Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodland Care Center during CMS and state inspections, most recent first.
Incomplete Fall Risk Assessments for Three Residents: The DON reviewed fall risk documentation for three residents with significant medical histories including dementia, TBI, epilepsy, stroke-related deficits, fractures, and prior falls. Each resident had severely impaired cognition and required varying levels of staff assistance, yet the Nursing Documentation Evaluation left key fall risk factors blank, including history of falls, disorientation/confusion, unsteady gait, impaired balance, and toileting assistance. The residents were later found on the floor or beside the bed/wheelchair, and one resident was transferred to acute care after a fall.
Kitchen staff were observed using pans that were still wet after washing and sanitizing, including one pan used for pureed chicken BBQ and another pan taken from the drying area while still dripping. The DS stated pans must be fully air-dried so sanitizer can work and to avoid chemical contamination, but the KDM said training did not specifically address checking for liquid particles before use. Record review showed the cooks' competency checklists and in-service binder did not document training or verification of proper air-drying of pots and pans.
A resident with HTN, dysphagia, and COPD reported that hot food was not served hot because meals were sometimes late. During breakfast trayline, kitchen staff stopped plating because of a lack of plates and then a missing base, while the DS said there were too many late trays from the prior evening and the last meal cart for one station was served late. The cart did not arrive until after the scheduled breakfast time, and nursing staff checked trays before CNA delivery.
Wet sanitized pans were used during food prep when kitchen staff took pans from the 3-compartment sink drying area before they were fully air-dried and transferred BBQ chicken into them. The DS stated the pans must be completely dry before use so the sanitizer can work and to avoid chemical contamination of food. Staff later acknowledged they used the pans even though parts were still wet and that food could be contaminated by the sanitizer solution.
A resident admitted with neurological impairments, fluctuating decision-making capacity, and PEG tube feedings had an admission MDS that did not accurately reflect their condition. The MDS documented full ability to express and understand communication despite clinical documentation and CNA observations that the resident was confused and unable to answer questions. It also overstated the proportion of calories and fluids received via tube feeding compared with physician orders and the MDSC’s later clarification, and it failed to record existing bilateral groin MASD that was already care planned. These inaccuracies conflicted with the medical record and facility policies requiring complete and accurate MDS assessments and documentation.
A resident with multiple chronic conditions, intact cognition, and independence in ADLs had inconsistent body weights documented in the medical record. A restorative nursing attendant recorded the resident’s weight as 148 lbs, but the ADON later entered 158 lbs on the weight summary instead of the correctly obtained value. A subsequent weighing by another RNA showed 143 lbs. The ADON and DON acknowledged that the 158-lb entry was incorrect and that the resident’s weight should have been documented as 148 lbs, contrary to the facility’s policy requiring objective, complete, and accurate charting.
A resident with multiple medical conditions experienced a change in condition involving eye symptoms after returning from being out of the facility, and although an LVN documented an initial assessment, there was no documented reassessment on the following day shift despite facility practice to monitor and reassess for 72 hours after a COC. In a separate episode, the same resident showed increased sleepiness and an altered routine, leading an MD to order stat labs including CBC, CMP, Keppra level, UA, and urine C&S; the resident refused to provide a urine specimen, the UA and C&S were not completed, and while the MD was informed of the blood test results, there was no documentation that the MD was notified of the urine refusal, contrary to facility expectations and policy requiring practitioner notification of treatment refusals.
A resident with multiple medical conditions, including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and HTN, returned from being out of the facility with noted left eye changes, including reported drooping and unequal pupils. An LVN assessed the resident, documented eye findings, and recorded on a Change of Condition form that the MD was notified, but entered an incorrect notification time instead of the actual time the MD was called. During interview and record review, the DON confirmed the inaccuracy and that documentation must be timely and accurate per facility policies on change in condition notification and charting.
A resident with intact cognition, independent ADLs, and multiple diagnoses, including Parkinson’s disease and bipolar disorder, had a care plan intervention requiring licensed nurses to discuss medications with the resident and validate and initial medication sheets for accuracy due to concerns about the POA denying or forgetting medication-related requests. The resident had a weekly pyridoxine HCL order, and the MAR showed scheduled and administered doses, while a separate facility-created medication list used to validate administration times showed pyridoxine checked as given on a specific day and time. During interview, an LVN admitted he had mistakenly documented pyridoxine as administered on the validation list even though the resident did not receive the dose, and the DON confirmed that this list was intended to verify that medications were given at the correct scheduled times, demonstrating a failure to accurately implement the care-planned medication validation process.
A resident with fractures and neuropathic pain did not receive methocarbamol and gabapentin at the prescribed times, with doses given outside the facility’s one-hour administration window and too close together. A lidocaine 4% patch was found still in place when it should have been removed by the prior shift, and the resident then refused a new patch. In addition, the admitting RN transcribed a hospital order for a lidocaine patch from twice daily to once daily without clear verification, while the physician later stated the frequency had not been changed and that hospital discharge instructions should have been followed.
A resident with Parkinson’s disease, hypotension, and bipolar disorder, who was cognitively intact and independent in ADLs, had a urology appointment cancelled at the request of the responsible party, which was documented by an RN in the progress notes and on the communication log. However, the oncoming nursing staff did not follow up on this request, did not notify Social Services, and did not cancel the arranged transportation. As a result, the resident was transported to the clinic for a cancelled appointment and returned without being seen.
A nurse failed to accurately document blood pressure readings for a resident with severe cognitive impairment and multiple cardiac diagnoses, instead copying earlier readings into the MAR before administering antihypertensive medication. The nurse admitted to falsifying documentation due to workload, and the DON confirmed this violated facility policy requiring real-time, accurate charting.
A resident with Parkinson's disease and hypotension did not receive a prescribed dose of midodrine, despite their blood pressure being within the physician-ordered parameters. An LVN withheld the medication out of concern for increased blood pressure, contrary to the order and facility policy, resulting in a failure to provide care according to professional standards.
A bottle of ketoconazole 2% shampoo, prescribed for a resident with seborrheic dermatitis, was found unattended on top of a toilet in a shared restroom instead of being secured in a locked treatment cart as required by facility policy. The treatment nurse confirmed that all medications should be stored securely, and the facility's policy mandates locked storage accessible only to authorized staff.
A resident was readmitted with multiple serious diagnoses and required significant assistance with daily activities, but the attending physician did not complete and document the required H&P assessment within 72 hours. The DON confirmed the delay, and the NP cited workload issues as the reason for not completing the H&P on time, contrary to facility policy requiring timely documentation.
A resident with severe cognitive impairment and multiple medical conditions was not provided with a physician-ordered nutritional supplement drink at breakfast and lunch, as required by their care plan and nutritional assessment. Staff interviews confirmed the supplement was not given, and the DON acknowledged it should have been provided according to orders and facility policy.
Two residents with severe cognitive impairment were not provided with meals that matched their documented food preferences, despite these preferences being clearly indicated on their dietary profiles and meal tickets. One resident did not receive mashed potatoes as preferred, and another did not receive coffee with lunch. Staff interviews and policy reviews confirmed that these omissions were inconsistent with facility procedures requiring adherence to resident meal preferences.
A resident did not receive prescribed Systane night ophthalmic gel for two nights because the medication was not delivered, and the LPN did not notify the physician about the missed doses. The DON confirmed that facility policy requires physician notification when medications are unavailable, but this was not done in this case.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident's clinical record was found to be incomplete due to missing documentation of scheduled Restorative Nurse Aide (RNA) treatments for active range of motion and ambulation. On several occasions, RNA staff did not sign or indicate whether the treatments were provided or refused, despite facility policy requiring such documentation. Interviews with the DSD and DON confirmed that staff should have recorded this information to ensure accurate records.
A resident with significant medical needs was not given scheduled oxycodone-acetaminophen for pain management as ordered by the physician. Although an LVN documented that the medication was administered, subsequent review showed the medication was not dispensed and the documentation was inaccurate. The resident reported not receiving the prescribed pain medication and only being offered Tylenol, which was ineffective.
A resident with multiple medical conditions did not receive a scheduled dose of oxycodone-acetaminophen as ordered by the physician. An LVN documented the administration of the medication in the MAR, but a review of medication records and interviews confirmed that the dose was not given. The resident reported not receiving effective pain relief and left the facility against medical advice. The facility's policy required accurate medication administration and documentation, which was not followed.
A resident with multiple medical conditions was prescribed oxycodone-acetaminophen for pain, but an LVN documented its administration in the MAR when it was not actually given. The resident reported not receiving the medication, and a review of medication records and the bubble pack confirmed that no doses were dispensed. The LVN later admitted to the documentation error, which resulted in an inaccurate medical record.
A resident with documented gluten and lactose allergies was served cream of wheat for breakfast, despite clear dietary orders and care plans specifying a gluten-free, lactose-free diet. The correct gluten-free substitute was not available in stock, and staff lacked adequate training and knowledge about gluten-containing foods. The meal ticket did not specify the appropriate substitute, and the food service manager did not verify the tray for dietary compliance before delivery, resulting in the resident being provided with an inappropriate meal.
Three residents with significant medical and cognitive needs were found without accessible call lights while in bed, including one with dementia and another with hemiplegia. In each case, the call light was either under the bed, dangling out of reach, or on the floor, and staff confirmed the devices were not positioned for resident use as required by facility policy.
Several residents did not have comprehensive, person-centered care plans addressing the use of bed siderails or contact isolation precautions, despite physician orders and facility policy requiring such plans. Staff and leadership confirmed that care plans lacked necessary interventions and guidance, and observations showed residents using siderails or under isolation without appropriate care planning.
Licensed nurses failed to rotate insulin injection sites for three residents with diabetes, administering repeated injections in the same area despite physician orders and facility policy requiring site rotation. This deficiency was confirmed through record review and staff interviews.
A resident with an unstageable pressure ulcer did not receive a required weekly wound assessment and missed a prescribed daily wound treatment, as confirmed by review of records and staff interviews. The facility failed to follow physician orders and its own policy for pressure ulcer management, resulting in incomplete monitoring and care.
