Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at York Healthcare & Wellness Centre during CMS and state inspections, most recent first.
The facility failed to maintain the HVAC system serving the day room and front lobby when a unit malfunctioned and emitted a burnt plastic odor and white smoke from the ceiling vents. Surveyors observed the odor and smoke in the common area, the ADM activated the emergency response for an internal fire event, and the local fire dept responded to inspect the ducts and rooftop unit. Nearby residents were monitored and denied SOB, coughing, or respiratory distress.
A resident with severe cognitive impairment and a history of falls was not provided with adequate fall prevention measures. The facility did not conduct timely fall assessments or update care plans with individualized interventions after unwitnessed falls. Despite the use of bed and wheelchair alarms, staff did not ensure the resident understood their purpose, nor was the resident closely monitored or moved closer to the nurse's station. This resulted in another unwitnessed fall causing a hip fracture and head injury, requiring hospitalization and surgery.
Three residents with significant physical or cognitive impairments were observed unable to access their call lights, despite care plans and facility policy requiring call lights to be within reach. Nursing staff and the DON confirmed the call lights were not accessible, and facility documentation specified the need for call light accessibility, particularly for residents at risk of falls or with communication difficulties.
Two residents did not receive care in accordance with infection control policies: one received high-contact care from a CNA who failed to wear a gown as required by enhanced barrier precautions for a wound infection and PICC line, and another had a used glove left on their blanket instead of being properly discarded. Staff and leadership confirmed these actions were not in line with facility protocols for PPE and infection prevention.
Two residents were not provided with a homelike environment when one was left without a wall clock, causing frustration, and another had a broken bedside table that exposed personal items. Both issues were acknowledged by staff as contrary to facility policy, which requires functional equipment and orientation aids in resident rooms.
A resident with severe cognitive impairment and dysphagia did not have a person-centered care plan developed for their speech therapy needs, despite physician orders and a detailed evaluation. The absence of this care plan left staff without guidance on addressing the resident's swallowing and communication deficits, contrary to facility policy.
Two residents did not have their comprehensive care plans revised to include individualized interventions after changes in their condition. One resident with dementia and a history of falls experienced multiple unwitnessed falls, but care plans lacked specific fall prevention strategies. Another resident with severe cognitive impairment and mobility issues began ambulating with assistance, but the PT care plan was not updated to reflect new goals or ambulation status. Staff confirmed that care plans were not person-centered and did not follow facility policy for timely revision.
Facility staff did not notify the physician when a resident with diabetes, sepsis, and kidney failure had multiple blood sugar readings above 300 mg/dL, as required by physician orders and facility policy. The resident, who had severely impaired cognition, was dependent on staff to follow medical directives, but documentation and interviews confirmed that the physician was not informed of these critical results.
A resident with an indwelling Foley catheter experienced a nonfunctioning and leaking catheter, with urine leaking around the urethra and no urine output for several hours. Despite care plan interventions and physician orders to change the catheter if leaking or occluded, nursing staff did not promptly change the catheter or notify the physician. The resident reported discomfort and staff were aware of the issue, but appropriate actions were delayed, resulting in a deficiency in catheter care.
A resident with end stage renal disease and dependent on dialysis did not have their post-dialysis weight documented on two occasions. Staff relied on weights from the dialysis center and did not obtain or record the weight at the facility when it was missing from the report, contrary to facility policy requiring complete documentation of dialysis care.
A resident receiving Apixaban for blood clot prevention was not properly monitored for signs of bleeding, as required by physician orders and facility policy. Nursing staff documented no bruising on the MAR despite the resident developing bruising, which was only brought to staff attention by the resident's daughter. The nurse practitioner assessed the bruising but did not document the findings or notify the physician, resulting in a failure to follow required monitoring and reporting protocols for anticoagulant therapy.
Two rooms in the facility were found to provide only 78 square feet per resident, below the required 80 square feet for multiple occupancy rooms. Despite staff and resident reports of adequate space for care, facility records and direct measurements confirmed the deficiency.
A resident with severe dementia, a history of falls, and a care plan requiring 1:1 supervision was left unsupervised when the assigned sitter took a break and the covering nurse left to assist another patient. During this lapse, the resident, who was unable to use the call light and known to attempt getting up alone, ambulated to the restroom and experienced an unwitnessed fall, resulting in a hospital transfer for evaluation.
A facility failed to readmit a resident after hospitalization, violating its bed-hold policy. The resident, diagnosed with Candida Auris, was medically stable for discharge but was refused readmission due to the facility's inability to provide a single room. This led to an unnecessary seven-day hospital stay. Staff interviews revealed a lack of communication and understanding of the resident's condition and the facility's obligations.
A resident with a history of diabetes and malnutrition developed Deep Tissue Injuries on both heels due to the facility's failure to provide necessary treatment and services. Despite being identified as at risk for pressure ulcers, the resident's care plan interventions were not adequately implemented, leading to the development of pressure injuries. The facility's policies required frequent skin monitoring and repositioning, which were not effectively carried out.
A resident with intact cognition was denied the opportunity to participate in self-care activities by two CNAs, despite expressing a desire to do so. The resident reported feeling embarrassed and angry after his arm was grabbed and twisted during the care. The facility's policies on resident rights, which emphasize promoting independence, were not followed.
A resident at high risk for pressure ulcers developed a Stage 2 ulcer on the sacrococcyx area, which was not documented or assessed by the facility. Despite requiring maximum assistance, the resident reported not being turned by staff. The LVN was unaware of the ulcer, and the TXN had not performed skin treatment on the day of observation. The facility's policy required regular skin assessments, but these were not adequately conducted, leading to a delay in treatment.
A resident at high risk for falls did not receive appropriate care as per their care plan, leading to a fall incident. The resident was not wearing proper footwear or on prescribed oxygen during the fall. Post-fall, the facility failed to perform timely neurological checks and did not update the care plan promptly. Documentation errors and delayed assessments further contributed to the deficiency.
The facility failed to revise care plans for two residents following their COVID-19 infection, as required by policy. The care plans indicated monitoring of vital signs every shift instead of every four hours. One resident had hemiplegia and required assistance with activities, while the other had a below-the-knee amputation and fluctuating decision-making capacity. The DON acknowledged the need for more frequent monitoring to identify symptoms like shortness of breath.
