2026 at 1:40 p.m., the Administrator reviewed the Facility Assessment and confirmed the facility did not have an active contracted RT company. The facility’s policy titled Facility Assessment, dated 1/2026, stated the assessment should be reviewed and updated as necessary and at least annually whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment.
Failure to Complete AMA Discharge Process
Penalty
Summary
The facility failed to follow its policy and procedure for discharge against medical advice (AMA) for one resident who left the facility on 5/22/2026. The resident was admitted with diagnoses including schizophrenia, anxiety, and epilepsy. The social services assessment dated 5/19/2026 indicated the resident could understand and be understood by others and had intact cognition. The care plan dated 5/19/2026 indicated the resident required staff supervision for activities of daily living. On 5/22/2026 at about 5:00 p.m., staff found the resident was nowhere to be found and searched inside and outside the facility. The Administrator and DON were notified. The incident report later stated the resident verbalized an intent to leave and left AMA, but there was no documented evidence that the AMA discharge process was completed, including physician notification, risk education, a signed AMA form, discharge instructions, or documentation of the resident's understanding of the risks of leaving AMA. RN 1 stated the required AMA discharge process was not completed, and LVN 1 stated the resident was agitated and pacing earlier that day, but she did not recall the resident requesting to leave and was unsure how the resident left the facility.
Delayed and Inaccurate Documentation of Resident Behavior
Penalty
Summary
The facility failed to ensure an LVN accurately and timely documented a resident’s aggressive behavior in the medical record. Resident 1 was admitted with diagnoses including schizophrenia, anxiety, and epilepsy. The record also indicated the resident had the ability to understand and be understood by others and that cognition was intact. A progress note authored by LVN 1 stated that on 5/22/2025 at 4:32 p.m., Resident 1 was pacing in the television room, became verbally aggressive when approached, and continued to show agitation when staff attempted to redirect the resident. During review of facility video surveillance footage from the same time period, the Administrator stated the footage did not show Resident 1 displaying aggressive behaviors and did not show staff present in the television room during the time documented in the note. LVN 1 stated the progress note was not documented at the time of the event and was entered four days later, and acknowledged it should have been documented timely and accurately. The DON stated staff were expected to document resident behaviors, incidents, assessments, and interventions timely and accurately, and confirmed the note regarding the alleged aggressive behavior was not documented timely. The facility’s charting and documentation policy stated all incidents, accidents, or changes in condition must be timely recorded in the medical record.
Failure to Administer Ordered Antifungal Treatments and Delay in Obtaining Rash Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered treatments for fungal skin infections were administered as prescribed for one resident. One resident with intact decision-making capacity and no cognitive impairment had physician orders dated 1/26/2026 for cleansing a rash with normal saline, patting dry, and applying Triamcinolone 0.5% cream topically under both breasts every day and evening shift for 14 days to treat candidiasis. Review of the Treatment Administration Record (TAR) for January 2026 showed that the evening doses on 1/27, 1/28, 1/29, and 1/31 were not documented as given. Subsequent physician orders dated 2/9/2026 directed cleansing with normal saline and application of Nystatin powder and Triamcinolone cream to the buttocks and perineal area every day and evening shift for candidiasis. The February 2026 TAR showed missed evening treatments on 2/11, 2/12, and 2/19. During interviews, an LVN and the treatment nurse confirmed that the resident did not receive all ordered evening treatments and doses of Nystatin and Triamcinolone during these periods. The deficiency also includes the facility’s failure to promptly obtain treatment orders for another resident who reported a new itchy rash. This resident, with pneumonia and epilepsy and moderate cognitive impairment, complained on 1/31/2026 of itchiness to the groin area with red, raised rashes. A progress note documented that the physician was called and that staff were awaiting a response on needed treatment. Review of progress notes, TARs for January and February 2026, and the 24-hour report sheet showed no documentation that the physician was successfully reached regarding the rash on that date, and no treatment orders were in place at that time. In a subsequent interview and record review, an LVN stated there was no supporting documentation that nurses were able to reach the physician about the rash identified on 1/31/2026 and that treatment orders were not obtained until 2/6/2026, six days after the initial complaint. The DON, upon review of the TARs, progress notes, and 24-hour report, stated that nurses did not administer all ordered doses of Nystatin and Triamcinolone for the first resident in January and February 2026 and acknowledged that all treatments should have been administered as ordered. The DON also stated that staff should have communicated to the upcoming shift when waiting for physician orders and characterized the six-day delay in obtaining orders for the second resident’s rash as a delay of care. Facility policies on medication administration and change in condition required medications to be administered as ordered and prompt physician notification when there is a need to significantly alter a resident’s medical treatment.
