Westlake Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 316 S Westlake Avenue, Los Angeles, California 90057
- CMS Provider Number
- 056242
- Inspections on file
- 26
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Westlake Convalescent Hospital during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, tracheostomy, ventilator dependence, impaired cognition, and total ADL dependence was found in a room where the privacy curtain strings were tangled and the ceiling had multiple brownish stains. During an observation with the DON and maintenance staff, it was confirmed that staff were expected to check rooms weekly and that curtains should not be tangled and ceilings should be free of stains. These conditions did not comply with the facility’s homelike environment policy, which requires a safe, clean environment with privacy curtains in good condition.
A resident with chronic respiratory failure, a tracheostomy, ventilator dependence, impaired cognition, and total dependence for ADLs was observed suspended in a Hoyer lift over the bed without staff present, despite a care plan identifying fall risk and the need for assistance with all transfers. An RN found the resident alone and summoned a CNA, who stated she had left to get another staff member and acknowledged she should not have left the resident unattended. The RN and DON both stated residents should never be left unattended in a Hoyer lift and that at least two staff should assist, and facility policies required safe lifting techniques and supervision to keep the environment free from accident hazards.
Surveyors found multiple environmental deficiencies, including a loose toilet with newspaper stuffed under its base and missing caulk in an all-gender bathroom, a sink countertop pulling away from the backsplash with cracked/crumbling grout and black mold-like buildup, and deteriorated walls and baseboards in several resident rooms and shared bathrooms. Additional issues included crumbling wall material behind fallen baseboards, rusted exposed sink pipes, peeling paint, and dirt and grime buildup in bathroom corners and around sliding glass doors. The Maintenance Assistant acknowledged all observed problems, and a review of the facility’s maintenance log showed no documentation of these issues despite a policy requiring a safe, clean, and homelike environment.
The facility did not maintain a safe environment when the upper end of a stairway handrail on the right side going up from the parking lot to the first floor was found loose and easily movable during an observation with maintenance staff. The Maintenance Supervisor and Maintenance Assistant confirmed the handrail was not properly secured to the wall. Review of the facility’s “Quality of Life - Homelike Environment” P&P showed a requirement to provide a safe, clean, comfortable, and homelike environment, which was not followed in this situation.
A resident with severe cognitive impairment and multiple medical conditions was admitted without a fully completed POLST form. The form lacked required selections and signatures from the legally recognized decision maker, and was signed only by the provider. Both nursing staff and the DON confirmed that the POLST was incomplete and not in accordance with facility policy, resulting in the resident's care preferences not being properly documented.
A resident with severe cognitive impairment and complex medical needs was transferred to a general acute care hospital, but staff failed to document the transfer in the medical record. The Clinical Manager confirmed the absence of required documentation, including the resident's clinical condition and vital signs at the time of transfer, resulting in incomplete records despite facility policy requiring thorough documentation of all services and changes.
A resident with multiple stage 4 and unstageable pressure ulcers, severe cognitive impairment, and total dependence on staff did not have a comprehensive care plan developed after admission. Only a baseline care plan was created, and facility staff confirmed that no interdisciplinary team care plan was in place to address the resident's complex wound care needs, contrary to facility policy and regulatory requirements.
A resident with multiple Stage 4 and unstageable pressure ulcers did not receive weekly reassessments and documentation of their wounds as required by professional standards. The treatment nurse confirmed that scheduled weekly evaluations, including measurements and descriptions, were missed, and facility policies lacked clear guidance on reassessment frequency. This failure occurred despite the resident's high risk and dependence on staff for care.
The facility failed to provide proper catheter care for three residents, leading to potential health risks. One resident's urinary collection bag was not emptied as ordered, another's catheter bag was improperly placed above bladder level, and a third resident was not assessed for catheter removal after wound healing. These deficiencies were acknowledged by the facility's staff, highlighting risks of infection.
The facility failed to store Tuberculin PPD according to the manufacturer's recommendation, keeping it refrigerated after opening instead of at room temperature. Additionally, a vial of Latanoprost lacked an open date, and multi-dose containers of Clearlax and Reguloid were not discarded within 60 days of opening, contrary to facility policy. These deficiencies were confirmed by nursing staff and the DON.
