Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Western Convalescent Hospital during CMS and state inspections, most recent first.
Pressure ulcer prevention and wound care deficiencies were identified for four residents. Two residents with severe cognitive impairment and total dependence had LALMs that repeatedly showed a low-pressure alarm, indicating an air leak in the system, while another resident with stage 4 PUs had a LALM set to the wrong weight setting instead of matching the resident’s actual weight. In addition, wound care for a resident with gangrene was documented by initials on the TAR, but the required wound assessment details such as wound bed color, size, drainage, and condition changes were not documented per the facility’s Wound Care policy.
Medication services were not provided as ordered for one resident when an LVN gave hydralazine despite low SBP and failed to give ordered insulin at the documented glucose level. Two residents had outdated G-tube medication orders even though they were taking meds by mouth, and the DON said nurses should have clarified the discrepancies. The facility also failed to obtain a second licensed nurse witness for non-controlled medication destruction and could not account for discontinued controlled meds, including Norco and phenobarbital, with staff stating the phenobarbital had been destroyed using the wrong process.
Food items were found improperly stored and not dated or labeled. A resident kept opened buns, rolls, and salad dressing at the bedside without dates, while dry storage contained unopened baking powder and peanut butter without labels or dates and an open container of beef base without a best-by date. Two discolored cabbages were also observed in the walk-in refrigerator. Staff stated the resident’s food was not dated, there was no system to track it, and facility policy required food to be covered, dated, labeled, and not stored beyond 72 hours.
Failure to Maintain Contact Isolation Precautions: Two residents on contact isolation for CRAB and CRE had documented orders and care plans for isolation, but a CNA entered one resident’s room without proper hand hygiene before re-entering with gloves, and a physician touched the other resident directly without gown or gloves, used a stethoscope without disinfecting it, and then went to the nurse’s station without hand hygiene.
Inaccurate MDS coding was found for two residents. One resident’s MDS did not reflect continuous O2 via T-piece, intermittent suctioning, or tracheostomy care despite orders, observations, and staff confirmation of those services. Another resident’s SCSA incorrectly coded venous/arterial ulcers as 0 even though wound documentation showed a vascular wound with gangrene on the left foot. Staff acknowledged the MDS entries were inaccurate.
Failure to Implement Ordered Bed Safety Interventions: Two residents with seizures and severe cognitive impairment were observed in bed without the padded side rails required by their care plans and physician orders, and another resident who had fallen from bed was observed without the ordered floor mats. An LVN confirmed the side rail padding was required for injury prevention, and an ADON stated the floor mats should have been in place as ordered.
Delayed Completion of Ordered Arterial and Venous Ultrasounds: A resident with severe cognitive impairment, PVD, prior CVA, and an above-knee amputation had ordered arterial and venous ultrasounds that were not completed as scheduled. RN3 stated the tests were done a day late, and the DON noted there was no documentation of a follow-up call to the ultrasound provider or communication to the ordering practitioner about the missed timing.
Informed Consent for Restraint Use Not Obtained by Physician: A resident with severe cognitive impairment, encephalopathy, and a gastrostomy had an order for hand mitten restraints, but the record did not show the physician obtained informed consent from the RP. The ADON stated he contacted the RP and explained the risks and benefits himself, while the DON stated the physician was responsible for obtaining consent and the nurse's role was only to verify it.
A resident with Alzheimer's Disease, bipolar disorder, and severe cognitive impairment was started on Lexapro and later Seroquel without an IDT or bioethics committee meeting before the psychotropic meds were initiated. RN and SSD interviews confirmed the resident lacked decision-making capacity, the informed consents were not valid, and no prior multidisciplinary review was held to address the psychotropic use.
Call Light Not Within Reach: A resident with epilepsy, a stage 4 pressure ulcer, and intracerebral hemorrhage had a call light found on the floor beside the bed and not within reach during observation with the ADON. The resident had severely impaired cognition, was dependent for ADLs, and had a care plan intervention to keep the call light within reach; the ADON stated it was on the wrong side of the bed due to a left hand contracture and should have been on the right side so the resident could call for assistance.
Personal belongings were not inventoried or documented for a resident with PVD, CKD, and polyneuropathy whose cognition was intact but who was dependent on staff for toileting hygiene, showering, and dressing. The resident had many personal items in her room, did not recall the last inventory, and the SSD and DON confirmed there was no inventory log or tracking of her belongings despite the facility policy requiring inventory and documentation upon admission and updates as needed.
A resident with severe cognitive impairment, gastrostomy, and encephalopathy had hand mitten restraints ordered, and staff also placed pillows under the fitted sheet on both sides of the body without an order or consent. The ADON stated the pillows functioned like bolster restraints and restricted movement. Staff also failed to document skin and circulation checks while the mittens were in use, and the DON and ADON could not locate evidence that those assessments were completed.
A resident with DM, atherosclerosis, and HTN was transferred to a hospital after a change in condition, but the facility did not have evidence that the written Notice of Proposed Transfer and Discharge was faxed to the local ombudsman. RN stated the notice should be completed within 24 hours and sent to the resident or family representative and the ombudsman at the same time, per facility policy.
Failure to develop a care plan for a resident’s PRN melatonin use. The resident had metabolic encephalopathy, severely impaired cognition, and was dependent on staff for all ADLs and mobility. The DON stated staff gave melatonin for sleep, but the resident had no care plan for sleep difficulties or melatonin use, and no documented non-drug interventions or monitoring plan for effectiveness.
Incomplete GI Referral Follow-Up: A resident with a G-tube, anemia, and DM had a physician order for GI referral and possible colonoscopy for a rectal ulcer, but the referral was not completed and no GI appointment was scheduled. RN stated the order was passed to social services for insurance and scheduling follow-up, while the SSD found no documentation that authorization was requested.
Two residents did not receive care in accordance with orders and professional standards. One resident with a sudden generalized rash was not monitored for the required 72 hours after the change of condition, and the DON confirmed the skin monitoring was not completed. Another resident with severe cognitive impairment and cardiac disease had an HR of 38 documented, but the abnormal HR was not timely reported to the physician; the physician was not notified until a later COC documented an HR of 36 and transfer to the ER was ordered.
Failure to Carry Out Ordered Labs After Significant Weight Loss: A resident with a gastrostomy, type 2 DM, severe cognitive impairment, and total dependence on staff had a 39 lb. weight loss in one month. The physician ordered prealbumin levels and a thyroid panel to evaluate malnutrition and possible thyroid-related causes, but the DON stated the prealbumin was never drawn and the thyroid panel was not collected until later. The facility policy on weight assessment and intervention included obtaining lab studies as part of care planning for significant weight changes.
A resident with a trach, chronic resp failure, and severe cognitive impairment received O2 via T-piece at 5 L/min with an empty humidifier bottle. RTs stated humidification was needed for comfort and secretion management, and one RT said the order should have been clarified because it was written in a way that could be misinterpreted; facility policy required a humidifier for O2 at 3 L/min or more and complete physician orders.
Incorrect Oxygen Flow Rate: A resident with COPD was observed receiving oxygen at 5 L, then later at 4.5 L, despite a physician order for 3 L. RN confirmed the ordered setting should have been 3 L. The resident’s care plan included checking the oxygen flow rate every shift, and facility policy required physician orders to be reviewed for accuracy and clarity.
Failure to Complete GI Referral Through Social Services: A resident with a gastrostomy tube, anemia, and DM had a physician order for GI follow-up for a possible colonoscopy related to a rectal ulcer, but the referral was not completed and no GI appointment was scheduled. RN stated the order was communicated to social services for insurance and scheduling, while the SSD stated there was no documentation that authorization was requested and that social services were responsible for arranging and documenting outside referrals.
A resident’s hydrocortisone 1% cream was left on a bedside table even though the resident could not self-administer topical meds, and the TN stated it should have been kept in the med cart. Another resident’s amlodipine bubble pack had an unclear pharmacy label stating to take by mouth via G-tube, while the DON stated the resident no longer had a G-tube and the nurse failed to verify the label’s accuracy.
A resident with a peripheral IV, osteomyelitis, osteoarthritis, and CKD had an IV dressing observed dated differently than the MAR documentation for site care. The MAR showed peripheral site care every 72 hours, but the DON confirmed the dressing should have been changed and dated to match the documented care; the facility policy required the dressing to be labeled with date, time, and nurse initials.
Open and Overfilled Trash Dumpsters: Two of two trash dumpsters were observed with lids open, and one dumpster was overfilled with trash. A Dietary Aide stated the lids should be closed at all times and noted that open, overfilled dumpsters can attract rodents and insects. The facility policy stated outside garbage bins should be kept closed at all times.
A resident with a GT, tracheostomy, respiratory failure, dysphagia, and severely impaired cognition, who was assessed as NPO and receiving total nutrition via GT, was mistakenly given another resident’s breakfast tray and consumed multiple food items and thickened liquids despite no diet order for oral intake. A CNA provided the tray in error, and an LVN and an RN, both aware the resident was NPO and without an order for oral feeding, failed to promptly notify the physician or document the incident in the medical record, contrary to facility policies requiring written diet orders before serving meals and complete, accurate documentation of incidents and changes in condition.