The facility failed to ensure that an outdoor refuse container was properly covered, as observed by a Dietary Aide. The container was one-third full with garbage and a foam plate with food items on top, without a secured lid. The Maintenance Supervisor confirmed that the lid should be closed to prevent infestation and illness. Facility policy requires food waste to be placed in covered garbage cans.
The facility failed to inform four alert and oriented residents about the State Long Term Ombudsman program, despite claims of providing this information during admission and Resident Council meetings. Interviews and record reviews revealed that these residents were unaware of the Ombudsman program and how to contact the office, violating their rights.
The facility failed to ensure proper handwashing by a dietary aide who, after handling dirty dishes, used a sanitizer solution meant for kitchen equipment to clean her hands before touching clean dishes. This practice was confirmed by interviews and violated the facility's infection control policy, potentially causing food-borne illnesses to residents.
The facility failed to ensure that three residents were properly informed and understood the Binding Arbitration Agreement (BAA) before signing it. The Admission Director did not thoroughly explain the BAA, leading to the residents unknowingly giving up their right to resolve disputes through a court of law before a jury. The facility's policy required that the agreement be explained in a form and manner the residents understand, which was not followed.
The facility failed to ensure a resident's call light was within reach, leaving the resident unable to call for assistance. The resident, with severe cognitive impairment and a history of falls, was observed struggling to reach the call light, which was found on the floor. The facility's policy requires call lights to be within reach, but this was not followed.
The facility failed to maintain a current copy of a resident's Advance Healthcare Directive (AHCD) in her medical record. Despite being aware of the AHCD since admission, the Social Service Worker did not follow up to obtain a copy, and the Director of Nurses confirmed that this was against facility protocol.
The facility failed to maintain privacy for two residents during care activities. An LVN did not pull the privacy curtain while administering medication to a resident, and another resident was observed using a bedside commode without the privacy curtain drawn. Both incidents violated the residents' rights to privacy and dignity.
A resident with a history of cerebral infarction, dysphagia, and diabetes did not have their care plan updated to address a new tooth infection and pain, despite a physician's order for medication. This oversight led to the resident experiencing difficulty eating and reduced meal intake.
The facility failed to implement a post-fall intervention for a high-risk resident, as indicated in the care plan. Despite the need for a bed alarm and bilateral floor mats, these measures were not in place, putting the resident at risk for recurrent falls. The resident had a history of falls and required various levels of assistance with daily activities. Both the LVN and DON confirmed that the necessary interventions were not implemented, contrary to the facility's fall management policy.
A resident with a history of cerebral infarction and moderate cognitive impairment did not receive their prescribed Carvedilol during a medication pass. LVN 4 administered four other medications but omitted the Carvedilol, which was confirmed during a review of the resident's order summary and an interview with the LVN. The DON emphasized the importance of timely administration of this medication.
A facility failed to ensure proper storage of medications for a resident, leaving opened and unopened medication tubes on the bedside table. The medications should have been capped and stored in the treatment cart to prevent contamination and improper storage.
A resident with a history of weight loss was not assessed for food preferences upon admission, resulting in her being served food she did not like and consuming only a small portion of her meals. This failure had the potential to worsen her weight loss and overall well-being.
The facility staff failed to ensure proper collaboration with the hospice agency for a resident receiving hospice care services by not including the hospice plan of care in the resident's medical record binder. Interviews revealed that staff were unaware of the plan's absence, leading to potential delays or lack of coordination in care delivery.
A CNA failed to wear an isolation gown while changing the brief and linens of a resident on contact isolation due to an MRSA infection. The resident had multiple diagnoses, including MRSA, and was cognitively intact. Both the DON and IPN confirmed the requirement for staff to wear gowns and gloves to prevent infection spread.
A resident with multiple health conditions was forced to manually lift the toilet water tank lid to flush due to a broken handle, causing discomfort and potential injury. The Maintenance Supervisor was not informed of the issue, and a CNA forgot to report it. The Director of Nurses acknowledged the handle should have been fixed immediately.
The facility failed to ensure that rooms 25 and 26 met the minimum required space of 80 square feet per resident. Room 25, occupied by a resident, and room 26, which was unoccupied, both measured 156 square feet, providing only 78 square feet per resident in a two-bed configuration. Staff and the resident reported no issues with the room size, and no adverse effects were observed during the survey.
The facility failed to implement a comprehensive care plan for a resident with dementia and cognitive communication deficit, who required one-to-one supervision and monitoring of a wander guard. Despite physician orders, the care plan did not reflect these interventions, and staffing logs showed inconsistencies in assigning a one-to-one sitter. The DON acknowledged the oversight and the need to update the care plan.
HVAC Malfunction Caused Burnt Odor and Smoke in Common Area
Penalty
Summary
The facility failed to ensure that the HVAC system was properly maintained to provide a safe and comfortable environment for 97 residents. The HVAC unit servicing the conference room malfunctioned and emitted a burnt plastic odor and white smoke into the facility. Surveyors observed a burning plastic odor coming from the ceiling ventilation vents in the day room/conference room area, and smoke was seen coming from the ceiling vent for approximately one minute before dissipating. The facility’s maintenance log showed routine HVAC inspections, and an invoice dated 5/20/2026 documented that HVAC #6 had a bad contactor that needed replacement. During the event, facility staff were notified immediately, and the Administrator initiated the Emergency Operations Plan for an internal fire event. The Administrator directed front desk staff to call 911, instructed staff to close resident room doors and monitor residents, and directed the Maintenance Supervisor to inspect the rooftop HVAC unit. The Maintenance Supervisor reported that power to the HVAC unit had been shut off after the burnt plastic odor was detected and stated there were no visible signs of fire, active smoke, or fire damage at the unit. The local fire department responded, inspected the ventilation ducts, and requested access to the rooftop HVAC unit. Residents in nearby rooms were interviewed and stated they were doing okay and denied shortness of breath, coughing, respiratory distress, or other related symptoms.
