Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Westwood Post Acute Care during CMS and state inspections, most recent first.
Infection control and laundry monitoring deficiencies were identified in the LTC facility. A resident’s urinal containing urine was observed on the bedside table next to food, a DON confirmed this created a cross-contamination concern, and another resident’s NC was observed on the floor while the resident was dependent on oxygen and had COPD and CHF. The facility also documented 180-degree dryer temperatures for two dryers even though both thermometers were broken and showed below 40 degrees, and staff confirmed the log entries were not accurate.
Failure to maintain privacy during ADL care: A resident with stroke, DM, and HTN who was cognitively intact and dependent on staff for ADLs was observed receiving care with private parts visible from the hallway. CNA stated the bedside privacy curtain did not cover the foot side of the bed, and the DON stated the expectation was for the curtain to be fully closed with no body parts exposed.
Failure to Obtain Valid Consent for Psychotherapeutic Medications: The facility did not ensure valid consent was obtained before starting psychotherapeutic drugs for two residents. One resident had schizophrenia, MDD, anxiety, COPD, HF, and moderate cognitive impairment and was ordered haloperidol for hallucinations; the consent form was signed by the physician and two LPNs, but the resident’s signature area was marked unable to sign, and the RP said no consent call was received. Another resident had encephalopathy, schizophrenia, severe cognitive impairment, and could not make medical decisions; escitalopram was ordered for depression, and the consent form listed verbal consent with physician and two LPN signatures, while the DON stated consent should come from a family representative or bioethics committee when a resident cannot consent.
Cluttered Resident Room: A resident’s room was observed with multiple clothing items and a large stuffed doll left on the floor and nightstand, and the resident said she had asked staff for storage containers for months without results. The resident was cognitively intact and independent with ADLs, while the RNS and DON stated belongings should be stored in the closet or nightstand to maintain cleanliness, order, and a homelike environment.
Failure to inform residents of the grievance process and address complaints. Three cognitively intact residents reported concerns including fear of backlash for complaining, long waits for call light response, and difficulty accessing the bathroom with a WC. During the Residents Council Meeting, they stated they did not know what a grievance was and would have filed one if they had known the process. Staff gave conflicting answers about who served as the GO, and the facility policy identified the Admin as the Grievance Official responsible for overseeing grievances.
A resident’s black pouch containing seven credit cards was found in a locked medication cart drawer after discharge, and the pouch and cards were not documented as returned to the resident. The resident had moderate cognitive impairment, though the H&P stated the resident had capacity for medical decisions. RN, BM, DON, and SSD all stated the cards should have been returned at discharge, and the facility record lacked a discharge PIF or documentation that the resident was contacted after discharge.
Late MDS Transmission for Two Residents: The facility failed to transmit required MDS data to IQIES within the required timeframe for two residents. One resident with dementia, osteoarthritis, and HTN had a quarterly MDS submitted late, and another resident with pancreatic neoplasm, DM, and HTN had a discharge MDS completed and submitted late. The MDSN and DON both stated that MDS assessments are used for resident care, billing, and compliance, and must be submitted within 14 days of the due date.
A resident with encephalopathy, schizophrenia, severe cognitive impairment, and extensive ADL assistance needs had a PASRR Level I completed with “NO” responses for serious mental illness, suspected mental illness, and psychotropic medication for serious mental illness. The record also included psychiatrist notes identifying MDD and an order for escitalopram for depression, while the DON stated that inaccurate PASRR completion could lead to improper placement, denial of specialized services, and delayed medical care.
A resident with bipolar disorder, Parkinson's disease, and mild cognitive impairment had an inaccurate PASRR Level I screen that marked SMI as negative and did not indicate a Level II evaluation was required. The RNS and DON both stated bipolar disorder is a SMI and that the PASRR response should have been marked yes; the resident's MDS also showed the resident was cognitively intact and needed ADL assistance.
A resident with bipolar disorder, Parkinson's disease, and mild cognitive impairment did not have a baseline care plan developed after admission/readmission. The RNS stated the resident lacked a care plan for bipolar disorder, and the DON stated the baseline care plan should have been initiated within 48 hours to guide psychosocial and emotional care and meet the facility's P&P.
Failure to Carry Out Post-Surgical Follow-Up Orders: A resident admitted with a post-op surgical site infection/possible abscess had orders for continued IV Vancomycin, an orthopedic follow-up, and a cervical spine CT after antibiotics were completed. The resident reported telling staff about the surgeon follow-up, but the RNS confirmed the facility had not scheduled the ortho visit or CT, and the DON stated physician orders should be carried out right away.
Improper Labeling of Enteral Feeding and Hydration Bags: A resident with a gastrostomy tube, dysphagia, and CVA-related deficits had an enteral feeding bottle and hydration bag that were not clearly labeled with the date/time hung and the correct flow rate. During observation, the hydration bag lacked required labeling, and the feeding bottle had an illegible start time with a rate listed at 48 ml/hr while the feeding was infusing at 60 ml/hr. An LVN said she did not hang the supplies and could not explain the importance or risks of mislabeling, while the DON stated labeling is needed to track intake accurately.
Unlabeled medications were found in two med carts, including one orange oval pill in MC-E and three additional pills in MC-W. RN 1 stated the pills could not be identified or linked to a resident, and the DON confirmed that unlabeled tablets in the med cart were not the right practice and should have been disposed of. Facility policy required medications to be stored with pharmacy labels and to include the resident name, facility name, medication name, and strength.
Unlabeled Food in Resident Refrigerator: The facility failed to label and date food items in the resident refrigerator for 81 of 86 medically compromised residents who receive oral nutrition. Surveyors found a half-full bottle of kefir in the resident refrigerator with no name, room number, or date visible, despite posted instructions requiring labeling and removal after 48 hours. The DON stated nursing at that station was responsible for labeling and dating food items and could not confirm whether the item belonged to a resident or an employee.
A resident with quadriplegia, DM, and COPD was ordered RNA passive ROM for all 4 extremities 4 times weekly, but restorative records showed multiple blank days and inconsistent entries for provision or refusal of care. The resident said RNA helped maintain movement, while RNA staff and the DON stated that every session or refusal should be documented in PCC to validate the service was done.
A resident’s IV Vancomycin bag with an intact label containing PHI was found in the resident’s room trash can. The resident was cognitively intact and had diagnoses including infection following a procedure, spinal stenosis, and DM. An LVN, RNS, and DON all stated the label should have been removed before disposal because it contained the resident’s information and was not appropriate for trash disposal.
Staff did not include a known pattern of wound care refusal in a resident’s baseline care plan, despite multiple documented refusals of ordered treatment for a right shin venous stasis ulcer. The resident, with COPD, depression, and dementia but intact decision-making per MDS, told Social Services and nursing staff that he preferred to have his wound treated at a GACH and at times declined facility wound care. TARs showed repeated refusals, and interviews with an LVN, treatment nurse, RN supervisor, and ADON confirmed that the resident was known to refuse care and that care plans are expected to be resident-specific and cover all care needs, yet the baseline care plan did not address the behavior of refusing wound care.
A resident with hemiplegia, hemiparesis, DM2, and HTN, who had moderate cognitive impairment and required staff assistance with ADLs, requested transfer to a facility in another city to be closer to family. Over several months, the resident and responsible party reported not being informed about the transfer process, not receiving a list of potential facilities, and not being able to speak with the ADM, while also receiving conflicting explanations about why the transfer could not occur. The SS director acknowledged the family’s ongoing request and that at least one potential receiving facility would not accept the resident’s insurance, but the facility did not assist with necessary insurance changes or document timely referrals or transfer planning, despite a care plan that called for discussing placement options and reviewing insurance verification as needed, resulting in an unreasonable delay in the resident’s requested transfer.
Surveyors found expired tomatoes and undated wilted celery in the refrigerator, indicating that food items were not removed as required by facility policy. The dietary supervisor confirmed that all food should be labeled and disposed of after the use by date, but this procedure was not followed.
Surveyors identified deficiencies in the dietary department, including unclean kitchen equipment, improper storage of partially cooked food, and failure to label and date potentially hazardous foods. Staff did not consistently follow menus or recipes, and required annual competency evaluations and performance reviews for dietary staff were missing.
A bedbound, visually impaired resident with Alzheimer's disease did not have a call light within reach and was unaware of its purpose, as confirmed by staff interviews and observation. The call light was found out of reach, and staff acknowledged the importance of accessibility and education for newly admitted residents per facility policy.
A resident with a full-code POLST was found unresponsive and pulseless in a wheelchair on the patio. Instead of starting CPR immediately as required by AHA guidelines and facility policy, staff moved the resident to his room before initiating resuscitation. Multiple staff and a physician confirmed that CPR was not started at the scene, resulting in a delay before emergency measures began. Paramedics later pronounced the resident dead after unsuccessful resuscitation.
A resident with multiple medical conditions was discharged to an ALF without proper coordination or communication regarding their gastrostomy tube, medication supply, or home health services. The facility did not regularly re-evaluate the discharge plan, failed to involve the resident's representative in the process, and did not notify the receiving ALF of the resident's g-tube. As a result, the resident arrived at the ALF unprepared, lacking necessary medication and home health arrangements, and the ALF had to arrange for additional medical care post-discharge.