Three dependent residents with significant cognitive and physical impairments were observed with poor oral hygiene, including thick secretions and dry, cracked lips. Staff interviews and record reviews confirmed that required oral care interventions, such as use of oral care kits and regular moisturizing, were not consistently provided as outlined in care plans and facility policy.
The facility failed to implement OT recommendations for hand splints and obtain physician orders for two residents with hand contractures, and did not reassess another resident's mobility needs after readmission and changes in condition. These actions were not in accordance with facility policy and led to residents not receiving appropriate interventions to maintain or improve range of motion.
A resident with significant cognitive and physical impairments sustained an unexplained right thumb fracture that was identified by nursing staff and confirmed by x-ray. Despite facility policy and federal regulations requiring immediate reporting of such injuries as potential abuse, the incident was not reported to CDPH within the mandated timeframe, and the results of the internal investigation were not sent to the state agency.
A resident with multiple medical conditions did not receive a complete dose of IV antibiotic as ordered, as the medication was not fully infused and the IV site was found dislodged and not properly maintained. Nursing staff did not ensure the IV was administered completely or monitor the site according to facility policy.
A resident with COPD and respiratory failure was observed receiving oxygen at a higher flow rate than ordered by the physician, despite care plan instructions and facility policy requiring administration as prescribed and regular monitoring. Staff confirmed the discrepancy between the order and the oxygen delivered.
A resident with complex medical needs did not have complete and accurate documentation in their clinical record regarding the application and tolerance of prescribed splint services. Although physician orders required daily use of hand and knee splints, staff failed to document the resident's inability to tolerate these devices on certain days, and the records inaccurately indicated that the services were provided. Facility policy required objective and accurate documentation, which was not met in this case.
A resident with severe cognitive impairment and multiple medical conditions was admitted without a fully completed POLST form. Key sections of the POLST, including those for CPR, medical interventions, nutrition, and required signatures, were left blank, and the form was not signed by the resident's legal decision maker. Staff interviews confirmed the form's incompleteness and acknowledged that it should have been fully filled out according to facility policy.
A resident with severe cognitive impairment and complex medical needs was transferred to a hospital, but staff failed to document the transfer, including the resident's clinical condition and vital signs. The Clinical Manager confirmed the medical record was incomplete, and facility policy requiring thorough documentation was not followed.
A resident with multiple stage 4 and unstageable pressure ulcers, severe cognitive impairment, and total dependence on staff did not have a comprehensive care plan developed after admission. Although a baseline care plan was in place, facility staff confirmed that the required interdisciplinary comprehensive care plan addressing wound care was not completed, contrary to facility policy.
A resident with multiple Stage 4 and unstageable pressure ulcers, who was totally dependent on staff and had impaired cognition, did not receive weekly reassessment and documentation of their wounds as required. The treatment nurse failed to complete scheduled evaluations, and facility policies did not mandate weekly reassessment, resulting in inadequate monitoring of the resident's pressure ulcers.
A resident with multiple complex diagnoses and total dependence on staff for ADLs did not have a comprehensive, person-centered care plan. The care plan lacked specific interventions, such as the need for two-person assistance, and did not include measurable objectives or timetables, contrary to facility policy. The DON confirmed the care plan was not individualized to ensure the resident's needs were met.
A resident with severe mobility and cognitive impairments, dependent on staff for all ADLs, was not provided the required two-person assist during care activities. Despite the care plan and facility policy specifying the need for two-person assistance to prevent accidents and injuries, a CNA performed care alone, and the DON confirmed this was not in accordance with the resident's care plan.
The facility failed to implement its infection control program, as a Laundry Aide did not perform hand hygiene or change gloves and gown after handling dirty linens, risking cross-contamination. Additionally, a resident's opened strawberry jam was not refrigerated as required, posing a risk of foodborne illness. The facility lacked a refrigerator for personal food items, contrary to its policy discouraging outside food due to safety concerns.
The facility failed to obtain and document informed consent for psychotropic medications for two residents. One resident received lorazepam and sertraline without proper consent, and another was prescribed duloxetine without documented consent. The Director of Nursing and Assistant Director of Nursing confirmed these oversights, which violated the facility's policy requiring informed consent before treatment.
The facility failed to ensure that room windows were able to close properly, resulting in cold conditions for three residents. Observations revealed that the windows were open and unable to be closed, with one window cracked and others taped. Residents reported the issue, and the Maintenance Aide acknowledged it but required an outside company for replacement. The Administrator confirmed a request for replacement was made, but the facility's policy on maintaining comfortable temperatures was not met.
A facility failed to monitor a resident's weight weekly as ordered, missing several scheduled weigh-ins, which could have impacted the resident's health. Additionally, another resident's orthostatic blood pressure was inaccurately measured, with identical readings recorded for lying and sitting positions, suggesting procedural errors. These deficiencies indicate non-compliance with the facility's policies on weight and blood pressure monitoring.
A facility failed to set a low air loss mattress correctly for a resident with a Stage 4 pressure ulcer, risking ineffective wound healing. Additionally, another resident at risk for pressure injuries was found without physician-ordered Prevalon boots, increasing the risk of skin breakdown. These deficiencies indicate non-compliance with care plans and physician orders.
The facility failed to provide appropriate ROM care for several residents, including not adhering to physician orders for splint application and duration, and missing RNA treatments. Residents did not receive timely annual JMAs, and splints were applied without orders, risking further decline in joint mobility. Staff interviews highlighted the importance of following orders to prevent worsening contractures.
The facility failed to provide adequate RNA staffing, affecting 81 residents with physician's orders for RNA treatments. Staffing records showed inconsistencies, with RNAs often reassigned to CNA duties due to CNA shortages. This led to difficulties in fulfilling RNA responsibilities, risking residents' range of motion and mobility. The Director of Nursing highlighted the importance of sufficient RNA staffing to prevent contractures and maintain joint mobility.
Two LVNs at the facility demonstrated inadequate competency in assessing orthostatic hypotension, as they misunderstood the procedure for taking blood pressure readings in different positions. This deficiency could lead to delays in care and potential resident injury. The DSD clarified the correct procedure, emphasizing the need for proper training to ensure quality care.
A facility failed to monitor a resident's blood pressure when administering amlodipine, as required by the care plan and physician's order. The resident's care plan indicated a risk for elevated blood pressure and falls due to antihypertensive medications, necessitating monitoring of vital signs. However, the MAR lacked documented blood pressure readings during the administration period, which was confirmed by the DON. This failure to document vital signs as per facility policy increased the risk of adverse effects.
A facility failed to ensure a resident was not prescribed Seroquel without an appropriate diagnosis, as the resident's records did not support a mental illness diagnosis. Additionally, the facility did not define or monitor behaviors related to lorazepam use for another resident, failing to document the resident's response to the medication. The Director of Nursing acknowledged these deficiencies, which contravened the facility's policy on psychotropic medication management.
A facility exceeded the acceptable medication error rate with two errors affecting two residents. One resident received an incorrect strength of cranberry supplement, while another was given a tablet instead of a liquid multivitamin. The errors were due to a failure to follow physician orders and proper medication labeling, as admitted by the LVN involved.
A resident did not receive the correct laboratory tests as ordered by the physician to monitor thyroid function due to Seroquel use. The care plan indicated a risk for dehydration, and a thyroid panel was recommended by the pharmacist. However, only a thyroid peroxidase and thyroglobulin antibody test was performed, not the complete thyroid panel. RN 2 confirmed the discrepancy, noting the tests conducted were not equivalent to the ordered thyroid panel.
The facility failed to follow the standardized recipes for residents on a soft and bite-size diet, serving whole bread instead of appropriately sized pieces. The menu did not reflect the new IDDSI standards, leading to inconsistencies with physician diet orders. This discrepancy was confirmed by dietary staff and posed potential risks to residents.
The facility failed to ensure sanitary food preparation practices, as a can opener blade in the kitchen was found dirty and worn, potentially harboring harmful bacteria. The Dietary Supervisor confirmed the residue and was unsure of the last cleaning. This deficiency risked cross-contamination for 47 out of 109 residents receiving food from the facility.
Pressure ulcer prevention and wound care deficiencies
Penalty
Summary
The facility failed to provide effective pressure ulcer prevention and wound care interventions for four sampled residents. Resident 40, who had chronic respiratory failure with hypoxia, encephalopathy, sepsis, severely impaired cognition, total dependence for activities of daily living and mobility, and a very high Braden risk score, was ordered to receive a low air loss mattress (LALM) for wound care and management. During multiple observations, the LALM pump at the foot of the bed displayed an orange flashing light and audible beeping low-pressure alarm, and the alarm remained present over several days while the resident continued to lie on the mattress. Resident 108, who had chronic respiratory failure with hypoxia, ventilator dependence, severely impaired cognition, and total dependence for activities of daily living and mobility, also had a physician order for a LALM for wound care and management and a high Braden risk score. During repeated observations, the LALM pump at the foot of the bed showed the same orange flashing low-pressure alarm with audible beeping. The maintenance assistant stated he had not received any report from nursing staff regarding malfunctioning LALMs, and the treatment nurse stated the alarm indicated an air leak in the system and that it was not appropriate for the alarm to go unaddressed for multiple days. Resident 10 had dementia, multiple stage 4 pressure ulcers, severely impaired cognition, and dependence on staff for all activities of daily living and mobility. The resident was ordered to receive a LALM for wound care and management, and the care plan directed use of pressure relieving devices including a specialty mattress. Observations showed the mattress setting did not match the resident’s weight: it was set at 200 lbs during one observation and 160 lbs during another, while the resident weighed 107 lbs. The assistant director of nursing and treatment nurse both stated the setting should match the resident’s weight, and the assistant director of nursing stated the mattress should have been set at 120 lbs. Resident 65 had left above-knee amputation, peripheral vascular disease, cerebral infarction, sepsis, severely impaired cognition, dependence for multiple activities of daily living, and risk for pressure ulcers. The resident’s TAR showed daily wound care for left foot gangrene, with staff initials documenting the treatment. However, the facility’s Wound Care policy required documentation of the wound assessment data during wound care, including wound bed color, size, drainage, resident tolerance, and any changes in condition. The RN stated the facility documented the initials on the TAR but did not assess and document the wound condition during wound care as required by the policy.
