Grand Valley Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 13524 Sherman Way, Van Nuys, California 91405
- CMS Provider Number
- 056363
- Inspections on file
- 68
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Grand Valley Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, extensive ADL dependence, multiple comorbidities, and a history of repeated falls experienced two documented falls, including an unwitnessed fall with a head laceration. Fall Risk Evaluations completed by the DON after each fall failed to accurately record the recent fall history and left key gait and balance items (such as decreased muscular coordination, change in gait pattern, and gait problems) unmarked, even while scoring balance problems and use of assistive devices. These actions did not align with the facility’s fall risk policy, which required comprehensive fall risk assessments after each fall to guide individualized care planning.
Licensed nurses completed dehydration risk assessments for a resident with severe cognitive impairment and multiple diagnoses, including dehydration, stroke, CKD, DM, and dementia, using unverified and incomplete information. On admission, an RN scored the resident’s oral intake as 75–50% and moderate risk based only on one observed meal, without reviewing hospital records or obtaining history from the resident or family. On readmission, another RN documented oral intake as 100–75% and low risk without confirming actual intake, without hospital record review, and with no reliable input from family or the resident, despite an active dehydration diagnosis, resulting in inaccurate hydration risk assessments contrary to facility policies.
A resident with multiple medical conditions and intact decision-making capacity requested that a specific CNA not provide care or be present in her room. Despite this request being acknowledged by facility staff, the CNA was initially assigned to the room and later entered the room to interact with the resident, causing discomfort and anxiety. This action was contrary to the facility's policy on resident dignity and privacy.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to transfer/discharge planning.
A resident with paraplegia, morbid obesity, and diabetes was found to have a low air loss mattress set for a much higher weight than their actual weight, contrary to physician orders and facility policy. Both an LVN and the DON confirmed the mattress setting was incorrect, which was identified during observation and record review.
A resident with multiple complex medical conditions received Oxycodone Hydrochloride, a controlled substance, which was signed out and administered by two LVNs but not documented on the MAR as required. The DON confirmed that facility policy mandates immediate documentation of medication administration on the MAR and that the MAR should match the Controlled Drug Record. This failure to document the administration of a narcotic medication resulted in a deficiency.
Two residents were not provided necessary assistance with mobility and getting out of bed, despite being dependent or requiring moderate help for these activities. One resident remained in bed throughout the day, with the assigned CNA admitting to forgetting to offer assistance, while another reported that only the physical therapist, not nursing staff, helped her get out of bed. Facility policy required staff to assist with ADLs, but this was not followed, resulting in prolonged bed rest for both residents.
A resident who was fully dependent on staff for activities of daily living did not receive required oral care, resulting in dry, cracked lips and an unclean tongue with a thick coating. The CNA assigned to the resident did not provide oral care, failed to promptly report the resident's oral condition to nursing staff, and only disclosed the issue after being questioned by a surveyor. Facility staff confirmed that oral care was not provided as required and that the resident's condition was not reported in a timely manner.
The facility did not complete required 72-hour follow-up assessments for two residents with bowel and bladder incontinence issues, resulting in missed opportunities to evaluate their candidacy for retraining programs and to implement appropriate care interventions, as required by facility policy.
Two residents were not informed in advance about the deep cleaning of their rooms, violating their rights to a dignified existence and self-determination. Both residents were informed on the day of cleaning, causing inconvenience and lack of preparation time. The facility's housekeeping schedule was not communicated to nursing staff or residents in advance.
A resident was physically assaulted by another resident, resulting in injuries requiring treatment. The incident occurred while the resident was sleeping, and the aggressor, who had severely impaired cognition and auditory hallucinations, punched the victim multiple times. The facility failed to prevent this altercation, leading to a deficiency in protecting residents from abuse.
A resident with a left hip fracture and dementia did not receive proper follow-up care for their surgical wound. The facility failed to obtain a physician's order to continue monitoring the wound after the initial 14-day period, and licensed nurses stopped documenting the wound's condition. The Treatment Nurse admitted to monitoring the wound without documentation, which is considered as not having been done. The facility's policy requires documentation of wound care, but this was not followed, resulting in a deficiency.
A resident with glaucoma did not receive their prescribed Latanoprost eye drops on the day of admission, yet the MAR inaccurately documented the administration. The LVN admitted to the error, and the DON highlighted the need for accurate documentation and physician notification when medications are unavailable.
The facility failed to ensure proper infection control practices, as a nurse did not perform hand hygiene after checking a resident's blood pressure, and another nurse did not perform hand hygiene between glove changes during wound treatment. Both incidents involved residents requiring assistance with daily activities, and the staff acknowledged the oversight, which was confirmed by the Infection Control Preventionist.
The facility failed to set low air loss mattresses (LALM) correctly for three residents, as per physician orders and guidelines. One resident's LALM was set to 210 lbs instead of their weight of 140 lbs, another's was set to firm despite weighing 132 lbs, and a third's was set to 280 lbs instead of 133 lbs. This non-compliance with LALM settings increased the risk of skin breakdown and pressure ulcers.
The facility failed to label leftover food brought by families with resident identifiers and use-by dates, as observed in three residents' cases. Various food containers in the residents' refrigerator were found without proper labeling, which the Dietary Manager confirmed should be done to prevent foodborne illness. The facility's policy requires perishable food to be labeled and disposed of within two days.
The facility failed to ensure proper infection control practices, including a nurse not wearing a gown while administering medications to a resident on enhanced barrier precautions, a CNA not performing hand hygiene after handling a dirty towel before assisting a resident with lunch, and unlabeled urinals in a resident's room, all of which could increase infection risk.
