Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Call Light Not Within Reach While Resident Was in Bed: A resident with ESRD, type 2 DM with diabetic neuropathy, and muscle wasting was observed lying in bed with the call light on the floor and not within reach. The resident was cognitively intact and required moderate assistance with toileting hygiene and bed mobility. An LVN and the DON both stated the call light should have been within reach so the resident could call for assistance, and the facility policy required the call light to be accessible when the resident was in bed.
Failure to document required 72-hour monitoring after a change in condition for two residents. One resident had intact cognition and was being monitored for psychosocial distress after reporting that a CNA hit the roommate, while another resident with severe cognitive impairment and multiple medical diagnoses was also placed on psychosocial distress monitoring after the same incident. The DON confirmed the LPN notes did not show the required 72-hour monitoring for either resident.
Improper Dumpster Area Sanitation: Surveyors observed soiled gloves, napkins, and disposable spoons on the floor around the dumpster, and the DS stated the area needed to be kept clean and free of trash to prevent mice and flies from coming into the facility for infection control purposes. Facility policy required trash to be disposed of in external receptacles and the surrounding area to be free of debris, but the dumpster area was not maintained in that condition.
Failure to implement the WMP occurred when the MS did not flush the hot water tank monthly as required and instead flushed it every 2 to 3 months without documentation. The MS and IPN stated they were responsible for the WMP, which was intended to control Legionella and other waterborne pathogens through monitoring and preventive maintenance measures.
A resident with DM, CHF, CKD, and HTN was using a CGM sensor in the upper arm, and nursing staff used the CGM readings to guide insulin administration. The resident had orders for insulin aspart and insulin glargine, but staff and the RN stated there was no physician order or documented monitoring procedure for the CGM. The DON confirmed that a physician order and ongoing monitoring are required for CGM use, and facility policy required glucose targets and monitoring regimens to be prescribed and incorporated into the MAR and care plan.
A facility failed to keep landing pads clear for several residents with fall risk, left one resident’s bed elevated instead of in the lowest position, and placed padded siderail protection incorrectly for a resident on seizure precautions. The facility also allowed a family member to feed a resident with dysphagia and dementia regular-texture outside food despite an order for pureed food and thickened liquids, and staff observed that the family had not notified nursing before feeding the resident.
A resident with DM, CHF, CKD, and HTN experienced significant weight loss while on a therapeutic diet and supplement orders, but ordered weekly weights were not completed and the RD did not perform a follow-up nutritional assessment after the weight variance was identified. Staff confirmed the missed weight monitoring and lack of reassessment, and the resident reported poor meal satisfaction and ongoing weight loss.
Failure to Monitor Pain Every Shift: A resident with epilepsy, a left upper extremity contracture, and muscle spasm had a physician order for pain monitoring every shift, but the MAR did not show that the assessment was completed. The resident’s care plan called for pain assessments per protocol and monitoring for non-verbal signs of pain, and both an LVN and the DON confirmed the pain monitoring was not done as ordered.
Food was not prepared and served in a palatable manner. A grilled bratwurst on the regular menu had burnt ends, and the DSD said it was overcooked and could have been removed because of its appearance. On an easy-to-chew test tray, hot items including a turkey patty, fried egg, and oatmeal were measured at low temperatures, and the DSD said the turkey patty was dry and a substitution. Several residents with dysphagia and other medical conditions reported cold meals or hard-to-chew items.
Unsafe food storage, dishwashing, and labeling practices were observed in the kitchen and resident refrigerator. A reach-in refrigerator and walk-in refrigerator had food debris and spills, dry storage had oatmeal particles, a freezer gasket was torn, a chest freezer lacked a thermometer, dented cans were stored with other cans, chopping boards were scratched and burned, and trays had cracks and chips. Staff also left scoop containers uncovered, stacked Cambro containers wet, allowed soap to spill onto drying pans, failed to wash hands after dishwashing tasks, and stored unlabeled food items in a resident refrigerator.
A facility failed to keep accurate clinical records when two residents receiving insulin did not have DM listed in their diagnosis records, despite physician orders, hospital documentation, and lab results supporting the diagnosis. In another case, an RNA signed a restorative ambulation entry as completed before actually providing the care, and the DSD observed the resident still being walked in the hallway when the record already showed the task finished.