Two residents were placed at increased risk for injury when one was left with an exposed, reachable cable above the bed despite cognitive impairment, and another did not have required landing pads on both sides of the bed as ordered after a fall. Staff and management acknowledged these hazards, which were not consistent with facility safety and fall management policies.
A nurse failed to document the administration of controlled medications on the required accountability logs after giving doses to three residents with chronic pain, neuropathy, and anxiety. This resulted in discrepancies between the medication bubble packs and the controlled drug records for hydrocodone-acetaminophen, pregabalin, and lorazepam, as discovered during a medication cart audit. The DON confirmed that facility policy was not followed, as immediate documentation is required when administering controlled substances.
Two residents experienced medication errors when nurses failed to administer medications as ordered—one received a lidocaine patch to only one wrist instead of both, and another did not receive a prescribed Omega 3 supplement. These errors resulted in a medication error rate above 5%, exceeding facility policy and standards.
Surveyors found that staff failed to rotate insulin injection sites for three residents and did not follow physician-ordered hold parameters for midodrine in another resident. These actions were confirmed through MAR review and staff interviews, with facility policy and physician orders clearly requiring site rotation and adherence to medication parameters. The residents involved had complex medical conditions and required staff assistance for daily care.
A resident with a documented gluten allergy and physician orders for a gluten-free diet was served cream of wheat due to a lack of staff training and competency evaluation on gluten-free diets. Dietary staff were unaware of proper substitutions and had not received specific training, resulting in repeated exposure to gluten-containing foods despite clear documentation of the resident's allergies and dietary needs.
A resident with moderate cognitive impairment and a history of paraplegia was served apple juice despite their meal tray ticket indicating an apple juice allergy, which had previously been removed from their records. Due to a system glitch and lack of proper tray verification by dietary and nursing staff, the outdated allergy information remained on the tray ticket, and the facility's policy for checking trays was not followed.
Surveyors found that food items, including pineapple Bavarian cream, cheese enchiladas, and pureed vegetables, were not prepared or served according to required temperature and consistency standards. Cold desserts were served above safe temperatures, enchiladas were dry and lacked sauce, and pureed vegetables were runny and did not hold their shape, all contrary to facility policies and recipes. These deficiencies were confirmed by dietary staff and placed many residents at risk of inadequate nutrition.
The facility did not prepare pureed foods according to required consistency standards, resulting in grainy cheese enchiladas, rice with visible grains, and runny vegetables with liquid separation. These deficiencies were confirmed by dietary staff and did not meet IDDSI Level 4 guidelines, potentially affecting 11 residents on pureed diets.
Surveyors identified multiple deficiencies in food storage and preparation, including corroded racks, cracked meal trays, and unclean kitchen equipment. Dietary staff were observed wearing prohibited jewelry during food handling, and a resident's leftover food from outside was not properly labeled with an identifier or use-by date. These actions were confirmed by staff interviews and were not in compliance with facility policies or the Food Code.
Improper disposal of garbage and refuse was observed, with soiled gloves, an empty spray bottle, plastic, and other trash found on the ground, and one dumpster contaminated with dried food spills and dirt. Both the Dietary Supervisor and Environmental Services Supervisor confirmed these unsanitary conditions, which had the potential to attract pests and spread infection to most residents, in violation of facility policy and the Food Code.
Surveyors found that a resident's nasal cannula oxygen tubing was left on the floor, leading to contamination, and that two residents' urinals were not labeled with identifiers, increasing the risk of cross-contamination. The Infection Preventionist and staff confirmed these lapses, and the facility lacked a specific policy for labeling urinals, despite having a general standard precautions policy.
A resident admitted for palliative care with end stage renal disease had a silver bracelet documented on admission. After the resident's death, the facility was unable to account for or return the bracelet to the resident's representative, as confirmed by the Social Services Director and facility records. This failure violated the facility's policy on safeguarding and releasing personal belongings.
A nurse administered several medications to a resident with multiple chronic conditions and moderate cognitive impairment without informing the resident of the medication names or their purposes, as required by facility policy. The nurse later acknowledged the omission, and the DON confirmed that this action did not align with resident rights policies.
A resident with intact cognitive skills and multiple medical diagnoses was not included in the quarterly IDT care conference for developing an individualized care plan. The resident was unaware of discharge plans and expressed frustration about not being consulted, while facility records and staff confirmed the absence of resident or representative participation, contrary to facility policy.
Two residents did not have their care plans updated after significant changes in their conditions. One resident's fall and subsequent new interventions were not reflected in the care plan, and another resident's care plan continued to list oxygen therapy after the physician order for oxygen was discontinued. Staff confirmed that care plans were not reviewed or revised as required by facility policy.
A resident dependent on staff for ADLs, including dressing and personal hygiene due to dementia and other conditions, was not provided with necessary care. The resident's clothing was not changed for three days, as shown by an old food stain, and oral hygiene was neglected after meals, leaving residue on the teeth. Staff and family confirmed these lapses, which were inconsistent with facility policies requiring daily assistance with grooming and hygiene.
A resident with an indwelling catheter did not receive daily catheter care, infection monitoring, or skin assessments as required by their care plan. Staff failed to provide and document these interventions, despite the resident's dependence on staff for personal hygiene and the facility's policy emphasizing the importance of catheter care.
The facility failed to obtain physician orders before administering oxygen to two residents and did not label oxygen tubing with the date of last change as required by policy. One resident with COPD continued to receive oxygen after the order was discontinued, and another received oxygen for shortness of breath without a current order, with unlabeled tubing remaining in the room. Staff confirmed these deficiencies during interviews and record reviews.
A resident's opened budesonide inhalation solution foil pouch was found in a medication cart without a date label, and five ampules were stored outside the protective pouch. An LVN and the DON confirmed that facility policy and manufacturer guidelines require labeling with the date of opening and that ampules stored outside the pouch expire in two weeks. The lack of labeling meant the expiration date could not be determined, resulting in potentially expired medication being available for use.
A resident with multiple medical conditions reported missing money after a hospital stay, but the facility did not notify the required authorities within the mandated timeframe. Although an internal investigation was conducted and the allegation was unsubstantiated, the administrator confirmed that notifications to the State Survey Agency, ombudsman, and law enforcement were not made as required by facility policy.
A resident with multiple medical conditions and intact cognition reported missing money after a hospital stay. The facility initiated a theft/loss report and conducted some staff interviews and searches, but did not notify law enforcement or interview all relevant staff. Documentation was inconsistent regarding the resident's funds, and a staff member found a wallet with cash but did not secure it. The facility did not follow up with the resident or report the allegation to authorities, failing to meet its own policy for investigating theft or misappropriation.
A resident with severe cognitive impairment and Alzheimer's Disease was discharged to an assisted living facility, but the MDS assessment was incorrectly coded to indicate discharge to a hospital. Multiple records, including the admission record, physician's orders, and discharge plan, confirmed the actual discharge destination, and the MDS Coordinator acknowledged the error during review.
Incomplete Fall Risk Assessments for Three Residents
Penalty
Summary
The facility failed to accurately assess and complete fall risk factors in the Nursing Documentation Evaluation for three residents. For Resident 1, the admission record showed diagnoses including traumatic brain injury, epilepsy, anemia, dementia, and a history of falling. The MDS indicated severely impaired cognition and dependence on staff for ADLs except eating, and the resident later fell and was found on the floor next to the bed with minimal bleeding to the lower lip before being transferred to acute care. The fall risk assessment dated at admission had check marks for history of falls, poor safety judgement, and impaired balance, but left disorientated/confused, predisposing disease or injury, requires assist for toileting, and unsteady gait blank. For Resident 2, the admission record showed diagnoses including disorders of bone density and structures, lumbar vertebra compression fracture, dementia, and history of falling. The MDS indicated severely impaired cognition and need for supervision or touching assistance with oral care, toileting, personal hygiene, bathing, dressing, bed mobility, and transfers. The resident was found lying on the floor outside the restroom with bleeding to the face and an abrasion and laceration to the right index finger, and was transferred to acute care. A later fall event was also documented when the chair alarm activated and the resident was found on the floor beside the wheelchair. The fall risk assessment checked disorientated/confused, poor safety judgement, predisposing disease or injury, and requires assist for toileting, but left history of falls in the last 6 months, impaired balance, and unsteady gait blank. For Resident 3, the admission record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction, abnormality of gait and mobility, left femur fracture, epilepsy, and history of falling. The MDS indicated severely impaired cognition and need for maximal assistance with toileting hygiene, bathing, and dressing, and moderate assistance with bed mobility and transfer. The resident was later found sitting on the floor next to the bed after staff heard the resident calling for help. The fall risk assessment checked poor safety judgement, impaired balance, predisposing disease or injury, and requires assist for toileting, but left history of falls within the last 6 months, disorientated/confused, and unsteady gait blank. The DON stated the assessments were not completed accurately or in their entirety and that inaccurate or incomplete assessments could prevent the facility from developing and implementing appropriate care plans to reduce residents' risk for falls.
Kitchen Staff Not Competency Tested on Air-Drying Utensils
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency in properly air-drying pans and other utensils after manual washing and sanitizing. During observation of food preparation, a deep pan was taken from the drying area with water particles dripping from both the inside and outside, and pureed chicken barbecue was poured into that wet pan. In a second observation, another pan from the three-compartment sink drying area was still dripping liquid when it was retrieved for use. During interview, the Dietary Supervisor stated that pans must be dried so the sanitizer can work and kill bacteria, and that air-drying is important so chemical contamination does not cross-contaminate food. The Dietary Supervisor also stated that a pan is considered completely dry when there is no liquid dripping. The Kitchen District Manager stated the kitchen staff were trained on washing, rinsing, sanitizing, and air-drying utensils, but the training did not specifically indicate checking for liquid particles before using pans. Record review showed the cooks' job descriptions included cleaning preparation areas and utensils and keeping the kitchen sanitary. However, the competency checklists for two cooks did not include verification of proper air-drying of pots and pans after manual washing in the three-compartment sink. The kitchen in-service binder also lacked documentation showing staff had been trained on air-drying utensils before use, and the Dietary Supervisor stated there had been no previous in-service training on the proper process of air-drying pots and pans.
