Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westwood Post Acute during CMS and state inspections, most recent first.
Failure to Protect Resident from Sexual Abuse: A CNA witnessed one resident place his penis inside another resident’s mouth while the resident was asleep. The resident was on hospice with advanced dementia and other serious diagnoses, and the other resident had severe cognitive impairment, dementia with behavioral disturbance, and orders for 1:1 intervention and close supervision due to unsafe behaviors. The incident was reported later to the ADM/DON, and the record noted the resident’s RP was not informed that day.
A facility failed to immediately report a witnessed sexual abuse incident after CNAs observed a resident with dementia and behavioral issues in another resident’s room with inappropriate sexual contact. The UM received the report but did not notify the Abuse Coordinator, police, CDPH, or Ombudsman within the required timeframe, and the DON and ADM later confirmed the delay. The abused resident was on hospice with advanced dementia, and the other resident was on 1:1 intervention for behavioral concerns.
Missed Quarterly Care Conferences: A resident with type 1 DM, diabetic autonomic neuropathy, and major limb amputations had a BIMS score of 15, but the IDT did not hold quarterly care conferences after the last documented meeting. SS staff confirmed the conferences should have occurred every 3 months and could not explain why they were missed, and MDS nurses stated the meetings were needed so residents would know the plan of care and whether needs were being met.
A resident with an SCD order for DVT prevention developed bilateral lower-extremity blisters, discoloration, swelling, and pain while the chart lacked documentation of SCD care, skin and circulation checks, and a care plan for the device. The DSA and DON confirmed the resident had plastic SCD sleeves in use, but nurses did not document ongoing monitoring of the legs or skin condition, and the resident was later transferred for further evaluation.
A resident with C. diff-associated diarrhea missed multiple doses of fidaxomicin because the medication was not available when ordered and the facility did not send the high-cost med PA to the pharmacy on time. MAR documentation showed doses marked as refused, not available, and one unsigned dose, while the CP confirmed the drug was not in the e-kit. During this period, the resident had hematochezia and mucoid stool, and the NP noted recent septic shock related to C. diff and that Dificid was unavailable per pharmacy.
A resident with severe cognitive impairment and diagnoses including dementia, Alzheimer’s disease, cauda equina syndrome, and syncope was heard shouting for help during shift change, but multiple staff passed by without checking on the resident. CNA A and CNA B minimized the calls for help, while the DON stated staff must check on residents asking for help and the ADM stated the resident should always be checked to ensure assistance is given when needed.
A resident with complex medical conditions, cognitive impairment, and total dependence for ADLs was repeatedly observed with very dry, white, scaly skin on both lower legs and heels, and with long, thick, discolored fingernails and toenails. Staff interviews confirmed that CNAs and LNs were responsible for moisturizing skin during ADL care and for routine nail trimming for non-diabetic residents, and facility policies required lotion use during bathing and regular nail care. Documentation on a shower day skin inspection inaccurately indicated that nail clipping was not needed, despite the resident’s clearly overgrown nails. Although there was a podiatry order, the resident’s insurance did not cover the podiatrist and unpaid charges led to withheld podiatry services, and this issue was not escalated to administration or discussed in daily meetings, resulting in the resident not receiving required grooming and personal care.
A resident on contact precautions for multidrug-resistant organisms, with a history of respiratory failure, MRSA, tracheostomy, and gastrostomy, had blood pressure taken by an LVN using a non-dedicated, battery-operated BP device brought from the medication cart. The LVN placed the device on the resident’s bed, applied the cuff to the resident’s lower leg, then removed the gown and gloves while holding the device and carried it out of the isolation room without cleaning or disinfecting it, placing it back on the medication cart. Staff interviews confirmed that dedicated BP equipment or proper cleaning between uses was required by CDC guidance and facility MDRO policy for residents on contact precautions, but this was not followed in this event.
A resident with chronic respiratory failure, ventilator dependence, and a longstanding GT experienced a GT dislodgement. An RN and an LVN, who had not been trained or deemed competent in GT reinsertion per facility policy, reinserted a larger 20 Fr tube instead of the ordered 16 Fr because the correct size was unavailable. They documented scant bleeding at the stoma and stated that placement was confirmed, but another LVN later explained that staff should avoid using a larger size due to risk of rupture. After reinsertion, the resident developed hypoxia, abdominal distension, and respiratory distress, requiring 911 activation and CPR. Hospital records showed the PEG was malpositioned into the peritoneum, causing a catastrophic intra‑abdominal process and severe septic shock, and the resident ultimately died. The facility’s policy required trained, competent licensed nurses and detailed documentation for PEG changes, which were not followed in this incident.
A resident with hemiplegia, hemiparesis after stroke, aphasia, MDD, anxiety, and insomnia had an order for PRN Zolpidem and a care plan for insomnia that included non-pharmacological interventions such as repositioning, snacks/drinks, reassurance, relaxation exercises, and monitoring hours of sleep. Review of nursing progress notes and the MAR for the month showed no documentation that sleep hours were monitored or that the non-pharmacological interventions were provided. During interviews, the IP confirmed the insomnia care plan was not implemented, and the DON stated that ordered monitoring and interventions should have been carried out and documented, contrary to the facility’s comprehensive person-centered care plan policy.
A resident with hemiplegia and hemiparesis, requiring significant assistance with daily activities, was found without access to a functioning call light or alternative call bell at bedside. The resident reported the call light had been nonfunctional for two weeks and no call bell was available, resulting in delays in receiving help. A treatment nurse and the DON confirmed the absence of a call bell, despite facility policy requiring accessible call systems for residents.
A resident with muscle weakness and intact cognition did not receive occupational therapy (OT) services as ordered by a physician, with therapy sessions frequently missed or reduced due to staffing shortages. Therapy records confirmed that the resident received OT less often than prescribed, and facility staff acknowledged the failure to follow the physician's order.
A resident with significant physical impairments was found with unexplained facial and ear bruising. Multiple staff observed the injury, but no cause was determined, and the incident was not reported to required agencies as mandated by the facility's abuse policy. Staff interviews revealed confusion about reporting responsibilities, and the injury was not care planned or externally investigated.
Surveyors observed multiple infection control failures, including improper handling of urinary catheter bags, oxygen tubing, and enteral feeding tubes, as well as lapses in hand hygiene and PPE use between resident care tasks. Staff did not consistently follow isolation precautions, failed to communicate infection status to outside providers, and used incorrect disinfectants on shared equipment. Signage and isolation carts were missing or inadequate, and staff were seen entering isolation rooms without proper PPE or using inappropriate products for hand hygiene.
Staff failed to maintain resident dignity and privacy by not fully drawing a privacy curtain for a cognitively impaired resident who removed her gown, referring to clothing protectors as "bibs" in front of multiple residents, and assisting a resident with eating while standing over her, contrary to facility policy.
Staff did not consistently turn and reposition two immobile residents with existing pressure ulcers, despite care plans and facility policy requiring repositioning at least every two hours. Both residents remained on their backs for extended periods, and staff interviews revealed a lack of adherence to established wound care protocols and insufficient use of pressure-relieving equipment.