Failure to Prevent Recurrent Falls in Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls, due to poor safety awareness, severe cognitive impairment, and a history of repeated falls, was provided with adequate care and services to prevent recurrent falls. Despite the resident's documented diagnoses of dementia, Alzheimer's disease, and previous fractures, the facility did not conduct timely fall assessments and reassessments after each unwitnessed fall, as required by their Fall Management Program. The care plans were not revised to address the specific causes of each fall, such as the resident's behavior, poor safety awareness, and inability to communicate, nor did they include individualized interventions based on the resident's needs and behaviors. The facility's records showed that after multiple unwitnessed falls, interventions such as bed and wheelchair alarms were implemented; however, there was no evidence that the resident understood the purpose of these alarms due to her cognitive impairment. Staff interviews confirmed that the alarms were not new interventions and that the resident was not placed under close monitoring or moved closer to the nurse's station, despite being identified as a high fall risk. The care plans primarily focused on monitoring the effects of medications rather than addressing the resident's behavioral risks and need for increased supervision. As a result of these deficiencies, the resident experienced another unwitnessed fall, which led to significant injuries including a left hip fracture and head bruising, requiring transfer to an acute care hospital and subsequent surgery. The facility's own policies on fall management, resident safety, and dementia care were not followed, as there was a lack of person-centered observation, failure to update care plans with effective interventions, and insufficient communication among staff regarding the resident's fall risk and required monitoring.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for three out of eight sampled residents, as required by their care plans and facility policy. For one resident with aphasia, dysphagia, and right-sided hemiplegia, observations revealed the call light was placed above the resident's head and not accessible to the resident's functional left hand. The resident was unable to locate or use the call light, and the assigned LVN confirmed it was not within reach, acknowledging that this prevented the resident from requesting assistance. Another resident, who had moderate cognitive impairment and required maximal assistance for mobility, was observed unable to reach the call light despite attempts to do so. The LVN present confirmed the call light was not within reach and emphasized the importance of accessibility for residents to request help. The resident's care plans specifically required the call light to be functional and reachable due to the resident's communication and fall risk needs. A third resident, with a history of anxiety disorder, muscle weakness, and high fall risk, was observed sitting in a wheelchair with the call light placed on the opposite side of the bed, out of reach. The resident stated an inability to access the call light when needed. The LVN and DON both confirmed that facility policy mandates call lights be within reach at all times, especially for residents at risk of falls or emergencies. Review of the facility's policy and procedures further supported the requirement for call lights to be accessible to all residents.
Failure to Follow Infection Control Policies for PPE and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its infection control policy for two residents, resulting in deficiencies related to the use of enhanced barrier precautions (EBP) and proper disposal of personal protective equipment (PPE). For one resident with a wound infection and a peripheral inserted central catheter (PICC) for antibiotic administration, a Certified Nurse Assistant (CNA) provided high-contact care, including grooming, changing clothes, and repositioning, without wearing a gown as required by EBP protocols. The resident's care plan and signage at the room indicated the need for EBP, and both the CNA and facility leadership acknowledged that PPE, including gowns, should have been used during such care activities to prevent the spread of infection and multidrug-resistant organisms (MDROs). In a separate incident, a used glove was found placed on top of another resident's blanket while the resident was in bed. The glove was observed to be inside out, indicating it had been used, and staff confirmed that used gloves should be disposed of in the trash bin. Facility policy requires that gloves be discarded after a single use to prevent the transmission of infectious material. Interviews with the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) confirmed that both the failure to use appropriate PPE during high-contact care and the improper disposal of used gloves were contrary to facility policies and posed a risk for the transmission of infections. The facility's written policies on EBP and PPE use were reviewed and clearly outlined the requirements that were not followed in these instances.
Failure to Provide Homelike Environment Due to Missing Wall Clock and Broken Bedside Table
Penalty
Summary
The facility failed to provide a homelike environment for two residents by not ensuring that one resident had a wall clock in their room and that another resident's bedside table was functional. Resident 89, who had diagnoses including hemiplegia, hemiparesis, depression, and anxiety disorder, was cognitively intact and required varying levels of assistance with daily activities. During an observation, it was noted that Resident 89's room did not have a wall clock, and the resident expressed frustration about having to ask staff for the time. A licensed vocational nurse confirmed that a wall clock should have been provided to assist with orientation and to make the room more homelike. Resident 32, who had hemiplegia, hemiparesis, chronic kidney disease, and generalized muscle weakness, was moderately cognitively impaired and required assistance with most activities of daily living. During an observation, Resident 32's bedside table was found to be broken, leaving personal items exposed. A nurse acknowledged that the table should have been fixed immediately and that the broken furniture was not homelike. Interviews with facility staff, including the maintenance supervisor and the director of nursing, confirmed that it was facility policy to ensure all resident rooms had wall clocks and that furniture and equipment should be maintained in a safe and operable condition. Facility policies reviewed also indicated the importance of providing a safe, clean, comfortable, and homelike environment for residents.
Failure to Develop Person-Centered Care Plan for Speech Therapy Needs
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who had been admitted with diagnoses including encephalopathy, muscle weakness, and gait abnormalities. Despite a physician's order for speech therapy (ST) to address dysphagia and cognitive-communication deficits, and a detailed ST evaluation outlining the resident's needs and goals, no ST care plan was initiated or incorporated into the resident's comprehensive care plan. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and significant dependence on staff for daily activities, further emphasizing the need for individualized care planning. Interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed that the absence of an ST care plan meant staff lacked guidance on how to address the resident's specific needs related to dysphagia and cognitive-communication deficits. The facility's policy required care plans to be reviewed and revised with the onset of new problems or changes in condition, but this was not followed. The MDSC acknowledged that not adhering to the policy could affect the resident's quality of care and that the facility was not providing the necessary direction for staff.
Failure to Revise Comprehensive Care Plans with Resident-Specific Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to include resident-specific interventions for two residents. For one resident with dementia, Alzheimer’s disease, a history of falls, and impaired cognition, multiple falls occurred, including unwitnessed incidents that resulted in injury and emergency transfer. Despite documented orders for bed and wheelchair alarms, landing pads, and monitoring, the care plans did not include individualized strategies to address the resident’s poor safety awareness or specific fall prevention interventions. The Assistant Director of Nursing acknowledged that the care plans were not person-centered and lacked interventions such as frequent visual checks. For another resident with encephalopathy, muscle weakness, and abnormal gait, the physical therapy (PT) care plan was not updated to reflect the resident’s current ambulation status or to set new, individualized goals after the resident began ambulating with assistance. The PT evaluation and progress reports indicated changes in the resident’s functional abilities, but the care plan did not include updated goals or specify the ambulation schedule and distance. The MDS Coordinator confirmed that the care plan should have been revised to guide staff and track the resident’s progress. Facility policy required that care plans be reviewed and revised upon changes in condition or behavior, but this was not followed. Staff interviews confirmed that the lack of updated, resident-specific interventions in the care plans could delay care and services tailored to the residents’ needs. The failure to revise care plans as required was based on direct observation, interviews, and record review.