Flies were observed in the trayline and dishwashing areas, including landing on the stove dial, food containers, and the fly light, while staff closed doors and remade food after one fly landed on a food container. The DS stated the flies were coming from the front dining room door and staff should not leave it open; a later observation also found a fly near the three-compartment sink.
Failure to Preserve Dignity During Meals and Feeding: A resident was served meals in disposable containers with plastic utensils without being told why the change was made, despite being cognitively able to understand and make decisions. In a separate event, a resident with dysphagia and dementia was observed being fed by an ST who was standing rather than sitting at eye level, contrary to the DON’s stated practice for dignified feeding and assessment.
A resident with nontraumatic intracerebral hemorrhage and intact cognition was given admission paperwork that included only one arbitration signature page instead of the full six-page arbitration agreement. The resident did not know what the page was, and the AC and ADM stated all pages are needed so residents can understand the agreement and make an informed decision.
A resident with dementia, impaired mobility, and a manual wheelchair had an over-bed table in the room that was observed to be wobbly and missing one wheel. The resident’s care plan called for a clutter-free room and consistent furniture arrangement, and an LVN stated the damaged table should be removed because it posed hazards and did not support a home-like environment. The DON stated staff are responsible for keeping furniture and equipment in good working order, with the MS responsible for repairs.
MDS Did Not Reflect Diabetes Diagnoses for Two Residents: The facility failed to list DM in the MDS for two residents who had active insulin orders for type 2 DM. One resident had severe cognitive impairment, dependence for ADLs, and a hospital H&P documenting type 2 DM with hyperglycemia; the other resident’s MDS also omitted DM despite an active insulin order for type 2 DM. The MDS nurse stated insulin therapy should be matched with an active diagnosis in the MDS, and facility policy required MDS information to match progress notes, care plans, and resident observations.
A facility failed to develop comprehensive care plans for two residents with DM and insulin orders. One resident had insulin aspart ordered for type 2 DM, and the care plan lacked goals or interventions for DM or insulin administration. Another resident had severe cognitive impairment, was dependent for ADLs, had type 2 DM with hyperglycemia, and had orders for insulin glargine and insulin lispro, but staff stated there was no care plan for DM management or insulin use. The facility policy required individualized care plans with clear objectives and timelines.
Failure to Assess Resident’s Hearing Impairment: A resident with cognitive impairment and multiple diagnoses was documented on the MDS as having adequate hearing, yet staff observations and interviews showed she was hard of hearing, needed speakers close by, and often relied on lip reading. The MDS Nurse, AD, AA, CNA, and DON all acknowledged the resident’s hearing difficulty, while other records identified her as hard of hearing and noted a need for accommodation for hearing loss.
LAL mattress not set to ordered weight. A resident with quadriplegia and multiple stage 4 pressure ulcers had a LAL mattress ordered for skin management at 165 lbs, but during observation the mattress was set between 120 and 150. An DSD and an LVN both stated the setting was inaccurate, and the MDSN confirmed the mattress manual directs staff to set the pressure based on the resident’s corresponding weight.
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.
Call Light Not Within Reach While Resident Was in Bed
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident while in bed. Resident 4 was admitted on 4/20/2026 and readmitted on 6/9/2026 with diagnoses including ESRD, type 2 DM with diabetic neuropathy, and muscle wasting and atrophy. The MDS dated 6/12/2026 indicated the resident was cognitively intact and required moderate assistance from staff for toileting hygiene, sit to lying, and lying to sitting on the side of the bed. During a concurrent observation and interview on 7/15/2026 at 1:35 p.m., Resident 4 was observed lying in bed with the call light on the floor and not within reach. LVN 1 stated the call light should have been within reach so the resident could call for assistance and that not having it within reach would result in delay of care and services. During an interview on 7/16/2026 at 4:15 p.m., the DON stated the call light should have been within reach for the resident to call for assistance and that without it, there would be a delay of care and services. The facility policy titled, Answering the Call Light, stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing, and from the floor.