The facility failed to follow food production recipes and fortified diet guidelines during lunch service. Fortified diets were not prepared or served to 10 residents, and six residents on a pureed diet did not receive pureed lettuce, tomato, and pickles as per the menu. Interviews revealed a lack of a written fortified diet menu and an oversight in preparing pureed items, potentially leading to meal dissatisfaction.
The facility failed to maintain safe food storage practices, with improperly labeled thawing meats and significant ice buildup in the walk-in freezer. The Dietary Supervisor confirmed the labeling errors, and the Maintenance Supervisor acknowledged the potential contamination risk from the leaking freezer.
A resident with multiple health conditions, including hemiplegia and impaired cognition, was found to have their call light out of reach, potentially preventing them from calling for assistance. The care plan required the call light to be within reach, but during an observation, it was found hanging off the bed. A CNA and the DON confirmed the deficiency, acknowledging the risk of the resident being unable to call for help.
A facility failed to include a resident's advance directive in their medical chart, despite the resident having chronic respiratory failure, end-stage renal disease, and dementia. The resident lacked decision-making capacity, and the absence of the directive was confirmed by the Director of Social Services and the DON. Facility policy required advance directives to be in the clinical record, but this was not followed.
A resident with Korean as their primary language was unable to effectively communicate their needs due to the facility's failure to provide a Korean communication board within reach. Despite the care plan's directive, the board was placed in a bin by the room entrance, not at the bedside. Staff interviews confirmed the oversight, and the resident expressed difficulty in communicating with staff, often using gestures.
A resident who was ventilator-dependent and had severe cognitive impairment did not receive adequate oral care, as required by physician orders and care plans. Observations showed dry, flaky lips and crusty patches on the tongue, indicating neglect. Staff interviews confirmed the lack of consistent oral care, which is crucial to prevent infections, especially ventilator-associated pneumonia.
The facility failed to implement seizure precautions for two residents with epilepsy, as required by their care plans and physician's orders. Observations revealed that the residents' bedrails were not padded, despite the need for such precautions to prevent injury. Staff confirmed the absence of required safety measures, and the Director of Nursing acknowledged the oversight, which could lead to injuries during seizure activity.
A resident with chronic respiratory failure did not have their oxygen tubing changed weekly as required by their care plan and physician's order. Observations showed the tubing was overdue for replacement, posing a risk of infection. Interviews with staff confirmed the oversight, which was contrary to facility policies aimed at maintaining infection control.
A facility failed to ensure timely in-person visits by a physician for a resident, as required by regulations. The attending physician did not conduct an initial visit within 30 days of readmission, and subsequent visits were not alternated with a Nurse Practitioner every 60 days after the first 90 days. This resulted in incomplete care, as confirmed by the DON.
The facility failed to enforce its infection control policy, leading to deficiencies in hand hygiene and IV catheter management for two residents. A nurse did not perform hand hygiene between glove changes during skin care for a resident with severe cognitive impairment and multiple health conditions. Another resident's IV catheter was not labeled or clamped, increasing the risk of contamination. These actions violated the facility's infection prevention protocols, which emphasize hand hygiene as crucial to preventing infection spread.
A resident with multiple diagnoses, including dysphagia and severe protein-calorie malnutrition, experienced a delay in receiving a modified barium swallow study (MBSS) due to the facility's failure to follow up on insurance authorization in a timely manner. Miscommunication and errors in transportation arrangements further contributed to the delay, causing the resident to become angry and refuse meals.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for one resident by not maintaining the resident’s room in accordance with its own policies. The resident, who had chronic respiratory failure, a tracheostomy, and was ventilator-dependent, had impaired cognition and was dependent on staff for all ADLs, and did not have the capacity to understand or make decisions. During an observation in the resident’s room, surveyors noted that the privacy curtain strings were tangled and the ceiling had multiple brownish stains. During the same observation, the Maintenance Staff stated that staff were supposed to check resident rooms weekly for any issues. The DON acknowledged that curtain strings were not supposed to be tangled and that there should not be stains on the ceiling in order to provide a clean and homelike environment. Review of the facility’s “Quality of Life: Homelike Environment” policy, last reviewed on 1/16/2026, indicated residents were to be provided with a safe, clean, and homelike environment characterized by cleanliness and order, with privacy curtains clean and in good condition. The observed conditions in the resident’s room did not meet these policy standards.