The facility did not develop a care plan for a resident with a gastrostomy tube, omitting necessary interventions and monitoring, and also failed to initiate a discharge care plan for another resident with cognitive and physical impairments. These omissions were confirmed by the DON and were not in accordance with facility policy.
A resident with Parkinson's disease, muscle weakness, and other physical impairments was unable to use the standard call light due to insufficient hand strength, leaving them unable to call staff for assistance. The issue was confirmed by a CNA, who noted the resident's inability to press the call light button and suggested a more accessible option.
A resident with multiple health conditions and severe cognitive impairment experienced a decline in a pressure ulcer after staff failed to timely implement a care plan intervention for a Low Air Loss (LAL) mattress, despite physician orders and facility policy requiring pressure reduction devices for residents at risk of skin breakdown.
A resident with severe cognitive impairment and multiple chronic conditions had incomplete and missing documentation of ADLs over several days. The DON confirmed that the lack of documentation was due to CNAs not having access to iPads, which had been stolen and not replaced, resulting in shared computer use and missed entries.
A medication error occurred when an LVN attempted to administer Empagliflozin (Jardiance) to a resident despite a physician's hold order and left the medication unattended at the bedside for a family member to give. The resident, who had diabetes and other chronic conditions, had the medication on hold per physician and family request, and the error was acknowledged by nursing staff as a failure to follow standard medication administration procedures.
Twelve residents requiring feeding assistance were labeled as 'feeders' by staff, who maintained a list with this term to assign care duties. Staff, including CNAs, LVNs, the DON, and the MDS coordinator, routinely used this terminology in both verbal and written communications, despite facility policy requiring respectful and dignified treatment. The residents affected had significant medical and cognitive needs, and the practice was acknowledged as standard among staff.
The facility did not ensure that advance directives were present and up-to-date in the clinical records for three residents with various medical conditions and cognitive statuses. During record reviews and interviews, an LVN confirmed the absence of these documents, which could cause confusion about residents' healthcare wishes in emergencies, contrary to facility policy.
An independent liaison, not affiliated with the facility or hospice, accessed and retained a resident's medical records without consent or proper authorization. The liaison did not meet with the resident or obtain consent, and used information from the records to arrange a discharge to hospice care. The resident had a terminal prognosis and intact decision-making capacity. Facility policy required limiting access to PHI, but this was not followed, resulting in a HIPAA violation.
A resident with diabetes, hyperlipidemia, stroke history, and hypertension was found to be cognitively intact but unaware of the reason for her insulin therapy. Review of her medical record showed no documentation that DM education was provided, despite facility policy requiring such documentation after new diagnoses. Both the RN Supervisor and DON confirmed the absence of required education documentation.
A resident with multiple medical conditions was found with topical medications and powder at the bedside, despite not being approved for self-administration according to facility assessment and policy. An LVN confirmed that medications should not be left at the bedside for residents not cleared for self-administration, and the DON stated that proper assessment and physician orders are required before allowing self-administration.
A resident did not have access to hot water for personal hygiene, and the cold water faucet in their room splashed water onto the resident and the floor. The TV was loose and tilted, and the window blinds were broken and improperly attached, creating an unsafe and uncomfortable environment. Facility staff confirmed these issues and identified the need for repairs.
A resident with a history of stroke, generalized weakness, diabetes, cognitive impairment, and dependence on staff for daily living did not have a baseline care plan developed as required by facility policy. The absence of this care plan, particularly for gastrostomy tube management, was confirmed by interviews with nursing leadership and was identified during record review.
A resident with cognitive impairment and multiple hospitalizations for g-tube dislodgement did not have an IDT meeting conducted as required by facility policy. Despite repeated changes in condition, there was no documentation that the resident or their representative were involved in care planning or decision-making, as confirmed by interviews with the ADON and DON.
A resident's room was found to have a loose, tilting TV and broken, bent blinds that were not properly attached, creating potential accident hazards. The resident, who was cognitively intact and independent, reported these issues, which were confirmed by observation and staff interviews. Facility policy requires rooms to be safe and well-maintained, but these hazards were not addressed at the time of the survey.
A resident with cognitive impairment and multiple medical conditions did not receive prescribed enteral nutrition when the feeding tube connection device was found on the floor and not attached to the gastrostomy tube, despite the feeding pump running. An LVN confirmed the improper connection, and the DON noted this could result in the resident not receiving necessary nutrition, contrary to facility policy.
A resident's protected health information was accessed and retained by an independent liaison who was not affiliated with the facility or hospice company. The liaison obtained the resident's medical records without consent and used the information to arrange a discharge to home hospice, without confirming the resident's wishes or involving the family in advance. Facility leadership confirmed the liaison was not authorized to access or use the resident's records, resulting in a violation of HIPAA privacy standards.
Two residents were not offered or administered the pneumococcal vaccine at admission as required by facility policy, and there was no documentation of consent or declination forms until a later date. This occurred despite both residents being cognitively intact and the facility's stated process for screening and documenting vaccination status.
Two residents were not properly offered or documented for COVID-19 vaccination as required by facility policy. Both residents, who were cognitively intact and had multiple medical conditions, lacked evidence of a consent or declination form for the vaccine in their records, despite the facility's process requiring this documentation upon admission.
A resident with type 1 diabetes did not receive insulin as ordered when blood sugar was critically high, and staff failed to consistently monitor and document blood sugar levels before administering insulin. Insulin was sometimes given without a current blood sugar reading, and required physician notifications for abnormal results were missed. These actions and omissions resulted in inadequate diabetic management and confusion among staff regarding appropriate interventions.
The facility failed to ensure staff were seated while feeding two residents, compromising their dignity and comfort. Observations showed CNAs standing over residents with severe cognitive impairments, contrary to facility policy. Interviews confirmed staff awareness of the requirement to sit, but one CNA cited a lack of available chairs as a reason for standing.
A resident with atrial fibrillation, muscle weakness, and polyneuropathy experienced delays in having their call light answered, despite the facility's policy requiring prompt responses. The resident reported that staff sometimes turned off call lights without returning to assist. During an observation, the call light remained on for over 10 minutes while staff were present in the hallway and nursing station, and an alarm was sounding. A nurse confirmed the expectation for prompt responses but could not explain the delay.
A resident with hemiplegia and CHF experienced a fall resulting in a forehead bump and headache. The facility failed to develop a comprehensive care plan with goals and interventions following the incident, as required by their Fall Management Program policy. This deficiency was confirmed by the Medical Record Director during a record review and interview.
A resident with a history of hemiplegia and CHF was found unresponsive and pronounced dead by paramedics. The facility failed to follow its policy requiring a physician's declaration of death and proper documentation, resulting in missing progress notes and a death certificate in the resident's medical records.
The facility failed to provide adequate respiratory care for two residents by not ensuring a physician's order for oxygen therapy and not changing nasal cannula tubing and humidifiers as per policy. One resident was using an oxygen concentrator without a physician's order, and both residents had unlabeled and unchanged equipment, contrary to facility policy.
Two residents experienced misappropriation of belongings due to the facility's failure to follow its theft and loss policy. One resident lost clothes after a scabies outbreak, and another lost clothes and neck pillows, with no inventory or labeling in place. Staff interviews confirmed the lack of initiated reports and adherence to procedures.
A resident with a history of falls and assessed as high risk was left unattended in a wheelchair, resulting in an unwitnessed fall and a laceration requiring sutures. Staff interviews revealed that both the charge nurse and a CNA were on break or attending to personal tasks at the time, and the facility's fall management policy requiring frequent observation was not followed.
The facility failed to implement effective infection control measures, leading to potential infection spread among residents. Three residents with severe cognitive impairments were not assessed for skin rashes, placed on contact precautions, or had their physicians notified about ineffective treatments. Observations revealed red, raised, scaly rashes and burrowing, indicating possible scabies. The facility's infection control policy was not followed, contributing to the deficiency.
