Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Harmony Village Of Beverly Hills during CMS and state inspections, most recent first.
A resident with severe mental illness, moderate cognitive impairment, prior homelessness, frostbite-related toe amputations, and a documented history of behavioral issues and past elopement risk left the facility unnoticed during cold weather. The resident was last reliably seen around midnight in common areas and then near the room, but the assigned RN and CNA did not perform further checks for the rest of the night, citing the resident’s aggression and refusal to allow staff into the room. Police encountered the resident off premises and transported the individual to a heated bus shelter, yet facility staff did not realize the resident was missing until the following afternoon during a routine smoke break escort, after which a building-wide search and missing resident procedures were initiated. The resident later reported leaving because of dissatisfaction with shoes and stated exiting through a dining room window, while the facility confirmed no door alarms were reported and identified a breakdown in purposeful rounding and timely supervision as the primary cause of the delayed detection of the elopement.
A resident with a history of falls, morbid obesity, and mobility needs fell out of a bariatric bed and sustained a head injury, forehead laceration, bruising, sutures, and ongoing pain. The resident had an active order for bilateral assist bars and had reported the bars were missing, but staff confirmed the bars were not on the bed because they did not fit. Facility documentation also noted the mattress was defective and deflated on one side at the time of the fall.
Unsafe Environment With Odors, Damaged Equipment, and Missing Hardware: Surveyors observed strong urine odors and stagnant air in multiple areas, including a resident’s room, the hallway, and the therapy gym. A resident’s overbed light pull cord was too short to reach, a shower bed mattress had rips exposing foam, and tube feeding pumps, poles, and nearby equipment were covered with dried spilled tube feed. Several dressers also had missing drawer pulls.
A resident’s call light was found out of reach on the floor and later placed about four feet away on a bedside dresser while the resident was in bed. The resident stated they could not reach it and would have to yell for help. A CNA acknowledged moving the call light and leaving it out of reach, and the NM confirmed it should be within reach.
Unnecessary PRN psychotropic use without documented non-pharmacological interventions. A resident with dementia, psychotic disorder, insomnia, and other diagnoses received scheduled lorazepam plus two PRN doses of Ativan for anxiety/restlessness. MAR and clinical documentation did not identify distressing behaviors or any non-pharmacological approaches attempted before either PRN dose, and one MAR entry was left blank. The DON stated nurses should try non-pharmacological interventions first and acknowledged the documentation did not reflect what actually happened.
A resident was observed moaning and complaining of neck pain, and an RN contacted the NP, who ordered oxycodone for pain. The RN documented that the order was carried out, but the MAR, controlled substance log, and backup supply records did not show that the oxycodone was administered or removed, and the RN could not provide proof that the medication had been given. The DON stated the medication should have been given and documented on the MAR.
A resident with spinal stenosis, dementia, and other diagnoses was observed moaning and reporting severe neck pain after Tylenol was not helping. The NP ordered oxycodone PRN, but the MAR and controlled substance log showed no documented administration or removal, and an RN could not provide proof the dose was pulled from back-up supply. The resident was still reporting neck pain the next day.
Failed bathroom ventilation led to lingering urine odors and stagnant air in a shared bathroom for two residents, as well as in the center hallway and therapy gym. Surveyors observed an extremely strong urine odor, confirmed that the bathroom exhaust vent had no suction despite the fan motor running, and noted that other nearby vents were functional; the NM/IP and ES Manager also acknowledged the odor, and the Administrator reported no specific ventilation policy.
A CNA engaged in intimidating and verbally aggressive behavior toward a resident with cognitive impairment by retrieving a baseball bat, displaying it in a threatening manner, and verbally threatening the resident. The incident was witnessed by another resident and a staff member, and although no physical harm occurred, the actions constituted mistreatment and failed to protect the resident from abuse.
A facility failed to promptly report an incident where a CNA, after a verbal altercation, retrieved a metal bat and displayed it to a resident, as witnessed by another staff member. The event was not reported to facility leadership or authorities as required by policy, and no physical harm to the resident was observed.
Nursing staff failed to perform required hand hygiene before and after administering medications to multiple residents, including after touching surfaces and resident items, in direct violation of facility policy and infection control standards.
A resident with multiple health conditions and severe cognitive impairment developed a Stage IV pressure ulcer with osteomyelitis after the facility failed to consistently implement and document prescribed skin care interventions, did not escalate wound care in a timely manner, and did not follow through on recommended treatments and diagnostic orders, resulting in a significant decline and hospitalization.
A resident with significant cognitive impairment and a history of malnutrition did not receive a physician-ordered nutritional supplement with their dinner meal. The supplement was omitted from the meal tray due to a recent diet change and staff being rushed, and was only provided after staff were prompted. Interviews revealed that both dietary and nursing staff failed to consistently ensure supplements were delivered as ordered, despite the resident's high nutritional risk.
Two medication errors were observed during medication administration, resulting in a medication error rate above the acceptable threshold. A resident did not receive Metoprolol and Thiamine as scheduled, with the RN admitting to documenting the administration of Thiamine when it had not been given and being unable to demonstrate that Metoprolol was prepared or administered during the observed period.
Surveyors found multiple loose, unidentifiable pills in two medication carts and a white round pill on the floor of a resident's room. An LPN picked up the pill with a bare hand and confirmed it was unidentifiable. Both the DON and LPN acknowledged the presence of loose, unidentified medications, and the facility could not provide a medication storage policy when requested.