Failure to Notify Physician of Critically High Blood Sugar Levels
Penalty
Summary
Facility staff failed to follow physician orders for a resident with diabetes mellitus, sepsis, and kidney failure, who was at risk for complications of hypoglycemia and hyperglycemia. The resident's care plan and physician orders required staff to notify the physician if the resident's blood sugar exceeded 300 mg/dL. Blood sugar records showed multiple instances where the resident's blood sugar was above this threshold, but there was no documented evidence that the physician was notified as required. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed that the physician was not informed of the elevated blood sugar readings, and the facility's policy required such notification. The resident had severely impaired cognition and was dependent on staff to follow medical orders. The failure to notify the physician occurred on several occasions, despite clear orders and facility policy outlining the need for communication regarding abnormal blood sugar results.
Failure to Provide Timely and Appropriate Catheter Care
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and benign prostatic hyperplasia, who was cognitively intact and dependent on an indwelling Foley catheter, did not receive appropriate catheter care. The resident's care plan included monitoring for signs and symptoms of catheter complications and reporting them to the medical doctor, as well as interventions to evaluate for urinary complaints and urine characteristics. Physician orders specified that the Foley catheter should be changed if leaking, occluded, dislodged, or excessively sedimented, and to irrigate if clogged. Despite these orders and care plan interventions, the resident experienced a nonfunctioning and leaking Foley catheter, with urine leaking around the urethra and onto bedding, and no urine output for several hours. Documentation showed that the issue was identified by nursing staff, who attempted to flush the catheter without success, but the catheter was not changed and the physician was not notified in a timely manner. The resident reported the problem and discomfort, and staff interviews confirmed awareness of the malfunctioning catheter and the need for physician notification and catheter change. The facility's policy required physician notification and discontinuation of nonfunctioning catheters, but these steps were not followed promptly, resulting in a failure to provide appropriate catheter care as required.
Failure to Document Post-Dialysis Weight for Dialysis Resident
Penalty
Summary
Facility staff failed to ensure that a resident receiving dialysis had their post-dialysis weight documented on two separate occasions. The resident, who had end stage renal disease, an arteriovenous fistula, and was dependent on renal dialysis, had a care plan that required monitoring of their vascular access and documentation of their condition before and after dialysis. However, reviews of the resident's Pre-Dialysis Evaluations showed that the post-dialysis weight was left blank on two dates. Interviews with staff revealed that weights were typically obtained from the dialysis center's report and not taken at the facility. The Director of Nursing acknowledged that the post-dialysis weight should have been documented and that staff should have re-weighed the resident upon return if the dialysis weight was not available. The facility's policy required completion of pre- and post-dialysis evaluations and maintenance of all dialysis-related documentation in the resident's medical record, but this was not followed in these instances.
Failure to Monitor and Document Adverse Reactions to Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident receiving Apixaban, an anticoagulant medication, was adequately monitored for signs and symptoms of bleeding as required by physician orders and facility policy. The resident, who had diagnoses including obstructive pulmonary embolism and atrial fibrillation, was cognitively intact but required moderate assistance with daily tasks. The care plan and physician orders specified that the resident should be monitored every shift for adverse reactions such as bruising, discolored urine, black tarry stools, and other symptoms associated with anticoagulant therapy, with documentation required on the Medication Administration Record (MAR). Despite these requirements, documentation on the MAR from the relevant period consistently indicated 'No' for observations of bruising, and there was no record of bruising being observed or reported by nursing staff during this time. The resident later reported to staff that she had bruising on her arms, which she believed was related to her medication. The nurse only became aware of the bruising after being informed by the resident's daughter, not through direct observation or documentation. The nurse practitioner was notified of the bruising but did not document the assessment in the medical record and did not notify the medical doctor, as she did not consider the situation urgent. Interviews with facility staff, including the medical director and pharmacy consultant, confirmed that monitoring for adverse reactions to anticoagulant therapy is required and that physician orders must be followed. Facility policy also mandates immediate reporting and documentation of suspected adverse drug reactions, as well as notification of the pharmacist. The lack of proper monitoring, documentation, and timely notification regarding the resident's bruising constituted a failure to meet pharmaceutical service requirements for residents receiving high-risk medications.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that two resident rooms, identified as Room A and Room B, met the minimum required space of 80 square feet per resident in multiple occupancy rooms. Both rooms were measured at 156 square feet each, resulting in only 78 square feet per resident when occupied by two residents. This deficiency was confirmed through observation, interviews, and review of facility records, including the Client Accommodation Analysis and direct measurements by the Maintenance Supervisor. The Administrator acknowledged that the rooms did not meet the required space and stated that the facility had applied for a waiver for these rooms. Interviews with a resident occupying one of the rooms and an LVN indicated that both residents and staff felt there was sufficient space to move around and provide care, and no issues were observed during the survey related to the room size. However, the documented measurements and facility records confirmed that the rooms did not comply with the regulatory requirement for minimum square footage per resident in multiple occupancy rooms.