Failure to Re-Evaluate and Revise Dermatitis Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to re-evaluate and revise a resident’s care plan for dermatitis as scheduled. A resident with a history of atrial fibrillation and atrial flutter, who had capacity to make decisions per a prior H&P and later showed moderate cognitive impairment on the MDS, was observed with a generalized rash on the back and reported having the rash for about a year with itchiness, especially at night. Physician’s orders dated 11/21/2025 directed cleansing the rash with normal saline and applying ketoconazole cream every shift and triamcinolone cream on day shift to the trunk for 30 days. A corresponding care plan for dermatitis of the trunk, initiated on 11/21/2025, set a goal that the resident would have no complaints of scaly, flaky, itchy, red skin for 30 days and no allergic reaction to the topical medications, and specified that a re-evaluation should occur on 12/21/2025. Review of the resident’s progress notes for 12/2025 showed no documentation that the treatment and plan of care were re-evaluated on the 12/21/2025 target date. During interviews, the treatment nurse stated that skin assessments are done daily and at the end of treatment, and that when treatment ends staff should notify the wound consultant to determine whether orders should be continued or changed, but acknowledged that this resident’s plan of care was not revised or re-evaluated on 12/21/2025 to determine if the dermatitis had resolved. The DON similarly stated that the treatment nurse should reassess whether a resident’s plan of care and treatment are working and document the re-evaluation in the progress notes, and confirmed that if the care plan was not re-evaluated after the target date, the resident’s skin condition could have worsened. The facility’s comprehensive care plan policy requires measurable objectives, timeframes, and documentation of alternative interventions as needed, but the required re-evaluation and potential revision of the dermatitis care plan were not completed or documented for this resident.
Failure to Ensure Functionally Accessible Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not providing an appropriate and usable call light. The resident, who had diagnoses including muscle weakness and hypertension, was care planned to have a call light within reach and answered promptly. The resident’s H&P documented that he did not have the capacity to understand and make decisions, while the MDS indicated he was usually able to understand and be understood, and was dependent for most ADLs and mobility, including transfers and toileting. During interview, the resident reported not knowing where his call light was, being unable to press it because he could not move his arms and hands, and stated he sometimes felt powerless and ignored, resorting to yelling or waiting until someone entered the room, and that when he called, he would be dirty and wanted to be cleaned. On observation with a CNA, the resident’s call light was found not within reach, and the CNA then placed it within reach. The resident reiterated he could not use the call light due to inability to move his arms and hands. The CNA acknowledged she had not asked the resident if he could use the call light and stated that not being able to use and access the call light could lead to feelings of neglect, delay in care, and in assisting the resident’s needs. The MDS nurse stated he was not aware the resident could not use the call light. The facility’s policy on call lights required that each resident be evaluated for unique needs and preferences to determine any special accommodations needed to utilize the call system and that the facility be adequately equipped with a call light at each resident’s bedside, toilet, and bathing area to allow residents to call for assistance.