The facility failed to ensure accessible call lights for two residents, leading to potential delays in care. One resident's call light was out of reach, while another required an adaptive call light due to upper extremity impairments. Both situations were confirmed by staff, highlighting a breach in the facility's call light policy.
A facility failed to inform a resident of their right to formulate an advance directive, as required by the Patient Self-Determination Act of 1990. The resident, who was capable of making and understanding decisions, did not have a signed form acknowledging receipt of this information. This oversight violated the resident's rights and could lead to conflicts with their healthcare wishes.
A resident with severe cognitive impairment and multiple health conditions was found in a room with a temperature of 68°F, below the facility's policy of 70-75°F. The resident expressed feeling cold, and an open window was identified as the cause. The facility's policy requires maintaining a comfortable temperature range for residents.
The facility failed to create person-centered care plans for two residents, one with range of motion limitations and another with bowel and bladder incontinence. Despite documented needs, no care plans were developed, leading to potential gaps in care. The facility's policy on comprehensive care planning was not followed, resulting in deficiencies in addressing the residents' specific needs.
A facility failed to involve a cognitively intact resident in IDT Care Conferences, depriving them of the right to participate in their care plan development. Additionally, the facility did not update another resident's care plan after symptoms of a burning sensation during urination resolved, potentially leading to inappropriate care. These actions were contrary to the facility's policies, resulting in deficiencies in care planning.
A facility failed to assess and provide appropriate equipment for a resident with limited ROM upon readmission. The resident, with conditions like osteomyelitis and diabetic neuropathy, was unable to use the standard call light due to impairments in both upper extremities. The initial nursing assessment and Occupational Therapy Evaluation missed these limitations, leading to the resident's inability to call for assistance, potentially delaying care.
A facility failed to conduct a timely fall risk evaluation for a resident with a history of falls and severely impaired cognition, potentially impacting their care plan. Additionally, an LVN left medications unattended at a resident's bedside, risking unauthorized access. These actions violated the facility's policies on fall risk prevention and medication administration.
An LVN failed to provide adequate respiratory care to a resident by not administering oxygen as ordered, not covering the suction catheter, and not labeling the suction tubing. The resident, with serious health conditions, was found with an oxygen saturation below the prescribed level due to these oversights.
A resident was inappropriately administered hydrocodone-acetaminophen (Norco) despite having a pain level of zero, contrary to the physician's orders which specified its use for severe pain. This occurred on two occasions, as confirmed by a nurse during a review of the Medication Administration Record (MAR). The nurse acknowledged the potential adverse consequences of unnecessary medication use.
A facility failed to complete a post-dialysis assessment for a resident with end-stage renal disease, missing vital signs and access site evaluation. The oversight was confirmed by an LVN and the ADON, who stated that licensed nurses are responsible for these assessments. The facility's policy requires documentation of vital signs, access site condition, and additional instructions, which was not followed, placing the resident at risk for complications.
The facility did not meet the federal regulation of providing at least 80 square feet per resident in multiple resident bedrooms, affecting four rooms. Despite this, residents did not express concerns, and observations showed adequate space for movement and care.
A facility failed to implement its policy for an allegation of financial abuse involving a resident with Alzheimer's Disease. The Business Office Manager reported the abuse, but the Administrator did not conduct a formal investigation or document findings. The Director of Nursing was not informed, resulting in no SBAR form completion or monitoring for emotional distress. This failure placed the resident at risk for further abuse.
A facility failed to report the results of a financial abuse investigation involving a resident with Alzheimer's and hydrocephalus. The resident's son, who was the financial POA, used the resident's Social Security checks for personal expenses instead of medical costs. The BOM reported the abuse, but the ADM did not conduct a formal investigation or document findings, violating the facility's abuse reporting policy.
A facility failed to create a care plan for a resident with hydrocephalus and Alzheimer's Disease involved in a financial abuse allegation. Despite the resident's impaired cognition and a significant billing balance, no care plan was developed. The DON was unaware of the abuse report and stated that a care plan would have been created if informed. The facility's policies on care planning and abuse reporting were not followed.
A resident with osteomyelitis and diabetes, requiring assistance with hygiene and mobility, was verbally abused by a CNA after requesting coffee. The CNA responded condescendingly, leading to a heated argument where both exchanged obscene language. An LVN witnessed the incident and reported it, with the facility's administration acknowledging the CNA's behavior as verbal abuse.
A resident with hypothyroidism did not receive Levothyroxine for a month due to the primary care physician's failure to review the medication list upon admission. This oversight led to the resident developing myxedema coma, requiring ICU admission. Interviews confirmed the physician did not adhere to facility policy requiring medication review.