Resident Left Unsupervised Despite 1:1 Supervision Requirement, Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with severe dementia, a history of falls, and poor safety awareness, who required 1:1 supervision, was left unsupervised. The resident's care plans and physician orders consistently indicated the need for constant supervision due to her cognitive impairment, unsteady gait, and tendency to attempt standing or walking unassisted. Despite these interventions, the assigned 1:1 sitter left the resident to take a bathroom break, and the charge nurse, who was supposed to provide coverage, also left the resident unattended to assist another resident. During this period of unsupervision, the resident, who was unable to use the call light and was known to attempt getting up independently, got out of bed, ambulated to the restroom, and experienced an unwitnessed fall. The fall was discovered when staff returned and found the resident on the bathroom floor, complaining of a headache. The resident was subsequently transferred to an acute care hospital for evaluation due to the reported head injury. Interviews with staff confirmed that the resident was frequently restless, attempted to get up without assistance, and required someone to be present at all times. Facility policy required that residents needing constant supervision should never be left unattended, and that staff assuming coverage for 1:1 supervision must remain with the resident. The failure to maintain continuous supervision directly led to the resident's fall and hospital transfer.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, violating its own bed-hold policy and the California Standard Admission Agreement. The resident was initially transferred to a general acute care hospital (GACH) for further evaluation of Candida Auris and was deemed medically stable for discharge back to the facility the following day. However, the facility refused to readmit the resident, resulting in an unnecessary seven-day hospital stay. The resident's medical records indicated a diagnosis of Candida Auris, which the facility was aware of prior to admission. Despite this, the facility claimed it could not accommodate the resident due to the need for a single room, as there were no other residents with the same diagnosis to cohort with. The facility's decision was based on a misunderstanding of the resident's medical needs and the facility's capacity to care for residents with Candida Auris. Interviews with facility staff revealed a lack of communication and understanding regarding the resident's condition and the facility's obligations under the bed-hold policy. The Director of Nursing admitted to not noticing the Candida Auris diagnosis during the pre-admission inquiry, and the facility's marketing director confirmed the decision not to readmit the resident. This resulted in the resident being discharged home with home health services instead of returning to the facility.
Failure to Prevent Pressure Injuries in Resident
Penalty
Summary
The facility failed to prevent a resident from developing pressure injuries by not providing the necessary treatment and services in accordance with the facility's policy and procedure and physician's order. The resident, who was admitted with a fracture of the left femur, Type 2 Diabetes Mellitus, and protein-calorie malnutrition, was initially assessed as having no pressure injuries. However, the resident was identified as being at risk for pressure ulcers based on the Braden Scale assessment conducted upon readmission. Despite being at risk, the resident developed Deep Tissue Injuries on both heels. The resident's care plan, initiated and revised after readmission, included interventions such as evaluating skin integrity and providing skin care as needed. However, the resident began to complain of pain and redness on the heels, which was noted by the staff. A subsequent assessment revealed non-blanchable redness and diabetic ulcers on both heels, which were not present upon readmission. The facility's policy required frequent monitoring of the resident's skin and repositioning every two hours, but the development of the pressure injuries suggests these measures were not adequately implemented. Interviews with staff indicated that the resident's condition changed suddenly, and interventions such as applying heel protectors and elevating the heels were implemented only after the injuries were identified. The facility's failure to adhere to its own policies and procedures contributed to the development of the pressure injuries.
Resident Denied Participation in Self-Care
Penalty
Summary
The facility failed to ensure that a resident was able to participate in self-care activities as outlined in their care plan, which emphasized promoting independence and autonomy. The resident, who was admitted with a diagnosis of metabolic encephalopathy but had the capacity to understand and make decisions, expressed that two CNAs denied him the opportunity to engage in his own personal hygiene. Despite the resident's clear communication of his desire to participate in his care, the CNAs insisted on performing the hygiene tasks themselves, leading to the resident feeling embarrassed and angry. The resident reported that during the care, his arm was grabbed and twisted, which contributed to his feelings of loss of independence. Interviews with the Social Service Director and one of the CNAs confirmed the resident's account, with the CNA acknowledging that the resident became frustrated and angry when denied the opportunity to clean himself. The facility's policies on resident rights emphasize the importance of promoting independence and respecting residents' choices, which were not adhered to in this instance.
Failure to Prevent and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure ulcers for a resident who was assessed as high risk for developing pressure ulcers. The resident, who was admitted without pressure ulcers, was later observed with a Stage 2 pressure ulcer on the sacrococcyx area. Despite being at high risk and requiring maximum assistance with turning and repositioning, the resident reported not being turned by staff and was unaware of the wound. The facility's records did not document the presence of the pressure ulcer, and the Licensed Vocational Nurse (LVN) was unaware of its existence. The Treatment Nurse (TXN) acknowledged the presence of Moisture Associated Skin Damage (MASD) but had not performed skin treatment on the day of observation. The Director of Nursing (DON) stated that Certified Nursing Assistants (CNAs) should report any changes in skin condition to charge nurses immediately, and LVNs should assess and report new pressure ulcers to the TXN or Registered Nurses (RNs). However, there was no documented evidence of such assessments or reports for the resident's pressure ulcer. The facility's policy required regular skin assessments, but these were not adequately conducted or documented, leading to a delay in treatment and potential risk of infection and deterioration of the wound.
Failure in Fall Management and Care Planning
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident according to professional standards and its own policies, particularly concerning fall management. The resident, who was at high risk for falls due to various medical conditions including gait abnormalities and muscle weakness, experienced a fall incident. At the time of the fall, the resident was not wearing appropriate footwear as indicated in their care plan and was not on oxygen as prescribed by the physician. This oversight occurred despite the resident's care plan specifying the need for such precautions to prevent falls. Following the fall incident, the facility did not perform the required neurological checks immediately as per their fall management protocol. The protocol necessitated neurological checks at specific intervals following a fall, but the records show that these checks were not completed in a timely manner. The neurological checklist was incomplete, lacking the necessary signatures and dates, and there was only one recorded assessment, which was not conducted at the required frequency. This lapse in monitoring could have compromised the resident's safety and delayed the identification of any potential injuries resulting from the fall. Additionally, the facility did not conduct a thorough assessment of the resident's fall risk evaluation or update the care plan promptly after the fall. The interdisciplinary team meeting, which should have reviewed and revised the care plan to address the resident's specific needs, was not conducted in a timely manner. The care plan was revised significantly later than the fall incident, and the documentation related to the fall was inaccurate, with incorrect dates and times recorded. These deficiencies in documentation and care planning could have contributed to the resident's risk of recurrent falls.
