Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Windsor Gardens Convalescent Hospital during CMS and state inspections, most recent first.
Informed Consent for Psychotropic Medications Not Properly Obtained: The facility failed to verify that two residents had the capacity to consent to psychotropic medications. One resident had severely impaired cognition, a BIMS score of 2, and a consent form for escitalopram and quetiapine that lacked the licensed staff verifier’s full name. Another resident with dementia and no representative had buspirone and valproic acid continued without valid consent; the ICC note showed only an LVN present, and the SSD and ADON stated the resident could not consent and no LTCRP representative had participated.
A resident with severe cognitive impairment and pain was given pain medication without first receiving documented non-pharmacological interventions listed in the care plan. Another resident with a G-tube was observed lying nearly flat while tube feeding was running, despite an order and care plan requiring HOB elevation of at least 30 degrees during feeds and afterward. A third resident with an indwelling catheter had a blank TAR entry for catheter care and monitoring on an evening shift, and the DON confirmed the care was not completed as documented.
Improper food labeling and cross-contamination practices were observed in the kitchen. Pre-poured milk cups and pineapple chunks were stored in the walk-in refrigerator without prep or use-by labels, a scoop was kept inside a container of food thickener, and expired apples and onions were left in storage. In addition, two KDs handled sanitized dishes with dirty gloves after working with soiled items, and a KA used the same gloves to handle scoops and then a dinner roll during meal service.
The facility failed to follow its infection prevention policies and WMP as written. The MS stated water temperatures were checked weekly, but chlorine residuals and pH were not tested, and the IPN was unsure whether those measures were monitored. In a separate event, an LVN entered a resident’s room under EBP and applied a lidocaine patch without donning a gown, even though the resident had EBP orders for a wound and the DON and RN stated gown and gloves were required for this close-contact care.
Delayed informed consent for COVID-19 vaccination was identified for two residents. The IPN and DON acknowledged that consent should reflect the resident’s current decision at the time of vaccination, but the records showed that consent discussions covering risks, benefits, and side effects were obtained weeks before the vaccine was administered. Both residents had intact cognitive skills for daily decisions, and the facility policy required education and signed consent before vaccination.
A resident with hepatic encephalopathy, schizoaffective disorder, bipolar type, and PTSD wanted more frequent opportunities to go out on pass and said his concerns were not being heard. Although the care plan addressed his needs and he was not at risk for elopement, staff reported that an active MD order was required and the prior order had been discontinued, while the SSD said he was permitted to go out on pass but escorts could not be provided weekly. The DON stated residents have rights to live normally and may go out on pass with family, a representative, or an escort if safety concerns exist.
Delayed Notification of Abnormal Potassium Result and Lack of Monitoring: A resident with dementia, cardiomyopathy, diabetes, acute kidney failure, and a cardiac pacemaker had a critical BMP potassium of 5.8 mEq/L, but the PCP was not notified right away and was also not told that Kayexalate was available in the E-kit. Staff interviews and record review showed no documented assessment or close monitoring after the change in condition, and a repeat lab later showed worsening hyperkalemia at 6.0 mEq/L.
Unattended Medication Labels Exposed Resident Information: Two residents' medication labels were left on top of a med cart in the hallway, exposing names, prescription numbers, and medication details. An LVN acknowledged the labels came from individual medication packages and that leaving them unattended was not facility policy because the information was confidential. The ADON stated the labels should not be left out because doing so would violate HIPAA and patient confidentiality.
A resident with stroke, HTN, hyperlipidemia, and hemiparesis had a LAL mattress set above the manufacturer-recommended weight setting. Staff observed the machine set for about 150 lbs even though the sticker indicated 98 lbs, and an LPN confirmed the setting exceeded the recommended level. The facility policy stated support surfaces are intended to promote comfort, prevent skin breakdown, and provide pressure relief.
MDS Pain Management Section Not Accurately Completed: The facility failed to accurately complete the MDS pain management section for a resident who was cognitively intact and needed assistance with ADLs. The MAR showed acetaminophen was given for pain rated 3/10 within the MDS look-back period, but the MDS was marked "No" for PRN pain meds or pain meds offered and declined, and the MDS coordinator said staff ask residents and nurses about pain when completing the MDS.
A resident with CHF, renal disease, dementia, and a history of hyperkalemia received Bactrim DS and sacubitril-valsartan together after an EMR DDI alert flagged increased risk for hyperkalemia, but the alert was overridden and the physician was not documented as being notified. After a BMP showed elevated potassium, the record did not show the required assessment and monitoring of LOC or neuromuscular status per the care plan. A repeat lab later showed critical hyperkalemia, and the resident expired the same day.
Eyeglasses Not Kept in Working Condition: A resident with cerebrovascular disease, alcoholic cirrhosis, atrial fibrillation, severe cognitive impairment, and impaired vision was observed watching TV up close and reported that his eyeglasses had been broken for months. He said he had informed staff and was frustrated that he could not see clearly or enjoy his preferred activity. An LVN stated there was no documentation or communication about the broken glasses, while the SSD and DON stated residents should have access to assistive devices and that vision is important for quality of life and safety.
Failure to Reassess and Update Fall Interventions After Repeated Falls: A resident with a history of falls, muscle weakness, gait instability, and poor safety awareness had repeated fall-related events after attempting to ambulate or stand without assistance. Although staff completed immediate post-fall checks, the MDS nurse stated reassessment was only done on admission, and RN confirmed there was no updated care plan reflecting the recent falls or documented reassessment after the most recent fall.
Incomplete Intake and Output Documentation for Dialysis Resident: A resident with ESRD, CHF, and a fluid restriction received hemodialysis, but the facility did not consistently document intake and output amounts in the medical record. The ADON stated the resident’s fluid allowance was divided between dietary and nursing shifts, yet there was no specific time or designated location for documenting intake/output, and the DON confirmed the facility relied on dialysis weights to assess fluid status.
Failure to Elevate HOB During G-Tube Feeding: A resident with Parkinsonism, dementia, dysphagia, and G-tube dependence was observed lying nearly flat while enteral feeding was running, despite a physician order, care plan, and facility policy requiring the HOB to be elevated at least 30 degrees during feeding and for one hour afterward. The ADON confirmed the resident was below the ordered angle and stated the facility lacked a measuring device to verify the HOB angle; the DON stated aspiration is a complication of enteral tube feeding.
Bed rail safety assessments were not documented as ongoing for a resident with DM2, diabetic neuropathy, HTN, and muscle weakness with gait and mobility abnormalities. The resident had a physician order for 1/4 side rails x2 as an enabler, and the Maintenance Supervisor stated bed rail zone measurements were done at admission only, with no evidence of annual measurements or periodic reassessment. Facility policies required assessment of entrapment risk and correct installation and maintenance of bed rails.
Failure to assess and monitor a resident’s behavioral health needs. A resident with hx of bipolar disorder, schizoaffective disorder, and PTSD reported ongoing distress related to combat trauma and difficulty getting staff to listen. Although the care plan addressed trauma, triggers, and support needs, the RN Supervisor stated there was no physician or nursing documentation of behavioral monitoring or trigger assessment, and that an order was needed to implement behavior monitoring.
Failure to Rotate Insulin Injection Sites: The facility did not ensure insulin injection sites were rotated for three residents receiving insulin for DM. Each resident was cognitively intact, and physician orders directed staff to rotate injection sites, but records showed repeated use of the same site for at least one resident and no documented rotation for others. The facility’s insulin administration policy also directed nursing staff to rotate injection sites, preferably within the same general area.
A resident with Parkinsonism, dementia, bipolar disorder, and schizoaffective disorder had an MRR recommendation to add acetaminophen for mild and severe pain, but the physician record did not show the recommendation was reviewed or acted on. RN and DON interviews confirmed there was no documentation that the pharmacist’s recommendation was acknowledged or addressed, despite the facility P&P requiring physician review and documentation of any actions taken.
A resident with metabolic encephalopathy, DM, CHF, and muscle weakness had an opened bottle of Pepto-Bismol left on the bedside table without a physician order. The resident’s MDS showed moderately impaired cognitive skills and need for moderate to maximum ADL assistance, and the LVN confirmed the resident was not approved to self-administer medication safely. The DON stated bedside medication is prohibited unless the resident is deemed capable, and the facility policy requires physician and care team determination for safe self-administration.
Improper Dishwasher Chlorine Testing by Dining Services Staff: The DSM and Kitchen Dishwashers were testing dishwasher chlorine by dipping test strips into the drainage outlet outside the dishwasher and recording results of 200 ppm. The DSM stated this was the usual method and that she had not been given written facility training on the process; a later-reviewed fact sheet stated the strip should be passed over the top of a dish after the cycle finishes and that the acceptable range is 50-100 ppm.
An LVN documented Finasteride as given to a resident with HTN heart disease, CKD with HF, AV block, and cardiomyopathy even though the med was not in the med cart and the pharmacy said it had not been delivered or dispensed to the facility. The MAR entry conflicted with the order and with the nurse’s statement that the medication was not received, resulting in inaccurate med documentation.