Medication Administration, Order Clarification, and Controlled Substance Disposition Deficiencies
Penalty
Summary
Medication administration was not carried out as ordered for a resident with high blood pressure and type 2 diabetes mellitus. The resident’s physician order required hydralazine 100 mg twice daily, but the medication was to be held if systolic blood pressure was below 110 mm Hg. On two occasions, an LVN documented a systolic blood pressure of 103 mm Hg and still administered hydralazine. In a separate event, the same resident had an order for 2 units of insulin when blood glucose was between 121 and 150 mg/dL, but when the blood glucose was documented as 123 mg/dL, an LVN did not administer the ordered insulin. Medication orders were not clarified when residents’ routes of administration changed from G-tube to oral intake. One resident had a physician order to discontinue G-tube feeding and change medications to by mouth, yet a later order still directed labetalol 200 mg to be given via G-tube twice daily. During observation, the resident took medications by mouth, and an RN stated the labetalol order had not been updated after the G-tube was removed. Another resident had a dietary evaluation indicating the G-tube should be discontinued, but a physician order still directed amlodipine to be administered via G-tube daily. During observation, that resident also took medications by mouth, and the DON stated nurses should check for discrepancies and clarify orders with physicians. Medication destruction and controlled substance accountability were also deficient. Twelve non-controlled medications were destroyed on a log without a second licensed nurse signature as witness. For controlled medications, the facility could not account for discontinued Norco 5/325 mg, 41 tablets, for one resident, and could not properly document the disposition of 2,622 mL of discontinued phenobarbital 20 mg/5 mL solution for another resident. The controlled medication logs showed endorsements to the ADON, but there were no signatures documenting destruction, and the facility could not locate the medications at the time of survey exit. Staff statements indicated the phenobarbital had been handled as non-controlled medication, despite being a controlled substance.
Food Items Not Dated, Labeled, or Properly Stored
Penalty
Summary
Food stored and served in the facility was not consistently dated, labeled, or kept in accordance with professional standards. Resident 103, who had diagnoses including PVD, CKD, and polyneuropathy, had intact cognition and was dependent on staff for toileting hygiene, showering, and dressing. During observation in the resident’s room, opened hot dog buns, bread rolls, and salad dressing were found on the bedside table without dates or labels. The resident stated she would allow staff to mark the dates on her food items, but staff had not done so. The ADON later observed the same items and stated they were open and not dated, and that if food items are not dated the resident would be at risk of getting an upset stomach. CNA 4 also stated the resident wanted to keep food at the bedside, the items were not dated, and there was no system in place to keep track of the food items. In the dry storage area, one unopened container of baking powder and one unopened container of peanut butter were found without labels and dates, and one open container of beef base had a delivery date of 2/26/2026 with no best-by date. In the walk-in refrigerator, two cabbages with discoloration and black markings on the edges were observed. The dietary aide stated the cabbage should be good and kept in the refrigerator for only 3 days and that giving expired food items to residents could result in food poisoning. Facility policies reviewed indicated staff would assist residents with safe storage of outside food, leftover or unused portions of packaged foods should be discarded, no food would be stored beyond 72 hours from the received date, and all items should be properly covered, dated, and labeled.
Failure to Maintain Contact Isolation Precautions
Penalty
Summary
Infection control practices were not maintained for a resident with contact isolation precautions for CRAB in sputum. The resident had diagnoses including need for assistance with personal care, generalized muscle weakness, tracheostomy, and gastrostomy, and the MDS indicated severely impaired cognition and dependence on staff for all attempted ADLs and mobility. The physician order and care plan directed staff to implement contact isolation precautions, and signage with PPE instructions was posted outside the room. During an observation outside the room, a CNA donned a gown and mask before entering, placed clean linens on the resident’s bed, and pulled the privacy curtain closed. The CNA then exited the room while still wearing the gown and put on gloves from the wall-mounted container outside the room without performing hand hygiene first. The CNA later re-entered the room. An RN stated it was not appropriate for the CNA to enter the room without gloves and that after touching surfaces in the room, the CNA should have removed PPE, performed hand hygiene, and then donned the correct PPE before re-entering. A second resident with CRE and severely impaired cognition and dependence on staff for all ADLs and mobility also had contact isolation precautions ordered and included in the care plan. A physician was observed at the bedside wearing only a mask, touching the resident directly without gown or gloves, pressing a stethoscope directly to the resident’s chest, and hanging the stethoscope around his neck after use. The physician then exited the room without performing hand hygiene or disinfecting the stethoscope and walked directly to the nurse’s station, where he removed a resident chart without cleaning his hands. The RN serving as infection preventionist stated no staff were exempt from contact isolation precautions and that the physician should have worn the required PPE, disinfected the stethoscope, and performed hand hygiene before touching other surfaces.
Inaccurate MDS Coding for Oxygen, Tracheostomy Care, and Vascular Wound
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for two residents. For one resident, the MDS dated 4/21/2026 did not reflect continuous oxygen therapy, intermittent suctioning, or tracheostomy care, even though the resident had diagnoses including tracheostomy and chronic respiratory failure with hypoxia. The resident’s face sheet showed admission and readmission to the facility, and the MDS indicated severe cognitive impairment and dependence on staff for all attempted activities of daily living and mobility. Record review and observations showed the resident was receiving oxygen through a T-piece at 5 L/min, and staff confirmed the resident was on continuous oxygen. A respiratory therapist stated the resident received suctioning as needed and tracheostomy care every shift and as needed. The MDS nurse also stated the resident had physician orders for continuous oxygen and was receiving tracheostomy care and intermittent suctioning, but the MDS did not accurately reflect those services. For another resident, the MDS Significant Change in Status Assessment dated 1/6/2026 did not accurately code Section M1030 for venous and arterial ulcers. The resident had diagnoses including left above-knee amputation, peripheral vascular disease, cerebral infarction, and sepsis, and wound care notes documented a vascular wound on the left anterior foot extending to the left great toe and second toe with gangrene. The MDS nurse stated the section should have been coded as 1 rather than 0 because the resident had one vascular wound classified by the wound specialist, and stated accurate MDS completion was important because it reflected the resident’s actual condition and the interventions provided by facility staff.
Failure to Implement Ordered Bed Safety Interventions
Penalty
Summary
The facility failed to provide a safe and hazard-free environment for three sampled residents when required safety interventions were not in place. Resident 76 had diagnoses including seizures, severely impaired cognition, and dependence on staff for all activities of daily living and mobility. His physician ordered upper half side rails while in bed, and his care plan for history of myoclonus indicated he was at risk for injury and that staff were to provide padded side rails. During observations on multiple occasions, he was seen lying in bed with side rails on both sides, but the rails were not padded. An LVN reviewed the care plan and confirmed that the resident was supposed to have padded side rails, and stated the padding was intended to prevent injury if he hit his head during a seizure. Resident 110 had diagnoses including anoxic brain damage, encephalopathy, and seizures, and her MDS indicated severely impaired cognition and dependence on staff for all attempted activities of daily living and mobility. Her physician ordered upper half side rails while in bed, and her seizure disorder care plan stated she was at risk for injury and that staff were to provide padded side rails. During several observations, she was seen lying in bed with side rails on both sides, but none of the rails were padded. An LVN reviewed the care plan and confirmed that padded side rails were required, and stated the resident needed padding on the side rails to protect her from injury. Resident 37 had diagnoses including seizures and contractures of both shoulders, and her MDS indicated she was rarely able to understand and be understood by others, had severely impaired cognition, and was dependent on staff for toileting, bathing, dressing, and personal hygiene. After she fell from her bed, the physician ordered floor mats to decrease potential injury. During a later observation in her room, she was lying in bed without floor mats on either side. The ADON stated the floor mats should have been present as ordered in case she fell so she would not land on the hard floor. The facility policy stated it was the facility's policy to strive to prevent accidents and provide adequate care plans with procedures to prevent accidents, and another policy stated staff would ensure interventions were implemented correctly and consistently.
