Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Burbank Healthcare & Rehab during CMS and state inspections, most recent first.
During a scabies outbreak, staff failed to follow infection control practices, including an RNA not changing gowns between two residents on contact isolation, a CNA entering a contact isolation room without PPE to deliver a meal tray while both the CNA and an LVN were unsure of the resident’s isolation status, and incomplete line listing of exposed residents by the IP. Additionally, housekeeping staff handled isolation trash and linens for residents with confirmed and suspected scabies without gloves, transported these items through common hallways, and deposited them via a chute used for regular laundry, resulting in mixing isolation linens with non-isolation linens instead of following the facility’s process for separate collection and hot-water laundering.
A resident with acute panmyelosis, MS, and PVD, who was dependent for all ADLs but cognitively intact and with decision-making capacity, had an Advance Health Care Directive and a DPOA naming a Resident Representative (RR) as attorney-in-fact. Facility records showed two documented changes in condition, including initiation of new medication for dermatitis and abnormal WBC and platelet counts, where only the resident was notified and there was no documentation that the RR was informed. During interview and record review, the DON acknowledged the RR was not notified and that staff were unaware of the POA, despite facility policies requiring notification of the resident representative for significant changes in condition and recognizing residents’ rights to appoint a legal representative.
A resident admitted with metabolic encephalopathy, pruritus, and a history of falls was placed on contact isolation to rule out scabies, and a skin scraping was ordered. Although the resident’s H&P documented decision-making capacity, the MDS later showed severely impaired cognitive skills and a need for moderate assistance with ADLs. Review of the record with the IP revealed there was no person-centered care plan addressing the ordered skin scraping or related care, despite facility policy requiring comprehensive care plans with measurable objectives and timeframes. The IP and DON both acknowledged that a care plan for the suspected scabies and skin scraping should have been developed to guide nursing staff actions.
A resident with metabolic encephalopathy, pruritus, and dermatitis had a physician order for clobetasol 0.05% cream to be applied to the general body twice daily for four weeks. Review of the Treatment Administration Record showed the evening application on one date was left blank. During interviews, the IP confirmed that a blank entry indicated the treatment was not given and that the nurse did not follow the order, and the DON acknowledged that Treatment Nurses are expected to administer clobetasol according to the physician’s orders. This was inconsistent with the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed.
A resident with dermatitis and other medical conditions had a physician order for contact isolation precautions every shift, but the MAR entry for one night shift was left blank, indicating the isolation was not documented as ongoing. During interviews, the IP confirmed the blank MAR entry reflected incomplete nursing documentation and a lack of documented evidence that contact isolation was in place, and the DON acknowledged that missing documentation of isolation could lead to spread of scabies. This failure did not comply with the facility’s charting and documentation policy requiring complete and accurate medical records.
A resident with cellulitis and multiple comorbidities was ordered cephalexin and clindamycin four times daily for seven days, but the facility failed to start the 9 p.m. doses on the first day and did not administer the final scheduled doses, resulting in an incomplete antibiotic course. Nursing documentation cited unavailability of the medications, even though both antibiotics were stocked in the facility’s oral e-kit. Review of the MAR, progress notes, and interviews with the IP and DON confirmed that the antibiotics were neither initiated within the required time frame nor extended to fulfill the full ordered duration, contrary to the facility’s medication administration and antibiotic stewardship policies.
A resident with intact decision-making capacity and complex medical conditions was readmitted from a hospital where scabies had been treated with permethrin. On readmission, staff obtained orders for weekly ivermectin and permethrin for four weeks, documented for unspecified dermatitis, and continued administering these medications even after a skin scraping for scabies was negative. Facility records, including the MAR and TAR, showed multiple administrations of both drugs, while interviews with the IP and DON confirmed there was no clear indication for scabies and acknowledged that these medications are scabies treatments that may have been unnecessary under the facility’s own policy on unnecessary drugs.
A resident with multiple chronic conditions, including MS and peripheral vascular disease, was started on clindamycin for leg cellulitis. The MAR shows the antibiotic was administered, and the care plan called for assessment of adverse reactions and side effects with physician notification as needed. However, review of the MAR and Progress Notes revealed no documented monitoring for adverse effects after the dose, despite facility policies on antibiotic stewardship and adverse consequence monitoring. The IP and DON confirmed that residents on antibiotics are expected to be monitored and that such monitoring should be documented.
The facility failed to revise comprehensive care plans for two residents following significant changes in condition and hospital readmissions. One resident, with intact cognition and multiple medical diagnoses, was sent to a GACH for altered level of consciousness and diagnosed with opioid intoxication, then readmitted without the care plan being updated to address this new diagnosis. Another resident, also cognitively intact and requiring moderate ADL assistance, expressed homicidal ideation toward another resident, was transferred for psychiatric evaluation, and later readmitted without the care plan being revised to reflect the psychiatric event or related goals and interventions. The DON and ADON acknowledged during record reviews that the care plans did not reflect these changes, despite facility policy requiring care plan updates after significant changes and hospital readmissions.
A resident with severe cognitive impairment and multiple medical conditions was found lying in a bed positioned with one side against the wall, which staff identified as a form of physical restraint. LVNs and the ADON acknowledged that using the bed in this way required an assessment, MD order, consent from the resident’s representative, and a care plan, but none of these were present. Review of the facility’s restraint policy showed that using equipment to prevent mobility is considered a restraint and must follow specific procedures, which were not followed in this case.
Staff failed to follow the facility’s hand hygiene policy after providing ADLs and incontinent care to a resident with dementia, generalized muscle weakness, and difficulty walking. Two CNAs provided perineal and incontinent care, dressing, and preparation for activities while wearing gloves, then removed and discarded their gloves at the doorway and did not perform hand hygiene with soap and water or ABHR before moving on to other tasks. Both CNAs later acknowledged they did not perform hand hygiene despite knowing it is required before and after resident contact, and the facility’s IP and Administrator confirmed that hand hygiene is required after direct care and glove removal per facility policy.
Kitchen staff failed to follow facility policies requiring daily calibration of food thermometers and routine monitoring and documentation of refrigerator and freezer temperatures. Logs reviewed with dietary leadership showed several days without recorded thermometer calibration and missing entries for multiple cold storage units on both morning and evening shifts. The DSS, ADS, and Administrator all acknowledged that without calibration and documented temperature checks, the accuracy of food temperature monitoring cannot be verified and food may spoil, creating a risk of foodborne illness for residents.
A resident with muscle weakness, prior falls, and a recent stroke was assessed as high fall risk and had physician orders and a care plan directing use of a low bed and floor mats to reduce injury. During observation, surveyors noted a fall-risk indicator at the bedside but no floor mats in place. The resident did not recall having a mat, and the IP, DSD, and Administrator each confirmed that floor mats were ordered, required per the care plan, and intended to prevent injury, yet were not present at the time of the survey, creating potential for injury or fracture if a fall occurred.
Staff failed to implement timely contact precautions and appropriate cohorting for a resident who developed diarrhea consistent with CDI and was later confirmed positive. Despite facility policy requiring contact precautions for suspected CDI and private room placement or cohorting only with low-risk roommates, the infected resident remained in a shared room with two roommates, including one who was immunocompromised and receiving chemotherapy. No infection risk assessments were completed for the roommates, they were not informed or educated about their potential CDI exposure or required precautions, and they were not monitored for CDI symptoms, even though an isolation cart and contact precaution signage were present outside the room.
A cognitively intact resident, admitted with muscle weakness and sepsis, reported that a family member visitor took his wallet, left the building, charged $500 to the resident’s credit card, and then returned the wallet. The resident stated he informed the SW of the incident, and the SW confirmed receiving this report. The Administrator acknowledged being aware that the resident had reported the alleged misappropriation but did not report the allegation to the SSA, despite a facility policy requiring immediate reporting of suspected theft or misappropriation of resident property to state authorities within two hours.
Surveyors found that the facility did not develop or implement a comprehensive, person-centered care plan for an immunocompromised resident with diffuse large B-cell lymphoma, undergoing antineoplastic chemotherapy and with an acquired absence of a kidney. Although the resident’s MDS showed intact cognition and a need for substantial/maximal assistance with ADLs such as toileting hygiene, bathing, lower body dressing, and footwear, staff did not initiate a care plan addressing the resident’s high infection risk. The DON confirmed that neither licensed staff nor the MDS Coordinator created a care plan to address the resident’s immunocompromised status, including the need to avoid cohorting with residents who had active infections, contrary to the facility’s policy requiring comprehensive care plans with measurable objectives and timetables based on a thorough assessment.
The facility failed to revise comprehensive, person-centered care plans for two residents after they were cohorted with a resident who developed CDI and was placed on contact isolation. The cohorted residents had multiple comorbidities, including lymphoma with chemotherapy and acquired absence of a kidney in one, and hypertrophic cardiomyopathy, CKD, type 2 DM, depression, and anxiety disorders in the other, and both required substantial/maximal assistance with ADLs such as toileting hygiene and lower body dressing. Despite the change in their situation when they were grouped with a CDI-positive resident, their care plans were not updated by licensed staff or the MDS coordinator, contrary to facility policy requiring ongoing assessment and revision of care plans when resident conditions change.
A resident with pneumonia and a history of acute kidney failure and UTI was started on levofloxacin 500 mg PO daily for seven days after an abnormal WBC and modest right lower lobe PNA were identified. The care plan directed staff to administer the antibiotic, monitor for adverse reactions, track progress, and monitor VS and infection-related symptoms. The DON reported that residents on antibiotics are to be monitored for adverse effects every shift and that nurses should document this monitoring in progress notes, but review of the record showed only one documented monitoring entry during the entire treatment period. The facility’s antibiotic stewardship policy described oversight of antibiotic use and education on related risks but did not specify monitoring frequency, and the DON acknowledged that monitoring and documentation of antibiotic adverse effects every shift did not occur for this resident.
A resident admitted with acute kidney failure, difficulty walking, and generalized weakness had intact decision-making capacity and required moderate assistance for ambulation. An order was in place for RNA ambulation with a FWW five times weekly, but on two consecutive days RNA staff documented the service as not applicable while another RNA later reported the resident had actually refused RNA multiple times on those days and remained in the facility. The refusals were not reported to the Charge Nurse as required, no RNA was provided on those days, and no person-centered care plan was developed to address the resident’s repeated refusal of RNA services, despite facility policy requiring comprehensive care plans that include services not provided due to a resident’s right to refuse treatment.
A resident with acute kidney failure, difficulty walking, and generalized weakness, who was cognitively intact and required moderate assistance for transfers and walking, had physician orders and a care plan for RNA ambulation with a FWW five times per week. On two consecutive days, RNA documentation was marked as “not applicable,” even though the resident remained in the facility for at least part of that time and no RNA ambulation was provided. An RNA reported the resident refused to walk while awaiting discharge but did not report these refusals to the charge nurse, and the DON stated that RNA ambulation is needed to help prevent decline in ROM and ambulation, contrary to the facility’s restorative nursing policy requiring implementation of individualized restorative interventions.
A resident with acute kidney failure, pneumonia, and intact decision-making capacity had abnormal lab results, including elevated WBC and low Hgb/Hct, for which a physician had been contacted and new orders were reportedly given. However, review of the chart with an RN and the DON showed that the progress notes did not include required documentation of the physician notification, including the time of contact, who called, or the physician’s response or orders. This lack of documentation conflicted with the facility’s charting policy, which requires complete, accurate, and detailed recording of changes in condition and physician notifications.
Two residents and their representatives were not properly notified in writing of transfers or discharges, nor were they informed of their appeal rights or provided with required information about bed-hold policies. In both cases, staff signed the notification forms instead of the residents or their representatives, and the facility failed to mail the notices as required by policy, resulting in incomplete communication of rights and procedures.