Infection Control and Laundry Temperature Monitoring Deficiencies
Penalty
Summary
Standard precautions were not implemented during care for one sampled resident. Resident 96 was admitted with diagnoses including traumatic subarachnoid hemorrhage, fracture of the base of skull, type 2 diabetes mellitus, hypertension, hyperlipidemia, muscle weakness, and a history of falling. A review of the resident’s history and physical dated 6/14/2026 indicated the resident had the capacity for medical decision making. During a facility tour on 6/15/2026 at 9:03 a.m., a urinal containing 500 milliliters of urine-like liquid was observed on Resident 96’s bedside table next to the resident’s fast food from El [NAME] loco. During an interview on 6/15/2026 at 9:08 a.m., LVN 2 stated the urinal had urine and should not be placed next to the resident’s food because of potential exposure to infection from harmful microorganisms. During an interview on 6/18/2026 at 5:45 p.m., the DON stated that placing the urinal by the resident’s food puts the resident at risk for possible cross contamination and infection. The facility’s Infection Control-Policies & Procedures dated 6/10/2026 stated the policies and procedures are intended to maintain a safe, sanitary, and comfortable environment and help prevent transmission of diseases and infections. The facility also failed to check the temperatures for Dryer 1 and Dryer 2 to ensure they were at 180 degrees according to the Laundry - Sorting, Washing & Drying policy. During a concurrent observation and interview on 6/16/2026 at 12:24 p.m., the manufacturer thermometers for both dryers indicated below 40 degrees Fahrenheit, and the Maintenance Supervisor confirmed both dryer thermometers were broken and did not know when they broke. The June 2026 laundry temperature log documented handwritten entries of 180 degrees every hour from 6 a.m. to 8 p.m. for both dryers from 6/1/2026 through 6/14/2026, and the Maintenance Supervisor, Laundry Staff, and Laundry Technician confirmed those entries were not correct because the thermometers showed below 40 degrees Fahrenheit. The facility’s policy stated the machine is set for the correct temperature and drying time for the load, and the manufacturer manual stated medium setting is 180 degrees Fahrenheit. Resident 82, who was admitted with COPD and CHF and had moderate cognitive impairment, was dependent on supplemental oxygen and required staff assistance with multiple ADLs. During an observation on 06/16/2026 from 8:43 a.m. to 8:55 a.m., Resident 82’s nasal cannula was observed on the floor in the resident’s room. LVN 3 stated that a nasal cannula on the floor can be an infection issue. The resident’s care plan indicated the resident was dependent on supplemental oxygen and that oxygen equipment should be properly functioning, secure, and positioned correctly.
Failure to Maintain Privacy During ADL Care
Penalty
Summary
The facility failed to ensure staff completely closed the bedside privacy/dignity curtain during ADL care for Resident 41, resulting in the resident's private parts being visible from the hallway. Resident 41 was admitted on 11/4/2025 with diagnoses including stroke, DM, and HTN, and the MDS dated 5/30/2026 indicated the resident was cognitively intact and dependent on staff for ADL care. During an observation on 6/15/2026 at 9:16 A.M., CNA 1 was providing ADL care in Resident 41's room and the resident's private parts were exposed and visible from the hallway. The privacy/dignity curtain at the foot of the bed was missing. CNA 1 stated the curtain only covered alongside the bed and did not cover the foot side of the bed, and that there should be a curtain covering along the foot side to provide privacy. The DON stated the facility expectation was to keep the privacy/dignity curtain closed all the way so no part of the resident's body was exposed, and that the curtains should provide full coverage from wall to wall.
Failure to Obtain Valid Consent for Psychotherapeutic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties had the ability to consent to psychotherapeutic medication treatment before the medications were started for two sampled residents. The report states that Resident 7 had diagnoses including major depressive disorder, schizophrenia, anxiety disorder, COPD, heart failure, anemia, difficulty walking, and repeated falls. Resident 7’s H&P indicated the resident had capacity to make medical decisions, while the MDS later showed moderate cognitive impairment and substantial to maximal assistance needs for multiple activities of daily living. For Resident 7, the physician order summary showed an order for haloperidol oral tablet 10 mg twice daily for schizoaffective disorder with visual hallucinations and seeing bugs crawling on the body. The psychotherapeutic drug informed consent form showed physician consent for haloperidol and signatures from two licensed nurses, but the resident’s name and signature section was handwritten as unable to sign. During telephone interview, the resident’s RP stated that the facility had never called to request consent authorization because the resident was unable to give consent. For Resident 9, the admission record listed diagnoses including encephalopathy, type 2 diabetes, difficulty walking, schizophrenia, polymyalgia rheumatica, COPD, and muscle weakness. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS showed severely impaired cognition with assistance needed for several ADLs. The physician order summary showed escitalopram oxalate 5 mg daily for depression, and the informed consent form indicated physician consent with two licensed nurses’ signatures, while the resident’s name and signature section was handwritten as verbal consent. The DON stated that if a resident is unable to sign, consent can be obtained from a family representative, and if a resident is self-responsible with no family representative or POA, the facility would form a bioethics committee. The facility policy stated that the attending physician determines capacity and that if the resident lacks capacity, a surrogate decision-maker is identified.
Cluttered Resident Room
Penalty
Summary
The facility failed to ensure Resident 88’s room was maintained in a safe, clean, comfortable, and homelike condition. During observation on 6/15/2026, Resident 88’s room floor was cluttered with multiple clothing items and a large stuffed mouse doll approximately 3 feet tall was observed on the floor and on the nightstand. Resident 88 stated that she had asked multiple facility staff for containers to store her belongings that were on the floor by her bedside for months, but nothing had happened. Resident 88 was admitted on 11/28/2023 with diagnoses including epilepsy, atrial fibrillation, and a femur fracture. Her MDS dated 3/3/2026 indicated she was cognitively intact and independent with ADLs. During interview and record review, the RNS stated the resident’s clothing and items should be in the closet or nightstand and not left on the floor or cluttered. The DON stated resident belongings needed to be stored in the closet, not on the floor, for infection control and to maintain a homelike environment. The facility’s policy stated residents are to be provided a safe, clean, comfortable, and homelike environment, with attention to cleanliness and order.
Failure to Inform Residents of Grievance Process and Resolve Complaints
Penalty
Summary
The facility failed to implement its policy and procedures titled, Grievances and Complaints, for three of eight sampled residents. The policy identified the Administrator as the Grievance Official responsible for overseeing the grievance process, receiving and tracking grievances through conclusion, maintaining confidentiality as needed, and ensuring written grievance decisions are provided upon request. It also stated that residents, family members, representatives, and appointed advocates may file grievances without fear of threat or reprisal, and that staff who hear a grievance should advise the resident of the process and assist with filing a written complaint. Resident 72 was admitted with diagnoses including hemiplegia, diabetes, and ESRD, and was cognitively intact on the MDS. During interview, the resident stated, "I am scared of backlash if I make a complaint." Resident 74, admitted with diagnoses including fracture of vertebrae, depression, and hypertension and also cognitively intact, stated during interview, "I have waited all day for staff to answer the call light, sometimes for hours." Resident 78, admitted with diagnoses including fracture of right femur, polyneuropathy, and depression and cognitively intact, stated, "I have difficulty moving in and out of the bathroom with my wheelchair. I told a couple of nurses ... and they didn't offer to change the room." During the Residents Council Meeting, Residents 72, 74, and 78 stated they did not know what a grievance was and would have filed a grievance if they had known the grievance process, and said this was frustrating. Interviews with the ADON, RNS, SSD, and Admin showed conflicting understanding of who served as the facility's Grievance Officer, with staff identifying both the SSD and the Admin. The Admin stated the SSD was the GO, while the SSD stated the Admin was the GO. The report also noted the Social Service Coordinator job description included assisting with the grievance protocol.
Resident Credit Cards Stored in Medication Cart and Not Returned at Discharge
Penalty
Summary
The facility failed to ensure staff did not store a black pouch containing seven credit cards in a locked drawer of Medication Cart MC-W for one resident, and failed to return the pouch and credit cards to the resident upon discharge. Resident 105 was admitted with diagnoses including essential hypertension and depression, and the record showed moderate cognitive impairment on the MDS. The physician’s H&P stated the resident had the capacity to make medical decisions. The admission Personal Effects Inventory Form documented zero belongings and valuables, and there was no documented evidence that a discharge PIF was reviewed and signed when the resident left the facility. During a concurrent observation and interview, an RN found the black pouch with the seven credit cards in the locked medication cart drawer. The RN, BM, DON, and SSD each stated that the facility should have returned the credit cards to the resident at discharge and that credit cards do not belong in the medication cart. The DON also stated that all charge nurses had access to the locked drawer, and the SSD stated there was no documentation that the facility contacted the resident after discharge. The facility policy on admission and discharge personal property stated that money and other valuables should be taken to the business office for safekeeping and that if belongings are not taken at discharge, Social Services or designee will contact the resident or representative.
Late MDS Transmission for Two Residents
Penalty
Summary
The facility failed to ensure that resident-specific assessment information for payment and quality measures was electronically transmitted to IQIES/ASAP within the required timeframe for two sampled residents. Resident 17 was admitted on 10/29/2025 with diagnoses including dementia, osteoarthritis, and HTN, and a later MDS showed the resident was cognitively impaired and dependent on staff for ADL care. Resident 87 was admitted on 1/8/2026, readmitted on 2/6/2026, and discharged on 2/11/2026; diagnoses included neoplasm of the head of pancreas, DM, and HTN, and the MDS indicated the resident was cognitively intact and dependent on staff for ADL care. During a concurrent interview and record review, the MDSN stated that MDS assessments are completed on admission, quarterly, annually, and with significant changes in condition, and then submitted in IQIES within 14 days of completion. The MDSN stated that Resident 17’s quarterly assessment was due for submission on 6/9/2026 but was not submitted until 6/16/2026. The MDSN also stated that Resident 87 required a discharge MDS on 2/11/2026, but the discharge MDS was completed and submitted on 3/3/2026. The DON stated that MDS assessments are used to guide resident care and for billing purposes, and that they need to be submitted within 14 days of their due date. The facility’s RAI process policy stated that MDS assessments are to be transmitted according to the facility’s assessment reporting schedules, and the CMS RAI Manual stated that required MDS data records must be transmitted to IQIES, with completion no later than 14 days after the ARD for non-admission OBRA and PPS assessments.