Late Breakfast Meal Service
Penalty
Summary
The facility failed to provide meals at regularly scheduled times in accordance with resident needs, preferences, and requests when Station 3's last meal cart was served late during breakfast on 5/1/2026. The dining room mealtime posting listed breakfast at 7:30 a.m., lunch at 12:30 p.m., and dinner at 5:30 p.m., and the facility's policies also reflected those same meal times. Resident 1 was admitted on 4/27/2026 with diagnoses including HTN, dysphagia, and COPD with acute exacerbation. Resident 1's MDS dated 4/30/2026 indicated the resident understood others and could make self-understood, and needed setup or clean-up assistance. During interview, Resident 1 stated hot food was not served hot because the food was served late at times. During observation of breakfast trayline service on 5/1/2026, kitchen staff stopped plating food because there were not enough plates available, and the dishwasher washed plates while the Dietary Supervisor stated there were meal trays from the previous dinner meal service that were not picked up until that morning. The Dietary Supervisor and another staff member stated they never run out of plates, but extra plates still needed to be washed. The Dietary Supervisor further stated there were too many late trays the prior night and the last meal cart for Station 3 was served late that morning. Observations showed trayline repeatedly stopped because there were no plates and then no base available, and the last meal cart did not arrive at Station 3 until 8:53 a.m.; nursing staff then checked each tray against the diet type report before CNA delivery to residents. The Dietary Supervisor later stated the breakfast trays were served late for the residents in Station 3 and that residents may become upset because breakfast is the first meal of the day and they expect meals to be served on time.
Wet Sanitized Pans Used During Food Preparation
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when kitchen staff used pans that were still wet from the three-compartment sink drying area. During an observation of food preparation, a deep pan was taken from the drying area with water particles dripping from the inside and outside, and pureed chicken barbecue was poured into that wet pan. In a concurrent observation, another pan was also taken from the drying area while still dripping liquid. The Dietary Supervisor stated that pans must air dry after sanitizing so the sanitizer can work and kill bacteria, and that using wet pans could create chemical contamination of food and pose a health and safety risk to residents because of the potential to cause foodborne illnesses. During the observation, the Dietary Supervisor stopped the kitchen staff from using the wet pan and provided in-service training to the staff involved, stating the pan was still dripping water and should not be used for food. The Dietary Supervisor also stated that the minced and moist BBQ chicken, pureed BBQ chicken, and carrots had to be discarded because they were contaminated by the quaternary ammonium compound sanitizer chemical. The facility policy for manual ware washing stated that all cookware, dishware, and service ware not processed through the dishmachine must be manually washed and sanitized, and that all service ware and cookware must be air dried prior to storage. The Food Code 2022 sections reviewed in the report also stated that food must be protected from contamination and that equipment and utensils must be air-dried after cleaning and sanitizing before contact with food. Staff interviews indicated they understood the pans should be completely dry before use, but one staff member stated he used a pan even though the lip was still wet because he did not think it was a problem, and another stated she did not pay attention before transferring food into the pan.
Inaccurate Admission MDS Assessment for Resident’s Communication, Nutrition, and Skin Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an admission Minimum Data Set (MDS) accurately reflected a resident’s clinical status. The resident was admitted with diagnoses including traumatic subdural hemorrhage, hemiplegia, hemiparesis, and epilepsy, and a history and physical documented fluctuating capacity to understand and make decisions. Despite this, the admission MDS indicated that the resident had the ability to express ideas and wants and to understand others, while simultaneously indicating that a brief interview for mental status should not be conducted because the resident was rarely or never understood. A CNA later stated the resident was alert but confused and unable to answer questions, which conflicted with the MDS documentation of communication abilities. The admission MDS also inaccurately documented the resident’s nutrition and skin status. The MDS indicated that the resident received 51% or more of total calories and at least 501 cc per day of fluids via tube feeding. However, the physician’s orders showed the resident was on a cardiac diet with minced and moist texture and thin liquids, and also received Jevity 1.2 via PEG tube as bolus feedings four times a day between meals, and the MDS Coordinator later confirmed that the resident was actually receiving less than 51% of total calories and less than 501 cc of fluids per day via tube feeding. These discrepancies showed that the MDS did not accurately represent the resident’s true nutritional intake. In addition, the MDS documented that the resident had no skin conditions, even though the IDT care conference notes and the care plan report showed that the resident had left and right groin moisture-associated skin damage (MASD), with care plans for both areas initiated shortly after admission. During interview and concurrent record review, the MDS Coordinator acknowledged that Sections B (Hearing, Speech and Vision), K (Swallowing/Nutrition Status), and M (Skin Conditions) of the admission MDS were inaccurate and did not align with the resident’s medical record, care plans, and observations. Facility policies on resident assessments and charting required that MDS information be consistent with progress notes, plans of care, and resident observations, and that documentation be objective, complete, and accurate, which was not followed in this case.
Inaccurate Documentation of Resident Body Weight
Penalty
Summary
The facility failed to accurately document a resident’s body weight in the medical record. The resident was originally admitted with diagnoses including Parkinson’s disease, dysphagia, dementia, bipolar disorder, and hypotension, and had intact cognition and independence with ADLs per the MDS. A weight summary for the resident from early January to early March showed weights of 159 lbs on two occasions and 158 lbs on a later date. However, a separate list of resident weights obtained by a restorative nursing attendant on February 28 documented the resident’s weight as 148 lbs. On March 5, another restorative nursing attendant weighed the resident and obtained a weight of 143 lbs. During a subsequent review and interview, the ADON confirmed that the weight summary entry of 158 lbs on March 3 had been entered by the ADON and was incorrect, and that the resident’s weight should have been documented as 148 lbs based on the February 28 measurement. The DON also stated that the resident’s body weight should have been accurately documented in the medical record to reflect the correct weight of 148 lbs. This inaccurate documentation was inconsistent with the facility’s charting and documentation policy, which requires that medical records be objective, complete, and accurate and facilitate communication about the resident’s condition and response to care.
Failure to Reassess After Change in Condition and Notify MD of Lab Refusal
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for one resident following documented changes in condition. The resident, admitted with diagnoses including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and hypertension, returned to the facility on 4/13/2025 at 4:30 p.m. with a reported change in condition involving left eye drooping and unequal pupils. A Change of Condition (COC) form documented that an LVN assessed the resident and noted no drooping, the left eye closed but able to open without difficulty, and redness of the left eye. However, review of the nursing progress notes for the following day shift on 4/14/2025 showed no documentation of a required reassessment after this change in condition, despite facility practice that residents are to be monitored for 72 hours with reassessments each shift following a COC. A second deficiency occurred when the facility failed to notify the resident’s physician that ordered laboratory tests were not fully completed due to the resident’s refusal to provide a urine specimen. On 9/18/2025, a COC form documented that the resident exhibited increased sleepiness and an altered routine, prompting notification of the physician, who ordered stat labs including a CBC, CMP, Keppra level, UA, and urine C&S. The laboratory requisition form for that date indicated the resident refused to provide a urine sample, and therefore the UA and C&S were not submitted for analysis. Nursing progress notes documented that the physician was informed of the CBC, CMP, and Keppra results, but there was no documentation that the physician was notified of the resident’s refusal to provide the urine specimen or that the UA and C&S were not completed. Interviews with facility staff confirmed these lapses. An LVN stated that after a COC, residents are to be monitored for three days with reassessments each shift, and acknowledged there was no documented reassessment on the day shift following the 4/13/2025 COC. The DON similarly stated that the standard of practice is to complete and document reassessments on each nursing shift after a COC and to notify the physician of any changes in condition, and confirmed there was no documented reassessment on 4/14/2025. The DON also stated that when a physician orders laboratory tests, the physician should be notified of the results, including any resident refusal to provide a specimen, and acknowledged there was no documentation that the physician was informed of the resident’s refusal to provide a urine sample on 9/18/2025. The facility’s policy on requesting, refusing, and/or discontinuing care or treatment indicated that the healthcare practitioner must be notified of treatment refusals in a timeframe determined by the resident’s condition and potential serious consequences of the request.
Inaccurate MD Notification Time Documented on Change of Condition Form
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation on a Change of Condition (COC) form for one resident. The resident, admitted with diagnoses including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and HTN, returned to the facility on 4/13/2025 at 4:30 p.m. after being out of the facility. The COC form for that date documented that the resident had left eye drooping and unequal pupils. An assessment by LVN 1 indicated no drooping was observed, the resident’s left eye was closed but could be opened without difficulty, and redness of the left eye was noted. LVN 1 documented on the COC form that the resident’s MD was notified of the change of condition and recorded the notification date and time as 4/13/2025 at midnight. During an interview and concurrent record review on 1/29/2026 at 3:05 p.m., the DON confirmed that the COC form showed left eye drooping and unequal pupils and acknowledged that the time documented for MD notification was not correct. The DON stated that LVN 1 should have documented the actual time the MD was called and notified of the change of condition on the COC form and that information on the COC form must be timely and accurate. Review of the facility’s policies on Change in Condition: Notification and Charting and Documentation showed that the facility requires residents, family/legal representatives, and physicians to be informed of changes in condition, and that all changes in a resident’s medical, physical, functional, or psychosocial condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team.
