Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Whittier Hills Health Care Ctr during CMS and state inspections, most recent first.
Two residents receiving IV antibiotics experienced medication management and documentation failures. One resident with cellulitis, polyneuropathy, and functional quadriplegia had ordered meropenem doses that were not documented on the IV MAR, and surveyors later found a cup with three white oral pills (identified by the resident as gabapentin, Norco, and a muscle relaxant) left on the bedside table, despite the admission record indicating the resident did not wish to self-administer and no IDT approval or bedside order. Staff interviews and facility policies confirmed that medications should not be left at the bedside, that staff must remain with residents until medications are swallowed, and that documentation must occur after administration. A second resident with DM, Parkinson’s disease, and chronic kidney disease had an ordered Zosyn dose that was also not documented on the IV MAR, and the RN Supervisor and DON acknowledged that missing documentation implied the dose might not have been given, contrary to the facility’s six rights and medication administration procedures.
A resident with Type 2 DM and dementia and the resident’s responsible party requested access to the resident’s medical records during an IDT care plan meeting attended by the SSA, RN, rehab staff, and AD. The SSA verbally agreed to obtain the records but did not document the request, did not complete the process, and did not inform the MRD. In the following weeks, the responsible party repeatedly called the facility, but the receptionist reported the SSA was unavailable and did not connect the caller with other staff. When eventually reached, the MRD stated she had not been informed of the earlier request and explained that a request form was required. The facility’s policy allowed resident access to records within 24 hours of a written or oral request, but this was not followed or explained.
Advance Directive Documentation Missing or Inaccessible: The facility failed to obtain and keep AD documentation accessible for multiple residents. Records and staff interviews showed that several residents with impaired cognition or limited decision-making capacity had no AD notification form in the chart or electronic record, and for other residents the Social Services assessment stated an AD was in place while the POLST and chart did not contain one. Staff confirmed the missing documentation and noted that the AD should be in the resident chart or uploaded to the EMR for access to resident wishes.
The facility inaccurately completed MDS ROM assessments for three residents. One resident with CVA-related deficits had impaired ROM in the left arm and needed ROM services for both arms and both legs, another resident with spinal cord cancer and functional quadriplegia had limited shoulder PROM and required restorative ROM to both arms and both legs, and a third resident with a left knee fusion and left leg cast had ROM limitations in the affected leg. Despite OT, PT, restorative, and physician documentation showing these limitations and services, the MDSs recorded no functional ROM limitation.
Failure to Post Daily Nursing Staffing Information: The facility did not keep the DHPPD and NSA posted with current nursing staffing data. During lobby observation, the posted forms were dated from prior days, and the DSD and DON stated the forms should be updated daily and as staffing changed so residents, visitors, and staff could see who was working and the staffing levels on the unit.
Food handling and sanitation deficiencies were observed in the kitchen and during tray delivery. A spice container lid was partially open above the food prep area, hot water machine spouts had a white chalky build-up, and desserts and salads on meal trays were left uncovered during transport and delivery. The DS stated the spice lid was not fully closed, the spouts had mineral deposits from hard water, and salads and desserts were not usually covered because CNAs moved trays directly to residents' rooms.
SSD Qualifications Not Verified: The facility failed to verify that the SSD met the required qualifications for the role. The SSD was first hired as MRD and later moved into the SSD position, but the employee file did not contain documented evidence of at least 1 year of supervised social work experience in a healthcare setting and direct work with individuals before employment in the SSD role. The SSD reported prior social services experience and training, but the facility could not provide documentation, and a signed SSD job description was also missing from the file.
Failure to Follow EBP During Resident Transfer: Two transportation staff entered a resident’s EBP room without hand hygiene and with gloves from a prior task, then transferred the resident to a gurney for a dialysis appointment without donning a gown or changing gloves. The resident had dementia, severely impaired cognition, and an indwelling dialysis catheter, and the IPN confirmed the staff left the room without removing gloves or performing hand hygiene.
Uncovered Catheter Drainage Bag Visible to Passersby: A resident with an indwelling catheter had the drainage bag left uncovered and visible to people walking past the room. The resident had diagnoses including urinary system disorders, DM, and acute kidney failure, and was documented as having moderate cognitive impairment. Staff, including a CNA, an LVN, and the DON, stated the catheter bag should have been covered with a privacy or dignity bag to maintain privacy, dignity, infection control, and hygiene, consistent with facility policy.
Call Light Not Within Reach for Two Residents With Limited Mobility. Two residents with hemiplegia, left-sided weakness, contractures, and cognitive or functional impairment were observed with call lights placed out of reach or positioned on the weaker side. One resident’s call light was tucked behind the shoulder, and the other resident’s call light was clipped to a pillow on the left side of the head, making it difficult to access with the more functional arm. Staff, including CNA, RN, LVN, and the DON, stated the call light should have been within reach and closer to the resident’s functional side.
A resident with a hx of CVA, dysphagia, difficulty walking, and hemiparesis was admitted with Spanish listed as the preferred language, but the admission agreement was written in English. During observation, the resident did not know how to contact the Ombudsman or State agency, and no Ombudsman or State agency information was posted in the dining room. Facility staff confirmed the agreement was not in the resident’s preferred language, despite policy stating resident rights information should be provided in a clear and understandable language.
Failure to notify the physician of residents’ change in condition. A resident with dementia and hemorrhoids developed painful discoloration of the left 2nd toe and ongoing hemorrhoid pain, but staff did not document or report the complaints to the PCP. Another resident with ARF, DM, and PNA fell, then reported right hip, shoulder, and ear pain with a skin tear/abrasion, but the primary provider did not respond and the Medical Director was not notified for further evaluation.
A resident with type 2 DM, schizoaffective disorder, and seizures was discharged with conflicting documentation: the discharge summary said the transfer was due to danger to others and aggressive behavior, while the Notice of Proposed Transfer/Discharge stated the resident had improved and no longer needed facility services. The notice also lacked a resident/representative signature, and the DON confirmed the documents did not match and should have been completed with the correct information.
MDS assessments were not timely completed and transmitted for two residents with diagnoses including DM2, muscle weakness, and acute respiratory failure with hypoxia. The MDS coordinator stated she was responsible for the 5-day MDSs and forgot to complete and transmit them, while the facility policy required accurate, complete MDS data to be electronically encoded to CMS as soon as possible.
A resident with a history of pressure ulcer, abnormal posture, and FTT had an order for a low air loss mattress for skin management, with the setting based on weight and function checked every shift. Record review and interviews with the TN and DON showed staff did not follow the physician’s order for the mattress setting, even though the resident’s weight was documented at 114 pounds and the facility policy required ordered pressure-relieving devices to be implemented as ordered.
Failure to Provide Ordered ROM and Restorative Nursing Services: The facility did not provide ordered ROM interventions for two residents with documented mobility limitations. One resident had impaired ROM in the arm and hand, and staff did not provide restorative ROM to both legs after therapy discharge. Another resident, who had a stroke history, severe cognitive impairment, and a clenched fist contracture, had restorative PROM to both arms and legs discontinued after hospice admission, and staff confirmed the resident went days without ROM despite prior therapy recommendations and ongoing limited movement.
Failure to monitor fluid intake for two residents on HD with ESRD and a 1000 mL/day fluid restriction. One resident had documented intake that exceeded the ordered limit on multiple days, and another resident's MAR lacked shift-by-shift intake documentation, preventing staff from determining actual intake. Both residents had DM with diabetic CKD, were on therapeutic diets, and had care plans and physician orders for intake and output monitoring each shift.
Failure to assess pain before giving PRN analgesic: A resident told an LPN his stomach hurt when he ate and requested pain medication. The LPN reviewed PRN Tylenol and tramadol, asked which he preferred, and gave tramadol 50 mg without first completing a pain assessment. The LPN later stated she forgot to assess the resident’s pain, and the DON confirmed that pain should be assessed first, including location and a numeric rating, before selecting the appropriate medication.
A resident received Hydrocodone-Acetaminophen in doses that did not match the physician’s ordered pain parameters. The MAR showed multiple instances where 2 tablets were given even though the resident’s pain score was below the severe-pain range, and the ADON confirmed giving 2 tablets for a pain level of 6 because the resident wanted Hydrocodone and knew she was due for it. The DON stated staff should have followed the order parameters, and facility policy required medications to be given according to the prescribed dose.
A resident admitted to hospice with advanced medical needs did not receive adequately coordinated hospice services. The record lacked a physician-signed hospice certification and physician orders were signed by the Hospice RN instead of a physician; the hospice binder also lacked the physician certification for benefit. Staff gave conflicting accounts of who was the hospice coordinator, the SSD said she was not informed of the role’s duties until later, and the record did not show the physician assessment or the CHHA and chaplain services listed in the hospice admission paperwork.
A therapy mat in the OT room was observed with a slanted, uneven surface because the height-adjustment mechanism was malfunctioning. The DOR tested the mat and saw that one side did not lift as the height increased, and stated residents would be imbalanced if sitting on it. Therapy staff had not reported any problems with the mat, despite the facility policy requiring equipment to remain in good working order for resident and staff safety.
Call light system malfunctioned for two residents. One resident with dementia, CVA-related weakness, and dependence for ADLs was observed unable to easily reach the call light, and the in-room indicator worked while the hallway dome light and central panel did not. Another resident with CKD, DM2, severe cognitive impairment, limited mobility, incontinence, and a fall history also had a call light issue, and staff confirmed the hallway indicator did not activate even though the bedside indicator did.
A resident with obesity, multiple comorbidities, impaired mobility, and documented fall risk had a physician’s order and care plan interventions for a bariatric bed with bilateral 1/2 side rails to assist with turning and safety. On readmission, the resident was placed in a regular bed without side rails, despite the bariatric bed being available and previously used, and despite facility policies requiring initiation of physician orders and maintenance of a safe environment. Nursing notes recorded that the resident initially refused the bariatric bed, but later told an LVN that she needed a bigger bed; the LVN did not switch the bed, and the resident remained in the regular bed, which staff stated she barely fit into. During the night, the roommate found the resident on the floor between the beds, unresponsive, and staff initiated emergency protocols; the resident was later pronounced deceased, with the medical examiner listing natural causes related to CHF and obesity.
A resident with multiple medical conditions had physician orders for routine nebulized Ipratropium/Albuterol and subcutaneous Heparin for DVT prophylaxis, but the facility failed to obtain and administer these medications from the resident’s own supply or the Cubex system as ordered. One LVN reported bypassing the Cubex process and using a Heparin vial belonging to another resident without documenting this, while another LVN acknowledged that Albuterol was charted as given on the MAR even though he did not recall administering it and may have clicked "yes" in error. Pharmacy and Cubex records showed no transactions for the resident and documented that the ordered medications were delivered and then returned, demonstrating failures in following the facility’s Six Rights of Medication Administration, including right resident, right medication, and right documentation.