Inaccurate PASRR Screening for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that Resident 9’s PASRR Level I screening was accurately completed to determine the facility’s ability to provide the necessary care and appropriate services for the resident. Resident 9 was admitted and re-admitted to the facility with diagnoses including encephalopathy, difficulty walking, COPD, type 2 diabetes, schizophrenia, polymyalgia rheumatica, and muscle weakness. The record also showed that Resident 9 could make needs known but could not make medical decisions, and the MDS indicated severely impaired cognition and assistance needs with eating, oral hygiene, toileting hygiene, dressing, bathing, and personal hygiene. The PASRR dated 5/4/26 documented “NO” for serious mental illness, suspected mental illness, and psychotropic medication for serious mental illness. However, psychiatrist notes dated 6/10/2026 identified a diagnosis of major depressive disorder, and the resident had an order for escitalopram for depression manifested by verbalization of worriedness about the health condition and fear of worsening health. During interview, the DON stated that failing to accurately complete a Level I PASRR could result in inaccurate assessment and recommendations, improper placement, denial of necessary specialized services, and delayed medical care. The facility policy stated that a PASRR would be completed and placed in the resident’s medical record, and the RN job description included accurately recording resident assessments in the medical record.
Inaccurate PASRR Level I Screening for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a PASRR Level I assessment was accurately completed for one sampled resident with a mental disorder. Resident 2 was admitted to the facility with diagnoses including bipolar disorder, Parkinson's disease, and mild cognitive impairment of unknown etiology. The resident's MDS dated 3/29/2026 indicated the resident was cognitively intact and required staff assistance with ADLs. A review of Resident 2's PASRR Level I dated 5/17/2025 showed the assessment was negative for SMI and indicated that a Level II mental health evaluation was not required. During interview and record review, the RNS stated that bipolar disorder is a serious mental illness and that the Level I response of "No" to question 9 was inaccurate. The DON also stated that bipolar disorder is definitely a SMI and that the answer to question 9 should have been "Yes." The facility's policy stated that PASRR Level I must be completed for each resident prior to admission and that the MDS Coordinator is responsible for ensuring PASRR updates are completed per MDS guidelines.
Failure to Develop Baseline Care Plan for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to develop a baseline care plan for Resident 2 in accordance with its Person-Centered Care Planning policy. Resident 2 was admitted on 5/3/2019 and readmitted on 4/30/2026 with diagnoses including bipolar disorder, Parkinson's disease, and mild cognitive impairment of unknown etiology. The MDS dated [DATE] indicated the resident was cognitively intact and required staff assistance with ADLs. During a concurrent interview and record review on 6/18/2026, the RNS stated that Resident 2 had a diagnosis of bipolar disorder but did not have a care plan for it, and stated that the resident should have had a baseline care plan initiated within three days of admission. The DON stated that a baseline care plan should be initiated within 48 hours of admission and that Resident 2 should have had a care plan for bipolar disorder so staff would know how to manage the resident's psychosocial and emotional care. The facility's policy stated that the baseline care plan must be developed and implemented within 48 hours of admission and include minimum healthcare information necessary to properly care for each resident immediately upon admission.
Failure to Carry Out Post-Surgical Follow-Up Orders
Penalty
Summary
The facility failed to ensure that physician orders were carried out for one resident who was admitted with diagnoses including infection following a procedure, spinal stenosis, and DM. The resident’s H&P documented a post-operative surgical site infection/possible abscess and an order to continue Vancomycin 1 gram IV every 12 hours for the post-operative wound infection. The discharge instructions also directed staff to schedule a cervical spine CT after completion of antibiotics, and a physician order dated 6/1/2026 directed orthopedic follow-up. During interview and record review, the resident stated that he had spoken to multiple facility staff about following up with the surgeon, but nothing had been done. The RNS reviewed the resident’s hospital records and physician orders and stated that the facility had not scheduled the orthopedic follow-up or the CT scan after the antibiotics were completed. The DON stated that physician orders should be carried out right away once received, and that the orthopedic follow-up and CT scan were important parts of the resident’s post-surgical care.
Improper Labeling of Enteral Feeding and Hydration Bags
Penalty
Summary
For one of two sampled residents, the facility failed to clearly label Resident 95’s enteral feeding bottle with the date and time staff started or hung the feeding, and failed to label the hydration infusion bag with the flow rate and the date and time it was started or hung. During a facility tour observation on 6/15/2026 at 8:17am, Resident 95’s enteral hydration bag was not labeled to indicate the date or time it was hung or the flow rate. The enteral feeding formula bottle label start time was illegible, and the infusion rate on the bottle was listed as 48 ml/hr while the feeding was infusing at 60 ml/hr into the resident. Resident 95 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, dysphagia following cerebral infarction, COPD, cognitive communication deficit, hypertension, gastrostomy status, history of mental and behavioral disorders, and hyperlipidemia. The resident’s H&P dated 6/12/2026 stated that Resident 95 was non-verbal and lacked capacity for medical decision making due to CVA. The order listing report dated 6/18/2026 showed enteral feed orders for continuous water flush at 40 cc/hr x 20 hours and enteral feed at 60 ml/hr x 20 hours. During interview, the LVN stated she did not hang the hydration or enteral feeding formula and was unable to state the importance and risks of failing to or mislabeling them. The DON stated that labeling hydration and enteral feeding formulas is important to ensure the resident’s consumption is accurately tracked and documented based on the ordered rate and time.
Unlabeled Medications Found in Medication Carts
Penalty
Summary
The facility failed to follow its Medication Storage in the Facility and Medication ordering and receiving from pharmacy policies for two medication carts, MC-E and MC-W, by leaving unlabeled medications in the carts. During observation and interview with RN 1 in the hallway, one drawer in MC-E contained an unlabeled orange oval-shaped pill. RN 1 stated it was difficult to tell what the pill was or which resident it belonged to, and said it was not acceptable because it did not have the resident name, medication name, or dosage and should have been discarded in the appropriate bin. During a separate observation and interview with RN 1, three additional unlabeled pills were found in a drawer of MC-W: a pink oval-shaped pill, a small yellow round pill, and a yellow capsule. RN 1 stated the facility should ensure all medications in medication carts are labeled appropriately and that anything could happen due to the unlabeled pills. The DON later stated it was not the right practice to have unlabeled tablets in the med cart and that they should have been disposed of. The facility policy stated medications dispensed by the pharmacy are to be stored in containers with pharmacy labels and that medications must be labeled with the resident's name, facility name, medication name, and strength.
Unlabeled Food in Resident Refrigerator
Penalty
Summary
The facility failed to label and date food items in the resident refrigerator for 81 of 86 medically compromised residents who receive nutrition orally in the facility, as required by the facility's policy and procedures titled Food brought in by Visitors dated 05/22/2025. During an observation on 06/15/2026 at 9:15 AM at the [NAME] Nursing Station, the resident refrigerator contained a half-full bottle of kefir lying on its side on the middle rack, and no labeling, date, or room number was visible on the bottle. A sign posted on the refrigerator door stated that the refrigerator was for resident use only, that items should be labeled with name, room number, and date, and that all items would be removed after 48 hours. The refrigerator also had a posted policy stating that the nursing home is responsible for labeling and discarding items within 48 hours. During interview on 06/16/2026 at 11:29 AM, the DON stated that nursing at the station where the resident refrigerator is located is responsible for labeling and dating food items, and could not confirm whether the unlabeled food item belonged to a resident or an employee. The facility policy reviewed during the investigation stated that food should be clearly labeled with the resident's name and date received and discarded after 48 hours if not consumed.
Incomplete Documentation of Restorative Nursing ROM Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Session (RNS) services were performed according to physician orders and the facility’s Resident Restorative Nursing Program Guidelines for one resident. The resident was admitted with diagnoses including quadriplegia, DM, and COPD, and the MDS indicated the resident was cognitively intact and dependent on staff for ADL care. The physician orders dated 1/27/2026 directed RNA program passive ROM exercises for the left lower extremity, right lower extremity, left upper extremity, and right upper extremity four times a week as tolerated. During interview, the resident stated he was unable to get out of bed, had limited mobility, and received RNA to help maintain movement and prevent further decline. Review of the restorative documentation for 3/2026 through 6/2026 showed multiple blank entries and inconsistent documentation of service provision or refusal. The entries included notations such as 15 minutes with resident encouragement, passive participation, and refusals, but many scheduled days had no documentation at all. RNA staff stated that blank documentation meant nothing was done and that every encounter, whether services were provided or refused, should be documented in the chart. The DON stated the facility expected RNAs to document when services were provided or not, and that documentation should occur as soon as able during the shift to validate the service was done. The DON also stated that a blank in the documentation or lack of a progress note indicated a task was not done. The facility’s policy stated that the RNA will document each session, including the type of activity performed, frequency/duration, level of assistance provided, and resident response and tolerance.