Failure to Revise COVID-19 Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents following their COVID-19 infection, which was a deviation from the facility's policy. The policy required that residents in the red area have their vital signs, including blood pressure, pulse, respiration rate, temperature, and oxygen saturation, documented every four hours. However, the care plans for both residents indicated that vital signs should be monitored every shift, not every four hours as required. This discrepancy was identified during a review of the care plans and medication administration records. Resident 1 was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, and had intact cognition but required assistance with functional activities. The care plan for Resident 1, dated 06/24/2024, did not reflect the necessary revision for COVID-19 monitoring every four hours. Similarly, Resident 2, who had a below-the-knee amputation and fluctuating decision-making capacity, also had a care plan that failed to include the required four-hour monitoring. The Director of Nursing acknowledged the oversight, stating that monitoring should be more frequent to identify symptoms such as shortness of breath or a decline in oxygenation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that one of two outdoor refuse containers was properly covered, as observed during a concurrent observation and interview with a Dietary Aide (DA) in the facility's parking lot. The refuse container was found to be one-third full with several closed plastic bags of garbage and a foam plate with food items on top, without a secured lid. The DA acknowledged that the lid should be closed at all times and reported the issue to the Maintenance Supervisor (MS). The MS confirmed that the lid should be closed to prevent infestation of insects and rodents and to prevent illness to residents, staff, and visitors. A review of the facility's policy indicated that food waste should be placed in covered garbage and trash cans.
Failure to Inform Residents About Ombudsman Program
Penalty
Summary
The facility failed to promote the residents' rights by not adequately informing them about the State Long Term Ombudsman program. During a Resident Council meeting, four out of eight alert and oriented residents reported they were unaware of the Ombudsman program and how to contact the Ombudsman's office. These residents expressed that knowing the role of the Ombudsman and having contact information would be beneficial for addressing unresolved issues in the facility. Interviews with the Activity Director (AD) and the Director of Nursing (DON) revealed that while the facility claimed to inform residents about the Ombudsman program during admission and Resident Council meetings, and had posted information in common areas, this information was not effectively communicated to all residents. The AD acknowledged the need to ensure that all residents, including those who do not attend Resident Council meetings, are informed about the Ombudsman program. The review of the records for Residents 23, 26, 31, and 58 indicated that these residents had varying degrees of cognitive impairment but were generally capable of understanding and making decisions. Despite this, they were not adequately informed about the Ombudsman program, which is a violation of their rights. The facility's policy and admission package also indicated that residents should be informed about advocacy groups, including the Ombudsman program, but this was not effectively implemented.
Improper Handwashing by Dietary Aide
Penalty
Summary
The facility failed to ensure that Dietary Aide (DA) 1 washed her hands properly before handling clean dishes after sorting dirty dishes. During an observation, DA 1 was seen wearing vinyl exam gloves while sorting dirty dishes and then pushing the dish rack into the dishwasher. Instead of washing her hands with soap and water, DA 1 dipped her gloved hands into a red bucket containing a sanitizer solution meant for cleaning kitchen equipment and then proceeded to touch clean dishes. This practice was confirmed during an interview with DA 1, who admitted to using the sanitizer solution for hand cleaning due to being busy and thinking it would be faster. Further interviews with DA 3 and the Dietary Supervisor (DS) confirmed that the sanitizer solution in the red bucket was not intended for hand cleaning and that proper handwashing with soap and water should be performed after handling dirty dishes and before touching clean dishes. The facility's policy and procedure on infection control for dietary employees, dated 11/9/16, also indicated that proper handwashing should be done immediately before engaging in food preparation and after handling soiled equipment or utensils. This deficient practice had the potential to cause food-borne illnesses to the residents.
Failure to Properly Inform Residents About Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that three residents (Residents 89, 77, and 193) were properly informed and understood the concept of the Binding Arbitration Agreement (BAA) before signing it. The Admission Director (AD) was responsible for explaining and obtaining the BAA from residents upon admission. However, the AD did not thoroughly explain the BAA, leading to the residents unknowingly giving up their right to resolve disputes through a court of law before a jury. Resident 89, who had intact cognitive skills, stated that the BAA was not thoroughly explained and believed it was just a first step to settle disputes. Resident 77, with mildly impaired cognitive skills, did not remember signing the BAA or having it explained. Resident 193, with intact cognitive skills, was not aware that signing the BAA meant giving up the right to settle disputes in court and thought it was just required paperwork upon admission. The AD also misunderstood the BAA, thinking it was just a first step to settle disputes and that residents still had the right to go to court. The facility's policy and procedure (P&P) on Arbitration Agreement, revised 5/25/2023, required that the agreement be explained to residents in a form and manner they understand, including the language they understand, and that the resident's understanding of the agreement be confirmed. The facility's BAA document, revised 10/5/2020, clearly stated that by entering into the agreement, both parties give up their constitutional right to have disputes decided in a court of law before a jury. The AD's failure to properly explain the BAA and ensure residents' understanding resulted in the residents unknowingly giving up their legal rights, which constitutes a violation of resident rights.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident 288 by not ensuring the call light was within reach. Resident 288, who had diagnoses including encephalopathy and a history of falls, was observed lying in bed with the head elevated and receiving oxygen via nasal cannula. During the observation, Resident 288 pointed to a yellow blanket at the foot of the bed and asked for it to be covered, but there was no staff present in the room or hallway. The call light was found on the floor on the right side of the bed, and Resident 288 was unable to reach it despite trying to turn and reach out with his right arm. Resident 288 expressed difficulty in locating the call light and appeared to be panting from the effort. The Case Manager confirmed that the call light was on the floor and out of Resident 288's reach. The facility's policy and procedure, dated 1/1/12, indicated that call cords should be placed within the resident's reach in their room. The failure to adhere to this policy had the potential to prevent Resident 288 from calling for assistance, especially during an emergency.