Failure to Notify Physician and Assess Rash on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and obtain treatment orders when a resident was readmitted with a rash on both lower extremities. The resident’s admission record showed an initial admission and a later readmission, with diagnoses including muscle wasting, atrophy, and lack of coordination. A History and Physical indicated the resident did not have the capacity to understand and make decisions, while a subsequent MDS documented that the resident was able to understand and be understood, and required varying levels of supervision and moderate assistance with ADLs and transfers. Progress notes from the readmission documented that the resident returned with a bilateral lower extremity rash. During an interview and concurrent record review, an LVN stated she admitted the resident on the readmission date, observed the bilateral lower extremity rash, but did not call the physician to notify him. She further stated she did not complete a Change of Condition assessment and no care plan was created related to the rash. The LVN acknowledged that the rash was not properly assessed and was not treated. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” indicated the facility should promptly notify the attending physician of changes in the resident’s medical condition or status, which was not followed in this case.
Failure to Perform Hand Hygiene and Proper Glove Use During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene and glove use during incontinence care for one resident. The resident had diagnoses including muscle weakness and hypertension, lacked capacity to make decisions per a recent H&P, and was highly dependent on staff for activities of daily living according to the MDS, requiring extensive assistance for mobility, toileting, and personal hygiene. During an observed care episode, an LVN donned gloves without performing hand hygiene, opened the resident’s soiled diaper, cleaned the pubic area with a towel, turned the resident, and cleaned the buttocks with another towel, placing the used towels on the resident’s bed. Without changing gloves or performing hand hygiene, the LVN then placed a clean diaper on the resident, covered the resident with a blanket, and touched the resident’s knees with the same contaminated gloves. In a concurrent interview, the LVN acknowledged not washing or sanitizing her hands before putting on gloves, not removing the used/dirty gloves prior to placing the clean diaper, and not performing hand hygiene after cleaning and before further contact with the resident. The LVN stated she should have washed or sanitized her hands prior to putting on gloves and before cleaning and touching the resident, and recognized that not doing so could lead to infections, including urinary and wound infections that could result in hospitalization. Review of the facility’s hand hygiene policy and hand hygiene table showed that staff are required to perform hand hygiene before applying and after removing PPE, including gloves, and before performing resident care procedures, which was not followed in this instance.
Failure to Maintain Functional Privacy Curtains in Shared Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide functional ceiling-suspended privacy curtains in shared resident rooms, resulting in a lack of full visual privacy for two residents. For Resident 1, review of the admission record showed diagnoses including anxiety disorder, paranoid schizophrenia, muscle wasting and atrophy, and lack of coordination. A History and Physical dated 10/9/2025 documented that Resident 1 did not have capacity to understand and make decisions, while an MDS dated 10/16/2025 indicated the resident usually could understand and be understood and required partial/moderate assistance with ADLs such as toileting hygiene, showering, lower body dressing, transfers, and walking. During an observation and interview on 2/10/2026 at 1:50 p.m., CNA 1 stated that Resident 1’s curtain was short, did not close completely, and did not provide enough privacy, allowing another resident to walk in and see the resident being changed. CNA 1 stated the short curtain could not offer full privacy and that it was the facility’s responsibility to ensure full privacy. For Resident 2, the admission record showed diagnoses of muscle weakness and hypertension, and an H&P dated 5/23/2025 indicated the resident did not have capacity to understand and make decisions. An MDS indicated Resident 2 usually was able to understand and be understood and was dependent for ADLs including eating, personal hygiene, toileting hygiene, showering, dressing, footwear, and transfers. During an observation and interview on 2/11/2026 at 1:18 p.m., LVN 2 reported that Resident 2’s curtain was shortened, did not provide enough privacy, and that the curtain strings appeared tangled; LVN 2 did not know how long the curtain had not been functional and stated that not having full privacy with the curtain placed the resident at risk of being exposed to other residents. Review of the facility’s policy titled “Resident Rooms,” dated 1/2025, showed that resident bedrooms must be designed and equipped for comfort and privacy and that all resident bedrooms will be equipped to assure full visual privacy, including ceiling-suspended curtains extending around each bed in non-private bedrooms. The observed conditions for Residents 1 and 2 did not meet this policy requirement.