Delayed Completion of Ordered Arterial and Venous Ultrasounds
Penalty
Summary
The facility failed to implement a physician order for arterial and venous ultrasounds in a timely manner for one resident. The resident was originally admitted and later readmitted to the facility and had diagnoses including left leg above-knee amputation, peripheral vascular disease, cerebral infarction, and sepsis. A physician order dated 12/16/2025 indicated the resident was to have arterial and venous ultrasounds completed on 12/17/2025, but the tests were not done on that date. During interview, RN3 stated the ultrasounds were not completed on 12/17/2025 and were instead completed on 12/18/2025, and that licensed nursing staff should have communicated to the physician that the tests were not done as ordered. The DON stated all physician orders, including ultrasound orders, should be completed in a timely manner and that there was no documentation in the resident’s progress notes showing a follow-up call to the ultrasound provider about why the ordered tests were not completed as scheduled. The resident’s MDS indicated severely impaired cognition and dependence on staff for several activities of daily living, and the H&P stated the resident did not have the capacity to understand and make decisions but could make decisions for activities of daily living.
Informed Consent for Restraint Use Not Obtained by Physician
Penalty
Summary
The facility failed to ensure the physician obtained informed consent for the use of hand mitten restraints for one resident. The resident had diagnoses including a gastrostomy and encephalopathy, and the H&P stated the resident did not have the capacity to understand or make decisions. The MDS indicated severe cognitive impairment and dependence on staff for all activities of daily living and mobility. A physician order dated 2/23/2026 directed staff to apply hand mitten restraints to both hands. The record titled Physical Restraint Informed Consent indicated the ADON verified that informed consent for the hand mitten restraints was obtained, but it did not show that the physician confirmed providing material information to the resident's RP. During interview, the ADON stated he contacted the RP to obtain consent and explained the risks and benefits of the restraints himself, while also stating the physician did not routinely obtain informed consent. The DON stated the physician was responsible for obtaining informed consent and the nurse's role was only to verify that the physician spoke with the RP and obtained consent. Facility policy stated restraints were only to be used after obtaining consent from the resident and/or RP, and the informed consent policy stated the attending physician was responsible for disclosing the risks of the proposed treatment or procedure.
Failure to Hold IDT or Bioethics Review Before Psychotropic Medications
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) meeting or a bioethics committee meeting was conducted before initiating psychotropic medications for a resident with Alzheimer's Disease and severe major neurocognitive disorder. Resident 2 was originally admitted and later readmitted to the facility, and records showed diagnoses of Alzheimer's Disease, bipolar disorder, and major depressive disorder. The history and physical dated 2/7/2026 stated the resident was unable to make decisions due to severe major neurocognitive disorder, and the MDS dated 2/11/2026 indicated cognition was severely impaired and the resident was dependent on staff for toileting hygiene, dressing, personal hygiene, and mobility. Physician orders showed Lexapro 20 mg by mouth in the evening was ordered for depression, and later Seroquel 50 mg by mouth at bedtime was ordered for bipolar disorder. During interview and record review, RN 5 stated the psychotherapeutic informed consents were obtained by the physician, but were not valid because the resident was unable to make decisions, and there were no prior IDT meetings to address the resident's psychotropic medication use. The SSD also stated the resident should have been placed under the care of the IDT or bioethics committee when the physician determined the resident lacked capacity, and confirmed there were no IDT or bioethics committee meetings prior to initiation of the psychotropic medications.
Call Light Not Within Reach
Penalty
Summary
Resident 73 had a call light that was not within reach during a concurrent observation and interview with the ADON. The call light was found on the floor to the left side of the bed, and the ADON stated it was on the wrong side of the bed because the resident had a left hand contracture. The ADON also stated the call light should have been on the right side of the bed so the resident could call for assistance or in an emergency. Resident 73’s record showed a history of epilepsy, stage 4 pressure ulcer, and intracerebral hemorrhage. The MDS dated 3/29/2026 indicated the resident was rarely able to understand and be understood, had severely impaired cognition, was dependent on staff for toileting hygiene, personal hygiene, and mobility, and was always incontinent. The care plan for altered elimination patterns related to bowel incontinence included an intervention to keep the call light within reach and encourage use for assistance, and the facility policy stated residents were to be provided a means to call staff for assistance through a communication system.
Personal belongings were not inventoried or documented
Penalty
Summary
The facility failed to ensure the belongings for one of five sampled residents, Resident 103, were inventoried and documented. Resident 103’s face sheet showed she was originally admitted to the facility and later readmitted. Her diagnoses included PVD, CKD, and polyneuropathy. The H&P dated 10/22/2025 indicated she had the capacity to understand and make decisions, and the MDS dated 4/28/2026 indicated her cognition was intact. The MDS also showed she was dependent on staff for toileting hygiene, showering, and dressing. During observation on 5/19/2026, Resident 103’s room contained an abundance of personal belongings. During interview, Resident 103 stated she had a lot of personal items in her room and did not recall the last time her items were inventoried. The SSD stated inventory was to be completed upon admission and during the resident’s stay, with an inventory log used to track belongings and their location. The DON stated staff were to document belongings when the resident received personal items or when family brought items in, but there was no documentation or tracking of Resident 103’s items. The facility policy titled Personal Property stated residents’ personal belongings and clothing were to be inventoried, documented upon admission, and updated as necessary.
Failure to Follow Restraint Policy and Monitor a Restrained Resident
Penalty
Summary
The facility failed to implement its policy and procedure titled Use of Restraints for one sampled resident with a gastrostomy and encephalopathy who had severe cognitive impairment, was dependent on staff for all activities of daily living and mobility, and had a physician order for hand mitten restraints to both hands. During observation, the resident was found lying in bed with hand mitten restraints on both hands and rolled pillows placed under the fitted bed sheet on both sides of the body. The Assistant Director of Nursing stated the facility used bolster restraints to prevent a resident from exiting the bed, that such restraints required informed consent and a physician order, and that the pillows under the fitted sheet mimicked bolster restraints and restricted the resident's movement. The ADON stated there should not have been anything under the fitted sheet to restrict movement, and the resident did not have orders for bolster restraints. The resident was also observed on multiple occasions with hand mitten restraints in place, but the facility could not locate documentation that the resident was assessed for skin and circulation while the restraints were used. The ADON stated the licensed nurse was to check the resident's skin and circulation every shift, and the DON stated the resident had been in hand mitten restraints since 12/2025 and that interventions to remove the restraints and assess skin and circulation were ordered later. The DON and ADON both stated they could not locate documentation showing those assessments were completed while the resident was restrained.
Failure to Send Transfer and Discharge Notice to Ombudsman
Penalty
Summary
The facility failed to ensure that a written Notice of Proposed Transfer and Discharge Form was sent to the local ombudsman for one resident, Resident 51, after the resident was transferred to a general acute care hospital. Resident 51 was originally admitted to the facility and later readmitted, and had diagnoses including DM, atherosclerosis, and HTN. The resident's H&P dated 1/6/2026 indicated fluctuating capacity to understand and make decisions, while the MDS dated 3/18/2026 indicated cognition was intact and that the resident required setup assistance with oral hygiene, toileting hygiene, and personal hygiene, and was independent with mobility. The resident experienced a change of condition with headache, redness of the cheeks, and swelling of the nose, and was transferred to the hospital on 12/28/2025. During interview and record review, RN 3 reviewed the Notice of Proposed Transfer and Discharge dated 12/28/2025 and stated there was no evidence of fax confirmation that the notice was sent to the ombudsman. RN 3 stated the notice should be completed within 24 hours of the transfer or discharge date and a copy should be sent to the resident or family representative and to the local ombudsman office. The facility policy titled Transfer or Discharge Notice stated a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice is provided to the resident and representative.
Failure to Develop Care Plan for PRN Melatonin Use
Penalty
Summary
The facility failed to ensure a care plan was developed for one resident who had an order for melatonin 5 mg at bedtime as needed for sleep aid. The resident’s Face Sheet showed an original admission and a readmission date, and the resident’s diagnoses included metabolic encephalopathy. The MDS dated 4/21/2026 indicated the resident’s cognition was severely impaired and that he was dependent on staff for all ADLs and mobility. During interview, the DON stated staff administered melatonin to assist the resident to sleep, but there were also non-pharmacological interventions that could have been attempted to aid sleep and that these interventions would be documented in a care plan. The DON stated the resident did not have a care plan for sleeping difficulties or melatonin use, but should have one, and that the care plan would ensure staff monitored the effectiveness of melatonin use and encouraged staff to attempt non-drug interventions. The facility policy on Care Plans, Comprehensive Person-Centered, stated a comprehensive, person-centered care plan that met the resident’s physical, psychosocial, and functional needs was to be developed and implemented for each resident.
Incomplete GI Referral Follow-Up
Penalty
Summary
The facility failed to ensure a physician order for a gastrointestinal referral was completed for one resident. The resident’s face sheet showed an original admission and a readmission to the facility, and the resident’s diagnoses included gastrostomy tube placement, anemia, and DM. The resident’s MDS dated 4/15/2026 indicated cognition was intact and that the resident was dependent on staff for toileting hygiene, upper and lower body dressing, and personal hygiene. A physician order dated 4/29/2026 directed follow-up on a gastrointestinal referral for possible colonoscopy for a rectal ulcer. During interview and record review on 5/20/2026, RN 4 stated the GI referral had not been completed and there was no scheduled GI appointment. RN 4 stated she had communicated the order to the social service department for insurance follow-up and scheduling. The SSD stated there was no documentation that social service staff requested insurance authorization for the GI referral, and the facility policy required residents to receive necessary care and services in accordance with the comprehensive assessment and plan of care.