Resident PHI Found on IV Antibiotic Bag in Trash
Penalty
Summary
The facility failed to protect and safeguard resident-identifiable information when an IV Vancomycin bag with an intact label containing Resident 38’s PHI was found inside a trash can in the resident’s room. Resident 38 was admitted on 5/29/2026 with diagnoses including infection following a procedure, spinal stenosis, and diabetes mellitus, and the MDS indicated the resident was cognitively intact and required staff setup or clean-up assistance with ADLs. During the initial tour on 6/15/2026, surveyors observed the labeled IV antibiotic bag in the trash can, and LVN 1 confirmed it should not have been there because it contained the resident’s information. During the same observation, LVN 1 stated the resident’s PHI should be removed because of HIPAA reasons. RNS 1 later stated that the label needed to be removed before disposal to protect the resident’s medical health information and privacy, and the DON stated staff are expected to remove the label from the IV Vancomycin bag before disposing of it because the resident’s trash can is not appropriate for disposal of resident health information. The facility’s policy on Storage and Destruction of the Designated Record Set stated that PHI must be destroyed in a manner that ensures confidentiality and that whole documents may not be thrown in the trash can.
Failure to Include Wound Care Refusal in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop and implement a baseline, individualized care plan within 48 hours of admission that addressed a resident’s known behavior of refusing ordered wound care. The resident was admitted with COPD, depression, and unspecified dementia, and an MDS assessment indicated intact cognitive skills for daily decision-making. Social Services documentation showed that the resident refused wound care on at least one occasion, stating he would skip treatment that day and have it done the next day, and the physician was notified of these episodes of refusal. The resident’s orders included daily treatment of a right shin venous stasis ulcer with normal saline cleansing, xeroform, and dry dressings on the day shift. Review of the resident’s baseline care plan revealed that it did not address the resident’s repeated refusals of wound care, despite the Treatment Administration Records documenting refusals on multiple dates in February and March. During interviews, the resident stated he preferred to have his wound changed and treated at a general acute care hospital where he frequently had appointments. Facility staff, including an LVN, the treatment nurse, the RN supervisor, and the ADON, acknowledged that the resident was known to refuse care and that care plans are essential, resident-specific, and must cover all areas of care needs. The treatment nurse confirmed that wound treatment nurses are responsible for initiating and updating wound care and that the resident’s baseline care plan did not include care planning for refusal of wound care, even though refusals continued to occur.
Failure to Assist Resident With Requested Transfer and Insurance Coordination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding transfer to another skilled nursing facility closer to family. A resident with diagnoses including hemiplegia, hemiparesis, type 2 diabetes mellitus, and essential primary hypertension, and with documented moderate cognitive impairment and dependence on staff for several ADLs, expressed a desire to transfer to a facility in Bakersfield to be closer to his sons. The resident reported wanting this for some time and stated he was not informed about the transfer process and was unaware of what was happening, indicating reliance on his responsible party to handle the transfer. The responsible party stated that it had been almost three months since the resident’s desire and request to transfer were communicated to the facility, but they were not provided with a list of available facilities in Bakersfield and did not receive consistent information about why the transfer could not occur. The responsible party further reported not being able to speak with the administrator despite requests and not receiving assistance from the facility in changing the resident’s insurance so that Bakersfield facilities could accept the resident. The social services director confirmed that the family had requested a transfer to Bakersfield for at least one to three months and acknowledged that a contacted Bakersfield facility did not accept the resident’s insurance, stating that changing insurance was the responsibility of the resident or responsible party. Progress notes showed that social services spoke with an admissions director at a Bakersfield facility and learned they did not take the resident’s insurance, but records did not show referrals or transfer plans prior to the complaint investigation date. The resident’s discharge care plan, which included interventions to discuss placement options as requested and review insurance verification and authorization as needed, did not reflect that these interventions were implemented before the complaint, resulting in an unreasonable delay and impediment to the resident’s requested transfer.
Failure to Remove Expired Food from Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to remove expired food items from the refrigerator in accordance with their policy. Specifically, a bin of tomatoes with a use by date that had passed and a bin of wilted celery with no date were found during an inspection. The facility's produce storage guidelines require that fresh vegetables be checked for ripeness, labeled, dated, and rotated so that the oldest produce is used first, and that expired items be disposed of. During an interview, the dietary supervisor confirmed that all deliveries are labeled upon receipt and should be discarded after the use by date, but this was not followed in practice.
Deficiencies in Food Safety Practices and Staff Competency in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food and nutrition service. The kitchen stove top was found with dried food and debris, and the refrigerator contained unlabeled and undated slices of cheese, a large container of egg salad, and a large container of tuna. During the inspection, a dietary cook was found storing partially cooked chicken and zucchini in the oven at 250 degrees, claiming it was not being cooked but stored. The cook did not follow the prescribed menu or recipe for meal preparation. The cook became visibly angry during the inspection, slamming hot pans and oven doors, which led the surveyor to exit the kitchen for safety concerns. The dietary supervisor confirmed that recipes and menus are to be followed unless changes are approved, and the dietician emphasized the importance of labeling and dating potentially hazardous foods. Further review of employee records revealed that annual competencies and performance evaluations were missing for multiple dietary staff members, including cooks and aides. The Director of Staff Development acknowledged that these evaluations are required to ensure staff competency and safe food preparation. Facility policies reviewed indicated that standardized recipes and menu adherence are mandatory, and that staff competency checks should be performed upon hire, annually, and as needed. The lack of adherence to these policies and procedures contributed to the observed deficiencies in food safety and staff competency.
Failure to Ensure Call Light Accessibility and Resident Education
Penalty
Summary
A deficiency occurred when a bedbound resident with blindness, muscle weakness, dysphagia, and Alzheimer's disease did not have access to a call light while in bed. During observation, the call light was not visible or within reach of the resident, and the resident stated they were unaware of what a call light was, indicating they had not been educated on its use. The call light was later found on a nightstand under a pillow, out of the resident's reach by more than an arm's length. Staff interviews confirmed that the call light should have been accessible and that education on its use is required upon admission. The CNA admitted to forgetting to check the call light's placement, and the LVN and DSD both acknowledged the importance of call light accessibility and resident education, especially for newly admitted, visually impaired, and primarily Spanish-speaking residents. Facility policy requires that residents be instructed on the use of the call system upon admission.
Failure to Immediately Initiate CPR for Unresponsive Resident
Penalty
Summary
Facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with American Heart Association (AHA) guidelines for a resident who was found unresponsive in the patio. The resident had a valid Physician Orders for Life-Sustaining Treatment (POLST) indicating a desire for full resuscitation and no advance directive limiting care. Upon discovery, the resident was unresponsive, with no vital signs appreciated, and was seated in a wheelchair. Instead of starting CPR at the location where the resident was found, staff moved the resident from the patio to his room before initiating CPR. Multiple staff members, including a Registered Nurse Supervisor (RNS), were involved in transferring the resident back to bed, which required six to seven people. Interviews with staff and another resident confirmed that CPR was not started on the patio, despite the resident being unresponsive and pulseless. The facility's policy and AHA guidelines both require immediate initiation of CPR when a person is found unresponsive and not breathing normally, but this was not followed in this instance. The delay in starting CPR was further corroborated by interviews with staff, a resident witness, and the facility's medical doctor, who all stated that CPR should have been started immediately at the site where the resident was found. The medical doctor also confirmed that the patio floor was an appropriate surface for CPR. Paramedics arrived after the resident had been moved to his room and found the resident pulseless and unresponsive, with CPR in progress. The resident was pronounced dead by paramedics after resuscitation efforts were unsuccessful.
Failure to Coordinate Discharge Planning and Communication for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure proper discharge planning and coordination for a resident with complex medical needs. The resident, who had a history of hemiplegia, hemiparesis, cerebral infarction, primary thrombophilia, depression, aphasia, seborrheic dermatitis, dysphagia, gastrostomy, hyperlipidemia, glaucoma, and coronary artery disease, was discharged to an assisted living facility (ALF) without adequate communication or preparation. The discharge process did not include regular re-evaluation of the discharge plan, nor was there effective coordination with the resident's representative. The resident's legal guardian participated in initial goal setting, but the overall discharge goal remained unclear, and no referrals were made to local contact agencies as required. During the discharge process, the facility did not ensure that the ALF was notified of the resident's gastrostomy tube, nor did it provide the resident with a supply of hydroxyzine, a medication prescribed for itching. The ALF and care coordinator reported a lack of communication from the facility's Director of Social Services (DSS), resulting in the ALF being unaware of the resident's g-tube and the need for home health services. The resident arrived at the ALF with the g-tube still in place, no home health services arranged, and without all necessary medications. The ALF had to arrange for the removal of the g-tube at a hospital and struggled to set up home health due to insurance issues. Interviews and record reviews revealed that the DSS did not follow up with the resident, family, or ALF after discharge, and did not provide necessary documentation or coordination for the resident's ongoing care needs. The facility's policies required discharge planning to begin at admission, regular updates to the care plan, and communication with all parties involved, but these steps were not consistently followed. The lack of follow-up and incomplete discharge preparation led to significant gaps in the resident's transition to the ALF.