Inaccurate Fall Risk Assessments Following Multiple Falls
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure accurate fall risk assessments and evaluations for a resident with significant medical and functional impairments. The resident was originally admitted with multiple diagnoses, including metabolic encephalopathy, dehydration, diabetes mellitus, anemia, dementia, hemiplegia and hemiparesis following a stroke, chronic kidney disease, and a history of repeated falls. An MDS dated 3/24/2026 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for toileting hygiene, showering/bathing, and lower body dressing, and required maximal assistance for eating, hygiene, dressing, bed mobility, and transfers. On 4/6/2026, an SBAR form documented that the resident had an unwitnessed fall in the room, sustained a laceration to the back right side of the head, and was transferred to the hospital. A Fall Risk Evaluation completed on the same date instructed staff to evaluate eight clinical condition parameters, including history of falls and gait/balance, and to consider a total score of 10 or greater as high risk requiring immediate prevention protocols and care plan documentation. However, in the history of falls section for the past three months, the evaluation indicated that the resident had no falls, despite the SBAR documenting a fall on that date. In the gait and balance section, the evaluation did not indicate decreased muscular coordination, changes in gait pattern, or gait problems, although it was scored for balance problems while standing, balance problems while walking, and use of assistive devices. On 4/9/2026, another SBAR documented an additional fall, and nursing progress notes indicated the resident was found lying on the left lateral side next to the bed. A Fall Risk Evaluation dated 4/9/2026 again left the items for decreased muscular coordination, change in gait pattern, and gait problems unmarked, while still scoring balance problems and use of assistive devices. During interview and record review, the DON acknowledged completing the Fall Risk Evaluations after the falls occurred, confirmed that the 4/6/2026 fall was not reflected in the history of falls section, and stated that gait and balance items were left blank on 4/6/2026 because the resident had been transferred to the hospital and could not be personally assessed. The DON further stated that for the 4/9/2026 evaluation, information from rehabilitation therapy staff indicated no issues with decreased muscular coordination, change in gait pattern, or gait problems, so those items were left blank. Facility policy required completion of a Fall Risk Assessment upon admission, quarterly, and after each fall, with review by the interdisciplinary team and recommendations for additional approaches to prevent further falls.
Inaccurate Dehydration Risk Assessments for High-Risk Resident
Penalty
Summary
Licensed nurses failed to accurately assess and complete dehydration risk assessments for a resident with multiple complex medical conditions. The resident had diagnoses including metabolic encephalopathy, dehydration, DM, anemia, dementia, hemiplegia/hemiparesis following stroke, chronic kidney disease, and repeated falls, and was documented on the MDS as having severely impaired cognition and requiring extensive to total assistance with ADLs, including eating. On an admission dehydration risk assessment, the nurse marked the oral intake section as 75% to 50% and recorded a total score of 6, indicating moderate dehydration risk. During interview, the RN who completed this assessment stated that the intake percentage was based solely on observation of one meal on the day of admission, without obtaining additional information from hospital records, the resident, or family, and acknowledged that this did not represent the resident’s usual intake and was therefore not accurate. On a subsequent dehydration risk assessment completed at readmission, the oral intake section was marked as 100% to 75%, with a total score of 2, indicating low dehydration risk, despite the resident carrying a diagnosis of dehydration at that time. The RN who completed this assessment stated that the intake range was documented without verification of the resident’s actual intake, that hospital records were not reviewed, family could not provide intake details, and the resident was unable to report intake amounts, so the accuracy of the documented oral intake could not be confirmed. Facility policies on Dehydration Risk Assessment and Hydration Management required that residents be assessed on admission, within the assessment period, and at least quarterly, and that residents identified with potential or actual dehydration be assessed for risk factors with appropriate recommendations documented on the care plan, but the assessments for this resident were not based on accurate or complete information.
Failure to Honor Resident's Request Regarding Caregiver Assignment
Penalty
Summary
The facility failed to honor a resident's explicit request to not have a specific Certified Nursing Assistant (CNA) provide care or be present in her room upon readmission. The resident, who had diagnoses including a left femur fracture, osteoporosis, rheumatoid arthritis, morbid obesity, and generalized anxiety disorder, had intact cognition and decision-making capacity. Upon readmission, the resident communicated her request to the case manager, who acknowledged it and assured her that the CNA would not be assigned to her care or be present. Despite this, the CNA was initially assigned to the resident's room and, after being informed of the restriction, was reassigned to the roommate but still entered the room and interacted with the resident, including responding to a call light and providing ice water. Interviews with facility staff, including the Assistant Director of Staff Development (ADSD), the case manager, and the Director of Nursing (DON), confirmed that the resident's request was known and that the CNA should not have entered the room or interacted with the resident. The facility's policy on dignity and privacy requires that residents be treated with respect and that their rights and preferences be honored. The DON acknowledged that the CNA's presence in the room had the potential to cause the resident increased anxiety, fear, and discomfort, which was contrary to the facility's stated policy and the resident's expressed wishes.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Incorrect Low Air Loss Mattress Setting for Resident
Penalty
Summary
A resident with multiple medical conditions, including paraplegia, morbid obesity, type 2 diabetes, and a history of poor wound healing, was admitted to the facility and required a low air loss mattress for skin management as per physician orders. Upon review, it was found that the mattress was set for a weight range of 600 to 1000 pounds, while the resident's actual weight was 246 pounds. This incorrect setting was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the mattress should have been set according to the resident's current weight. The facility's policy on the prevention of pressure injuries specifies the use of specialized mattresses as an intervention to prevent skin breakdown. However, the failure to set the mattress correctly for the resident's weight constituted a lapse in following this policy. The deficiency was identified through observation, interview, and record review, and it was confirmed that the mattress setting was not appropriate for the resident's needs at the time of the survey.
Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain accurate clinical records for one resident by not properly documenting the administration of Oxycodone Hydrochloride on the Medication Administration Record (MAR). Specifically, the Controlled Drug Record showed that Oxycodone was signed out and administered by two different Licensed Vocational Nurses on two occasions, but these administrations were not recorded on the MAR. The Director of Nursing confirmed that medication administration should be documented on the MAR immediately after the medication is given and that the MAR entries should align with the Controlled Drug Record. The resident involved had multiple diagnoses, including a right femur fracture, type 2 diabetes, end stage renal disease, and muscle weakness, and was assessed as having intact cognition and decision-making capacity. Facility policy required that all administered medications be documented on the MAR by the person administering them, and that the MAR be reviewed at the end of each medication pass to ensure accuracy. The failure to document the administration of a controlled substance as required by policy and professional standards constituted the deficiency.