Failure to Meet Professional Standards in Medication Administration
Penalty
Summary
The facility failed to meet professional standards in the preparation and administration of medications for three of five sampled residents. In one instance, a nurse prepared all of a resident's medications in a single cup and provided them without identifying the medications, despite the resident's request for information. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, reported that nurses never informed her about the medications she was given. Another resident, also with moderate cognitive impairment and dependent on staff for daily activities, received all medications in a plastic cup without explanation from the nurse. The nurse acknowledged that medications should be administered one at a time and that it was the resident's right to know what medications were being given. The resident confirmed that nurses did not explain the medications and expressed that it was his right to be informed about what he was taking. A third resident, who had cognitive impairment and was dependent on staff, received all medications crushed together in a plastic bag and administered via gastrostomy tube. The nurse stated that he typically crushed all medications together and was unaware of the facility's policy regarding separate crushing. The nurse also acknowledged that medications should be administered separately to identify any adverse reactions. The facility's policy indicated that medications should be administered by licensed nurses in accordance with professional standards and that the purpose of medication administration should be explained.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's bathroom wall had black and red spots, and the bathroom door panel was damaged. The resident reported that the maintenance supervisor had been notified about the broken door two weeks prior, but no repairs had been made. The resident stated that the broken door panel posed a safety risk, as it had previously caused injury to his foot. Housekeeping staff confirmed the door had been broken for several weeks and that the issue was not documented in the maintenance repair book. The housekeeping supervisor acknowledged the risk of injury and stated that it was the facility's responsibility to ensure resident safety. In another instance, a resident's toilet seat cover was observed to be broken in half. The maintenance supervisor agreed that the toilet seat should have been fixed to maintain a safe and homelike environment. Housekeeping staff observed the broken toilet seat the previous day but did not document it in the maintenance book or inform the maintenance supervisor. The certified nursing assistant stated that a broken toilet placed the resident at risk for skin injuries and falls. The director of nursing confirmed that the facility must keep bathrooms, doors, toilet seats, and walls in good condition to provide a safe environment. Facility policies reviewed indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were administered psychotropic drugs without adequate justification or in a manner that could limit their functional abilities. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Complete and Retain Staff Background Checks
Penalty
Summary
The facility failed to complete and retain documentation of background reports for five out of six sampled staff members, including registered nurses, licensed vocational nurses, a treatment nurse, and a certified nursing assistant. During interviews and record reviews, it was found that several employee files lacked background check documentation, with some background checks either missing, incomplete, or conducted years after the staff member's hire date. In some cases, background reports were still processing or had not been printed and reviewed once completed. The Director of Staff Development (DSD) confirmed that background checks should have been completed upon hire and that missing documentation was partly attributed to a change in facility ownership, during which some records were misplaced. The Director of Nursing (DON) stated that it was the responsibility of the Human Resources Department or the DSD to ensure background checks were completed for newly hired nurses. Both the DSD and DON acknowledged that background checks were necessary to confirm staff eligibility to provide care and to ensure resident safety. The facility's policy and procedure required background checks and verification of employment eligibility status to be conducted in accordance with established policies, but these procedures were not consistently followed, resulting in incomplete or missing background check documentation for multiple staff members.