Delayed Informed Consent for Influenza Vaccination: The facility failed to ensure timely informed consent before giving influenza vaccine to two residents. One resident had a history including metabolic encephalopathy, hyperlipidemia, and HTN, and the other had dysphagia, schizoaffective disorder, and muscle weakness; both had intact cognitive skills for daily decisions per MDS. The IPN confirmed consent was obtained days to weeks before vaccine administration, and the DON stated informed consent is needed so residents understand risks, benefits, and their right to accept or refuse treatment.
Call Light Not Within Reach: A resident with CHF, Afib, a prosthetic heart valve, HTN, BPH, and a prior cerebral infarction was observed awake and sitting in bed with the call light tied up on the wall and not within reach. The resident was cognitively intact per BIMS and required assistance with multiple ADLs, while an LVN confirmed the call light was not accessible and stated it should be within reach for help. The care plan identified the resident as high fall risk and directed staff to keep the call light within reach.
Three residents with varying levels of dependence and medical needs reported that staff did not respond promptly to their call lights and requests for assistance, particularly during the night shift. Residents described long waits for help, observed staff sleeping in the nursing station, and expressed feelings of irritation, anger, and disrespect. Staff interviews confirmed that sleeping in the nurses' station is against facility policy, and facility procedures require immediate response to resident requests.
A resident with diabetes had multiple blood sugar checks performed by nursing staff without a physician order, and the physician was not notified or documentation was lacking when the resident's blood sugar levels were repeatedly elevated. Facility policy required both a physician order for such procedures and documentation of physician notifications, but these were not followed.
A resident with severe cognitive impairment, impaired mobility, and multiple medical conditions was found on the floor after a fall, despite being care planned for fall risk with interventions such as a clutter-free environment and call light accessibility. Staff interviews indicated the resident was bedbound and fully dependent, but supervision was insufficient, and the last observation time was unclear, leading to the resident's transfer to an acute care hospital.
The facility did not follow the planned menu or provide appropriate dietary options for residents with specific needs, including serving boiled chicken instead of baked chicken to a resident who disliked fish, failing to provide vegan menu items to a vegan resident, and substituting peas for oven French fries for residents on a renal diet. Staff were unaware of some residents' dietary requirements, and menu substitutions were made without proper review.
Twelve residents on pureed diets were served carrots with a thin, soupy consistency instead of the required smooth, pudding-like texture. The cook acknowledged using too much liquid, and the dietary supervisor confirmed the food did not meet the facility's policy or recipe standards for pureed diets, which require a homogenous, cohesive texture to ensure safe swallowing.
Surveyors found that a can opener blade in the kitchen was worn, dented, stained, and had metal shavings and dried residue, which was confirmed by the Dietary Supervisor. The blade's condition did not meet facility policy or FDA Food Code requirements for cleanliness and repair, resulting in a deficiency in safe and sanitary food preparation practices.
The facility did not obtain informed consent before starting or increasing psychotropic medications for three residents with mental health diagnoses. In each case, either the required education about risks and benefits was not provided, or consent forms were incomplete or missing, despite facility policy and staff acknowledgment that consent was necessary.
A resident with dementia, chronic kidney disease, and limited mobility did not have their call light within reach while in bed, despite being dependent on staff for care. Staff confirmed the call light was inaccessible, and facility policy required it to be accessible at all times.
A resident with multiple diagnoses received a nicotine patch as ordered, but staff failed to document the removal of the patch after 24 hours on several occasions. The MAR showed administration dates, but there was no record of patch removal, and a nurse confirmed this documentation was missing, contrary to facility policy.
A resident's MDS assessment was completed without including active diagnoses of schizophrenia, depression, and bipolar disorder, despite these being documented in the medical record and supported by psychiatric notes and physician orders. The DON confirmed the assessment was inaccurate and did not match the resident's clinical information.
Two residents did not have their care plans updated after changes in their care needs: one resident with severe cognitive impairment refused to wear hearing aids, but the care plan was not revised to reflect this or to add alternative interventions; another resident was prescribed a nicotine patch, but the care plan did not include instructions for monitoring, removal, or documentation of the patch. Facility policy requires care plans to be reviewed and revised as resident needs change, but this was not done.
Two residents who required assistance with ADLs were found with long and unclean fingernails, despite care plans and facility policy requiring regular assessment, cleaning, and trimming. Staff acknowledged the oversight, and interviews confirmed that daily nail care was expected but not performed as required.
A resident with severe cognitive impairment and hearing loss was not assisted by staff in wearing hearing aids as required by her care plan, resulting in communication difficulties. Staff interviews and observations confirmed the hearing aids were not provided daily, despite facility policy and assessment indicating the need for such assistance.
A resident with severe cognitive impairment and multiple medical conditions, including an unstageable pressure ulcer, was found to have a low air loss (LAL) mattress set at 325 lbs instead of the physician-ordered 113 lbs. This discrepancy was confirmed by the DSD, who noted the setting did not match the resident's weight and placed the resident at risk for skin breakdown, contrary to facility policy and physician orders.
Staff did not notify the physician when a resident with an indwelling catheter showed signs of sediment in the urine, despite care plans and orders requiring such notification. Documentation review confirmed no record of physician notification, and both an LVN and the DON acknowledged this omission during interviews. This failure could have delayed appropriate treatment for a possible UTI.
A resident dependent on staff for care and receiving tube feeding for dysphagia was found with feeding formula leaking from the gastrostomy tube onto their skin and bedding. Staff failed to properly assess and secure the tube, with both CNA and LVN relying on the previous shift and not fully checking the resident. Facility policy required verification of tube placement and reporting of complications, but these steps were not followed, resulting in the resident not receiving prescribed nutrition and being exposed to risk of skin breakdown.
A resident with a history of cerebral infarction, venous thrombosis, and end stage renal failure on hemodialysis was prescribed aspirin and Eliquis for blood clot prevention. Despite being identified as high risk for bleeding, staff did not monitor or document signs and symptoms of bleeding or bruising as required by the care plan and facility policy. The DON confirmed this lapse in monitoring for the duration of the resident's anticoagulant therapy.
Two residents experienced medication administration errors when nurses failed to follow physician orders: one received a carbamazepine suspension that was not shaken prior to dosing, and another was given a multivitamin without minerals instead of the prescribed formulation with minerals. These incidents resulted in a medication error rate above the acceptable threshold.
Two residents experienced significant medication errors when a nurse failed to shake a carbamazepine suspension before administration and antihypertensive medications were given outside of prescribed blood pressure parameters. Staff interviews and record reviews confirmed that facility policies for safe medication administration were not followed in these cases.
A treatment nurse failed to change gloves between removing soiled dressings, cleaning wounds, and applying new dressings for a resident with multiple wounds, contrary to facility infection control policy. The nurse and facility leadership confirmed that gloves should be changed at each step to prevent cross-contamination, but this was not done during the observed wound care.
A facility failed to provide a resident's records upon request from their legal representative. The request was faxed to an incorrect number, and the Administrator, responsible for handling such requests, did not receive it. The facility's policy mandates providing access to records within 24 hours of a request, but this was not met, violating the resident's rights.
A resident did not receive prescribed skin treatments and glaucoma eye drops on multiple occasions, as the facility failed to document these in the TAR and MAR. The resident, who was confused and dependent on assistance, was admitted with conditions including a left above-knee amputation and glaucoma. The facility's policies require immediate documentation of administered treatments, which was not followed in this case.
A facility failed to verify a resident's DNR status upon admission, despite the resident having a DNR order from a hospital. The resident, with metabolic encephalopathy and dementia, was admitted without confirmation of their code status with the NOK or physician. Staff interviews revealed the resident was considered full code, contrary to the hospital's DNR order, highlighting a lapse in communication and documentation.
A resident with severe cognitive impairment and multiple health issues was not readmitted to the LTC facility after hospitalization, despite available beds. The facility's bed-hold policy was not implemented, leading to the resident remaining in the hospital. Interviews revealed a communication breakdown, as the Director of Nursing was unaware of the discharge readiness.
A resident's oxygen tubing was not changed weekly and was found on the floor, contrary to facility policy. The resident, who required oxygen for shortness of breath, had tubing dated over two weeks old. Both an LVN and the DON confirmed the deficiency, acknowledging the risk of infection due to the tubing's condition and placement.
A CNA failed to wear gloves when entering a COVID-19 isolation room and did not remove her face shield and N-95 mask upon exiting, contrary to the facility's infection control policies. The resident in the room had severe cognitive impairment and tested positive for COVID-19, requiring novel respiratory precautions. Interviews confirmed the importance of following PPE protocols to prevent infection spread.