Failure to Document Required 72-Hour Monitoring After Change in Condition
Penalty
Summary
The facility failed to ensure nursing staff implemented and documented the required 72-hour monitoring after a change in condition for two residents. Resident 2 was admitted with diagnoses including subluxation of the C4/C5 cervical vertebrae, DM, and HTN. The MDS indicated the resident had intact cognitive skills for daily decision making and was independent with oral hygiene, toileting, personal hygiene, dressing, and eating, with supervision needed for bathing. The care plan initiated after the resident reported that a CNA hit the roommate indicated the resident was to be monitored for psychosocial distress. Resident 3 was readmitted with diagnoses including palliative care, Parkinson's disease without dyskinesia, acute kidney failure, and CHF. The MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting, personal hygiene, dressing, showering, and eating. The care plan initiated after the resident was involved in the same reported incident indicated the resident was at risk for psychosocial distress and was to be monitored for signs and symptoms of psychosocial distress and offered support as indicated. Review of the licensed nurse progress notes for both residents did not show the required 72-hour monitoring, and the DON stated there was no documentation that either resident was monitored for 72 hours following the change in condition.
Improper Dumpster Area Sanitation
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the dumpster area with trash and litter on the surrounding floor. During a concurrent observation and interview with the Dietary Supervisor, soiled gloves, napkins, and disposable spoons were seen on the dumpster floor surroundings. The Dietary Supervisor stated the dumpster surroundings needed to be kept clean and free of trash to prevent mice and flies from coming into the facility for infection control purposes. A review of the facility’s policy and procedure titled Environment stated that all trash would be properly disposed of in external receptacles and the surrounding area would be free of debris. A review of the policy titled Dispose of Garbage and Refuse stated that all garbage would be collected and disposed of in a safe and efficient manner, and that the Dining Service Director coordinates with the Director of Maintenance to ensure the exterior dumpster area is maintained free of rubbish or other debris. The report also cited Food Code 2022 guidance stating that proper storage and disposal of garbage and refuse are necessary to minimize odors and prevent waste from becoming an attractant and harborage for insects and rodents.
Failure to Follow Water Management Program for Hot Water Tank Flushing
Penalty
Summary
The facility failed to implement its Water Management Program by not ensuring the hot water tank was flushed monthly. During a concurrent interview and record review, the Maintenance Supervisor stated that he and the Infection Preventionist Nurse were responsible for implementing the facility’s WMP and that, under the control measures, hot water tanks should be flushed monthly to eliminate impurities from the bottom of the tank. He stated that he flushed the hot water tank every two to three months and did not have documentation for this control measure. The Maintenance Supervisor stated that flushing the hot water tank was intended to prevent growth of opportunistic waterborne pathogens such as Legionella by eliminating stagnant water and controlling temperatures. The Infection Preventionist Nurse stated that she collaborated with the Maintenance Supervisor in implementing the WMP and that he was responsible for monitoring the facility’s water system. Review of the facility’s WMP, titled Risk management plan for Legionella Control, indicated the plan was intended to control the growth and survival of Legionella and other waterborne pathogens in water systems and manage epidemics in the facility. Review of the facility’s Policy and Procedures titled Legionella Surveillance and Detection indicated a commitment to the prevention, detection, and control of water-borne contaminants, including Legionella.
Missing Physician Order for CGM Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of continuous glucose monitoring (CGM) for one resident with diabetes mellitus. The resident was admitted to the facility on 8/27/2025 and readmitted on 3/27/2026 with diagnoses including DM, chronic heart failure, chronic kidney disease, and hypertension. The resident's MDS dated 3/30/2026 indicated intact cognition, need for varying levels of physical assistance with ADLs, and receipt of insulin during the assessment period. The resident's order summary included insulin aspart 4 units subcutaneously with meals and insulin glargine 14 units subcutaneously at bedtime, both dated 3/28/2026. The care plan for uncontrolled type 2 DM, revised on 5/27/2026, included a goal for the resident to remain free from signs and symptoms of hypoglycemia and hyperglycemia, with interventions for ongoing monitoring and education regarding those signs, symptoms, and related complications. During observation on 6/1/2026, the resident was seen with a sensor under the skin in the left upper arm and stated that nursing staff used the CGM blood sugar reading. During interviews, an LVN stated she used the resident's CGM readings before administering mealtime insulin and that there was no physician order or documentation for CGM use. An RN stated there was no documented physician order for the CGM device or for monitoring procedures related to CGM readings. The DON stated that a physician order and ongoing monitoring are required for CGM use. Facility policy required providers to prescribe glucose targets and monitoring regimens and to integrate those orders into the MAR and care plan, and the insulin administration policy stated blood glucose should be checked according to physician orders or facility protocol.