Failure to Maintain Proper Head of Bed Elevation During G-Tube Feeding
Penalty
Summary
A deficiency occurred when a resident receiving gastrostomy tube (G-tube) feeding was observed lying in bed with the head of bed (HOB) at a 20-degree angle, which was below the required 30-45 degree elevation specified in the facility's policy and the resident's care plan. The assigned LVN confirmed that the HOB was lower than the required angle during the feeding. The resident was receiving Glucerna 1.2 at 60 cc per hour via G-tube at the time of observation. The resident had a medical history including chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis following a stroke, and aphasia. The care plan and physician orders both specified that the HOB should be elevated at least 30-45 degrees during and for at least one hour after tube feeding to reduce the risk of complications. The facility's policy also required staff to be trained and competent in enteral feeding safety precautions, including maintaining proper HOB elevation. Despite these requirements, the resident was not positioned as directed during the feeding.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Supervise and Secure Exit for Elopement Risk Resident
Penalty
Summary
A facility failed to ensure the safety and adequate supervision of a resident with a known risk for elopement and multiple complex medical and psychiatric diagnoses, including paranoid schizophrenia, COPD, hypertension, and epilepsy. The resident had a documented history of exit-seeking behavior, restlessness, agitation, and impaired cognition, and required supervision for activities of daily living and ambulation. Despite these risks, the resident was able to leave the facility through an unlocked and disarmed exit door without staff noticing, as there was no staff present in the hallway at the time and the door alarm had not been activated as required by facility policy and the resident's care plan. The lack of communication among staff and the interdisciplinary care team contributed to the deficiency. The social services director was aware of the resident's prior elopement attempts and exit-seeking behaviors, as reported by the responsible party, but this information was not shared with the care team or nursing staff. As a result, the care plan interventions for elopement risk were not effectively communicated or implemented. Licensed nurses and other staff members were not made aware of the resident's specific risks, and shift huddles intended to communicate such information were not conducted. Staff assigned to the resident did not read or were not informed of the care plan interventions, and did not provide the necessary supervision or monitoring. Additionally, there were no systems in place to ensure that exit door alarms were armed at the required times, and staff were not consistently checking or activating the alarms. Multiple staff members, including licensed nurses and supervisors, did not verify the status of the alarms or ensure that the environment was secure, as required by both facility policy and the resident's care plan. This failure to supervise, communicate, and implement safety measures resulted in the resident eloping from the facility and subsequently being found deceased off the premises.
Failure to Maintain Cleanliness in Shower Room and Toilet
Penalty
Summary
The facility failed to implement proper infection control practices by not ensuring that the shower room and toilet were cleaned after use. During an observation in Building A Shower Room B3, the shower floor was found to be wet, and staff interviews confirmed that the floor should have been dry and cleaned after use to prevent cross-contamination. Maintenance staff and a CNA acknowledged that leaving the floor wet and dirty linen on the floor posed infection control risks. The Director of Nursing also stated that a wet floor could lead to mold and respiratory issues among residents. Additionally, the toilet in the same shower room was observed to contain yellow and brown fluid and lacked a lid, which was confirmed by both the Maintenance Supervisor and the DON as being dirty and inappropriate for resident use. The facility's own policies and procedures require routine cleaning of environmental surfaces and maintaining a clean, homelike environment, but these were not followed in this instance.
Failure to Maintain Safe and Comfortable Resident Equipment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents by not ensuring that essential equipment such as Geri chairs and shower chairs were in good repair. Observations revealed that six out of eight Geri chairs in Building A were either broken or had ripped upholstery, with issues including missing cushions, broken footrests, handrests, and backrests, as well as exposed padding, wood, and metal parts. Two out of eight shower chairs were also found to be broken or ripped, with missing or damaged seat pads and backrests. These deficiencies were confirmed through interviews with the Maintenance Supervisor, who acknowledged the need for repairs to ensure resident comfort and safety. Further interviews with the DON confirmed that the damaged equipment compromised resident comfort and posed a risk of skin injury. Review of the manufacturer's manual for the Geri chair indicated the need for regular inspection and replacement of damaged parts, while the maintenance job description and facility policy emphasized the importance of maintaining equipment for resident safety and comfort. The facility's failure to adhere to these guidelines resulted in an environment that was not safe or comfortable for residents.