A resident with multiple health issues and high risk for UTI was started on an antibiotic before urine culture and sensitivity results were available due to delays in receiving lab results. The initial antibiotic was later found to be ineffective, requiring a change in therapy once the delayed results were obtained. Staff interviews confirmed ongoing issues with timely access to lab results.
A resident with multiple medical conditions and moderate cognitive impairment was left without dentures for approximately six months after admission, due to the facility's failure to provide timely dental services and follow-up. Despite dental consultations and awareness of Medicaid coverage limitations, the facility did not assist the resident or their representative in obtaining replacement dentures or explore alternative solutions until prompted by a surveyor. The facility's outdated dental policy and lack of documented efforts contributed to the resident's ongoing risk for malnutrition and inadequate oral care.
Two residents were involved in physical altercations after a dispute over a chair in the hallway, with staff failing to intervene before escalation and care plans lacking targeted interventions. Another resident with a history of falls was observed using a wheelchair with a nonfunctional anti-roll back device, and staff did not ensure the device was working or that wheelchair brakes were locked, despite multiple falls and recommendations for interventions. Behavioral tracking and documentation of interventions were also lacking.
The facility failed to maintain an accurate infection control surveillance system, affecting all 29 residents, including a resident with a UTI. The Infection Control Surveillance binder lacked data for December, and the monthly log was incomplete. The DON and an LPN failed to document antibiotic use for a resident's UTI in a timely manner, contrary to the facility's infection prevention policy.
A resident with diabetes, kidney disease, and dementia received incorrect medication administration due to an ambiguous physician order that was not clarified by nursing staff. Despite a recommendation from a Consultant Pharmacist to clarify the order for Insulin Lispro, the nursing staff assumed the medication and administered it without proper verification. The Director of Nursing acknowledged the error and the failure to address the issue for two months.
A facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and PTSD. The care plan did not address specific behaviors related to psychotropic medication use or identify PTSD triggers. Staff were unaware of these triggers, and no trauma-informed care assessment was conducted. Despite recommendations from psychological consultations, the facility did not implement necessary interventions, resulting in a deficiency in care planning.
A cognitively impaired resident eloped from a facility by entering a passcode to exit through a secured back door, walking two miles away, and was found by police. The resident, who felt threatened, was taken to a hospital for evaluation. The facility failed to provide adequate supervision and implement elopement policies.
A facility failed to provide adequate urostomy care and monitoring for a resident, as there were no physician orders guiding staff on necessary care. The resident was observed with a poorly managed urostomy bag, and staff assistance was inconsistent. Despite the care plan noting the urostomy, the absence of specific orders led to inadequate documentation and monitoring. The facility also could not provide a policy on ostomy care during the survey.
A facility failed to provide trauma-informed care for a resident with PTSD, resulting in potential exposure to trauma triggers. The resident, with severe cognitive impairment and a history of abuse, had no identified PTSD triggers or interventions in their care plan. Staff interviews revealed a lack of awareness and action regarding the resident's PTSD needs, and the facility did not adhere to its trauma-informed care policy.
A facility failed to account for and document controlled substances for a resident during discharge. The resident, with conditions including Parkinson's and anxiety, was discharged without proper records of Xanax and Morphine Sulfate. The facility's administration could not provide documentation or recall specifics about the medications, and the receiving facility did not document any medication arrival.
The facility failed to ensure proper documentation and non-pharmacological interventions for residents on psychotropic medications. For one resident, there were no non-pharmacological interventions attempted before administering PRN alprazolam, and no monitoring of adverse side effects or targeted behaviors. Another resident's behavior management assessment was incomplete, and recommendations from psych services were not implemented. Interviews revealed gaps in social service assessments and behavior management reviews.
The facility failed to maintain an effective Antibiotic Stewardship program, leading to inappropriate antibiotic administration for two residents. One resident was given antibiotics for a UTI without a culture and sensitivity test, despite a lab report showing no bacteria. Another resident was started on antibiotics without obtaining a urine sample due to initial refusal, and the facility did not attempt to collect the sample later. The facility also failed to provide an Antibiotic Stewardship Policy when requested.