Failure to Assist Residents with Mobility and Getting Out of Bed
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically mobility and getting out of bed, for two residents. One resident, who had diagnoses including traumatic subdural hemorrhage, pneumonia, and epilepsy, was assessed as cognitively moderately impaired and fully dependent on staff for mobility and other ADLs. Observations throughout the day showed this resident remained in bed with the call light within reach, and the gastrostomy tube feeding was alternately on and off. The assigned CNA admitted not offering to get the resident out of bed, citing forgetfulness and the presence of a g-tube, despite acknowledging the importance of mobility for preventing bed sores and maintaining function. The Director of Staff Development confirmed that getting residents out of bed is part of morning care and does not require a physician's order, but stated the facility preferred to keep the resident in bed during feeding times. Another resident, with diagnoses including pneumonia, COPD, and low back pain, was cognitively intact and required partial or moderate assistance for mobility. Observations showed this resident remained in bed throughout the morning and early afternoon, with staff assisting only with lunch. The resident reported that only the physical therapist, not nursing staff, assisted her with getting out of bed, and that nursing staff had not offered to help her transfer to a chair. The Director of Staff Development stated that CNAs are expected to offer and assist all residents with getting out of bed and to report refusals to the charge nurse, emphasizing that this is a standard part of daily responsibilities. A review of facility policies confirmed that staff are required to monitor, assist with, and provide ADLs, including transferring from bed to chair, to ensure residents attain or maintain their highest practicable well-being. Despite these policies, the facility did not ensure that the two residents were offered or provided necessary assistance with mobility and getting out of bed, resulting in prolonged periods spent in bed and potential compromise of dignity, preferences, and functional well-being.
Failure to Provide Oral Care and Timely Reporting for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident who was dependent on staff for all activities of daily living, including oral hygiene. The resident had a history of traumatic subdural hemorrhage, pneumonia, and epilepsy, and was assessed as having moderately impaired cognition and being fully dependent on staff for personal care. The resident's care plan specifically required staff to assist with personal hygiene and provide oral care. On the day in question, the resident was observed in bed with dry, cracked lips. A CNA assigned to the resident that day initially stated that oral care had been provided, but upon further questioning, admitted that oral care was not given. The CNA described the resident's tongue as unclean, with a thick white and yellow coating, and stated that this condition had persisted for a long time. The CNA also admitted to not reporting the condition to the nurse until prompted by the surveyor and did not provide oral care because the resident began to scream. Interviews with facility staff, including the LVN, Assistant Director of Nursing, and Director of Staff Development, confirmed that oral care was not provided as required and that the condition of the resident's tongue was not reported in a timely manner. Review of facility policies indicated that oral care should be provided at least once per shift and that staff are responsible for monitoring and assisting with activities of daily living, including mouth care, and reporting any changes in resident condition.
Failure to Timely Reassess Bowel and Bladder Function for Two Residents
Penalty
Summary
The facility failed to implement an effective bowel and bladder retraining program for two residents by not ensuring timely reassessment of their bowel and bladder status. For one resident, the initial bowel and bladder assessment indicated functional incontinence and occasional episodes of both bladder and bowel incontinence. The facility's protocol required a follow-up evaluation 72 hours after admission, but this evaluation was not completed until ten days later. The delay was acknowledged by the registered nurse, who confirmed that the late assessment prevented the facility from providing appropriate interventions based on the resident's needs. For another resident, the admission record showed a history of traumatic subdural hemorrhage, pneumonia, and epilepsy, with the resident being dependent on staff for most activities of daily living. The initial bowel and bladder assessment indicated the resident was always continent of bladder but always incontinent of bowel. However, the required 72-hour follow-up evaluation was left blank and not completed. The registered nurse confirmed that the assessment was missing and emphasized the importance of timely completion to ensure proper care planning and interventions. The facility's policy on bowel and bladder retraining, last reviewed in August 2024, specifies that the purpose of the program is to assist incontinent residents in regaining control over excretory functions. The failure to complete timely reassessments as outlined in the policy resulted in missed opportunities to accurately assess residents as candidates for retraining programs and to implement appropriate care interventions.
Failure to Inform Residents of Room Cleaning Schedule
Penalty
Summary
The facility failed to inform two residents, Resident 2 and Resident 3, in advance about the deep cleaning of their rooms, which is a violation of their rights to a dignified existence and self-determination. Resident 2, who was admitted with right knee and ankle fractures and hypothyroidism, was informed on the morning of the cleaning and was not given details about the duration or reason for the cleaning. Resident 2 expressed a desire to be informed at least one or two days in advance to prepare for the inconvenience. Similarly, Resident 3, who was admitted with Guillain-Barre syndrome, was also informed on the day of the cleaning and was not given adequate time to arrange personal belongings. Resident 3 expressed a preference for being informed three days in advance. Both residents were left waiting outside their rooms without clear communication about when they could return. The facility's housekeeping department had a monthly cleaning schedule, but it was not communicated to the nursing staff or residents in advance. The Director of Nursing acknowledged the need for a better system to inform residents about cleaning schedules. The facility's policy on resident rights emphasizes the importance of providing residents with information material to their decisions, which was not adhered to in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. On January 8, 2025, Resident 2 physically assaulted Resident 1 by punching him in the face multiple times. This incident occurred while Resident 1 was trying to sleep, leading to injuries including a left periorbital discoloration, an abrasion on the left eyebrow, and skin tears on the left forearm and dorsal hand. These injuries required first aid and daily wound treatments. Resident 1 was admitted to the facility on December 5, 2024, with diagnoses including cauda equina syndrome, osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb. The Minimum Data Set (MDS) indicated that Resident 1 had intact cognition. In contrast, Resident 2, admitted on December 12, 2024, had diagnoses including chronic obstructive pulmonary disease, unspecified dementia, opioid dependence, and nicotine dependence, with the MDS indicating severely impaired cognition. On the day of the incident, Resident 2 reported hearing voices instructing him to punch his roommate, Resident 1, and was noted to be agitated and experiencing auditory hallucinations. The facility's policy on abuse reporting and prevention mandates the protection of residents' rights and the prevention of resident-to-resident altercations. However, the facility failed to prevent the altercation between Resident 1 and Resident 2, resulting in physical abuse. The incident was confirmed through interviews with staff and residents, and the facility's investigative report corroborated the occurrence of the physical assault. Despite the facility's policy, the actions and inactions leading to this deficiency highlight a failure to adequately protect Resident 1 from harm.