Failure to Accurately Implement Care-Planned Medication Validation and Documentation
Penalty
Summary
The deficiency involved the facility’s failure to implement a resident’s comprehensive care plan related to medication validation and documentation. The resident, who had intact cognition and was independent with ADLs, had diagnoses including Parkinson’s disease, hypotension, and bipolar disorder, and an order for pyridoxine HCL 25 mg, 0.5 tablet by mouth once every seven days for vitamin B6 deficiency, with monitoring for neurologic symptoms of excess vitamin B6. The resident’s care plan, initiated earlier and last revised in August, identified that the resident’s POA had episodes of denying or forgetting requests made, including for medications or supplements, and included an intervention for licensed nurses to discuss medications with the resident and to validate and initial in the medication sheets the medications and times of administration. Record review showed that the MAR documented pyridoxine as scheduled and administered on four Thursdays in December, and a separate medication list created by the facility to validate that the resident received medications at scheduled times showed pyridoxine 25 mg, 0.5 tablet every seven days on Thursday at 9 a.m., marked with a check on a specific December date. During interview and concurrent record review, the LVN acknowledged that he had mistakenly documented on the medication list that pyridoxine was administered on that date, while confirming the resident did not actually receive the medication. The DON confirmed that the medication list was intended to validate that medications were given at scheduled times and that the LVN had checked pyridoxine as administered on a Wednesday, although it was ordered for weekly Thursday administration, and that this process was part of the care-planned intervention for validating medications and administration times.
Failure to Administer and Manage Pain Medications per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders for one resident with multiple right rib fractures, a lumbar wedge compression fracture, and a history of falls. The resident was cognitively intact and required moderate assistance with several ADLs. Physician orders on admission included methocarbamol 500 mg PO three times daily for muscle spasm, gabapentin 100 mg PO three times daily for neuropathy, and a lidocaine 4% patch applied topically to the right chest area once daily for pain management with removal per schedule. Medication Administration Record (MAR) audit data showed that on one date, the 9 a.m. doses of methocarbamol and gabapentin were not administered until 12:07 p.m., and the 1 p.m. doses were not administered until 2:42 p.m., outside the facility’s stated one-hour before/after administration window. The LVN who passed these medications acknowledged being late with the medication pass and confirmed that some medications were given outside the time frame, resulting in the two scheduled doses of both methocarbamol and gabapentin being administered too close together. The DON confirmed that these administration times were not timely per the physician’s orders and that the doses were administered too close together. The facility also failed to ensure proper management of the resident’s lidocaine 4% patch. One LVN reported finding an old lidocaine patch still in place on the resident’s lower lumbar area that should have been removed by the prior 3 p.m.–11 p.m. shift nurse, and documented that the resident was upset and refused a new patch. The DON stated the patch was supposed to be removed daily at 9 p.m. by the evening shift and referenced hospital discharge instructions indicating the patch should be removed after 8–12 hours. Additionally, hospital discharge instructions directed application of one lidocaine 4% patch to the affected area twice daily for seven days, but the admitting RN carried over the order as once daily and could not recall how the order was verified with the physician. The primary care physician later stated he did not change the lidocaine patch frequency from twice daily to once daily and that the facility should have followed the hospital discharge instructions.
Failure to Cancel Transportation After Appointment Cancellation Request
Penalty
Summary
The deficiency involves the facility’s failure to follow up on and cancel a resident’s transportation after the resident’s responsible party requested cancellation of a scheduled urology appointment. The resident, who had diagnoses including Parkinson’s disease, hypotension, and bipolar disorder, was cognitively intact and independent in ADLs per the MDS. On the night prior to the appointment, a nursing progress note documented that the responsible party requested cancellation of the urology appointment. RN 2 also entered this request into the facility’s communication log for the morning staff to follow up, but did not provide a verbal handoff to the next shift. Despite this documented request and communication log entry, the morning nurse did not follow up to cancel the resident’s transportation. As a result, the resident left the facility for the urology appointment and traveled to the clinic, only to find that the appointment had been cancelled. The resident then returned to the facility without being seen by the urologist. The DON and Social Services Director confirmed that nursing staff did not notify Social Services to address the cancelled appointment and that there was no documentation that transportation had been cancelled, leading to the unnecessary transport.
Falsification of Blood Pressure Documentation in Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for one resident by not ensuring that a Licensed Vocational Nurse (LVN) documented actual blood pressure readings prior to administering antihypertensive medication. The resident in question had a history of heart failure, cardiomegaly, and essential hypertension, and required substantial assistance with daily activities due to severe cognitive impairment. According to the resident's medication orders, blood pressure was to be checked and documented before administering diltiazem, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg. On multiple occasions, the LVN documented blood pressure readings in the Medication Administration Record (MAR) at 1 p.m. that were identical to those recorded at 9 a.m. on the same days, rather than recording the actual readings taken at the later time. During interviews, the LVN admitted to copying the earlier readings instead of documenting the true values, citing a fast-paced work environment and a high resident load as reasons for this action. The Director of Nursing confirmed that this constituted falsification of documentation, as staff are required to document blood pressure readings in real time and accurately reflect the resident's condition. Facility policies reviewed also emphasized the importance of timely, accurate, and comprehensive documentation in the medical record.
Failure to Administer Prescribed Medication per Physician Order
Penalty
Summary
The facility failed to ensure that a resident received pharmaceutical services in accordance with professional standards of practice by not administering midodrine as prescribed by the physician. The resident, who had diagnoses including Parkinson's disease and hypotension, had a physician's order for midodrine hydrochloride 10 mg by mouth three times daily, to be held only if systolic blood pressure (SBP) exceeded 150. On the date in question, the resident's blood pressure was 150/89, which was within the prescribed parameters for administration, yet the medication was not given. During interviews and record reviews, it was confirmed that the medication was withheld by an LVN who was concerned about the resident's blood pressure increasing, despite the physician's order specifying when to hold the medication. The facility's policy required medications to be administered as prescribed and in a timely manner. The omission of the medication was acknowledged by both the MDS nurse and the LVN, who stated that the medication should have been administered according to the physician's order.
Medication Storage Lapse: Topical Medication Left Unsecured
Penalty
Summary
A bottle of ketoconazole 2% shampoo, prescribed for a resident with seborrheic dermatitis, was found unattended on top of a toilet in a shared restroom. The medication was intended for topical use on the scalp and was ordered to be applied on specific days. Facility policy requires all drugs and biologicals to be stored in locked compartments, with access limited to authorized personnel. During an observation, the shampoo was not secured in the treatment cart as required, but instead left in a location accessible to others. The resident involved had intact cognition and was independent with personal care tasks, including hygiene and toileting. The treatment nurse confirmed during an interview that the medication should have been stored in the treatment cart for safety, in accordance with facility policy. The facility's policy and procedure on medication storage, reviewed earlier in the year, specifies that all medications must be stored securely and only accessible to authorized staff. The failure to secure the ketoconazole shampoo constituted a breach of these requirements.
Delayed Physician H&P Documentation After Resident Readmission
Penalty
Summary
The facility failed to ensure that a resident's attending physician completed and documented a History and Physical (H&P) assessment within 72 hours following the resident's readmission. Specifically, the medical record review showed that the resident, who was readmitted with diagnoses including toxic encephalopathy, sepsis, and pneumonia, did not have an H&P completed until six days after readmission. The resident's Minimum Data Set indicated severely impaired cognition and a need for substantial to maximal assistance with daily activities. Interviews with the DON confirmed that the H&P was not completed within the required timeframe, and the Nurse Practitioner acknowledged being behind on documentation due to a high workload, resulting in delayed completion and signing of the H&P. Facility policies reviewed indicated that timely documentation and physician visits are required to ensure proper care coordination and communication among the interdisciplinary team, but these were not followed in this instance.
Failure to Provide Ordered Nutritional Supplement Drink
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including toxic encephalopathy, sepsis, and pneumonia, was readmitted to the facility and had physician orders for a regular, pureed diet with thin consistency, as well as a nutritional supplement drink to be provided with breakfast and lunch. The resident's care plan and nutritional assessment both specified the need for the supplement drink twice daily to provide additional calories and protein. However, during an observation of the resident's lunch, the nutritional supplement drink was not present on the meal tray. Interviews with dietary and nursing staff revealed that the kitchen does not provide the supplement drinks, and it is the responsibility of nursing staff to administer them. Both the certified nursing assistant and restorative nursing assistant who assisted the resident with meals confirmed that the supplement drink was not provided at breakfast or lunch. The DON acknowledged that the supplement should have been given as per the physician's order. The facility's policy states that therapeutic diets are to be provided according to physician orders and care plans.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of two residents, as identified through observation, interview, and record review. One resident, who was readmitted with diagnoses including toxic encephalopathy, sepsis, and pneumonia, had a severely impaired cognitive status and required substantial assistance with eating. The resident's dietary profile indicated a preference for mashed potatoes at lunch and dinner, and this preference was noted on the meal ticket. However, during a lunch observation, the resident was not served mashed potatoes as indicated, and the Assistant Dietary Supervisor confirmed the omission. Another resident, admitted with encephalopathy, dysphagia, and Alzheimer's disease, also had severe cognitive impairment and required assistance with eating. This resident's dietary profile specified a preference for coffee with all meals, and the meal ticket for lunch included coffee. During observation, the resident's lunch tray did not include coffee, and both the resident and staff confirmed the omission during interviews. The Director of Nursing and Registered Dietician both acknowledged the importance of following meal tickets and resident preferences to ensure adequate nutritional intake. A review of the facility's policies indicated that the dietary department is responsible for providing meals consistent with residents' preferences as documented on tray cards and that therapeutic diets should align with the resident's goals and preferences. Despite these policies, the facility did not follow the documented preferences for the two residents, resulting in the identified deficiencies.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify a resident's physician when a prescribed medication, Systane night ophthalmic gel, was not available and therefore not administered for two consecutive days. The resident, who had diagnoses including Parkinson's disease, hypotension, and bipolar disorder, was cognitively intact and independent in activities of daily living. The medication was ordered to be instilled in both eyes at bedtime for dry eyes, but the Medication Administration Record showed it was not given on two specified dates due to the medication not being delivered. During interviews and record reviews, the Licensed Vocational Nurse confirmed that the medication was unavailable and had not been administered, and also acknowledged that the resident's physician had not been informed of the missed doses. The Director of Nursing stated that facility policy requires nurses to notify physicians when medications are not available, as this could affect the resident's plan of care. The facility's policy on physician notification was reviewed and supported this requirement.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Document Restorative Nursing Treatments in Resident Record
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not properly documenting the delivery of Restorative Nurse Aide (RNA) treatments. Specifically, the Restorative Nursing Records for the resident showed missing signatures and no indication of whether scheduled RNA treatments for upper extremity active range of motion and ambulation with an assistive device were provided or refused on multiple dates. The lack of documentation occurred despite the resident having diagnoses including Parkinson's disease, acute respiratory failure with hypoxia, and dysphagia, and being assessed as having intact cognition and independence in activities of daily living. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that RNA staff were expected to sign or document on the Restorative Nursing Record if the resident received or refused treatment, or if the resident was unavailable. The facility's policy required that documentation related to physician orders be maintained in the resident's medical record, with current month's administration records kept in the appropriate binders. The failure to document RNA treatments as required led to incomplete clinical records for the resident.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type 2 diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was not administered his scheduled pain medication as ordered by his physician. The physician's order specified that the resident should receive oxycodone-acetaminophen 7.5-325 mg orally three times a day for pain management. Review of the Medication Administration Record (MAR) indicated that a Licensed Vocational Nurse (LVN) documented administration of the medication on the morning following admission. However, further investigation revealed that the medication was not actually given. The resident's medication bubble pack remained intact with all 30 tablets present, and the controlled drug record confirmed that none of the prescribed doses had been dispensed. The LVN responsible for the resident's care admitted during an interview that she did not administer the medication and had mistakenly documented its administration in the MAR while in a rush. The resident later reported that he did not receive his prescribed pain medication and was only offered Tylenol, which he stated was ineffective for his pain. Facility leadership confirmed that the medication was not administered as ordered and that the documentation in the MAR was inaccurate. The facility's pain management policy required daily assessment and documentation of pain interventions, but in this instance, the resident did not receive the scheduled pain medication, and the documentation did not reflect the actual care provided.