Informed Consent for Psychotropic Medications Not Properly Obtained
Penalty
Summary
The facility failed to ensure that two residents had the capacity to sign consent for anti-psychotropic medications. For one resident, the record showed diagnoses including hepatic encephalopathy, schizoaffective disorder, and TIA. The MDS dated 01/14/2026 indicated severely impaired cognitive skills for daily decisions, and the BIMS score was 2, which the ADON stated indicated lack of capacity to make decisions. Despite this, the psychotropic medication informed consent for escitalopram and quetiapine documented verbal consent from the resident, and the form did not include the name of the licensed staff who verified the consent prior to initiation. During observation, that resident was found lying in bed, awake, alert, and oriented to name only, not to place or time. The ADON stated that residents prescribed anti-psychotropic medication require informed consent outlining risks and benefits, that it was inappropriate to obtain informed consent from a resident lacking capacity, and that the consent form should include the complete licensed staff name verifying consent. The DON stated that when a resident can sign, a licensed nurse verifies informed consent to ensure the resident is aware of risks and benefits and has the right to accept or refuse treatment, and that if residents cannot understand, they are not able to give informed consent. For the second resident, the record showed diagnoses including parkinsonism, dementia, bipolar disorder, and anxiety, with no family or resident representative on record. The MDS indicated the resident was rarely or never understood, dependent on staff for all functional abilities, and could never or rarely make decisions. The resident had orders for buspirone and valproic acid, and the care plans addressed anti-anxiety medication and black box warnings for valproic acid. The ICC note showed one LVN attended and decided to continue psychotropic medication, but it did not show a physician or resident representative in attendance. The SSD stated the resident did not have consent for psychotropics because she was not able to consent for herself and had no designated representative, and that the LTCRP had not come to participate in the ICC. The ADON stated the medications were continued after hospitalization, but consent was not obtained because they had been initiated in the hospital; later, the ADON acknowledged the consent form was completed incorrectly and that consent was not obtained for buspirone or valproic acid.
Failure to Follow Pain, Tube Feeding, and Catheter Care Plans
Penalty
Summary
Resident 16, who was admitted with ESRD, difficulty walking, fractures, osteoporosis, and dependence on hemodialysis, had a BIMS score of 6 indicating severe cognitive impairment and required partial to moderate assistance with activities of daily living. During morning care, the resident yelled that he was hurting all over his head and arm and repeatedly asked for help. The LVN later stated that non-pharmacological interventions such as repositioning, distraction, or other comfort measures were part of pain management, but on that day pain medication was given without first attempting those measures. The RNS stated that there was no documentation showing non-pharmacological measures were tried before medication was administered, and the resident’s care plan listed positioning for comfort, hot pack, cold pack, massage, and distraction as interventions for pain. Resident 3, who had Parkinsonism, dementia, dysphagia, and gastrostomy status, received nutrition through a G-tube and had impaired range of motion in both upper and lower extremities. The physician’s order required the head of bed to be elevated to at least 30 degrees during feeds and for one hour afterward. During a concurrent observation and interview, the resident was found lying nearly flat with the tube feeding machine on, and the ADON stated the head of bed was less than 30 degrees. The ADON also stated the resident should have been raised higher during tube feeding to prevent aspiration. Later, the ADON confirmed that the aspiration-related care plan requiring head-of-bed elevation was not implemented based on the observation. Resident 50, who had polyneuropathy, sepsis, a UTI history, intact cognition, and an indwelling catheter, had active orders for catheter monitoring and daily Foley catheter care. The orders required monitoring for signs and symptoms of possible urinary infection, documenting urine character every shift, and cleansing the urethral meatus daily with normal saline. Review of the TAR showed a blank space for indwelling catheter care and monitoring on an evening shift, and staff stated that a blank entry meant the task was not documented or not completed. The DON stated the charge nurse was responsible for completing catheter care on evening and night shifts, confirmed the TAR was blank, and stated the care was not followed for that shift.
Improper Food Labeling and Cross-Contamination in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices were maintained in the kitchen. During observation in the walk-in refrigerator, three trays of pre-poured milk cups and a tray of individually packed pineapple chunks were stored without labels showing the preparation date or use-by date. The Dining Services Manager stated the items needed those labels so staff would know when they were prepared and when they expired. A food scoop was observed stored inside a container of white powder identified as food thickener. The Dining Services Manager stated the scoop should not have been kept in the container because it was dirty and could increase the risk of contamination of resident food. In another observation, a bucket of onions and a bucket of apples were found with labels showing use-by dates of 4/10/2026, and the Dining Services Manager stated both items should have been thrown out because they were expired. Dishwashing and food service practices were also observed to involve dirty gloves being used while handling clean items. One kitchen dishwasher rinsed dirty water pitchers, then used the same gloves to remove freshly sanitized dishes from the dishwasher and load the dirty pitchers. Another dishwasher rinsed dirty plates and then used the same gloves to handle freshly sanitized plate covers. During lunch service, a kitchen aide used gloved hands to handle food scoops and then used the same gloves to pick up a dinner roll for a resident. The kitchen aide stated she forgot she should use tongs for the bread and should not have used her dirty gloves, and the Dining Services Manager and Infection Preventionist stated dirty gloves should not be used when moving between tasks because they can contaminate food and dishes.
Infection Control and Enhanced Barrier Precautions Not Followed
Penalty
Summary
The facility failed to follow its Infection Prevention and Control Policy and Water Management Program (WMP) as written. During interview and record review, the Maintenance Supervisor stated that he handled water monitoring and that water temperatures were checked weekly on Fridays, but chlorine residuals and pH levels were not tested because he said it was not required. The Infection Preventionist stated she was unsure whether chlorine residuals and pH were monitored. The WMP, which addressed control measures to reduce the growth and dissemination of Legionella, described operational monitoring through the TELS preventative maintenance program and internal facility logs, with effectiveness assessed through infection control surveillance. The facility also failed to ensure staff followed enhanced barrier precautions for a resident with an active wound. Resident 93 was admitted with diagnoses including diffuse large B-cell lymphoma, diabetes mellitus, and an unspecified fracture of the lower left leg. The resident’s MDS indicated intact cognition, independence for eating, moderate assistance for personal hygiene and upper body dressing, supervision for oral hygiene, and dependence for footwear, toileting, lower body dressing, and showering. The resident had orders for enhanced barrier precautions for a wound. During observation of medication administration, an LVN entered Resident 93’s room and applied a lidocaine patch to the resident’s left arm without donning a gown first. The LVN stated that for a resident on enhanced barrier precautions, staff should perform hand hygiene, put on gloves, and a gown, and acknowledged he did not put on a gown before entering the room. RN 1 and the DON both stated that gown and gloves were needed for close contact activities, including applying a lidocaine patch, and the DON stated the LVN should have used a gown while applying the patch.
Delayed Informed Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure informed consent was obtained in a timely manner before administering the COVID-19 vaccine to two residents. For one resident, the informed consent discussion covering the risks, benefits, and potential side effects was obtained 34 days before the vaccine was given. For the second resident, the informed consent discussion was obtained 21 days before the vaccine was administered. The report stated that both residents had intact cognitive skills for daily decisions on MDS review, and one resident required minimal to moderate assistance with ADLs while the other was independent for ADLs. During interview and record review, the IPN confirmed that informed consent for both residents had been obtained well before the vaccine administrations and stated that the residents could have changed their minds in the interim. The DON stated that informed consent ensures residents are aware of the risks and benefits and have the right to accept or refuse treatment. The facility policy stated that residents or their representatives may accept or decline the COVID-19 vaccine and may change their decision at any time, and that before vaccination residents receive information about benefits, risks, and potential side effects, with the medical record showing education and signed consent.
Failure to Support Resident Choice for Out on Pass
Penalty
Summary
The facility failed to accommodate a resident’s preference to go out on pass, despite the resident’s stated desire for more frequent opportunities to leave the facility and his report that his concerns were not being heard by staff. The resident was admitted with diagnoses including hepatic encephalopathy, schizoaffective disorder, bipolar type, and PTSD. His MDS dated 03/02/2026 indicated moderately impaired cognitive skills for daily decisions and mild to moderate assistance needed for some ADLs, while the H&P stated that he had the capacity to make decisions. During observation and interview, the resident was awake, alert, and oriented to name, time, and place, and stated that going out adds meaning and satisfaction to his life and that he wanted a simpler process to pursue his preferences. Record review and staff interviews showed that the resident’s care plan included an intervention to anticipate and meet his needs and provide activities of interest, and an elopement evaluation dated 10/07/2025 indicated he was not at risk for elopement. However, the LVN stated that a physician’s order was required for out on pass and that the resident had no active order because the prior order had been discontinued on 02/28/2026. The SSD stated the resident was permitted to go out on pass, while also stating escorts could not be provided every week or twice a week. The DON stated residents have rights to live normally, may go out on pass with family, a representative, or an escort if safety concerns exist, and that exercising these rights is important to their well-being.
Delayed Notification of Abnormal Potassium Result and Lack of Monitoring
Penalty
Summary
The facility failed to promptly notify the PCP of a resident’s abnormal potassium result and failed to notify the PCP that Kayexalate was available in the facility when the resident had hyperkalemia. Resident 96 was admitted with multiple diagnoses including dementia, hypertension, anemia, dysphagia, cardiomyopathy, diabetes, acute kidney failure, and a cardiac pacemaker. On 3/13/2026 at 8:55 a.m., the resident’s BMP showed a potassium level of 5.8 mEq/L, which was above the normal range. The PCP was not notified until 1:00 p.m., and the record also showed the abnormal lab was relayed later in the day with an order to repeat the lab on 3/16/2026. The record and interviews showed the resident’s change of condition was identified on 3/13/2026, but there was no documented evidence that the resident was assessed or closely monitored for hyperkalemia-related symptoms after the abnormal result was received. RN 1 stated the resident should have been assessed and that a call and faxed report to the physician should have been made when the abnormal lab was identified. RN 1 also stated there was no documented evidence that the resident’s level of consciousness or neuromuscular function was assessed or monitored at least once every shift for three days. A repeat lab collected on 3/16/2026 at 10:25 a.m. showed a potassium level of 6.0 mEq/L, confirming worsening hyperkalemia. Staff interviews indicated that abnormal or critical lab results should be reported to the physician as soon as possible, and that Kayexalate was available in the E-kit for treatment of elevated potassium. The DON stated there was no documentation that the risks and benefits of not correcting hyperkalemia were discussed with the resident’s family members.