Failure to Develop Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents with specific needs. For one male resident with multiple diagnoses including hemiplegia, dysphagia, and a gastrostomy, the care plan did not address the presence or management of the gastrostomy tube, despite documentation in the Minimum Data Set and physician orders indicating its use for water administration. The care plan only referenced dietary restrictions and dysphagia, omitting any interventions or monitoring related to the gastrostomy tube. The Director of Nursing confirmed that a care plan for the gastrostomy tube was missing, even though it was required. For a female resident with diagnoses including monoplegia, dysphagia, and cognitive impairment, the facility did not initiate a discharge care plan upon admission, as required by facility policy. The Director of Nursing acknowledged that discharge planning should begin at admission and be updated as needed, but there was no evidence of a discharge care plan being developed for this resident. The facility's policy mandates that a comprehensive care plan, including discharge planning, be developed within seven days of the comprehensive assessment, but this was not followed.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with significant physical limitations had access to a call light that could be used independently. The resident, who had diagnoses including Parkinson's disease, abnormal posture, muscle wasting, generalized osteoarthritis, and muscle weakness, was cognitively intact but required maximal to total assistance for most activities of daily living. During observation and interview, the resident was unable to locate or use the call light due to insufficient hand strength to press the button, and expressed difficulty in calling for help. A CNA confirmed that the resident was unable to press the call light button and suggested an alternative device for easier use. This deficiency resulted from the facility's inaction in providing a call light system that accommodated the resident's physical limitations, thereby preventing the resident from being able to summon staff assistance when needed.
Failure to Timely Implement Pressure Ulcer Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident at risk for pressure ulcers. The resident, who had multiple diagnoses including diabetes mellitus, abnormal posture, muscle weakness, osteoarthritis, heart failure, hypertension, and dementia, was dependent on staff for most activities of daily living and had severe cognitive impairment. The care plan, dated 2/6/25, specified the use of a Low Air Loss (LAL) mattress to prevent further decline in the resident's pressure ulcer condition. However, despite physician orders for the LAL mattress on multiple dates, the mattress was not installed until several days after a noted decline in the resident's pressure ulcer status. The delay in providing the LAL mattress was attributed to concerns from the resident's family about the risk of falls due to the increased bed height. The Director of Nursing confirmed that the mattress was not put in place until after the resident's condition had worsened. Facility policy required the provision of appropriate mattresses to residents at risk for skin breakdown, but this was not followed in a timely manner for this resident, resulting in a decline in the pressure ulcer.
Incomplete ADL Documentation Due to Lack of CNA Access to Electronic Devices
Penalty
Summary
The facility failed to ensure that medical record documentation of activities of daily living (ADLs) was accurate and complete for one of five sampled residents. The resident in question had multiple diagnoses, including diabetes mellitus, abnormal posture, muscle weakness, generalized osteoarthritis, heart failure, hypertension, and dementia, and was assessed as having severe cognitive impairment. According to the Minimum Data Set (MDS), the resident required significant assistance with most ADLs and had a history of rejecting care on several occasions during the assessment period. A review of the resident's ADL records over a ten-day period revealed multiple instances of missing documentation for essential care tasks such as eating, bed mobility, personal hygiene, toilet hygiene, and oral hygiene across various shifts. During an interview and record review, the Director of Nursing (DON) confirmed the missing documentation and attributed the issue to the theft of iPads used by CNAs for documentation, which had not been replaced. As a result, CNAs had to share computers with nurses, leading to delays and omissions in documentation due to limited access.
Medication Error Due to Failure to Follow Hold Order and Unattended Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow a physician's order to hold the medication Empagliflozin (Jardiance) for a resident with diabetes, hypertension, and atherosclerotic heart disease. The medication was on hold per physician order and family request, as documented in the resident's medical record and medication administration record. Despite the hold order, the LVN attempted to administer the medication during a morning shift and left the medication unattended at the resident's bedside at the request of a family member, intending for the family to administer it after oral care. The LVN acknowledged during an interview that leaving the medication with the family and attempting to administer a medication that was on hold was not standard nursing practice. The registered nurse supervisor confirmed that the medication was on hold and later discontinued, and that the error was discussed with the LVN and the family. The assistant director of nursing also stated that medication administration should be witnessed by licensed staff and that all medication orders, including holds and discontinuations, are clearly visible in the medication administration record. Facility policy and procedure require that medications be administered only as ordered by a physician or licensed independent practitioner, and define a medication error as administering a medication that is not currently prescribed. The LVN's actions in attempting to administer and leaving a held medication unattended constituted a failure to comply with these requirements, resulting in a medication error for the resident.
Residents Labeled as 'Feeders' in Staff Assignments
Penalty
Summary
The facility failed to treat twelve residents who required feeding assistance with respect and dignity by referring to them as "feeders" and maintaining a list labeled as such for staff assignment purposes. Staff, including CNAs, LVNs, the DON, and the MDS coordinator, consistently used the term "feeders" to identify and assign residents needing feeding assistance. This terminology was used in staff communications, written lists, and verbal exchanges, and was acknowledged by multiple staff members during interviews. The list of "feeders" was used to distribute workload among staff, and the term was used both in conversation and in written documentation. The residents involved had significant medical needs, including diagnoses such as diabetes Type 2, muscle weakness, Parkinson's disease, quadriplegia, schizophrenia, hypertension, and anxiety disorder. Most of these residents had severely impaired cognition and required substantial or maximal assistance with all activities of daily living, including eating. Some residents had intact cognition but still required extensive assistance. The use of the term "feeders" was applied regardless of cognitive status, and staff described entire rooms as being "feeders" and discussed their care in these terms. Facility policy required that residents be treated with dignity and respect, including being addressed by their name of choice and prohibiting demeaning practices. However, staff interviews and record reviews confirmed that the practice of labeling and referring to residents as "feeders" was routine and accepted among staff, despite the policy. The report notes that this practice caused or had the potential to cause depression among the affected residents.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to maintain accurate and current copies of advance directives in the clinical records for three out of four sampled residents. During record reviews and interviews, it was found that the medical charts for these residents did not contain their advance directives, despite facility policy requiring such documentation. Licensed vocational nursing staff confirmed the absence of these documents in the residents' charts, acknowledging that this could lead to confusion regarding the residents' wishes in the event of a medical emergency. The residents involved had varying medical conditions, including muscle weakness, rheumatoid arthritis, hypertension, atrial fibrillation, and diabetes, with cognitive statuses ranging from intact to moderately impaired. The Minimum Data Set assessments indicated differing levels of assistance required for activities of daily living. The facility's policy states that residents have the right to formulate advance directives and that these should be included in their records, but this was not followed for the residents in question.
Unauthorized Access and Disclosure of Resident Medical Records
Penalty
Summary
A deficiency occurred when an independent liaison, who was not an employee of the facility or the hospice company, obtained and retained medical records for a resident without proper authorization or consent. The liaison stated she did not meet with the resident or the resident's sister prior to arranging the discharge and did not receive the resident's consent to access or review the medical records. The liaison acquired the records from the hospice company and used information from them to facilitate the resident's discharge, despite not having a medical background or a direct relationship with the facility or hospice. The resident involved had a history of paraplegia, essential hypertension, and recurrent urinary tract infections with sepsis, and was readmitted to the facility with a terminal prognosis. The resident's medical records indicated intact cognition and the capacity to make medical decisions. The discharge summary and care plan noted the resident's terminal condition and the plan for a safe transition home, but there was no documentation that the physician spoke to the resident's family about the terminal prognosis. The discharge planning review form was also found to be incomplete. Facility policy required that access to protected health information (PHI) be limited to the minimum necessary and that the entire medical record should not be disclosed unless specifically justified, particularly for non-treatment purposes. The liaison's access and retention of the resident's medical records, without proper consent or justification, constituted a violation of the Health Insurance Portability and Accountability Act (HIPAA) and the facility's own policies regarding the disclosure of PHI.
Failure to Document and Provide Diabetes Education to Resident
Penalty
Summary
Facility staff failed to accurately and completely document diabetes mellitus (DM) education in the medical record for one resident. The resident, who had a history of DM, hyperlipidemia, cerebral vascular accident without residuals, and hypertension, was found to be cognitively intact and required staff assistance with activities of daily living. During an interview, the resident stated she did not know why she was taking insulin, indicating a lack of understanding about her diagnosis and treatment. A review of the resident's chart with the Registered Nurse Supervisor revealed no documented evidence that education regarding the DM diagnosis was provided to the resident or her representative. The facility's process requires that new diagnoses be discussed in an interdisciplinary team meeting with the resident or representative, with documentation in the progress notes. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that documentation of education was missing, and facility policy requires that each discipline document relevant information in the resident's progress notes.