Two residents did not have their care plans updated after an incident where one experienced fear and pain following an interaction with a roommate who had acute neurological symptoms. Despite documented distress, pain, and safety concerns, as well as new medical symptoms, the facility did not revise the care plans to address these events or the residents' needs.
Resident room temperatures were found below the facility’s required 71 to 81 F range for multiple residents. A resident with CHF and DM, another resident with CHF and DM, and a third resident with MDD and HTN all reported feeling cold, with one resident saying there was no warm air from the vent and another saying the room was too cold to sleep well. Maintenance measured room temperatures in the mid-to-high 60s, and the DON acknowledged the rooms were not within the policy range.
Two residents with significant risk factors for pressure ulcers did not receive care in accordance with physician orders and care plans, including failure to limit sitting time, improper use of pressure-relieving devices, and incorrect settings on low air loss mattresses. Staff did not consistently document or perform required turning and repositioning, and mattress settings were not adjusted to match residents' weights, as confirmed by staff interviews and observations.
A resident with severe dementia and high assistance needs was mistakenly sent alone to a medical appointment intended for another resident, due to staff confusion over similar names and lack of verification. Staff were unaware of the resident's cognitive status and did not notify the responsible party, resulting in the resident being transported unsupervised to a distant clinic, causing distress and a lapse in required supervision.
A resident with a gastrostomy tube and an NPO order was given medications by mouth due to inaccurate physician orders and lack of clarification by nursing staff. The MAR reflected repeated oral administration of Tylenol and Tramadol, despite the resident's need for medications via GT. Nursing leadership confirmed the error and acknowledged that orders and administration routes were not properly verified.
The facility failed to maintain dignity and privacy for two residents. A resident with severe cognitive impairment was exposed during a dressing change due to an open privacy curtain, causing emotional distress. Another resident with an indwelling catheter had an uncovered drainage bag, contrary to facility policy. The Director of Nursing acknowledged the importance of privacy, which was not upheld in these cases.
A facility failed to provide reasonable accommodation for a resident by not ensuring a functional television, impacting her emotional well-being. Additionally, the facility did not ensure call lights were within reach for three residents, increasing the risk of delayed care and falls. These deficiencies were acknowledged by staff, highlighting the need for improved response times.
The facility failed to complete and submit the quarterly MDS assessments for three residents within the required timeframe. A resident with difficulty walking and diabetes had their MDS completed 37 days late. Another resident with severe sepsis and seizures, and a third resident with hyperlipidemia and dementia, had their MDS assessments incomplete and not submitted. The MDSN acknowledged the delays, and the DON emphasized the importance of timely MDS completion for accurate care planning.
The facility failed to create timely, individualized care plans for residents at high risk for elopement, compromising their safety. Despite being identified as high risk, care plans for four residents were delayed, with interventions not documented until months after initial assessments. Staff acknowledged the importance of timely care plans, but facility policies requiring comprehensive plans within 48 hours of admission were not followed.
The facility failed to implement timely care plans for residents at high risk of elopement. Despite assessments indicating high risk, care plans and interventions were delayed for several residents with cognitive impairments, leaving them vulnerable to elopement. Staff acknowledged the importance of these plans, but documentation was lacking.
The facility failed to ensure safe respiratory care for three residents receiving oxygen therapy. A resident's oxygen tubing and nasal cannula were found on the floor, another resident had an empty humidifier bottle, and a third resident's tubing was also on the floor. The ADON and DON confirmed these practices were against facility policy, which requires equipment to be dated, kept off the floor, and stored in labeled bags when not in use.
The facility failed to reseal and replace an IM e-kit within 72 hours after use, as required. Medications were removed from the e-kit for two residents with diabetes and hyperlipidemia. Despite transitioning to CUBEX for emergency medication supply, the e-kit was not returned to the pharmacy, leading to the oversight. Staff acknowledged the failure to reseal the e-kit, which would have indicated the need for replacement and prevented unauthorized access.
The facility failed to complete daily refrigerator temperature logs, compromising its ability to monitor food storage temperatures effectively. During a kitchen tour, it was observed that logs were incomplete, with missing entries for Freezer #1. The Dietary Director acknowledged the oversight, and the Dietary Staff emphasized the importance of recording temperatures twice daily as part of food safety protocols. The facility's policy requires staff to review and record temperatures to ensure safe food storage.
A facility's QAA committee failed to develop an admission policy, resulting in a deficiency in care for a resident with Diabetes Mellitus. The absence of a structured admission process led to a lack of monitoring for blood sugar levels, as there was no checklist to guide RNs in reviewing necessary hospital records. Interviews revealed that the facility relied on RNs' judgment without a formal procedure, leading to the oversight.
A facility failed to maintain infection control standards by not placing contact isolation signage for a resident with shingles and allowing a family member to enter without proper PPE. Additionally, a resident's Foley catheter bag was observed touching the floor, contrary to facility policy. These deficiencies could increase infection risk among residents, staff, and visitors.
A facility failed to maintain a sanitary environment by leaving an unknown back brace in a resident's room, risking cross-contamination. Additionally, a patio door leading to a smoking area was not latching properly, allowing smoke to enter the facility. Staff failed to report the door issue, and maintenance did not conduct routine checks, leading to safety concerns.
A facility failed to include a resident's Advance Directive in their chart, despite it being indicated in the POLST. The document was not found during a review, and the Social Service Assistant suggested it might have been misplaced during a hospital transfer. The Director of Nursing confirmed that facility policy requires the Advance Directive to be in the chart for emergency access.
A facility failed to complete and submit the MDS for a resident with significant medical conditions within the required timeframe. The MDS Nurse was behind schedule, and the DON stressed the importance of timely MDS completion for accurate care planning.
A resident with a history of type 2 DM was admitted to a facility without proper monitoring or management of their condition. The facility failed to review the resident's discharge packet from the GACH, which documented the DM diagnosis and previous insulin administration. The Admitting RN did not clarify the need for blood sugar monitoring with the physician, and no care plan was developed to address the resident's diabetes. This oversight had the potential to lead to serious complications.
A resident with a fractured patella did not receive a properly placed and sized knee immobilizer, as observed by staff. The immobilizer frequently slipped and was loose, failing to provide adequate support. Despite the resident's complaints and staff observations, no action was taken to order a properly sized replacement, placing the resident at risk for injury and discomfort.
A resident at risk for weight loss did not receive the prescribed health shake with meals as ordered by the physician. The oversight was observed when the meal tray lacked the health shake, despite the meal ticket indicating its inclusion. Interviews with staff and family confirmed the importance of the shake for the resident's nutritional needs. The facility's policy requires adherence to physician diet orders.
A facility failed to ensure a NP reviewed a resident's care, leading to an oversight in monitoring the resident's type 2 Diabetes Mellitus. The resident, admitted with multiple diagnoses, had a documented history of DM, but this was not reflected in the NP's initial progress note. The NP did not review the hospital discharge packet, assuming another NP had done so, resulting in a lack of blood sugar monitoring.
A resident was administered a higher than necessary dose of Ativan despite not exhibiting anxiety symptoms. Initially, a PNP recommended reducing the dose based on the resident's behavior records, but the dose was reverted after the resident's request without reassessment. This practice violated the facility's policy on psychotropic medications, which requires administration only when necessary for a specific condition.
A facility failed to implement its smoking policy, resulting in a deficiency related to providing a smoke-free environment for a resident. Despite the resident's grievance about cigarette smoke entering her room from the smoking patio, the issue persisted due to a broken latch on the patio door, which was left open during smoke breaks. Staff confirmed the presence of smoke in the hallway, and the facility's smoking policy was not upheld.
The facility did not ensure that six residents were aware of the Ombudsman's contact information, as revealed during a Resident Council meeting. Interviews with staff confirmed the lack of documentation showing that residents were informed about the Ombudsman's role and contact details, which is a part of their rights.
The facility failed to inform six residents about the location of the Annual Recertification Survey results, including the Plan of Correction. During a Resident Council meeting, these residents expressed their lack of awareness, which was confirmed by staff interviews. The Activity Director and Admission Assistant did not provide documented evidence of informing residents about the survey results, despite the Director of Nurses highlighting its importance as a resident right.
Failure to Document IV Antibiotics and Prevent Unsafe Bedside Medication Practices
Penalty
Summary
The deficiency involves failures in medication management and documentation for two residents receiving IV antibiotics and oral medications. For the first resident, who had cellulitis of the corpus cavernosum and penis, specified polyneuropathies, and functional quadriplegia, the facility did not document administration of ordered meropenem IV doses on two specified evenings. The physician’s order directed meropenem 500 mg IV every eight hours for 10 days to treat an ESBL E. coli sacrococcygeal wound infection, but the IV MAR for the month showed no documentation that the 10 PM doses on two dates were given. The Registered Nurse Supervisor stated that IV medications should be documented after administration and that lack of documentation meant the medication might not have been given, and the DON confirmed there was no documentation for those doses and that this implied the medication was not given and must be investigated. In addition, the same resident’s oral medications were not properly managed at the bedside. The resident’s admission record indicated he did not desire to self-administer drugs, and the facility’s self-administration policy required an IDT assessment and specific physician orders, including “may keep at bedside,” before a resident could self-administer medications. Despite this, during an observation in the resident’s room, a medicine cup containing three white pills was found on the bedside table. The resident identified the pills as gabapentin for nerve pain, Norco for pain, and a muscle relaxant, and stated they were his afternoon medications left there because he was on the phone and had asked the nurse to leave them. Facility policy for oral medication administration required staff to pour the correct tablets, administer the medication, remain with the resident while it was swallowed, and then document administration on the MAR. LVN 1, the RN Supervisor, and the DON all stated that medications should not be left at the bedside, that staff must ensure medications are taken before leaving the room, and that documentation should occur only after the resident actually takes the medication. For the second resident, who had type 2 diabetes mellitus, Parkinson’s disease, and chronic kidney disease with renal insufficiency or ESRD, the facility also failed to document an ordered IV antibiotic dose. The physician’s order specified Zosyn 3.375 g IV every eight hours for a wound infection for seven days. Review of the IV MAR for the month showed no documentation that the 10 PM Zosyn dose on a specified date was administered. The RN Supervisor stated she was unsure if she had documented that dose but that it should have been documented to prove it was given. The DON reviewed the IV MAR and confirmed there was no documentation for that Zosyn dose and that, as with the first resident’s meropenem doses, the absence of documentation implied the medication was not given and required investigation. Facility policies on specific medication administration procedures and the six rights of medication administration required documentation after administration for all medications, including IV drugs, and emphasized right documentation as a core component of safe medication administration. The facility’s own policies on self-administration and medication administration further underscored the deficiencies. The self-administration policy required that residents be informed of their right to self-administer, that the IDT assess and determine if the practice was safe, and that physician orders for self-administered medications specify that they may be kept at the bedside, with conditions for secure storage and documentation of quantities supplied and used. In this case, the first resident’s initial admission record showed he did not wish to self-administer medications, and there was no indication of an IDT determination or an order allowing bedside medications, yet oral medications were left at the bedside in a manner inconsistent with policy. The general and oral medication administration procedures required staff to administer medications, remain with the resident while they were swallowed, and then document on the MAR, and the six rights policy required documentation after administration or refusal. The observed practices and missing documentation for both residents’ IV antibiotics and the bedside pills for the first resident directly conflicted with these written procedures.