Resident Left Unattended in Hoyer Lift Contrary to Safety Policies
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when a resident was left unattended in a Hoyer lift. The resident had chronic respiratory failure, a tracheostomy, and was ventilator-dependent, with documented impaired cognition and dependence on staff for all ADLs, including transfers. The resident’s H&P stated the resident did not have capacity to understand or make decisions, and the care plan identified a risk for falls due to poor safety awareness, with instructions that staff assist the resident with all transfers. During observation in the resident’s room, the resident was seen suspended in a Hoyer lift over the bed with no staff present. An RN immediately called for a CNA, who reported she had left the resident in the lift while she went to call another staff member for assistance and acknowledged she was not supposed to leave the resident unattended in the Hoyer lift. The RN stated residents should not be left unattended when up in a Hoyer lift due to safety concerns. The DON stated that residents should not be left unattended when using a Hoyer lift and that it was best practice to have at least two staff assist with Hoyer lift use. Facility policies on safe lifting and resident safety/supervision indicated the facility would use appropriate techniques and devices to protect resident safety and make the environment as free from accident hazards as possible.
Failure to Maintain Clean, Safe, and Well-Maintained Resident Bathrooms and Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident-use areas, including bathrooms and resident rooms. Surveyors observed that the all-gender bathroom next to the nursing station had a toilet that was loose from the floor, with newspaper stuffed between the toilet and the floor and missing caulk to seal it. In the same bathroom, the sink countertop was pulling away from the backsplash with missing or cracked and crumbling grout/caulk, and there was a black mold-like buildup under the lip where the countertop met the sink bowl. The Maintenance Assistant (MA) acknowledged these conditions, explaining that recent plumbing work left the toilet not flush with the floor and confirming that the countertop and cleanliness issues existed. Additional observations showed environmental deterioration in several resident rooms and shared bathrooms. In one resident room, the baseboard near the patio sliding glass door was peeling off the wall and fell away when the curtain was moved, exposing a completely crumbled wall area; the MA confirmed this and stated there were no mice currently in the space. In the bathroom between two resident rooms, the sink was pulling away from the wall with cracked and crumbling caulk/grout, peeled paint, rust on exposed sink pipes, dirt and grime buildup in the corners, and a baseboard peeling away from the wall; the MA validated these findings. In another resident room, the baseboard near the sliding glass door was peeling away from the wall with some paint, and the corners of the sliding glass door had visible dirt and grime buildup, which the MA also confirmed. Review of the facility’s daily maintenance log over several months showed no entries documenting these environmental issues, and the facility’s policy on providing a safe, clean, comfortable, and homelike environment emphasized cleanliness and order, which contrasted with the observed conditions.
Loose Stairway Handrail Not Secured to Wall
Penalty
Summary
The facility failed to maintain a safe environment by not securing the upper end of the stairway handrail on the right side as you go up from the parking lot to the first floor. During an observation and concurrent interview with the Maintenance Supervisor and Maintenance Assistant, the top end of this handrail was found to be loose from the wall and easily movable. Both maintenance staff confirmed that the handrail was loose. Record review of the facility’s policy and procedure titled “Quality of Life - Homelike Environment,” revised 1/10/25, showed that residents are to be provided with a safe, clean, comfortable, and homelike environment, including cleanliness and order, which was not met in this instance. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
A deficiency occurred when the facility failed to complete the Physician Orders for Life-Sustaining Treatment (POLST) for a resident who was admitted with multiple complex medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was determined to lack capacity to make medical decisions, as documented in both the History and Physical and the Minimum Data Set, which indicated severely impaired cognitive skills and total dependence on staff for daily activities. Upon review, the resident's POLST form was found to be incomplete. Key sections of the form, including those addressing cardiopulmonary resuscitation, medical interventions, artificially administered nutrition, and the information and signatures section, were not filled out. The form was signed only by the provider and not by the resident's legally recognized decision maker, as required when the resident lacks capacity. The responsible registered nurse confirmed that the POLST should not have been signed by the provider alone and that all sections must be completed for the document to be valid. The Director of Nursing stated that it was the responsibility of the social worker and licensed nursing staff to ensure the POLST was fully completed. Facility policy also required that the provider confirm the orders with the resident or, if incapacitated, the legally recognized decision maker before signing. The failure to complete the POLST as required resulted in the resident's medical wishes not being properly documented or available to guide care in the event of an emergency.