Failure to Administer and Accurately Document Scheduled Pain Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer a prescribed dose of oxycodone-acetaminophen 7.5-325 mg to a resident at the scheduled time, as ordered by the physician. The resident, who had been admitted with diagnoses including type two diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was alert, oriented, and able to communicate needs. The physician's order specified that the pain medication should be given three times daily for pain management. Despite the order, the medication was not administered to the resident on the morning in question. The Medication Administration Record (MAR) incorrectly indicated that the dose had been given, as the LVN documented administration without actually providing the medication. This was later confirmed through interviews and a review of the resident's medication bubble pack and controlled drug record, both of which showed that the medication remained untouched and the count was intact. The resident later reported not receiving any pain medication other than Tylenol, which was ineffective for his pain, and subsequently left the facility against medical advice. The LVN acknowledged the documentation error, stating it was made in haste and that the medication had not been administered. The facility's policy required accurate and timely documentation of medication administration, which was not followed in this instance.
Inaccurate Medication Administration Documentation by LVN
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN 3) inaccurately documented the administration of a prescribed pain medication, oxycodone-acetaminophen, to a resident. The resident, who was admitted with diagnoses including type two diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was ordered to receive oxycodone-acetaminophen 7.5-325 mg three times daily for pain management. The Medication Administration Record (MAR) indicated that the medication was given at 6:00 a.m. on 6/14/2025. However, upon review, it was found that the resident did not receive the medication as documented. The resident reported not receiving any pain medication except Tylenol, which was ineffective for his pain, and stated he left the facility the morning after admission due to lack of pain management and other comfort issues. Further investigation by nursing staff confirmed that the bubble pack containing the prescribed oxycodone-acetaminophen remained intact with all 30 tablets present, and the controlled drug record also showed no doses had been dispensed. There were no doses available in the emergency medication kit either. During interviews, LVN 3 admitted to mistakenly documenting the administration of the medication when it had not been given, attributing the error to being rushed while tending to another resident. The Director of Nursing confirmed that the documentation was inaccurate and did not reflect the actual care provided. Facility policies require accurate and timely documentation of medication administration, and the failure to do so resulted in an inaccurate medical record for the resident.
Failure to Prevent Serving Allergen-Containing Food to Resident with Documented Food Allergies
Penalty
Summary
A resident with documented allergies to gluten and lactose was served cream of wheat for breakfast, despite multiple records indicating these allergies. The resident's care plan, physician's orders, allergy list, dietary profile, and other medical documentation all specified the need for a gluten-free and lactose-free diet. The resident's meal ticket did indicate a gluten restriction, but the actual food provided did not comply, and the meal ticket did not specify the correct gluten-free substitute (cream of rice). The resident reported previous instances of being served foods containing gluten and stated that staff had been informed of these allergies. The dietary staff prepared only oatmeal and cream of wheat for breakfast, and cream of rice, the appropriate substitute, was not available in stock. Staff responsible for preparing and checking trays were either unaware that cream of wheat contained gluten or had been incorrectly informed that it was safe for gluten-free diets. The kitchen staff had not received training on gluten-free diets, and the facility's software failed to update the meal ticket to reflect the resident's dietary needs. The food service manager or supervisor did not check the resident's tray for the correct diet before it was delivered, as required by facility policy. Interviews with staff revealed gaps in knowledge and communication regarding food allergies and dietary restrictions. The licensed nurse who checked the tray was not able to accurately identify whether the hot cereal was gluten-free and relied on incomplete information from the meal ticket. The dietary aide responsible for tray accuracy had been told by a previous supervisor that cream of wheat was acceptable for gluten-free diets, leading to repeated errors. The facility's purchasing records showed that cream of rice had not been restocked in a timely manner, further contributing to the deficiency.
Removal Plan
- The DON immediately assessed Resident 71 for any adverse reaction and there were none noted.
- The facility notified Resident 71's attending physician and Resident 71's family of the incident of giving food containing allergies. The attending physician did not give any new orders.
- The Minimum Data Set Coordinator 1 (MDSC 1) updated Resident 71's allergy Care Plan to remove gluten allergy and Resident 71's nutrition risk Care Plan to reflect gluten intolerance prior to a diagnostic test for allergies.
- The Registered Dietitian (RD) evaluated Resident 71 and updated food preferences, reviewed allergies and food intolerances, and completed a nutritional assessment.
- The Director of Staff Development (DSD) provided one-on-one in-service training to Licensed Vocational Nurse 3 (LVN 3, who checked Resident 71's breakfast prior to serving) to ensure: a) Identification of food allergies using the daily Allergy Report provided by DON and/or designee. The daily Allergy Report can be found in a special needs binder located at each nursing station and dining room. b) Prior to tray passing to residents during mealtimes, a licensed nurse will check all trays for accuracy of meal ticket and physician diet orders against what is on the residents' meal tray using the diet report. c) Prior to passing the meal trays to the residents during mealtimes, a licensed nurse will check the diet type report and the meal ticket on each tray against the food on the resident's meal tray. d) Prior to tray passing to residents during mealtime, a licensed nurse will check all the trays to ensure any resident with a gluten allergy is not served unless food item on food tray is labeled gluten free.
- The DON, the DSD, the RD, the Dietary Supervisor (DS) initiated an in-service to staff (including RNs, LVNs, CNAs, Rehabilitation Therapists, the Dietary Manager, cooks, tray line staff, dishwashers, Dietary Preparation staff, and Department Heads) about identification of food allergies using the daily Allergy Report, 2 licensed nurse will check all the trays to ensure meal ticket, physicians orders and Diet Type Report are accurate against resident's food trays. The in-service also included checking all the trays to ensure all trays are checked for gluten allergies and not served foods containing gluten. Snacks for residents on gluten free diet will be labeled gluten free. A licensed nurse will check the diet type report, snacks label and food to ensure accuracy before serving it to the residents.
- The DS completed an in-service to the dietary staff (Dietary Manager, cooks, tray line staff, dishwashers, and dietary preparation staff) related to food allergy, labeling of gluten-free food items, and ensuring all trays are checked accurately to ensure residents are not served a food item they are allergic prior to trays being sent out of the kitchen. Tray line staff will refer to Diet Manual for Guidance on alternatives for residents on gluten restricted diet/gluten allergy/intolerance. Staff that have not yet been in-serviced (those on vacation and per diem employees) will be in-serviced on their first reported day back to work.
- The DON and or designee will update the Allergy report daily at the clinical meeting (Monday to Friday), and ensure it is available at each nursing station and dining room and a copy will be provided to the kitchen.
- The DON, the Assistant DON (ADON), the MDS Nurse and the DSD observed the licensed nurses checking for tray accuracy prior to trays being served to residents. No issues were identified and the 10 residents who had food allergies and or food intolerances had accurate trays. The DON and ADON assessed the 10 residents for any signs and symptoms of allergic reaction, and none noted.
- The RD provided in-service to final tray line staff who checked Resident 71's breakfast tray.
- The DON reviewed all residents and identified 10 residents with food allergies. Resident 71 the only resident identified to be on a gluten restricted diet. One resident identified having gluten allergy had been hospitalized for unrelated medical condition. Upon this resident readmitted to the facility, the nurse will obtain an order from the MD for allergy test.
- The Regional RD observed breakfast tray line to ensure accuracy of the meal tickets to what was being placed on resident's meal trays. There were no issues identified and the 10 residents who had food allergies and or intolerances had accurate trays.
- The DON completed competency for the licensed nurse who checked Resident 71's tray and met expectations as evidenced by the licensed nurse being able to correctly check the diet orders, resident allergies against the food tray.
- The DON and or designee will complete a random daily visual check of meal trays for residents with identified food allergies using the Daily Food Allergy Audit Form. This audit will remain on-going until the goal is achieved.
- The DON and or designee will review the change in conditions daily related to food allergies.