Failure to Provide and Explain Access to Medical Records Upon Request
Penalty
Summary
The facility failed to provide and explain the process for obtaining a copy of a resident’s medical records upon request, in accordance with its policy on Protected Health Information. A resident with Type 2 DM and dementia was admitted in early February, and an IDT care plan review was conducted later that month, authored by the Social Service Assistant (SSA) and attended by an RN, rehabilitation staff, the Activity Director (AD), the resident, and the resident’s responsible party (RP). The IDT documentation did not include the topics discussed during the meeting and was not signed and dated by the SSA. During this IDT meeting, the RP requested the resident’s medical records, and the SSA verbally stated she would obtain the records, but no documentation of this request or follow-through was made. Following the meeting, the RP waited several weeks without receiving the records and repeatedly called the facility to follow up. The receptionist reported the SSA was unavailable and did not connect the RP with another staff member who could assist. After multiple attempts, the RP was eventually transferred to the Medical Records Director (MRD), who stated she had not been informed of the earlier request and told the RP that a request form needed to be completed. The MRD reported that the SSA, who no longer worked at the facility, had not communicated the RP’s request from the IDT meeting. The AD confirmed being present at the IDT meeting and recalled the RP asking for the records and the SSA stating she would get them. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request, excluding weekends and holidays, but this process was not followed or explained to the RP.
Advance Directive Documentation Missing or Inaccessible
Penalty
Summary
The facility failed to ensure that Advance Directive (AD) documentation was obtained and accessible in the medical records for multiple sampled residents. During record review and interviews, the Social Services Designee (SSD) stated that the AD notification form was believed to be in the hard chart for Residents 1, 8, 16, and 95, but the form was not found in either the electronic medical record or the hard chart. The SSD stated that maintaining the AD notification form documents compliance with federal law and shows that the resident or responsible party was informed of medical care rights. Resident 1 was readmitted with encephalopathy and dementia, and the History and Physical (H&P) stated the resident did not have the capacity to understand and make decisions. The Minimum Data Set (MDS) described severely impaired cognition. Resident 8 was readmitted with dementia and metabolic encephalopathy, and the H&P stated the resident did not have capacity to understand and make decisions; the MDS described moderately impaired cognition. Resident 16 was admitted with hypertension and depression, and the H&P stated the resident could make needs known but could not make medical decisions; the MDS described moderately impaired cognition. Resident 95 was admitted with diabetes mellitus and hypertension, and the H&P stated the resident had the capacity to make decisions; the MDS described moderately impaired cognition. For Resident 135, the admission record, H&P, and MDS indicated the resident had diagnoses including acute on chronic systolic heart failure, cellulitis of the right lower limb, and muscle weakness, with capacity to understand and make decisions and intact cognition. The Social Services Assessment/Evaluation stated the resident had an Advance Health Care Directive in place, but the POLST stated the resident did not have an Advance Directive. During interview and record review, the Medical Records Director confirmed there was no advance directive in the chart, and the SSD could not find one in the electronic record. For Resident 201, the admission record, H&P, and MDS showed diagnoses including COPD with acute exacerbation, hypertension, and difficulty walking, with moderately impaired cognition and an assessment stating the resident had an Advance Health Care Directive in place. The POLST stated the resident did not have an Advance Directive and identified the resident as DNR with selective treatment. During interview and record review, staff confirmed the advance directive was not found in the chart or electronic record, and SSA 1 stated it was an honest mistake and that the POLST and Social Services Assessment should have matched.
Inaccurate ROM Assessments on MDS
Penalty
Summary
The facility failed to accurately assess functional limitation in range of motion for three sampled residents during MDS assessments. Resident 8 was admitted with diagnoses including dysphagia following a cerebral infarction, lack of coordination, and metabolic encephalopathy. The resident’s MDS assessments indicated no functional limitation in ROM in the arms and legs, but OT and PT records showed impaired ROM in the left shoulder, wrist, and hand, with the left arm not moving at all during restorative care and the resident receiving ROM exercises to both arms. PT and restorative documentation also showed the resident was dependent for bed mobility and was expected to receive ROM exercises to both legs, while the MDS still reflected no ROM limitation. Resident 12 was admitted with diagnoses including malignant neoplasm of the spinal cord and functional quadriplegia. The resident’s MDS assessments also indicated no functional limitation in ROM in the arms and legs. However, OT documentation showed limited PROM in the left shoulder due to pain, PT documentation showed impaired strength in both legs, and discharge and physician orders directed restorative ROM services for both arms, the left shoulder, and both legs. During observation, the resident was receiving PROM to both legs, ROM to the left shoulder, and AROM to the right arm, while the resident stated restorative ROM was being provided because of inability to feel and move both legs. Resident 49 was admitted with diagnoses including a left artificial knee joint, infection of the left artificial knee joint, and muscle weakness. The resident’s MDS assessments indicated no functional limitation in ROM in the arms and legs. OT documentation showed WFL AROM in both arms, while PT documentation noted a history of multiple left knee surgeries, a left knee fusion, a midshaft tibia fracture in the left leg immobilized with a cast, and that the left knee and ankle ROM were not assessed because of the cast. Restorative and physician orders directed AROM for both arms, the right leg, and the left hip, and during observation the resident performed AROM to both arms, the right leg, and the left hip while wearing a cast on the left leg. The MDS nurse stated the assessments were inaccurate and should have reflected functional limitation in ROM for the affected limb(s).
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that daily nursing staffing information was posted. On 2/23/2026, observation in the lobby showed the posted Census and Daily Hours Per Patient Day (DHPPD) form dated 2/19/2026 and the Nursing Staffing Assignment and Sign-In Sheet (NSA) dated 2/20/2026. These records showed that the required daily nursing staffing information had not been posted for 2/21/2026, 2/22/2026, and 2/23/2026. During interview, the Director of Staff Development stated that the DHPPD and NSA were used to show the ratio of residents to licensed staff and to let staff, residents, and visitors know who was working and whether there were enough staff to meet resident needs. The DSD stated the forms should have been posted daily and updated throughout the day if staff called off or staffing changed, including on weekends. The DON also stated the forms should have been posted daily and as needed with changes. Review of the facility policy titled Nursing Services/Posted Nurse Staffing Information, dated November 2016, showed the facility policy was to post nursing staffing data daily at the beginning of each shift and make it readily accessible to residents and visitors.
Food Storage, Equipment Cleanliness, and Tray Coverage Deficiencies
Penalty
Summary
The facility failed to ensure proper food handling and to maintain the food service area in a clean and sanitary manner in accordance with the FDA Food Code 2022 and its own policies. During kitchen observations, the ground cinnamon spice container lid was partially open on a shelf above the food preparation area by the stove, and the two hot water machine spouts were observed with a white chalky build-up. The Dietary Supervisor stated the cinnamon lid was not closed all the way and that the chalky build-up on the hot water spouts was mineral deposit from hard water. The Dietary Supervisor Assistant reviewed the kitchen Daily Cleaning Log and stated the coffee machines were cleaned on 2/22/2026 and 2/23/2026, with cleaning including the immediate surface area around the hot water machines, checking the exterior for visible cracks or dents, and wiping down the machines including the hot water spouts. The facility also failed to keep food covered during tray transport. A regular diet test tray was observed being delivered from the hallway to the boardroom with the peach cobbler dessert uncovered. In Station 1, a CNA stated Resident 25's dessert bowl was not covered while delivering the lunch tray to the resident's room, and another CNA stated Resident 207's salad cup and dessert bowl were not covered on the lunch tray. Lunch trays in the metallic delivery food cart for Station 2 were also observed with salad cups and dessert bowls uncovered. The Dietary Supervisor stated the salads and desserts on resident trays were not usually covered because CNAs transfer the trays from the transportation cart directly to the resident's room. The FDA Food Code 2022 stated foods shall be protected from cross contamination by storing the food in packages, covered containers, or wrapping, and equipment that dispenses liquids shall be designed so the delivery tube or chute and orifices are protected from dust, insects, rodents, and other contamination.
SSD Qualifications Not Verified
Penalty
Summary
The facility failed to ensure the Social Services Director (SSD) met the qualifications required for a social worker in a facility with more than 120 resident beds. The SSD was hired by the facility on 8/15/2025 as Medical Records Director and later had a Personnel Action/Change Form dated 9/15/2025 showing a title change from Medical Records Director to SSD and a department change to Social Services. The SSD’s employee file contained a Bachelor of Science degree in Elementary Education and a Certificate of Completion for Social Service Designee dated 12/2/2024, but it did not contain documented evidence that she had at least one year of supervised social work experience in a healthcare setting and working directly with individuals before starting in the SSD role. The SSD stated during interview that she had received 45 hours of Social Services Designee training and that she had a certification for counseling for 180 hours supervised by a social worker, but neither she nor the facility could provide documented evidence of that experience. She also stated she had held social services positions at prior facilities with 56 and 99 beds and had covered for the SSD when the Social Services Designee was gone, which she considered her experience as SSD. The Administrator stated the SSD was initially hired as MRD, later considered for the SSD position, and that the facility did not have her complete a new application or sign a job description for the SSD role, although the signed job description should have been in the employee file.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The facility failed to adhere to infection control practices for one resident who had Enhanced Barrier Precautions signage posted because of a dialysis catheter. The resident’s record showed a diagnosis of dementia and end stage renal disease, and the History and Physical indicated the resident did not have capacity to understand and make decisions. The Minimum Data Set dated 2/3/2026 indicated severely impaired cognition. During an observation on 2/26/2026 at 10:13 AM, two transportation staff entered the resident’s room, which was designated for Enhanced Barrier Precautions, without performing hand hygiene and while wearing gloves from a prior task. They did not don an isolation gown as required and made direct contact with the resident to transfer her onto a gurney for a dialysis appointment. During an interview at 10:16 AM, the Infection Prevention Nurse stated the staff were seen transferring the resident without gown and clean gloves, using the same gloves worn upon entering the room, and leaving without removing their gloves or performing hand hygiene. The facility policy stated that Enhanced Barrier Precautions require gown and glove use during high-contact resident care activities for residents with indwelling medical devices.