Unsafe Bedside Conditions and Improper Feeding
Penalty
Summary
The facility failed to keep the areas around low beds with bilateral landing pads free of objects for Resident 58, Resident 84, Resident 125, and Resident 15. Each of these residents had diagnoses and assessments showing significant fall risk, including impaired cognition, need for assistance with activities of daily living, and physician orders for a low bed with landing pads on both sides with placement monitored every shift. During observations in each resident’s room, an over-bed table was found placed on top of the landing pad, and in one room a wheelchair was also placed on the landing pad. Staff interviewed during the observations stated that objects should not be on the landing pads because they create a hazard and could cause injury if a resident fell. The facility also failed to keep Resident 9’s bed in the lowest position. Resident 9 had diagnoses including muscle wasting, history of falling, atrial fibrillation, and parkinsonism, and the record showed fall precautions and a care plan for fall risk related to impaired mobility and generalized weakness. During observation, the bed was left elevated to waist level. Staff stated the bed should have been lowered for safety and that beds should consistently be kept at their lowest setting because elevating the bed increases the risk of injury. The facility further failed to ensure Resident 101’s upper side rails were fully padded as ordered. Resident 101 had epilepsy, contracture of the left upper arm, and weakness, and the physician ordered bilateral upper padded siderails for seizure precautions. During observation, padding was placed outside the right upper side rail instead of on the inside facing the resident. Staff stated the padding was incorrectly placed and was intended to protect the resident from direct contact with the metal rail during a seizure. The facility also failed to protect Resident 4 from unsafe feeding by a family member. Resident 4 had dysphagia and dementia, was severely impaired in cognition, and had physician orders for a regular diet with pureed texture and mildly thick liquids. During dining observation, Family Member 2 fed Resident 4 food from an outside container that was not from the facility tray. The DON observed that the food was regular texture and not pureed as ordered. The DON and Administrator later confirmed that the family member had not notified staff about bringing outside food, and the family member stated he knew Resident 4 was on a puree diet but wanted to give her a break.
Failure to Follow Weight Monitoring and RD Assessment Orders
Penalty
Summary
The facility failed to provide nutritional care and services consistent with a resident’s nutritional assessment and physician orders for one resident who had diabetes mellitus, chronic heart failure, chronic kidney disease, and hypertension. The resident’s record showed a therapeutic diet order, a supplement order, and an order for RD consultation. The resident’s weight declined from 210 lbs. to 195 lbs., then to 189 lbs., and the resident’s albumin was 3.1 g/dL. The change in condition evaluation documented a 15-lb. loss over 30 days, oral intake of 50% to 100% with intermittent meal refusal, and notification of the primary physician with orders for the RD to continue following nutritional status, oral intake, supplement tolerance, and weekly weights. Despite the physician’s direction and the facility’s care plan to monitor weight trends and record weekly weights for four weeks, weekly weight monitoring was not carried out after the weight loss was identified. LVN 2 stated the weekly weight checks were not done after the resident’s 5/14/2026 weight loss and that there were no weekly weights recorded after that date. The ADON also stated she was responsible for monitoring weight changes but overlooked the resident’s weight loss and failed to conduct the ordered weight checks. RN 1 confirmed there were no documented weights after 5/14/2026 and that the physician order for ongoing weight monitoring was not implemented. The resident also did not receive a nutritional assessment after the weight loss was identified. The ADON stated the last nutritional assessment had been completed on 4/29/2026, with no further assessments after the 5/14/2026 weight loss. The RD stated she was responsible for conducting nutritional assessments and that these are typically completed within one to two days after a weight variance is identified, but no assessment was completed for this resident after the weight loss was identified. The resident also told staff he was dissatisfied with the food provided and believed he had lost weight, and CNA 2 reported the resident did not like the breakfast served and had relayed that concern to LVN 2.