Unattended Medication Labels Exposed Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of resident medical records when medication labels for two residents were left unattended on top of a medication cart in the facility hallway. During a concurrent observation and interview on 4/16/2026 at 10:46 AM, LVN 4 was observed with two medication labels on the cart. One label identified Resident 1 and listed a prescription number and doxazosin mesylate 4 mg tablet, and the other identified Resident 74 and listed a prescription number and lisinopril 10 mg tablet. LVN 4 stated the labels came from each resident's individual medication package and acknowledged that leaving them unattended was not facility policy because the labels contained confidential patient information. During an interview on 4/16/2026 at 11:17 AM, the ADON stated medication labels should not be left out on medication carts because they contain confidential information and leaving them out would violate HIPAA and patient confidentiality. Review of the facility's policy and procedure titled "Confidentiality of Information and Personal Privacy," last reviewed 3/5/2026, showed the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records and will strive to protect resident privacy regarding medical treatments.
Improper LAL Mattress Setting
Penalty
Summary
The facility failed to ensure that the pressure-relieving device on a low air loss mattress for Resident 71 was set according to the manufacturer's recommended guidelines. Resident 71 was admitted with diagnoses including stroke, hypertension, hyperlipidemia, and hemiparesis. The resident's MDS dated 3/18/2026 indicated the resident was rarely/never understood and was dependent with eating, toileting hygiene, and showering. During observation on 04/13/2026, Resident 71's bed had a low air loss mattress machine with a sticker indicating the setting should be at weight 98, but it was set at approximately 150 lbs. During a later interview and observation, a CNA stated the setting was 150 lbs even though the machine indicated 98 lbs, and stated treatment LVN managed the settings. An LVN later stated the mattress settings were weight based and that the settings exceeded the recommended settings, adding that if the mattress is too hard it is not good for the resident's skin and that is why the LAL mattress is ordered. The facility policy titled Support Surface Guidelines stated that redistributing support surfaces are to promote comfort, prevent skin breakdown, promote circulation, and provide pressure relief or reduction.
MDS Pain Management Section Not Accurately Completed
Penalty
Summary
The facility failed to accurately complete the MDS pain management section for one of three sampled residents, Resident 23. Resident 23 was admitted with diagnoses including lack of coordination affecting transfers and mobility, mild protein-calorie malnutrition, diverticulosis of the large intestine, and diaphragmatic hernia. The MDS dated [DATE] showed a BIMS score of 13, indicating the resident was cognitively intact, and documented that the resident required supervision or touching assistance with activities of daily living such as dressing, standing, sitting, walking, transfers, and toileting, with partial/moderate assistance for showering. During record review, the MDS section J0100 pain management did not match the MAR. The MAR showed acetaminophen was administered for pain rated 3/10 on 1/29/2026, which was within the five-day look-back period for the MDS assessment reference date of 1/28/2026 to 2/2/2026. However, during the concurrent interview and record review on 04/16/2026, the MDS coordinator stated that the MDS indicated "No" to whether Resident 23 received PRN pain medications or was offered and declined during the last five days, despite stating that staff ask residents and nurses about pain when completing the MDS.
Failure to Act on Hyperkalemia Alert and Monitor Resident
Penalty
Summary
The facility failed to provide necessary treatment and monitoring for a resident with a history of hyperkalemia, CHF, cardiomyopathy, diabetes, acute kidney failure, dementia, and other chronic conditions. The resident had a care plan for risk for complications related to cardiac status due to hyperkalemia that called for assessment and documentation of level of consciousness and neuromuscular function, monitoring of serum potassium, and awareness that cardiac arrest could occur. The resident also had a care plan for multiple medications that included monitoring for adverse reactions and reporting any change of condition to the physician. On 3/12/2026, the resident was ordered sacubitril-valsartan for CHF and hypertension, and the same day Bactrim DS was started for vaginal discharge after an Interact change-of-condition evaluation. The MAR showed the resident received both medications together through 3/16/2026. The EMR generated a drug-drug interaction alert for the concurrent use of Bactrim and sacubitril-valsartan, warning of increased risk for hyperkalemia, but the alert was overridden and there was no documented evidence that the physician was notified of the interaction. Nursing staff and the DON stated the alert should have been reviewed and discussed with the physician, but the record did not show that this occurred. The resident’s BMP on 3/13/2026 showed potassium of 5.8 mEq/L, and the Interact COC evaluation documented abnormal potassium. Nursing notes stated the abnormal lab was relayed to the physician and a repeat lab was ordered for 3/16/2026, but there was no documented evidence that the resident was assessed and monitored for level of consciousness or neuromuscular status as required by the care plan. Staff interviews confirmed there was no documentation of close monitoring over the following days. A repeat lab collected on 3/16/2026 showed a critical potassium level of 6.0 mEq/L, and the resident expired later that day. The resident had DNR and comfort-focused directives, and staff stated that DNR status did not change the need for assessment and monitoring.
Eyeglasses Not Kept in Working Condition
Penalty
Summary
The facility failed to ensure that Resident 11’s eyeglasses were kept in working condition. Resident 11 was admitted with diagnoses including cerebrovascular disease, alcoholic cirrhosis, and atrial fibrillation, and the MDS dated 03/12/2026 indicated severe impairment in cognitive skills for daily decisions, full dependence on staff for ADLs, and impaired vision with the use of corrective glasses. During observation on 4/13/2026, Resident 11 was awake, alert, and responsive while watching television up close and stated that his eyeglasses had broken two or three months earlier and that he had informed staff. He expressed frustration about not being able to see clearly and said he enjoyed watching television. During interview and record review, LVN 4 stated that nurses are responsible for ensuring assistive devices are always available to residents and addressing problems as they arise, but there was no documentation or communication about Resident 11’s broken eyeglasses. LVN 4 stated that eyeglasses are crucial for reading, watching television, and participating in daily activities. The SSD stated that residents should always have access to assistive devices to support quality of life and care, and that limited vision poses a safety risk. The DON stated that the entire team was responsible for ensuring assistive devices were available and reporting issues as needed. Resident 11’s care plan for impaired visual function included arranging eye care consultations as needed and providing suitable visual aids for activity participation, and the facility’s Resident Rights policy stated residents have the right to access services and receive facility support in exercising those rights.
Failure to Reassess and Update Fall Interventions After Repeated Falls
Penalty
Summary
The facility failed to ensure that Resident 6 was re-assessed after each fall and that fall prevention interventions were implemented and reflected in the care plan. Resident 6 was admitted with diagnoses including hypertension, atherosclerotic heart disease, benign prostatic hyperplasia, history of falls, muscle weakness, and gait instability. The MDS dated 02/11/2026 indicated the resident required extensive assistance with mobility and ADLs and was at risk for falls. The care plan identified the resident as high risk for falls and injury related to repeated falls, poor safety awareness, and unsteady gait, with a focus on providing physical assistance with ambulation to ensure safety. The record showed multiple fall-related events. IDT documentation dated 7/28/2025 stated the resident slipped out of a wheelchair onto the floor in the hallway while attempting to ambulate without assistance, and IDT documentation dated 09/04/2025 stated the resident was observed sitting on a floor mat after attempting to ambulate independently without staff assistance. A later fall occurred when the resident attempted to stand independently from the wheelchair, leaned forward, and fell. Staff interviews confirmed post-fall assessments such as a head-to-toe assessment, neurological checks, and vital sign monitoring were completed, but the MDS nurse stated there was no re-assessment done after each fall and that reassessment was only done on admission. RN 1 also confirmed there was no updated care plan reflecting recent falls or documented reassessment following the most recent fall.
Incomplete Intake and Output Documentation for Dialysis Resident
Penalty
Summary
The facility failed to ensure adequate documentation of intake and output for one resident receiving hemodialysis. Resident 8 was admitted with diagnoses including ESRD, chronic systolic CHF, polyneuropathy, and adult failure to thrive. The MDS indicated the resident’s cognitive status was not fully intact and that the resident required varying levels of assistance with activities of daily living, including maximal assistance with toileting, bathing, and lower body dressing. During interview and record review, the LVN stated that dialysis residents receive hemodialysis at an outpatient dialysis clinic and that the completed Hemodialysis Communication Record is uploaded into the medical record. The ADON stated Resident 8 had a physician order for a 1200 mL/24 hour fluid restriction divided between dietary and nursing shifts, but also stated there was no specific time and no designated location in the resident’s documentation where intake and/or output amounts were consistently recorded for dialysis residents. The DON stated the purpose of obtaining pre- and post-dialysis weights was to determine fluid status and ensure the resident was not fluid overloaded. Facility policy stated nursing and dietary staff would carefully organize the division and distribution of fluid and that all documentation concerning dialysis services and care would be maintained in the resident’s medical record.