Uncovered Catheter Drainage Bag Visible to Passersby
Penalty
Summary
The facility failed to ensure the privacy and dignity of one sampled resident with an indwelling catheter when the catheter drainage bag was left uncovered and visible to people walking past the resident's room. Resident 23 was admitted with diagnoses including disorders of the urinary system, type 2 DM, and acute kidney failure, and the H&P indicated the resident did not have the capacity to make medical or financial decisions. The resident's physician ordered an indwelling catheter for obstructive uropathy/wound management, and the MDS documented moderate cognitive impairment and the presence of an indwelling catheter. During observation, Resident 23's catheter bag was hanging on the right side of the bed without a cover and contained about 250 ml of urine, making it visible from the hallway. Staff interviews confirmed the bag should have been covered in a privacy or dignity bag and placed in a basin to maintain privacy, dignity, infection control, and hygiene. The DON also stated the uncovered catheter was a dignity concern because it could be seen by others. The facility policy required residents to be treated with dignity and privacy and directed staff to cover the drainage bag with a privacy bag to maintain dignity.
Call Light Not Kept Within Reach for Residents With Limited Mobility
Penalty
Summary
The facility failed to ensure that the call light was within reach and accessible for two residents with significant physical limitations. Resident 35 was admitted with diagnoses including hemiplegia, hemiparesis, left hand contracture, and degenerative nervous system disease. Records showed the resident had zero self-care and mobility function, was dependent on staff for all self-care and mobility, and had a care plan addressing limited physical mobility to press the call light related to contractures. During observation, Resident 35’s left hand was closed and unable to open or move fingers, and the call light was observed tucked behind the resident’s left shoulder and not within reach. Resident 35 stated the call light should have been in front of her and that not being able to reach it made her feel awful because she was unable to call staff. CNA 2, LVN 1, and the DON each stated the call light should have been within the resident’s reach, with LVN 1 noting it should have been near the resident’s dominant hand. Resident 8 was admitted and readmitted with diagnoses including metabolic encephalopathy, dementia, lack of coordination, memory deficit following CVA, and left-sided weakness with impaired mobility. The care plan directed that the call light be within reach and that needed items be kept close. During observation, Resident 8 was lying in bed with the call light clipped to her pillow on the left side of her head, and she had difficulty reaching it with her right hand across her body. Resident 8 stated she had pressed the button for staff but did not know where it was. CNA 5 stated the call light was by the left side of her head and clipped to her pillow, and RN 1 stated that for a resident with one-sided weakness the call light should be past mid-line and closer to the more functional side of the body.
Admission Agreement Not Provided in Resident’s Preferred Language
Penalty
Summary
The facility failed to provide Resident 17 with an admission agreement in the resident’s preferred language of Spanish. Resident 17 was admitted on 9/7/2025 with diagnoses including difficulty walking, dysphagia following a cerebral infarction, and hemiparesis. The resident’s MDS, dated 12/5/2025, identified Spanish as the preferred language and noted clear speech, understanding of verbal content, ability to express ideas and wants, and moderately impaired cognition. During a 2/24/2026 observation and interview in the dining room, Resident 17 did not know how to contact the Ombudsman or the State agency, and the dining room had no posted Ombudsman or State agency information. On 2/26/2026, the Admission Coordinator reviewed the admission agreement dated 9/7/2025 and stated it was signed by Resident 17 but written in English, even though the resident’s preferred language was Spanish. The Director of Marketing and Admissions stated residents should receive an admission agreement in their preferred language to easily understand the information. The facility policy stated residents are informed of their rights orally and in writing in a language that is clear and understandable to the resident.
Failure to Notify Physician of Residents’ Change in Condition
Penalty
Summary
The facility failed to notify the physician when Resident 8 developed pain and discoloration of the left second toe and continued to have hemorrhoid pain. Resident 8 was admitted and later readmitted with diagnoses including metabolic encephalopathy, dementia, and memory deficit following a CVA. Her care plan identified her as at risk for altered gastrointestinal status related to hemorrhoids and included Proctozone-HC cream as needed after bowel movements. A podiatry evaluation documented thickened, discolored, brittle, painful toenails on the left foot, and the resident’s record also showed an order allowing podiatry treatment. During observations, Resident 8 was seen reacting with pain when her left sock was removed and the second toe was touched, with redness near the nail bed and discoloration at the nail bed. She repeatedly stated that her toe hurt and also repeatedly stated that her “butthole hurts” while staff were providing brief care. Staff observed and treated the hemorrhoid by applying ointment and pushing it back into the rectum area. RN 1 stated there was no documented evidence of Resident 8’s left second toenail pain or hemorrhoids, that she was not aware of the complaints, and that the PCP was not notified because the change in condition was not recognized. The facility also failed to notify the Medical Director when Resident 194 fell and complained of right hip, right shoulder, and right ear pain after the fall, and when the primary physician did not respond. Resident 194 was admitted for rehabilitation with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus, and lobar pneumonia, and had moderately impaired cognition with substantial assistance needed for toileting hygiene, showering, and mobility. After the fall, the change-of-condition record documented pain, a skin tear on the back of the right shoulder, and a pending response from the physician. Nursing documentation also noted right shoulder, right hip, and right ear pain, and later skin assessment showed a right shoulder abrasion with light bleeding. RN 1, the ADON, and the DON stated there was no documented evidence of additional follow-up to the physician, and that the Medical Director should have been notified when the primary physician could not be reached.
Inconsistent discharge documentation and missing signature on transfer notice
Penalty
Summary
The facility failed to ensure that the reason for discharge and the notice of proposed transfer/discharge were completed consistently for one of three closed records reviewed, Resident 193. The resident’s admission record showed diagnoses including type 2 diabetes mellitus, other schizoaffective disorders, and seizures, and the resident was discharged on 12/5/2025. The discharge summary stated the transfer/discharge was necessary because the health and safety of individuals in the facility would be endangered, and that the resident was transferred to the hospital due to aggressive behavior. The Notice of Proposed Transfer/Discharge for the same resident, dated 12/5/2025, stated the transfer/discharge was appropriate because the resident’s health had improved sufficiently and no longer required services provided by the facility. The notice also did not include a resident/representative signature. During interview and record review, the DON confirmed that the reason on the discharge summary and the notice did not match and stated the forms should match and be completed with the correct information. The facility policy titled Criteria for Transfer and Discharge stated that when a resident is transferred or discharged, the transfer or discharge must be documented in the medical record and appropriate information communicated to the receiving health care institution or provider.
MDS Assessments Not Timely Completed and Transmitted
Penalty
Summary
The facility failed to ensure that the minimum data set (MDS) was completed and transmitted to CMS within the required timeframe for 2 of 3 sampled residents, Resident 32 and Resident 71. Resident 32 was admitted with diagnoses including Type 2 diabetes mellitus and muscle weakness, and the H&P dated 11/14/2025 stated the resident had the capacity to understand and make decisions. Resident 71 was admitted with diagnoses including acute respiratory failure with hypoxia and Type 2 diabetes mellitus, and the H&P dated 10/24/2025 stated the resident had the capacity to make needs known but could not make medical decisions. Both residents had 5-day scheduled MDS assessments dated [DATE]. During interview and record review on 2/25/2026 at 2:15 PM, the MDS coordinator stated she was responsible for completing and transmitting the 5-day MDS assessments for Resident 32 and Resident 71, and stated, "I forgot to complete transmit the MDS for Resident 32 and for Resident 71, I hadn't realized it until now." The facility's CMS submission report showed Resident 32's last submission was 3/10/2025 and Resident 71's last submission was 2/24/2026. The facility's policy titled Resident assessment and associated processes, revised 4/2025, stated the facility will electronically encode accurate and complete MDS data to the CMS system as soon as possible.
Failure to Set Low Air Loss Mattress According to Weight
Penalty
Summary
The facility failed to provide care and services to prevent skin injury for a resident with a history of pressure ulcer of the right hip, abnormal posture, and adult failure to thrive. The resident was admitted with orders for a low air loss mattress for skin management, with the setting to be adjusted according to the resident’s weight and the function checked every shift. The resident’s care plan also directed staff to maintain intact skin, provide ordered treatments, perform daily body checks, and use the low air loss mattress with the setting based on weight. Record review showed the resident’s weight was 114 pounds, and interviews with the TN and DON confirmed that the mattress setting should have been consistent with the resident’s weight. During the interviews, both stated the facility staff were not following the physician’s order for the mattress setting. The low air loss mattress user manual stated the analog pressure dial should be adjusted to correspond to the patient’s appropriate weight setting or comfort level. The facility policy also required staff to initiate physician orders, use pressure-relieving devices as part of skin and wound management, and confirm all orders had been implemented as ordered.
Failure to Provide Ordered ROM and Restorative Nursing Services
Penalty
Summary
The facility failed to provide range of motion interventions for two residents with documented ROM limitations. For one resident, the OT evaluation dated 1/19/2026 documented impaired ROM in the right shoulder, wrist, and hand, but did not include measurements for the right thumb, index finger, middle finger, ring finger, and little finger. The resident’s OT discharge summary and physician orders called for restorative nursing AROM to the right arm and AAROM to the left arm three times per week as tolerated, and PT documentation indicated the resident also needed ongoing therapy services and ROM to both legs. During observation, the resident was seen receiving ROM to both arms, but staff stated the resident did not have restorative ROM for both legs, and PT staff stated the resident did not receive additional PT services after discharge and had not received ROM intervention to both legs for approximately one month. For the second resident, the facility discontinued restorative nursing ROM after the resident was admitted to hospice. The resident had a history of stroke affecting the left side, severe cognitive impairment, and documented ROM limitations, including a clenched fist contracture at rest in the left hand and limited shoulder motion. Prior OT and PT discharge summaries recommended gentle PROM to both arms and ROM to both legs three times per week as tolerated. However, physician orders dated 2/17/2026 and 2/18/2026 discontinued restorative nursing PROM to both arms and both legs because of hospice care. Facility staff later confirmed the resident did not receive ROM to both arms for nine days and to both legs for eight days after those orders were entered. The record also showed the resident continued to have limited movement during the period without restorative ROM. The resident was observed using the right arm to eat and the left hand remained bent into a nearly closed fist, with no movement of the left arm during lunch. Staff, including the DON, stated that residents on hospice should continue to receive nursing services such as ROM to prevent stiffness and contractures, and the hospice medical director stated residents on hospice should not have limitation in receiving ROM within tolerance. The facility’s ROM and Contracture Prevention policy stated residents should maintain or improve ROM and mobility unless reduction is clinically unavoidable.