Failure to Monitor Effectiveness of Rash Treatment per Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident by not monitoring the effectiveness of treatment for the resident's rash. The resident, who had diagnoses including metabolic encephalopathy and type 2 diabetes mellitus, was cognitively intact and required supervision or assistance with activities of daily living such as upper body dressing and personal hygiene. The care plan specifically directed staff to monitor the effectiveness of the rash treatment and to notify the physician as needed. A review of nursing progress notes after the care plan was established showed no documentation that nurses monitored the effectiveness of the rash treatment. During interviews and record reviews, the Director of Nursing confirmed that there was no supporting documentation to indicate that the required monitoring had occurred, as outlined in the resident's care plan. Facility policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed in this instance.
Failure to Timely Reassess Pain After Administration of Pain Medication
Penalty
Summary
The facility failed to provide effective pain management for one resident by not reassessing the resident's pain in a timely manner after administering Hydrocodone-Acetaminophen (Norco) on two separate occasions. On one occasion, the nurse reassessed the resident's pain approximately five hours after medication administration, rather than within the expected timeframe. On another occasion, there was no documentation that the resident's pain was reassessed at all after receiving the medication. The facility's policy required pain to be reassessed and documented with adequate detail to gauge the effectiveness of interventions. The resident involved had diagnoses including metabolic encephalopathy and type 2 diabetes mellitus, and was cognitively intact, requiring some assistance with activities of daily living. The resident reported receiving pain medication but stated that no nurse returned to check if the medication was effective. Review of the medical record and interviews with the Director of Nursing confirmed that pain reassessment was either delayed or not documented, contrary to facility policy.
Failure to Document PRN Pain Medication Administration
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to document the administration of Hydrocodone-Acetaminophen (Norco) for a resident who was cognitively intact and required some assistance with activities of daily living. The resident, who had diagnoses including Metabolic Encephalopathy and Type 2 Diabetes Mellitus, reported receiving a dose of Norco around 9 a.m. on the specified date. Upon review, the LVN confirmed administering the medication but did not document it at the time, stating that he became occupied with another resident and forgot to complete the documentation. The facility's policy and procedure for medication administration required that medications be administered by licensed nurses as ordered and that the Medication Administration Record (MAR) be signed immediately after administration, ensuring the six rights of medication administration, including right documentation. The Director of Nursing confirmed that nurses are expected to document medication administration immediately after giving the medication to prevent errors.
Lack of Refrigeration for Resident Food from Visitors
Penalty
Summary
The facility failed to provide a refrigerator for the storage of residents' food brought in by visitors, resulting in staff disposing of leftover food that required refrigeration. Interviews with the Dietary Supervisor and Infection Preventionist confirmed that there was no dedicated refrigerator available for residents' personal food items, and that per facility policy, only shelf-stable foods could be stored at the resident's bedside. Foods needing refrigeration were discarded if not consumed immediately, as there was no appropriate storage option available. The facility's policy indicated that staff would determine if food items were shelf stable and could be stored in the resident room or under refrigeration, but in practice, the lack of a refrigerator led to the disposal of perishable foods.