Three residents receiving oxygen therapy did not receive safe and appropriate care: two residents had oxygen concentrator filters with significant buildup despite orders and policy for weekly cleaning, and another resident with COPD was given oxygen at a higher rate than ordered, with staff aware of but not following the physician's order.
A resident with osteoarthritis, muscle weakness, and difficulty walking requested assistance via call light to transfer from bed to wheelchair. A CNA entered, turned off the call light, and left without providing help. Interviews and policy review confirmed staff are required to assess and assist residents when the call light is used.
Direct care staffing numbers and nursing staff schedules were not posted or accessible in several hallways, with the DON confirming that this information was only available near the main entrance and not at all nursing stations as required.
Nursing staff failed to consistently document the administration of controlled medications on the MAR after signing them out from the CDR for several residents, and did not obtain required co-signatures from another nurse when wasting controlled substances, resulting in incomplete records for both administration and disposal of these medications.
Multiple residents reported that their meals lacked flavor and that vegetables were overcooked and mushy. During a test tray review, the mashed potatoes were confirmed by dietary staff to lack flavor. These issues were observed in both Regular and Pureed Diet trays, affecting a significant number of residents.
The facility did not provide evening or bedtime snacks to all residents, with staff only offering snacks to those with a physician's order and no system in place for others after kitchen hours. A resident with diabetes did not receive her ordered bedtime snack, and several residents reported never being offered snacks at night, despite the facility's policy requiring routine offering of bedtime snacks.
Surveyors found that food items such as frozen fish and cereals were stored without required labeling for open and use by dates, and a metal container was stacked while still wet. Additionally, pureed food was prepared using a container placed in a wet sink, contrary to best practices and facility policy. These actions did not meet professional standards for food storage and preparation.
A resident with severe cognitive impairment and multiple medical conditions, including a gastrostomy, was using a peek-a-boo mitten as ordered to prevent removal of her feeding tube. However, nursing staff failed to document the use of the mitten and related observations in the resident's weekly summaries over several weeks, despite facility policy requiring complete and accurate documentation of all services and interventions.
Two residents were physically abused by another resident who, in separate unprovoked incidents, struck one resident in the hallway and slapped another in the activities room. Both events were witnessed by CNAs and resulted in minor injuries to the victims, despite the facility's policy to protect residents from abuse.
Two residents had personal care instructions, including clinical details and safety precautions, openly posted in their rooms where they were visible to visitors. Facility staff, including the ADON, LVN, and DON, confirmed that these postings were not in accordance with facility policy, which requires confidential information to be protected and not openly displayed.
A resident admitted with diagnoses including schizotypal disorder and prescribed Trazodone for depression was not accurately identified as having a serious mental illness on the PASARR Level I screening. The screening, completed by hospital staff, incorrectly marked 'no' for both diagnosed mental disorder and psychotropic medication use, despite documentation to the contrary. The MDS director confirmed these discrepancies during review.
A resident with severe cognitive impairment and multiple medical conditions was repeatedly observed partially undressed and exposed in her room, with staff confirming her ongoing behavior of removing her gown. Despite this, no individualized care plan was developed or implemented to address the behavior, and staff interviews confirmed the absence of documented interventions.
A resident with a history of atrial fibrillation and heart failure did not receive scheduled doses of Diltiazem and Carvedilol, and vital signs were not monitored as ordered. There was no documentation explaining the missed medication administration or lack of vital sign checks, despite facility policy requiring such documentation. The DON confirmed these omissions during record review.
A resident with diabetes and one-sided weakness did not receive timely podiatry care despite requesting services and having an order for regular podiatry evaluation. Her toenails were observed to be long, thick, and growing inward, causing pain and concern for infection. Staff confirmed the resident was not seen by the podiatrist as required, and her request for care was not addressed.
A resident receiving vitamin B12 and vitamin D3 supplements for deficiency did not have required laboratory monitoring for vitamin D and B12 levels as ordered by the physician. The absence of these lab results was confirmed by the ADON, indicating inadequate monitoring of the resident's medication regimen.
A resident with complex medical needs was discharged without the necessary home health services, as ordered by the physician. The resident, who required assistance with gastrostomy tube feeding and other therapies, was picked up by a friend of the SSA without a confirmed home health agency. The initial referral was denied, and as of several days post-discharge, no agency was in place, violating the facility's discharge policy.
A resident with complex medical conditions experienced deficiencies in care planning and medication documentation. The baseline care plan for dysphagia and tube feeding was delayed, and the facility failed to provide the prescribed tube feeding formula upon admission. Additionally, a medication administration record was incorrectly initialed by an LVN instead of the RN who administered the IV antibiotic.
A facility failed to provide timely pharmaceutical services, resulting in delayed administration of IV antibiotics for three residents. One resident with multiple diagnoses, including cancer, did not receive Vancomycin on time despite its availability in the emergency kit. Another resident with chronic respiratory failure experienced a delay due to a claimed but undocumented IV access issue. A third resident with osteomyelitis also faced a delay without explanation. Additionally, a nurse used another resident's normal saline to mix Vancomycin, violating facility policy.
A resident with reduced mobility fell during a physical therapy session, sustaining minor injuries. The physical therapist did not report the fall to the nursing staff, relying on the resident's son to inform them. This delay in communication potentially delayed assessment and treatment. Facility policy requires prompt notification of changes in a resident's condition to the physician and responsible representative.
A facility failed to promote respect and dignity for a resident when a social services staff member threatened to call 911 for a 5150 assessment while the resident was advocating for her roommate. The resident, who had a history of multiple medical conditions, felt threatened and called the police herself. The facility's management did not address the issue or clarify the situation with the resident afterward.
A resident with multiple diagnoses was found to have their morning medications left at their bedside, despite the medications being documented as given. The licensed vocational nurse did not observe the resident taking the medications and left the room to attend to another resident. The incident was discovered by a family member and confirmed by a certified nursing assistant.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from sexual abuse when a CNA witnessed another resident place his penis inside the resident’s mouth. The resident involved had advanced frontotemporal dementia, was on hospice services, and had a BIMS score of 12. His record also showed diagnoses including contractures, atrial fibrillation, anxiety, major depressive disorder, and dementia. The report stated the resident was receiving comfort-focused care with morphine ordered as needed for breakthrough pain. The other resident involved had severe cognitive impairment with a BIMS score of 4 and diagnoses including polyneuropathy, hypertensive heart and chronic kidney disease, atherosclerotic heart disease, and dementia with behavioral disturbance. His orders and care plan reflected the need for 1:1 intervention, redirection, calm communication, encouragement to express feelings and concerns, and close/protective supervision due to behaviors such as entering other residents’ rooms, taking staff or resident property, and sudden angry outbursts. The care plan also noted depression manifested by intense affection toward others and seeking company obsessively. On the day of the incident, CNA C stated she and CNA D entered the resident’s room and saw the other resident standing by the bedside while the resident was asleep with eyes closed, and CNA C stated the other resident’s penis was inside the resident’s mouth. CNA C said the other resident was told to leave the room and that staff were aware he needed supervision because of his behaviors. The Administrator and DON stated the incident was reported to them later, and the Unit Manager stated the resident’s responsible party was not informed on the day of the incident. The facility’s 5-day investigation report described the event as an alleged inappropriate physical interaction involving exposed genitalia and contact with the resident’s head area, and the facility’s abuse reporting policy required immediate reporting, not later than 2 hours for abuse, to the Ombudsman, CDPH, and police.