Failure to Monitor Fluid Intake for Residents on Hemodialysis
Penalty
Summary
The facility did not ensure that fluid intake was monitored for two residents with ESRD who were on hemodialysis and ordered a 1000 mL per 24-hour fluid restriction. Resident 70 was admitted and later readmitted with diagnoses including Type 2 DM with diabetic chronic kidney disease, ESRD, and dependence on renal dialysis. Her care plan and physician order required intake and output monitoring each shift with a 1000 mL fluid restriction, and the order divided the allowance between nursing and dietary fluids. Resident 204 was also readmitted with diagnoses including DM with diabetic chronic kidney disease, ESRD, and dependence on renal dialysis, and her care plan and orders likewise required intake and output monitoring each shift with a 1000 mL per 24-hour fluid restriction. For Resident 70, the surveyor observed her sitting in her wheelchair with three partially consumed 8-ounce water bottles on her overbed table. She stated she could not remember when she received the water bottles and was unsure how much water she had drank that day, saying she only took sips of water. During record review, RN 1 reviewed the MAR and point-of-care fluid intake records and stated that on 2/3/2026, 2/4/2026, 2/17/2026, 2/18/2026, and 2/24/2026, documentation showed Resident 70's fluid consumption exceeded the 1000 mL per day restriction. RN 1 stated licensed nurses were responsible for ensuring the resident's total daily fluid intake stayed within the ordered limit. For Resident 204, the ADON reviewed the MAR from 2/13/2026 to 2/25/2026 and stated the record did not document the resident's shift-by-shift fluid intake. The ADON explained that without numerical values, licensed nurses could not determine the resident's actual fluid intake, and therefore Resident 204 may have exceeded her 1000 mL per day fluid restriction. The facility policy titled Licensed Nurse Procedures: Fluid Restrictions stated that nursing would note fluid restrictions and complete intake and output, but the documentation reviewed for Resident 204 did not show the required shift-by-shift intake amounts.
Failure to Assess Pain Before Administering PRN Analgesic
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met when staff failed to assess the pain level for Resident 203 after he verbalized pain during medication pass. Resident 203 was admitted to the facility with diagnoses not fully listed in the report, and his H&P dated 2/12/2026 indicated he had the capacity to understand and make decisions. His order summary dated 2/26/2026 included PRN pain medications for acetaminophen 325 mg, 2 tablets every 6 hours as needed for mild pain (1-3), and tramadol HCL 50 mg, 1 tablet every 6 hours as needed for moderate pain (4-6). During medication pass observation on 2/25/2026 at 8:48 AM, Resident 203 told LVN 2 that his stomach hurt when he eats and asked for pain medication. LVN 2 reviewed the medications, removed Tylenol and tramadol, asked which one he preferred, and the resident chose tramadol, stating he had not taken it in a while. LVN 2 then administered tramadol 50 mg without first assessing the resident’s pain. In follow-up interview, LVN 2 stated she forgot to assess the resident’s pain and acknowledged that facility practice is to ask the resident to rate pain on a 1-10 scale and ask questions about onset and what makes it worse. The DON stated that when a resident verbalizes pain, nurses are required to perform a pain assessment first, including location and numeric pain rating, to select the appropriate medication.
Improper Hydrocodone Dosing Despite Pain Levels Below Ordered Parameters
Penalty
Summary
The facility failed to follow physician orders for one resident receiving Hydrocodone-Acetaminophen for pain management. The resident was admitted with diagnoses including toxic encephalopathy, specified disorders of the urinary system, and extended spectrum beta lactamase, and the H&P stated the resident had capacity to make medical and financial decisions. The order summary showed an order for Hydrocodone-Acetaminophen 5-325 mg, 1 tablet every 4 hours as needed for moderate pain (4-7), and a later order for 2 tablets every 4 hours as needed for severe pain (8-10). The MAR showed multiple administrations of 2 tablets even when the resident’s documented pain level was below 8-10, including pain levels of 7, 0, 4, 6, and 7 on several occasions. During interview and record review, the DON stated nurses should have followed the physician’s orders because the orders indicate the parameters for the pain medication, and that not following the orders could result in sedation, drowsiness, and overmedication. The ADON confirmed giving the resident 2 tablets for a pain level of 6 because the resident said she wanted Hydrocodone and knew she was due for pain medication. The ADON stated that if the physician order is not followed, the resident could experience dizziness or sleepiness. The facility policy on the Six Rights of Medication Administration stated medications must be administered according to the prescribed dose, and the Pain Recognition and Management policy stated pain management should be consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the resident’s goals and preferences.
Hospice Coordination and Certification Deficiencies
Penalty
Summary
The facility failed to provide adequate hospice services to one resident who was admitted to hospice care with diagnoses including atherosclerotic heart disease, acquired absence of the left toes, muscle weakness, and dysphagia. The resident’s MDS dated 1/5/2026 indicated clear speech, some difficulty communicating words or finishing thoughts, severely impaired cognition, and dependence or substantial/maximal assistance for multiple activities of daily living including eating, oral hygiene, toileting, dressing, and transfers. On 2/16/2026, the resident’s admission Orders/Hospice Certification indicated hospice admission for atherosclerotic heart disease, but the certification was not signed by a physician. The handwritten physician’s orders for hospice admission were signed by the Hospice RN rather than a physician. The hospice binder did not include a Physician’s Certification for Hospice Benefit, and the DON stated the resident’s hospice records did not include a physician assessment. The resident’s hospice documentation also showed visits by the Hospice RN and social worker, but the record did not show the CHHA services listed in the admission Orders/Hospice Certification. Facility staff gave conflicting statements about who served as the hospice coordinator. The SSD, RNS, and DON each identified different roles, and the SSD stated she was not informed of the hospice coordinator duties until 2/25/2026. The DON stated the SSD was responsible for ensuring the resident received the necessary hospice services and assessments. The SSD later provided a 60-day Physician Certification for Hospice Benefit covering 2/16/2026 to 4/16/2026 and stated the facility received it on 2/25/2026, after it should already have been in the hospice binder. The resident’s RP stated on 2/26/2026 that hospice was supposed to assess the resident, but no additional information about hospice services had been provided.
Therapy Mat Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure therapy equipment was maintained in safe operating condition for one of two adjustable height therapy mats. During a concurrent observation and interview on 2/24/2026 at 9:01 a.m. in the OT room with the Director of Rehabilitation, an adjustable therapy mat was observed in a slanted position with an uneven surface due to a malfunctioning height-adjustment mechanism. When the DOR lowered and increased the height of the mat, the side closer to the wall did not lift as the height increased, creating the slanted position. The DOR stated therapy staff had not reported any problems with the mat and also stated residents would be imbalanced if sitting on it. The facility policy titled Equipment Maintenance, revised 5/2016, stated the facility ensured equipment remained in good working order for resident and staff safety.
Call light system malfunctioned for two residents
Penalty
Summary
The facility failed to ensure that the call light system was maintained in proper functioning for two residents, Resident 8 and Resident 96, in accordance with its policy and procedure for equipment maintenance. Resident 8 was admitted and later readmitted with diagnoses including metabolic encephalopathy, dementia, lack of coordination, memory deficit following CVA, and left-sided weakness with impaired mobility. Her care plan identified her as at risk for falls and injury and directed staff to keep the call light within reach, encourage its use, and ensure a safe environment with a working and reachable call light. Her MDS showed she was dependent on staff for toileting hygiene, bathing, repositioning, and transfers, and her history and physical stated she did not have the capacity to understand and make decisions. Resident 96 was admitted and readmitted with diagnoses including CKD, Type 2 DM, and muscle wasting and atrophy. Her history and physical stated she could make her needs known but could not make medical decisions. Her care plan identified her as at risk for falls and injury related to limited mobility, bowel and bladder incontinence, and a history of falls, and it also directed staff to ensure the call light was within reach, encourage its use, and maintain a safe environment with a working and reachable call light. Her MDS indicated severely impaired cognitive skills and dependence on staff for ADLs, repositioning, and transfers. During observation and interview, Resident 8 was seen in bed with the call light clipped to her pillow and positioned by the left side of her head, while she had difficulty reaching it and stated she pressed the button for the nurses but did not know where the button was. The in-room call light indicator lit up, but the hallway nurse call dome light above the room did not turn on, and the centralized call light panel at the nursing station did not show a call light activation. CNA 5 tested the bedside call lights for Residents 8 and 96 and stated that although the in-room indicators worked, the hallway dome light did not light up and he was unaware that Resident 8 had activated her call light. The Maintenance Supervisor reviewed testing and maintenance records and stated the call lights had been documented as functioning properly on prior testing dates and that he was not aware of the malfunction until it was reported by CNA 5.
Failure to Provide Ordered Bariatric Bed and Side Rails for Obese, High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s assessed need and physician’s order for a bariatric bed with bilateral 1/2 side rails. The resident had diagnoses including obesity due to excess calories, hyperlipidemia, major depressive disorder, respiratory failure with hypoxia, CKD, HTN, pneumonia, CHF, COPD, asthma, neuropathy, depression, impaired mobility, and incontinence. The resident’s H&P documented capacity to understand and make decisions. The physician’s order summary and the resident’s care plans specified the use of a bariatric bed with bilateral 1/2 side rails as an intervention, including for assistance with turning and as part of fall risk interventions that also called for side rails as ordered and a safe environment. On readmission, the resident was placed in a regular bed without side rails, despite the existing physician’s order and care plan interventions for a bariatric bed with 1/2 side rails. Nursing notes documented that the resident initially refused to change to a bariatric bed, stating a desire to rest. The DON later confirmed that a bariatric bed had been used prior to the recent hospitalization and that the bariatric bed was available and in the hallway at the time of readmission. The Maintenance Supervisor confirmed that the bed in the room at readmission was a regular bed, not a bariatric bed. Staff interviews indicated that the resident was “really big,” almost 300 lbs, and barely fit in the regular bed, and that the readmission bed did not have side rails. During the night shift following readmission, an LVN reported speaking with the resident about the new room and that the resident mentioned needing a bigger bed and that the current bed needed to be switched out. The LVN did not offer to switch the bed and did not change the bed to a bariatric bed despite this request and the existing order. Later that night, the resident’s roommate found the resident on the floor between the two beds, unresponsive, and called for help. Staff found the resident lying on her left side, unresponsive, not breathing, and without a pulse. Emergency protocols were initiated, including CPR, and emergency services were contacted. The resident was later pronounced deceased, with the medical examiner determining the manner of death as natural, caused by congestive heart failure and obesity. The facility’s policies on admissions and resident safety required that physician orders be noted and initiated and that room checks and bedside observations be conducted to ensure a safe environment, but the ordered bariatric bed with side rails was not in place at the time of the event. The facility’s fall risk care plan for the resident identified her as at risk for falls related to multiple comorbidities and impaired mobility and specified that side rails be used as ordered and that a safe environment be maintained, including appropriate assistive devices. The DON stated that the 1/2 side rails were used as an enabler for the resident. Despite this, the resident remained in a regular bed without side rails from the time of readmission through the time she was found on the floor. Multiple staff, including the DON, LVNs, and the Maintenance Supervisor, acknowledged the discrepancy between the physician’s order and care plan interventions and the actual bed provided and maintained for the resident during this period. The nursing progress notes and staff interviews further showed that the resident’s refusal of the bariatric bed at the time of readmission was documented but not followed by any documented reassessment or alternative accommodation when the resident later expressed a need for a bigger bed. The facility’s own policies required that physician orders be initiated at admission and that safety measures, including appropriate assistive devices and room setup, be in place. Nonetheless, the ordered bariatric bed with 1/2 side rails was not implemented, and the resident remained in a regular bed without side rails until she was discovered on the floor, unresponsive.