Failure to Monitor Skin Change and Report Abnormal HR
Penalty
Summary
Resident 104 was not monitored for 72 hours after a change of condition involving a sudden onset generalized rash throughout the body. The resident’s face sheet listed diagnoses including COPD, osteoarthritis, and anemia. The H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated cognition was intact and that the resident required partial/moderate assistance with toileting hygiene, showering, and putting on footwear. The MDS also noted skin treatment applications for ointment medications. On 5/19/2026, Resident 104 was observed in the room with a scattered itchy skin rash. The change of condition record dated 5/14/2026 documented the sudden onset generalized rash and that the resident reported itching and discomfort. During interview and record review, the DON stated the protocol was for licensed staff to assess and monitor the resident’s skin every shift for 72 hours after the change of condition. The DON also stated there were no licensed nurse skin assessments for the rash on 5/16/2026 and that the 72-hour monitoring was not completed after the change of condition. Resident 120’s abnormal heart rate was not reported to the physician in a timely manner. The resident’s diagnoses included hypotension, heart disease, and anemia, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident was never able to understand or be understood by others, had severely impaired cognition, and was dependent on staff for all ADLs and mobility. The physician ordered Metoprolol Tartrate twice daily via G-tube and to hold the medication if SBP was less than 110 or HR was greater than 60. The MAR showed the medication was not given on 2/21/2026 at 5:00 p.m. because of the hold parameters, and a later nurse’s note documented a pulse of 38 at 4:43 p.m. The COC dated 2/22/2026 at 1:10 a.m. documented an HR of 36, at which time the physician was notified and ordered transfer to the nearest hospital emergency room. An LVN stated that an HR under 60 should be reported to the RN supervisor and the resident’s physician, but she did not find documentation that the HR of 38 was reported.
Failure to Carry Out Ordered Labs After Significant Weight Loss
Penalty
Summary
The facility failed to ensure interventions were carried out to prevent malnutrition for one sampled resident after a 39 lb. weight loss in one month. The resident had diagnoses including a gastrostomy and type 2 diabetes mellitus, and the Minimum Data Set indicated severe cognitive impairment and dependence on staff for all activities of daily living and mobility. A Change of Condition assessment dated 7/18/2025 documented the significant weight loss and noted that the physician was notified and ordered laboratory collection of prealbumin levels and a thyroid panel. During interview, the DON stated the thyroid panel was intended to identify thyroid hormone issues that could be causing the resident's weight loss and that prealbumin levels would identify malnutrition or protein needs. The DON stated the prealbumin levels were never drawn and the thyroid panel was not collected until 10/7/2025. The facility policy on Weight Assessment and Intervention indicated that care planning for significant weight changes was a multidisciplinary effort and that treatment options included obtaining laboratory studies.
Oxygen Therapy Given Without Humidification and Unclear Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was deficient for one resident with a tracheostomy and chronic respiratory failure with hypoxia. The resident’s MDS indicated severe cognitive impairment and total dependence on staff for activities of daily living and mobility. A physician order dated 1/15/2026 directed staff to administer oxygen by T-piece at 5 L/min every 6 hours. During observation on 5/19/2026, the resident was receiving oxygen through a T-piece, and the humidifier bottle was dated 5/17/2026 and was empty. RT 1 stated humidifying oxygen was intended to make oxygen administration more comfortable and to keep secretions loose and easier to cough up and/or suction, and that an empty humidifier bottle could irritate the airway. RT 2 reviewed the order and stated it should have been clarified because it was written in a way that could be misinterpreted; the facility policy stated oxygen at 3 L/min or more required a humidifier and physician orders had to be specific and complete.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to follow physician orders for oxygen administration for one sampled resident with COPD, osteoarthritis, and anemia. The resident’s H&P dated 2/18/2026 indicated the resident did not have the capacity to understand and make decisions, while the MDS dated 2/18/2026 indicated cognition was intact and that the resident received oxygen therapy. During an observation on 5/19/2026 at 10:45 a.m., the resident had a nasal cannula attached to the concentrator set at 5 liters, although the physician order dated 3/11/2026 directed oxygen therapy at 3 liters. The resident’s care plan, dated 3/31/2026, included an intervention to check the oxygen flow rate every shift. During a concurrent interview and record review on 5/20/2026, RN 6 reviewed the physician order and stated the oxygen should be set at 3 liters per the order. During a later observation the same day, the resident’s oxygen was set at 4.5 liters, and RN 6 stated the setting was incorrect and should be 3 liters. The facility policy titled Physician Orders and Telephone Orders required orders to be specific and complete and to be reviewed monthly for accuracy, completeness, and clarity.
Failure to Complete GI Referral Through Social Services
Penalty
Summary
The facility failed to ensure medically related social services were provided for a gastrointestinal referral for Resident 98. Resident 98 was originally admitted and later readmitted to the facility, and her diagnoses included gastrostomy tube placement, anemia, and DM. Her MDS dated 4/15/2026 indicated cognition was intact and that she was dependent on staff for toileting hygiene, upper and lower body dressing, and personal hygiene. A physician order dated 4/29/2026 directed follow-up on a GI referral for possible colonoscopy for a rectal ulcer. During a concurrent interview and record review on 5/20/2026, RN 4 stated the GI referral had not been completed and there was no scheduled GI appointment. RN 4 stated she had communicated the order to social services because they were responsible for insurance follow-up and scheduling. The SSD stated there was no documentation that social service staff requested insurance authorization for the GI referral and stated it was the responsibility of social service staff to refer residents needing outside referral services. Facility policy stated social services were responsible for making referrals, obtaining needed outside services, collaborating with nursing or other disciplines to arrange physician-ordered services, and documenting the referral in the medical record.
Medication Storage and Labeling Errors
Penalty
Summary
Hydrocortisone 1% cream was found on Resident 104’s bedside table during a concurrent observation and interview, even though the resident’s record indicated she could not administer topical medications. Resident 104’s face sheet listed diagnoses of COPD, osteoarthritis, and anemia, and her H&P stated she did not have the capacity to understand and make decisions. Her MDS indicated intact cognition, partial/moderate assistance with toileting hygiene, showering, and footwear, and skin treatment applications for ointment medications. The physician order directed hydrocortisone 1% cream to be applied topically every shift for pruritus, and the resident stated the cream had been given to her for itching. The treatment nurse stated the cream should not have been left on the bedside table and should have been stored in the medication cart so the resident would not have access to it. Resident 103’s amlodipine bubble pack had a pharmacy label that instructed to take 1 tablet by mouth via G-tube, while the physician order directed amlodipine 1 tablet via G-tube daily. Resident 103’s face sheet listed diagnoses of PVD and dysphagia, and a dietary evaluation indicated the G-tube had been discontinued. During interview, the DON stated Resident 103 did not have a G-tube in place and the label should have been specific to by mouth or via G-tube. The DON also stated the nurse failed to check the label for accuracy. The facility policy on administering medications stated the person administering the medication would check the label three times to verify the right route before giving the medication.
IV Dressing Documentation Did Not Match Site Care Record
Penalty
Summary
The facility failed to ensure that one sampled resident with a right upper arm peripheral IV had the IV dressing changed every 72 hours in a manner that matched the documentation on the MAR. Resident 9 was admitted and later readmitted to the facility and had diagnoses including osteomyelitis, osteoarthritis, and chronic kidney disease. The H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderately impaired cognition and dependence on staff for toileting hygiene, showering, and dressing. During observation, Resident 9’s right upper arm peripheral IV dressing was dated 5/13/2026. The physician orders and MAR both indicated peripheral site care was to be done every 72 hours, and the MAR documented site care on 5/14/2026 and 5/17/2026. The DON reviewed the picture and MAR and stated the dressing should have been dated 5/17/2026, that site care meant the IV dressing should be changed every 72 hours, and that the dressing was not changed as documented. The facility policy for Peripheral Catheter Dressing Change stated the licensed nurse was to remove the old dressing and label the peripheral site dressing with the date, time, and nurse’s initials.
Open and Overfilled Trash Dumpsters
Penalty
Summary
The facility failed to ensure that two of two trash dumpsters were closed and not overfilled. During a concurrent observation and interview on 5/19/2026 at 8:42 a.m. outside the facility, two dumpster lids were observed open and one dumpster was overfilled with trash. A Dietary Aide stated that the dumpster lids should be closed at all times and that open and overfilled dumpsters can attract rodents and insects and provide a place for them to harbor and go inside the facility. A review of the 2022 U.S. Food and Drug Administration Food Code, section 5-501.116, indicated outside receptacles must have tight-fitting lids or covers to prevent scattering of garbage or refuse by birds, breeding of flies, or entry of rodents. A review of the facility policy titled Waste Control and Disposal, undated, indicated outside garbage bins should be kept closed at all times and the surrounding area must be kept clean.