Delayed Reporting of Witnessed Sexual Abuse
Penalty
Summary
The facility failed to ensure an alleged sexual abuse incident was reported immediately when a Unit Manager did not notify the police, the State Agency, or the Ombudsman on the day the abuse was witnessed. The report states that CNA C and CNA D observed Resident 5 in Resident 4’s room with inappropriate sexual contact involving Resident 4, and that the incident was reported to the Unit Manager on the same day it occurred. The Unit Manager did not report the allegation to the Abuse Coordinator/Administrator until several days later, and the facility’s investigation and external reporting were delayed. Resident 4 had multiple diagnoses including dementia, anxiety, depression, and other neurocognitive disorder, and was on hospice care with a terminal diagnosis of advanced frontotemporal dementia, sepsis, and age-related physical debility. Resident 5 had diagnoses including dementia with behavioral disturbance and was on 1:1 intervention, with care plan and orders reflecting behaviors such as sudden angry outbursts, entering other residents’ rooms, and being closely supervised. The record also showed Resident 5 had medication orders for mood disorder and depression, and care plan entries addressing behavioral concerns and close supervision. During interviews, the Administrator and DON stated CNA C reported that Resident 5 was seen in Resident 4’s room with his pants down and that his genitals touched Resident 4’s head. CNA C stated she saw Resident 5 standing by Resident 4’s bedside and observed sexual contact, and that staff were supposed to supervise Resident 5 because of his behaviors. The Unit Manager stated she received the report on the day of the incident but did not notify the responsible party or report to the Abuse Coordinator until several days later, and acknowledged that the facility’s abuse reporting protocol required reporting within two hours to the Ombudsman, CDPH, and police. The facility’s 5-day investigation report described the event as an alleged inappropriate physical interaction that occurred in Resident 4’s room, and the facility policy required alleged abuse to be reported immediately, but not later than two hours when abuse was involved.
Missed Quarterly Care Conferences
Penalty
Summary
The facility failed to facilitate person-centered care planning meetings for one resident when the interdisciplinary team did not hold the resident’s quarterly care conferences. The resident was admitted with diagnoses including type 1 diabetes mellitus with diabetic autonomic neuropathy and acquired absence of both upper limbs below the elbows and both lower limbs above the knees. The resident’s quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. Review of the resident’s care conference records showed the last interdisciplinary care conference was held on 8/4/2025, and no additional care conferences were documented afterward. During interviews, Social Services staff confirmed the resident should have had care conferences every three months but could not find documentation explaining why they were not held. Social Services staff also confirmed there were no documented care conferences in 10/2025, 1/2026, or 4/2026, and MDS nurses stated quarterly care conferences should have been completed so residents would know the plan of care and whether their needs were being met.
Failure to Monitor SCD Use and Document Skin Care
Penalty
Summary
The facility failed to provide care according to orders and professional standards for one resident who had an order for sequential compression devices (SCDs) to both lower legs every shift for DVT prevention. The resident had diagnoses including malignant neoplasm of overlapping sites of urinary organs, myelodysplastic syndrome, and type 2 diabetes mellitus. The record review and interviews showed licensed nurses had no documentation of the resident’s SCD use or care, including no documented monitoring of bilateral lower leg skin condition or circulation, and no care plan was developed for SCD use. The Director of Sub-Acute confirmed the resident had SCDs in use and stated the resident had plastic sleeves that were rough. The DSA also stated the resident developed blisters to the legs and that the physician saw discoloration and blisters to the left lower leg, with the family member insisting on transfer to the hospital. The DSA confirmed licensed nurses should have monitored the resident’s skin every two hours while the SCDs were in use, but there was no monitoring of the bilateral lower leg skin condition since SCD use began. Licensed nurse documentation showed the resident had a change in condition with poor circulation and an intact fluid-filled blister on the left lower leg, and the resident was transferred to the ER for further evaluation. Hospital records documented blisters to both lower extremities, bilateral foot discoloration, skin tears, and heel redness, with notes stating the resident had been on compression therapy and that the lower legs and feet were swollen and painful. The DON confirmed there was no documentation of SCD care such as skin and circulation checks and that no care plan had been developed for SCD use.
Delayed Availability of Fidaxomicin
Penalty
Summary
The facility failed to ensure the availability of fidaxomicin for one resident who had an order for fidaxomicin 200 mg by mouth twice daily for C. difficile-associated diarrhea. The resident’s January 2026 MAR showed missed doses on 1/29/26 at 0900, 1/29/26 at 1700, 1/30/26 at 0900, and 1/30/26 at 1700, with documentation reflecting drug refusal on two doses, drug not available on one dose, and one unsigned dose with no documentation. The resident’s diagnoses included Parkinson’s disease and cardiogenic shock. Progress notes showed that on 1/29/26 the nurse documented the antibiotic was not available and that pharmacy was contacted for follow-up, with delivery expected on 1/30/26 at 1:00 p.m. The consultant pharmacist later confirmed the medication was not in the e-kit. The pharmacist also stated the pharmacy received the order on 1/28/26 at 10:16 p.m. and that fidaxomicin was a high-cost medication requiring authorization from the facility. The pharmacy sent a Prior Authorization for High Cost Medication to the facility on 1/29/26, but the signed authorization was not received by the pharmacy until 1/31/26 at 12:06 a.m., after which the medication was dispensed for delivery. A pharmacy delivery receipt showed fidaxomicin was delivered on 1/31/26 at 5:00 a.m. During this period, a nurse practitioner documented significant hematochezia with mucoid stool, noted recent hospitalization for septic shock related to C. difficile infection, and stated fidaxomicin was unavailable per pharmacy, limiting treatment options at the facility.
Failure to Check on Resident Calling for Help During Shift Change
Penalty
Summary
The facility failed to ensure that Resident 1 was provided needed care and services in accordance with the resident’s preferences and goals when the resident was heard shouting for help during shift change and was not checked by staff. During a concurrent observation and interview on 4/9/26 at 2:53 p.m. outside Resident 1’s room, the resident could be heard shouting “Help” while the door was open. Staff were observed completing shift report, and CNA A was using a tablet attached to the wall in the hallway near the resident’s room. Multiple staff passed by the room without checking on the resident, and CNA A stated, “He’s always like that,” when asked if it was acceptable not to check on the resident. CNA B stated, “He just says things,” when asked if the resident should be checked when asking for help. Resident 1 was admitted on 7/4/25 and had diagnoses including cauda equina syndrome, atherosclerotic heart disease, bilateral primary osteoarthritis of the knee, dementia, Alzheimer’s disease, and syncope and collapse. The MDS dated 3/26/26 showed a BIMS score of 3, indicating severe cognitive impairment. During interview, the DON stated staff must check on residents asking for help and must always be polite and professional. The ADM stated Resident 1 usually yells for help even if it is nothing, but staff must always check on the resident to ensure assistance is given when needed. The CNA job description stated residents are to be monitored and supervised at all times to ensure safety, and the facility’s Resident Rights policy stated residents have the right to be treated with respect, kindness, and dignity and to be free from neglect.