Medication Borrowing and Inaccurate MAR Documentation for Anticoagulant and Respiratory Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and safe medication administration for a resident in accordance with physician orders and the facility’s “Six Rights of Medication Administration” policy. The resident was initially admitted and later readmitted with diagnoses including obesity due to excess calories, hyperlipidemia, and major depressive disorder, and had documented capacity to understand and make decisions. Physician orders dated 1/2/2026 included routine Ipratropium Albuterol inhalation solution via nebulizer every six hours for respiratory failure and Heparin 5000 units subcutaneously every eight hours for DVT prophylaxis, with the first Heparin dose to be taken from the Cubex automated medication system. Review of the Medication Administration Record for January 2026 showed that Heparin 5000 units was documented as last given on 1/2/2026 at 10 PM and Albuterol inhalation solution was documented as last given on 1/3/2026 at 12 AM. However, Cubex transaction reports from 1/2/2026 to 1/3/2026 indicated no medication transactions for this resident, and a pharmacy delivery receipt dated 1/3/2026 at 5:15 AM showed that multiple medications for the resident, including Ipratropium Albuterol solution and Heparin vials, were delivered but then returned to the pharmacy. This documentation pattern showed that the resident’s ordered medications were not obtained from the Cubex or from the resident’s own supply as intended. In interviews, one LVN stated she attempted to obtain Heparin from the Cubex during her 3 PM to 11 PM shift on 1/2/2026 but did not complete the process because it took too much time, and instead used a Heparin vial belonging to another resident who was receiving the same dose. She acknowledged she did not document that the Heparin administered came from another resident’s supply. Another LVN stated he did not actually administer Albuterol to the resident despite the MAR indicating it was given, explaining that he may have clicked “yes” on the MAR by accident and did not remember administering Albuterol or any other medications to the resident. These actions and documentation errors were inconsistent with the facility’s policy requiring the right resident, right time, right medication order, right dose, right route, and right documentation for medication administration.
Failure to Update Person-Centered Care Plans After Resident Incident
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents following a significant incident. For the first resident, who had a history of hemiplegia, hemiparesis, difficulty walking, and falls, multiple staff members reported that she was scared of her roommate after an incident in which the roommate was found standing by her bed, causing her distress and leading to a fall. Despite the resident expressing fear, pain, and a desire not to return to her room, the care plan was not updated to address her emotional response, safety concerns, or the interaction with her roommate. The second resident involved in the incident had diagnoses including metabolic encephalopathy and major depressive disorder, and experienced right arm numbness and sudden vision loss during the event. The care plan for this resident was also not updated to reflect the incident, her acute medical symptoms, or her actions during the event. Documentation showed that the resident had a severe headache, sudden blindness, and accidentally knocked down equipment, which contributed to the other resident's distress and fall. Interviews and record reviews confirmed that the facility's interdisciplinary team did not revise or implement care plans for either resident following the incident, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes after each assessment or significant event. The lack of updated care plans meant that the specific needs and responses of both residents were not addressed in their individualized plans of care.
Resident room temperatures remained below required range
Penalty
Summary
The facility failed to maintain resident room temperatures between 71 and 81 degrees Fahrenheit for three sampled residents. Resident 1 was admitted with diagnoses including CHF and type II diabetes mellitus and had moderately impaired cognition and memory, with extensive assistance needs for personal care and transfers. Resident 2 was admitted with diagnoses including CHF and type II diabetes mellitus and had intact cognition and memory, with assistance needs for eating, hygiene, bathing, transfers, and toileting. Resident 3 was admitted with diagnoses including major depressive disorder and hypertension and had intact cognition and memory, with assistance needs for eating, hygiene, bathing, transfers, and toileting. During observation and interview, Resident 1 was wearing a thick flannel jacket and multiple blankets, including one over the head, and stated he felt cold since the weather became cooler, especially at night and early morning. Resident 1 stated there was no warm air from the vent and no heater in the room, and that his hands were cold and his joints hurt because of the low room temperature. Resident 2, observed wearing a fleece sweater, black jacket, long pants, and socks, stated the room got cold at night and had never been warm during colder days, and that he could not sleep well during the cold nights. Resident 3 stated the room got really cold at nighttime, there was no warm air or heater in the room, staff provided extra blankets, and he could not get restful sleep because the room was too cold. Maintenance staff measured room temperatures of 68 F, 66 F, 68.9 F, 66.7 F, and 67.6 F in the residents' rooms, all below the facility's stated comfortable and safe range of 71 to 81 F. Maintenance staff stated the temperatures were below the required level and that the facility had not contacted the outside company to switch the temperature regulator machine from summer mode to winter mode until that day. The maintenance log from 11/1/2025 to 11/25/2025 had no requests regarding residents' room temperature, and CNA 1 stated he had provided extra clothing and blankets to Resident 1 but had not checked the room temperature or reported it to maintenance. The DON stated the resident rooms were not between 71 F and 81 F as required by the facility policy.
Failure to Follow Physician Orders and Care Plans for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow physician's orders and care plans for two residents by not adhering to specific instructions regarding pressure ulcer prevention and management. For one resident with a history of diabetes, dementia, anemia, and moderate risk for pressure ulcers, staff did not limit the resident's sitting time in a wheelchair to one to two hours as ordered, nor did they ensure the use of a gel cushion as specified. Observations showed the resident was seated in a wheelchair for approximately three hours, and staff interviews confirmed that the required documentation for turning and repositioning was incomplete or missing for several shifts. Additionally, the resident's low air loss mattress was not set according to the resident's weight, as required by physician's orders and the care plan, with the analog pressure dial set significantly higher than the resident's actual weight. Staff interviews revealed that the lack of documentation and failure to follow orders could result in the facility being unaware if repositioning was performed, and that the incorrect mattress setting could pose a risk of falls or injury. The treatment nurse and DON both acknowledged that the mattress settings were not correct and that staff were not following the care plan interventions. The care plan for this resident included specific interventions for pressure ulcer prevention, such as limiting sitting time, using a gel cushion, and adjusting the mattress settings according to weight and height, but these were not consistently implemented. For the second resident, who had a stage four pressure ulcer, atrophy, and anemia, the facility also failed to set the low air loss mattress according to the resident's weight as ordered. Observations and interviews confirmed that the mattress was set for a much higher weight than the resident's actual weight. The care plan for this resident required the use of a pressure-relieving device and proper mattress settings, but these interventions were not followed. The DON and treatment nurse both confirmed that the settings were incorrect and that the facility was not adhering to its own policies and procedures for skin and wound management, as well as comprehensive person-centered care planning.
Resident with Dementia Sent Unsupervised to Incorrect Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia was mistakenly sent, unsupervised, to a medical appointment that was actually scheduled for another resident. The resident required maximal assistance with several activities of daily living and was not capable of safely attending appointments alone. The error originated when the Social Service Director (SSD) entered an orthopedic appointment and transportation order for the wrong resident, due to confusion caused by multiple residents sharing the same first name. This resulted in the resident being transported eleven miles away from the facility without proper supervision or notification to the responsible party. Facility staff, including a Licensed Vocational Nurse (LVN), were unaware of the resident's cognitive status and did not verify the appropriateness of the appointment or the need for supervision. The LVN prepared the resident for the appointment based on the facility's appointment calendar and handed the resident an envelope for the doctor, without confirming with the responsible party or ensuring the resident's safety. The responsible party only became aware of the situation after receiving a notification from the transportation company and subsequently alerted the facility, which was not initially aware that the resident had left the premises. Interviews with staff revealed a lack of communication and verification processes regarding off-site appointments for residents with cognitive impairments. The facility's policy required continuity of care during leaves of absence, but this was not followed in this instance. The resident, who was unable to recall details of the event due to her dementia, expressed feelings of anxiety and fear during the unsupervised trip. The incident highlighted failures in resident identification, staff awareness of resident needs, and adherence to established procedures for resident safety during off-site appointments.
Failure to Accurately Document and Administer Medications for NPO Resident with Gastrostomy Tube
Penalty
Summary
A physician failed to accurately document medication orders for a resident with a gastrostomy tube (GT) who was readmitted to the facility with an NPO (nothing by mouth) order. Despite the resident's NPO status and the presence of a GT for medication and nutrition administration, the physician's orders specified that medications such as Tylenol and Tramadol be given orally. This order was not clarified by nursing staff, and the medications were subsequently documented and administered by mouth according to the Medication Administration Record (MAR). Record reviews showed that over several days, the resident received multiple doses of Tylenol and Tramadol by mouth, as indicated on the MAR, even though the resident was not to receive anything orally due to the NPO order. Both the Registered Nurse Supervisor (RNS) and Assistant Director of Nursing (ADON) confirmed during interviews that the medications were given by mouth and acknowledged that this was inconsistent with the resident's NPO status and the correct route for administration via GT. The facility's policy on the six rights of medication administration requires that medications be given according to the prescribed route, and that orders be checked for accuracy before administration. In this case, the nursing staff did not clarify the conflicting orders with the physician or pharmacy, and the medications were administered and documented incorrectly, resulting in a failure to follow accepted professional standards for safeguarding resident care and accurate medical recordkeeping.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to promote dignity and respect for two residents, Resident 18 and Resident 100, by not ensuring privacy during care activities. Resident 100, who was admitted with severe cognitive impairment and dependency in lower body dressing, was exposed from the waist down during a dressing change. The privacy curtain was left open by the Rehabilitation Aide and Physical Therapist Assistant, leading to Resident 100 feeling hurt and expressing that the exposure was unacceptable. The facility's policy required privacy to be maintained, but this was not adhered to during the incident. Resident 18, who had intact cognition and required an indwelling catheter due to obstructive uropathy, was observed with an uncovered catheter drainage bag while sleeping in their room. The Assistant Director of Nursing confirmed the absence of a dignity cover, although the Director of Nursing later stated that the drainage bag should always be covered for privacy. The facility's policy emphasized maintaining privacy during personal hygiene activities, which was not followed in this case. The facility's failure to adhere to its own policies on dignity and privacy resulted in emotional distress for Resident 100 and a potential decline in dignity for Resident 18. The Director of Nursing acknowledged the importance of privacy and the potential for residents to become upset or stressed due to such incidents. The facility's policy and procedure on dignity and privacy, dated November 2021, outlined the expectation for residents to be treated with kindness, dignity, and respect, which was not met in these instances.