Failure to Monitor Pain Every Shift
Penalty
Summary
The facility failed to assess and monitor Resident 101's pain every shift as ordered by the physician. Resident 101 was admitted with diagnoses including epilepsy, contracture of the left upper arm, and muscle spasm. The resident's MDS dated 2/25/2026 indicated moderate cognitive impairment, that the resident could make self understood and understand others, and that the resident received pain medication, PRN pain medication or was offered and declined, and non-medication interventions for pain. Resident 101's care plan for alterations in comfort/pain related to multiple complex medical conditions, abdominal pain, contracture of the left upper extremity, and muscle spasm included interventions to complete pain assessments per protocol, monitor for non-verbal signs of pain such as increased agitation, grimacing, and resistance to care, and monitor the frequency of breakthrough pain episodes to determine whether pain medication needed adjustment. During interview and record review, LVN 3 stated the physician order required pain monitoring every shift, but the MAR for 6/2026 did not show that this was performed. LVN 3 stated the order had been entered incorrectly and was not on the MAR for nurses to know it was to be done, and stated the absence of documentation meant Resident 101's pain was not monitored every shift. The DON also stated Resident 101's pain was not monitored every shift as ordered.
Food Not Served at Palatable Temperature or Appearance
Penalty
Summary
Food and drink were not prepared in a manner that conserved flavor, appearance, and palatable temperature. During trayline and test tray observations, the grilled bratwurst on the regular diet had black, burnt ends on several pieces, and the dining services director stated the bratwurst was a little overcooked and well done. The director also stated the bratwurst could have been removed from the trayline because of its appearance and that residents might complain about how it looked, not eat it, and become upset. The facility’s menu spreadsheet for the regular diet included grilled bratwurst, buttered new potatoes, sauerkraut, a roll with margarine, and an oatmeal raisin cookie. The facility’s recipe for grilled bratwurst directed staff to cook the sausage until it reached an internal temperature of 165 F, either on a grill or in a 350 F oven for approximately 30 minutes. The facility’s policy stated food would be prepared by methods that conserve nutritive value, flavor, and appearance, and that food would be palatable, attractive, and served in a manner, form, and texture to meet residents’ needs. Breakfast foods were also served at non-palatable temperatures. On a test tray for the easy-to-chew diet, the dining services director took temperatures of the turkey patty at 94 F, the fried egg at 105 F, and the oatmeal at 112 F, and stated the hot foods were under 120 F and could have been better. The director stated the fried egg did not hold temperature well, the sausage patty was cut into pieces and had less heat retention, and the turkey patty was dry and a food substitution. Residents interviewed reported cold meals, including one resident who said there had been no warm meals since admission, another who said lunch and breakfast were cold, another who said bacon and fried eggs were cold, and another who said toast was over-toasted and sausage was hard to chew. The residents referenced had diagnoses including dysphagia, malnutrition, diabetes with hyperglycemia, CKD, hypotension, GERD, and other conditions, and several required set-up, clean-up, supervision, or touching assistance when eating.
Unsafe Food Storage, Dishwashing, and Labeling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and food preparation conditions in the kitchen and related food service areas. During observation, the reach-in refrigerator by the trayline had amber discoloration and food debris on the shelves, and the walk-in refrigerator had dirt, butter, paper trash, gelatin, dry food debris, and dry milk residue on the floor and shelves. The dry storage room floor had oatmeal particles, the freezer by the exit door had a torn gasket, and the chest freezer did not have a thermometer inside it. Three dented cans were stored with non-dented cans in the dry storage room. Food contact and non-food contact surfaces were also observed in poor condition. Two green chopping boards had brownish discoloration, burn marks, scratches, and cut marks. Two clear Cambro containers used for scoops and utensils were uncovered and had dirt debris inside. Cambro containers on the shelves were stacked while wet, and the drying racks for domes and covers had dirt debris on the bottom. Four resident trays had visible cracks and chips. An oven grill was observed on the floor, and soap from the first compartment sink spilled onto the upper counter where pans were air-dried during dishwashing. Hand hygiene and food labeling practices were also not followed during dishwashing and food storage. A dietary aide handled coffee creamer and jams after cleaning the second compartment sink without washing hands. Another dietary aide touched clean scoops and later handled creamer and jam without washing hands after dishwashing activities. In the resident refrigerator, a vanilla bar, an ice cream box, and a plastic bag of food were not labeled, and two food items were not labeled with the resident's name. The dietary supervisor and other staff acknowledged several of these conditions during interview, including the debris, damaged equipment, wet stacking, and lack of labeling.