Failure to Provide Skin Moisturizing and Nail Care for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary grooming and personal care services, including skin moisturizing and nail care, to a dependent resident. The resident was admitted with multiple complex medical conditions, including respiratory failure with hypoxia, MRSA infection, tracheostomy status, and gastrostomy status, and was documented on the MDS as having both long-term and short-term memory problems and being dependent for all ADLs. During multiple observations in the resident’s room, surveyors and nursing staff noted that the resident’s bilateral lower legs and heels were very white and scaly due to dryness. A LVN, an RN, a CNA, the DON, and facility policies all confirmed that CNAs and/or licensed nurses were responsible for moisturizing residents’ skin during ADL care, after bed baths and showers, and as needed, but this was not done for this resident. The facility also failed to provide appropriate nail care for the same resident. On observation, the resident’s left great toenail was long, thick, and light yellow; the left second toenail was long, curved, and brown/black; the right great toenail was long and thick; and both fingernails were long and thick. The RN confirmed the nails were long and stated CNAs should have trimmed the resident’s fingernails and toenails, noting the resident did not have diabetes. The DSA stated that CNAs trimmed residents’ nails every Saturday and could also do so on shower days, and that CNAs and LNs were responsible for nail trimming when not complicated. The resident’s shower days were identified, and a shower day skin inspection record showed that the CNA documented that fingernails did not need clipping and left the toenail clipping section unmarked, despite the observed condition of the nails. Further record review and interviews showed that there was an existing podiatry order for the resident, but the resident’s insurance did not cover the facility’s podiatrist, and the family owed the podiatrist money, so services were withheld until payment was made. Social services confirmed that the administrator had not been informed of this issue and it had not been brought forward for guidance. The DON stated that CNAs or LNs should trim nails for non-diabetic residents and that CNAs should notify LNs and social services when diabetic residents needed toenail trimming. A later podiatry note documented that the resident’s nails were long and thickened to about one inch, with a bruise on the right big toe and a mild ingrown nail on the left second toe. Facility policies on bathing, nail care, foot care, and ADL support all required routine skin observation, moisturizing, daily cleaning, regular trimming of nails, and provision of foot care in accordance with professional standards, which were not carried out for this resident.
Failure to Clean or Dedicate Blood Pressure Equipment for a Resident on Contact Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices when a nurse used non-dedicated equipment in a contact isolation room without cleaning and disinfecting it afterward. Resident 1’s record showed admission with respiratory failure with hypoxia, MRSA infection, tracheostomy status, and gastrostomy status, and a physician’s order for contact precautions every shift due to carbapenemase-producing organisms. Contact isolation signage was posted on the resident’s door, and staff interviews confirmed the resident was on contact isolation for multidrug-resistant organisms (CRO/CPO). CDC guidance and the facility’s MDRO policy required the use of dedicated or disposable equipment for residents on contact precautions, or cleaning and disinfection of shared equipment between residents. During observation inside the resident’s room, an LVN donned gown and gloves, brought a battery-operated BP apparatus from the medication cart into the room, placed it on the bed, and used the cuff on the resident’s right lower leg to obtain a blood pressure reading. After use, the LVN removed the gown and gloves while holding the BP device, then carried the BP apparatus out of the room with bare hands and placed it on top of the medication cart without cleaning or sanitizing it. In interviews, the LVN confirmed there was no dedicated BP device in the room, acknowledged that each contact isolation room should have a dedicated BP apparatus, and stated she should have cleaned and sanitized the device before removing it from the room. The director of sub-acute and the infection preventionist both stated that dedicated BP devices were to be used for contact isolation residents and that equipment should be cleaned after each use, consistent with CDC and facility policy, which was not followed in this instance.
Improper GT Reinsertion by Untrained Staff Leading to Misplacement and Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to provide services according to professional standards when nursing staff reinserted a resident’s gastrostomy tube (GT) without proper training, competency, and verification of placement. The resident had chronic respiratory failure with hypoxia, was ventilator‑dependent, had Ogilvie syndrome, and a longstanding GT. On the day of the incident, nursing alert charting documented that at 4:00 p.m. the resident’s GT was found out. The assigned RN could not locate the ordered 16 Fr GT and instead used a 20 Fr GT for reinsertion. The charting noted scant bleeding at the stoma and stated that GT placement was confirmed by two nurses and that the physician was notified and approved continuation of feeding. Interviews and record review showed that the nurses who performed and assisted with the reinsertion (an RN and an LVN) had not received training or demonstrated competency in GT reinsertion at the time of the procedure, despite facility policy requiring that PEG tube replacement be performed only by licensed nurses who have received training and demonstrated competency. The Director of Staff Development confirmed that these nurses did not have a training and competency checklist for GT reinsertion until a later date, and that nurses without such training were not supposed to reinsert GTs. The LVN who reinserted the tube stated he used a 20 Fr GT because no 16 Fr was available and verified placement by aspirating stomach contents and injecting 40 ml of air while another nurse listened for a whooshing sound. Another LVN explained that when the ordered size is unavailable, staff should try to use a smaller size rather than a larger one because a larger tube might rupture something, and demonstrated that a 20 Fr GT is significantly larger than a 16 Fr GT. Following the reinsertion, the resident developed a change in condition documented in the SBAR/change of condition note: low oxygen level and abdominal distension were noted, and later respiratory distress occurred, prompting a 911 call and initiation of CPR by facility staff. The resident was transferred to the hospital, where ICU records documented severe septic shock due to a catastrophic intra‑abdominal process from a misplaced G tube. A MICU progress note described the abdomen as significantly distended and tense, and a CT scan showed the PEG entering the peritoneum with free fluid and contrast in the peritoneal cavity. The hospital death summary stated that surgical intervention to address the PEG misplacement would likely require multiple surgeries and would not improve quality of life but add considerable pain, and documented that the resident subsequently died at 11:55 p.m. The facility’s own policy on changing a PEG tube required that the procedure be performed only by a trained, competent licensed nurse and that detailed documentation of the procedure and assessments be entered in the medical record, requirements that were not met in this case.
Failure to Implement and Document Insomnia Care Plan Interventions
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement a comprehensive, person-centered care plan for a resident with insomnia. The resident’s admission record documented multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, major depressive disorder, anxiety disorder, and insomnia. The resident had a physician’s order for Zolpidem Tartrate 5 mg, to be given by mouth as needed for insomnia for 14 days, with instructions that 1 to 2 tablets could be given as needed. The resident’s care plan for insomnia, initiated on 9/12/2023, included specific non-pharmacological interventions such as repositioning/limb elevation, snacks/drinks, redirection/reassurance/emotional support, deep breathing/relaxation exercises, and monitoring and recording the number of hours of sleep, as well as trying measures like avoiding heavy meals, caffeine, and large fluid intake before sleep and offering milk. Review of the resident’s September 2023 nursing progress notes and MAR showed no documentation that the resident’s hours of sleep were monitored or that the listed non-pharmacological interventions were provided. During an interview and concurrent record review, the infection preventionist nurse confirmed that there was no documentation of sleep monitoring or non-pharmacological interventions and acknowledged that the insomnia care plan had not been implemented. In a separate phone interview, the DON stated that if the care plan directed nurses to monitor hours of sleep and provide non-pharmacological interventions, those interventions should have been implemented and documented in the nurse’s notes or MAR. The facility’s policy on comprehensive person-centered care plans, revised March 2022, required development and implementation of care plans with measurable objectives and timetables to meet residents’ needs, underscoring that the required insomnia care plan interventions for this resident were not carried out or documented.