Failure to Supervise Leads to Undetected Resident Elopement in Cold Weather
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent a resident with severe mental illness and a history of homelessness and frostbite from exiting the building without staff knowledge. The resident had diagnoses including paranoid schizophrenia, adjustment disorder, unspecified psychological development disorder, insomnia, malnutrition, unsheltered homelessness, hyperlipidemia, and bilateral toe amputations due to prior frostbite and gangrene. An MDS assessment documented moderate cognitive impairment and independence with mobility. The resident had a history of behavioral issues toward staff, such as hitting self, tearing items, urinating in garbage cans, removing bed sheets, screaming at staff, and throwing water on the floor. The resident had previously been assessed as an elopement risk from 2/14/24 to 1/25/25, but after 1/25/25 was no longer assessed as an elopement risk. A community mental health assessment documented that the resident’s mental illness was severe, interfered with self-care, and that due to severe mental illness and chronic homelessness, the resident needed to remain in the facility for long-term care. On the evening and night prior to the elopement, the resident consumed 100% of an evening snack at 7:28 PM and received scheduled bedtime medications at approximately 10:15 PM. Around 12:30 AM, the resident was observed by multiple staff members in the dining room and later ambulating toward the room, with staff reporting no distress, agitation, or expressed desire to leave. A CNA reported seeing the resident in the room around midnight to 12:30 AM while pulling garbage and did not return for the remainder of the shift. The night RN reported last seeing the resident in the room at about 12:30 AM and did not check again for the rest of the shift, despite stating that the standard of care was to check residents every two hours. Both the RN and CNA cited the resident’s history of aggression and refusal to allow staff into the room as reasons they did not perform further checks. The day-shift RN later inaccurately documented that the resident refused morning medications and initially told the Administrator and police that the resident had been seen at 2:00 AM, which was later acknowledged as untrue when police records showed the resident had already been picked up off premises by that time. Police documentation showed that the resident had exited the building before 1:33 AM and was encountered walking down the road, stating an intention to go to a casino. Law enforcement transported the resident to a heated bus shelter and left the resident there shortly after 1:33 AM. The facility did not become aware that the resident was missing until approximately 2:00 PM, when staff attempted to escort the resident for a customary smoke break and could not locate the resident. A house-wide sweep and full census head count confirmed all other residents were accounted for, and the facility’s Missing Resident Procedure was then activated. During a later hospital interview, the resident stated that he left because he was upset about his shoes and reported exiting through a dining room window, saying he manipulated the window to open and closed it behind him. The Administrator reported that there were footprints in the snow outside the window, although the window’s side panels were mechanically limited to open only four to five inches. The Administrator acknowledged uncertainty about the exact route of exit but confirmed that no door alarms were reported as activated and that the facility did not use video surveillance. The facility’s own root cause analysis identified a breakdown in consistent resident supervision, specifically the failure to complete purposeful rounding and timely checks on the resident, which delayed recognition of the resident’s absence for approximately 13 hours.
Removal Plan
- Completed a full-house head count confirming all other residents were accounted for and safe.
- Implemented one-to-one monitoring at the primary exit.
- Maintained one-to-one monitoring until door codes were changed and the door push-button was disabled.
- Completed elopement risk assessments on all residents and updated care plans as indicated.
- Suspended involved staff pending investigation.
- Implemented mandatory purposeful rounding with nurses and CNAs.
- Implemented CNA walking rounds and shift-to-shift handoff documentation reviewed by charge nurses.
- Completed facility-wide education on elopement prevention, supervision expectations, abuse and neglect prevention, shift-to-shift reporting and rounding, purposeful rounding, and documentation integrity.
- Provided the same education to staff not present on the education date on their next scheduled workday.
Fall With Head Injury After Missing Bed Rails and Defective Mattress
Penalty
Summary
The facility failed to prevent a fall with significant injury for one resident who had a history of falls, morbid obesity, osteoarthritis, sciatica, lung disease, depression, and adjustment disorder with anxiety. The resident reported that they rolled out of a bariatric hospital bed during the night, hit their head on the floor, and required hospital treatment with stitches. At the time of survey observation, bruising was noted under the resident’s eyes, and the resident reported ongoing pain in the back of the head after the fall. Record review showed the resident had an active physician order for bilateral assist bars to aid bed mobility, and the care plan and Kardex identified the need for one-person extensive assistance with bed mobility and bilateral assist bars for positioning in bed. The resident also stated that the mobility bars had been removed by facility staff even though they had used them for safe bed mobility and felt unsafe without them. The resident had previously expressed concern that the assist bars were missing, and facility documentation reflected that the resident did not like the bed and that the assist bars were missing. The resident’s fall occurred while the resident was in a bariatric bed that was later described in facility documentation as having a defective mattress that deflated on one side. Staff interviews confirmed the resident did not have mobility bars on the bed at the time of the fall because they did not fit and had been removed, and therapy was trying to obtain compatible bars. The resident was later provided a wider bariatric bed with attached rails after the fall. The resident’s hospital summary documented a head injury and forehead laceration, and facility notes documented facial bruising, sutures, and complaints of headache and back pain after the incident.
Unsafe Environment With Odors, Damaged Equipment, and Missing Hardware
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment as evidenced by multiple observations of odors, soiled equipment, and broken or missing equipment parts. Surveyors observed lingering urine odors and stagnant air in room [ROOM NUMBER], room 119, the center hallway, the therapy gym, and in the room of R42. In the rehabilitation room, the sun was coming through the windows and the room felt warmer, while housekeeping had cleaned the floors but the urine smell still permeated the room. R42 was observed lying in bed with an extremely strong urine odor in the room, and the resident’s overbed light pull cord chain was only about a foot long and could not be reached by the resident. Surveyors also observed equipment and furnishings in disrepair or contaminated with dried tube feeding material. In the east shower room, CNA N confirmed there was one shower bed in the facility, and its blue mattress had various rips and tears exposing tan foam-like material. In two resident rooms, enteral nutrition pumps, poles, and stands had dried spilled tube feed on the faces and sides of the pumps and moderate amounts of dried tan staining on the poles and stands; one room also had splashes of the same dried material on a black portable oxygen concentrator and on the floor around the equipment. In addition, a three-drawer bedside dresser in R42’s room had two missing drawer handle pulls, and another built-in dresser in a separate room was missing the top drawer hardware pulls. The Environmental Services Manager confirmed the missing drawer pulls, and the Administrator stated there was no specific policy for overbed light pull cords.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure a resident’s call light was accessible. On 12/2/25, R42 was observed lying in bed with the call light on the floor mat and out of reach. When asked how they would summon assistance, R42 stated they would yell for help and said they could not reach the call light from where it was placed. The assigned CNA later stated he had pushed it off. On 12/4/25, R42 was again observed in bed with the call light placed around the bedside dresser about four feet away and still out of reach. The resident stated they could not reach it if they needed assistance. During a later observation with the NM, the NM confirmed the call light should be within reach and placed it next to the resident on the bed. The resident’s assigned CNA then stated the call light had been placed on the bedside dresser while the resident was being pulled up in bed for breakfast and acknowledged it had remained out of reach since then. The facility policy stated staff will ensure the call light is within reach of the resident with each interaction in the room or bathroom.