Failure to Elevate Head of Bed During G-Tube Feeding
Penalty
Summary
Resident 3 had diagnoses including Parkinsonism, dementia, dysphagia, and gastrostomy status, and received nutrition through a G-tube. The resident’s MDS indicated the resident was rarely/never understood and had impairment in range of motion to both upper and lower extremities. The resident’s nursing documentation evaluation stated that nutritional supplements were given through enteral feeding via G-tube, and the physician’s order dated 1/24/2025 directed that the head of bed be elevated to at least a 30-degree angle during enteral feeding and for one hour after feeding. The care plan for aspiration risk related to the G-tube also directed that the head of bed be elevated at least 30 degrees during feeding and for one hour after feeding. During a concurrent observation and interview, Resident 3 was found lying nearly flat in bed while the tube feeding machine was on. The ADON stated the resident was lying flat and the head of bed was at less than a 30-degree angle, and also stated the facility did not have a measuring device to measure the angle of the head of bed. The ADON stated the resident’s head should be raised higher, to at least a 30-degree angle, while receiving enteral feedings. The DON stated aspiration is a complication of enteral tube feeding and that the head of bed should be raised to a 30-45-degree angle during feeding. The facility policy titled Enteral Feeding also indicated the head of bed should be elevated at a 30-degree angle during feedings.
Bed Rail Safety Assessment Not Documented
Penalty
Summary
The facility failed to ensure bed rail zone measurements were completed annually or that ongoing bed safety reassessments were performed for one sampled resident, Resident 12. Resident 12’s admission record listed diagnoses including type 2 diabetes mellitus, diabetic neuropathy, essential hypertension, and muscle weakness with abnormalities of gait and mobility. A physician’s order dated 01/23/2026 directed 1/4 side rail x 2 up in bed as an enabler to assist with mobility, nonrestraint. During an observation on 04/15/2026, Resident 12 was seen in bed with bed rails in use. A record review of the Bed System Measurement Device Test Results Worksheet dated 02/10/2025 showed bed system measurements were completed for Bed ID 24A. During interviews with the Maintenance Supervisor, it was stated that bed rail zone measurements were completed at the time of admission but there was no follow-up, and that there was no documented evidence of annual measurements or periodic reassessment to ensure continued bed system safety. The facility’s Bedrails policy stated the facility would assure correct installation and maintenance of bed rails prior to use and assess the resident’s risk from using bed rails, including the risk of entrapment between the mattress and the bed rail or in the bed rail itself. The Siderails policy stated the space between the mattress and the side rails would be assessed to reduce the risk of entrapment upon admission when side rails were required or after admission if side rails were required.
Failure to Assess and Monitor Behavioral Health Needs
Penalty
Summary
The facility failed to provide behavioral health treatment and services to help one resident attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident was admitted with diagnoses including hepatic encephalopathy, schizoaffective disorder bipolar type, and PTSD. The resident’s MDS showed moderately impaired cognitive skills for daily decisions and mild to moderate assistance needed for ADLs, while the H&P stated the resident had capacity to make decisions. During observation and interview, the resident was awake, alert, and in a wheelchair, reported a history of bipolar disorder, schizoaffective disorder, and PTSD, and stated that being independent made him feel satisfied but that he had difficulty getting staff to listen. The resident’s trauma assessment documented that he was still affected by a combat event and needed support with his needs and medications. The care plan addressed past trauma and included goals for the resident to feel safe, identify stressors, and report them to staff, with interventions such as recognizing trauma and triggers, respecting concerns, involving the resident in decisions, listening without judgment, and evaluating the need for psychological or behavioral health consultation. However, the RN Supervisor stated there was no physician or nursing documentation of behavioral monitoring or assessment of the resident’s triggers, and that a physician order was needed for tally or behavior monitoring to implement the care plan. The Social Service Director stated that trauma assessments should be used to monitor behavioral health, minimize behavioral risks, reduce triggers, prevent aggression, and ensure safety and comfort.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure insulin injection sites were rotated for three sampled residents who were receiving insulin for diabetes mellitus. Resident 61 had a history of left-sided hemiparesis/hemiplegia and cerebral infarction, and the MDS indicated the resident was cognitively intact and receiving insulin injections. The physician order for regular insulin directed staff to rotate injection sites, but the record review of the location of administration for insulin injections documented the same site use without rotation. Resident 9’s MDS indicated the resident was cognitively intact and receiving assistance with some activities of daily living. The MAR showed insulin was administered on the right arm on two consecutive administrations without rotation, despite the physician order directing staff to rotate injection sites. Resident 57 had diagnoses including anemia, hypertension, and diabetes mellitus, and the MDS indicated the resident was cognitively intact and receiving assistance with personal care. The physician order for regular insulin also directed staff to rotate injection sites, and the facility’s insulin administration policy stated that injection sites should be rotated, preferably within the same general area.
Failure to Review and Document Pharmacist MRR Recommendation
Penalty
Summary
The facility failed to ensure the pharmacist consultant’s Medication Regimen Review recommendation was reviewed and acted upon for one resident. The resident had diagnoses including Parkinsonism, dementia, bipolar disorder, and schizoaffective disorder, and the latest MDS indicated the resident was rarely or never understood, dependent on staff for all functional abilities, and had impaired range of motion in both upper and lower extremities. The resident’s physician order included acetaminophen 325 mg, two tablets every four hours as needed for moderate pain. The MRR dated 3/18/2026 recommended adding an acetaminophen order for mild and severe pain, but during record review and interviews, there was no documentation that the physician acknowledged or acted on the recommendation. RN 1 stated there was no physician documentation of review or action taken, and the DON also stated he could not find documentation that the MRR recommendation was reviewed or executed. The facility policy stated that upon receiving the MRR report, the attending physician reviews and responds to the report and documents the pharmacist’s recommendations and any actions taken.
Medication Left at Bedside Without Order
Penalty
Summary
A medication was found left at the bedside of Resident 15 without a physician's order. During observation on 4/13/2026 at 9:00 a.m., an opened bottle of pink liquid medication was seen on the resident's bedside table. Resident 15 stated the medication was Pepto-Bismol that she took for gas and bloating. Resident 15's admission record showed diagnoses including metabolic encephalopathy, DM, CHF, and muscle weakness. The MDS dated 4/01/2026 indicated the resident's cognitive skills for daily decisions were moderately impaired and that she required moderate to maximum assistance with ADLs. During interview and record review on 4/13/2026 at 9:32 a.m., LVN 6 reviewed the physician order summary report and self-administration evaluation and stated there was no active order for Pepto-Bismol. LVN 6 stated Resident 15 was not able to self-administer medication safely per the Medication Self-Administration Evaluation dated 11/24/2025. LVN 6 also stated the bedside medication needed to be removed because of possible medication interactions, safety concerns, and inability to monitor usage or prevent access by other residents. The DON stated on 4/16/2026 that leaving medication at the bedside is prohibited and that residents may self-administer medication only if deemed capable. The facility policy stated residents may self-administer medications only if the Attending Physician and the Interdisciplinary Care Planning Team determine they have the decision-making capacity to do so safely.
Improper Dishwasher Chlorine Testing by Dining Services Staff
Penalty
Summary
The facility failed to ensure the Dining Services Manager (DSM) had the appropriate competencies and skills to carry out duties in the kitchen when she incorrectly tested the dishwasher’s chlorine sanitizer levels. During a concurrent observation and interview in the kitchen, the DSM removed a test strip from the bottle and dipped it into the liquid draining from the outlet outside the dishwasher, held it there for 5 seconds, and then compared the strip to the bottle’s color guide, interpreting the result as 200 ppm. She stated this was the usual method used by her and the Kitchen Dishwashers to check chlorine levels at the start of the morning and afternoon shifts and record the results in the sanitizer logs. Record review showed the Dish Machine Log-Low Temperature (Chemical Sanitizer) Log for April 2026 documented chlorine ppm levels of at least 200 ppm throughout the month, and the DSM stated she had been told during training that this was an acceptable level. The District Manager stated the test strips should not be dipped in the drainage outlet outside the dishwasher because that is not an accurate assessment of chlorine levels on the dishes, and that the strips should be swabbed on the actual kitchenware. The DSM later stated the facility did not have a policy or written training outlining how to perform chlorine level testing, and that her only training came from the company that maintained the dishwasher. A Daily Chlorine Testing Station fact sheet reviewed later stated the test strip should be passed over the top of a dish after the cycle finishes and that the acceptable range is 50-100 ppm; the DSM stated she had never seen the sheet before that day. A Kitchen Dishwasher also stated his usual practice was to dip the test strip in the drainage outlet outside the dishwasher.
Inaccurate MAR Documentation for Finasteride
Penalty
Summary
The facility failed to ensure that LVN 3 accurately documented medication administration for one sampled resident, Resident 44. Resident 44 was admitted and later re-admitted to the facility with diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, atrioventricular block, and cardiomyopathies. The resident’s MDS dated 01/2/2026 indicated no cognitive impairment, with a Brief Interview for Mental Status score of 15. A review of the MAR dated 4/15/2026 showed Finasteride 5 mg oral tablet was documented as administered at 9:00 a.m. However, the physician’s order dated 1/15/2026 directed Finasteride 5 mg by mouth once daily for BPH. During observation on 4/16/2026 at 9:59 a.m., the medication was not available in the medication cart. Pharmacy 1 stated during telephone interview on 4/16/2026 at 10:18 a.m. that no Finasteride had been delivered to the facility on 4/15/2026 and there was no record of dispensing it to the facility. During concurrent interview and record review on 4/16/2026 at 11:20 a.m., LVN 3 stated the medication was not received from the pharmacy, despite the MAR showing it as administered. The facility policy required medications to be documented in the MAR only when actually given and for the MAR to accurately reflect medications administered to the resident.