Failure to Prevent Unauthorized Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed and approved for self-administration of medications. The resident, who had diagnoses of hypertension, generalized weakness, and diabetes mellitus, was admitted to the facility and had a self-administration assessment indicating a need for assistance with ointments and topical medications. The assessment specifically stated that the resident was not approved for self-administration or for keeping medications at the bedside. Despite this, during an observation, the resident was found with two creams and a powder medication at the bedside, which the resident identified as prednisolone cream, Vitamin A&D ointment, and athlete's foot powder. A Licensed Vocational Nurse confirmed that these medications should not have been left at the bedside, as the resident was not approved for self-administration and all medications should be administered by licensed staff and securely stored. The Director of Nursing stated that the facility's process requires an assessment and a physician's order for self-administration, and that medications should not be left with residents who are not approved, to prevent potential medication errors. The facility's policy also requires IDT and physician determination before allowing self-administration, which was not followed in this case.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for one resident, as evidenced by the lack of access to hot water for grooming and personal hygiene, and a malfunctioning cold water faucet that splashed water onto the resident and the floor. The resident reported that the hot water in the room did not function properly, taking over ten minutes to become warm and then only dribbling out, while the cold water came out at an odd angle and caused splashing. Additionally, the television in the room was loose, tilted to the side, and appeared unstable, and the window blinds were broken, bent, and not properly attached, creating the appearance that they might fall at any time. Observations confirmed the resident's room was clean and free of unusual odors, but the TV was loosely affixed and tilted, and the blinds were in disrepair with broken slats and a bent top. The bathroom faucet did not provide hot water, and the cold water splashed outside the sink. The facility's maintenance supervisor acknowledged these issues, attributing the hot water problem to a possible pipe clog and noting the need for repairs to the faucet, TV bracket, and blinds. Facility policies require the maintenance department to keep the building and equipment safe and operable at all times and to provide residents with a safe, clean, comfortable, and homelike environment.
Failure to Develop Baseline Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a baseline care plan in accordance with its own policy and procedures for one resident. Record review showed that the resident was admitted and later readmitted with diagnoses including stroke, generalized weakness, and diabetes mellitus. The resident's Minimum Data Set indicated cognitive impairment and dependence on staff for activities of daily living. Despite these needs, there was no baseline care plan developed to address the resident's specific conditions, including the management of a gastrostomy tube (g-tube). Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the absence of a care plan could result in staff not having unified or appropriate interventions for the resident, particularly regarding the risk of g-tube dislodgement. The facility's policy required a comprehensive, person-centered care plan to be developed for each resident to meet their health, safety, psychosocial, behavioral, and environmental needs, but this was not done for the resident in question.
Failure to Conduct Interdisciplinary Team Meeting After Change in Condition
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) meeting for one of three sampled residents, as required by facility policy. Specifically, a resident with a history of cerebral vascular accident, generalized weakness, and diabetes mellitus was admitted and later readmitted to the facility. The resident was noted to have cognitive impairment and was dependent on staff for activities of daily living. From January 2025 onward, the resident experienced multiple hospitalizations due to gastrostomy tube (g-tube) dislodgements. However, there was no documented evidence that an IDT meeting was conducted to address these incidents, despite the facility's policy requiring such meetings upon admission, quarterly, annually, and as needed, particularly at changes of condition. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that IDT meetings should have been held to involve the resident's representative and develop a comprehensive care plan, especially after repeated g-tube dislodgements and hospitalizations. The facility's policy on comprehensive person-centered care planning also specifies that the IDT team must include the resident and their representative. The lack of documented IDT meetings meant that the resident and their representative were not involved in care planning or decision-making regarding the resident's care needs during these significant events.
Failure to Maintain Resident Room Free from Accident Hazards
Penalty
Summary
A deficiency was identified when a resident's room was found to have accident hazards and did not provide a safe, comfortable, and homelike environment. The resident, who was cognitively intact and primarily independent with diagnoses including hypertension and muscle weakness, reported that the television in the room was loose, tilting to the right, and appeared as though it might fall. Additionally, the blinds in the room were broken, bent, and not properly attached, creating the appearance that they could fall at any time. These issues were confirmed during an observation of the room, where the TV was seen to be loosely affixed and the blinds were in disrepair. Interviews with facility staff, including the Maintenance Supervisor, confirmed that the TV had a loose screw and the blinds were damaged, both of which had not yet been addressed at the time of the initial observation. The facility's policies and procedures require that the maintenance department keep the building and equipment safe and operable at all times, and that resident rooms provide a safe, clean, comfortable, and homelike environment. The failure to maintain the resident's room in good repair and free from hazards constituted a deficiency.
Failure to Properly Administer and Connect Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral vascular accident, generalized weakness, and diabetes mellitus, who was dependent on staff for activities of daily living and had cognitive impairment, did not receive appropriate care related to their enteral feeding. The resident had a physician's order for Glucerna 1.5 to be administered via gastrostomy tube twice daily at a specified rate. During observation, the feeding tube connection device was found on the floor, disconnected from the resident's gastrostomy tube, while the feeding pump continued to run. Upon further investigation, a Licensed Vocational Nurse confirmed that the feeding tube was not properly connected, which could result in the resident not receiving their prescribed nutrition. The Director of Nursing also acknowledged that the tube feeding set should be a closed unit to prevent infection and that failure to connect the feeding could lead to nutritional deficits. Facility policy required enteral feedings to be administered per physician order and connected to the resident, which was not followed in this instance.
Unauthorized Access and Disclosure of Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards for one resident. An independent liaison, who was not an employee of the facility, hospice company, or corporation, obtained and retained the resident's medical records without the resident's consent. The liaison accessed these records through the hospice company and used the information to arrange for the resident's discharge to home hospice services, despite not having a medical background or prior contact with the resident or their family. The resident in question had a diagnosis of complete paraplegia and essential hypertension, with medical records indicating intact cognition and the capacity to make medical decisions. The resident required significant assistance with activities of daily living. The liaison did not confirm the resident's wishes or obtain consent before accessing and using the resident's protected health information (PHI) for discharge planning. The family was informed by the liaison, who identified herself as a case manager for the corporate office, that the resident needed to be discharged the next day, without prior notice or direct communication from facility staff. Facility leadership, including the Vice President of Operations, confirmed that the liaison was not affiliated with the facility or corporation and had no authorization to access or use the resident's medical records. The facility's failure to control access to PHI resulted in a violation of HIPAA privacy standards, as the liaison was able to obtain, review, and act upon the resident's medical information without proper authorization or consent.
Failure to Offer and Document Pneumococcal Vaccination per Policy
Penalty
Summary
The facility failed to ensure that pneumococcal (PNA) vaccines were offered and/or administered to two of five sampled residents in accordance with facility policy. For both residents, who were cognitively intact and required varying levels of assistance with activities of daily living, there was no documented evidence that a consent or declination form for the PNA vaccine was obtained at the time of admission. Instead, the consents were obtained at a later date, well after their respective admissions. The facility's process, as described by the Infection Prevention (IP) Nurse, involves screening residents upon admission for vaccination status using resident or representative interviews and checking immunization registries, followed by obtaining consent or declination forms based on current vaccination status. Record reviews confirmed that for both residents, the required documentation regarding the offer or administration of the PNA vaccine was missing at admission, contrary to the facility's policy and CDC recommendations. The facility policy, reviewed previously, specified that pneumococcal immunization should be offered according to CDC guidelines, but this was not followed for the two residents identified in the report.
Failure to Document and Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccination was offered and/or administered to two of five sampled residents in accordance with its policy and procedures. For one resident, the admission record showed they were admitted and readmitted with diagnoses including spinal stenosis, muscle spasm, and GERD. The Minimum Data Set (MDS) indicated the resident was cognitively intact and required assistance with activities of daily living. Upon review of the electronic chart and interview with the Infection Prevention (IP) Nurse, it was found that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident at the time of admission, as required by facility policy. Similarly, another resident was admitted with diagnoses of anemia, generalized weakness, and diabetes mellitus, and was also found to be cognitively intact and moderately dependent on staff for activities of daily living. Record review and interview with the IP Nurse revealed that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident either. The facility's policy, reviewed on 12/18/2020, required that residents be screened for vaccination status and that appropriate documentation be obtained, but this was not followed for the two residents identified.