Unnecessary PRN psychotropic use without documented non-pharmacological interventions
Penalty
Summary
The facility failed to ensure chemical restraints were not used for staff convenience and failed to identify non-pharmacological approaches attempted before administering PRN psychotropic medication for one resident. The resident was admitted and readmitted with diagnoses including cognitive communication deficit, adult failure to thrive, other psychotic disorder not due to a substance or known physiological condition, delusional disorders, Alzheimer's disease with early onset, dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbance, insomnia, and malignant neoplasm of bladder. The MDS indicated moderately impaired cognition, no communication concerns, no signs or symptoms of delirium, delusions, hallucinations, mood or behavioral concerns, and use of antianxiety medication. The resident had two lorazepam orders: scheduled lorazepam 1 mg at bedtime for anxiety or restlessness and PRN lorazepam 0.5 mg every six hours for anxiety and restlessness for 12 days. MAR and controlled substance records showed the resident received the scheduled dose and two PRN doses, one documented at 8:00 AM and another at 7:51 AM, both by Nurse C. The documentation for the 7:51 AM dose was blank in the MAR note section, and the record contained no identification of distressing behaviors or non-pharmacological interventions attempted before either PRN administration. Later nursing notes by Nurse C described the resident as attempting to get out of bed and talking about going back to work, and another note described the resident talking to self and looking up at the air, with PRN Ativan given with good effect. The DON stated nurses should try non-pharmacological interventions first and acknowledged the documentation did not capture what actually happened or include the approaches attempted before medication was given.
Inaccurate Medication Documentation and Failure to Administer Ordered Pain Medication
Penalty
Summary
The facility failed to ensure pain medication was administered per physician’s orders and that documentation in the record was accurate for one resident, R31. On 12/2/25, R31 was observed in a wheelchair in the doorway of the room, moaning and complaining of neck pain. RN A assessed the resident after the resident requested that the physician be called. RN A later told the resident that the physician had ordered oxycodone for pain, and a progress note entered at 10:22 AM stated that the resident reported pain in the back of the neck, the NP was notified, and oxycodone 5 mg PRN for 5 days was ordered and carried out. However, the physician’s order reviewed later that day showed oxycodone 5 mg every 12 hours as needed, and the MAR did not document any administration of oxycodone. A second review the next day again showed no oxycodone administration on 12/2/25, and the controlled substance log did not show any removal of oxycodone from the resident’s supply. During interview, RN A stated they removed 5 mg of oxycodone from the back-up medication supply and administered it, but could not provide evidence that it had been pulled, and gave no confirmation or denial when asked again if it had been given. The DON stated the medication should have been given and documented on the MAR, and also stated that the resident’s pain is what the resident says it is and they should have gotten the medication.
Pain medication not documented or verified as administered
Penalty
Summary
The facility failed to ensure pain medication was administered as ordered for a resident who was complaining of neck pain. The resident was observed moaning in a wheelchair in the doorway of the room and told nursing staff that the Tylenol they had just received was not working, that the neck hurt "real bad," and that the pain was moving down the middle of the neck. The resident also requested to go to the hospital and asked the nurse to call the physician. The resident’s record showed diagnoses including spinal stenosis, heart attack, diabetes, bipolar disorder, epilepsy, osteoarthritis, delusional disorder, schizoaffective disorder, and dementia, and the most recent MDS indicated moderately impaired cognition. The care plan stated the resident may experience pain related to spinal stenosis and that staff should anticipate the need for pain relief and respond immediately to any complaint of pain. A nurse later documented that the nurse practitioner was notified and ordered oxycodone 5 mg PRN for 5 days, and the physician’s orders later showed oxycodone 5 mg every 12 hours as needed. However, the MAR did not show any administration of oxycodone, and the controlled substance log did not document any removal of oxycodone from the resident’s supply. During interview, Nurse A stated they removed 5 mg of oxycodone from the back-up medication supply and administered it, but also said the MAR would not allow documentation because the physician had not signed the controlled substance order. Nurse A could not provide evidence that the medication had been pulled from back-up supply and gave no confirmation or denial when asked again whether it had been administered. The next day, the resident was still observed in the hallway and stated the neck still hurt.
Failed Bathroom Ventilation With Lingering Odors
Penalty
Summary
The facility failed to maintain mechanical ventilation in the shared bathroom for room [ROOM NUMBER] and 119, resulting in lingering urine odors and uncirculated air. During observations from 12/2/25 through 12/4/25, surveyors noted multiple instances of strong urine odor and stagnant air in the shared bathroom area, the center hallway, and the therapy gym. On 12/2/25 at 10:45 AM, room [ROOM NUMBER] and 119 were observed to have an extremely strong urine odor that was acknowledged by the residents, and the bathroom exhaust vent was tested with toilet paper with no suction observed. On 12/4/25, the Environmental Services Manager acknowledged lingering urine odor and stagnant air on the center hall and deferred to nursing for room [ROOM NUMBER]. The Nurse Manager, who also served as the Infection Preventionist, entered the resident's room and confirmed the strong urine odor, suggesting the resident may have leaked from a urostomy; however, the assigned CNA later checked the urostomy area and reported it was dry. When the Environmental Services Manager rechecked the bathroom ventilation, the fan motor could be heard but toilet paper did not suction to the vent, while other nearby room vents did function. The Administrator later reported there was no specific policy for ceiling or bathroom ventilation.