Failure to Accommodate Resident Needs and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident 72 by not ensuring the resident had a functional television for personal use, as identified in the resident's care plan. Resident 72, who was admitted with diagnoses including asthma and a history of falling, had a care plan indicating enjoyment of watching television. However, the resident's television was not functioning, forcing her to share a television with another resident, which was often unavailable due to privacy curtains being drawn during care. This situation caused frustration and agitation for Resident 72, impacting her emotional well-being. Additionally, the facility failed to ensure that the call lights were within reach for Residents 3, 81, and 93, as required by the facility's policy and each resident's care plan. Resident 3, who was at risk for falls, had a call light hanging between the headboard and wall, out of reach. Resident 81, with severely impaired cognition and a high risk for falls, had a call light on the floor, not accessible. Similarly, Resident 93, also at high risk for falls, had a call light placed on the headboard, beyond reach. These deficiencies in call light accessibility could lead to delayed care and increased risk of falls and injuries. The facility's failure to address these issues promptly was acknowledged by staff, including the maintenance staff and the facility administrator, who recognized the need for faster response times to such deficiencies. The Director of Nursing confirmed the importance of having call lights within reach to ensure residents can call for assistance when needed, as outlined in the facility's policy and procedure.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Sets (MDS) for three residents were completed and submitted to the CMS database within the required timeframe. Resident 85 was initially admitted on February 21, 2022, and readmitted later with diagnoses including difficulty walking, muscle weakness, and type 2 diabetes mellitus. The quarterly MDS for Resident 85 had an assessment reference date (ARD) of November 18, 2024, but was not completed and signed by the Registered Nurse Assessment Coordinator (RNAC) until January 8, 2025, which was 37 days late. Resident 98, admitted on August 31, 2022, with severe sepsis, seizures, and muscle weakness, had an ARD of November 21, 2024, but the MDS was not completed or submitted by the RNAC. Resident 116, admitted on October 1, 2023, with hyperlipidemia, dementia, and anxiety, had an ARD of November 29, 2024, but the MDS was also not completed or submitted by the RNAC. The MDS Nurse (MDSN) acknowledged during interviews that the assessments for Residents 85, 98, and 116 were not completed and submitted within the required 14-day period following the ARD. The Director of Nursing (DON) confirmed that the MDSN was responsible for updating and transmitting the MDS quarterly and annually, emphasizing the importance of timely completion to ensure accurate and up-to-date resident status for care planning. The facility's policy and procedure, as well as the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, require that the MDS completion date must be no later than 14 calendar days following the ARD, which was not adhered to in these cases.
Failure to Develop Timely Elopement Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to develop personalized care plans for four residents at high risk for elopement, compromising their safety and supervision. Resident 56, diagnosed with Alzheimer's disease and other conditions, was identified as high risk for elopement on 10/2/2024, but a care plan was not created until 1/7/2025. The MDS Nurse acknowledged the absence of a care plan and interventions following the initial evaluation, indicating a lack of documented evidence in the Interdisciplinary Team's records. Resident 154, with Alzheimer's disease and other diagnoses, was also at high risk for elopement as of 12/25/2024. The Social Services Assistant met with the resident on 1/7/2025 and created a care plan after the resident expressed a desire to leave the facility. However, the SSA did not review the elopement risk assessment or document the conversation, leading to a delay in implementing necessary interventions. Similarly, Resident 89 and Resident 29 were identified as high risk for elopement in September and November 2024, respectively, but care plans were not developed until January 2025. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of timely care plans to prevent elopement, yet no interventions were documented in the residents' records. The facility's policies require comprehensive, individualized care plans within 48 hours of admission, but these were not adhered to, resulting in a failure to address the residents' elopement risks effectively.
Failure to Implement Elopement Prevention Plans for High-Risk Residents
Penalty
Summary
The facility failed to provide necessary interventions and supervision for four residents who were at high risk for elopement. Resident 56, diagnosed with Alzheimer's disease and other conditions, was identified as high risk for elopement on 10/2/2024, but no care plan or interventions were documented until 1/7/2025. The MDS Nurse acknowledged the absence of a care plan and interventions, which are crucial for addressing the resident's needs. Similarly, Resident 154, with Alzheimer's disease and other diagnoses, was assessed as high risk for elopement on 12/25/2024. However, a care plan was only created on 1/7/2025 after the Social Services Assistant noted the resident's desire to leave the facility. The Medical Records Director confirmed the lack of documentation in the Interdisciplinary Team's care planning records. Resident 89 and Resident 29 also faced similar issues. Resident 89, with dementia and other conditions, was evaluated as high risk for elopement on 9/4/2024, but no care plan was documented until 1/7/2025. Resident 29, with severe cognitive impairment, was assessed on 11/16/2024, but a care plan was only created on 1/8/2025. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of timely care plans to prevent elopement, yet documentation was lacking in the facility's records.
Deficient Respiratory Care Practices in Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents receiving oxygen therapy, as observed during a survey. Resident 27's oxygen tubing and nasal cannula were found on the floor, which was confirmed by the Assistant Director of Nursing (ADON) during an observation. The ADON acknowledged that the nasal cannula and tubing should be placed in a bag when not in use to prevent infection. Resident 201 was observed receiving oxygen therapy with an empty humidifier bottle, which was supposed to be changed weekly. The ADON confirmed the empty humidifier bottle and stated it should be changed every week. Resident 201's medical history included lobar pneumonia, sepsis, and acute erythroid leukemia in relapse, and the resident had the capacity to understand and make decisions. Resident 202's oxygen tubing was also observed touching the floor, which was verified by a licensed vocational nurse (LVN). The LVN stated that the tubing should not be on the floor to prevent infection spread. The Director of Nursing (DON) confirmed that oxygen equipment should not touch the floor and should be replaced immediately. The facility's policy indicated that oxygen equipment should be dated and kept off the floor, and labeled bags should be used for storage when not in use.
Failure to Reseal and Replace Emergency Kit
Penalty
Summary
The facility failed to reseal an intramuscular emergency kit (IM e-kit) and replace it within 72 hours after use, as required by their policy. This deficiency was identified during a review of the facility's IM/E-KIT log and interviews with staff. The report highlights two instances where medications were removed from the e-kit for residents with specific medical conditions. Resident 251, who had diabetes mellitus and hyperlipidemia, received a dose of Furosemide from the e-kit on December 5, 2024. Similarly, Resident 48, who also had diabetes mellitus and hyperlipidemia, was administered Glucagon from the e-kit on December 30, 2024, due to low blood sugar levels. The facility had transitioned to using CUBEX, an automated unit dose system, for emergency medication supply as of December 20, 2024, and was expected to discontinue the use of physical e-kits. However, the IM e-kit was not returned to the pharmacy and was still in use, leading to the oversight. The Registered Nurse (RN) and Director of Nursing (DON) acknowledged the failure to reseal the e-kit with the required orange zip ties, which would have indicated the need for replacement and prevented unauthorized access. The pharmacist was unaware that the facility still had the e-kit, resulting in the pharmacy not replacing it as needed.
Incomplete Refrigerator Temperature Logs
Penalty
Summary
The facility failed to ensure the completion of daily refrigerator temperature logs as required by its policy, which compromised its ability to effectively monitor food storage temperatures. During an initial kitchen tour with the Dietary Director (DD), it was observed that the refrigerator temperature logs were incomplete, with no temperature entries documented for the AM and PM shifts on 1/4/2025 for Freezer #1. In a subsequent interview and record review, the DD acknowledged the missing entries and stated that she should have followed up on the completion of the log. Additionally, during an interview, the Dietary Staff (DS) stated that staff are expected to record refrigerator temperatures twice a day as part of the facility's food safety protocols. The absence of these logs means there is no way to verify if food has been stored at safe temperatures, potentially leading to food spoilage or bacterial growth. The facility's policy and procedure on cold storage temperature monitoring and record-keeping requires Food and Nutrition staff to review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling.
Lack of Admission Policy Leads to Deficiency in Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to develop a policy and procedure related to the admission process, which led to a deficiency in the care provided to a resident. The resident, who was admitted with a diagnosis of Diabetes Mellitus (DM) among other conditions, was not monitored for signs and symptoms of high or low blood sugar levels. The admission process lacked a structured approach, as there was no prefilled area in the Admission Report Check List to remind Registered Nurses (RNs) to ask for vital signs, including blood sugar checks, or if insulin was administered during the hospital stay. Interviews with facility staff revealed that there was no written procedure or checklist for RNs to follow during the admission process. The Director of Nurses (DON) confirmed the absence of a policy and procedure guide for admissions, relying instead on the RNs' judgment to know which hospital records to review. This lack of structured guidance and documentation led to the oversight in monitoring the resident's blood sugar levels, as there were no physician orders or progress notes indicating the need for such monitoring. The deficiency was identified through a review of the resident's admission records and interviews with the facility's nursing staff.
Infection Control Deficiencies in PPE Use and Foley Catheter Management
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, as evidenced by two specific incidents. In the first incident, the facility did not place contact isolation precaution signage at the entrance of a resident's room who was under contact isolation due to shingles. Additionally, a family member visiting the resident was not wearing the required personal protective equipment (PPE), specifically an isolation gown, while in the room. The Infection Prevention Nurse (IPN) acknowledged the oversight and emphasized the importance of proper signage and PPE to prevent exposure to infections. In the second incident, a resident's Foley catheter bag was observed touching the floor, which is against the facility's policy. The Licensed Vocational Nurse (LVN) present during the observation confirmed that the Foley bag should not be in contact with the floor to avoid contamination. The Director of Nursing (DON) reiterated that the facility's policy requires catheter drainage bags to be kept off the floor to prevent cross-contamination. Both incidents highlight deficiencies in the facility's infection prevention and control practices, which could potentially increase the risk of infection spread among residents, staff, and visitors. The facility's policies and procedures were not adequately followed, leading to these lapses in infection control measures.
Sanitation and Safety Deficiencies in Resident Room and Patio Door
Penalty
Summary
The facility failed to provide a sanitary environment for a resident by allowing an unknown black back brace to remain in the resident's room. The resident, who was admitted with diagnoses including generalized epilepsy and severe cognitive impairment, did not have the back brace listed among their personal belongings. Observations and interviews revealed that the back brace was not the resident's property and had been left in the room since the start of a CNA's shift. The Director of Nurses acknowledged that staff should not leave personal items in residents' rooms due to the risk of cross-contamination. Additionally, the facility did not maintain a functional door with locks that latch, leading to the patio area. Observations showed that the door was not latching properly, allowing cigarette smoke from the designated smoking area to enter the facility. The activities assistant supervising the smoke break admitted to being unable to close the door completely and failed to report the issue to maintenance. The Maintenance Supervisor confirmed the door's malfunction and stated that it was not part of routine maintenance checks. The facility's policies and procedures indicated that faulty equipment should be reported immediately and that routine inspections should be recorded. However, the Maintenance Supervisor did not have a log for routine inspections and relied on visual observations and staff reports to address maintenance issues. The Administrator and Director of Nursing were unaware of the door's malfunction until it was brought to their attention, highlighting a lapse in communication and adherence to safety protocols.