Failure to Provide Accessible Call Light or Alternative for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident was found without access to a functioning call light or an alternative call bell at bedside. During observation and interview, the resident reported that the call light in her room had not been working for two weeks and that she did not have a call bell available. The resident stated she had to call the front desk for assistance, which resulted in delays. A treatment nurse confirmed the absence of a call bell after searching the resident's bedside area and acknowledged that the call lights in the room were not operational. The Director of Nursing later confirmed that bells were supposed to be provided to all residents in the affected area, and that residents were expected to have a bell at bedside until the call lights were repaired. The resident involved had a history of hemiplegia and hemiparesis, requiring varying levels of assistance with activities of daily living, including being dependent for toileting, lower body dressing, and transfers. The resident was cognitively intact, as indicated by a BIMS score of 15. Facility policy required that call lights or their alternatives be accessible to residents at all times, including when in bed, on the toilet, or in the shower. The failure to provide a call bell or functioning call light was contrary to these policies and procedures.
Failure to Provide Physician-Ordered Occupational Therapy Services
Penalty
Summary
The facility failed to provide occupational therapy (OT) services as ordered by a physician for one resident. The physician's order specified that the resident should receive skilled OT five times per week for eight weeks, including specific therapy modalities. However, therapy records and interviews revealed that the resident received OT only three or four times per week on several occasions, with multiple therapy sessions missing and no documented reasons for the absences. The Director of Rehab and the Assistant Director of Rehab both confirmed that the resident did not consistently receive therapy according to the physician's order. The resident, who was admitted with a diagnosis of muscle weakness and was cognitively intact, reported that therapy sessions were skipped due to insufficient therapy staff. The resident expressed that therapy was beneficial for self-care and that he needed more therapy, but sessions were reduced due to staffing shortages. Facility policy required therapy services to be scheduled in accordance with the resident's treatment plan, but this was not followed in the resident's case.
Failure to Report Injury of Unknown Source as Required by Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy and procedure when it did not report an injury of unknown source for a resident. The resident, who had a history of hemiplegia, hemiparesis following a stroke, dysphagia, and was chronically bedbound, was found with discoloration and swelling on the right side of the face and ear. Multiple staff members, including nurses and the assistant director of nursing, observed the injury but could not determine its cause. The resident was able to communicate but was unaware of how the injury occurred, and there were no documented falls or behavioral incidents that could explain the injury. Despite the facility's policy requiring immediate reporting of injuries of unknown source to state agencies, law enforcement, and the ombudsman, the injury was not reported to any of these authorities. Staff interviews revealed that the incident was discussed internally, with some staff assuming the injury was caused by a feeding pump falling on the resident, although no one witnessed this event and some staff questioned the plausibility of this explanation given the resident's physical limitations. The interdisciplinary team reviewed the case days after the initial discovery, but the possible contributing factors were not documented, and the injury was not care planned. Key staff members, including the DON, ADONs, and the administrator, confirmed that the injury was not reported externally because they believed the cause had been determined or deferred the decision to others. The facility's social services staff was not informed of the incident, and several nurses and CNAs expressed uncertainty about reporting requirements, with some believing it was the administration's responsibility. The facility's policy clearly states that all injuries of unknown source must be reported to the appropriate agencies within 24 hours, but this was not followed in this case.
Widespread Infection Control Failures and Lapses in PPE Use
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed throughout the facility. Staff failed to maintain proper handling of medical equipment, such as allowing a urinary catheter drainage bag to touch the floor and leaving oxygen tubing and enteral feeding tube tips exposed or improperly stored. In several instances, staff did not perform hand hygiene or change personal protective equipment (PPE) between resident care tasks, including when assisting with meals, handling invasive devices, or entering and exiting isolation rooms. There were also failures to don appropriate PPE when entering rooms of residents on contact or COVID-19 precautions, and improper use of disinfectant wipes for hand hygiene was noted. Communication lapses were identified, such as the failure to notify a dialysis center of a resident's isolation status and infection type. Signage and isolation carts for contact precautions were either missing or not clearly visible at room entrances, and PPE was not always readily accessible. Staff were observed entering contact precaution rooms without proper PPE, and in one case, a staff member used hand sanitizer instead of washing hands with soap and water after contact with a resident with C. difficile infection, contrary to CDC guidelines. Additionally, a registered nurse was observed wearing a double mask (N-95 over a surgical mask) when only an N-95 was required, potentially compromising the effectiveness of the respirator. Further deficiencies included improper cleaning and disinfection of shared medical equipment, such as using alcohol wipes instead of the required disinfectant for glucometers, which may not be effective against certain bloodborne pathogens. Staff also failed to ensure that oxygen cannulas not in use were stored properly, and that oxygen tubing was not entangled or lying on the floor. These actions and inactions were directly observed and confirmed through staff interviews and review of facility policies, highlighting widespread non-compliance with established infection control protocols.
Failure to Maintain Resident Dignity and Privacy During Care and Mealtimes
Penalty
Summary
The facility failed to uphold residents' dignity and privacy in several observed instances. One resident with severe cognitive impairment and a history of removing her clothing was found half-naked in bed with her privacy curtain only half drawn, making her visible to others in the room. Staff confirmed that there was no care plan in place to address this behavior, and that the resident should be checked more frequently, especially when family was not present. The facility's policy required staff to treat cognitively impaired residents with dignity and to address the root causes of such behaviors, but this was not followed in this case. Additionally, the Assistant Director of Nursing referred to residents' clothing protectors as "bibs" in front of approximately 15 residents during a mealtime, which was confirmed in an interview. In another instance, a CNA was observed assisting a resident with eating while standing over her, despite facility policy requiring staff to sit while feeding residents to maintain dignity. These actions were observed in the dining room and had the potential to affect the psychosocial well-being of multiple residents present.