Failure to Implement Infection Control Measures and Precautions
Penalty
Summary
The facility failed to implement and maintain infection control measures for multiple residents, specifically by not applying Enhanced Barrier Precautions (EBP) for twelve residents who met the criteria due to the presence of indwelling medical devices such as gastrostomy tubes, open wounds, or multidrug-resistant organisms (MDROs). Observations revealed that there was no signage or personal protective equipment (PPE) available outside the rooms of these residents, and the Infection Preventionist (IP) confirmed that EBP was not being used for any residents, despite facility policy requiring it for those with certain risk factors. Documentation reviews for each affected resident confirmed the presence of conditions necessitating EBP, yet the required precautions were not in place. The facility also failed to maintain and implement a water management system designed to reduce the risk of Legionella and other opportunistic pathogens. The Maintenance Supervisor was unable to provide records of the water management plan or documentation describing the facility's water system, and the IP had not participated in any water management activities, despite being listed as a team member in the facility's policy. The policy required regular verification of the system's implementation and annual evaluation of its effectiveness, but there was no evidence these activities had occurred. Additional infection control lapses were observed, including an incident where a resident with moderate cognitive impairment ate food from another resident's partially consumed tray left on a hallway food cart. Staff interviews confirmed that residents should be monitored to prevent such occurrences, but monitoring was not consistently in place. Furthermore, a Treatment Nurse did not perform hand hygiene between glove changes while providing wound care to a resident with a Stage 4 pressure ulcer, contrary to facility policy and best practices. The nurse acknowledged the lapse and its potential to introduce bacteria during wound care.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain proper informed consent prior to administering psychotropic medications to multiple residents. In several cases, residents who lacked the capacity to make medical decisions were either asked to provide consent themselves or did not have a legally authorized representative involved in the consent process. For example, one resident with severe cognitive impairment and no listed emergency contact or next of kin was administered antipsychotic, antidepressant, and anticonvulsant medications after the facility obtained consent directly from the resident, despite documentation indicating the resident could not understand or make decisions. The Social Services Director and Director of Nursing both confirmed that the resident should not have been consenting and that a conservator should have been appointed to make such decisions. Another resident with an appointed Public Guardian (PG) received multiple psychotropic medications without the facility obtaining informed consent from the PG. The consent forms for these medications were incomplete, lacking documentation of who provided consent and the date it was obtained. The DON acknowledged that the PG was not given the opportunity to make an informed decision regarding the resident's care, as required. Additionally, a resident with severe cognitive impairment and no current emergency contacts had an outdated psychotropic consent form that was not renewed every six months as required, and a new consent was not obtained when a new medication order was placed. Further deficiencies included a resident who received a monthly antipsychotic injection without any signed or completed informed consent form, and another resident whose consent form for an antipsychotic medication was incomplete, missing the resident's name, date, and verification that consent was obtained. In each of these cases, facility staff acknowledged the failures to properly document and obtain informed consent, as required by facility policy and procedure. These actions resulted in residents or their representatives not being fully informed or able to make decisions regarding the use of psychotropic medications.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Minimum Data Set (MDS) assessments for five residents, resulting in the transmission of inaccurate data to CMS and the potential for unmet care needs. For one resident with end stage renal disease and dependence on hemodialysis, the MDS did not accurately reflect the resident's therapeutic diet or the presence of a Permacath for dialysis, despite clear documentation in the medical record and direct observation. The MDS nurse acknowledged these inaccuracies and confirmed that the assessment should have included these details, as the MDS guides the resident's care plan. Another resident with chronic obstructive pulmonary disease, diabetes, and depression was assessed in the MDS as preferring English and not needing an interpreter, even though the resident primarily spoke Cantonese and used a communication board with Cantonese translations. Interviews with the resident, family, and staff revealed that the resident preferred Cantonese and had difficulty communicating in English, but this was not verified or accurately documented in the MDS. Similarly, a resident whose preferred language was Korean was documented in the MDS as not needing an interpreter, but interviews revealed that staff communicated with the resident in English or Spanish, which the resident did not understand well, and no interpreter or translation services were used. Additional deficiencies were found in the assessment of oral and dental status. One resident was documented in the MDS as having no oral or dental issues, despite not having natural teeth and using dentures, which the resident reported as loose and difficult to use during meals. Another resident was also incorrectly assessed as having no dental issues, even though observation confirmed the absence of natural teeth. The facility's policies required comprehensive and accurate assessments, including direct observation and communication with residents, but these were not followed, leading to inaccurate MDS documentation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bell Gardens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Del Rio Gardens | 1.1 mi | ★★★★★ | 0 | 0 |
| Briarcrest Nursing Center | 1.4 mi | ★★★★★ | 46 | 0 |
| Bell Convalescent Hospital | 1.7 mi | ★★★★★ | 32 | 0 |
| Riviera Healthcare Center | 2.4 mi | ★★★★★ | 28 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 2.4 mi | ★★★★★ | 27 | 0 |
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