Plan Of Correction
F-578 Corrective Action On 9/8/25, the Director of Nursing (DON) gave the Social Service Designee (SSD) an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
A deficiency occurred when the facility failed to document the transfer of a resident to a general acute care hospital (GACH) in the resident's medical records. The review of the resident's records showed that there was no documentation by facility staff indicating the transfer, despite a physician's telephone order for the transfer being present. The Clinical Manager confirmed during an interview and record review that the medical records were incomplete and not accurate, specifically noting the absence of documentation regarding the resident's transfer. The resident involved had a complex medical history, including chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube placement. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities such as oral hygiene, toileting, and dressing. The resident did not have the capacity to understand or make decisions, as indicated in the history and physical and the Minimum Data Set (MDS) assessment. Facility policy and procedure documents reviewed indicated that all services provided, progress toward care plan goals, and any changes in the resident's condition should be documented in the medical record. However, in this instance, the licensed nurse did not document the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. This lack of documentation resulted in incomplete medical records for the resident.
Plan Of Correction
F-628 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. On 9/9/25, the Director of Nursing (DON) gave the transferring RN for Resident 1 an inservice about the facility's policy on discharge process. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. Identification of Others On 9/11/25, the DON and Clinical Manager assessed other discharge charts. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan for a resident with multiple pressure ulcers. The resident was admitted with several stage 4 and unstageable pressure ulcers, as well as other significant medical conditions including a urinary tract infection and a gastrostomy tube. The resident was assessed as having severely impaired cognitive skills and was totally dependent on staff for daily care activities. Despite these complex needs, only a baseline care plan was created upon admission, and no comprehensive care plan was developed more than two months after admission. Interviews with facility staff confirmed the absence of a comprehensive care plan. The Clinical Manager acknowledged that while a baseline care plan was in place, there was no comprehensive care plan addressing the resident's multiple pressure ulcers. The Clinical Manager emphasized the importance of such a plan for guiding the monitoring and treatment of the wounds, noting that without it, there was no specific guidance for wound care. The Director of Nursing also confirmed that the baseline care plan is only valid for 14 days and that a comprehensive care plan should have been developed by the interdisciplinary team within that timeframe. A review of the facility's policy and procedure on comprehensive care plans indicated that care plans should be created for skin alterations, including pressure ulcers, and that goals should be realistic, measurable, and include a timeframe for re-evaluation. The failure to develop a comprehensive care plan for the resident's pressure ulcers was contrary to both regulatory requirements and the facility's own policy, resulting in a lack of documented, coordinated interventions for the resident's wound care needs.
Plan Of Correction
F -656 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Perform Weekly Pressure Ulcer Reassessments
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers did not receive care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers, was found to have not had their pressure ulcers reassessed and documented on a weekly basis as required. The treatment nurse confirmed that a scheduled weekly reassessment and documentation of the pressure ulcers, including type, location, measurement, and description, was not completed for one week. This omission was acknowledged during an interview and record review, where the nurse stated that such reassessments are necessary to determine the status and progression of the ulcers and to make any needed adjustments to the wound care plan. The resident in question had significant medical issues, including severely impaired cognitive skills, total dependence on staff for daily activities, and a history of pressure ulcers present upon admission. The baseline care plan and Minimum Data Set (MDS) documented the presence of multiple pressure ulcers and the resident's high risk for developing additional ulcers. Despite these risk factors and the need for close monitoring, the required weekly wound assessments were not consistently performed or documented. Further review of facility policies and the treatment nurse's job description revealed gaps in guidance regarding the frequency and documentation of pressure ulcer reassessments. The facility's policy did not specify the need for scheduled weekly reassessments to monitor the progression of pressure ulcers, and the job description did not require the treatment nurse to review and revise the care plan as needed for accurate wound care guidance. These omissions contributed to the failure to provide care consistent with professional standards for pressure ulcer management.