Failure to Reposition Bedbound Residents with Pressure Ulcers
Penalty
Summary
Staff failed to provide appropriate pressure ulcer care and prevention for two residents who were immobile and unable to reposition themselves. Multiple observations over two consecutive days showed that both residents remained lying on their backs for extended periods, despite care plans and medical records indicating the need for repositioning every two hours or as needed. Certified Nursing Assistants (CNAs) and other staff did not consistently implement these interventions, and one CNA stated that repositioning was not necessary for one of the residents, contrary to established protocols. Resident 190 had a history of severe medical conditions, including aphasia, chronic respiratory failure, hemiplegia, and a stage 4 pressure ulcer on the sacral/coccyx region, as well as deep tissue damage on the left heel. The resident was non-ambulatory, required extensive assistance with bed mobility, and was cognitively impaired. Despite these needs, observations confirmed that the resident was not turned or repositioned as required, and the wound size remained unchanged over several days. The care plan specifically called for repositioning every two hours, but this was not consistently followed. Resident 546 also had significant medical issues, including pneumonia, respiratory failure, diabetes, and lower extremity embolism and thrombosis. This resident was similarly non-ambulatory, cognitively impaired, and dependent on staff for repositioning. Observations revealed that the resident was left lying on her back for long periods, and staff reported difficulties in repositioning due to lack of appropriate equipment, such as a wedge pillow. The facility's own policy emphasized the importance of frequent repositioning, especially for residents with existing pressure ulcers, but these guidelines were not adhered to in practice.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide proper care and treatment for residents receiving oxygen therapy. Two residents with orders for continuous oxygen via concentrator were observed with thick grayish substance buildup on the filters of their oxygen concentrators, despite physician orders and facility policy requiring weekly cleaning or changing of the filters. The infection preventionist was unsure who was responsible for this task, and the DON stated it should have been done weekly by nurses or central supply staff. Both residents had significant respiratory diagnoses, including acute respiratory failure, hypoxia, pneumonia, and COPD, and were observed in bed on oxygen therapy at the time of the deficiency. Additionally, another resident with a diagnosis of COPD was administered oxygen at a rate of 5 liters per minute, contrary to the physician's order for 2 liters per minute via nasal cannula. The LVN present acknowledged awareness of the correct order but did not adjust the oxygen flow. The resident's care plan also specified that oxygen should be administered as ordered. Facility policy required verification of physician orders prior to oxygen administration, but this was not followed in this instance.
Failure to Assist Resident After Call Light Activation
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to assist a resident who requested help transferring from bed to wheelchair. During observation, the resident, who has diagnoses including primary osteoarthritis of the ankles, feet, and hips, muscle weakness, and difficulty walking, pressed the call light for assistance. The CNA entered the room, turned off the call light, and left without providing any help. The CNA later confirmed in an interview that no assistance was given at that time. Interviews with facility staff, including the case manager and the director of nursing, confirmed that staff are expected to ask residents if they need help before turning off the call light and to address residents' needs whenever the call light is activated. Review of the facility's policy on answering call lights also indicated that staff should respond immediately and fulfill requests within five minutes if possible. The resident's medical record and assessment showed she was cognitively intact but physically limited, further emphasizing her need for assistance.
Failure to Post Daily Nurse Staffing Information at All Nursing Stations
Penalty
Summary
The facility failed to post direct care staffing numbers and the names of nursing staff responsible for resident care in a prominent place at each of the four nursing stations. Observations on multiple hallways revealed that no staff schedule or direct patient care hours were posted or accessible to residents in Hallways 2, 3, 4, and 5. During an interview, the DON confirmed that staffing information was only posted in Hall 1, near the main entrance, and acknowledged that direct daily patient care hours and staffing schedules had never been posted elsewhere in the facility. No specific residents or their medical histories were mentioned in relation to this deficiency.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for several residents. In multiple instances, nursing staff signed out controlled medications from the Controlled Drug Record (CDR) but did not document the administration of these medications on the Medication Administration Record (MAR). This discrepancy was identified for four out of five residents reviewed, with specific examples including missed documentation for oxycodone and hydrocodone/acetaminophen administrations. The Assistant Director of Nursing (ADON) confirmed that these administrations should have been recorded on the MAR, as required by facility policy. Additionally, the facility did not consistently follow its policy for the proper disposal (wasting) of controlled medications. The records showed that wasted medications for several residents were not co-signed by a second nurse, as mandated by the facility's procedures. Specific instances included wasted doses of oxycodone, diazepam, and buprenorphine without the required witness signature. Both the Director of Nursing (DON) and a Registered Nurse (RN) acknowledged that the double signature was missing in these cases and confirmed that the policy requires two signatures for wasted controlled substances. A review of the facility's policies confirmed that staff are required to document medication administration on the MAR and to have two signatures for the wasting of controlled substances. The survey findings demonstrated that these procedures were not consistently followed, resulting in incomplete records for both the administration and disposal of controlled medications.
Unpalatable and Overcooked Food Served to Residents
Penalty
Summary
The facility failed to ensure that food served to residents on a Regular Diet was palatable, as evidenced by multiple observations and resident interviews. During dining observations, one resident refused to eat mashed potatoes, stating they had no flavor and did not taste good. Other residents reported that the food was terrible, lacked flavor, and that vegetables, specifically carrots, were overcooked and mushy. These observations were corroborated by residents who did not finish their meals due to the poor quality of the food. A lunch test tray review conducted with the Dietary Manager, Dietary Director, and Registered Dieticians confirmed that the mashed potatoes served on both Regular and Pureed Diet trays lacked flavor. The facility's ordered diet list indicated that 105 residents were on Regular or Pureed diets. A review of the facility's policy and procedure on Food Preparation stated that food should be prepared to conserve nutritive value, flavor, and appearance, which was not adhered to in these instances.
Failure to Provide Evening and Bedtime Snacks to All Residents
Penalty
Summary
The facility failed to ensure that evening and bedtime snacks were offered to all residents, as required by their own policy and federal regulations. Multiple residents reported during interviews and a Resident Council meeting that they had never received snacks, particularly after the kitchen closed in the evening. Staff interviews confirmed that snacks were only provided to residents with a physician's order, and that there were no snacks available for other residents after kitchen hours. The kitchen closed at 7 p.m. or 9:30 p.m., and there was no system in place for nursing staff to access or provide snacks outside of these hours. Residents expressed that they sometimes wanted snacks at night, but their requests were not accommodated. One resident with diabetes specifically reported not receiving her ordered bedtime snack, despite having a diagnosis that requires careful blood sugar management. The registered dietitians confirmed that snacks were only prepared for residents with physician orders, and that nurses were expected to provide these snacks if requested. However, both nursing and dietary staff indicated that there was no storage or process for providing snacks after kitchen hours, resulting in residents, including those with medical needs, not receiving snacks as ordered or requested. The facility's own policy stated that bedtime snacks should be routinely offered to all residents unless contraindicated, but this was not being followed.
Deficiencies in Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and sanitation. An opened box of frozen fish was found in the freezer without a use by date, and two opened cereals in the dry pantry were not labeled with open or use by dates. The Dietary Manager confirmed that these items should have been labeled according to facility policy, which requires all food items in storage to be labeled and dated. Additionally, facility guidelines specify that ready-to-eat cereals can be stored for two months after opening, but the lack of labeling made it impossible to determine compliance. Further observations revealed that a metal container was stored while still wet, which was confirmed by the Registered Dietician, who stated that containers must be dry when stacked. During food preparation, a dietary aide placed a metal container in a wet food preparation sink and poured pureed meat into it, rather than using a dry container and scooping the food as per best practice. The Dietary Director acknowledged that the preferred method is to scoop pureed food into a container rather than placing the container in the sink. These actions were not in accordance with the facility's policies and procedures for food preparation and sanitation.