Incomplete diagnoses and premature restorative documentation
Penalty
Summary
The facility failed to maintain accurate clinical records for residents with diabetes mellitus by not listing the diagnosis in the medical record for two residents who were receiving insulin therapy. One resident’s admission record listed diagnoses including metabolic encephalopathy and acute respiratory failure with hypoxia, and the resident’s order summary showed active insulin aspart orders for type 2 DM before meals and at bedtime. During interview, the MDS nurse stated DM should have been listed in the diagnosis list because the resident had the diagnosis and was being treated for it, and that the diagnosis list should be complete so staff would be aware of the condition. A second resident’s admission record listed diagnoses including HTN, schizophrenia, epilepsy, and cerebral infarction, while the MDS showed severe cognitive impairment, dependence for ADLs, and receipt of insulin injections. The resident’s hospital H&P documented type 2 DM with hyperglycemia, and the facility’s order summary showed insulin glargine every 12 hours and insulin lispro before meals and at bedtime for diabetes. A laboratory report showed an A1C of 8.3%. During interview, RN 1 stated the resident had physician orders for insulin glargine and insulin lispro, that nursing staff entering physician orders were responsible for verifying corresponding diagnoses, and that there was no care plan in place for diabetes management or insulin administration. The MDS nurse stated that when insulin therapy is ordered, an active medical diagnosis must be documented to initiate treatment promptly and that failure to document may lead to missing care plans. The facility also failed to document a restorative nursing treatment accurately for another resident. The resident’s orders included restorative ambulation with a front wheeled walker five times a week and active range of motion to both upper extremities five times a week. The restorative administration record showed RNA 1 signed the ambulation treatment as completed, but during observation the survey team and DSD saw RNA 1 walking with the resident in the hallway at the same time. The DSD stated RNA 1 signed the record before completing the treatment, and RNA 1 stated he knew he was supposed to sign after completing the task. The DON stated the facility’s practice is to document care after it is completed and not before.
Flies Observed in Kitchen Food Prep and Dishwashing Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department when flies were observed in the trayline and dishwashing areas of the kitchen. During observations on 6/1/2026, a fly was seen flying around the trayline and landing on the stove dial, lingering around the trayline area, landing on the disposable box container for food, landing on the fly light top surface, and landing again on the disposable food container during lunch trayline. Staff were observed responding by killing one fly, closing the door, and remaking the food after a fly landed on the food container. The Dietary Supervisor stated the flies were coming from the front door dining room and that staff should not leave it open. During a later observation on 6/4/2026, a fly was seen flying around the three-compartment sink area. The facility's pest control policy stated a program would be established for control of insects and rodents for the Dining Services Department. The pest control report noted no fly during inspection and service on 5/10/2026, but also documented use of exterior insecticide at the slide door to target flies and a fly light in the kitchen. The Food Code 2022 cited in the report stated the premises shall be maintained free of insects, rodents, and other pests.