Failure to Protect Resident from Staff Intimidation and Verbal Aggression
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) engaged in intimidating and verbally aggressive behavior toward a resident with moderate cognitive impairment, including Alzheimer's disease, schizophrenia, and an anxiety disorder. The incident began when the resident used profane language toward the CNA, who then left the building, retrieved a baseball bat from their car, and re-entered the facility. The CNA displayed the bat in a threatening manner, including hitting it on the ground, in the presence of the resident. This act was witnessed by another resident and a maintenance employee, both of whom confirmed the intimidating behavior. The resident who was the target of the intimidation was unable to recall the incident and denied experiencing fear, pain, or distress when interviewed. No physical harm or injuries were observed or reported. The witness resident, who was alert and oriented, reported feeling upset by the incident but stated they felt safe in the facility. The maintenance employee also confirmed that the CNA did not physically approach or chase the resident with the bat but did display it in a manner that drew attention and was inappropriate. The facility's policy defines abuse to include intimidation and verbal aggression, both of which were substantiated in this incident. The event was not immediately reported to facility management, and the CNA's actions were later confirmed by multiple staff and resident interviews. The incident was reported to law enforcement, and the facility's investigation concluded that the CNA's conduct constituted mistreatment and failed to protect the resident from abuse and intimidation.
Failure to Timely Report Alleged Staff-to-Resident Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged incident of staff-to-resident abuse involving one resident and a certified nurse assistant (CNA). The incident occurred when the CNA, following a verbal altercation with the resident, retrieved a metal bat from her car, reentered the building, and displayed the bat to the resident, hitting it on the floor before walking away. A staff member witnessed the event but did not report it to the facility at the time. The resident did not appear fearful, and there was no physical contact or harm observed. According to the facility's policy, all alleged violations involving abuse or intimidation must be reported immediately to the facility administrator and to state agencies within specified timeframes. In this case, the incident was not reported as required, constituting a failure to follow established procedures for reporting suspected abuse or mistreatment. The deficiency centers on the delay and failure in reporting the incident to the appropriate authorities as outlined in facility policy.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate infection control practices, specifically hand hygiene, during medication administration for five residents. Multiple observations revealed that nursing staff, including RNs and LPNs, did not perform hand hygiene before or after preparing and administering medications. For example, a nurse was seen administering medications to residents without washing or sanitizing hands, even after touching various surfaces and resident items such as control pads, call lights, bedside tables, and blankets. In one instance, a nurse removed a Band-Aid and touched a computer screen before handling medications, again without performing hand hygiene. These lapses were observed during several medication passes, both in resident rooms and common areas, and involved direct contact with residents and their personal items. The facility's own policy, dated February 2025, requires hand washing or sanitizing prior to medication administration to prevent contamination or infection. Despite this policy, staff did not consistently follow these procedures, as confirmed by direct observation and acknowledged by facility leadership.
Failure to Prevent and Timely Treat Pressure Ulcer Resulting in Stage IV Wound
Penalty
Summary
A resident with significant medical conditions, including cerebral infarction, dysphasia, adjustment disorder, and moderate protein-calorie malnutrition, was admitted to the facility and identified as being at moderate risk for pressure ulcers. The resident was severely cognitively impaired, required extensive assistance with activities of daily living, and was bedfast. Initial care plans and orders included regular skin assessments, use of barrier creams, and pressure-relieving mattresses. However, documentation revealed gaps in the implementation of these interventions, including a period from mid-November to early December when no skin treatments were administered despite ongoing skin issues such as excoriation and discoloration. Throughout the resident's stay, weekly skin sweeps consistently noted excoriation and skin breakdown on the buttocks, but there was a lack of timely and appropriate escalation in wound care. Orders for skin barrier ointment were not transferred to the treatment administration record, and there was no evidence that these treatments were provided. When wound care was eventually initiated, the wound had progressed to a full-thickness injury. Recommendations for further interventions, such as wound imaging and specific wound treatments, were either delayed or not implemented at all. For example, an order for an x-ray to rule out osteomyelitis was not completed, and recommended treatments like Dakins solution were not ordered or administered. The resident's condition deteriorated, resulting in the development of a Stage IV pressure ulcer with associated osteomyelitis, necessitating an extensive hospital stay. Interviews with facility staff, including the wound nurse, nurse practitioner, and DON, revealed a lack of awareness regarding the resident's wound progression and lapses in following through with prescribed treatments and assessments. The facility's own policy required systematic skin assessments and timely interventions for residents at risk, but these were not consistently followed, directly contributing to the resident's severe wound development.