A resident with multiple diagnoses, including dementia and hypertension, experienced a 20 mmHg drop in systolic blood pressure between lying and sitting positions while on antipsychotic medication. Despite physician orders and facility policy requiring notification for such changes, the nurse did not notify the physician, and there was no documentation of physician contact regarding this event.
The facility did not ensure that the discharge portion of Inventory Lists was completed for two residents, resulting in incomplete documentation of personal belongings at discharge. Staff interviews revealed that Inventory Lists were not consistently filled out or verified, and belongings were picked up without proper listing or signatures, contrary to facility policy.
A nurse administered blood pressure medication to a resident without reassessing vital signs immediately prior to administration, as required by the physician's order. The nurse had checked the resident's blood pressure and heart rate about 30 minutes earlier, but after the resident initially refused the medication, the nurse later gave the previously prepared medication without a new assessment, resulting in a medication error.
A nurse failed to wear gown and gloves or perform hand hygiene when entering a resident's room under contact isolation precautions. Additionally, after the resident refused crushed medications, the nurse placed the labeled medicine cup inside a medication cart next to a glucometer used for multiple residents, contrary to infection control policy.
A resident with chronic kidney disease and other conditions was placed on contact isolation precautions, and housekeeping staff performed a deep cleaning of the room. However, the required Deep Clean Checkoff List was not completed, resulting in an incomplete medical record. Interviews confirmed the cleaning took place, but no documentation was made to verify the specific actions performed, contrary to facility policy.
A resident with an indwelling urinary catheter and a history of kidney and urinary conditions did not have physician orders for catheter care or monitoring after returning from the hospital. Nursing staff observed abnormal urine characteristics, including hematuria, but did not report these findings to the physician, considering them baseline. Catheter care and irrigation were performed without orders or proper documentation, and the resident was not monitored as required, resulting in undetected infection confirmed by laboratory results.
Two residents with indwelling urinary catheters did not receive proper care, including failure to anchor catheter tubing, monitor urine for hematuria and sediments, and apply wound dressings as required. Staff did not document or report abnormal urine findings, and catheter care orders were missing or not followed, resulting in abnormal urine characteristics and lab results indicating infection.
A resident with an indwelling urinary catheter and multiple urological conditions did not receive care in accordance with their comprehensive care plan. Nursing staff observed abnormal urine characteristics and improper catheter anchoring but did not report these findings to the physician. After a hospital stay, catheter care orders were not renewed, and there was no documentation of catheter care provided, contrary to facility policy and the resident's care plan.
A resident with high risk for pressure ulcers was found to have their low air-loss mattress set at 200 lbs, despite a documented weight of 116 lbs and care instructions to set the mattress based on weight. Nursing staff and the DON confirmed the setting was incorrect and not in line with care plan, physician orders, or manufacturer guidelines, placing the resident at risk for pressure ulcer development.
A CNA failed to accurately document a resident's meal intake percentages at the correct times, resulting in incomplete and inaccurate medical records. The issue was confirmed by both the DSD and DON, who stated that meal intake should be recorded after consumption and for each respective meal. The resident involved had multiple medical conditions and required moderate assistance with eating.
The facility failed to maintain accountability for controlled medications, resulting in missing doses for two residents. Licensed nurses did not document administration in the eMAR, and the DON did not investigate discrepancies or report missing medications to the Administrator. The DON collected medications without proper documentation, and a universal key bypassed the double-lock system, contributing to the deficiency.
The facility failed to document and assess the use of restraints for several residents, including pad alarms and beds placed against walls, without obtaining necessary physician's orders, informed consents, and care plans, as required by policy.
The facility's nursing staff failed to rotate insulin injection sites for four residents, leading to potential adverse effects. Despite physician orders and facility policies requiring site rotation, insulin was repeatedly administered in the same areas, risking tissue injury and affecting medication absorption. The ADON and DON confirmed these deficiencies, highlighting a lack of adherence to professional standards of care.
The facility failed to provide proper pressure ulcer care for four residents by inaccurately labeling and setting Low Air Loss Mattresses (LALM) according to residents' weights or physician orders. One resident's LALM was set at 160 pounds but labeled for 200 pounds, while another's was set at 200 pounds per a physician's order despite weighing 151 pounds. A third resident's LALM was set at 160 pounds, although the resident weighed 131 pounds, and the machine was labeled for 120 pounds. Additionally, a fourth resident used a LALM without a physician's order, set to 280 pounds, far above the resident's weight of 138 pounds.
The facility failed to maintain a safe environment for residents, with improper use of fall mats, a malfunctioning bed pad alarm, and inadequate assessment of bed placement as a restraint. These deficiencies increased the risk of injury for several residents.
The facility failed to properly dispose of medications in Medication Room Station 1, where the pharmaceutical waste bin contained intact loose medication tablets, capsules, and an albuterol inhaler. The DON acknowledged that the medications were not disposed of according to facility policy, which requires disintegration by liquid to prevent retrieval. The improper disposal practices did not align with EPA recommendations and facility policies, increasing the risk of medication diversion and accidental exposure.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications by not providing specific, measurable target behaviors for quetiapine use. The lack of specificity in monitoring led to inconsistent documentation by different nurses, hindering accurate assessment of the medication's effectiveness. Facility policies required specific target behaviors for behavioral symptoms, which were not followed.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. Two residents were affected: one did not receive a prescribed dose of oyster shell calcium due to unavailability, and another missed a dose of docusate due to oversight. The errors were acknowledged by the LVNs involved and confirmed by the DON, highlighting deviations from the facility's medication administration policies.
A LTC facility failed to ensure residents were free from significant medication errors, including improper administration of epoetin alfa and failure to rotate insulin injection sites. One resident received epoetin alfa against physician orders, while four others had insulin administered in the same areas, risking tissue injury. The facility's policies and guidelines were not followed, leading to these deficiencies.
The facility failed to manage medications properly, leading to deficiencies such as expired anastrazole for a resident with breast cancer, unlabeled budesonide and formoterol inhaler for a resident with COPD, and expired loperamide and improperly stored ipratropium with albuterol inhalation solution. These oversights were acknowledged by the DON and LVNs, highlighting the risk of administering ineffective medications.
The facility did not adhere to prescribed menu and portion sizes, affecting 123 residents on regular texture diets. A staff member failed to level off the scoop when serving rice and carrots, leading to larger portions than specified. This action was against facility policy, which requires correct portioning to prevent unintentional weight gain and complications for diabetic residents. The Dietary Supervisor confirmed the error, highlighting a lapse in following standardized recipes and portion sizes.
The facility failed to prepare puree foods according to IDDSI Level 4 standards, resulting in puree spinach that was too sticky and did not pass the spoon tilt test. This affected 24 residents on a puree diet, potentially due to excessive thickener use, and could lead to difficulties in swallowing or choking.
The facility failed to honor the food preferences of three residents, leading to dissatisfaction and potential nutritional issues. A resident was served green beans despite disliking them, another was incorrectly labeled as lactose intolerant, restricting their preferred dairy options, and a third resident was repeatedly given milkshakes despite disliking milk. These oversights in catering to resident preferences could lead to decreased food intake and weight loss.
The facility failed to maintain safe and sanitary food storage and preparation practices, with chipped racks, ice buildup, and dirty equipment observed in the kitchen. Dented cans were improperly stored, and staff did not fully cover their hair, risking contamination. These deficiencies could affect all 168 residents receiving food and ice.
The facility failed to update their medical director application with the State Agency, resulting in non-compliance with State and Federal regulations. Despite receiving a correction notice, the facility did not address the deficiencies, and the Administrator did not verify the facility's license status, relying on corporate notifications instead.
The facility failed to maintain effective infection control, with issues such as oxygen tubing touching the floor, lack of hand hygiene in the dining room, improper water temperature management, and inadequate use of Enhanced Barrier Precautions during enteral feeding. These deficiencies put residents at risk of infection.
A resident with impaired cognitive function and no representative was improperly given verbal consent for antipsychotic medication without convening the required Bioethics Committee. Facility staff acknowledged the oversight, which violated the policy for residents lacking decision-making capacity.
The facility failed to properly document and communicate discharge information for two residents, leading to potential discontinuity of care. A resident's discharge lacked documentation of vital signs, follow-up instructions, and accurate discharge location. Another resident was discharged without vital signs being documented. These deficiencies highlight lapses in the facility's discharge process.
Failure to Implement Infection Control Practices During Scabies Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program during a scabies outbreak, particularly in the use of contact isolation and handling of contaminated materials for multiple residents. For two residents on contact isolation for dermatitis and suspected scabies, a Restorative Nursing Assistant entered their shared room wearing PPE, assisted one resident to the restroom, then changed only gloves and continued providing care to the other resident while wearing the same gown. The assistant then returned to the first resident without removing gloves or gown. The RNA later acknowledged that both residents were on contact isolation and that both gown and gloves should have been changed between residents to prevent spread of scabies. The DON stated that staff should don gowns and gloves before entering contact isolation rooms and change both between residents. The facility also failed to ensure proper PPE use and staff awareness of isolation status for another resident on contact isolation for unspecified dermatitis. A CNA delivered and set up a breakfast tray for this resident without wearing PPE, then returned to set up a tray for the roommate. The resident’s orders showed contact isolation precautions for four weeks, but an LVN stated the resident was not on contact isolation and instead on Enhanced Barrier Precautions for a wound, and admitted not being sure which residents were on EBP versus contact isolation. The CNA similarly stated she was unsure whether PPE was required when delivering food trays to residents on contact isolation and did not know whether this resident was on contact isolation or EBP, noting she had only worked at the facility for two months and did not know why residents were placed on these precautions. The DON stated that staff should know which residents are on contact isolation versus EBP and should wear proper PPE when delivering food trays and providing care to residents on contact isolation. The Infection Preventionist’s resident line listing for the scabies outbreak was incomplete and did not include two residents who had been roommates of a suspected scabies case. The IP acknowledged that these two residents had been exposed to scabies, were treated, and should have been added to the line list for ongoing monitoring. The DON stated that these residents should have been included on the line list because they were roommates of a suspected scabies resident and that including all affected residents is important so the facility can monitor them for signs and symptoms and notify the physician. The ACDC Scabies Prevention and Control Guidelines reviewed by surveyors indicated that a line listing of symptomatic residents and their contacts should be prepared. The facility also failed to follow its own procedures and external guidelines for handling isolation trash and linens for residents with confirmed or suspected scabies. For a resident with confirmed scabies and another resident on contact isolation to rule out scabies, contact isolation signage and isolation carts were present at the doorways, and trash and soiled linen carts were inside the rooms. A housekeeping staff member, without wearing gloves, removed the isolation trash and soiled linen carts from each room, pushed them along the hallway, tied the clear plastic bags containing isolation trash and linens, and dropped them at a parachute door leading to the laundry room, then returned the empty carts to the rooms. In the soiled laundry room, tied clear bags of soiled linens were observed on top of a large yellow container, and the housekeeping staff member stated he was not sure which bags contained isolation linens. A laundry staff member stated that all linens currently in the soiled laundry room were from non-isolation rooms and that isolation linens were supposed to be collected separately and washed in a dedicated washer and dryer. The laundry supervisor described the facility’s intended process for isolation linens and trash: bringing a cart designated only for isolation to the room doorway, donning gloves and gown, tying and double-bagging trash and soiled linens inside the isolation room, placing them in the cart in the hallway, and transporting them outside the facility so they would not mix with non-isolation linens. The supervisor stated that because the housekeeping staff dropped off isolation linens through the parachute drop-off, they became mixed with regular non-isolation linens, which could contaminate other linens and cause spread of infection. The Infection Preventionist stated that contact isolation rooms had red hampers for trash and soiled linens and that the parachute laundry door was intended for regular soiled linens, not isolation linens, and that mixing laundry with isolation linens could potentially spread scabies to other residents, staff, and visitors. The facility’s scabies policy and the ACDC guidelines reviewed by surveyors specified that linens, towels, and clothing used by affected persons should be bagged inside the resident’s room, handled by gloved and gowned staff without sorting, and laundered in hot water and dried on a hot cycle.