Failure to Monitor and Document Surgical Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following up with the physician to obtain an order to continue monitoring the resident's surgical wound. The resident, who was admitted with a left hip fracture and dementia, had an order to monitor the surgical wound for signs of infection for 14 days. However, after the 14-day period, the licensed nurses stopped documenting the monitoring of the wound, and no follow-up order was obtained from the physician. During an interview, the Treatment Nurse admitted to monitoring the wound but not documenting it, which is considered as not having been done according to the Assistant Director of Nursing. The resident's surgical wound was partially covered with a non-removable dressing and had visible staples, which were not observed the previous day. The facility's policy requires documentation of wound care, but this was not adhered to, leading to a deficiency in the care provided to the resident.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of a physician-ordered eye drop medication in the Medication Administration Record (MAR) for a resident diagnosed with glaucoma. The resident was admitted with a physician's order to receive Latanoprost eye drops at bedtime. However, the MAR inaccurately indicated that the medication was administered on the day of admission, despite the medication not being delivered to the facility until the following day. This discrepancy was confirmed during interviews with the resident, the Assistant Director of Nursing (ADON), and the Licensed Vocational Nurse (LVN) responsible for the documentation. The resident, who had intact cognitive skills and required varying levels of assistance with daily activities, reported not receiving the eye drops on the evening of admission. The LVN admitted to incorrectly documenting the administration of the medication in the MAR, acknowledging the importance of accurate documentation to ensure continuity of care. The Director of Nursing (DON) stated that the licensed nurses should have notified the physician about the unavailability of the medication and documented the situation accurately in the MAR. The facility's policy on medication administration emphasizes the need for accurate documentation and appropriate actions when medications are not administered as scheduled.
Infection Control Lapses in Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by two separate incidents involving staff members. In the first incident, a Licensed Vocational Nurse (LVN) did not perform hand hygiene after checking a resident's blood pressure with bare hands. The resident, who was admitted with diagnoses including glaucoma, required various levels of assistance for daily activities. The LVN admitted to forgetting to wear gloves and perform hand hygiene, acknowledging the risk of cross-contamination. In the second incident, a Treatment Nurse (TN) failed to perform hand hygiene between glove changes while providing wound treatment to another resident. This resident, who had been readmitted with lymphedema, required maximum assistance with dressing and transfer. The TN initially performed hand hygiene and wore gloves but neglected to do so between glove changes during the treatment process. The Infection Control Preventionist confirmed that hand hygiene should be performed before and after wearing gloves and between glove changes to prevent cross-contamination. The facility's policy on infection control and hand hygiene supports these practices.
Incorrect LALM Settings for Residents
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALM) for three residents were set at the correct settings, as per physician orders and the LALM operator's manual. Resident 88, who was admitted with multiple fractures and diabetes, had a care plan indicating high risk for skin breakdown and required a LALM set to their weight of approximately 140 lbs. However, during an observation, the LALM was set to 210 lbs, which was not in accordance with the physician's order or the manual's guidelines. Similarly, Resident 11, admitted with a fracture and requiring maximal assistance for activities of daily living, had a physician's order for a LALM for wound management. Despite weighing 132 lbs, the LALM was observed to be set to firm, or greater than 350 lbs. This setting was inconsistent with the facility's practice of setting the LALM according to the resident's weight to prevent wound development. Resident 196, admitted with osteomyelitis and stage III pressure ulcers, also had a physician's order for a LALM. The mattress was observed to be set at 280 lbs, while the resident's weight was 133 lbs. The Assistant Director of Nursing confirmed that the LALM should be set according to the resident's weight to effectively manage and prevent wounds. The facility's policy and procedure for wound care emphasized the importance of following guidelines to promote healing, which was not adhered to in these cases.
Improper Labeling of Leftover Food Brought by Families
Penalty
Summary
The facility failed to ensure that leftover food brought in by residents' families and visitors was properly labeled with a resident identifier and use-by date. This deficiency was observed in the cases of three residents. During a kitchen observation, various food containers were found in the residents' refrigerator without proper labeling. A red container belonging to one resident had no use-by date, an orange container with food items had no resident name or use-by date, a plastic container belonging to another resident had no use-by date, and a clear plastic container belonging to a third resident also lacked a use-by date. The Dietary Manager confirmed that leftover food from outside should be labeled with a resident identifier and dated to ensure it is discarded by the use-by date. The facility's policy on food brought from outside sources requires that perishable food be stored properly and labeled with the date opened, to be disposed of within two days. The failure to adhere to these procedures had the potential to result in foodborne illness for the residents.