Delayed Informed Consent for Influenza Vaccination
Penalty
Summary
The facility failed to ensure informed consent was obtained in a timely manner before administering influenza vaccine to two residents. For Resident 19, the record showed an admission diagnosis history including metabolic encephalopathy, hyperlipidemia, and hypertension, and the MDS indicated cognitive skills for daily decisions were intact and that the resident required minimal to moderate assistance with ADLs. A physician’s order for influenza vaccine 0.5 ml IM during flu season was initiated on 09/02/2025, but the informed consent for the vaccine, including discussion of risks, benefits, and potential side effects, had been obtained on 08/27/2025, 6 days before administration. For Resident 20, the admission record showed diagnoses including dysphagia, schizoaffective disorder, and muscle weakness, and the MDS indicated cognitive skills for daily decisions were intact and the resident was independent for ADLs. A physician’s order for influenza vaccine 0.5 ml IM one time only for immunization was initiated on 09/17/2025, but the informed consent for the vaccine had been obtained on 08/27/2025, 21 days before administration. During interview, the IPN stated informed consent is crucial for residents to understand the risks, benefits, and side effects of vaccination and acknowledged that the residents could have changed their minds between consent and administration. The DON stated informed consent ensures residents are aware of risks and benefits and have the right to accept or refuse treatment.
Call Light Not Within Reach
Penalty
Summary
Make sure that a working call system is available in each resident's bathroom and bathing area. The facility failed to ensure that one sampled resident had a call light within reach. Resident 30 was admitted with chronic systolic congestive heart failure, atrial fibrillation, a prosthetic heart valve, essential hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, and cerebral infarction due to embolism of a cerebral artery. The MDS dated 4/8/2026 showed a BIMS score of 13, indicating the resident was cognitively intact, and that the resident required partial/moderate assistance with dressing, standing, sitting, walking, transfers, and toileting, and was dependent on help with showering. During observation and interview on 4/13/2026 at 12:46 p.m., Resident 30 was awake and sitting in bed, and the call light was not within reach because it was tied up on the wall at the head of the bed. During a concurrent interview, LVN 3 stated the call light was on the wall and not within reach, that it was important to have the call light to call for help if needed, and that everybody was responsible for ensuring call lights were within reach. The care plan for the resident identified a high fall risk and directed staff to be sure the resident's call light was within reach and to encourage use for assistance as needed. The facility policy titled Answering the Call Light stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Failure to Respond Timely to Resident Call Lights and Requests for Assistance
Penalty
Summary
The facility failed to meet the needs of three residents by not responding to call lights and requests for assistance in a timely manner. Resident 1, who was admitted with diabetes mellitus and generalized muscle weakness and was occasionally incontinent, reported calling for assistance during the night shift and not receiving help, observing staff sleeping in the nursing station, and feeling irritated by the lack of response. Resident 2, with diabetes mellitus, age-related debility, and total incontinence, stated he requested to be changed in the evening and again during the night shift, but was not assisted until early morning. He also observed a CNA sleeping in the nursing station and expressed anger and upset over the lack of care. Resident 3, with a history of cerebral infarction and difficulty walking but independent in ADLs, reported calling for assistance during the night shift and not being attended to for approximately two hours, leading to feelings of disrespect from staff. Interviews with staff confirmed that CNAs take turns on 30-minute breaks and are expected to cover each other's responsibilities, with explicit policies prohibiting sleeping in the nursing station. The DON and DSD both stated that while staff may rest during their breaks, sleeping in the nurses' station is not permitted. Facility policies reviewed require immediate response to call lights and prompt fulfillment of resident requests, typically within five minutes if possible. The observed staff behaviors and delayed responses to resident needs were inconsistent with these policies and contributed to the residents' negative experiences.
Failure to Obtain Physician Order and Notify Physician for Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to obtain a physician order prior to performing fingerstick blood sugar level (BSL) checks for a newly admitted resident with diabetes mellitus and generalized muscle weakness. The resident's care plan required that medications, treatments, and other services be administered in accordance with physician orders. Despite this, nursing staff performed multiple BSL checks at the resident's request without a physician order on several occasions. Interviews with nursing staff confirmed that they were aware a physician order was required but proceeded with the checks regardless. Additionally, the facility did not notify the physician when the resident's BSL results were repeatedly above 189 mg/dL, with some readings as high as 400 mg/dL. Although a nurse stated that the physician was notified about the elevated BSLs, there was no documentation to support this communication, as required by the facility's policy on charting and documentation. The policy also specified that physician orders must be written and maintained, and that all physician notifications should be documented, which was not done in this case.
Failure to Prevent Fall in Cognitively Impaired, Bedbound Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety of a resident with severe cognitive impairment, impaired mobility, and multiple medical diagnoses, including metabolic encephalopathy, chronic kidney disease, weakness, and Alzheimer's disease. The resident was assessed as being at high risk for falls, with a care plan in place that included maintaining a clutter-free environment, monitoring and assisting with toileting needs, and ensuring call lights were within reach. Despite these interventions, the resident was found on the floor next to the bed in the early morning hours and was subsequently transferred to a general acute care hospital for evaluation following the fall. Interviews with facility staff revealed that the resident was bedbound and required full assistance for mobility, with staff noting the resident's dependence and inability to turn or get up independently. The staff could not recall the last time the resident was observed in bed prior to the fall. The facility's policies required assessment for fall risk and implementation of appropriate interventions, but the incident demonstrated a failure to provide adequate supervision and accident hazard prevention, resulting in the resident's fall and hospital transfer.
Failure to Follow Menus and Provide Appropriate Dietary Options
Penalty
Summary
The facility failed to follow the planned menu and provide appropriate food options for residents with specific dietary needs and preferences. One resident who disliked fish was served boiled diced chicken instead of the baked chicken alternative listed on the menu. The cook prepared the boiled chicken due to a lack of available chicken breast or thigh, and the dietary supervisor confirmed there had been delays in food deliveries. The resident's meal ticket indicated baked chicken and oven French fries, but the resident received boiled diced chicken, mashed potatoes, and carrots instead. Another resident, who followed a vegan plant-based diet, did not receive the vegan options specified on the menu. Instead, the resident was served pureed carrots and mashed potatoes, with the mashed potatoes containing chicken bouillon powder. The cook and dietary staff were unaware of the resident's vegan status, and the vegan menu items such as veggie cutlets and non-dairy beverages were not prepared. The resident confirmed her long-term vegan status and stated she does not consume animal products. Additionally, six residents on a renal diet received peas instead of the oven French fries listed on the menu. The cooks stated they did not check the menu and believed potatoes were not allowed on the renal diet, so they substituted peas. Both the cook and dietary supervisor acknowledged that the menu should have been followed. Facility policies require that missing food groups be replaced with appropriate alternatives and that renal diets be individualized with input from a registered dietitian.
Improper Pureed Diet Texture Provided to Residents
Penalty
Summary
The facility failed to provide pureed food with the correct texture to 12 residents who required a pureed diet. During a lunch tray line observation, residents on pureed diets were served carrots that had a thin, soupy, liquid consistency rather than the required homogenous, cohesive, pudding-like texture. The cook responsible for preparing the carrots stated that she added liquid and blended the carrots until smooth, but acknowledged that the final product was too thin. The dietary supervisor confirmed that the carrots did not meet the required consistency and explained to the cook that less water should be used, and that pureed foods should have a pudding-like consistency. A review of the facility's recipe for pureed buttered carrots and the policy for Dysphagia Diets Puree IDDSI Level 4 indicated that pureed foods should be lump-free, hold their shape, and not have separated liquids, with a smooth, pudding-like consistency. The recipe also specified the use of a thickener and a spoon tilt test to ensure proper texture. The failure to follow these guidelines resulted in the serving of improperly prepared pureed carrots to residents requiring this specific diet texture.
Unsanitary and Damaged Can Opener Blade in Kitchen
Penalty
Summary
Surveyors observed that a can opener blade in the kitchen food preparation area was worn, dented, stained, and covered with dried brown residue and metal shavings. The blade was not smooth to the touch, and its condition was verified by the Dietary Supervisor during the inspection. The Dietary Supervisor acknowledged the presence of metal shavings and dents on the blade and was unable to state when the blade was last changed, noting that she was new to the position. A review of the facility's policy and procedure on sanitization indicated that all utensils and equipment are to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Additionally, the 2022 U.S. Food and Drug Administration Food Code specifies that can opener blades must be kept sharp to minimize the creation of metal fragments and must be replaced if they become pitted or uncleanable. The facility failed to adhere to these standards, resulting in a deficiency related to safe and sanitary food preparation practices.