Failure to Notify Resident Representative Holding POA of Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated Resident Representative (RR), who also held Durable Power of Attorney (DPOA), of changes in the resident’s condition on two occasions. The resident, admitted in 2014, had diagnoses including acute panmyelosis, multiple sclerosis, and peripheral vascular disease, and was dependent on staff for all ADLs. An Advance Health Care Directive Acknowledgement Form dated 5/14/2024 identified the RR as the resident’s representative, and a DPOA dated and notarized 7/23/2014 appointed the same RR as attorney-in-fact, effective that date. The resident’s MDS dated 3/19/2026 documented intact cognitive skills for daily decisions, and a History and Physical dated 3/26/2026 indicated the resident had capacity to understand and make decisions. On 3/16/2026, a Change of Condition (COC) form documented that the resident had a new medication for dermatitis and that the resident was notified, but there was no indication that the RR was notified. On 3/18/2026, another COC documented elevated WBC and platelet counts, again indicating only that the resident was notified, with no documentation of RR notification. During concurrent interview and record review on 4/24/2026, the DON confirmed that the COCs from 3/16/2026 and 3/18/2026 did not show RR notification and stated the facility was not aware that the resident had appointed the RR as POA, acknowledging this may have violated the resident’s and RR’s right to be informed. In an interview the same day, the resident and RR confirmed that the resident had an Advance Health Care Directive naming the RR. Facility policies on Resident Rights and Change in a Resident’s Condition or Status required that residents be allowed to appoint a legal representative and that the resident representative be promptly notified of changes in the resident’s condition unless otherwise instructed by the resident, which did not occur in this case.
Failure to Care Plan for Skin Scraping to Rule Out Scabies
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident related to a skin scraping ordered to rule out scabies. The resident was admitted with diagnoses including metabolic encephalopathy, unspecified pruritus, and a history of falls. An H&P documented that the resident had the capacity to understand and make decisions, while a subsequent MDS assessment indicated severely impaired cognitive skills for daily decisions and a need for moderate assistance with ADLs. A change of condition note documented that the resident was placed on contact isolation to rule out scabies, and an order summary showed that a skin scraping was ordered. During an interview and concurrent record review, the Infection Preventionist confirmed that there was no care plan developed for the resident’s skin scraping to test for scabies and stated that the care plan serves as a guide for nurses on what to do when the skin scraping results. The DON also stated that a care plan for skin scraping for scabies should have been developed and that without a care plan, nurses would not have a guide on what to do for a suspected scabies resident. The facility’s policy on Comprehensive Person-Centered Care Plans required a comprehensive, person-centered care plan with measurable objectives, timeframes, and services to meet residents’ needs, reflecting recognized standards of practice, which was not followed in this case.
Failure to Administer Ordered Topical Medication as Prescribed
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the administration of a prescribed topical medication for one resident. The resident was admitted with diagnoses including metabolic encephalopathy, unspecified pruritus, and a history of falls. A History and Physical dated 4/20/2026 documented that the resident had the capacity to understand and make decisions, while an MDS dated 4/24/2026 later indicated severely impaired cognitive skills for daily decisions and a need for moderate assistance with ADLs. A physician’s order dated 4/22/2026 directed that clobetasol propionate 0.05% cream be applied to the resident’s general body topically every day and evening for four weeks for unspecified dermatitis. Review of the Treatment Administration Record for April 2026 showed that the clobetasol application for the evening shift on 4/23/2026 was left blank. During a concurrent interview and record review with the Infection Preventionist on 4/24/2026, the IP confirmed that the physician had ordered clobetasol twice daily and stated that a blank entry on the TAR meant the medication was not given and that the nurse did not follow the order. In a separate interview, the DON stated that the resident’s rashes could worsen because the clobetasol was not administered and that Treatment Nurses were expected to apply clobetasol according to the physician’s order. The facility’s “Administering Medications” policy, last reviewed on 2/20/2026, stated that medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including required time frames, which was not followed in this instance.
Failure to Accurately Document Ordered Contact Isolation Precautions
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one of three sampled residents by not documenting ordered contact isolation precautions on a specific night shift. The resident had been admitted with diagnoses including unspecified emphysema, unspecified dermatitis, and a history of falls. A History and Physical dated 12/5/2025 indicated the resident did not have the capacity to understand and make decisions, while a Minimum Data Set dated 4/2/2026 documented intact cognitive skills for daily decisions. An Order Summary Report dated 4/22/2026 showed a physician order for contact isolation precautions every shift for four weeks due to unspecified dermatitis. However, review of the Medication Administration Record (MAR) for April 2026 revealed that the contact isolation entry for the night shift on 4/22/2026 was left blank. During a concurrent interview and record review with the Infection Preventionist on 4/24/2026, it was confirmed that the MAR entry for contact isolation on 4/22/2026 night shift was blank, which the Infection Preventionist stated meant contact isolation was not documented as ongoing and that the nurses did not complete their documentation task. The Infection Preventionist stated there was no documented evidence that the resident was on contact isolation during that shift and that this could cause confusion in care. In a separate interview, the DON stated that without documentation of contact isolation, it could cause spread of scabies to other residents and staff. Review of the facility’s Charting and Documentation policy, last reviewed on 2/20/2026, indicated that documentation in the medical record must be objective, complete, and accurate, which was not met in this instance.
Failure to Timely Initiate and Complete Ordered Antibiotic Therapy
Penalty
Summary
The facility failed to provide pharmaceutical services by not ensuring timely administration of prescribed antibiotics for a resident with right lower leg cellulitis. The resident was admitted with diagnoses including unspecified multiple sclerosis, acute panmyelosis, and unspecified peripheral vascular disease, and had intact cognitive skills and capacity to make decisions. Physician orders dated 3/14/2026 directed that cephalexin 500 mg and clindamycin 150 mg be given orally four times a day for seven days to treat the cellulitis. The resident was readmitted from a general acute care hospital on the evening of 3/14/2026, but the Medication Administration Record for March 2026 showed that the 9 p.m. doses of both cephalexin and clindamycin were not started as ordered. Progress notes entered on 3/14/2026 at 9:42 p.m. and 9:43 p.m. documented that cephalexin and clindamycin were not available. However, review of the facility’s oral emergency drug supply showed that the e-kit contained cephalexin 250 mg tablets and clindamycin 150 mg capsules at that time. During interviews, the Infection Preventionist and the DON confirmed that the antibiotics were not started on 3/14/2026 and acknowledged that these medications should have been available in the e-kit and started that evening. The facility’s policy on administering medications required that medications be administered in a safe and timely manner, in accordance with prescriber orders and within one hour of the prescribed time. Further review of the resident’s March 2026 MAR showed that cephalexin and clindamycin were also not administered at 9 p.m. on 3/21/2026, resulting in the seven-day antibiotic course not being completed as ordered. The Infection Preventionist stated that because the antibiotics were not started on time on 3/14/2026, the nurses should have extended the medications to complete the full seven days of therapy, and that one dose of each antibiotic was missed, causing an incomplete course of treatment. The DON similarly stated that if the antibiotics were not started as scheduled, they should have been extended to complete the ordered dose. The facility’s antibiotic stewardship policy required that antibiotics be prescribed and administered with complete orders including duration of treatment, and outlined procedures for nurses to follow when removing antibiotics from the emergency supply, including verifying the correct drug and strength and completing pharmacy removal slips.
Unnecessary Scabies Treatment Continued After Negative Diagnostic Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications. The resident was admitted with multiple serious diagnoses, including unspecified multiple sclerosis, acute panmyelosis, and unspecified peripheral vascular disease, and had intact cognitive skills and capacity to make decisions. Hospital records from a recent GACH stay documented scabies as an active problem and treatment with topical permethrin, with infectious disease notes indicating suspected chronic scabies and treatment provided. Upon readmission, the facility obtained orders dated 3/16/2026 for a skin scraping, oral ivermectin weekly for four weeks, and topical permethrin weekly for four weeks, with the indication documented as unspecified dermatitis. The facility’s own documentation showed that a skin scraping for scabies performed on 3/24/2026 was negative. Despite this negative laboratory result, the MAR and TAR indicated the resident continued to receive ivermectin and permethrin on multiple subsequent dates in March and April. The Skin Rash Report referenced the prior hospitalization and scabies treatment, but there was no documentation of confirmed scabies in the facility. The facility’s scabies policy stated that diagnosis may be made by signs and symptoms and that treatment is often followed without scraping, but also noted that ivermectin by mouth should be considered during widespread outbreaks or when topical treatment is unsuccessful, and that a single permethrin treatment is generally adequate. During interviews, the family member reported that the resident had been treated for scabies in the hospital and that, upon return, the facility denied the resident had scabies yet continued scabies treatment. The Infection Preventionist stated that the hospital had treated scabies with permethrin and that, on readmission, permethrin and ivermectin were ordered for unspecified dermatitis, acknowledging these medications are treatments for scabies and that the resident could have received unnecessary medication. The IP indicated that Treatment Nurse 1 obtained the orders from the primary physician for unspecified dermatitis. The DON confirmed the resident was medicated with permethrin and ivermectin without a clear indication for scabies, noted the negative skin scraping, and stated that ivermectin is a treatment for scabies and could be unnecessary medication in this case. The facility’s policy on adverse consequences and unnecessary medications defined an unnecessary drug as one used without adequate indication, which was not met for this resident’s continued treatment.
Failure to Monitor and Document Adverse Effects for Resident on Clindamycin
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship and adverse consequence monitoring policies for a resident who was prescribed clindamycin for right upper and lower leg cellulitis. The resident, admitted with diagnoses including unspecified multiple sclerosis, acute panmyelosis, and unspecified peripheral vascular disease, had documented capacity to understand and make decisions and was dependent on staff for all ADLs. On 3/8/2026, a physician order directed administration of a single 150 mg oral dose of clindamycin from the emergency kit, and the MAR shows the dose was given at 10:26 p.m. The resident’s care plan for antibiotic therapy, initiated on 3/9/2026, included an intervention to assess for signs and symptoms of adverse reactions or side effects and to notify the physician. During interviews and record review, the Infection Preventionist and the DON both stated that residents on antibiotics should be monitored for side effects or adverse effects and that such monitoring should be documented in the resident’s Progress Notes or MAR. Review of the resident’s Progress Notes and MAR for 3/8/2026 showed no documented monitoring for side effects or adverse effects of clindamycin following administration. This lack of documentation and monitoring occurred despite facility policies on Antibiotic Stewardship and on Adverse Consequences, Medication Errors and Unnecessary Medications, which state that antibiotics will be prescribed and administered under the guidance of the antibiotic stewardship program and that residents receiving medications with potential for adverse consequences will be monitored to ensure such consequences are promptly identified and reported, including monitoring mental status and level of consciousness.