Failure to Preserve Dignity During Meals and Feeding
Penalty
Summary
The facility failed to inform a resident of the reason single-use disposable food containers and plastic utensils were being used for meals. The resident was admitted and later re-admitted with diagnoses including metabolic encephalopathy, acute respiratory failure with hypoxia, and need for assistance with personal care. The resident’s MDS indicated the resident could make self-understood and understand others, required set-up assistance, and the H&P stated the resident had capacity to make own decisions. During observation, the resident was eating from a brown disposable container with plastic utensils and stated the food got cold quickly, that she preferred real dishes, and that no one explained why the switch had been made. She also stated this had happened at other times during her stay and staff did not explain why disposables were being used. A LVN stated nursing staff were not informed when the kitchen started using disposable containers and utensils and that she did not tell residents the reason because she did not know what to say. The LVN stated residents have the right to know when and why disposables are being used for meals. The ADM stated administration did not inform staff about the switch from regular dishes and utensils to disposables or the rationale for it, and stated residents should be informed of changes in their home. The facility’s Resident Rights policy stated residents have the right to be treated with respect, kindness, and dignity, and the Dignity policy stated each resident is cared for in a manner that promotes individuality, well-being, satisfaction with life, and feelings of self-worth and self-esteem. The facility also failed to provide assistance with eating in a dignified manner for a resident with dysphagia and dementia. The resident’s record showed diagnoses of dysphagia and dementia, and the MDS indicated severe cognitive impairment with partial/moderate assistance needed for eating. During dining observation, the DON observed the resident being fed lunch by the ST, who was standing beside the resident rather than feeding at eye level. When asked, the ST stated she usually sits at the resident’s eye level when feeding and that doing so is easier for positioning and helps her assess how the resident is eating and how the mouth is moving. The DON stated residents needing assistance with eating are to be fed at eye level to provide dignity and to ensure swallowing is fully assessed. The DON also reviewed the facility’s dignity policy and an in-service titled Assistance During Eating, which indicated staff are to feed a resident at eye level by sitting down to ensure assessment while eating.
Incomplete Arbitration Agreement Provided
Penalty
Summary
The facility failed to provide the full six-page arbitration agreement to Resident 154, resulting in the resident not being fully informed to make a decision about the agreement. Resident 154 was admitted with a diagnosis that included nontraumatic intracerebral hemorrhage. The resident's MDS dated 6/4/2026 indicated the resident was cognitively intact and had the skills required for daily decision making, and required setup or clean-up assistance with eating. During a concurrent interview and record review, Resident 154 stated the facility gave him admission paperwork to review, and the arbitration signature page was among the documents. Resident 154 did not know what that page was. Admissions Coordinator 1 stated the admission packet had only one arbitration agreement page, but the agreement should contain six pages. She stated the packet would be redone so Resident 154 would have all pages, and identified that all pages were needed for residents to make an informed decision. The Administrator also stated the admissions department gives all pages of the arbitration agreement so residents can understand the agreement and make an informed decision about whether to enter into it.
Wobbly Over-Bed Table in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one sampled resident when an over-bed table in the resident’s room was observed to be wobbly and missing one wheel. Resident 58 was admitted with diagnoses including dementia, difficulty walking, adult failure to thrive, and a right femur closed fracture. The resident’s MDS indicated severely impaired cognition, required assistance with activities of daily living, and used a manual wheelchair for mobility. The resident’s care plan for risk for falls and injury included interventions such as a low bed with bilateral landing pads, a clutter-free room, and consistent furniture arrangement. During observation with an LVN, the over-bed table was seen with a broken wheel on the left side landing pad. The LVN stated that broken wheels on over-bed tables should be removed from the resident’s room because they pose hazards and do not contribute to a home-like environment, and that the damaged wheel must be repaired or replaced by the MS. The DON stated that all staff are responsible for ensuring furniture and equipment remain in good working order and that the MS was responsible for addressing and fixing issues as needed.
MDS Did Not Reflect Diabetes Diagnoses for Two Residents
Penalty
Summary
The facility failed to ensure that the diagnoses of diabetes mellitus were reflected in the Minimum Data Set (MDS) for two sampled residents. For one resident, the admission record listed hypertension, schizophrenia, and cerebral infarction, and the MDS showed severe cognitive impairment, dependence for ADLs, and receipt of insulin injections. A hospital history and physical documented type 2 diabetes mellitus with hyperglycemia, and the order summary showed active orders for insulin glargine and insulin lispro for diabetes. During interview, the RN stated staff entering physician orders were responsible for verifying corresponding diagnoses, and the MDS nurse was responsible for diagnosis coding. For the second resident, the admission record showed diagnoses including metabolic encephalopathy and acute respiratory failure with hypoxia. The MDS indicated the resident was sometimes able to make himself understood, sometimes understood others, and was dependent on staff for most ADLs, but it did not list diabetes mellitus under Active Diagnoses. The order summary showed an active order for insulin aspart for type 2 diabetes before meals and at bedtime. During interview, the MDS nurse stated the resident's MDS did not indicate diabetes mellitus under Active Diagnoses and should have because the resident was receiving insulin treatment for that diagnosis. The MDS nurse stated that when a physician orders insulin therapy, an active medical diagnosis must be documented within the MDS. The nurse also stated that all relevant diagnoses should be included so the resident's information and treatment are accurately reflected. The facility policy stated that MDS assessments should match progress notes, care plans, and observations or interviews, and that the results are used to create, update, and revise the comprehensive care plan.