Failure to Maintain Resident's Advance Healthcare Directive
Penalty
Summary
The facility failed to maintain a current copy of Resident 69's Advance Healthcare Directive (AHCD) in her medical record. Resident 69, who was admitted with diagnoses including end-stage renal disease, type 2 diabetes mellitus, weakness, and depression, stated she had created an AHCD a long time ago. Despite the facility being aware of the AHCD since 5/15/23, there was no documentation indicating that the Social Service Worker (SSW) followed up with Resident 69's family member to obtain a copy of the AHCD. The SSW acknowledged the importance of having the AHCD on file but failed to ensure it was included in the resident's medical record. During interviews, both the SSW and the Director of Nurses (DON) confirmed that it is the facility's protocol to keep a copy of the resident's AHCD on file, as it indicates the resident's wishes for medical emergencies and end-of-life care. A review of the facility's policy and procedure on Advance Directives, revised in July 2018, also indicated that a copy of the resident's advance directive should be included in the medical record upon admission. However, this protocol was not followed in the case of Resident 69, leading to the deficiency noted in the report.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain privacy for two residents during care activities. In the first instance, a Licensed Vocational Nurse (LVN) did not pull the privacy curtain while administering medication to a resident. The resident, who had cognitive impairments but could understand and make decisions, expressed that he did not want others to know about his medications. The LVN acknowledged the oversight, and the Director of Nursing (DON) confirmed that the privacy curtain should have been drawn to protect the resident's privacy rights. In the second instance, another resident was observed using a bedside commode with her pants down, and the privacy curtains were not drawn. This allowed anyone passing by to see the resident, violating her privacy and dignity. The resident, who had intact cognitive skills but required assistance with mobility and personal hygiene, expressed difficulty in drawing the curtain herself. The LVN and DON both acknowledged that the privacy curtain should have been drawn to maintain the resident's dignity and privacy. Both incidents were found to be in violation of the facility's policy on resident rights and quality of life, which mandates that residents be treated with dignity and respect, and that their privacy be maintained during personal care and treatment procedures. The facility's failure to adhere to these policies compromised the residents' rights to privacy and dignity.
Failure to Update Care Plan for Resident's Dental Issues
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan to address the medical and physical needs of a resident who had a physician order to receive Amoxicillin-Pot Clavulanate and Tylenol for a tooth infection and tooth pain. Despite the resident's complaint of a toothache and swollen gums, and the subsequent physician's order for medication, the care plan was not updated to reflect this change in condition. The Director of Nurses (DON) and Minimum Data Set Nurse (MDSN) confirmed that the care plan should have been initiated after the change of condition was noted on 5/6/2024, but it was not done. This oversight was observed during a review of the resident's electronic medical record and confirmed through interviews with the DON and MDSN. The resident, who had a history of cerebral infarction with hemiplegia and hemiparesis, dysphagia, and diabetes, was observed with swollen gums and reported difficulty eating due to the toothache. The resident's meal intake records indicated a significant reduction in food consumption, likely due to the dental pain. The facility's policy on comprehensive person-centered care planning requires that care plans be updated to reflect any new problems or changes in condition, which was not adhered to in this case. The DON acknowledged that a care plan should have been started immediately to address the resident's dental issues and prevent potential complications such as weight loss.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement a post-fall intervention for Resident 13, who was at high risk for falls. Despite the care plan indicating the need for a bed alarm and bilateral floor mats to prevent falls, these interventions were not in place. Resident 13, who has diagnoses including generalized muscle weakness, cervical disc disorder with radiculopathy, and anxiety disorder, was observed without the necessary fall prevention measures. The resident's cognitive skills were mildly impaired, and they required varying levels of assistance with daily activities. During an observation, it was noted that the resident's bed did not have a bed alarm, and there were no bilateral floor mats, contrary to the care plan's requirements. The Licensed Vocational Nurse (LVN) confirmed that these interventions should have been in place to mitigate the fall risk. Resident 13 had a history of falls, including an incident where they were found on the footrest of their wheelchair after attempting to walk. The facility's Fall Risk Evaluation indicated that Resident 13 was at high risk for falls, and the care plan was revised to include specific interventions to minimize fall incidents. However, these interventions were not implemented, as confirmed by both the LVN and the Director of Nursing (DON). The facility's policy on fall management emphasizes providing a safe environment and documenting interventions in the care plan, but these protocols were not followed for Resident 13, putting the resident at risk for recurrent falls and potential injury.
Omission of Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that Resident 67 was free from significant medication errors by omitting Carvedilol, a medication used to treat high blood pressure, during a medication pass observation. On 5/8/24 at 9:01 AM, LVN 4 administered four medications to Resident 67 but omitted Carvedilol 25 mg, which was prescribed for hypertension. This omission was confirmed during a review of Resident 67's May 2024 Order Summary and an interview with LVN 4, who acknowledged the error and emphasized the importance of administering antihypertensive medication as prescribed. Resident 67, who was admitted to the facility with diagnoses including aphasia and dysphagia following a cerebral infarction, required partial assistance for daily activities and had moderate cognitive impairment. The Director of Nursing also confirmed the importance of timely administration of Carvedilol to manage high blood pressure and reduce the risk of related health issues. The facility's policy on medication administration, dated 5/2022, mandates that medications be administered as per prescriber orders, highlighting the significance of this deficiency.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure proper storage of medications and treatment supplies for a resident who was observed with an opened tube of Fluocinonide, an opened tube of Hydrocortisone, and an unopened tube of Ketoconazole in the wash basin on their bedside table. During an initial facility tour, a Licensed Vocational Nurse (LVN) confirmed that these medications should not have been left on the bedside table and should have been capped to prevent infection. The Treatment Nurse admitted that the medications should have been stored back in the treatment cart to avoid contamination and improper storage. The resident involved had a history of depression and hypertension and required moderate assistance from staff for various activities. The resident's medical records indicated that they had the capacity to understand and make decisions. The medications observed were prescribed for specific conditions, including scalp treatment and itchiness. The facility's policy on medication disposal emphasized the importance of removing medications from active supply immediately upon discontinuation and storing them in a locked, secure area until disposal or return. However, this policy was not followed in this instance, leading to the observed deficiency.
Failure to Assess and Serve Food According to Resident Preferences
Penalty
Summary
The facility failed to ensure that Resident 55, who had a history of weight loss, was assessed and served food according to her preferences. Despite being admitted with diagnoses including type 2 diabetes mellitus and protein-calorie malnutrition, the resident reported that the facility's staff never asked about her food preferences. As a result, she was often served food she did not like and consumed only about twenty percent of her meals. This lack of proper dietary assessment and accommodation had the potential to exacerbate her weight loss and negatively impact her well-being. The Dietary Supervisor confirmed that all residents should be screened for food preferences upon admission, and this information should be documented in the resident's record. However, a review of Resident 55's Profile record indicated that the dietary assessment for likes and dislikes was not completed until well after her admission. The Director of Nurses acknowledged that the failure to assess food preferences upon admission could lead to weight loss due to serving food not from the resident's liking list. The facility's policy required the Dietary Manager to complete a Dietary Profile within 72 hours of admission, but this protocol was not followed in Resident 55's case.