Infection Control Deficiencies in PPE Use, Hand Hygiene, and Labeling
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) donned a gown before administering medications via a gastrostomy tube to a resident on enhanced barrier precautions (EBP). The resident, who was admitted with diagnoses including encephalopathy and gastrostomy status, had severely impaired cognition and required maximal assistance for most activities of daily living. During an observation, the LVN was seen administering medications without wearing a gown, which was confirmed by the LVN in an interview. The Infection Preventionist (IP) stated that proper personal protective equipment (PPE) is necessary to prevent the spread of infection, especially for residents with indwelling medical devices. The facility also failed to ensure that a Certified Nursing Assistant (CNA) performed hand hygiene after picking up a dirty towel from the floor and before assisting a resident with lunch. The resident had intact cognition and required moderate assistance for most activities of daily living. During an observation, the CNA was seen picking up a dirty towel and then assisting the resident with their lunch tray without performing hand hygiene. The CNA confirmed this lapse in an interview, and the IP emphasized the importance of hand hygiene to prevent infection spread. Additionally, the facility did not label a urinal with a resident's name, which is required to prevent cross-contamination. The resident, who had severely impaired cognition and was dependent on assistance for personal care, was observed with unlabeled urinals in their room. The Restorative Nurse Assistant (RNA) and the Assistant Director of Nursing (ADON) confirmed that urinals should be labeled according to facility policy to prevent infection spread.
Failure to Provide Accessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that Resident 16's call light was within reach while the resident was in bed. Resident 16, who was admitted with diagnoses including chronic obstructive pulmonary disease, dysphagia following cerebral infarction, and hypertension, required substantial assistance with activities of daily living. During an observation, it was noted that the call light was hanging behind the bed and out of reach, which the resident confirmed they were unaware of its location. Both a Certified Nursing Assistant and the Assistant Director of Nursing acknowledged that the call light should always be within reach to prevent delays in care. The facility also failed to provide an adaptive call light for Resident 28, who was readmitted with conditions such as osteomyelitis of the vertebra, type 2 diabetes mellitus with diabetic neuropathy, and congestive heart failure. Resident 28 had impairments in both upper extremities, making it impossible to use the standard push-button call light provided. During observations, it was confirmed by both the Treatment Nurse and a Registered Nurse that Resident 28 was unable to press the call light button due to contracted wrists and hands, necessitating an adaptive call light to prevent delays in care. The facility's policy on call lights, last reviewed in August 2024, mandates that call lights be accessible to residents in various locations, including in bed, and that residents should be able to demonstrate how to use them. The failure to adhere to this policy for both residents resulted in the potential for delayed care, as neither resident could effectively signal for assistance when needed.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to ensure that an advance directive was discussed and written information was provided to a resident, identified as Resident 6, or their responsible parties. This deficiency was identified during a review of Resident 6's admission records and Minimum Data Set (MDS), which indicated that the resident had the ability to make self-understood decisions and understand others. Despite this, the facility did not have a signed Patient Self-Determination Act of 1990 form for Resident 6, which is meant to inform residents of their right to formulate an advance directive. The Assistant Director of Nursing (ADON) confirmed that the absence of a signature on the form indicated that Resident 6 was not informed of their right to formulate an advance directive. This oversight violated the resident's right to be fully informed of their healthcare options and could potentially lead to conflicts with their healthcare wishes. The facility's policy, last reviewed in August 2024, mandates that all residents and their representatives be presented with written information about their rights to accept or refuse medical treatment and to formulate an advance directive upon admission.
Failure to Maintain Safe Room Temperature for Resident
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature level for a resident, identified as Resident 30, which had the potential to result in loss of body heat and risk of hypothermia. Resident 30 was initially admitted on February 22, 2024, and readmitted on August 30, 2024, with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity, degenerative disease of the nervous system, and repeated falls. The resident had severely impaired cognition and was dependent on assistance for daily activities. During an observation on November 4, 2024, Resident 30 was found in his room, covered with a blanket, and expressed feeling cold. The Maintenance Supervisor Assistant measured the room temperature at 68 degrees Fahrenheit, which was below the facility's policy range of 70-75 degrees Fahrenheit. The Maintenance Supervisor later identified an open window in the bathroom as the cause of the low temperature. Interviews with the Maintenance Supervisor and the Assistant Director of Nursing confirmed that the temperature should be maintained within the specified range to ensure resident comfort. The facility's policy, last reviewed on August 15, 2024, indicated that room temperatures should be maintained at a comfortable level for residents, generally between 70-75 degrees Fahrenheit.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. Resident 28, who was readmitted with multiple diagnoses including osteomyelitis, diabetes with neuropathy, and congestive heart failure, exhibited significant range of motion (ROM) limitations in the upper extremities. Despite being alert and oriented, Resident 28 was unable to move his arms without assistance and could not use the call light button, which was confirmed by both the resident and Treatment Nurse 1. The facility's records showed no care plan addressing these ROM limitations, as confirmed by Registered Nurse 1 and the Assistant Director of Nursing, indicating a failure to document and plan for the resident's needs. Similarly, the facility did not develop a care plan for Resident 50's bowel and bladder incontinence. Resident 50, who was readmitted with conditions such as gastroesophageal reflux disease and dysphagia, was frequently incontinent of bowel and bladder, requiring moderate assistance for daily activities. Despite these needs being documented in the Minimum Data Set, there was no corresponding care plan to address the incontinence, as confirmed by Registered Nurse 2. This lack of a care plan meant that the resident's care needs might not be adequately met, potentially leading to further complications. The facility's policy on comprehensive care planning, which mandates the development of a person-centered care plan with measurable objectives and timetables based on resident assessments, was not adhered to in these cases. The policy requires regular review and revision of care plans to reflect any changes in the resident's condition, but this was not done for Residents 28 and 50, resulting in a failure to provide necessary care and services.