Failure to Revise Care Plans After Hospitalization and Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive, person-centered care plans after significant changes in condition and hospital readmissions for two residents. For Resident 1, the admission record showed an original admission on 12/1/2025 and a later readmission with diagnoses including encephalopathy, acute kidney failure, and type 2 diabetes mellitus. An MDS dated 2/27/2026 documented intact cognitive functioning and a need for substantial assistance with personal hygiene and transfers, and moderate assistance with oral hygiene and dressing. A History and Physical dated 3/20/2026 indicated Resident 1 had the capacity to understand and make decisions. On 3/15/2026, a Change of Condition form documented that Resident 1 was transferred to a general acute care hospital (GACH) for evaluation due to altered level of consciousness. The GACH H&P dated 3/18/2026 indicated a diagnosis of opioid intoxication, with a urine drug screen positive for fentanyl. A facility Progress Note dated 3/18/2026 at 5:55 p.m. documented that Resident 1 was readmitted from the GACH. During an interview and concurrent record review on 4/8/2026, the DON confirmed that Resident 1’s care plan did not address the new diagnosis of opioid intoxication and stated that the admitting nurse should have reviewed the GACH records and revised the care plan to update the plan of care with necessary interventions and monitoring. For Resident 2, the admission record showed an original admission on 3/5/2013 and a later readmission with diagnoses including hemiplegia, epilepsy, and depression. An H&P dated 3/26/2026 indicated Resident 2 had the capacity to understand and make decisions, and an MDS documented intact cognitive functioning and a need for moderate assistance with oral hygiene, toileting hygiene, personal hygiene, and dressing. A Change of Condition form dated 3/11/2026 recorded that Resident 2 verbalized wanting to kill another resident at 10 a.m. A Progress Note dated 3/12/2026 documented transfer to the GACH for psychiatric evaluation, and a Progress Note dated 3/24/2026 at 2 p.m. documented readmission to the facility. During an interview and concurrent record review on 4/7/2026, the ADON stated that Resident 2’s care plan did not address the change of condition and hospital transfer for psychiatric evaluation and that the care plan should have been updated with goals and interventions. The facility’s policy on comprehensive person-centered care plans required the interdisciplinary team to review and update the care plan when there is a significant change in condition and when a resident is readmitted from a hospital stay.
Failure to Assess and Authorize Use of Bed as Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the use of physical restraints when a resident’s bed was placed with one side against the wall without appropriate assessment, orders, or care planning. The resident had been admitted with diagnoses including unspecified dementia, age-related osteoporosis, and hypotension, and an MDS dated 1/23/2026 documented severely impaired cognitive skills for daily decision-making and a need for moderate assistance with rolling in bed. During observation, the resident was seen lying in bed with the right side of the bed against the wall. An LVN present during the observation stated that placing a bed against the wall is considered a form of restraint, which requires a physician order, signed consent, and a care plan, none of which were in place for this resident. Further record review and interviews confirmed that there was no physician order, no consent from the resident’s representative, and no care plan addressing the bed being placed against the wall. Another LVN verified that the bed’s position could limit the resident’s movement and acknowledged the absence of documentation supporting its use. The ADON stated that licensed nurses should assess the need for the bed to be against the wall and that such use should be supported by a physician order, consent, and a care plan, and acknowledged that this had not been done. The facility’s restraint policy defined practices that inappropriately utilize equipment to prevent resident mobility as restraints and required assessment, physician order, consent, and care plan, including measures to reduce or eliminate restraint use, none of which were followed in this case.
Failure to Perform Hand Hygiene After Providing ADLs and Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene practices by CNAs following provision of ADLs. Resident 4, who had diagnoses including generalized muscle weakness, difficulty walking, and dementia, had documented self-care deficits and required assistance with ADLs, including incontinent care. The resident’s MDS indicated dependence for showering, substantial assistance with toileting, partial assistance with oral hygiene and dressing, and supervision with eating. During an observation, CNA 2 was seen at the doorway of the resident’s room wearing gloves after providing care, then removing and discarding the gloves in a trash receptacle near the doorway without performing hand hygiene with soap and water or alcohol-based hand rub (ABHR). Shortly afterward, CNA 1 was observed removing and discarding gloves in the same manner and then proceeding to a table to document, again without performing hand hygiene. In subsequent interviews, CNA 1 stated she had provided incontinent care and assisted the resident to activities, acknowledged she removed her gloves upon exiting the room, and confirmed she did not perform hand hygiene using ABHR, despite stating that hand hygiene should be performed after resident care due to the risk of contamination. CNA 2 reported she had provided perineal care with warm water and mild soap, assisted with dressing, and prepared the resident for activities, and confirmed she did not perform hand hygiene after providing care, while acknowledging that hand hygiene should be performed before and after resident contact. The Infection Preventionist stated staff are required to perform hand hygiene before entering and after exiting resident rooms and after providing direct care, and that CNA 1 and CNA 2 should have performed hand hygiene after removing gloves. The Administrator stated hand hygiene is required before and after resident care and after resident contact. Review of the facility’s Handwashing/Hand Hygiene policy showed that all personnel are required to perform hand hygiene before and after direct resident contact, after contact with bodily fluids, after removing gloves, and as the final step after removal of PPE, and that glove use does not replace the requirement for hand hygiene.
Failure to Calibrate Thermometers and Document Cold Storage Temperatures
Penalty
Summary
Surveyors identified a deficiency in safe and sanitary food preparation practices when kitchen staff failed to calibrate food thermometers and to monitor and document refrigerator and freezer temperatures as required. Review of the Thermometer Calibration Log with the Dietary Service Supervisor (DSS) showed that thermometer calibration had not been done or documented for multiple consecutive days, including 3/2, 3/3, and 3/4. Review of the Refrigerator & Freezer Temperature Log showed that the p.m. shift temperatures for multiple refrigerators and freezers on 3/3 were not documented, and the a.m. shift temperatures for 3/4 had not yet been logged. The DSS stated that if temperatures and calibrations are not logged, the facility cannot confirm they were done. During interviews, the Assistant Dietary Supervisor (ADS) explained that cooks are responsible for checking refrigerator and freezer temperatures at the start of the a.m. and p.m. shifts and that thermometers are to be calibrated before temperature checks and logged in the morning and monitored throughout the day. The ADS acknowledged that failure to calibrate thermometers and to record refrigerator and freezer temperatures could result in inaccurate readings and potential foodborne illness, and that undocumented temperatures cannot be verified. The Administrator confirmed that calibration is required daily to ensure accurate temperatures and that refrigerator and freezer temperatures must be taken to prevent food from spoiling or going bad, which could cause residents to become ill. Review of facility policies showed written requirements that thermometers be calibrated before each shift and that dietary staff check and record refrigerator and freezer temperatures at the beginning of each shift, with specified acceptable temperature ranges.
Failure to Implement Ordered Floor Mats for High Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement ordered fall-prevention interventions for a resident assessed as high risk for falls. The resident was admitted with diagnoses including muscle weakness, history of falling, and cerebral infarction, and had a fall risk score of 11, indicating high fall risk. Physician orders dated 2/24/2026 directed the use of a low bed and floor mat to decrease potential injury, and the care plan for fall and injury risk instructed staff to utilize safety and supportive devices as ordered and provide adequate supervision and safety cues. The facility’s Falls and Fall Risk, Managing policy stated that staff will identify interventions based on evaluations and current data to prevent falls and minimize complications. On 3/4/2026, during observation of the resident’s room, surveyors noted a yellow star behind the bed indicating the resident was a fall risk and should have a low bed and floor mats in place, but no floor mats were present. The resident reported a history of falls but did not recall having a mat by the bed. The Infection Preventionist confirmed that the star signified the need for a low bed and floor mats and acknowledged that the absence of floor mats was not following the plan of care and could lead to a fall with possible injury. The Director of Staff Development stated the resident uses two landing mats and confirmed that at the time of observation the mats were not in the room and that the mats are intended to prevent injury when a resident falls. The Administrator also confirmed the resident had an order for floor mats, was a fall risk, and should have floor mats while in bed, and that without them there was potential for a fall resulting in injury or fracture.
Failure to Implement Contact Precautions and Risk Assessment for Suspected and Confirmed C. difficile
Penalty
Summary
The deficiency involves the facility’s failure to implement contact isolation precautions for a resident who developed signs and symptoms consistent with Clostridioides difficile infection (CDI) and was later confirmed positive. The resident was admitted with diagnoses including pulmonary embolism and sepsis and subsequently developed diarrhea meeting the facility’s criteria for suspected CDI on 1/18/2026. A physician ordered a stool test for CDI on that date, but the resident was not placed on contact precautions at the time of suspicion, despite facility policy requiring contact precautions for residents with diarrhea and suspected CDI while awaiting laboratory results. The resident’s change in condition evaluation on 1/20/2026 documented CDI with onset of symptoms on 1/18/2026, and the resident was not placed on contact isolation until 1/20/2026, after the physician ordered contact isolation for a positive CDI result. During this period, the CDI-positive resident continued to share a room with two roommates. One roommate had diffuse large B-cell lymphoma, was actively receiving antineoplastic chemotherapy, and was identified as immunocompromised and at high risk for infection. This roommate’s care plan, initiated later, identified her as at high risk for nosocomial infection and indicated staff should perform hand hygiene and wear gowns and gloves during high-contact activities, but there was no evidence that this high-risk status was used to prevent her from being cohorted with a resident with active CDI. The other roommate had multiple chronic conditions, including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety, and required substantial assistance with ADLs. Both roommates remained in the same room with the CDI-positive resident while an isolation cart and contact precaution sign were posted outside the room. The facility did not complete infection risk assessments for either roommate before or during their cohorting with the resident who had CDI. The DON confirmed there was no documented evidence of infection risk assessments for these roommates between 1/17/2026 and 1/30/2026, and stated that such assessments should have been completed by the Infection Preventionist or a licensed nurse to determine appropriate roommate placement when a resident had an infection. The Infection Preventionist Nurse and DON acknowledged that the immunocompromised roommate should not have been placed with the CDI-positive resident and that the facility failed to follow its own CDI and isolation policies, which required private rooms when possible or cohorting only with low-risk roommates. The facility also failed to inform and educate the two roommates about their potential risk of acquiring CDI and the infection control guidelines they should follow. One roommate reported not understanding why the room was on isolation and stated that staff did not provide any explanation when asked. The other roommate, aware of her compromised immune system and ongoing chemotherapy, stated she was not told why staff were wearing gowns when caring for her roommate and was reassured that it had nothing to do with her, despite her expressed concerns. The Infection Preventionist Nurse confirmed there was no documented evidence that staff notified or educated the roommates about their risk for CDI or appropriate precautions. Additionally, the facility did not monitor the two roommates for signs and symptoms of CDI after their exposure to the infected resident. The Infection Preventionist Nurse stated that no monitoring was conducted for these roommates for CDI-related symptoms such as fever, abdominal pain or spasms, diarrhea, nausea, or vomiting. The Medical Director stated that staff were aware of appropriate infection control measures but failed to implement them, and that staff did not follow facility policy or CDC guidelines regarding cohorting and isolation for CDI. The DON described this as a failure in the facility’s system process, including lack of staff training on isolation precautions and infection risk assessments, which contributed to the deficient practice. The facility’s written policies required that residents with diarrhea and suspected CDI be placed on contact precautions while awaiting lab results, and that residents with diarrhea associated with CDI be placed on contact precautions. The isolation policy further required that residents on contact precautions be placed in a private room if possible, or, if not, that the Infection Preventionist assess risks and cohort only with low-risk roommates. Despite these written requirements, the resident with CDI remained in a shared room with an immunocompromised roommate and another medically complex roommate, without documented risk assessments, without timely initiation of contact precautions at the time of suspicion, without education of roommates about their risk and needed precautions, and without monitoring of the roommates for CDI symptoms. These actions and omissions formed the basis of the cited infection control deficiency under F880.
Removal Plan
- Moved Resident 2 to Room B with no roommates due to immunocompromised condition and initiated RN Supervisor monitoring every shift for 40 days for CDI signs/symptoms.
- Designated Room A as a single isolation room and assigned Resident 1 no roommates.
- Reviewed and revised Resident 2’s care plan to reflect immunocompromised status and that Resident 2 should not share a room with a resident who has an active infection.