Failure to Ensure Hospice Plan of Care in Resident's Medical Record
Penalty
Summary
The facility staff failed to ensure proper collaboration with the hospice agency for Resident 288, who was receiving hospice care services. The deficiency was identified when it was found that the hospice plan of care was not included in the resident's medical record binder. Resident 288, who had diagnoses including encephalopathy and acute respiratory failure, required various levels of assistance for daily activities and was admitted to hospice care under a routine level of care. Despite the facility's policy requiring the hospice plan of care to be maintained in the resident's medical record, this was not done, leading to potential delays or lack of coordination in the delivery of hospice care and services to the resident. During interviews, it was revealed that the facility staff, including a Registered Nurse (RN), the Social Services Supervisor (SSS), and the Director of Nursing (DON), were unaware of the hospice plan of care's absence in the medical record. The RN admitted to not knowing the frequency of hospice nurse visits and the specific care provided, while the SSS and DON confirmed that the hospice plan of care should be kept in the resident's medical record or hospice binder to ensure effective communication and collaboration between facility and hospice staff. The facility's policies were reviewed and indicated that both hospice and facility staff should maintain a copy of the patient's plan of care in their respective clinical records, which was not adhered to in this case.
Failure to Implement Contact Isolation Protocols
Penalty
Summary
The facility failed to ensure that staff implemented the policy and procedure for Resident Isolation - Categories of Transmission-Based Precautions. Specifically, a Certified Nurse Assistant (CNA) did not wear an isolation gown while changing the brief and linens of a resident who was on contact isolation due to a Methicillin Resistant Staphylococcus Aureus (MRSA) infection in the right hip wound. This lapse was observed during a concurrent observation and interview, where the CNA admitted to forgetting to wear the gown. The resident involved had multiple diagnoses, including MRSA, type 2 diabetes mellitus, protein-calorie malnutrition, and muscle weakness. The resident was cognitively intact and had a physician's order for contact isolation due to the MRSA infection. The Director of Nurses (DON) and the Infection Prevention Nurse (IPN) both confirmed that staff are required to wear gowns and gloves when dealing with residents on contact isolation to prevent the spread of infection. The facility's policy also mandates the use of gowns for interactions involving contact with the resident or potentially contaminated items in the resident's environment.
Failure to Maintain Functional Toilet Handle
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for a resident by not maintaining a functional toilet handle in the resident's restroom. Resident 34, who has diagnoses including peripheral vascular diseases, type 2 diabetes mellitus, protein-calorie malnutrition, and muscle weakness, was observed manually lifting the toilet water tank lid to flush the toilet. This situation persisted for a week, causing discomfort and potential risk of injury to the resident. The resident expressed that the water tank cover was too heavy for her to lift, which could lead to accidents and injuries. The Maintenance Supervisor (MS) stated that housekeepers are responsible for checking the toilet handles daily, but he was not informed of the broken handle in Resident 34's room. A Certified Nurse Assistant (CNA) discovered the broken handle but forgot to report it. The MS confirmed that the handle is easy to fix and should be reported immediately to avoid unsanitary conditions. The Director of Nurses (DON) acknowledged that the handle should have been fixed right away to prevent compromising the resident's safety. The facility's policy indicates that the Maintenance Department is responsible for maintaining equipment in a safe and operable manner at all times.
Room Size Deficiency
Penalty
Summary
The facility failed to ensure that rooms 25 and 26 met the minimum required space of 80 square feet per resident. Room 25, which was occupied by Resident 82, and room 26, which was unoccupied, both measured 156 square feet, providing only 78 square feet per resident in a two-bed configuration. The Administrator acknowledged that multiple rooms did not meet the space requirement but stated that a room waiver was in place and would be requested again for the current year. The Administrator and other staff members, including the Assistant Director of Nurses, Licensed Vocational Nurse, and Certified Nurse Assistant, indicated that the room size did not impact the care provided to the residents. Resident 82, who was observed in a wheelchair, also reported no issues with the room size and confirmed that the nurses could move around the room to provide care without difficulty. During the recertification survey, no adverse effects were observed regarding the adequacy of space, nursing care, comfort, and privacy for the residents in the affected rooms. The rooms were found to have enough space for the operation and use of wheelchairs, walkers, or canes, and the room variance did not affect the care and services provided. The facility's Room Waiver Request indicated that the rooms had enough space to provide for each resident's care, dignity, and privacy, and did not have any adverse effect on the residents' health and safety or impede their ability to attain their highest practicable well-being.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who required one-to-one staff supervision and monitoring of a wander guard. The resident, diagnosed with dementia and cognitive communication deficit, was admitted with a history of elopement risk and wandering behaviors. Despite physician orders to monitor the wander guard every shift, the care plan did not reflect the current interventions, including the placement of the wander guard in the resident's red headband and the need for a one-to-one sitter. Interviews with staff revealed inconsistencies in the assignment and instructions for the one-to-one sitter, and the care plan was not updated to include these critical interventions. The deficiency was further evidenced by the lack of documented physician orders for a one-to-one sitter and the absence of this intervention in the resident's care plan. The facility's staffing logs also indicated that a one-to-one sitter was not consistently assigned to the resident. The Director of Nursing acknowledged the oversight and confirmed that the care plan needed to be updated to ensure proper interventions were in place. The facility's policies on comprehensive person-centered care planning and the use of signaling devices were not followed, leading to a failure in addressing the resident's immediate needs and ensuring their safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Park Skilled Nursing And Wellness Center | 0.9 mi | ★★★★★ | 22 | 0 |
| South Pasadena Care Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Montecito Heights Healthcare & Wellness Centre, Lp | 1.8 mi | ★★★★★ | 0 | 0 |
| College Vista Post-acute | 1.9 mi | ★★★★★ | 0 | 0 |
| Solheim Senior Community | 2.2 mi | ★★★★★ | 17 | 0 |
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