Failure to Provide Ordered Nutritional Supplement to High-Risk Resident
Penalty
Summary
A resident with a history of stroke, bladder cancer, difficulty swallowing, pressure ulcer, and malnutrition was re-admitted to the facility following multiple hospitalizations and was identified as being at nutritional risk. The resident had significant cognitive impairment and required 1:1 assistance during meals, as well as a physician order for a house supplement (health shake) to be provided twice daily with lunch and dinner. The care plan and dietary orders reflected these needs, and the resident had experienced significant weight loss during recent hospitalizations. On the day of observation, the resident did not receive their dinner tray at the same time as other residents, and when the tray was eventually delivered, it was missing the ordered health shake supplement. The RN assigned to the resident was unaware of the missing supplement until prompted and had to leave the room to retrieve it. Interviews with staff, including the RN, Unit Manager, Dietary Manager, and DON, revealed that the process for ensuring residents received their prescribed supplements was not consistently followed. The dietary staff missed including the supplement due to a recent diet change and being rushed, and there was a lack of double-checking by both kitchen and floor staff. Facility policy required a systematic approach to maintaining residents' nutritional status, including assessment, individualized care planning, and consistent implementation and monitoring of interventions. However, the failure to provide the ordered nutritional supplement as part of the resident's meal demonstrated a breakdown in these processes, as staff did not ensure the supplement was delivered as ordered, despite the resident's high nutritional risk and need for assistance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two medication errors were observed out of 30 opportunities during medication administration, resulting in a 6.67% error rate. During observation, a resident was scheduled to receive Metoprolol 25 mg and Thiamine 100 mg at 9:00 AM, but neither medication was observed being prepared or administered at the designated time. Upon questioning, the administering RN admitted to documenting the administration of Thiamine when it had not been given and subsequently provided the medication after the discrepancy was identified. The RN also stated that Metoprolol had been administered but could not provide evidence of its preparation or administration during the observation period.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed multiple instances of improper medication storage and labeling within the facility. During a medication administration in a resident's room, a white round pill was found on the floor near the bathroom. The pill had no identifying marks and was picked up by an LPN with their bare hand. The LPN confirmed that the pill was unidentifiable and acknowledged it should not have been on the floor. Further inspection of two medication carts revealed several loose, unidentifiable pills in multiple drawers. These included various colored and shaped pills that were not stored in containers and lacked any form of identification. Both the DON and the LPN acknowledged the presence of these loose, unidentified medications in the carts and the issue of the pill found on the floor. The facility was unable to provide a policy for medication storage when requested by surveyors.
Delay in Laboratory Results Led to Inappropriate Antibiotic Administration
Penalty
Summary
The facility failed to ensure timely receipt of laboratory services for a urine culture and sensitivity (C/S) test, resulting in the administration of an antibiotic that was not effective against the infection. A resident with a sacral ulcer, osteomyelitis, incontinence, impaired mobility, and severe cognitive impairment was at high risk for urinary tract infections. A urinalysis and urine C/S were obtained and sent to the lab, but only the urinalysis results were received promptly. The C/S results, which would have indicated the appropriate antibiotic, were not available to the facility in a timely manner due to issues with accessing results from the lab's software portal. As a result, the resident was started on Nitrofurantoin (Macrobid) based on the urinalysis findings, without the benefit of the C/S results. It was later discovered that the infection was resistant to Macrobid, necessitating a change to a different antibiotic (Levaquin) after the delayed C/S results were finally obtained. Interviews with staff confirmed that there were ongoing concerns with the lab's timeliness and that the C/S results should have been available within 2-3 days but were not received until nearly two weeks after collection.
Failure to Ensure Timely Dental Services and Denture Replacement
Penalty
Summary
A deficiency occurred when the facility failed to assist and ensure timely dental services for a resident who required replacement dentures. The resident, admitted from another skilled nursing facility, had multiple medical conditions including a neck fracture, temporomandibular joint disorder, anemia, vitamin deficiency, and protein calorie malnutrition. Upon admission, it was noted that the resident did not have their dentures, and only an upper denture was later received from the previous facility. There was no further documentation or follow-up regarding the missing dentures until the issue was brought to the facility's attention by a surveyor several months later. The resident underwent an initial dental consult nearly a month after admission, and a follow-up visit resulted in the completion of initial impressions for new dentures. However, the dental provider informed the facility that Medicaid would not cover new dentures until several years later, and a private pay option was presented to the resident's representative. The facility did not document any efforts to assist the resident or their representative in obtaining the dentures through other means, nor did they reach out to the previous facility or external resources until prompted by the surveyor. The facility's social worker and administrator were both unaware of or unable to explain the process for assisting a Medicaid resident in this situation, and no clear plan was in place to address the resident's needs. The facility's policy on dental services was outdated and did not specify procedures for determining responsibility for lost dentures or for assisting residents in obtaining replacements. The lack of timely follow-up and assistance resulted in the resident remaining without dentures for approximately six months, despite being at risk for malnutrition and having a modified diet due to oral functional problems. The deficiency was identified through observation, interviews, and record review, which revealed significant gaps in the facility's response to the resident's dental needs.
Failure to Prevent Resident-to-Resident Incidents and Inconsistent Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision to prevent two physical resident-to-resident incidents involving three residents. One incident occurred when a resident removed a chair from the hallway for a guest, which another resident believed was their personal chair. This misunderstanding escalated into a verbal altercation and resulted in one resident kicking the other in the ankle. The incident was brought to staff attention by another resident, not by staff, and initial assessments found no injury, though mild pain and swelling were later noted. The care plan for the resident who kicked did not address their belief about the chair or include follow-up interventions related to this behavior. A second incident involved the same resident making physical contact with another resident after a perceived invasion of personal space, again related to the chair outside their room. Staff and documentation confirmed that the chair was a contributing factor in both incidents, but the issue was not addressed prior to the events. Additionally, the facility failed to consistently implement fall prevention interventions for a resident with a history of multiple falls. The resident, who had moderate cognitive impairment and was at high risk for falls, was observed using a wheelchair with an anti-roll back device that was not functioning properly. The device's lever was repeatedly found in a nonfunctional position, and the wheelchair brakes were not locked during multiple observations. Staff, including nurses and CNAs, were seen interacting with the resident but did not address the malfunctioning device. The resident's medical records documented several falls, with root causes identified as failure to lock the wheelchair. Interventions such as the anti-roll back device were recommended, but there was no evidence of follow-up or adjustment in the care plan after subsequent falls. Behavioral tracking logs for the involved residents were blank, and there was no targeted behavior tracking or documentation of interventions for behaviors such as swearing or invading personal space. Staff interviews confirmed that expectations for ensuring safety devices were in place and functioning were not consistently met. The facility's policy required identification, evaluation, and implementation of interventions to reduce hazards, but these processes were not effectively carried out for the residents involved in the incidents and falls.