- Conducted in-service training for all nursing staff on Infection Control policy, with written quizzes to validate understanding; provided phone/follow-up training for staff not present prior to next shift; removed from schedule any staff who did not complete training until completed.
- Provided one-on-one in-service to the Administrator and DON on the admission process for residents requiring isolation precautions and appropriate cohorting.
- Provided one-on-one in-service training to the Infection Preventionist Nurse on infection control practices, including proper PPE use and appropriate cohorting.
- Conducted record review of all residents with changes in condition to identify residents with signs/symptoms consistent with CDI; found no other affected residents.
- Assessed all residents for CDI signs/symptoms; found no additional affected residents.
- Implemented process for DON and Infection Preventionist Nurse to review all incoming admissions to determine need for isolation/precautions and arrange appropriate room placement/cohorting.
- Implemented Infection Preventionist Nurse tracking log for all residents with active infections, including CDI, to prevent spread.
- Established monthly infection control meetings led by Administrator and IDT to ensure adherence to infection control and PPE policies and to promptly identify/address room placement and cohorting issues.
- Developed a QAPI plan for Infection Control practices including root cause analysis to be reviewed and updated during monthly QAPI meetings for three months to ensure corrective actions are effective and sustained.
Failure to Report Allegation of Misappropriation of Resident Property to SSA
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the State Survey Agency (SSA) as required by regulation and facility policy. A resident admitted with muscle weakness and sepsis had documentation in the History and Physical and Minimum Data Set indicating intact cognitive function and capacity to understand and make decisions. During an interview, the resident reported that a family member visitor took his wallet, left the facility, charged $500 to his credit card, and then returned the wallet and card. The resident stated he had informed the Social Worker of this incident, though he could not recall the exact date and time of either the event or the report. The Social Worker confirmed that the resident had reported that the family member took the wallet and charged $500 to the resident’s credit card, without specifying the date and time. The Administrator acknowledged that the resident had informed the Social Worker of the allegation and that she did not report this allegation of misappropriation of property to the SSA. The facility’s abuse, neglect, exploitation, and misappropriation reporting policy, last reviewed on 8/15/2025, states that all reports of theft or misappropriation of resident property must be reported to local, state, and federal agencies as required, and that suspected misappropriation must be reported immediately to the Administrator and to the state licensing/certification agency, with “immediately” defined as within two hours for allegations involving abuse or misappropriation. Despite this policy, the allegation was not reported to the SSA.
Failure to Care Plan for Immunocompromised Resident at High Risk for Infection
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident who was immunocompromised and at high risk for infection. The resident’s face sheet showed an original admission with a readmission date and diagnoses including diffuse large B-cell lymphoma, encounter for antineoplastic chemotherapy, and acquired absence of kidney. The resident’s MDS indicated intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Despite these documented conditions and functional needs, there was no care plan addressing the resident’s immunocompromised status. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator did not initiate a care plan upon admission to address the resident’s immunocompromised condition related to diffuse large B-cell lymphoma. The DON acknowledged that the care plan should have included interventions such as not cohorting the resident with others who had active infections and that the existing care plan was not comprehensive or person-centered. Review of the facility’s policy on comprehensive, person-centered care plans showed that care plans were required to include measurable objectives and timetables, be derived from a thorough assessment, describe needed services, and reflect recognized standards of practice, which was not done for this resident’s immunocompromised status.
Failure to Revise Care Plans After Cohorting with CDI-Positive Resident
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive, person-centered care plans for two residents after they were cohorted with another resident who had a suspected and later confirmed Clostridium difficile (CDI) infection. Resident 1 was admitted with diagnoses including pulmonary embolism and sepsis, and later developed enterocolitis due to CDI, with symptom onset identified as occurring on 1/18/2026. A physician ordered stool collection for CDI testing on 1/18/2026, and a Change in Condition evaluation completed on 1/20/2026 documented CDI, diarrhea meeting CDI criteria, and placement of Resident 1 on contact isolation. Despite these developments and the infection-control implications, the care plans for the cohorted residents were not updated. Resident 2 had a history of diffuse large B-cell lymphoma, chemotherapy, and acquired absence of a kidney, with an MDS indicating intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Resident 3 had diagnoses including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety disorders, with an MDS showing moderately impaired cognition and a need for substantial/maximal assistance with toileting hygiene, lower body dressing, and footwear. Both residents were cohorted with Resident 1 when CDI was suspected and then confirmed, but their care plans were not revised to reflect this change in condition and exposure risk. During an interview and concurrent record review with the DON on 1/30/2026, it was confirmed that staff did not update the care plans for Residents 2 and 3 when they were cohorted with the CDI-positive resident. The DON stated that licensed staff and the MDS Coordinator were responsible for updating care plans and acknowledged that the existing care plans for these residents were not comprehensive or person-centered in light of the new circumstances. The facility’s own policy on comprehensive, person-centered care plans requires that care plans be derived from thorough assessment, describe services to meet residents’ highest practicable well-being, reflect current standards of practice, and be revised as residents’ conditions change. The failure to revise the care plans after the cohorting event constituted the cited deficiency.
Failure to Monitor Antibiotic Adverse Effects Under Stewardship Program
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship policy by not monitoring a resident for adverse effects of levofloxacin during a prescribed treatment period. The resident was admitted with diagnoses including unspecified acute kidney failure, UTI, and generalized weakness, and was documented as cognitively intact and able to make decisions. An Interact Assessment Form dated 12/23/2025 showed an abnormal WBC of 15.2 and modest right lower lobe pneumonia, after which the physician was notified and ordered levofloxacin 500 mg orally once daily for seven days. The resident’s MAR confirmed administration of levofloxacin from 12/23/2025 to 12/29/2025. The resident’s care plan for pneumonia, initiated on 12/24/2025, included interventions to administer levofloxacin as ordered, monitor for adverse reactions, monitor for progress of status, notify the physician if the intervention was not effective, and monitor vital signs and infection-related symptoms. During interviews and record review on 1/14/2026, the DON stated that residents receiving antibiotics are to be monitored for adverse effects every shift so that any adverse effects can be identified and the physician notified to change the antibiotic if needed. The DON acknowledged there was no documented monitoring for antibiotic adverse effects in the resident’s progress notes from 12/23/2025 to 12/29/2025, except for one entry on 12/26/2025 at 6:06 p.m., and stated that monitoring should have been done every shift. LVN 2 reported that nurses monitor residents on antibiotics for adverse reactions and document in the progress notes whether there was an adverse reaction or not. Review of the facility’s Antibiotic Stewardship policy, dated 12/2016 and last reviewed 8/15/2025, indicated that antibiotics will be prescribed and administered under the guidance of the facility’s antibiotic stewardship program and that training and education will emphasize the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections, and medication interactions. The DON stated the policy did not specify the frequency of monitoring, but that nurses should monitor and document adverse effects of antibiotics every shift. The surveyors determined the facility failed to monitor this resident for adverse effects of levofloxacin from 12/23/2025 to 12/29/2025.
Failure to Care Plan Resident’s Refusal of Restorative Nursing Services
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan to address a resident’s refusal of Restorative Nursing Assistance (RNA) services. The resident was admitted with diagnoses including unspecified acute kidney failure, difficulty in walking, and generalized weakness. A History and Physical and a Minimum Data Set assessment documented that the resident had intact cognitive skills and the capacity to understand and make decisions, and required moderate assistance for transfers and walking. An order was in place for RNA ambulation with a front wheeled walker five times per week. Record review of the resident’s Documentation Survey Report for December showed that on two consecutive days, RNA for ambulation with a front wheeled walker was documented as “not applicable.” One RNA staff member stated that “NA” is used when a resident is in the hospital or not in the facility. However, another RNA staff member reported that on those same two days the resident was present, refused RNA while waiting to be discharged, and that the resident refused RNA three times on one of those days. This RNA staff member acknowledged that no RNA was provided on those days and that the refusals were not reported to the Charge Nurse as required. The DON stated that when a resident refuses RNA services three times, the RNA staff should report this to the Charge Nurse so the Charge Nurse can speak with the resident, determine the reason for refusal, and encourage participation. The DON further stated that a care plan should have been developed to address the resident’s refusal of RNA services, and acknowledged that nurses did not have a guide on how to proceed with the plan of care for this refusal. The facility’s policy on Comprehensive Person-Centered Care Plans requires development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, including services not provided due to the resident’s exercise of the right to refuse treatment, and specifies that assessments are ongoing and care plans are revised as residents’ conditions change. This was not done for the resident’s RNA refusals.
Failure to Provide Ordered Restorative Ambulation Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered Restorative Nursing Assistance (RNA) ambulation services to a resident with mobility limitations and a physician’s order for RNA ambulation five times per week. The resident was admitted with diagnoses including unspecified acute kidney failure, difficulty in walking, and generalized weakness, and was assessed as cognitively intact and able to make decisions. The Minimum Data Set indicated the resident required moderate assistance for transfers and walking. The physician’s order recap and the resident’s care plan both specified RNA ambulation with a front wheeled walker as tolerated, five times a week. However, documentation for two consecutive days showed RNA marked as “not applicable.” During interviews, the Director of Rehabilitation confirmed the resident had been on RNA ambulation since late in the month. RNA 1 explained that “not applicable” is used when a resident is not in the facility or is in a general acute care hospital, but the resident was in the facility on at least one of the days in question. RNA 2 stated that on one of those days the resident refused to walk while waiting to be discharged home and was not actually discharged until the following day. RNA 2 further stated that no RNA ambulation was provided on either of the two days, acknowledged that RNA ambulation should have been provided, and that refusals should have been reported to the charge nurse. The DON stated that providing RNA ambulation helps prevent decline in range of motion and ambulation, and that not providing it could result in weakness and possible falls. The facility’s restorative nursing policy required residents to receive restorative care as needed to promote optimal safety and independence, with goals and interventions outlined in the plan of care, which was not followed for this resident on the identified days.
Failure to Document Physician Notification and Response for Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one resident by not documenting physician notification and response after abnormal lab results were received. The resident was admitted with diagnoses including unspecified acute kidney failure, difficulty in walking, and generalized weakness. A history and physical dated several days after admission indicated the resident had the capacity to understand and make decisions, and a subsequent MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact and that the resident required moderate assistance for transfers and walking. An Interact Assessment Form dated 12/23/2025 showed the resident had an abnormal WBC of 15.2 and modest right lower lobe pneumonia. The form indicated that an LVN notified the physician, who ordered levofloxacin and additional blood tests including a CBC, CMP, and procalcitonin on 12/26/2025. A laboratory test result dated 12/26/2025 at 5:55 p.m. showed low hemoglobin and hematocrit, with a written note indicating the physician was notified on that date. However, when surveyors reviewed the resident’s laboratory results and progress notes with an RN on 1/14/2026, the RN confirmed that the progress notes did not document that the physician was notified of the abnormal blood test results. The RN stated there was no documentation of the time the physician was notified, who called the physician, or the physician’s response, including whether any new orders were given. In a separate concurrent review, the DON also confirmed that the progress notes lacked documentation of physician notification regarding the abnormal blood test result and acknowledged documentation issues in the resident’s medical record. The facility’s charting and documentation policy required that all services, changes in condition, and notifications, including date, time, name and title of the person providing care, assessment data, and notification of the physician, be documented in the medical record. The absence of this required documentation for the abnormal lab result rendered the resident’s medical record incomplete and inaccurate.