Failure to Document Use of Peek-a-Boo Mitten in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards for one resident who was using a peek-a-boo mitten to prevent removal of a gastrostomy tube. The resident, who had diagnoses including obstructive hydrocephalus, benign neoplasm of the spinal cord, other specified brain disorders, dysphagia, and was receiving care for a gastrostomy, had severe cognitive impairment as indicated by a BIMS score of 0. An order for the use of a peek-a-boo hand mitten was present in the resident's clinical record since admission. Despite the ongoing use of the mitten, the resident's weekly summaries did not document its use or any related observations in multiple entries over several weeks. The DON confirmed that the restraint box should have been checked and relevant behaviors or observations should have been documented, but this was not done. The facility's own policy required that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented objectively, completely, and accurately, which was not followed in this case.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. In the first incident, one resident was observed by a CNA to strike another resident in the face and push her to the floor as they crossed paths in the hallway. The aggressor was described as having a history of anger outbursts and being aggressive toward both staff and other residents, with previous attempts to physically harm staff. The victim sustained redness to the left side of her face as a result of the assault. Documentation and witness interviews confirmed the unprovoked nature of the attack and the aggressor's inability to be easily redirected. In a separate incident, the same resident entered the activities room and, without provocation, slapped another resident multiple times on the head while she was sitting at a table. This event was also witnessed by a CNA, and the victim sustained redness on her forehead. Both incidents were reported to the appropriate authorities and documented in mandated reports and facility investigative records. The facility's policy states a commitment to protecting residents from abuse by anyone, including other residents, but these events demonstrate a failure to uphold that standard.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information for two residents. In one instance, a resident was observed in bed with care instructions posted above the head of the bed, including details such as the need to elevate the head of the bed during feeding and instructions related to left side weakness and repositioning. These instructions were visible to the roommate's visitors. The assistant director of nursing confirmed that the care instructions were still posted and acknowledged that they should have been covered. In another case, a different resident had a care instruction posted above the bed indicating a choking risk and specifying 'no food by mouth.' This information was also visible in the room. A licensed vocational nurse confirmed the observation and stated that the care instruction should not have been posted in that manner. The director of nursing further confirmed that care instructions should be covered when posted. Facility policy reviewed indicated that confidential clinical information, including care needs, should not be openly posted in resident rooms, except for discreet postings for safety reasons.
Inaccurate PASARR Screening for Mental Disorder
Penalty
Summary
The facility failed to ensure that a pre-admission screening and resident review (PASARR) was accurately completed for one resident. The resident was admitted with multiple diagnoses, including acute respiratory failure, influenza, emphysema, and schizotypal disorder. The clinical record showed the resident was prescribed Trazodone for depression and was being monitored for behaviors associated with schizotypal disorder, such as social anxiety and a preference for solitary activities. Despite these documented mental health conditions and the use of psychotropic medication, the PASARR Level I screening indicated negative for serious mental illness, with questions regarding diagnosed mental disorders and psychotropic medication use both marked as "no." During an interview, the MDS director confirmed the resident's diagnoses and medication use, and acknowledged that the PASARR was completed by hospital staff and should have indicated "yes" for those questions. The facility's policy requires all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders per the PASARR process.
Failure to Develop and Implement Care Plan for Resident's Disrobing Behavior
Penalty
Summary
The facility failed to develop and implement an individualized, resident-centered care plan for a resident who exhibited the behavior of pulling off her clothes or facility gown. The resident, who was admitted with diagnoses including obstructive hydrocephalus, benign neoplasm of the spinal cord, other specified brain disorders, dysphagia, and a gastrostomy, had a severe cognitive impairment as indicated by a BIMS score of 0. Multiple observations revealed the resident was frequently found half naked in her bed, with her upper chest exposed, and her privacy curtain only partially drawn, making her visible to others in the room. Interviews with staff, including a CNA, social services, RN, and the DON, confirmed that the resident had a known behavior of stripping off her gown and that there was no care plan in place to address this behavior. Staff acknowledged the need for frequent checks, especially when family was not present, but no formal interventions or strategies had been documented or implemented. Review of facility policy indicated that the interdisciplinary team is responsible for developing comprehensive, person-centered care plans, but this process was not followed for the resident's specific behavioral needs.
Failure to Administer Medications and Monitor Vital Signs per Physician Orders
Penalty
Summary
A resident with diagnoses of paroxysmal atrial fibrillation and acute on chronic combined systolic and diastolic heart failure did not receive treatment and care in accordance with professional standards of practice. Physician orders required administration of Diltiazem and Carvedilol for hypertension, with specific parameters to hold the medications if systolic blood pressure was less than 100 or pulse was less than 60. The resident's medical record showed that Carvedilol was last administered at 9 a.m. and Diltiazem at 1 p.m. on the day prior to the resident being found unresponsive. Blood pressure was last checked at 11:09 a.m. and pulse at 6 p.m., with the pulse noted to be elevated at 103 beats per minute. There was no documentation explaining why the afternoon doses of Carvedilol and Diltiazem were not given, nor why vital signs were not checked in the afternoon. The Director of Nursing confirmed during interview and record review that the lack of documentation for missed medication administration and vital sign monitoring was not in accordance with facility policy. Facility policies required that vital signs be obtained as appropriate and that all medications administered, as well as procedures and treatments, be documented in the resident's medical record, including reasons for refusal or omission. The failure to follow these protocols resulted in a deficiency related to providing treatment and care according to orders and professional standards.
Failure to Provide Timely Podiatry Services for a Resident with Diabetes and Mobility Impairments
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including hemiplegia, hemiparesis, and diabetes, did not receive necessary podiatry services as ordered. The resident's clinical records indicated an order for podiatry evaluation, treatment, and follow-up every 61 days and as needed. Despite the resident's request for podiatry services, her toenails were observed to be long, thick, and growing inward, causing her pain and concern for potential ingrown toenails or infection. The resident reported that although she was shown documentation stating she had been seen by the podiatrist, she was not actually seen, and her toenails remained untreated. Interviews with staff confirmed that the resident's request for podiatry services was documented, but she was not scheduled or seen during the most recent podiatry visit. Observations by both staff and surveyors confirmed the resident's toenails were not trimmed and did not appear to have been recently cared for by a podiatrist. The facility's policy requires referral to qualified professionals for residents with medical conditions associated with foot complications, but this was not followed in the resident's case.