Plan Of Correction
F-686 Corrective Action On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. Identification of Others On 9/11/25, the DON and Treatment nurse reviewed other residents' weekly wound assessments and documentation. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the DON and/or designee will review 5 random charts of residents with wounds and review if they have completed their weekly wound assessment; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Deficient Catheter Care in LTC Facility
Penalty
Summary
The facility failed to provide proper care for residents with indwelling catheters, leading to potential health risks. For one resident, the staff did not empty the urinary collection bag as ordered by the physician. The resident reported that the bag had not been emptied since the previous day, and a CNA confirmed that the bag was full and had not been checked or emptied during the current shift. The Director of Nursing acknowledged this as a deficient practice, noting the potential for infection. Another resident's urinary catheter bag was improperly maintained above the level of the bladder, contrary to the facility's policy. An LVN confirmed the incorrect placement and acknowledged the risk of urinary tract infection due to potential backflow of urine. The Director of Nursing reiterated that the catheter bag should be placed below the bladder level to prevent infection. A third resident had an indwelling catheter placed for wound management, but there was no assessment for its removal after the wound had healed. An LVN stated that the catheter was no longer appropriate as the resident's pressure sore had resolved. The Director of Nursing confirmed that the resident should have been assessed for catheter removal to avoid unnecessary infection risk.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store Tuberculin purified protein derivative (Tuberculin PPD) according to the manufacturer's recommendation. During an observation, a vial of Tuberculin PPD was found in the medication refrigerator with an open date of 5/29/2024, despite the manufacturer's instructions to store it at room temperature after opening. This oversight was confirmed by RN 2, who acknowledged the discrepancy between the storage practice and the manufacturer's guidelines. Additionally, the facility did not adhere to proper labeling and disposal protocols for other medications. An open vial of Latanoprost was found without an open date, and multi-dose containers of Clearlax and Reguloid were not discarded within the 60-day period after opening, as required by the facility's policy. LVN 5 and LVN 6 confirmed these lapses during interviews, and the Director of Nursing reiterated the importance of following the facility's policy and manufacturer's recommendations to ensure medication efficacy.
Failure to Follow Fortified and Pureed Diet Guidelines
Penalty
Summary
The facility failed to ensure that staff followed food production recipes and fortified diet guidelines during lunch service. Specifically, fortified diets, which are designed to increase caloric intake for residents who cannot consume adequate calories or protein, were not prepared or served to 10 residents who were on such diets. During a tray line observation, it was noted that the dietary aide communicated the fortified diet orders, but the staff member serving the food did not add any additional food items as per the fortified menu. Interviews with the dietary aide and the dietary supervisor revealed that there was no written fortified diet menu, and extra butter or gravy, which are typically added to increase calorie density, were not included in the meals served that day. Additionally, the facility did not adhere to the menu for residents on a pureed diet. Six residents on a pureed diet did not receive pureed lettuce, tomato, and pickles with their meal as specified in the menu. During the tray line observation, it was found that only pureed hamburger, bread, and corn were served. An interview with the dietary supervisor and the staff member serving the food confirmed that there was a mistake, and the pureed items were not prepared or served as required. This oversight had the potential to result in meal dissatisfaction for residents on a pureed diet.
Deficiencies in Food Storage and Freezer Maintenance
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices, as observed during a survey. Two previously cooked and frozen roast pork items were found thawing in the walk-in refrigerator without a pull-out or thaw date, and a large turkey was labeled with the wrong thaw date. The Dietary Supervisor confirmed that the roast pork was removed from the freezer to thaw but was not dated correctly, and the turkey was mislabeled. The facility's policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, which was not adhered to in these instances. Additionally, the walk-in freezer had significant ice buildup on the ceiling, condenser, and pipes, with icicles hanging above the food. A large pan filled with solid ice and water was observed, indicating a leak from above. The floor of the freezer was slippery with ice. The Dietary Supervisor acknowledged the issue and stated that an outside company was expected to fix it. The Maintenance Supervisor was informed of the problem and recognized the potential for contamination from the leaking water. The facility's sanitation policy requires equipment to be maintained in good repair, which was not the case here.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 22, which could potentially prevent the resident from calling for assistance when needed. Resident 22 was admitted with multiple diagnoses, including hemiplegia, blindness in one eye, and dependence on a wheelchair, and had moderately impaired cognition. The resident required substantial assistance with daily activities, including toileting and personal hygiene. The care plan for Resident 22 specified that the call light should be kept close and within reach to ensure the resident could call for help. During an observation, it was noted that Resident 22's call light was hanging off the bed and not within reach, and the resident was unable to locate it. A CNA confirmed the call light was not accessible and acknowledged the potential risk of the resident being unable to call for help. The Director of Nursing also stated that call lights should always be within reach to prevent residents from being unable to call for assistance. The facility's policy indicated that call lights should be easily accessible to residents when they are in bed or confined to a chair.