Failure to Notify Residents and Representatives of Transfer/Discharge and Appeal Rights
Penalty
Summary
The facility failed to properly notify residents and their representatives of transfers or discharges, as well as their rights to appeal and information regarding bed-hold policies, for two out of three sampled residents. In the case of the first resident, who had severe cognitive impairment and was unable to make decisions, the facility did not ensure that the resident's representative, who held power of attorney and was the legally recognized decision-maker, received the required Notice of Proposed Transfer/Discharge (NTD). Although the NTD was completed and included necessary information about the transfer and appeal rights, it was not signed by the representative, and the representative later confirmed she did not receive the notice. Staff signed the NTD instead of the resident or representative, contrary to facility policy. For the second resident, who was cognitively intact and able to make decisions, the facility also failed to ensure proper notification procedures were followed. The NTD for this resident was signed by a staff member rather than the resident or their representative. Interviews with staff revealed that if the resident or representative was not present at the time of transfer, the NTD was not mailed to the representative as required. The facility's own policy stated that the NTD should be mailed to the representative the next day if not signed in person, but there was no documentation that this occurred. Interviews with facility leadership, including the DON and Administrator, confirmed that the required notifications were not mailed to the residents' representatives and that the facility's policy and procedure for notification and documentation were not followed. The lack of proper notification meant that the residents' representatives were not informed of their right to appeal the transfer or discharge, nor were they provided with contact information for the Ombudsman or the Department, as required by regulation and facility policy.
Failure to Notify Physician of Significant Blood Pressure Drop
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care consistent with professional standards of practice by not notifying the physician after a significant change in blood pressure. The resident, who had diagnoses including unspecified psychosis, unspecified dementia, and essential hypertension, was admitted with orders to monitor for orthostatic hypotension and to notify the physician if there was a 20 mmHg drop in systolic blood pressure (SBP) or a 10 mmHg drop in diastolic blood pressure (DBP) between lying and sitting positions. On the specified date, the resident's SBP dropped by 20 mmHg from lying to sitting position, as documented in the Medication Administration Record (MAR). Despite this significant change, there was no documentation that the physician was notified as required by the physician's order and the facility's policy on changes in a resident's condition. The Director of Nursing confirmed that the nurse did not follow the physician's order to notify the physician of the blood pressure drop and acknowledged that the facility's policy mandates prompt notification of the physician for significant changes in a resident's condition.
Incomplete Documentation of Resident Inventory Lists at Discharge
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents when the discharge portion of their Inventory Lists was left blank. For one resident with severe cognitive impairment and another with intact cognitive skills, the Inventory Lists at discharge were not completed, and in one case, belongings were picked up without being listed or signed for. Interviews with staff revealed that Certified Nursing Assistants were responsible for filling out the Inventory List at discharge, while Social Services was tasked with verifying its completion the following day. However, audits by Medical Records indicated that Social Services was not consistently completing or verifying the Inventory Lists, and there was a lack of communication regarding incomplete documentation. The facility's policy required that residents' personal belongings be inventoried and documented upon admission and updated as necessary, but this was not followed at discharge for the two residents. Staff interviews confirmed that belongings were packed and held by Social Services until picked up by family, but without a completed and signed Inventory List, there was potential for items to be lost. The Administrator acknowledged that the Social Service Department failed to check and complete the inventory lists after discharge, and failed to obtain the necessary signatures when belongings were picked up.
Failure to Follow Medication Administration Parameters
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow a physician's ordered parameters for administering valsartan to a resident with diagnoses including essential hypertension, osteoarthritis, and hyperlipidemia. The physician's order specified that valsartan should be withheld if the resident's systolic blood pressure was less than 110 mmHg or if the heart rate was less than 60 beats per minute. The LVN initially checked the resident's blood pressure and heart rate approximately 30 minutes before attempting to administer the medication, but the resident refused the medication at that time. The LVN then labeled the prepared medication and stored it in the locked medication cart. Later, the LVN administered the previously prepared crushed medications mixed with applesauce to the resident without reassessing the resident's vital signs immediately prior to administration, as required by the physician's order. The facility's policies indicated that medications must be administered in accordance with prescriber orders and that a medication error includes any administration not in accordance with such orders. The Director of Nursing confirmed that parameters such as blood pressure and heart rate must be checked immediately before medication administration to avoid adverse effects.
Failure to Follow Contact Isolation and Infection Control Procedures
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow the facility's infection control policy for a resident who was on contact isolation precautions. The LVN entered the resident's room without wearing the required gown and gloves, despite a contact isolation sign being posted outside the room. The LVN also did not perform hand hygiene before or after entering the room. The resident had severe cognitive impairment and required significant assistance with daily activities, and the need for contact isolation was documented in the resident's records. During medication administration, the LVN prepared crushed medications mixed with applesauce for the resident. When the resident refused the medication, the LVN labeled the medicine cup and placed it inside the locked medication cart, specifically in a section next to a glucometer that is used for multiple residents. The facility's Director of Nursing confirmed that the safest practice would have been to discard the prepared medication to prevent confusion and potential cross-contamination, and acknowledged that placing the medicine cup next to a shared glucometer could contribute to the spread of infection. A review of the facility's policies confirmed that staff are required to wear gloves and gowns when entering rooms under contact precautions, and to perform hand hygiene before and after room entry. The infection control policy also emphasizes maintaining a safe and sanitary environment to prevent the transmission of disease and infections. The observed actions by the LVN did not align with these established procedures.
Incomplete Documentation of Deep Cleaning for Resident on Isolation Precautions
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented after performing a deep clean of the resident's room. The resident, who had diagnoses including chronic kidney disease, muscle weakness, and hyperlipidemia, was placed on contact isolation precautions. Housekeeping staff began deep cleaning rooms in response to rash incidents, with the process involving disinfecting hard-to-reach areas such as beds and curtains. Although a designated Deep Clean Checkoff List for isolation rooms existed, it was not completed for this resident's room. Interviews with housekeeping staff and the Housekeeping Supervisor confirmed that deep cleaning was performed, but no checklist or documentation was completed to verify the specific actions taken. The resident confirmed that her room had been deep cleaned while she was showering. The Director of Nursing stated that accurate and timely documentation is necessary to confirm completed actions and to inform subsequent shifts. Review of facility policy indicated that documentation in the medical record should be objective, complete, and accurate, but this was not followed in this instance.
Failure to Ensure Physician Orders and Monitoring for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with an indwelling urinary catheter by not ensuring there were physician orders for catheter care and monitoring. The resident, who had a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, was admitted with an indwelling urinary catheter and was at risk for urinary tract infection (UTI) as documented in the care plan. Despite this, there were no documented physician orders for catheter care after the resident returned from a general acute care hospital, and the treatment administration records did not show evidence that catheter care was provided or monitored as required. Observations and interviews revealed that nursing staff observed abnormal urine characteristics, including dark yellow, blood-tinged, and cloudy urine with hematuria, but did not report these findings to the attending physician. Both LVNs involved stated that the urine appearance was considered the resident's baseline and therefore did not notify the physician, even though the care plan and facility policy required prompt reporting of such findings. Additionally, one LVN performed a urinary catheter irrigation without a physician order, and another provided catheter care and changed the drainage bag without proper documentation or orders. The facility's Director of Nursing confirmed that there were no urinary catheter care orders in place prior to the observed change in the resident's condition and that the resident's catheter was not being monitored as required. Laboratory results later confirmed the presence of infection, with elevated white blood cell count and bacteria in the urine. Facility policies reviewed indicated that catheter care, monitoring, and documentation were required, and that changes in condition should be promptly reported to the physician, but these procedures were not followed in this case.
Failure to Provide Proper Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide proper care and services for two residents with indwelling urinary catheters, resulting in multiple deficiencies. For one resident with a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, the facility did not monitor urine output for hematuria as required by the care plan and physician documentation. Observations revealed that the resident's catheter tubing was not anchored to the leg, and the urine in the drainage bag was dark yellow to dark red, cloudy, and contained visible sediments and blood. Staff interviews confirmed that the catheter was not secured, and abnormal urine characteristics were not reported to the physician. Additionally, there was no documentation of catheter care or monitoring after the resident returned from the hospital, and catheter care orders were not in place until after the deficiency was observed. Another resident with similar diagnoses and a suprapubic catheter also did not receive appropriate monitoring or care. The care plan required daily treatment of the catheter site and monitoring of urine for sediment, cloudiness, odor, blood, and output. However, observations showed that the resident's catheter was not anchored, there was no wound dressing at the stoma site, and the urine was yellow, cloudy, and contained sediments. Staff acknowledged that these findings indicated a potential infection and should have been reported to the physician, but there was no evidence that this was done. The facility's policy required securement of catheters and prompt reporting of unusual urine findings, but these procedures were not followed. Record reviews and staff interviews further confirmed that both residents' catheters were not properly anchored, and abnormal urine findings were not documented or reported as required. The Director of Nursing acknowledged the failures in monitoring, documentation, and adherence to physician orders and facility policy. These deficiencies resulted in the presence of abnormal urine characteristics and laboratory findings indicating infection or inflammation, without appropriate assessment or intervention by the facility staff.
Failure to Implement Comprehensive Care Plan for Resident with Indwelling Urinary Catheter
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with an indwelling urinary catheter. The resident had a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, and was at risk for urinary tract infection due to the catheter. The care plan noted the need to monitor the catheter and urine characteristics and to report findings to the attending physician, but these interventions were not fully carried out. Observations and interviews revealed that nursing staff noted dark yellow, blood-tinged, and cloudy urine in the resident's catheter, and the catheter tubing was not properly anchored. Despite these findings, the appearance of the urine was not reported to the physician as required. Additionally, after the resident returned from a hospital stay, catheter care orders were not reordered, and there was no documented evidence that catheter care was provided during this period. The Director of Nursing confirmed that the care plan was not followed, and the resident's catheter was not monitored or reported for visible hematuria. Facility policies required comprehensive care plans and complete documentation of services and changes in condition, but these were not adhered to in this case, resulting in a failure to address the resident's identified needs related to the indwelling urinary catheter.
Failure to Set Low Air-Loss Mattress According to Resident Weight
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident at high risk for pressure ulcers received care consistent with professional standards of practice. The resident, who had diagnoses including acute kidney failure, benign prostatic hyperplasia, and anemia, was assessed as having moderately impaired cognitive skills and required maximal assistance for mobility. The resident's care plan and physician orders specified the use of a low air-loss mattress (LALM) for wound care and management, with the mattress setting to be adjusted according to the resident's weight. The resident's most recent documented weight was 116 pounds, and the LALM was supposed to be set at 120 lbs as indicated by a label on the machine. However, during observation, the LALM was found set at 200 lbs, which did not correspond to the resident's actual weight. Both nursing staff and the Director of Nursing confirmed that the mattress should have been set based on the resident's weight and acknowledged that the incorrect setting was not in accordance with the care plan, physician orders, and manufacturer guidelines. This failure to maintain the correct LALM setting placed the resident at risk for the development of pressure ulcers, as the mattress was not providing the intended pressure relief.
Inaccurate Documentation of Resident Meal Intake
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that a CNA documented the resident's meal intake percentages at the correct times. Specifically, the CNA recorded the percentages for breakfast and lunch meals at times that did not correspond to when the meals were actually consumed, as evidenced by multiple entries where both breakfast and lunch intakes were documented at the same time in the afternoon. The CNA acknowledged that the documentation times were inaccurate and that meal intake should be recorded after the resident has eaten. The Director of Staff Development and the Director of Nursing both confirmed that the documentation was inaccurate and did not reflect the resident's actual meal intake for each respective meal. The facility's policy requires that all services and changes in a resident's condition be documented objectively, completely, and accurately to facilitate communication among the interdisciplinary team. The resident involved had multiple diagnoses, including a cervical vertebra fracture, epilepsy, and anemia in chronic kidney disease, and required moderate assistance with eating. The inaccurate documentation resulted in incomplete and inaccurate medical records for the resident.