Deficiencies in Resident Involvement and Care Plan Updates
Penalty
Summary
The facility failed to involve Resident 50 in two quarterly Interdisciplinary Team (IDT) Care Conferences, despite the resident having intact cognitive skills and no appointed representative. The care plan conferences were attended by representatives from various departments and a family member via telephone, but there was no documentation that the resident was invited or refused to attend. This omission deprived the resident of the right to participate in developing a resident-centered care plan, which is crucial for addressing the resident's needs effectively. Additionally, the facility did not revise the care plan for Resident 30 after the resident's symptoms of a burning sensation during urination resolved. The resident, who had severely impaired cognition and was dependent on assistance for daily activities, initially complained of pain during urination. A urinalysis and urine culture were conducted, revealing a significant bacterial presence. However, the resident's symptoms resolved within three days, and no new antibiotic orders were received. Despite this, the care plan was not updated to reflect the resolved symptoms, potentially leading to inappropriate care. The facility's policies and procedures emphasize the importance of involving residents and their representatives in care planning and ensuring care plans are based on comprehensive assessments. However, in these cases, the facility did not adhere to its policies, resulting in deficiencies in care planning for both residents. The lack of resident involvement and failure to update care plans as needed were identified as deficient practices during the survey.
Failure to Assess and Provide Equipment for Resident's Limited ROM
Penalty
Summary
The facility failed to comprehensively assess the limited mobility and range of motion (ROM) for Resident 28 upon readmission. Resident 28, who was readmitted with conditions including osteomyelitis of the vertebra, type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure, and abnormalities of gait and mobility, was not provided with the appropriate equipment to maintain their maximum practicable independence. The resident was observed to have impairments in both upper extremities, with the right wrist contracted and the left hand mostly closed, rendering them unable to use the standard call light provided by the facility. Interviews and record reviews revealed that the initial nursing assessment failed to note the resident's upper extremity ROM limitations. The Occupational Therapy Evaluation also missed the left hand's ROM limitations, despite the resident's inability to push a call button. The facility's policy on call lights, which requires accessibility and the ability for residents to demonstrate usage, was not adhered to, resulting in the resident's inability to call for assistance, potentially delaying care.
Deficiencies in Fall Risk Evaluation and Medication Administration
Penalty
Summary
The facility failed to ensure a fall risk evaluation was completed after a fall incident involving a resident. The resident, who had a history of repeated falls and severely impaired cognition, was found on the floor and sent to a hospital for evaluation. Despite the fall, the facility did not conduct a fall risk evaluation immediately after the incident, and the subsequent evaluation inaccurately reported no falls in the past three months. This oversight had the potential to negatively impact the resident's care plan and the delivery of necessary services. Additionally, the facility did not adhere to medication administration protocols, as observed with a licensed vocational nurse (LVN) who left prepared medications unattended at a resident's bedside. The resident, who had severely impaired cognition and required maximal assistance for daily activities, was left with medications within reach while the LVN retrieved a stethoscope. This practice posed a risk of unauthorized access to medications by other residents, potentially leading to adverse effects or allergic reactions. The facility's policies on fall risk prevention and medication administration were not followed, as evidenced by the lack of timely fall risk assessments and the improper handling of medications. These deficiencies highlight lapses in the facility's adherence to its own procedures, which are designed to ensure resident safety and proper care management.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to provide necessary respiratory care to a resident, identified as Resident 242, in accordance with professional standards and physician orders. The deficiencies included not covering the suction catheter with a sleeve when not in use, not administering oxygen as per the physician's order, and not labeling the suction tubing with the date it was last changed. These actions were observed during a review of Resident 242's records and an observation on November 4, 2024, where the resident was found without the prescribed continuous oxygen administration, and the suction equipment was improperly maintained. Resident 242 had been admitted with serious health conditions, including malignant neoplasm of the colon, acute systolic heart failure, acute respiratory failure, and pleural effusion. The resident's physician had ordered continuous oxygen administration at 2 liters per minute via nasal cannula to maintain oxygen saturation above 94%. However, during an observation, the resident's oxygen saturation was found to be at 93% due to the oxygen not being administered. Additionally, the suction catheter was improperly stored, and the tubing was not labeled, increasing the risk of respiratory infection. The facility's policies required adherence to physician orders and proper maintenance of medical equipment, which were not followed in this instance.
Inappropriate Administration of Pain Medication
Penalty
Summary
The facility failed to administer pain medication as prescribed by the physician for a resident, identified as Resident 6. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and muscle weakness. According to the physician's orders, the resident was prescribed hydrocodone-acetaminophen (Norco) to be administered orally every four hours as needed for severe pain, with a pain level of 7-10 on a numerical scale. However, a review of the Medication Administration Record (MAR) revealed that the resident was administered Norco on two occasions when their pain level was recorded as zero. During an interview and record review, Registered Nurse 2 confirmed that the medication was administered inappropriately on these occasions, as the resident's pain level did not warrant the use of Norco. The nurse acknowledged that administering the medication without the appropriate pain level could lead to unnecessary use and potential adverse consequences such as constipation, respiratory depression, and sedation, which could increase the risk of falls and injury. The facility's documentation on medication issues for older adults also highlighted the potential adverse effects of opioid analgesics like hydrocodone.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident who required dialysis services. The resident, admitted with end-stage renal disease and dependent on dialysis, had moderately impaired cognition and required substantial assistance with daily activities. On a specific date, the post-dialysis assessment was not completed, and there was no documentation of vital signs or assessment of the dialysis access site. This oversight was confirmed during a review with a Licensed Vocational Nurse, who acknowledged the missing documentation and stated that charge nurses are responsible for completing the assessment upon the resident's return to the facility. The Assistant Director of Nursing confirmed that licensed nurses are responsible for completing the post-dialysis assessment, which should include vital signs and signs of bleeding to ensure the resident's stability. The facility's policy on dialysis care, last reviewed in August 2024, requires the completion of a post-dialysis checklist, including documentation of vital signs, access site condition, skin condition, and any additional instructions from the dialysis unit. The failure to complete this assessment placed the resident at risk for complications associated with dialysis.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as observed in four of the 38 resident rooms (Rooms 1, 3, 9, and 11). Each of these rooms contained two beds, but the floor area per resident was below the federal regulation requirement. Specifically, Room 1 had 73 square feet per resident, Room 3 had 77.5 square feet, Room 9 had 71.5 square feet, and Room 11 had 75.5 square feet. The minimum required square footage for a two-bed room is 160 square feet, which these rooms did not meet. Despite the deficiency in room size, during a resident council meeting, no concerns were raised by the residents regarding the size of the rooms. Additionally, general observations conducted on two consecutive days indicated that residents had ample space to move freely within their rooms. There was sufficient space for residents' freedom of movement and for nursing staff to provide care, as well as adequate space for beds, side tables, and resident care equipment.