Missing Care Plans for DM and Insulin Administration
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with diabetes mellitus and insulin orders. For one resident, the admission record showed a history of metabolic encephalopathy and acute respiratory failure with hypoxia, and the MDS dated 4/24/2026 indicated the resident was sometimes able to make himself understood, sometimes understood others, and was dependent on staff for most ADLs. The resident’s order summary included insulin aspart by sliding scale before meals and at bedtime for type 2 DM, ordered 3/4/2026, but the care plan reviewed with the MDS nurse did not include goals or interventions related to DM or insulin administration. For the second resident, the admission record listed diagnoses including hypertension, schizophrenia, and cerebral infarction. The MDS indicated severely impaired cognition, dependence on staff for physical assistance with ADLs, and receipt of insulin injections. A hospital history and physical dated 2/23/2026 documented type 2 DM with hyperglycemia. The order summary dated 6/4/2026 listed insulin glargine 10 units subcutaneously every 12 hours for diabetes and insulin lispro before meals and at bedtime per sliding scale, with both orders including rotation of injection sites. During interviews, RN 1 stated the resident had no care plan for diabetes management and insulin administration, and the MDS nurse stated that when a resident has DM, she formulates a care plan to facilitate medication administration, monitoring, and necessary treatments. The MDS nurse also stated there was no care plan for the resident’s DM or insulin use. The facility’s policy required an individualized comprehensive care plan for each resident with clear objectives and timelines, developed by the IDT and completed within seven days after the MDS is completed.
Failure to Assess Resident’s Hearing Impairment
Penalty
Summary
The facility failed to ensure Resident 101 received proper evaluation for hearing loss and proper treatment or assistive devices to maintain hearing abilities. Resident 101 was admitted with diagnoses including epilepsy, contracture of the left upper arm, and weakness, and the record also showed moderate cognitive impairment on the MDS. Although the MDS documented adequate hearing and no hearing aid use, the resident’s H&P stated she did not have the capacity to understand and make her own decisions. During observation and interview, Resident 101 spoke in an elevated voice and stated she could not hear when spoken to in a normal tone from the foot of the bed or even when the speaker was next to her bed. She asked the surveyor to remove a worn mask so she could hear and understand better, and she stated that she was hard of hearing and did not have or use a hearing aid. The MDS Nurse stated that the resident’s hearing had changed and was currently impaired, and that she had to raise her voice for the resident to hear her. The MDS Nurse also stated that the resident’s hearing was documented as adequate on the MDSs reviewed. Additional records and staff interviews reflected hearing difficulty throughout the resident’s stay. The Psychological Evaluation and Psychological Consult both identified the resident as hard of hearing, and the Recreation Comprehensive Assessment indicated the resident would benefit from accommodation for hearing loss. The care plan included speaking loudly as an intervention. The Activities Director, Activities Assistant, and CNA 3 each stated the resident had been hard of hearing since admission and needed staff to get close, speak louder, or remove masks so she could read lips. The DON stated the facility failed to assess the resident’s hearing impairment and that proper assessment was important to determine what care and treatment the resident needed.
LAL Mattress Not Set to Ordered Weight
Penalty
Summary
During a concurrent observation and interview, the resident’s low air loss mattress was found set between 120 and 150, and the DSD stated the setting was not accurate with the physician order and should be closer to 165 lbs. During a concurrent observation and interview, an LVN also observed the mattress setting appeared to be at 130 or 140 lbs and stated she needed to correct it to match the resident’s weight at 165 lbs. During a later interview and record review, the MDSN reviewed the mattress operational manual and identified that the pressure setting should be selected according to the patient’s corresponding weight.
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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,431 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near 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 | ★★★★★ | 30 | 0 |
| Eisenberg Village | 1.5 mi | ★★★★★ | 22 | 0 |
| Northridge Care Center | 1.5 mi | ★★★★★ | 49 | 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 October 2026) and official state health department websites.