Failure to Administer Insulin and Monitor Blood Sugar per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with type 1 diabetes mellitus did not receive appropriate insulin administration and blood sugar (BS) monitoring according to physician orders and facility policy. On one occasion, the resident's BS was found to be 541 mg/dL, but the prescribed dose of Humalog KwikPen insulin was not administered, and the physician was not notified as required. Additionally, there were multiple instances where the licensed vocational nurse (LVN) failed to check the resident's BS prior to administering insulin, and in one case, administered insulin based on a BS reading taken several hours earlier without rechecking the current level. The facility's policy required BS checks and physician notification for readings above 350 mg/dL, but these steps were not consistently followed. The resident's medical records indicated a history of type 1 diabetes and essential hypertension, with orders for both scheduled and sliding scale insulin. Documentation showed that the resident experienced a severe hypoglycemic event, with a BS of 25 mg/dL, resulting in unresponsiveness and transfer to the hospital. Despite this event, subsequent insulin administration and BS monitoring remained inconsistent. The LVN involved stated that fear of another hypoglycemic episode influenced the decision not to administer insulin when the BS was high, but this was not communicated to the physician in a timely manner. There were also discrepancies in the documentation of BS checks and insulin administration, with some doses given without recent BS readings and some high BS readings not followed by the required interventions. Interviews with staff and review of facility policies confirmed that the required protocols for diabetic care, including timely BS monitoring, insulin administration, and physician notification, were not adhered to. The director of nursing acknowledged that the nurse should have rechecked the BS before administering insulin and should have notified the physician of significant changes. The facility's policies emphasized the importance of monitoring and documentation, but these were not consistently implemented, leading to confusion among staff and inadequate care for the resident.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care that promoted or enhanced the dignity and respect of residents by not ensuring staff were seated while feeding residents. This deficiency was observed in two residents who required assistance with feeding due to severe cognitive impairments and other medical conditions such as dysphagia and dementia. During observations, Certified Nursing Assistants (CNAs) were seen standing over the residents while feeding them, causing the residents to raise their necks and look up at the staff, which is contrary to the facility's policy that staff should be seated to ensure comfort and dignity for the residents. Interviews with the CNAs and a Licensed Vocational Nurse (LVN) confirmed that the staff were aware of the requirement to sit while feeding residents to maintain their dignity and comfort. However, one CNA did not sit due to the unavailability of a chair, and another CNA initially stood before sitting down after being reminded. The facility's policies, including the Restorative Dining Program and Feeding the Resident, clearly state that staff should sit while assisting or feeding residents, and residents should be properly positioned to facilitate eating.
Failure to Promptly Answer Resident's Call Light
Penalty
Summary
The facility failed to ensure that a resident's call light was answered promptly, which is a device used to notify the nurse that the resident needs assistance. This deficiency was observed for one of the sampled residents, who was admitted with diagnoses including atrial fibrillation, muscle weakness, and polyneuropathy. The resident's cognitive skills for daily decisions were intact, and they required moderate assistance from staff for activities of daily living. During an observation and interview, the resident expressed that staff took a while to answer call lights and sometimes turned them off without returning to assist. On the day of the observation, the resident pressed the call light for help, and it remained on for more than 10 minutes while staff were observed walking in the hallway and present in the nursing station. An alarm sound was heard in the nursing station, indicating that the call light was active. A Licensed Vocational Nurse confirmed that call lights should be answered right away and that any staff could respond to them. However, the nurse was unable to explain why the call light had not been answered promptly. The facility's policy and procedure indicated that call alerts should be answered promptly and courteously, which was not adhered to in this instance.
Failure to Implement Comprehensive Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident following a fall incident with injury. The resident, who had been admitted with conditions including hemiplegia, hemiparesis, and congestive heart failure, experienced a fall on 12/5/2024, resulting in a bump on the forehead and a headache. Despite the incident, there was no care plan developed with goals and interventions to address the fall, as confirmed by a review of the resident's electronic and paper health records. The facility's policy on Fall Management Program, which requires interventions to be documented in the resident's plan of care, was not followed. This deficiency was identified during a record review and interview with the Medical Record Director, who confirmed the absence of a care plan for the resident after the fall incident. The lack of a comprehensive care plan following the fall had the potential to negatively impact the resident's health and safety, as well as the quality of care and services received.
Failure to Document Resident's Death According to Policy
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not implementing the facility's policy and procedure titled 'Death of a Resident' when the resident passed away. The resident, who had a history of hemiplegia, hemiparesis, and congestive heart failure, was found unresponsive by a Certified Nursing Assistant. Paramedics pronounced the resident dead, but there was no physician's progress note or record of death filed in the resident's medical records. The facility's policy required that only a licensed physician could declare a resident dead and that all documentation related to the resident's death should be maintained in the medical record. However, the Medical Record Director confirmed that there were no physician's progress notes or death certificate on file for the resident. This oversight resulted in an incomplete assessment and documentation as required by the facility's policy and procedure upon the resident's death.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents by not ensuring a physician's order was in place for oxygen therapy for one resident and not changing the nasal cannula tubing and humidifier as per facility policy for both residents. Resident 4, who was admitted with diagnoses including atrial fibrillation and muscle weakness, was observed using an oxygen concentrator without a physician's order for supplemental oxygen therapy. Additionally, the nasal cannula tubing and humidifier for Resident 4 were not labeled with a date and the humidifier was empty, indicating a failure to follow the facility's policy of changing and labeling these items weekly. Resident 2, admitted with conditions such as type II diabetes mellitus and heart failure, also experienced deficiencies in respiratory care. The nasal cannula tubing and humidifier for Resident 2 were not labeled with a date and had not been changed since admission, contrary to the facility's policy. The humidifier was observed to be more than halfway empty, and no bubbling was noted, suggesting it was not functioning properly. Licensed Vocational Nurses confirmed these observations and acknowledged the lack of adherence to the facility's policy, which requires weekly changes and labeling of the equipment.
Failure to Protect Residents' Belongings
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their personal belongings. Resident 1, who was admitted with a left femur fracture, bipolar disorder, and depression, reported missing clothes after a scabies outbreak led to her clothes being laundered and stored in the basement. Despite a list being made of her clothes, the items were not returned, and she was given clothes from the donation stock instead. Interviews with staff confirmed that a theft and loss report was not initiated, contrary to the facility's policy. Resident 2, admitted with hemiplegia and hemiparesis following a cerebral infarction, reported missing clothes and neck pillows that were sent to the laundry. The facility failed to maintain an inventory of Resident 2's belongings upon admission, and her clothes were not labeled, making it difficult to identify them. The Assistant Director of Nursing confirmed the absence of an inventory list and acknowledged the need for labeling residents' clothes. The facility's policy on theft and loss requires the initiation of a report and investigation when personal property is reported missing. However, this procedure was not followed for either resident, resulting in the unresolved loss of their belongings. The policy also mandates the documentation of residents' belongings upon admission and the labeling of clothes, which was not adhered to in these cases.
Failure to Supervise High-Risk Resident Leads to Fall
Penalty
Summary
The facility failed to adequately supervise and monitor a resident, identified as Resident 1, who was at high risk for falls. Resident 1 had a history of recurrent falls and was assessed as a high risk for falls, with a fall risk evaluation score of 12, indicating a high risk for potential falls. The resident's care plan included interventions to anticipate and meet the resident's needs and to provide a safe environment. Despite these measures, on the evening of November 8, 2024, Resident 1 suffered an unwitnessed fall from a wheelchair, resulting in a laceration on the left eyebrow that required three sutures. The incident occurred when Resident 1 was left unattended in a wheelchair across from their room. Interviews with staff revealed that both the charge nurse and a certified nursing assistant were on break or attending to personal tasks at the time of the fall. The resident was found on the floor in a prone position by the doorway, with a skin tear and minimal bleeding. The facility's policy on fall management, which requires more frequent observation for residents with multiple falls, was not adhered to, contributing to the incident. The report highlights that the facility's failure to provide adequate supervision and a safe environment for Resident 1, who was known to be at high risk for falls, directly led to the resident's fall and subsequent injury. Interviews with staff and the review of the facility's policies indicate a lack of adherence to established protocols for monitoring high-risk residents, which resulted in the deficiency noted in the report.
Failure to Implement Effective Infection Control Measures
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment, leading to the potential spread of infection among residents, visitors, and the community. Three residents were affected by this deficiency, as the facility did not assess their skin rashes, place them on contact precautions, or notify a physician about ineffective treatments. Resident 1 was observed with red, raised scaly rashes on her lower legs and had severe cognitive impairment, requiring assistance with daily activities. Resident 3, who had diabetes and other health issues, was seen with red, raised, scaly rashes and burrowing on his body, indicating a possible scabies infestation. Resident 4, also with severe cognitive impairment, had similar rashes and was observed scratching continuously. The facility's Director of Nursing (DON) admitted that the staff had not reassessed Resident 3's condition after suspecting an allergic reaction, leading to a delay in effective treatment. The DON also confirmed that the nursing staff failed to identify Resident 4's rash, resulting in a delay in care and worsening of the condition. The facility's policy on scabies prevention and management was not followed, as residents with undiagnosed rashes were not placed on contact isolation, and there was no confirmation of scabies diagnosis through skin scrapings. The dermatologist's notes for Residents 3 and 4 indicated the presence of erythematous eczematous patches, linear burrows, and scabietic nodules, suggesting a scabies infestation. Despite these findings, the facility did not take appropriate measures to prevent the spread of infection. The lack of timely assessment, communication with physicians, and adherence to infection control policies contributed to the deficiency, putting the health and safety of residents and others at risk.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,200 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Brentwood Health Care Center | 0.6 mi | ★★★★★ | 10 | 0 |
| New Vista Post-acute Care Center | 0.8 mi | ★★★★★ | 44 | 0 |
| Ocean Park Healthcare | 1.1 mi | ★★★★★ | 4 | 0 |
| Sunset Park Healthcare | 1.1 mi | ★★★★★ | 3 | 0 |
| Berkley East Healthcare Center | 1.3 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Westwood Post Acute Care.
100% money-back within 48 hours.
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.