NPO Resident Incorrectly Served Meal and Incident Not Timely Reported or Documented
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards for a resident with a gastrostomy tube, tracheostomy, respiratory failure, dysphagia, and severely impaired cognitive status. The resident’s MDS indicated they were rarely able to be understood, sometimes able to understand others, and had severely impaired decision-making, with eating not attempted due to medical or safety concerns. The resident’s orders from 3/24/2026 through 4/21/2026 included aspiration precautions and Glucerna via GT, with no order for oral intake, and the nutritional assessment documented the resident as NPO with total nutrition via GT. The baseline care plan directed staff to provide diet and fluids as ordered and GT feeding and care as ordered. Despite these orders and assessments, a CNA mistakenly provided the resident with a breakfast tray intended for another resident, and the resident consumed bacon, toast, dry cereal, scrambled eggs, and thickened liquids. An LVN observed the resident eating and knew the resident was NPO and had no order for oral intake but did not notify the physician or document the incident in the medical record. An RN was also notified that the resident was eating while NPO and acknowledged that she should have notified the physician and documented the event but did not do so. The DON later confirmed that the incident was not documented in the medical record until eight days after it occurred and that the physician was not notified until seven days after the incident. Facility policies required that a written diet order appear in the medical record before a resident may be served and that changes in condition, events, incidents, or accidents be objectively, completely, and accurately documented to facilitate communication among the interdisciplinary team.
Failure to Provide Adequate Oral Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral hygiene to three out of five sampled residents who were dependent on staff for activities of daily living. Observations revealed that these residents had visible signs of poor oral care, such as thick, white secretions, white crusty discharges, and dry, cracked lips. Interviews with staff and residents confirmed that oral care was not consistently provided as required by the residents' care plans and facility policies. Resident 2, who had diagnoses including hemiplegia, hemiparesis, diabetes, and hypertension, was observed with thick, white secretions in the mouth and reported that nurses did not provide daily oral care. Resident 3, with severe cognitive impairment and similar physical limitations, was found with white crusty discharges on the lips, and staff acknowledged that oral care was difficult but still necessary. Resident 4, also dependent on staff and with severe cognitive impairment, was observed with dry, crusty mucus on the lips, and staff noted that moisturizer was not always applied as part of oral care. Record reviews for all three residents showed that their care plans required daily and every shift oral care, including the use of oral care kits with Chlorhexidine Gluconate, brushing teeth twice daily, and moisturizing the lips. Despite these documented interventions, the observed conditions and staff interviews indicated that these measures were not consistently implemented, resulting in poor oral hygiene for the affected residents.
Failure to Implement Therapy Recommendations and Reassess Mobility Needs
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for hand splints and to obtain physician orders for two residents with significant or developing hand contractures. One resident, who was non-ambulatory and dependent on staff for all activities of daily living, had severe loss of passive range of motion in both hands. Despite an OT evaluation recommending hand rolls for both hands to reduce pain and maintain joint mobility, the resident was not assessed for hand splints, and no physician order was obtained until after the surveyor's visit. Observations confirmed the resident's hands were contracted in a fist position, and the OT acknowledged that the absence of hand splints could worsen the contractures. Another resident with muscle weakness and a history of respiratory failure was also identified as being at risk for contracture development. The OT evaluation recommended resting hand splints for both hands, but the OT did not follow up to obtain a physician order, and the resident had not worn splints for over a month. The resident was observed with contracted fingers and reported not receiving restorative nursing assistance for finger exercises. The facility's policy required the therapist to order splints and ensure physician orders were in place, but this was not followed. Additionally, the facility did not implement its policy for screening and reassessment after a change in condition or readmission for another resident with a history of traumatic brain injury and severe contractures. After readmission, the resident was ordered to receive hand and knee splints, but the rehabilitation department did not formally assess the resident prior to resuming these services. When the resident was unable to tolerate the splints, no new recommendations were made, and the required reassessment was not completed. The facility's policy specified that a PT or OT should complete a joint mobility screening after readmission or a change in condition, but this was not done.
Failure to Timely Report Unexplained Fracture as Possible Abuse
Penalty
Summary
The facility failed to report a resident's right thumb fracture to the California Department of Public Health (CDPH) within the required two-hour timeframe, as mandated by federal regulations. The resident, who had a history of tracheostomy, gastrostomy, ventilator dependence, and dementia, was found to have redness and swelling on the right thumb, which was later confirmed by x-ray to be an acute nondisplaced fracture. The resident was highly dependent, unable to communicate, and lacked decision-making capacity. The injury was not witnessed by staff, and there was no explanation provided by the resident due to their condition. Despite the facility's policy requiring immediate reporting of suspected abuse or unexplained injuries, the Administrator, who also served as the abuse coordinator, did not report the incident to CDPH, citing the absence of hospitalization or surgical intervention. The Registered Nurse involved recognized that the injury could be a result of abuse or mishandling, as it was unexplained and severe. The facility also failed to send the results of the abuse investigation to the State Survey Agency, contrary to their own policies and regulatory requirements.
Failure to Ensure Complete IV Antibiotic Administration and Secure IV Site
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus did not receive intravenous (IV) antibiotic medication as ordered. The physician's order and care plan required the administration of Ertapenem Sodium 1 gram IV every 24 hours for a UTI, with the expectation that the IV site would be maintained and free of complications. However, during observation, it was found that the IV antibiotic bag, which should have been completely infused by 6:30 a.m., still had 40 cc remaining at 11:15 a.m., indicating the medication was not fully administered. The Assistant Director of Nursing confirmed that the medication should have been completely infused and that failure to do so would not treat the infection. Further observation revealed that the resident's saline lock needle tip was dislodged and lying on the skin, rather than being properly inserted into the vein. The registered nurse acknowledged that a patent saline lock should be in the vein to administer IV medications. Review of facility policy confirmed that nurses are required to monitor the IV site frequently for complications and ensure proper administration. These failures resulted in the resident not receiving the complete dose of antibiotic medication and the IV site not being securely maintained.
Failure to Administer Oxygen as Ordered
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), respiratory failure, urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus was admitted and readmitted to the facility. The resident's care plan specified the use of oxygen therapy, with a goal to remain free from adverse effects and interventions to provide oxygen as ordered, monitor oxygen saturation, and check the rate of oxygen flow every shift. The physician's order directed that oxygen be administered at 2 liters per minute (L/min) via nasal cannula, with titration up to 3 L/min if oxygen saturation fell below 92%. Despite these orders, observations on two separate occasions found the resident receiving oxygen at 3 L/min via nasal cannula, without documentation that the oxygen saturation was below 92% to warrant the increased flow. A registered nurse confirmed that the physician's order was for 2 L/min and acknowledged the risk of over-oxygenation. The facility's policy on medication reconciliation emphasized the importance of accurate medication dosages upon admission or readmission, but the resident was not administered oxygen according to the prescribed amount.
Incomplete and Inaccurate Documentation of Resident Services
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained complete and accurate documentation of services not received, as required by its own policy and procedure on charting and documentation. Specifically, a resident with a history of traumatic brain injury, tracheostomy, ventilator dependence, and gastrostomy had physician orders for Restorative Nursing Assistant (RNA) program interventions, including the application of bilateral resting hand splints and bilateral knee extension splints. Documentation indicated that the resident received and tolerated these splints for specified periods; however, interviews and record reviews revealed that the resident was unable to tolerate the splints during certain dates, and this was not accurately documented in the medical record. RNA staff acknowledged that they did not write progress notes to reflect the resident's inability to tolerate the splints, despite being aware of the issue and notifying the Director of Rehabilitative Services (DOR) during an RNA meeting. The DOR confirmed that documentation should have accurately reflected the services provided and the resident's tolerance, and that oversight of RNA services and documentation accuracy was their responsibility. The facility's policy required objective, complete, and accurate documentation of treatments and resident tolerance, which was not followed in this instance.
Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
The facility failed to complete the Physician Orders for Life-Sustaining Treatments (POLST) for one resident who was admitted with multiple serious medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was documented as lacking capacity to make decisions and was assessed as having severely impaired cognitive skills, being totally dependent on staff for daily care. Despite this, the resident's POLST form was found to be incomplete, with critical sections such as Cardiopulmonary Resuscitation, Medical Interventions, Artificially Administered Nutrition, and Information and Signatures left unchecked. The form was also not signed by the resident's legally recognized decision maker, but only by the provider. During interviews, staff confirmed that the POLST was incomplete and acknowledged that all sections should be filled out as it is a legal document reflecting the resident's care preferences in emergencies. The facility's policy required that the provider speak with the resident or their legal representative to ensure the POLST accurately reflected the resident's wishes before signing. However, this process was not followed, and the responsibility for ensuring the POLST was complete was not met by the social worker and licensed nursing staff, as stated by the Director of Nursing.
Failure to Document Resident Hospital Transfer
Penalty
Summary
The facility failed to document the transfer of a resident to a general acute care hospital in the resident's medical records. The resident, who had chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube, was noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities. The physician had placed a telephone order for the transfer, but there was no documentation by facility staff regarding the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. During a review, the Clinical Manager confirmed that the medical records were incomplete and not accurate, specifically lacking documentation of the transfer event. Facility policies required complete and accurate documentation of all services provided and any changes in the resident's condition, but these were not followed in this instance. The absence of documentation was identified through interviews and record reviews, highlighting a failure to maintain systematic and accessible medical records as per facility policy.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple pressure ulcers, despite the resident's complex medical history and high level of dependency. Upon admission, the resident was diagnosed with several stage 4 and unstageable pressure ulcers, a urinary tract infection, and had a gastrostomy tube in place. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily care activities. Although a baseline care plan was created at admission, no comprehensive care plan was developed more than two months later to address the resident's pressure ulcers. Interviews with facility staff confirmed that the comprehensive care plan, which should have been developed by the interdisciplinary team within 14 days of admission, was not completed. The Clinical Manager acknowledged the absence of a comprehensive care plan for the resident's wounds, and the Director of Nursing confirmed that the baseline care plan was only valid for 14 days. Facility policy required comprehensive care plans for skin alterations and pressure ulcers, with realistic, measurable goals and time frames for re-evaluation, but this was not followed in the resident's case.