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to maintain an accurate and current infection control surveillance system, which affected all 29 residents, including a specific resident identified as R13. During a review of the facility's Infection Control Surveillance binder, it was found that there was no data provided for December 2024. The Director of Nursing (DON), who also served as the Infection Preventionist, and an LPN assisting with infection control, were unable to provide documentation of surveillance for December 2024. The monthly infection control log for December 2024 contained only two entries, one of which documented that R13 had a urinary tract infection (UTI) with an onset date of December 16, 2024, and was receiving an oral antibiotic starting on the same date. Further review of R13's December 2024 Medication Administration Record (MAR) revealed an order for Cipro Oral Tablet 500 MG to be given twice daily for chronic UTIs starting December 16, 2024, and another order for Cefpodixime Proxetil Oral Tablet 200 MG for a UTI starting December 3, 2024. The latter was not initially documented on the line listing. When questioned, the DON acknowledged that it should have been included and directed the LPN to add it. The facility's policy on infection prevention and control, revised in January 2024, mandates a system of surveillance for identifying and controlling infections, including an antibiotic stewardship program. However, the failure to document infections and antibiotic use at the time of occurrence indicates a lapse in adherence to this policy.
Failure to Clarify Ambiguous Medication Orders for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate medication orders and clarify ambiguous orders with the physician for a resident, identified as R16, who was admitted with diagnoses including diabetes, kidney disease, and dementia. The resident was cognitively intact according to the Minimum Data Set assessment. A Consultant Pharmacist's Medication Regimen Review recommended clarifying an order for Insulin Lispro, which was not present in the electronic medical record, but the order was marked as completed without proper clarification. The physician's order dated 10/16/24 was incomplete, lacking a specified medication, yet nursing staff documented administration of 7 units subcutaneously with meals. Interviews with the assigned nurse, RN J, and the Director of Nursing (DON) revealed that the nursing staff assumed the medication to be Insulin Lispro and administered it without proper clarification from the physician. The DON acknowledged the error in the order entry and the failure to clarify the order for two months. The facility's job descriptions for Charge Nurses emphasized the importance of administering medications as prescribed by the physician and clarifying any unclear orders, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident with PTSD and Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R17, who was observed with severe cognitive impairment and a history of post-traumatic stress disorder (PTSD), bipolar disorder, traumatic brain injury, and dementia. The resident was seen exhibiting nonsensical speech and wandering behaviors, yet the care plan did not address specific targeted behaviors related to the use of psychotropic medication or identify potential PTSD triggers. Despite the resident's complex medical history and behavioral issues, the care plan only included a reference to PTSD in a nutrition care plan, lacking a thorough assessment and implementation of trauma-informed care. Observations and interviews revealed that the nursing staff and social worker were unaware of any PTSD triggers for the resident, and there was no trauma-informed care assessment conducted. The facility's policy on trauma-informed care emphasizes the importance of recognizing trauma symptoms and identifying triggers, yet this was not reflected in the care plan for R17. Additionally, the facility's policy on psychotropic medication use requires a holistic approach to behavior management, which was not evident in the care provided to the resident. Consultations with psychological services highlighted the resident's significant behavioral and emotional disturbances, including aggression and impulsivity, which were not addressed in the care plan. Recommendations from these consultations, such as providing a low-stimulation environment and promoting non-pharmaceutical interventions, were not implemented. The facility's failure to incorporate these recommendations and adequately assess the resident's needs resulted in a deficiency in care planning for R17.
Resident Elopes Due to Inadequate Supervision and Elopement Policy Implementation
Penalty
Summary
The facility failed to provide adequate supervision and implement elopement policies for a cognitively impaired resident, resulting in the resident leaving the facility unsupervised. The resident, who believed they were in danger, managed to exit through a secured back door by entering the passcode and walked approximately two miles away from the facility. The resident was found by the police and taken to a local hospital for evaluation. The incident was reported by the facility, and an interview with the resident confirmed that they left the facility due to feeling threatened. The resident approached a house and requested the occupants to call the police, who then transported the resident to the hospital. The facility administrator acknowledged the resident's tendency to feel threatened and explained that the resident had learned the door code, which allowed them to exit the facility. The administrator also noted that the police notified the facility of the resident's location and subsequent transport to the hospital.