- The DON and or designee will complete a Monthly Food Allergy Interview Audit Tool to ensure that each residents allergies are current, and up to date. This audit will remain ongoing until the goal is achieved.
- The DON obtained an order from Medical Doctor (MD) for Tissue Transglutaminase ([tTG-igA], blood test to diagnose celiac disease, a disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food) to be drawn.
- The DON discussed with MD to update Resident 71's gluten intolerance to gluten allergy. The DON updated allergy profile and care plan to reflect resident's gluten allergy. The DON provided dietary communication form to dietary staff for gluten allergy update.
- Registered Nurse Supervisor obtained order from MD for Resident 71 for psychology consult for psychosocial support.
- The RN Supervisor and or designee will update the Allergy report and special needs binder on the weekends (Saturday and Sunday) at each nursing station, and dining room.
- The RD will check food inventory weekly based on the upcoming week's menu using the Inventory form. If any items are missing, the RD will notify the Dietary Manager/designee, and the RD will approve appropriate alternative with same nutritional value if necessary.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, each with significant medical and cognitive needs. For one resident with a history of subdural hemorrhage, atrial fibrillation, and dementia, the call light was observed hanging under the bed and out of reach while the resident was in bed with bilateral siderails up. The resident confirmed she could not reach the call light, and the attending LVN acknowledged the call light was not positioned within reach. Another resident, admitted with hemiplegia, hemiparesis, ataxia, and dysphagia, was found lying in bed with the call light dangling and out of reach. The resident attempted to locate the call light but was unable to find it and stated that she sometimes had to yell for help. A CNA confirmed the call light was not accessible and repositioned it within the resident's reach, stating it should always be accessible. A third resident, with a history of falls, bradycardia, and major depressive disorder, was observed sitting on the bed with the call light on the floor and out of reach. The resident stated that staff had changed his beddings and forgot to return the call light to an accessible position. The ADON confirmed the call light was not within reach and repositioned it. Facility policy and staff interviews confirmed that call lights are required to be accessible to residents at all times.
Failure to Develop Comprehensive Care Plans for Siderail Use and Contact Isolation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically regarding the use of bed siderails and contact isolation precautions. For three residents who used bed siderails, the care plans did not address the use of these devices, despite physician orders and observations confirming their use. Staff interviews and record reviews revealed that the care plans lacked interventions to address the risks associated with siderail use, such as entrapment, and did not provide guidance for staff on prevention or response to such incidents. Facility policy required a bedrail evaluation and care plan reflecting that evaluation, but this was not completed for the affected residents. Additionally, one resident placed on contact isolation due to a multidrug-resistant organism (MDRO) infection did not have a comprehensive care plan addressing the isolation precautions. The resident's care plan did not include person-centered interventions or goals related to managing care needs while on contact isolation. Staff interviews confirmed that the required care plan was not developed, and facility policy mandated that such a plan be created within seven days of the comprehensive assessment. The deficiencies were identified through interviews, record reviews, and direct observations. Staff, including MDS coordinators and nursing leadership, acknowledged the absence of required care plans and interventions for both siderail use and contact isolation. Facility policies and procedures reviewed during the investigation confirmed the expectation for comprehensive, measurable, and timely care plans to address each resident's specific needs, which was not met in these cases.
Failure to Rotate Insulin Injection Sites as Ordered
Penalty
Summary
Licensed nurses at the facility failed to rotate insulin injection sites as required by professional standards and physician orders for three residents with diabetes. For one resident, documentation showed repeated administration of insulin in the same area, such as the left arm or the right lower quadrant of the abdomen, over multiple days. The resident's care plan and physician orders specifically instructed staff to rotate injection sites, but this was not consistently followed, as confirmed by review of the Medication Administration Record (MAR) and interviews with nursing staff. A second resident also received insulin injections in the same location, the left lower quadrant of the abdomen, on consecutive days. The MAR and physician orders indicated the need to rotate injection sites, but this was not done for several days in March. Staff interviews confirmed that the injections were not rotated as required, and the Director of Nursing acknowledged the failure to follow the physician's orders and professional standards. A third resident received both long-acting and sliding scale insulin injections repeatedly in the left upper quadrant of the abdomen over several days, as documented in the MAR. Facility policy and manufacturer guidelines reviewed by surveyors also required rotation of injection sites. Interviews with the Assistant Director of Nursing confirmed that the injection sites were not rotated as required by policy and physician orders.
Failure to Provide Required Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the formation and progression of a pressure ulcer for one resident with an unstageable pressure ulcer. Specifically, the facility did not complete a required weekly measurement and assessment of the resident's wound during one week, as confirmed by both the treatment nurse and the Director of Nursing. The absence of this weekly skin report meant that the licensed nurses and physician did not have updated information on the wound's status, which is essential for monitoring healing or deterioration. Additionally, the facility did not administer the prescribed wound treatment on one day, as evidenced by a blank entry in the Treatment Administration Record. The resident's care plan and physician's orders required daily wound care, including cleansing and application of Thera-Honey gel with a silicone border dressing. The facility's own policy also mandated weekly wound measurements and daily monitoring. These lapses in care were confirmed through interviews and record reviews, indicating a failure to follow both physician orders and facility policy for pressure ulcer management.
Failure to Eliminate Accident Hazards and Ensure Fall Prevention Measures
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. For one resident with diagnoses including metabolic encephalopathy, dementia, and fluctuating decision-making capacity, a long, looped cable was exposed above the head of the bed and within reach. This resident was observed repeatedly reaching for the cord, which was not secured in the wall-mounted cord protector. Both the Social Services Director and Maintenance Supervisor acknowledged the hazard, noting the resident's confusion and the potential for harm. The resident's care plan specifically called for a clutter-free environment, but this was not maintained. For another resident with muscle weakness, abnormal posture, and a history of lumbar fracture, the facility failed to follow physician orders to place landing pads on both sides of the bed. The resident had previously fallen while reaching for an item and was hospitalized. Despite orders and care plan interventions to reduce fall risk, observations showed that the landing pads were not positioned as required, with one pad against the wall and another in front of an unoccupied bed, both away from the resident. The Assistant Director of Nursing and Director of Nursing confirmed that the pads were not in place as ordered and that staff failed to monitor their placement as required by the physician's order. Both deficiencies were identified through observation, interview, and record review, and were inconsistent with the facility's policies on resident safety and fall management, which require maintaining a safe environment and implementing interventions to reduce fall risk.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that the Antibiotic or Controlled Drug Record accurately matched the quantity of controlled medications present in the medication bubble packs for three residents. During an observation and record review, discrepancies were found between the documented counts on the accountability logs and the actual number of medication doses remaining in the bubble packs for hydrocodone-acetaminophen, pregabalin, and lorazepam. Specifically, one dose each of hydrocodone-acetaminophen and lorazepam was missing for two residents, and both a pregabalin capsule and a hydrocodone-acetaminophen tablet were missing for another resident, with no documentation of administration for these doses. The residents involved had medical histories including chronic pain, osteoarthritis, neuropathy, and anxiety, and were prescribed controlled medications for these conditions. The discrepancies were identified during a medication cart audit, where it was found that the number of doses in the bubble packs did not align with the amounts recorded on the accountability logs after the last documented administration. There was no evidence in the records to account for the missing doses, and the medication administration records did not reflect any additional administrations. A Licensed Vocational Nurse admitted to administering the missing doses to the residents earlier that day but failed to sign off on the Antibiotic or Controlled Drug Record accountability logs as required by facility policy. The Director of Nursing confirmed that the nurse did not follow the policy of immediate documentation on the accountability records when preparing and administering controlled medications. The facility's policy requires that the administering nurse immediately document the date, time, amount, and signature on the accountability record at the time the medication is removed from the supply.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in two medication errors out of 27 observed opportunities, yielding a 7.41% error rate. The first error involved a resident with chronic kidney disease, anxiety, depression, hypertension, and arthritis, who was prescribed a lidocaine 5% patch to be applied to both wrists for neuropathy. During medication administration, the nurse applied the patch to only one wrist, contrary to the physician's order. The nurse acknowledged not following the five rights of medication administration and recognized this as a medication error. The second error involved a resident with Parkinson's disease, hypotension, and chronic kidney disease, who was prescribed multiple medications, including Omega 3 1000 mg to be administered once daily. During a medication pass, the nurse administered all prescribed medications except for Omega 3. The omission was observed and later confirmed by the nurse, who admitted to failing to follow the five rights of medication administration. The nurse and the DON both recognized this as a medication error and acknowledged that the medication was not administered as ordered. Both incidents were observed and confirmed through interviews with the involved nurses and the Director of Nursing. The facility's policies on medication administration and medication errors require that medications be administered as prescribed and that the medication error rate remain at or below five percent. The observed errors directly contributed to the facility exceeding the acceptable medication error rate.
Failure to Rotate Insulin Injection Sites and Adhere to Medication Hold Parameters
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically in the administration of insulin and midodrine. For three residents receiving insulin, staff did not rotate injection sites as ordered by physicians and as required by facility policy. Documentation in the Medication Administration Records (MARs) showed repeated administration of insulin in the same anatomical area over consecutive days, despite clear orders to rotate sites. Interviews with nursing staff and the Director of Nursing confirmed that this practice was not followed, and that such failures were considered medication errors. Additionally, for one resident prescribed midodrine for hypotension, staff did not adhere to the physician's hold parameters. The medication was administered even when the resident's systolic blood pressure exceeded the threshold specified in the order. This was confirmed through MAR review and staff interviews, with the Director of Nursing acknowledging that the medication should not have been given under those circumstances and that this constituted a medication administration error. The residents involved had complex medical histories, including diabetes, end-stage renal disease, major depressive disorder, acute kidney failure, and dementia. All were dependent on staff for various activities of daily living and required careful medication management. The facility's own policies, as well as manufacturer guidelines for insulin, emphasized the importance of rotating injection sites and administering medications according to prescriber orders, but these were not followed in the cited instances.