Failure to Perform Weekly Pressure Ulcer Reassessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers and had severely impaired cognitive skills, was dependent on staff for all activities of daily living. The baseline care plan identified impaired skin integrity and required treatment as ordered, with monitoring for signs of infection. However, the weekly reassessment and documentation of the resident's pressure ulcers, including type, location, measurement, and description, were not completed as required. Specifically, the treatment nurse did not reassess or document the pressure ulcers on a scheduled weekly basis, as confirmed during an interview and record review. The facility's treatment nurse job description required maintaining and updating a pressure ulcer profile weekly, but did not specify reviewing and revising the care plan for accurate wound care guidance. Additionally, the facility's policy on pressure ulcers did not require scheduled weekly reassessment to determine progression. This lack of consistent and thorough reassessment and documentation increased the risk of the resident's pressure ulcers worsening or receiving inappropriate or delayed treatment, as the status and progression of the wounds were not adequately monitored.
Failure to Develop Comprehensive, Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident with significant care needs. The resident had multiple diagnoses, including a disorder of bone density, contractures at multiple sites, functional quadriplegia, and respiratory failure. Documentation showed the resident was totally dependent on staff for activities of daily living (ADLs) such as showering, dressing, oral hygiene, and personal hygiene, and lacked the capacity to understand or make decisions. Despite these needs, the care plan interventions were generic and did not specify critical details, such as the requirement for two-person assistance during care, nor did they provide measurable objectives or timetables tailored to the resident's condition. During interviews and record reviews, the DON acknowledged that the care plan was not person-centered and did not ensure the resident's needs were being met. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not reflected in the resident's care plan. The lack of specificity and individualized planning placed the resident at risk for injuries and unmet needs.
Failure to Provide Required Two-Person Assist During Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living (ADLs) due to conditions such as functional quadriplegia, contractures, and cognitive impairment, was not provided the required two-person assist during care. The resident's care plan specifically indicated the need for two-person assistance with transfers, repositioning, and daily care due to their high risk for falls and injuries, as well as their inability to participate in or understand care activities. Despite this, a Certified Nursing Assistant (CNA) reported performing the resident's ADL care alone, including cleaning and turning, without assistance from another staff member. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and acknowledged that failing to follow this intervention placed the resident at risk for further injuries. Facility policy emphasized the importance of safety, supervision, and targeted interventions to reduce individual risks, including communicating and assigning responsibility for specific interventions. The failure to provide the required two-person assist as outlined in the care plan and facility policy constituted the deficiency.
Infection Control and Food Safety Deficiencies
Penalty
Summary
The facility failed to implement its infection control program effectively, as evidenced by two key deficiencies. Firstly, a Laundry Aide (LA) was observed handling both dirty and clean linens without performing necessary hand hygiene or changing contaminated gloves and gown. This occurred after the LA sorted dirty linen and then proceeded to handle clean linen, which could lead to cross-contamination and infection. The Infection Prevention Nurse (IPN) confirmed that the LA should have changed her gown and gloves after handling the dirty linen to prevent the transfer of contaminants such as urine and feces to clean linen. The facility's policy and procedure on laundry processes also indicated that staff should wash hands after handling soiled linens to prevent cross-contamination. Secondly, the facility failed to refrigerate an opened food item as required, which involved a resident who had a bottle of strawberry jam on their bedside table. The label on the jam indicated it should be refrigerated after opening, but the facility did not have a refrigerator for storing residents' personal food items. A Licensed Vocational Nurse (LVN) observed the jam and acknowledged that not refrigerating it could lead to foodborne illnesses. The facility's policy discouraged food from outside sources due to food safety and infection control concerns. The resident involved had diagnoses including hyperlipidemia and hypertension, and was capable of understanding and making decisions, with no limitations to their extremities as per their assessment records.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of psychotropic medications to two residents. Resident 83 was administered lorazepam and sertraline without proper informed consent. The clinical records showed that lorazepam was given for anxiety over a period of 14 days, and sertraline was administered for depression. However, there was no documentation that Resident 83 or her responsible party received education regarding the risks and benefits of lorazepam before its administration. Informed consent for sertraline was obtained only after the medication had been initiated and subsequently discontinued. The Director of Nursing (DON) acknowledged the failure to obtain informed consent for Resident 83's medications, stating that this oversight increased the risk that the resident or her representative might not have been able to exercise their right to opt out of treatment. The facility's policy on psychotropic medications and informed consent requires that residents or their representatives be informed of the risks and alternatives before treatment, which was not adhered to in this case. Similarly, Resident 46 was prescribed duloxetine for peripheral neuropathy without documented informed consent. The resident's Minimum Data Set indicated the ability to express ideas and understand others, yet there was no consent form in the resident's chart. Both the RN and the Assistant Director of Nursing (ADON) confirmed the absence of informed consent documentation, which is required by the facility's policy before initiating treatment.
Failure to Ensure Windows Close Properly
Penalty
Summary
The facility failed to ensure that room windows were able to close properly in the rooms of three residents, resulting in the rooms being cold. During an initial tour, it was observed that the windows in the rooms of Residents 23, 55, and 102 were open and unable to be closed. Resident 102's window had a crack, and the windows in the rooms of Residents 23 and 55 were taped on three sides. Interviews with the residents revealed that they were aware of the issue and had to dress warmly to stay comfortable. Resident 102 reported the issue to a Certified Nursing Assistant, and a Maintenance Aide checked the window but was unable to fix it. The Maintenance Aide acknowledged the problem and stated that he had requested the windows to be replaced, but he was not qualified to do the replacement himself. The Administrator confirmed that a request for window replacement had been made and was awaiting a work order from the management company. The facility's policy on providing a homelike environment with comfortable temperatures was not adhered to, as the residents experienced cold conditions due to the inability to close the windows.
Deficiencies in Weight Monitoring and Blood Pressure Measurement
Penalty
Summary
The facility failed to ensure that a resident received weekly weight monitoring as ordered by the physician. The resident, who was admitted with conditions including hypotension, diabetes, and asthma, was dependent on staff for daily activities. The physician had ordered weekly weights for four weeks to manage the resident's weight, but the weights were only recorded on two occasions, missing the scheduled dates. This lack of monitoring meant that staff were unaware of any potential weight loss, which could have impacted the resident's health and dietary needs. Another deficiency involved the inaccurate measurement of orthostatic blood pressure for a resident with hypertension, muscle weakness, and bipolar disorder. The physician's order required monitoring for orthostatic hypotension, with specific instructions to notify the doctor if there was a significant drop in blood pressure readings between lying and sitting positions. However, the recorded blood pressures were identical for both positions, suggesting that the procedure was not followed correctly. The Director of Staff Development noted that the use of a manual blood pressure cuff might have led to rounding errors, preventing accurate assessment of the resident's condition. The facility's policies on weight assessment and blood pressure measurement were not adhered to, leading to these deficiencies. The policy required residents to be weighed at specified intervals and for blood pressure changes to be noted accurately. The failure to follow these procedures resulted in inadequate monitoring of the residents' health conditions, potentially delaying necessary interventions.
Improper Use of Pressure Relieving Devices
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set correctly for a resident with a Stage 4 pressure ulcer. The resident, who was small-framed and weighed less than 400 pounds, had a mattress set at 400 pounds, which was inappropriate for their weight. This incorrect setting could result in the mattress being too firm or too soft, thereby not promoting wound healing effectively. Interviews with the LVN, Wound Care Nurse, and DON confirmed that the incorrect setting would not be beneficial and could lead to slower healing or worsening of the pressure ulcer. Another deficiency was identified with a resident who was at risk for developing pressure injuries. The resident had a physician's order for Prevalon boots to offload pressure from the heels and prevent skin breakdown. However, during an observation, the resident was found without the boots, and the LVN present could not explain their intended use. The Director of Staff Development confirmed that the absence of the boots put the resident at risk for skin breakdown. These deficiencies highlight the facility's failure to adhere to care plans and physician orders, which are critical for managing and preventing pressure ulcers. The facility's policies on pressure injury prevention and wound care emphasize the importance of using appropriate supportive devices, yet these were not followed, placing residents at risk for further complications.