Failure to Obtain Informed Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent from residents or their responsible parties prior to initiating or increasing psychotropic medication therapy in multiple cases. For one resident with schizophrenia and bipolar disorder, there was no documentation that either the resident or a responsible party received education regarding the risks and benefits of divalproex before it was started. Similarly, another resident with schizoaffective disorder had her aripiprazole dose increased upon readmission from the hospital, but there was no evidence that informed consent was obtained for the higher dose. The DON confirmed that the increase in dosage was likely unintentional and that informed consent was not secured as required. Additionally, a third resident with encephalopathy, schizoaffective disorder, and PTSD received an intramuscular injection of aripiprazole without a completed or signed consent form. The resident's cognitive status was documented as intact, and facility protocol required consent for antipsychotic medications prior to administration. Both the RN and DON acknowledged that the consent process was not completed, and the resident was not made aware of the medication's risks and benefits as required by facility policy. Facility policies reviewed indicated that residents and/or their representatives must be educated about the risks, benefits, and alternatives to psychotropic medications, and have the right to decline such treatments. In these cases, the required process for obtaining and documenting informed consent was not followed, as confirmed by staff interviews and record reviews.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, dementia, and contractures of the left hand did not have their call light within reach while in their room. The resident was dependent on staff for showering, dressing, and personal hygiene, and their ability to understand ranged from rarely to never understood. During an observation, the call light was found hanging from the rail toward the floor, making it inaccessible to the resident. Interviews with facility staff confirmed that the call light was not within reach and emphasized the importance of accessibility for communication and assistance. The facility's policy required that call lights be accessible to residents at all times. The failure to ensure the call light was within reach constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Document Nicotine Patch Removal
Penalty
Summary
The facility failed to document the removal of a nicotine patch for one resident who was admitted with diagnoses including encephalopathy, schizoaffective disorder, and PTSD. The resident's Minimum Data Set indicated intact cognition and a need for substantial assistance with activities of daily living. The care plan allowed the resident to smoke independently but did not mention the nicotine patch. Physician's orders specified the use of a 21 mg nicotine patch to be applied every 24 hours as needed. Review of the Medication Administration Record (MAR) showed that the nicotine patch was administered on several dates, but there was no documentation of when the patch was removed after 24 hours as required. During a concurrent review, a registered nurse confirmed that the removal of the patch should have been documented on the MAR and was unable to locate such documentation. The facility's policy required timely and comprehensive documentation of care provided, but this was not followed in the case of the nicotine patch removal for this resident.
Failure to Accurately Complete MDS Assessment for Active Psychiatric Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment Section I for a resident by omitting active diagnoses of schizophrenia, depression, and bipolar disorder, despite these conditions being documented in the resident's medical record. The resident's admission record, psychiatric notes, and physician orders all indicated a history and current treatment for these mental health conditions, including prescribed medications specifically for schizophrenia and bipolar disorder. However, the MDS assessment did not reflect any of these diagnoses. During an interview, the Director of Nursing acknowledged that the MDS assessment was inaccurate compared to the resident's clinical record, confirming that the psychiatric section failed to list the resident's actual diagnoses. The facility's policy requires that MDS assessments consistently reflect information found in progress notes, care plans, and resident interviews, which was not followed in this case.
Failure to Revise Care Plans for Changes in Resident Needs
Penalty
Summary
The facility failed to revise and update care plans for two residents following changes in their care needs. For one resident with severe cognitive impairment and a history of COPD, dementia, and heart failure, the care plan indicated the use of hearing aids and staff assistance to ensure they were in place daily. However, observations showed the resident was not wearing hearing aids and had difficulty hearing staff, and the DON confirmed the resident was refusing to wear them. Despite this, the care plan was not revised to reflect the resident's refusal or to include alternative interventions, contrary to facility policy requiring care plans to be updated as resident needs change. For another resident with diagnoses including encephalopathy, schizoaffective disorder, and PTSD, the care plan addressed independent smoking but did not include interventions related to a newly ordered nicotine patch. The physician's order specified the use of a nicotine patch, but the care plan lacked instructions for monitoring, removal, or documentation of the patch's disposal. The RN acknowledged that the care plan should have been updated to include these interventions. Facility policy requires comprehensive, person-centered care plans to be reviewed and revised as new information arises, which was not done in these cases.
Failure to Maintain Clean and Trimmed Fingernails for Dependent Residents
Penalty
Summary
The facility failed to provide proper care and assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. Both residents had documented deficits in self-care related to their medical conditions, including dementia, hypothyroidism, hypertension, major depressive disorder, and impaired mobility or balance. Care plans for both residents specified that fingernail length should be checked and nails should be trimmed and cleaned during bathing and as necessary. However, during observations, both residents were found to have long and unclean fingernails. Certified Nurse Assistants (CNAs) acknowledged that the residents' nails were long and dirty, and stated that nail care was performed every two weeks or as needed, but had not been done at the time of observation. Interviews with facility staff, including the Infection Preventionist and Director of Nursing, confirmed that daily assessment and maintenance of residents' fingernails were expected as part of ADL care. The facility's policy also required daily cleaning and regular trimming of nails to prevent skin problems and accidental injury. Despite these policies and care plan interventions, the observed failure to maintain clean and trimmed fingernails for the two dependent residents constituted a deficiency in providing care according to professional standards.
Failure to Assist Resident with Hearing Aid Use
Penalty
Summary
Facility staff failed to assist a resident with severe cognitive impairment and multiple diagnoses, including COPD, dementia, and heart failure, in wearing hearing aids as required by her care plan. Observations on two separate occasions showed the resident was not wearing her hearing aids and had difficulty hearing and communicating with staff. The resident's Minimum Data Set indicated a high level of hearing impairment and a need for hearing aids, with moderate assistance required for daily activities. Interviews with the Social Service Director and the Director of Nursing confirmed that the hearing aids were not in use and were stored in the medication cart. Both acknowledged that the hearing aids should be offered daily and that staff were responsible for assisting the resident in applying them. The facility's policy required staff to assist hearing-impaired residents with their devices and to evaluate their adaptive needs regularly, but these procedures were not followed for this resident.
Incorrect LAL Mattress Setting for Pressure Ulcer Care
Penalty
Summary
A resident with diagnoses including malignant neoplasm, diabetes mellitus, and parkinsonism was admitted to the facility and assessed as having severely impaired cognition and being dependent on staff for personal care. The resident was identified as having an unstageable pressure ulcer and was prescribed a low air loss (LAL) mattress with the control knob to be set at 113 lbs, according to physician orders. However, during observation, the LAL mattress was found to be set at 325 lbs, which did not align with the resident's weight or the physician's order. The discrepancy in the LAL mattress setting was confirmed during an interview with the Director of Staff Development, who acknowledged that the incorrect setting placed the resident at risk for skin breakdown. The facility's policy on skin integrity management required appropriate assessment and implementation of support surfaces as needed, but this was not followed in this instance. The failure to set the LAL mattress correctly constituted a deficiency in providing appropriate pressure ulcer care and prevention.
Failure to Notify Physician of Catheter Sediment in Resident with UTI Risk
Penalty
Summary
Facility staff failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was dependent on staff for toileting and hygiene, had a care plan and physician orders requiring staff to monitor for and report signs and symptoms of possible UTI, including changes in urine character, foul smell, and sediment. Despite these directives, staff did not notify the resident's physician when cloudy sediment was observed in the catheter tubing. Progress notes reviewed over a three-month period showed no documentation of physician notification regarding the presence of sediment in the urine. During an observation, a nurse confirmed the presence of sediment in the resident's catheter tubing and acknowledged that the physician should have been notified. The facility's policy and procedure for preventing catheter-associated UTIs required documentation and reporting of UTI symptoms to the physician. The Director of Nursing also confirmed that there was no documentation of physician notification or specific symptoms of UTI, which was necessary for appropriate treatment. This lack of action had the potential to delay healing or worsen the resident's urinary tract infection.
Failure to Prevent and Address Gastrostomy Tube Feeding Leakage
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (GT) did not receive appropriate care to prevent complications associated with tube feeding. The resident, who was dependent on staff for mobility and had diagnoses including major depressive disorder, protein-calorie malnutrition, and dysphagia, was observed with tube feeding leaking from the GT onto their skin and bed linen. Staff interviews revealed that the Certified Nurse Assistant (CNA) was unaware of the leakage and did not assess the resident's body, only checking the face for signs of life. The CNA also indicated that it was the night shift's responsibility to ensure the feeding tube was properly attached and functioning. The Licensed Vocational Nurse (LVN) confirmed the presence of leaking formula and acknowledged that the standard process was to check the tube site at the start of the shift, but admitted to relying on the previous shift and not fully checking the resident. The Director of Nursing (DON) stated that both CNAs and LVNs are required to make rounds at the beginning of their shifts to ensure residents' needs are met and to assess for any problems, including issues with gastrostomy tubes. Facility policy required verification of tube placement and prompt reporting of complications. Despite these policies, the resident's tube feeding was not securely connected, resulting in leakage and failure to deliver nutrition as ordered. This lapse in care placed the resident at risk for malnutrition and skin breakdown, as the feeding formula was not being properly administered and was instead soaking the resident and their bedding.