Failure to Investigate Financial Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for an allegation of financial abuse concerning a resident. The Business Office Manager (BOM) reported the financial abuse to the Social Security Administration (SSA) after discovering that the resident's son, who was the financial power of attorney, was using the resident's Social Security checks for personal expenses instead of paying the resident's share of cost for medical services. Despite this report, the Administrator (ADM) did not conduct a formal investigation or document the findings, as required by the facility's policy. The facility's policy mandates that the ADM, as the abuse coordinator, thoroughly investigate any alleged violations and report the results to the appropriate agencies within five working days. However, the ADM only engaged in informal conversations with the resident's son and did not document any investigation or conclusions. Additionally, the Director of Nursing (DON) was not informed of the financial abuse allegation, which resulted in the nursing department not completing an SBAR form or monitoring the resident for emotional distress or negative outcomes. The resident involved had moderately impaired cognition due to Alzheimer's Disease and hydrocephalus, making them vulnerable to financial abuse. The facility's failure to follow its abuse reporting and prevention policy, including conducting a thorough investigation and ensuring proper communication and monitoring, placed the resident at risk for further abuse and potential emotional distress.
Failure to Report Financial Abuse Investigation Results
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically financial abuse, in accordance with Section 1150B of the Act. This deficiency involved a resident who was diagnosed with hydrocephalus and Alzheimer's Disease, and had moderately impaired cognition. The resident's financial power of attorney, their son, was receiving the resident's Social Security checks but was not paying the resident's share of cost for medical expenses. Instead, he used the funds for his daughter's school expenses, which was identified as financial abuse by the Business Office Manager (BOM). The BOM reported the financial abuse allegation to the State Survey Agency (SSA) on behalf of the resident. However, the Administrator (ADM), who is the abuse coordinator, did not conduct a formal investigation or document the findings. Despite being aware of the facility's policy and the requirement to report the investigation results within five working days, the ADM only engaged in informal conversations with the resident's son and did not complete a conclusion letter. This lack of formal documentation and reporting constituted a failure to comply with the facility's abuse reporting policy.
Failure to Develop Care Plan for Financial Abuse Allegation
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident involved in an allegation of financial abuse. The resident, who had diagnoses including hydrocephalus and Alzheimer's Disease, was found to have a significant outstanding balance on their billing statement. Despite the resident's moderately impaired cognition and the presence of a financial power of attorney, no care plan was developed to address the financial abuse allegation. Interviews with the Medical Records Director and the Director of Staff Development confirmed the absence of a care plan related to the financial abuse. The Director of Nursing was unaware of the financial abuse report and stated that if informed, a care plan would have been developed, including interventions such as reporting to the physician and monitoring the resident for emotional distress. The facility's policy on comprehensive care planning requires the development of a care plan with measurable objectives and timeframes, which was not adhered to in this case. Additionally, the facility's abuse reporting policy mandates initiating a care plan in response to abuse allegations, which was not followed.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a verbal altercation between the CNA and a resident, who was admitted with osteomyelitis and type two diabetes mellitus with a foot ulcer. The resident, who was cognitively intact and required assistance with personal hygiene and mobility, requested a cup of coffee from the CNA. The CNA responded in a condescending manner, leading to an argument where both parties exchanged heated words. During the altercation, the resident and the CNA were heard yelling at each other, with the CNA using obscene language in response to the resident's provocation. A Licensed Vocational Nurse (LVN) witnessed the exchange and reported it to a Registered Nurse (RN). The facility's Administrator and Director of Nursing acknowledged the CNA's behavior as verbal abuse, although the Administrator noted it was not abusive. The facility's policy on abuse reporting and prevention defines verbal abuse as the use of derogatory language, which was violated in this incident.
Failure to Review Medication List Leads to Severe Health Decline
Penalty
Summary
The facility failed to ensure that the primary care physician (PMD 1) for a resident with a history of hypothyroidism reviewed the resident's progress notes and medication list upon admission. The resident was admitted to the facility with a diagnosis of hypothyroidism and had been taking Levothyroxine as a routine home medication. However, PMD 1 did not review the resident's home medication list and consequently did not prescribe Levothyroxine during the resident's stay at the facility. As a result of this oversight, the resident did not receive 30 doses of Levothyroxine over a period of one month. This led to the resident experiencing a severe health decline, culminating in a myxedema coma, a life-threatening condition associated with severe hypothyroidism. The resident was subsequently transferred to a hospital and admitted to the ICU for critical care. Interviews with PMD 1 and the Director of Nursing confirmed that the physician did not review the resident's medication list, which was a critical component of the resident's care plan. The facility's policy required physicians to review and sign off on all medications and treatments, but this was not adhered to in this case, resulting in significant harm to the resident.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