Deficiencies in ROM Care and RNA Services
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for six out of ten sampled residents. The deficiencies included not adhering to physician orders for the application and duration of splints, as well as failing to complete restorative nursing aide (RNA) treatments as prescribed. For instance, Resident 15 was observed wearing a right resting hand splint and a right elbow splint for longer than the physician-ordered four hours, which was confirmed by documentation showing the splints were applied for six hours on multiple occasions. Additionally, RNA treatments for Resident 15 were not completed on several specified dates. Resident 2 also did not receive RNA treatments as ordered, with documentation indicating missed sessions for PROM exercises and splint applications. Furthermore, Resident 2 did not receive timely annual Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint ROM, with the last assessments being significantly outdated. Similar issues were noted for Resident 8, who did not receive timely annual JMAs, and Resident 24, who had ankle splints applied without a physician's order. Resident 24 also missed annual OT JMS, which are crucial for tracking and comparing joint ROM to identify any decline. Residents 17 and 67 experienced similar deficiencies, with RNA treatments not being completed as ordered. Resident 17's documentation showed missed RNA services for the application of hand rolls and elbow splints, while Resident 67's RNA task form indicated inconsistent application of a right PRAFO. Interviews with staff, including the Director of Nursing and the Director of Rehabilitation, highlighted the importance of following physician orders and completing RNA treatments to prevent worsening contractures and maintain joint mobility. The facility's policies and procedures emphasized the need for timely and appropriate RNA services, which were not adhered to in these cases.
Inadequate RNA Staffing Leads to Potential Decline in Resident Care
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Aide (RNA) treatments. This deficiency was identified through observation, interviews, and record reviews, revealing that 81 residents with physician's orders for RNA services were at risk of experiencing a decline in range of motion, mobility, and activities of daily living function. The facility's staffing records for February and March 2025 showed inconsistencies in RNA staffing, with some days having no RNA staff available, leading to the reassignment of RNAs to Certified Nursing Assistant (CNA) duties. Interviews with RNA staff and the Director of Staff Development confirmed that RNAs were often reassigned to CNA duties due to a shortage of CNA staff, making it difficult for them to fulfill their RNA responsibilities. The Director of Nursing emphasized the importance of sufficient RNA staffing to ensure residents received their necessary treatments to prevent contractures and maintain joint mobility. The facility's policy on staffing indicated a commitment to providing sufficient nursing staff to meet residents' needs, but the observed staffing levels did not align with this policy.
Inadequate Competency in Assessing Orthostatic Hypotension
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVNs) possessed the necessary competencies to properly assess orthostatic hypotension in residents. During interviews, LVN 4 demonstrated a misunderstanding of the procedure by stating that if a resident's blood pressure in the lying position did not indicate hypotension, there was no need to take a sitting blood pressure reading. LVN 6 also showed a lack of understanding by indicating that blood pressure readings could be taken at the resident's convenience without a specific timeframe, contrary to the standard procedure. This misunderstanding of the procedure for assessing orthostatic hypotension could lead to a delay in care and services, potentially resulting in falls or injury to residents. The Director of Staff Development (DSD) clarified the correct procedure, which involves taking the resident's blood pressure in the lying position, then having the resident sit and waiting about five minutes before taking another reading. A change of 20 mmHg in the systolic or 10 mmHg in the diastolic value would indicate orthostatic hypotension, necessitating notification of the doctor for further orders. The facility's job description for LVNs requires them to ensure physicians' orders are followed and quality care is provided, highlighting the importance of proper training and understanding of procedures to prevent deficiencies in care.
Failure to Monitor Blood Pressure for Amlodipine Administration
Penalty
Summary
The facility failed to monitor the blood pressure of Resident 83 in relation to the administration of amlodipine, a medication used to treat high blood pressure, between March 23, 2024, and March 31, 2024. The resident's care plan, revised on March 27, 2024, indicated a risk for elevated blood pressure and required monitoring of pulse rate and blood pressure as ordered. Additionally, the care plan noted a risk of falls or injury related to antihypertensive medications, necessitating an assessment for possible adverse effects. Despite these directives, the Medication Administration Record (MAR) for March 2024 showed no documented blood pressure readings corresponding to the administration of amlodipine during the specified period. The Director of Nursing (DON) confirmed that the facility did not consistently document blood pressure readings in the MAR, which was necessary to adhere to the hold parameters specified in the physician's order for amlodipine. The facility's policy and procedure required obtaining and recording vital signs prior to medication administration, and the documentation of medication administration policy mandated the inclusion of specific medication parameters, such as blood pressure. The lack of documentation in the MAR made it impossible to determine if the medication was administered within the prescribed parameters, increasing the risk of adverse effects for the resident.
Failure to Appropriately Prescribe and Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was not prescribed Seroquel without an appropriate diagnosis. The resident was admitted with conditions such as hypotension, diabetes, and asthma, but there was no indication of a mental illness in their medical records. Despite this, an order was placed for Seroquel to be administered for psychosis, a diagnosis not supported by the resident's history or assessments. The facility's policy requires that psychotropic medications be prescribed only when necessary to treat a specific, documented condition, which was not adhered to in this case. Additionally, the facility did not adequately define and monitor behaviors related to the use of lorazepam for another resident. This resident, diagnosed with vascular dementia and anxiety, was prescribed lorazepam as needed for moderate anxiety. However, the facility failed to document or monitor the resident's behaviors during the administration of the medication, as required by their care plan and facility policy. The lack of monitoring meant that the effectiveness of the medication and the resident's response to it were not assessed. The Director of Nursing acknowledged the failure to monitor and define behaviors related to the use of lorazepam, which is crucial for assessing the medication's effectiveness and ensuring the resident's condition is adequately treated. The facility's policy emphasizes the importance of involving residents and their representatives in medication management and ensuring adequate monitoring for efficacy, which was not followed in these instances.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06% due to two medication errors out of 33 opportunities. The errors affected two residents during medication administration. Resident 4 was prescribed a cranberry supplement at 425 mg but was administered a 450 mg dose. This discrepancy was observed when the Licensed Vocational Nurse (LVN 4) prepared and administered the incorrect dosage by crushing the tablet and mixing it with applesauce for the resident to consume. The error was acknowledged by LVN 4, who admitted to not clarifying the order with the physician to adjust for the available product strength. Resident 83 was prescribed a liquid formulation of multivitamins but was given a crushed tablet form instead. LVN 4 prepared and administered the incorrect formulation by mixing the crushed tablet with applesauce. During an interview, LVN 4 admitted to mistakenly believing the tablet and liquid formulations were interchangeable, not realizing the differences in formulation and strength. The facility's policy and procedure for medication administration emphasize adherence to physician orders and proper medication labeling, which were not followed in these instances.
Failure to Conduct Ordered Thyroid Panel for Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct laboratory tests as ordered by the physician, which was necessary to monitor the resident's thyroid function due to the use of Seroquel, a medication for bipolar disorder. The resident's care plan indicated a risk for dehydration due to medication use, and the consultant pharmacist recommended a thyroid panel to assess thyroid function. However, the laboratory results showed that only a thyroid peroxidase and thyroglobulin antibody test was performed, rather than the complete thyroid panel that was ordered. During an interview, RN 2 confirmed that the thyroid panel was ordered but not conducted, and explained that the tests performed were not equivalent to a thyroid panel, which includes triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH). This oversight could prevent the physician from identifying potential thyroid issues in the resident. The facility's policy required staff to process and arrange for tests as ordered by the physician, but this was not followed in this instance.
Failure to Follow Soft and Bite-Size Diet Menu
Penalty
Summary
The facility failed to ensure that the standardized recipes for the lunch menu were followed, specifically for residents on a soft and bite-size diet. On March 18, 2025, eighteen residents who required a soft and bite-size diet received whole bread instead of bread cut into smaller pieces, as per their dietary needs. The facility's lunch menu did not include the texture-modified diet that was ordered for these residents, and the menu lacked a serving guide for the bread at each meal. This discrepancy was observed during a kitchen inspection and interviews with the dietary staff, who admitted that the menu was still following old standards and had not yet transitioned to the new IDDSI standards, which the physician diet orders were based on. The Registered Dietitians and the Speech and Language Therapist confirmed that the facility was in the process of transitioning to the new IDDSI menu, but the current menu did not reflect the updated diet orders. The facility's diet manual, dated 2020, did not include a description or plan for a soft and bite-size diet, leading to inconsistencies between the diet orders and the menu. The facility's policies indicated that menus should be prepared using standardized recipes and that diet orders should align with the approved diet manual, which was not the case. This failure had the potential to result in meal dissatisfaction, decreased nutritional intake, and increased choking risk for the affected residents.
Unsanitary Can Opener Blade in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation practices in the kitchen, as observed during a survey. A can opener blade was found to be dirty, with a dry brown sticky residue, and worn out, which could potentially harbor harmful bacteria. The Dietary Supervisor confirmed the presence of the residue and was unable to identify its nature, although they suggested it could be removed with washing. The supervisor also admitted to not knowing when the blade was last cleaned. The facility's policy and procedure on sanitizing equipment and surfaces, which was undated, required that all equipment, shelves, serving utensils, and surface areas be clean and in good condition. Additionally, the 2022 U.S. Food and Drug Administration Food Code specified that can opener blades should be kept sharp to prevent metal fragments from contaminating food and that can openers must be replaced if they become uncleanable. This deficiency had the potential to result in harmful bacteria growth and cross-contamination, affecting 47 out of 109 residents who received food from the facility.
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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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. John Of God Retirement | 0.6 mi | ★★★★★ | 34 | 0 |
| East Terrace Rehabilitation & Wellness Centre, Lp | 0.6 mi | ★★★★★ | 25 | 0 |
| St Andrews | 0.8 mi | ★★★★★ | 20 | 0 |
| Sunray Healthcare Center | 1.2 mi | — | 32 | 2 |
| The Rehabilitation Center On Pico | 1.2 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.