Failure in Controlled Medication Accountability
Penalty
Summary
The facility failed to maintain a system-wide method of accountability for controlled medications, resulting in the inability to account for 43 doses of Norco 5-325 mg for one resident and an unspecified amount of Oxycodone-Acetaminophen 5-325 mg for another resident. Licensed nurses did not document the administration of controlled substances in the electronic Medication Administration Record (eMAR) for one resident, and there were no records maintained for the transfer of controlled medications from licensed nurses to the Director of Nursing (DON) after the resident was discharged. Additionally, the DON did not investigate discrepancies related to the controlled medication reconciliation for both residents. The report highlights that the DON failed to report the missing controlled medications to the Administrator. Interviews with licensed vocational nurses revealed that the DON would collect controlled medications without requiring signatures or documentation, leading to a lack of evidence that medications were turned over to the DON. The facility's contracted pharmacist confirmed the delivery of 112 tablets of Norco 5-325 mg for one resident, but only 59 tablets were recorded as administered, with 10 remaining in the medication cart, leaving 43 tablets unaccounted for. Furthermore, the report indicates that the DON had access to a universal key that could open all medication carts and controlled medication drawers, bypassing the double-lock system intended for controlled substances. This lack of secure storage and documentation contributed to the missing medications. The facility's policies and procedures for controlled substances, including storage, disposal, and recordkeeping, were not followed, leading to the deficiency.
Removal Plan
- Resident 1 left against medical advice (AMA).
- A complete search of all six medication carts, all two medication rooms, and the controlled medications for disposal inside the controlled medications drawer located in the DON's office for Resident 1's hydrocodone-acetaminophen 5-325 mg was conducted and confirmed a total of ten remaining hydrocodone-acetaminophen 5-325 mg tablets with the corresponding Controlled Medication Count Sheet. A total of 43 tablets of Hydrocodone Acetaminophen 5-325 mg were confirmed missing and unaccounted for.
- The DON was suspended pending completion of investigation.
- The Assistant Director of Nursing (ADON), who also had access to the DON's office where the controlled medications for disposal were stored, will be placed on suspension upon her return from her medical leave.
- In-services were provided to licensed nurses regarding the controlled medication policy, covering the following: All licensed nurses are responsible for maintaining accurate records of controlled medication receipts, medication administrations, disposal, loss of medications or possible drug diversion.
- Documentation of controlled medication disposal will be maintained accurately in a log, including the following endorsement information: Medication information, including name, strength and quantity, Releasing nurse signature, Receiving party (Acting DON) signature, Disposal information including the medication information, medication name, strength and quantity.
- Proper procedures for controlled medications when discharging a resident to a lower level of care, including residents who discharged AMA will be implemented. The discharging licensed nurse will be responsible for controlled medication(s) when discharging a resident to a lower level of care, including AMA. Obtain a physician's order specifying the controlled medications, including the name and quantity of medications to be provided to the resident or responsible party, if indicated. The discharging licensed nurse must document the released quantity of the controlled medication in the Controlled Medication Count Sheet with signatures from the licensed nurse and receiving party. For resident(s) who are discharging on weekends, the licensed nurse will continue to keep and account for the discharged controlled medications stored in the controlled medication drawer inside the medication cart until the Acting DON is back on duty to receive the controlled medications.
- During the in-services, the licensed nurses were observed for possible signs of being under the influence of using controlled medications. No staff were identified to be under the influence of using controlled medications.
- The local Police Narcotic Unit was notified and went onsite to obtain information regarding the missing controlled substances.
- The Maintenance Supervisor replaced the locks to the DON's office, the storage room inside the DON's office, and the controlled medications drawer inside the storage room of the DON's office.
- The universal key that accesses all medication carts, including controlled medications drawer, was discontinued and removed from the facility.
Failure to Document and Assess Use of Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints without proper documentation and procedures. For six of the eight sampled residents, the facility did not have the necessary physician's orders, restraint assessments, informed consents, and care plans in place for the use of various restraints. These included pad alarms, beds placed against walls, and pillows tucked under sheets, which were used without the required documentation and assessments to ensure their appropriateness and safety. For instance, Resident 31 was observed with a pad alarm used for fall prevention, but there was no physician's order, informed consent, or restraint assessment documented. Similarly, Resident 5 was also using a pad alarm without the necessary documentation. Resident 30 and Resident 33 had their beds placed against the wall, which was considered a restraint, yet lacked the required physician's orders, informed consents, and care plans. Resident 63 had a pillow tucked under the sheet, used as a restraint, without the necessary documentation. The facility's policy and procedure on the use of restraints require a thorough assessment, physician's order, informed consent, and a care plan before implementing any restraint. However, these steps were not followed for the residents involved, leading to the deficiency. The lack of proper documentation and adherence to the facility's policy potentially compromised the residents' rights and safety.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards of care by not rotating subcutaneous insulin administration sites for four residents, leading to potential adverse effects. Resident 49, who was admitted with type 2 diabetes mellitus and other serious health conditions, received insulin injections repeatedly in the same area, contrary to physician orders and manufacturer's guidelines. The Assistant Director of Nursing (ADON) confirmed that the insulin administration sites were not rotated as required, which could lead to tissue injury and affect medication absorption. Similarly, Resident 159, with a history of diabetes and other health issues, also received insulin injections without proper site rotation. The ADON verified that the insulin administration sites were not rotated according to the physician's orders, increasing the risk of lipodystrophy and amyloidosis. The facility's policy and procedure on insulin administration, which mandates site rotation, was not followed, as confirmed by the ADON. Resident 73 and Resident 100 also experienced similar deficiencies in insulin administration. Both residents had orders for insulin injections with specific instructions to rotate injection sites, which were not adhered to. Interviews with nursing staff and the Director of Nursing (DON) confirmed the failure to rotate injection sites, which could lead to discomfort and malabsorption of medication. The facility's policy on insulin administration, which emphasizes the importance of site rotation, was not implemented effectively, as evidenced by the repeated use of the same injection sites for these residents.
Inaccurate LALM Settings and Labeling Lead to Pressure Ulcer Care Deficiencies
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for four residents by not accurately labeling and setting Low Air Loss Mattresses (LALM) according to the residents' weights or physician orders. For Resident 124, the LALM machine was set at 160 pounds, but it was incorrectly labeled to be set at 200 pounds, despite the resident's weight being 163 pounds. This discrepancy was acknowledged by the Licensed Vocational Nurse and the Director of Nursing (DON), who stated that the incorrect labeling could lead to improper settings and potential skin issues. Resident 100's LALM was set at 200 pounds per a physician's order, although the resident weighed 151 pounds. The machine was mislabeled with a setting of 160 pounds, which could confuse staff and result in incorrect settings. The DON confirmed that the LALM should be set according to the resident's weight unless otherwise specified by a physician, and the mislabeling was likely due to a previous resident's settings not being updated. Resident 30's LALM was set at 160 pounds, while the resident's weight was 131 pounds, and the machine was labeled for 120 pounds. The DON and staff confirmed that the LALM should be set closest to the resident's weight to maximize its pressure-reducing function. Additionally, Resident 110 was using a LALM without a physician's order, and the mattress was set to 280 pounds, far above the resident's weight of 138 pounds. The DON acknowledged that a physician's order is required for LALM use to ensure appropriate treatment, and the incorrect setting could lead to ineffective pressure injury prevention.
Deficiencies in Resident Safety and Equipment Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to increased risks of injury. For Residents 124, 2, and 174, fall mats intended to prevent injury during falls were improperly used, with furniture or equipment placed on top of them. This misuse was observed during room inspections, where a side table, an oxygen concentrator, and a folded metal chair were found on the mats, potentially compromising their effectiveness and increasing the risk of injury during falls. Staff interviews confirmed that such placements could depress the mats and reduce their ability to cushion falls, contrary to the facility's policy and manufacturer's guidelines. Resident 334's safety was compromised due to a malfunctioning bed pad alarm, which was found unplugged during an inspection. The alarm was intended to alert staff if the resident attempted to get out of bed unassisted, a critical safety measure given the resident's need for substantial assistance with mobility. Staff interviews revealed that the alarm's functionality was not checked as required every shift, leaving the resident at risk of falls and injury. For Resident 129, the facility failed to properly assess and document the risks associated with placing the resident's bed against the wall, a practice considered a restraint. Despite the resident's severe mobility limitations and the potential for entrapment, the bed was positioned against the wall without a current physician's order, risk assessment, or informed consent. This oversight was acknowledged by staff, who noted that the necessary procedures were not followed upon the resident's readmission, thus increasing the risk of injury due to improper restraint use.
Improper Medication Disposal in Medication Room
Penalty
Summary
The facility failed to properly dispose of medications in one of the two inspected medication rooms, specifically Medication Room Station 1. During an observation and interview with the Director of Nursing (DON), it was noted that the pharmaceutical waste bin contained a mixture of intact loose medication tablets and capsules, medications in manufacturer bottles, insulin pens, and an albuterol inhaler. The DON acknowledged that the medications were not disposed of according to facility policy, which requires medications to be disintegrated by pouring liquid over them to prevent retrieval. Additionally, aerosolized inhalers, which can explode, were improperly disposed of in the pharmaceutical waste bin. The facility's policy and procedures, as reviewed, indicated that medications should be disposed of in accordance with federal, state, and local regulations. The policy specified that medications should be taken out of their original containers and mixed with an undesirable substance to ensure they are not retrievable. However, the observation revealed that the pharmaceutical waste bin did not contain the required amount of liquid to disintegrate the medications, leaving them in their original form and easily accessible for potential misuse or diversion. The review of the facility's policies on medication destruction and hazardous waste pharmaceuticals highlighted that the facility did not adhere to the guidelines for managing non-hazardous pharmaceuticals, hazardous waste, and controlled substances. The improper disposal practices observed in Medication Room Station 1 did not align with the Environmental Protection Agency's recommendations and the facility's own policies, increasing the risk of medication diversion and accidental exposure to harmful substances for residents and staff.
Failure to Monitor Specific Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the use of quetiapine, an antipsychotic medication. The resident, who was moderately impaired with cognitive skills for daily decision-making, was prescribed quetiapine to manage psychosis manifested by an inability to process internal stimuli causing anger or stress. However, the facility did not provide specific, measurable target behaviors related to the use of quetiapine, as required by their policy and procedures. Interviews with licensed vocational nurses and the Director of Nursing revealed that the quetiapine order lacked monitoring for specific types of internal stimuli causing anger or stress. This lack of specificity led to variations in behavior monitoring by different licensed nurses, resulting in inconsistent documentation. Consequently, the physician could not accurately assess the effectiveness of the medication therapy for the resident. The facility's policies and procedures, which were reviewed, indicated that when medications are prescribed for behavioral symptoms, documentation should include specific target behaviors. Additionally, psychotropic medications should only be used when clinically indicated to treat a specific condition. The facility's failure to adhere to these policies resulted in the potential use of unnecessary psychotropic medication for the resident.