Failure to Include Advance Directive in Resident's Medical Chart
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the resident's medical chart. This deficiency was identified for a resident who was admitted with chronic respiratory failure, end-stage renal disease, and dementia. The resident's physician history and physical indicated that the resident lacked the capacity to understand and make decisions, and the Minimum Data Set assessment showed moderately impaired cognition and dependence on multiple helpers for daily activities. During interviews, the Director of Social Services acknowledged that the resident's advance directive was not found in the clinical record, despite an acknowledgment form indicating its existence. The Director of Nursing confirmed that the advance directive should have been in the resident's chart to guide staff in honoring the resident's medical decisions. The facility's policy required that advance directives be placed in the clinical record when provided by the resident or their representative, but this was not adhered to in this case.
Failure to Provide Accessible Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to accommodate the communication needs of a resident whose primary language is Korean. The resident, admitted with conditions such as osteomyelitis, type 2 diabetes, and muscle weakness, required a Korean communication board to effectively communicate with staff. Despite the care plan indicating the need for a visual communication board at the resident's bedside, the board was found in a folder placed in a bin secured to the wall by the entrance of the resident's room, out of the resident's reach. This oversight was confirmed during observations and interviews with staff, including a Licensed Vocational Nurse and the Social Services Director, who acknowledged the importance of having the communication board accessible to the resident. Interviews with the resident, facilitated by translation services, revealed that the resident experienced difficulty communicating with staff due to the language barrier, often resorting to gestures. The Director of Nursing also confirmed that the communication board should have been near the resident's bedside to ensure easy access and facilitate communication. The facility's policy on accommodating communication deficits emphasized the need for care plans to reflect accurate and current assessments related to communication needs, which was not adhered to in this case.
Failure to Provide Oral Care for Ventilator-Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident who was completely dependent on staff for all activities of daily living, including oral hygiene. The resident, who had severe cognitive impairment and was dependent on a ventilator due to chronic respiratory failure, was observed with dry, flaky lips and off-white crusty patches on the tongue, indicating a lack of oral care. Despite physician orders and care plans specifying the need for oral care every shift to prevent infection, observations and staff interviews revealed that oral care was not consistently provided. Interviews with staff, including a CNA, a respiratory therapist, the Director of Staff Development, and the Director of Nursing, confirmed that the resident had not received proper mouth care for some time. The facility's policy required oral care to maintain oral hygiene and prevent infections, especially important for residents on ventilators to avoid ventilator-associated pneumonia. The deficiency was identified through observations and staff admissions that oral care was neglected, putting the resident at risk for infection.
Failure to Implement Seizure Precautions for Residents
Penalty
Summary
The facility failed to implement necessary seizure precautions for two residents, both diagnosed with epilepsy, which placed them at risk for injury. Resident 2, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a care plan that required padded side rails as a precaution against seizures. However, during an observation, it was noted that Resident 2's bedrails were not padded, contrary to the physician's orders and the care plan. Licensed Vocational Nurse 4 confirmed the absence of padding and acknowledged that it was required to protect the resident from harm. Similarly, Resident 20, who had moderate cognitive impairment and required substantial assistance for daily activities, also had a care plan that included seizure precautions such as padded side rails. Observations revealed that Resident 20's bedrails were not padded, and there were no pillows or wedge pillows in place as required. Licensed Vocational Nurse 1 confirmed the lack of padding despite having documented that the precautions were in place. The Director of Nursing acknowledged the failure to implement the physician's orders, which could lead to injuries during seizure activity. The facility's policy emphasized the importance of implementing interventions to reduce accident risks, which were not followed in these cases.