Failure to Train Dietary Staff on Gluten-Free Diets Leads to Allergen Exposure
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in preparing and serving gluten-free diets, resulting in a resident with a documented gluten allergy being served cream of wheat. The resident, who had diagnoses including cachexia, intestinal malabsorption, and non-celiac gluten sensitivity, was admitted with clear physician orders and allergy documentation indicating the need for a gluten-free and lactose-free diet. Despite these orders, the resident was served cream of wheat, a product containing gluten, for breakfast. The resident identified the error and reported previous instances of being served inappropriate foods, such as oatmeal and regular bread, despite informing staff of his allergies. Interviews with dietary staff revealed confusion and lack of knowledge regarding gluten-free diets. One dietary aide stated she was told by a previous supervisor that cream of wheat was acceptable for gluten-free diets and reported that it was served daily to residents on such diets. The dietary supervisor confirmed that no training on gluten-free diets had been provided to kitchen staff since assuming her position. Additionally, the registered dietitian acknowledged that the facility's menu software did not properly flag the resident's gluten allergy, and there was a lack of clarity regarding the availability of gluten-free alternatives such as cream of rice, which was in stock but not used. A review of facility policies, procedures, and competency checklists showed that while staff were trained on general food allergies and preferences, there was no specific training or competency verification for gluten-free diets. The facility's policies required identification and accommodation of food allergies, but these were not effectively implemented. The deficiency was further evidenced by the lack of accurate tray identification and the absence of gluten-free diet training in staff in-service records.
Failure to Verify Meal Tray Contents Against Updated Allergy Information
Penalty
Summary
The facility failed to ensure that kitchen staff or licensed nurses checked the contents of a meal tray against the meal tray ticket for a resident during breakfast service. Specifically, a resident with a history of paraplegia and moderate cognitive impairment was served apple juice, despite the meal tray ticket indicating an allergy to apple juice. The resident confirmed they were not allergic to apple juice, and previous assessments and care plan updates had removed apple juice from the resident's allergy list. However, the meal tray ticket still listed the allergy due to a system glitch during a transition to a new dietary meal ticket system. Dietary staff did not review the tray on the day in question, and the discrepancy between the resident's actual allergy status and the information on the meal tray ticket was not identified by either dietary or nursing staff. The facility's policy required both dietary and nursing staff to check trays for correct diets and allergies before serving, but this process was not followed, resulting in the resident being served an item incorrectly listed as an allergen on their tray ticket.
Deficient Food Preparation and Service Affecting Palatability and Safety
Penalty
Summary
Surveyors identified that the facility failed to ensure food was prepared and served in a manner that conserved temperature, flavor, and appearance. Specifically, pineapple Bavarian cream and its pureed version were served at 70°F and 73°F, respectively, which was above the required cold holding temperature of 41°F or below. The Dietary Supervisor confirmed these temperatures were not acceptable for palatability and could result in residents not eating the food. Facility policies and standardized recipes required cold desserts to be maintained at or below 41°F during service, but this was not followed. Additionally, cheese enchiladas served to residents were observed to be dry, hard, and lacking sufficient sauce, making them crunchy rather than soft as intended. Both the Dietary Supervisor and Registered Dietitian agreed that the enchiladas did not meet the expected quality, with the Registered Dietitian noting that the food was not palatable and could lead to dissatisfaction. The standardized recipe for cheese enchiladas specified that each portion should be topped with sauce, which was not adhered to during meal service. Pureed mixed vegetables were also found to be runny, with liquid separating from the puree, rather than holding their shape as required by the facility's recipe and texture standards. The Registered Dietitian and Dietary Supervisor both noted that the puree did not meet consistency requirements, as it failed the spoon tilt and fork drip tests outlined in the recipe. These deficiencies in food preparation and service placed a significant number of residents at risk of poor food intake and related complications.
Failure to Provide Properly Prepared Pureed Foods for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents on a puree diet. Observations revealed that the puree cheese enchilada was grainy, the puree rice contained rice grains, and the puree vegetables had a runny consistency with liquid separating from the product. These issues were identified during meal preparation and trayline assembly, where it was noted that the foods did not meet the required smooth, pudding-like consistency for pureed diets. During a test tray evaluation, both the Dietary Supervisor (DS) and Registered Dietitian (RD) confirmed that the puree cheese enchilada was not smooth enough, the puree rice still had chunks, and the puree vegetables were excessively runny with liquid separation. The RD stated that the puree foods should be smooth, lump-free, and hold their shape, as outlined in the facility's diet manual and standardized recipes. The DS also noted that the runny puree vegetables would likely be unappealing to residents and could result in decreased food intake. A review of the facility's policies and procedures, diet manual, and standardized recipes indicated that all pureed foods should meet the International Dysphagia Diet Standardisation Initiative (IDDSI) Level 4 guidelines, which require foods to be lump-free, not sticky, and able to hold their shape without liquid separation. The facility's failure to adhere to these guidelines during food preparation and service resulted in the provision of pureed foods that did not meet the prescribed consistency and texture for residents requiring modified diets.
Deficient Food Storage, Sanitation, and Labeling Practices Identified
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Observations revealed that multiple racks in both the walk-in refrigerator and dry storage room were corroded with amber discoloration, and all resident meal trays were cracked and chipped. Both the Registered Dietitian and Dietary Supervisor confirmed that these surfaces were not smooth, were difficult to clean, and needed replacement to prevent bacterial contamination. Facility policies and the Food Code require food-contact surfaces to be smooth and free of cracks or rust, but these standards were not met. Further observations showed that kitchen equipment and areas were not properly cleaned and sanitized. The walk-in refrigerator and freezer floors had visible food debris, including pieces of bread, cream cheese, and sandwich spread, as well as dirt. The chest freezer had dust buildup and a sticky door, and the walk-in refrigerator gasket was dirty. Staff interviews confirmed that these areas were supposed to be cleaned regularly, but the cleaning schedule was not sufficient to maintain sanitation. Facility policies and the Food Code require regular cleaning of both food-contact and non-food-contact surfaces to prevent accumulation of soil and contamination. Additionally, dietary staff were observed wearing bracelets made of gold, leather, and rubber during food preparation and pot washing, in violation of both facility policy and the Food Code, which prohibit jewelry other than a plain wedding band during food handling. In a separate incident, a resident's leftover food brought from outside was not labeled with the resident's identifier or use-by date, contrary to facility policy. The Director of Staff Development confirmed that such labeling is required to prevent foodborne illness.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed improper disposal of garbage and refuse in the facility, including 15 soiled gloves, an empty spray bottle, plastic, and other trash scattered on the ground near the dumpster area. One of three dumpsters was found to have brown dried food spills and dirt on its surface. During interviews, both the Dietary Supervisor and the Environmental Services Supervisor acknowledged the presence of soiled gloves and trash on the floor, as well as the unclean condition of the dumpster, and stated that these conditions were not acceptable. The facility's policy and procedure required that outside dumpsters be kept closed and free of surrounding litter, and the Food Code 2022 specified that garbage and refuse must be properly stored and disposed of to prevent attracting pests and spreading infection. The observed failures had the potential to attract birds, flies, insects, and pests, possibly spreading infection to 142 of 149 residents. The Environmental Services Supervisor stated that the area was expected to be cleaned daily and dumpsters washed weekly, but these standards were not met at the time of the survey.
Infection Control Deficiencies: Unlabeled Urinals and Contaminated Oxygen Tubing
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two key areas. For one resident, the nasal cannula oxygen tubing was observed lying on the floor during a concurrent observation and interview with the Infection Preventionist (IP). The IP confirmed that the tubing was contaminated and needed immediate replacement, as it could introduce bacteria to the resident. The resident had diagnoses including cachexia and atelectasis, required partial to moderate assistance with activities of daily living, and had an order for oxygen therapy via nasal cannula as needed for low oxygen. Additionally, the facility did not ensure that urinals used by two residents were labeled with resident identifiers. In one case, a plastic urinal bottle at a resident's bedside was found without any written identifier, and the IP stated that labeling was necessary to prevent accidental use by roommates. In another case, two unlabeled urinals were observed at a different resident's bedside, and a Certified Nursing Assistant (CNA) confirmed the lack of labeling. The IP emphasized the importance of labeling urinals to prevent cross-contamination among residents. The facility's policy on Standard Precautions requires that all resident-care equipment soiled with blood, body fluids, secretions, and excretions be handled in a manner that prevents contamination and transfer of microorganisms. However, the Director of Nursing (DON) stated that there was no specific policy addressing the labeling of urinals for infection control. The observations and interviews confirmed that the facility did not consistently implement its own infection control policies regarding the handling and labeling of resident care equipment.
Failure to Return Deceased Resident's Personal Belonging
Penalty
Summary
The facility failed to ensure that a resident's personal belonging, specifically a silver bracelet, was returned to the resident's representative following the resident's death. Upon admission, the resident, who was receiving palliative care for end stage renal disease, had a silver bracelet documented on the Inventory of Personal Effects (IPE) form. After the resident expired in the facility, there was no documentation indicating that the bracelet was turned over to the facility, and staff were unable to locate the item. During an interview and record review, the Social Services Director confirmed that all personal belongings are to be inventoried and released to the family upon a resident's discharge or death, as per facility policy. The Director acknowledged that the silver bracelet was not accounted for and had not been returned to the resident's representative. The facility's policy requires safeguarding and proper release of personal belongings, but in this instance, the process was not followed, resulting in the loss of the resident's possession.