Medication Errors Result in 6.9% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate during a medication administration task. Two medication errors were identified involving two residents. Resident 28 did not receive a prescribed dose of oyster shell calcium, a dietary supplement for bone support, due to the medication not being available in the medication cart. This omission was observed during a medication administration round, and the Licensed Vocational Nurse (LVN) acknowledged the error, stating the importance of timely medication availability. Resident 39 was also affected by a medication error when a dose of docusate, prescribed for constipation, was not administered at the scheduled time. The LVN responsible for this resident's care admitted to overlooking the administration of the medication, which was due in the morning. The Director of Nursing (DON) confirmed these omissions as medication errors, emphasizing the facility's policy that medications should be administered within a 60-minute window of the scheduled time. The facility's policies and procedures, last reviewed in September 2024, outline the guidelines for medication administration, including the requirement to compare the medication and dosage schedule with the resident's Medication Administration Record (MAR) and to administer medications according to physician orders. The policy also defines a medication error as any deviation from physician orders or accepted professional standards, with omission being a specific example. These errors were acknowledged by the facility's staff and were considered deviations from the established protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of epoetin alfa and insulin. For one resident, epoetin alfa was administered despite physician orders to hold the medication if hemoglobin levels were greater than or equal to 10. This resident received two doses of epoetin alfa with documented hemoglobin levels of 10.1, contrary to the physician's instructions. The Director of Nursing confirmed that this constituted a significant medication error, as it could lead to adverse consequences such as increased hemoglobin levels and thickened blood. Additionally, the facility did not adhere to physician orders and standards of practice regarding the rotation of insulin injection sites for four residents. Insulin was repeatedly administered in the same areas, which could lead to tissue injury, lipodystrophy, and amyloidosis. The Assistant Director of Nursing verified that the insulin administration sites were not rotated as required, and this was considered a medication error due to non-compliance with physician orders and professional standards. The facility's policies and procedures, as well as manufacturer's guidelines, emphasize the importance of rotating injection sites to prevent adverse effects. However, the facility staff failed to follow these guidelines, resulting in medication errors for multiple residents. The Director of Nursing acknowledged that not rotating insulin administration sites could cause discomfort and malabsorption of the medication, further highlighting the significance of these deficiencies.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage medications in accordance with both facility and manufacturer guidelines, leading to several deficiencies. In one instance, an expired bottle of anastrazole, a medication used for breast cancer, was found in a medication room. The Director of Nursing (DON) acknowledged that the medication, which had an expiration date of November 2024, should have been removed and discarded by the end of that month. The failure to do so meant that the medication could potentially be used, despite having lost its potency, which is crucial for treating breast cancer effectively. Another deficiency was observed with a budesonide and formoterol inhalation aerosol for a resident with chronic obstructive pulmonary disease (COPD). The inhaler was not labeled with an open date, making it impossible to determine its expiration. According to the manufacturer's guidelines, the inhaler should be used or discarded within three months of opening. The Licensed Vocational Nurse (LVN) present during the inspection confirmed that the inhaler was not labeled as required, which could lead to the use of an expired and ineffective medication, potentially exacerbating the resident's COPD. Additionally, expired loperamide medication boxes were found in two medication carts, and an ipratropium with albuterol inhalation solution was improperly stored outside its protective foil pouch. The loperamide boxes, intended for facility stock, were not removed by their expiration date, and the inhalation solution, which should have been used or discarded within two weeks of opening, was found outside the foil pouch beyond this period. These oversights were acknowledged by the LVNs and the DON, who stated that such expired medications would not be effective in treating the residents' conditions, potentially leading to adverse health outcomes.
Failure to Follow Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion sizes, impacting the nutritional needs of 123 out of 168 residents on regular texture diets. During an observation, it was noted that a staff member did not level off the scoop when serving rice and carrots, resulting in larger portions being served to residents. This action was contrary to the facility's policy, which requires the use of proper utensils to ensure correct portion sizes as per the menu spreadsheet. The Dietary Supervisor confirmed that the staff member was not following the correct procedure, which could lead to unintentional weight gain and complications for diabetic residents due to excessive calorie and carbohydrate intake. The facility's policies and procedures, reviewed on 9/20/2024, emphasize the importance of following standardized recipes and portion sizes to meet the nutritional needs of residents. The menu, prepared by a dietitian, is designed to ensure nutritional adequacy and variety, with specific portion sizes indicated for each food item. The failure to follow these guidelines was observed during a meal service, where the staff did not adhere to the portion size of 1/3 cup for Cajun Country Rice as specified in the recipe. This oversight highlights a lapse in the facility's adherence to its own policies, potentially affecting the health and well-being of the residents.
Failure to Prepare Puree Foods to IDDSI Standards
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for residents on a puree diet, specifically IDDSI Level 4, which requires food to be smooth, moist, and not sticky. During an observation, it was noted that the puree spinach was too sticky and did not pass the spoon tilt test, a method used to assess the stickiness and consistency of pureed foods. The Dietary Supervisor and Registered Dietitian acknowledged that the puree spinach did not fall from the spoon as required, indicating it was too sticky, potentially due to excessive thickener use. This deficiency was observed during a review of the facility's daily menu and food preparation process. The facility's policies and procedures, as well as the IDDSI guidelines, require that pureed foods pass specific tests to ensure they are safe for residents with dysphagia. The failure to adhere to these guidelines and the facility's own policies could lead to residents rejecting the food, experiencing difficulty swallowing, or even choking. The issue was identified as affecting 24 out of 168 residents on a puree diet.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to meet the food preferences of three residents, leading to dissatisfaction and potential nutritional issues. Resident 34, who was cognitively intact and dependent on staff for eating, was served green beans despite having a documented dislike for them. The Registered Dietitian (RD) confirmed that the kitchen staff was aware of this preference but could not explain why the resident was served green beans. This oversight in catering to Resident 34's food preferences could lead to decreased food intake and weight loss. Resident 1, who had moderately impaired cognition and required assistance with eating, was incorrectly labeled as lactose intolerant on their meal ticket. This error restricted the resident from receiving dairy products they enjoyed, such as yogurt and cheese, except for milk, which they disliked. Despite informing the kitchen staff of the mistake, the issue persisted, causing the resident to feel deprived of certain foods. The Director of Nursing (DON) acknowledged the error and noted that it limited the resident's meal options, potentially leading to dissatisfaction and weight loss. Resident 20, who had intact cognitive function and specific dietary preferences, was repeatedly served milkshakes despite expressing a dislike for milk and milk alternatives. The resident's care plan emphasized adherence to food preferences, yet the dietary team failed to honor this, resulting in frustration and refusal to eat. The Social Services Assistant (SSA) noted the issue and planned to inform the dietary team to prevent further occurrences. The facility's policy required the Dietary Service Supervisor to update meal tickets according to resident preferences, but this was not effectively implemented, leading to the deficiencies observed.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Three out of five green racks in the walk-in refrigerator had chips with paint coming off, which could harbor dirt and bacteria, leading to cross-contamination of residents' food. Additionally, the walk-in freezer had ice crystal buildup on the roof and right-side wall, potentially indicating a malfunction that could prevent food from being stored at the correct temperatures. The reach-in refrigerator's bottom shelves had dirt and dust buildup, and the dry storage room floor had food debris, both of which could lead to contamination. Further observations revealed that the juice machine filter was dusty, and the racks were sticky and dusty to touch. The scoops and paper drawer contained food debris, and the ice container had white residue buildup. The coffee machine's hot waterspout had dried mineral water buildup. These conditions were not in compliance with the facility's policies and procedures, which required daily cleaning and sanitizing of equipment and surfaces to prevent cross-contamination and foodborne illnesses. Additionally, ten dented cans were stored with non-dented cans in the dry storage area, posing a potential hazard due to the risk of botulism. Two trayline staff members were observed with their hair not fully covered by hairnets while serving food, which could lead to physical contamination of the food. These deficiencies were identified as having the potential to result in harmful bacteria growth and cross-contamination, affecting all 168 medically compromised residents who received food and ice from the kitchen.
Failure to Update Medical Director Application
Penalty
Summary
The facility failed to follow through with their submitted application to the State Agency 1 (SA 1) for the change of medical director, which is a requirement for compliance with State and Federal regulations. The application was initially sent on 6/30/2022 and received by SA 1 on 7/7/2022, but it was found to be non-compliant due to missing information or needed corrections. Despite receiving a 30-Day Correction letter from SA 1 on 1/9/2023, the facility did not address the deficiencies, leading to a determination on 3/1/2023 that the application was still not in compliance. The Administrator (ADM) assumed her position on 3/21/2024 and admitted during interviews that she did not verify the facility's license status or the active medical director, relying instead on corporate notifications. The ADM acknowledged the importance of having a medical director listed on the facility's license to oversee physician and clinical services but was unaware of the potential implications of not having this information updated. The facility's policy and procedure indicate that the medical director is responsible for ensuring compliance with regulations, but the ADM did not have proof of mailing for the resubmitted corrections in March 2023.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. One significant issue involved the improper handling of oxygen nasal cannula tubing for a resident with acute respiratory failure. The tubing was observed touching the floor, which was confirmed by a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) as a contamination risk. The facility's policy required that the tubing be kept off the floor, but this was not adhered to, placing the resident at risk of infection. Another deficiency was noted in the dining room, where staff failed to perform hand hygiene before distributing food trays and assisting residents with eating. Additionally, residents were not offered the opportunity to sanitize their hands before meals. This lapse in protocol was confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the importance of hand hygiene in preventing food-borne illnesses. The facility's policy clearly stated the need for handwashing before and after direct care and eating, but this was not followed. Further issues included the failure to maintain appropriate water temperatures to prevent Legionella growth, improper use of sit-to-stand slings, and inadequate hand hygiene by a Certified Nursing Assistant (CNA) when assisting multiple residents with feeding. Additionally, a Licensed Vocational Nurse (LVN) did not implement Enhanced Barrier Precautions (EBP) while administering enteral feeding to a resident with a gastrostomy tube, despite the facility's policy requiring gown and glove use for such procedures. These deficiencies collectively highlighted significant lapses in the facility's infection control practices, putting residents at risk of acquiring infections.
Failure to Obtain Proper Informed Consent for Resident Lacking Capacity
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the informed consent process for a resident who lacked the capacity to make medical decisions. Resident 37, who was diagnosed with dementia, bipolar disorder, and other mental health conditions, was admitted without a resident representative. Despite the resident's impaired cognitive function and lack of capacity to make medical decisions, as indicated in their medical records, the facility obtained verbal consent from the resident for the administration of an antipsychotic medication, Zyprexa. This action was contrary to the facility's policy, which requires the involvement of a Bioethics Committee when a resident lacks capacity and does not have a representative. Interviews with facility staff, including a Licensed Vocational Nurse, Registered Nurse, Social Services Director, and Director of Nursing, confirmed that the informed consent was not obtained correctly. The staff acknowledged that the Bioethics Committee should have been convened to address the resident's treatment plan. The facility's policy mandates that when a resident lacks capacity for informed consent, a Bioethics Committee meeting should be held, including the resident's primary physician and other interdisciplinary team members. However, this procedure was not followed, leading to the deficiency in the informed consent process for Resident 37.
Deficiencies in Discharge Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication of discharge information for two residents, leading to potential discontinuity of care. For Resident 54, the facility did not document vital signs prior to discharge, failed to provide special instructions for follow-up with a gastrointestinal physician, and did not accurately document the discharge location address and contact information. The discharge was facility-initiated due to the resident's health improvement, but the necessary documentation and communication were not completed as required. Resident 54's discharge process was marked by several lapses. The Licensed Vocational Nurse (LVN) responsible for the discharge did not document the resident's vital signs, did not complete the post-discharge plan of care, and failed to go over the medications with the resident. The LVN also did not document the discharge location address, relying instead on information relayed by a Registered Nurse (RN) supervisor. The Director of Nursing (DON) emphasized the importance of documenting vital signs and discharge information accurately to ensure a safe transition of care. For Resident 75, the facility also failed to document vital signs prior to discharge. The resident was discharged home with a family member, but there was no documentation of the vital signs at the time of discharge. The facility's policy and procedure require that details of the transfer or discharge be documented in the medical record, including the resident's new location and a summary of their medical condition. The lack of documentation and communication in these cases highlights deficiencies in the facility's discharge process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burbank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Griffith Park Healthcare Center | 0 mi | — | 35 | 1 |
| Alameda Care Center | 0.1 mi | — | 15 | 0 |
| Dreier's Nursing Care Center | 1.7 mi | — | 3 | 0 |
| Broadway Manor Care Center | 2.5 mi | — | 17 | 0 |
| Royal Palms Post Acute | 2.5 mi | — | 34 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.