Failure to Change Oxygen Tubing as Per Care Plan
Penalty
Summary
The facility failed to adhere to the care plan and physician's order for Resident 2, who required oxygen therapy due to chronic respiratory failure and other conditions. The care plan specified that the resident's oxygen tubing should be changed every seven days to prevent infection and maintain cleanliness. However, observations revealed that the oxygen tubing had not been changed as scheduled, with the tubing dated 6/14/2024, indicating it was overdue for replacement by the time of the surveyor's observation on 6/21/2024 and 6/22/2024. Interviews with the respiratory therapist and the Director of Nursing confirmed that the tubing should have been changed weekly, and the failure to do so posed a risk of infection. The facility's policy and procedure documents supported the requirement for regular changes to maintain infection control. Despite these guidelines, the oversight in changing the oxygen tubing as per the care plan and physician's order resulted in a deficiency, highlighting a lapse in the facility's adherence to prescribed care protocols.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a physician completed in-person visits in a timely manner for a resident, as required by regulations. Specifically, the attending physician did not conduct an initial comprehensive visit within 30 days after the resident's readmission. Instead, a Nurse Practitioner (NP) completed the History and Physical (H&P) assessment. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the attending physician was required to perform the initial visit personally. Additionally, the facility did not adhere to the required schedule of alternating physician and NP visits every 60 days after the first 90 days of the resident's admission. The resident's progress notes from November 2023 to March 2024 were all completed by an NP, with no documented visits from the attending physician. The DON confirmed that the attending physician had not visited the resident since November 2023, which could lead to incomplete care. The facility's policy mandates that the attending physician must visit residents at least once every 30 days for the first 90 days and then at least every 60 days thereafter, with alternate visits by an NP allowed only after the initial 90 days.
Infection Control Deficiencies in Hand Hygiene and IV Management
Penalty
Summary
The facility failed to enforce its infection prevention and control policy, resulting in deficiencies related to hand hygiene and intravenous catheter management for two residents. For Resident 29, who was admitted with severe cognitive impairment and multiple health conditions including sepsis and chronic kidney disease, the facility did not ensure proper hand hygiene between glove changes during skin care procedures. Licensed Vocational Nurse 2 was observed changing gloves multiple times without performing hand hygiene, which is against the facility's policy and increases the risk of spreading infectious microorganisms. Resident 10, who had intact cognition and required assistance with daily activities, was receiving intravenous antibiotic treatment. The facility failed to label the intravenous catheter with the date of insertion and did not clamp the needleless lock system after use. This oversight was confirmed by Registered Nurse 1, who acknowledged that the open system could lead to cross-contamination. The Director of Nursing also confirmed that the facility's protocol requires labeling and clamping to prevent contamination. The facility's policy emphasizes hand hygiene as the primary means to prevent infection spread, stating that gloves do not replace the need for handwashing. The policy outlines specific instances when hand hygiene should be performed, such as between glove changes and after contact with a resident's skin or contaminated equipment. The failure to adhere to these protocols for both residents highlights a significant lapse in maintaining a safe and sanitary environment, as required by the facility's infection prevention and control policies.
Failure to Timely Follow Up on Insurance Authorization for MBSS
Penalty
Summary
The facility failed to follow up on insurance authorization for a modified barium swallow study (MBSS) in a timely manner for a resident, leading to a delay in service. The resident, who had multiple diagnoses including hemiplegia, COPD, dysphagia, and severe protein-calorie malnutrition, was admitted with a g-tube for feeding. Despite a physician's order for an MBSS, the facility did not ensure the authorization process was completed promptly, causing the resident to become angry and refuse meals. The resident's appointment for the MBSS was initially scheduled, but due to miscommunication and errors in transportation arrangements, the appointment was missed. The facility's business office assistant (BOA) faced difficulties in obtaining the necessary authorization from the insurance company, experiencing a runaround between the insurance company and the medical group. Despite multiple follow-up attempts, the authorization process was delayed, and the resident was not informed of the status in a timely manner. The resident expressed frustration and anger due to the delay in receiving the MBSS, which was necessary for evaluating the removal of the g-tube. The resident's refusal to eat the provided puree diet and the ongoing issues with the authorization process contributed to the resident's deteriorating mental state and increased agitation. The facility's failure to follow its own policy and procedures for timely follow-up on authorizations led to a significant delay in the resident's care and exacerbated the resident's distress.
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.