Failure to Inform Resident of Medication Names and Indications During Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered multiple medications to a resident without informing them of the names and indications of each medication prior to administration. The resident, who had a history of chronic kidney disease, anxiety, depression, hypertension, and arthritis, and was assessed as having moderate cognitive impairment, received several oral medications and a lidocaine patch during a morning medication pass. The LVN did not provide the resident with information about the medications or their purposes at the time of administration. During interviews, the LVN acknowledged failing to inform the resident of the medication names and indications, stating that this step is usually performed but was forgotten on this occasion. The Director of Nursing confirmed that the LVN did not follow facility policy, which requires informing residents about their medications and their purposes to support resident rights. Review of facility policy indicated that residents have the right to be informed of and participate in their care planning and treatment.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or the resident's representative in the quarterly Interdisciplinary Team (IDT) Care Conference for the development of an individualized Comprehensive Care Plan. The resident, who had diagnoses including gastroesophageal reflux disease and hypertension, was cognitively intact and required staff assistance with activities of daily living. Despite this, the resident was not included in discussions regarding discharge plans or care goals, and was unaware of his discharge status or plans, expressing frustration about not being consulted. Record review and staff interviews confirmed that the IDT Care Conference notes did not document participation by the resident or the resident's representative, contrary to facility policy which requires such involvement to the extent possible. The facility's policies also specify that care plans should be individualized and developed collaboratively with the resident or their representative. The lack of resident involvement led to the resident's frustration and the potential for unmet physical and psychosocial needs.
Failure to Update Care Plans After Resident Fall and Discontinuation of Oxygen Therapy
Penalty
Summary
The facility failed to review and update care plans for two residents following significant changes in their conditions. For one resident with a history of muscle weakness, abnormal posture, and a lumbar fracture, the care plan for fall risk was not revised after the resident experienced a fall while attempting to reach for a document, which resulted in hospitalization due to low oxygen saturation. Although new physician orders were issued to place the bed in a low position with bilateral landing pads and to monitor their placement, these interventions were not incorporated into the resident's care plan. Both the MDS Coordinator and the Director of Nursing confirmed that the care plan was not reviewed or updated after the fall, despite facility policy requiring such updates following a change in condition or hospital readmission. Another resident with chronic obstructive pulmonary disease, major depressive disorder, and respiratory failure had a care plan that was not updated after the discontinuation of continuous oxygen therapy. The resident's care plan continued to list oxygen administration as an intervention even after the physician order for oxygen was discontinued following a hospitalization. Observations revealed that the resident was still using oxygen equipment in the room, and staff were unaware that the order had been discontinued. The Director of Nursing confirmed that the care plan had not been revised to reflect the change in physician orders, and the resident was not informed that oxygen was no longer required. Facility policies reviewed indicated that care plans should be updated to reflect new interventions after a fall or a significant change in a resident's condition, including changes in physician orders. The failure to update care plans in both cases was acknowledged by facility staff and was not in accordance with the facility's own policies and procedures.
Failure to Provide Necessary ADL Assistance for Dependent Resident
Penalty
Summary
A resident with diagnoses including abnormal posture, weakness, dysphagia, and unspecified dementia was admitted to the facility and was documented as being dependent on staff for activities of daily living (ADLs) such as toileting, dressing, and personal hygiene. The resident's care plan included interventions for dressing and changing as needed. However, observations and interviews revealed that the resident's clothing had not been changed for three days, as evidenced by a persistent red food stain on the left sleeve of the resident's long-sleeved shirt. Family and staff confirmed the clothing had not been changed, and the stain appeared old and dried. Additionally, it was observed and reported that the resident's teeth were not brushed after breakfast, leaving brownish dried residue on the teeth. Staff interviews confirmed that residents should have their clothing changed and teeth brushed at least once daily. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive necessary services to maintain grooming, dressing, and personal and oral hygiene, as well as the right to a dignified existence. These services were not provided as required for this resident.
Failure to Provide and Document Indwelling Catheter Care
Penalty
Summary
A deficiency was identified when a resident with an indwelling catheter did not receive proper catheter care as outlined in their care plan. The resident, who had diagnoses including dysphagia, major depressive disorder, and type 2 diabetes mellitus, was dependent on staff for personal hygiene and bathing. The care plan required daily and as-needed catheter care, monitoring for signs and symptoms of infection, and skin irritation checks every shift. However, review of the Treatment Administration Record (TAR) showed no evidence that licensed staff provided or documented daily catheter care, infection monitoring, or skin assessments as required. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the required catheter care and monitoring were not documented or performed according to the resident's care plan. The facility's policy on urinary catheters emphasized the importance of such care to prevent complications, but staff failed to implement and record these interventions for the resident.
Failure to Obtain Physician Orders and Label Oxygen Tubing for Respiratory Care
Penalty
Summary
The facility failed to implement its own policy and procedure for oxygen administration by not obtaining a physician's order prior to administering oxygen to two residents. In the case of one resident with a history of COPD, major depressive disorder, and respiratory failure, the resident had previously received continuous oxygen therapy as ordered by a physician. However, after the physician's order for oxygen was discontinued following a hospitalization, staff continued to provide oxygen without a current physician's order. This was confirmed through interviews and record reviews, where both the LVN and DON acknowledged the absence of a valid order and the ongoing administration of oxygen. For another resident with a history of amputation, osteomyelitis, diabetes, asthma, and sleep apnea, oxygen was administered for shortness of breath without a physician's order. The resident's care plan indicated a risk for respiratory complications and included interventions for oxygen therapy as ordered, but no current physician order was found in the records. Staff confirmed that oxygen had been given and that the tubing and nasal cannula used for oxygen delivery were not labeled with the date they were last changed, as required by facility policy. Observations revealed that the oxygen tubing for this resident remained in the room and was not labeled, and staff interviews confirmed that the tubing had not been changed or labeled according to protocol. The facility's policy required verification of a physician's order before oxygen administration and mandated that oxygen tubing be labeled with the date of the last change to prevent infection. These requirements were not followed in both cases, as confirmed by staff and record review.
Improper Labeling and Storage of Inhalation Medication
Penalty
Summary
Surveyors observed that an opened budesonide inhalation solution foil pouch for one resident was not labeled with the date it was opened, and five inhalation solution ampules were stored outside the protective foil pouch in a medication cart. The Licensed Vocational Nurse (LVN) confirmed that the facility's policy requires multi-dose products, such as inhalation solutions, to be labeled with the date they are first opened to determine their expiration. The LVN also stated that, according to the manufacturer's guidelines, inhalation solutions must remain in the foil pouch or, if stored outside, be discarded within two weeks. Since the date of opening was not documented, it was unknown when the five ampules would expire, and they were considered expired and potentially ineffective. The Director of Nursing (DON) confirmed that inhalation solutions removed from their foil pouches must be labeled with the date of removal to determine the beyond use date, and that any solutions stored outside the pouch expire in two weeks. The facility's policy and the manufacturer's instructions both require proper labeling and storage to ensure medication effectiveness. The failure to label and store the budesonide inhalation solutions as required resulted in the presence of potentially expired medication in the medication cart, with no way to determine if it was still safe or effective for use.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely reporting of an allegation of misappropriation of resident property. Specifically, after a resident reported missing money following a hospital stay, the facility did not notify the State Survey Agency, the ombudsman, or local law enforcement within 24 hours as required. The resident, who had diagnoses including acute kidney failure, diabetes type 2, and atherosclerotic heart disease, reported the missing money to the administrator and was assured it would be returned, but did not receive it. The theft/loss report was initiated, and an internal investigation was conducted, including staff interviews and searches, but no money was found and the police were not notified. The administrator confirmed that the allegation was investigated and found to be unsubstantiated, but acknowledged that the required notifications to authorities were not made. The facility's policy clearly states that such incidents must be reported to specific agencies and individuals within 24 hours, and the results of the investigation must be reported within five working days. The failure to report the allegation as required constituted a deficiency in the facility's handling of suspected misappropriation of resident property.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Money
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of money reported by a resident with intact cognition and multiple medical conditions, including acute kidney failure, diabetes type 2, and atherosclerotic heart disease. After returning from a hospital stay, the resident reported missing money, initially estimated between $20 and $50, but later stated the amount was $400. The resident kept his money in his bedside table and did not take his wallet during the hospitalization. The theft/loss report was initiated, and staff interviews and searches were conducted, but the police were not notified, and the investigation did not include all relevant staff. Documentation revealed inconsistencies regarding the amount of money the resident possessed, with inventory records indicating no money, while a staff member later observed a wallet with about $30 in the resident's bedside table. This staff member did not secure the wallet with social services until the resident's return. The Director of Social Services confirmed there was no follow-up with the resident after the report, and the resident continued to keep money in his wallet at the bedside despite being offered the facility safe. The Director of Nursing acknowledged that staff should have secured valuables and that all staff involved should have been interviewed to ensure a thorough investigation. The Administrator confirmed the allegation was not reported to the state agency, ombudsman, or law enforcement, and was unaware of the staff member's observation of the wallet until after the fact. The facility's policy required prompt investigation of all theft or misappropriation reports, but this was not fully carried out in this case.
Incorrect Discharge Location Coded on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's discharge location on the Discharge Minimum Data Set (MDS) for one resident who had been discharged. The resident, who had Alzheimer's Disease and was severely cognitively impaired, was admitted to the facility and later discharged. Documentation in the Admission Record, Physician's Orders, Discharge Summary, and Discharge Plan all indicated that the resident was discharged to an assisted living facility, which is a lower level of care. However, the MDS assessment incorrectly coded the discharge location as a short-term general hospital. During an interview and record review, the MDS Coordinator acknowledged the error, stating that the discharge section of the MDS was completed incorrectly and that the resident was actually discharged to an assisted living facility. The facility's policy requires that all portions of the MDS assessment be completed accurately and certified by the responsible staff. The inaccurate coding on the MDS resulted in an inaccurate assessment for the resident.
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Illustrative
What surveyors actually found near you
We read the 3,512 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reseda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grancell Village Of The Jewish Homes For The Aging | 0.6 mi | — | 5 | 0 |
| Joyce Eisenberg Keefer Medical Center D/p Snf | 0.6 mi | ★★★★★ | 28 | 0 |
| Park View Nursing And Subacute | 1.1 mi | ★★★★★ | 7 | 0 |
| Eisenberg Village | 1.5 mi | ★★★★★ | 22 | 0 |
| Northridge Care Center | 1.5 mi | ★★★★★ | 44 | 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.