Failure to Maintain Resident's Advance Directive in Chart
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive was included in their chart, which is a critical document specifying the resident's healthcare wishes in case they become unable to make decisions. This deficiency was identified during a review of the resident's records, which showed that although the Physician Orders for Life Sustaining Treatment (POLST) indicated the existence of an Advance Directive, the document was not found in the resident's chart. The Social Service Assistant acknowledged the absence of the Advance Directive and suggested it might have been misplaced during the resident's transfer to the hospital and subsequent readmission. The Director of Nursing confirmed that the facility's policy requires a copy of the Advance Directive to be kept in the resident's chart to ensure accessibility during emergencies. The facility's policy, revised in December 2023, mandates that all adult residents be informed and provided with written information regarding their right to obtain a copy of their Advance Directive, which should be placed in their health record. The failure to adhere to this policy could lead to misinformation regarding medical care and treatment, potentially not honoring the resident's wishes if they or their responsible party are unable to make healthcare decisions.
Failure to Timely Complete and Submit MDS for a Resident
Penalty
Summary
The facility failed to ensure the timely completion and submission of the comprehensive Minimum Data Set (MDS) for Resident 22, as required by federal regulations. Resident 22 was admitted with significant medical conditions, including hemiplegia, hemiparesis, abnormal posture, muscle weakness, and dysphagia. The MDS Nurse acknowledged that the annual comprehensive MDS for Resident 22, with an Assessment Reference Date (ARD) of December 1, 2024, was not completed and submitted within the mandated 14-day period, which should have been by December 15, 2024. Interviews with the MDS Nurse and the Director of Nursing (DON) revealed that the MDS Nurse was behind schedule in completing and submitting MDS assessments to the CMS database. The DON emphasized the importance of timely MDS completion and submission to ensure accurate and updated resident status, which is crucial for revising or initiating care plans based on the resident's current conditions. The facility's policy and procedure documents also highlighted the responsibility of the MDS Coordinator to adhere to state and federal requirements for the Resident Assessment Instrument (RAI) process.
Failure to Monitor and Manage Diabetes Mellitus
Penalty
Summary
The facility failed to provide adequate care and services to a resident with a diagnosis of Diabetes Mellitus (DM). The deficiency involved the failure to monitor the resident's blood sugar levels and to clarify the need for such monitoring and treatment with the resident's physician. The resident was admitted with a history of type 2 DM, as documented in the General Acute Hospital (GACH) discharge packet, but this information was not adequately reviewed or acted upon by the facility's staff. Upon admission, the resident's medical records from the GACH indicated a history of type 2 DM and previous administration of insulin Lispro. However, the facility's Admission Record did not reflect this diagnosis, and no care plan was developed to address the resident's diabetes. The Admitting Registered Nurse (RN) failed to clarify the resident's blood sugar monitoring and treatment needs with the physician, and the Nurse Practitioner (NP) who took over care did not thoroughly review the discharge packet to justify the continuation or discontinuation of blood sugar monitoring and treatment. The facility's Director of Nurses (DON) acknowledged that the admitting RN should have reviewed the discharge packet thoroughly and clarified the orders and diagnosis. The facility lacked a policy and procedure guide for RNs to follow during resident admissions, which contributed to the oversight. The failure to monitor and manage the resident's blood sugar levels had the potential to result in uncontrolled blood sugar levels, leading to serious complications such as ketoacidosis, coma, hospitalization, or death.
Improperly Fitted Knee Immobilizer for Resident
Penalty
Summary
The facility failed to provide a properly placed and sized knee immobilizer for a resident, identified as Resident 351, who was admitted with a fracture of the right patella and a history of falling. The resident had the mental capacity to make medical decisions and was dependent on staff for activities of daily living. During observations, the knee immobilizer was found to be improperly positioned, either at the resident's ankle or loose around the knee and thigh, which was confirmed by a Licensed Vocational Nurse (LVN 3) and a Physical Therapist (PT 1). The resident reported that the immobilizer frequently slipped and did not provide adequate support. Despite the resident's complaints and the observations made by staff, no action was taken to order a properly sized replacement immobilizer. The Director of Nursing (DON) acknowledged the importance of a properly fitting immobilizer for stabilizing the joint and preventing further injury. However, there were no reports made to nursing leadership regarding the improper fit, and no corrective actions were initiated to address the issue. This inaction placed the resident at risk for injury, discomfort, and complications such as impaired mobility and skin breakdown.
Failure to Provide Prescribed Nutritional Supplement
Penalty
Summary
The facility failed to ensure that a resident identified as at risk for weight loss received the prescribed health shake three times a day as ordered by the physician. This oversight was observed during a meal service when the resident's meal tray did not include the health shake, despite the meal ticket indicating it should be provided. The resident, who was admitted with multiple diagnoses including hypertension, difficulty in walking, and cognitive impairment, was at risk for nutritional problems and weight loss. The care plan for the resident included the provision of health shakes with meals to maintain adequate nutritional status. During interviews, the family member of the resident, a registered nurse, the dietary supervisor, and the director of nursing all confirmed the importance of the health shake in addressing the resident's nutritional needs. The dietary supervisor acknowledged that the omission was accidental, and the director of nursing emphasized the necessity of following physician diet orders to maintain the nutritional health of residents, particularly those with weight loss concerns. The facility's policy and procedure on diet orders, revised in 2023, mandates that diet orders prescribed by the physician be provided by the Food & Nutrition Services Department.
Failure to Monitor Resident's Diabetes Mellitus
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) thoroughly reviewed the overall care needed for a resident with a history of type 2 Diabetes Mellitus (DM). The resident was admitted with multiple diagnoses, including hemiplegia, hemiparesis, hyperparathyroidism, hyperlipidemia, and Alzheimer's disease. Despite the resident's documented history of DM in various admission records, the NP's initial progress note did not reflect this history, nor did it indicate that blood sugar levels were monitored. The deficiency occurred because NP 1, who took over the resident's care after returning from vacation, did not review the hospital discharge packet or clarify the resident's diagnosis and orders. NP 1 assumed that NP 2, who covered during her absence, had reviewed the necessary documents and informed her of the resident's DM history. The Director of Nurses confirmed that NP 1 should have reviewed the hospital record and clarified the diagnosis and orders upon taking over the resident's care. This oversight had the potential to result in uncontrolled blood sugar levels for the resident.
Inappropriate Administration of Ativan
Penalty
Summary
The facility was found to have administered a higher than necessary dose of Ativan to a resident who did not exhibit any behaviors of anxiety disorder. The resident, identified as Resident 73, was receiving Ativan 1 mg twice daily despite not showing signs of anxiety, as documented in the Medication Administration Record for December 2024 and January 2025, which indicated no episodes of anxiety. This practice was contrary to the facility's policy, which requires that psychotropic medications be used only when necessary to treat a specific condition. The Psychiatric Nurse Practitioner (PNP) had initially recommended a gradual dose reduction of Ativan from 1 mg twice daily to 0.5 mg as needed, based on her assessment and the resident's behavior monitoring records. However, the resident requested to revert to the previous dosage, and the PNP authorized the change without reassessing the resident. This decision was made despite the resident's agreement to the initial dose reduction plan and the absence of documented anxiety symptoms. The facility's policy on psychotropic medications, revised in December 2023, emphasizes that such drugs should not be administered for convenience or discipline. The failure to adhere to this policy and the subsequent administration of a higher dose of Ativan without documented necessity put the resident at risk of adverse effects, impacting their overall well-being.
Failure to Implement Smoking Policy
Penalty
Summary
The facility failed to implement its smoking policy and procedure, resulting in a deficiency related to providing a smoke-free environment for Resident 97. The resident, who was admitted with a stress fracture and morbid obesity, had intact cognition and the capacity to make decisions. Despite filing a grievance about the strong smell of cigarette smoke entering her room from the smoking patio, the issue persisted. The facility attempted to address the grievance by offering a room change and posting a sign to keep the door closed during smoke breaks, but these measures were ineffective. Observations revealed that the patio door across from Resident 97's room was often left open during smoke breaks, allowing smoke to enter the facility. Interviews with staff confirmed the presence of smoke in the hallway and identified a broken latch on the patio door as the cause. The maintenance assistant was unaware of the broken latch, and the Director of Nursing acknowledged the potential health risks of secondhand smoke but was not informed of the door issue until later. The facility's smoking policy, revised in 2016, mandates a smoke-free environment, which was not upheld in this instance.
Failure to Inform Residents of Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that six out of twelve residents who attended a Resident Council meeting were aware of the Ombudsman's contact information. During a group interview, these residents expressed that they did not know who the Ombudsman was or how to contact them, and they indicated that having this information would be beneficial for addressing unresolved issues within the facility. The Activity Director admitted that there was no documented evidence of providing this information during the Resident Council meetings. Further interviews revealed that the Admission Assistant also lacked documentation showing that residents were informed about the Ombudsman's role and contact information upon admission. The Director of Nurses acknowledged the importance of residents having access to the Ombudsman's contact details as part of their rights, emphasizing that it allows residents to voice concerns and seek assistance outside the facility. The facility's policy on Resident Rights supports this, stating that residents should have access to contact information for relevant state agencies and advocacy groups.
Residents Unaware of Survey Results Location
Penalty
Summary
The facility failed to ensure that six out of twelve residents who attended a Resident Council meeting were aware of where to find and how to read the facility's previous Annual Recertification Survey results, including the Plan of Correction (POC). During a group interview, these six residents expressed that they were not informed about the location of the survey results and indicated that having this information would be beneficial. This lack of awareness among residents was identified during a Resident Council meeting. Interviews with facility staff revealed that there was no documented evidence of communication to residents regarding the location of the survey results. The Activity Director confirmed that she did not inform or remind residents about the survey results during the monthly Resident Council meetings. Similarly, the Admission Assistant acknowledged that information about the survey results was not included when explaining resident rights upon admission. The Director of Nurses emphasized the importance of residents knowing where to find the survey results, as it is a resident right. The facility's policy on Resident Rights also supports this, indicating that residents have the right to examine the results of the most recent survey and any plan of correction in effect.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Whittier
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bonita Hills Post Acute | 1.3 mi | ★★★★★ | 44 | 0 |
| Park Regency Care Center | 1.3 mi | ★★★★★ | 23 | 0 |
| Whittier Hospital Medical Ctr D/p Snf | 1.8 mi | ★★★★★ | 1 | 0 |
| Imperial Healthcare Center | 2.2 mi | ★★★★★ | 1 | 0 |
| Sunny Hills Post Acute | 2.3 mi | ★★★★★ | 37 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.