Failure to Monitor Vitamin Supplement Levels as Ordered
Penalty
Summary
A resident with a history of B group vitamin deficiency and falls was admitted and prescribed daily cyanocobalamin (vitamin B12) and vitamin D3 supplements. The physician's orders included routine monitoring of vitamin D levels every six months and ongoing administration of vitamin B12 for deficiency. However, a review of the clinical record revealed that no vitamin D laboratory results were available for the specified monitoring periods, and no vitamin B12 level had been drawn since the initiation of the order over two years prior. During an interview and record review, the Assistant Director of Nursing confirmed the absence of required vitamin D and B12 laboratory results, despite efforts to locate them. The facility's policy required staff and physicians to evaluate the effectiveness and effects of medications, but this was not followed, as evidenced by the lack of laboratory monitoring for the resident's prescribed supplements. This resulted in inadequate monitoring related to medication management for the resident.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was discharged without the necessary home health services as ordered by the physician. The resident, who had a history of hearing loss, a gastrostomy, and malignant neoplasm of the larynx, was discharged on January 1, 2025, without an established home health agency to provide the required physical therapy, occupational therapy, speech therapy, registered nurse services, and durable medical equipment. The resident was picked up by a friend of the Social Services Assistant (SSA) in a private car, and it was noted that the resident's home was cluttered and that the resident required assistance with feeding through the gastrostomy tube. The SSA admitted that the referral to the home health agency was not confirmed before the resident's discharge, and the initial referral was denied by the agency due to the lack of speech therapy services. As of January 6, 2025, the resident still did not have a home health agency in place. The facility's policy required that a post-discharge plan be developed, including arrangements for follow-up care and services, but this was not provided. The Director of Nursing confirmed that the physician's discharge orders must be followed, indicating a failure in adhering to the established discharge procedures.
Deficiencies in Care Planning and Medication Documentation
Penalty
Summary
The facility failed to provide services according to professional standards for a resident with multiple complex medical conditions, including malignant neoplasm of the esophagus, secondary malignant neoplasm of unspecified lung, liver, intrahepatic bile duct, and digestive organs, severe protein-calorie malnutrition, dysphagia, and gastrostomy status. The baseline care plan for the resident's dysphagia and tube feeding was not developed in a timely manner, being completed five days after admission instead of within the required 48 hours. This delay was confirmed by the registered dietitian and social worker involved in the care planning process. Additionally, upon the resident's admission, the facility did not have the prescribed tube feeding formula in stock. The resident's family member had to obtain the formula from the hospital, and the facility staff failed to notify the dietitian or the attending physician to obtain an alternative formula. The new tube feeding formula was only initiated five days after admission, which was confirmed by the director of nursing and assistant director of nursing. Furthermore, there was an issue with medication administration documentation. A licensed vocational nurse incorrectly initialed the medication administration record for an IV antibiotic administered by a registered nurse. This error was acknowledged by the director of nursing and assistant director of nursing, who confirmed that the registered nurse should have documented the administration. The facility's policy requires the individual administering the medication to document it in the resident's medical record.
Delayed Administration of IV Antibiotics and Medication Errors
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of three residents, resulting in delayed administration of intravenous (IV) antibiotics. Resident 1, who was admitted with multiple diagnoses including malignant neoplasm of the esophagus and severe protein-calorie malnutrition, did not receive the ordered Vancomycin at the scheduled times. The first dose was administered late on the evening of 7/11/2024, and the second dose was delayed until the afternoon of 7/12/2024. Despite having Vancomycin available in the emergency kit, the medication was not administered on time, as confirmed by the licensed vocational nurse and the director of nursing. Resident 2, diagnosed with chronic respiratory failure and infections including MRSA, also experienced a delay in receiving Vancomycin. The medication was scheduled for 8:00 p.m. on 12/21/2024 but was not administered until 10:51 p.m. The registered nurse responsible for Resident 2's care cited a clogged IV access as the reason for the delay, but there was no documentation to support this claim, and no PICC line was inserted as stated. Resident 3, with a history of chronic osteomyelitis and MRSA infection, was scheduled to receive Vancomycin at 9:00 p.m. on 12/9/2024, but the medication was not given until 1:36 a.m. the following day. There was no documentation explaining the delay. Additionally, a nurse used another resident's normal saline to mix Vancomycin for Resident 1, which was confirmed by the assistant director of nursing. This action was against the facility's policy, which requires using the emergency kit for such needs and verifying medication labels three times to ensure the correct resident receives the correct medication.
Failure to Notify Physician of Resident Fall During Physical Therapy
Penalty
Summary
The facility failed to promptly notify the physician when a resident fell during a physical therapy session and sustained minor injuries. The incident involved a resident who was admitted with diagnoses including oral surgical aftercare, cancer, and reduced mobility. During a physical therapy session, the resident fell outside the facility, resulting in small excoriations on both knees. The physical therapist did not report the fall to the nursing staff, as the resident's son had already informed them. This delay in communication had the potential to result in a delay of assessment and possible treatment. Interviews with facility staff revealed that the physical therapist did not consider the fall a reportable event and therefore did not notify the charge nurse. The Director of Rehab and the Assistant Director of Nursing confirmed that the therapist should have reported the fall immediately to the nursing staff. The facility's policy requires prompt notification of changes in a resident's condition to the physician and responsible representative. The failure to adhere to this policy led to a delay in assessing and treating the resident's injuries.
Failure to Promote Respect and Dignity for Resident
Penalty
Summary
The facility failed to promote respect and dignity for a resident when a social services staff member threatened to call 911 for a 5150 assessment. The incident occurred when the resident was advocating for her roommate, who was experiencing a fever. The social services staff member's threat made the resident feel threatened and led her to call the police herself. The facility's management did not address the issue or clarify the situation with the resident afterward. Interviews with other staff members confirmed that the resident was cognitively intact and had no history of being a danger to herself or others. The resident had a history of type 1 diabetes, major depression disorder, anxiety disorder, pancreatic cancer, and the absence of both upper limbs below elbows and both legs above knees. The social services staff member involved was not the resident's assigned social services staff and had been directed not to communicate with the resident. The facility's policy and procedure on resident rights emphasized treating all residents with kindness, respect, and dignity, which was not upheld in this situation.
Failure to Ensure Medication Administration Compliance
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice when a licensed nurse did not observe a resident taking their medications. The resident, who had multiple diagnoses including fractures, hypertension, hyperlipidemia, and atrial fibrillation, was found to have their morning medications left at their bedside. The medications were documented as given in the Medication Administration Record (MAR), but the nurse did not verify that the resident had actually taken them before attending to another resident. The incident was discovered when a family member notified the Case Manager about the medications found at the resident's bedside. A certified nursing assistant confirmed seeing the pills but did not report it to anyone. The licensed vocational nurse later acknowledged that he had documented the medications as given without observing the resident taking them. He admitted that he should have ensured the resident took the medications and reported the incident to the physician and the Director of Nursing (DON). The DON confirmed that the nurse had left the room during the medication administration process and had documented the medications as given. The facility's policy on administering medications requires that medications be administered within one hour of their prescribed time and that any discrepancies be reported. The nurse was re-educated on the proper procedures for medication administration and observation to ensure compliance with professional standards of practice.
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Illustrative
What surveyors actually found near you
We read the 438 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Childrens Hc Org No Ca Saratoga Pediatric Subacute | 1.6 mi | ★★★★★ | 7 | 0 |
| Creekside Post-acute | 2.2 mi | ★★★★★ | 2 | 0 |
| Baywood Post Acute | 2.3 mi | ★★★★★ | 0 | 0 |
| Courtyard Care Center | 2.5 mi | ★★★★★ | 2 | 0 |
| A Grace Sub Acute & Skilled Care | 2.8 mi | ★★★★★ | 3 | 0 |
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