Failure to Monitor for Bleeding in Resident on Anticoagulants
Penalty
Summary
Facility staff failed to monitor for signs and symptoms of bleeding and bruising in a resident who was prescribed both aspirin and Eliquis for blood clot prevention. The resident had a history of cerebral infarction, venous thrombosis, end stage renal failure, and was receiving hemodialysis, all of which increased the risk of bleeding. Despite a care plan identifying the resident as high risk for bleeding and instructing staff to monitor for related symptoms, there was no documented monitoring for bleeding or bruising in the Medication Administration Record (MAR) during the specified period. The Director of Nursing confirmed that monitoring for bleeding and bruising was not performed or documented for the resident while on anticoagulant therapy, despite the resident's increased risk due to frequent dialysis port access. The facility's policy required staff and physicians to monitor for complications in individuals on anticoagulation therapy and to consult with a physician if signs of bleeding were observed, but this protocol was not followed for the resident in question.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors out of 26 observed opportunities, resulting in a 7.69% error rate. In one instance, a nurse prepared a dose of carbamazepine suspension for a resident with chronic pain without first shaking the bottle, despite the pharmacy label and physician's order specifying that the suspension must be shaken well prior to use. The nurse acknowledged during an interview that failing to shake the suspension could result in the resident receiving an incorrect dose of medication. In another instance, a nurse administered a regular multivitamin tablet without minerals to a resident whose physician's order specified a multivitamin with minerals. The nurse admitted to overlooking the correct formulation and stated that she usually checks the product label against the order but failed to do so in this case. Both errors were observed during medication administration and were confirmed through interviews with the involved nursing staff.
Failure to Prevent Significant Medication Errors During Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in two separate incidents involving medication administration. In the first incident, a nurse was observed preparing a dose of carbamazepine suspension for a resident with chronic pain without first shaking the bottle, as required by the medication's instructions. The nurse acknowledged the error, explaining that suspensions must be shaken to ensure the correct dosage, and that failing to do so could result in the resident receiving too much or too little of the medication. The facility's policy required medications to be administered as prescribed, including following specific preparation instructions. In the second incident, the facility did not adhere to prescribed parameters for administering antihypertensive medications to a resident with a history of hypotension, muscle weakness, and diabetes. The resident's orders specified that certain blood pressure medications should be held if the systolic blood pressure was below 110 or the heart rate was below 60. However, medication administration records showed that these medications were given on multiple occasions when the resident's blood pressure was below the specified threshold. Nursing staff confirmed that medications should be held and the physician notified if parameters were not met, and that administering them outside of parameters was unsafe. Both incidents were confirmed through observation, record review, and staff interviews. The facility's policies required medications to be administered safely and in accordance with prescriber orders, but these requirements were not followed in the cases described, resulting in significant medication errors for the affected residents.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for a resident. The treatment nurse was observed removing soiled dressings from multiple wounds on a resident's right foot, left heel, and right buttocks without changing gloves between steps such as removing the soiled dressing, cleaning the wound, and applying new dressings. The nurse did not change gloves after removing soiled dressings and before cleaning wounds, nor before applying clean dressings, despite facility policy and standard infection control procedures requiring glove changes at these points. The nurse acknowledged during interview that gloves should be changed after removing soiled dressings and before proceeding with wound cleaning and dressing application to prevent cross-contamination. The resident involved had significant medical conditions, including Alzheimer's disease, muscle wasting, atrophy, and lack of coordination, and was dependent on staff for activities of daily living. Physician orders for wound care specified the use of various topical treatments and dressings for arterial and pressure ulcers. Interviews with the infection preventionist and the director of nursing confirmed that the observed wound care did not follow facility policy or accepted infection control practices, which require hand hygiene and glove changes at specific points during wound care to prevent contamination.
Failure to Provide Resident Records Upon Request
Penalty
Summary
The facility failed to provide a copy of the records upon written request from a legal representative of a resident. The legal representative of the resident faxed a record request to the facility, but the request was sent to a number not accessible by the Administrator, who was responsible for handling medical record requests in the absence of the medical records director. The facility's Administrator stated that the legal representative did not obtain the correct fax number and did not ask to speak to the person responsible for handling medical records. The Director of Nursing confirmed that the resident was admitted to the facility for a few days before being transferred to a General Acute Care Hospital and did not return to the facility. The facility's policy and procedure require providing access to view all records to the resident or their legal representative as soon as possible and no later than 24 hours from receipt of a request, excluding weekends and facility holidays. However, the facility did not receive the record request, resulting in a violation of the resident's rights.
Failure to Administer and Document Medications and Treatments
Penalty
Summary
The facility failed to ensure that a resident received necessary skin treatments and medications as documented in their Treatment Administration Record (TAR) and Medication Administration Record (MAR). Specifically, the resident did not receive their prescribed skin treatment on two consecutive days, as the TAR was not signed to confirm the treatment was administered. Additionally, the resident did not receive their prescribed eye drops for glaucoma on two separate occasions, as the MAR was not signed to indicate administration. These omissions were confirmed during a review with the Director of Nursing (DON), who acknowledged the lack of documentation. The resident involved was admitted with multiple diagnoses, including being a left above-knee amputee, muscle weakness, and glaucoma. The Minimum Data Set (MDS) assessment indicated the resident was confused and dependent on assistance for daily activities. The facility's policies require that medications and treatments be documented immediately after administration, but this was not adhered to in the case of the resident's skin treatment and eye drops. The failure to document and administer these treatments could potentially affect the resident's skin healing and eye pressure management.
Failure to Verify Resident's DNR Status
Penalty
Summary
The facility failed to ensure that a resident's wishes for medical care and treatment were clarified with the resident and/or their representative. This deficiency involved a resident who had a do not resuscitate (DNR) order at a general acute hospital prior to being admitted to the facility. Upon admission, the facility did not verify the resident's code status with the family or the physician, leading to a lack of clarity regarding the resident's treatment preferences during emergencies. The resident, who had diagnoses including metabolic encephalopathy and dementia, was admitted to the facility with a DNR order from the hospital. However, the facility did not confirm this status with the resident's next of kin (NOK) or document the verification of the code status upon admission. Interviews with facility staff, including a licensed vocational nurse and the director of nursing, revealed that the resident was considered full code at the facility, despite the DNR order from the hospital. The facility's policy and procedure on nursing documentation and resident rights emphasize the importance of clear and accurate communication regarding a resident's condition and treatment preferences, which was not adhered to in this case.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating their bed-hold policy. The resident, who had been admitted with chronic obstructive pulmonary disease, encephalopathy, and respiratory failure, was transferred to a general acute care hospital for treatment. Despite being ready for discharge back to the facility, the resident was not readmitted due to the facility's claim of no available bed, even though the census indicated otherwise. Interviews with the facility's Admission Director and Director of Nursing confirmed that beds were available, and the resident should have been readmitted. The facility's policy requires that residents be allowed to return after hospitalization or therapeutic leave, regardless of payer source, and that they be informed of bed-hold policies in advance. The facility's failure to adhere to this policy resulted in the resident remaining at the hospital, potentially causing psychosocial harm. The Director of Nursing was unaware of the resident's readiness for discharge, indicating a communication breakdown within the facility.
Failure to Change Oxygen Tubing Weekly and Keep Off Floor
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the management of oxygen tubing for a resident who was on oxygen via nasal cannula. The deficiency was identified during an observation where the oxygen tubing for a resident was found to be dated 7/31/2024, indicating it had not been changed weekly as required by the facility's policy. Additionally, the nasal cannula end of the tubing was observed to be on the floor, which is against the facility's guidelines that require the tubing to be kept off the ground. The resident involved was admitted with conditions including sepsis, type 2 diabetes, and essential hypertension. The resident was cognitively intact and required varying levels of assistance for personal care. The physician's order specified oxygen administration at 2-3 liters per minute via nasal cannula for shortness of breath. During interviews, both an LVN and the DON confirmed the findings and acknowledged that the failure to change the tubing weekly and keep it off the floor could lead to an infection, such as pneumonia, due to potential contamination.
Infection Control Breach in Isolation Precaution Room
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically in the case of a Certified Nurse Assistant (CNA 1) who did not wear gloves when entering a novel respiratory isolation precaution room for a resident diagnosed with COVID-19. The resident, admitted with conditions including hemiplegia, hemiparesis, and type 2 diabetes mellitus, tested positive for COVID-19 and was placed under novel respiratory precautions. Despite the clear signage and policy requirements for wearing gloves, CNA 1 entered the resident's room without gloves while delivering a lunch tray. Additionally, CNA 1 did not remove her face shield and N-95 mask upon exiting the isolation room, contrary to the facility's policy that mandates the removal and disposal of all personal protective equipment (PPE) before leaving such rooms. Interviews with the Infection Preventionist Nurse and the Director of Staff Development confirmed the importance of these protocols to prevent the spread of infection. The facility's policies clearly outlined the necessary PPE for COVID-19 precautions, which CNA 1 failed to follow, increasing the risk of infection transmission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alcott Rehabilitation Hospital | 0.2 mi | ★★★★★ | 16 | 0 |
| Sunray Healthcare Center | 0.8 mi | — | 32 | 2 |
| The Rehabilitation Center On Pico | 0.8 mi | ★★★★★ | 18 | 0 |
| St Andrews | 1.3 mi | ★★★★★ | 0 | 0 |
| East Terrace Rehabilitation & Wellness Centre, Lp | 1.6 mi | ★★★★★ | 29 | 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.