Inadequate Urostomy Care and Monitoring
Penalty
Summary
The facility failed to ensure proper urostomy care and monitoring for a resident who required such services. The resident was observed with a urostomy bag that was not properly managed, as evidenced by small brown and wet spots on their bed sheets. The resident reported that staff assistance with emptying the urostomy bag was inconsistent, and they were unsure about the frequency of bag changes and site assessments for infection. The resident's medical record indicated a need for setup and cleanup assistance with toileting hygiene, and their care plan acknowledged the presence of a urostomy due to renal insufficiency. However, there were no physician orders in place to guide staff on the necessary care and monitoring of the urostomy site. The Director of Nursing and a nurse confirmed the absence of physician orders for the resident's urostomy care, which should have been documented in the medical record. The nurse acknowledged the need for such orders to document site assessments and care completion. Despite the care plan noting the resident's urostomy, the lack of specific physician orders led to inadequate documentation and monitoring. Additionally, the facility was unable to provide a policy or procedure on ostomy care when requested during the survey, further highlighting the deficiency in ensuring proper care for the resident's urostomy needs.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), resulting in the potential for exposure to trauma triggers and re-traumatization. The resident, who had a history of both witnessing and experiencing abuse, was admitted with severe cognitive impairment and a diagnosis of chronic PTSD. Despite these conditions, the facility did not identify or implement interventions to mitigate potential PTSD triggers, as evidenced by the lack of documentation in the resident's clinical record and care plans. Interviews with facility staff revealed a lack of awareness and action regarding the resident's PTSD triggers. Nursing staff assigned to the resident were unaware of any PTSD triggers, and the social worker admitted that a trauma-informed care assessment had not been conducted. The social worker also failed to communicate with consulting psychiatric services to identify and implement recommended interventions for the resident's PTSD. The facility's policy on trauma-informed care emphasizes collaboration and the identification of trauma triggers to develop individualized care plans. However, the facility did not adhere to this policy, as the only mention of the resident's PTSD was on a nutrition care plan, and no specific details about potential trauma triggers were included. The administrator acknowledged these concerns, indicating a failure to thoroughly assess and address the resident's PTSD needs.
Controlled Substance Documentation Deficiency
Penalty
Summary
The facility failed to ensure accountability and accurate documentation of controlled substances for a resident, identified as R226, during their discharge process. R226, who had diagnoses including Parkinson's disease, dementia, and anxiety, was discharged to another nursing facility due to facility depopulation. The resident's clinical records indicated the use of controlled medications, specifically Xanax and Morphine Sulfate, which were not properly documented or accounted for from late June to early July, leading to concerns about potential medication diversion. Interviews and record reviews revealed that the facility did not maintain controlled substance proof-of-use records for R226's medications during the specified period. The Medication Administration Records (MARs) showed inconsistencies, with no documented administrations of Morphine Sulfate and incomplete records for Xanax. The Director of Nursing (DON) and the Administrator were unable to provide documentation or recall specifics about the medications at the time of discharge, and there was no policy provided for controlled substances management. Further investigation showed that the resident's son transported R226 to the new facility, and the medications were reportedly given to him, although the receiving facility did not document the arrival of any medications. The facility acknowledged past non-compliance regarding controlled substances but did not have documentation addressing the accountability of R226's medications. The lack of documentation and accountability for controlled substances was confirmed by the facility's administration and quality staff during the survey.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents prescribed psychotropic medications had adequate documentation to support their continued use, as well as to identify and monitor resident-specific targeted behaviors and implement non-pharmacological approaches. For Resident R126, the medical record review revealed that there were no non-pharmacological interventions attempted prior to the administration of PRN alprazolam, and there was no system in place for monitoring adverse side effects or targeted behaviors that the medications were treating. Social Worker A confirmed the absence of non-pharmacological interventions and targeted behaviors for R126. For Resident R17, the facility did not complete a thorough behavior management assessment. The Behavior Management Program Review and Symptom Analysis were incomplete, lacking details on behavior assessment, interventions, and mood symptoms. The facility also failed to document any attempts at Gradual Dose Reduction (GDR) for the resident's use of Seroquel. Despite recommendations from consulting psych services to provide a quieter environment and other non-pharmaceutical methods, these were not identified or implemented by the facility. Interviews with Social Worker A and the MDS Nurse revealed gaps in the process of completing social service assessments and behavior management reviews. Social Worker A acknowledged the lack of documentation and the failure to identify resident-specific behaviors and potential trauma triggers. The MDS Nurse confirmed inaccuracies in the MDS section related to GDR information. The facility's policy on psychotropic medication use emphasizes the need for a holistic approach to behavior management, which was not adhered to in these cases.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective Antibiotic Stewardship program, as evidenced by the inconsistent implementation of protocols for appropriate antibiotic administration. This deficiency was observed in the cases of two residents who were prescribed and administered antibiotics without meeting the necessary infection criteria. One resident was documented as having a urinary tract infection (UTI) in May 2024, but no organism was identified, and a culture and sensitivity (C&S) test was not performed prior to the start of antibiotic treatment. Despite a lab report indicating no bacteria were detected in the resident's urine, the resident was administered Bactrim DS for five days. Another resident was documented as having a UTI in December 2024, but similarly, no organism was identified, and a C&S test was not obtained before starting antibiotics. The resident initially refused to provide a urine sample, preferring to go smoke, and the facility did not attempt to collect the sample at a more convenient time. The resident was started on Cipro for five days without the necessary testing. Additionally, the facility failed to provide an Antibiotic Stewardship Policy when requested during the survey, indicating a lack of established protocols for antibiotic use.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,179 citations issued within 25 miles in the last 12 months — including the 5 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 Beverly Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfield Rehab And Nursing Center | 1.1 mi | ★★★★★ | 4 | 0 |
| Evergreen Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 18 | 0 |
| Medilodge Of Southfield | 2.4 mi | ★★★★★ | 25 | 1 |
| Lahser Hills Care Centre | 2.8 mi | ★★★★★ | 0 | 0 |
| Regency At Troy | 3 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.