Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Cheviot Hills Post Acute during CMS and state inspections, most recent first.
The facility failed to implement its transfer/discharge policy by not providing required orientation and caregiver training to a responsible party before a high fall-risk resident with HTN, DM, CHF, moderate cognitive impairment, and substantial/maximal ADL assistance needs was discharged home. OT and PT notes documented falls, poor safety awareness, and the need for precautions, with therapy staff stating the resident required minimal to moderate assistance and cueing for ambulation and transfers. Both therapy staff and the ADON confirmed that no caregiver training or orientation was provided or documented for the responsible party, despite policy requiring resident/representative notification, orientation, and documentation for discharges.
A resident with schizophrenia, HTN, and MDD with psychotic features, and documented severe cognitive impairment requiring substantial/maximal assistance with ADLs, was receiving Quetiapine (Seroquel) 100 mg PO daily without documented informed consent. The ADON reported that antipsychotic consents are required on admission and with new orders and must include the medication name, dose, route, and frequency, but confirmed there was no consent on file for this antipsychotic. Facility policy on informed consent for psychotropic drugs required disclosure of reasons for use, benefits, risks (including black box warnings), and alternatives to the resident or RP, yet this process was not completed for the resident’s Seroquel order.
A resident with schizophrenia, HTN, MDD with psychotic features, and severe cognitive impairment was receiving Quetiapine (Seroquel) for MDD with psychotic features manifested by inconsolable screaming, but the facility did not develop or implement a comprehensive, individualized care plan for either the antipsychotic medication or the monitoring of psychotic behaviors. Despite physician orders specifying Quetiapine dosing and the need for behavior monitoring, and facility policies requiring care plans for behavioral symptoms and medications, there was no behavior monitoring care plan and no medication care plan. As confirmed by the ADON, this resulted in the resident’s psychotic behaviors and potential adverse drug reactions going unmonitored.
A resident admitted with sequelae of cerebral infarction, DM, and heart failure was assessed on admission as having excessive dry skin to the face and BLE, but no individualized care plan was developed to address this skin abnormality. The ADON acknowledged that dry skin is a skin abnormality that must be care planned and confirmed that no such care plan existed. The DON stated that not accurately assessing the dry skin could have resulted in broken skin or infection. Review of facility P&P showed that the IDT is required to develop a comprehensive person-centered care plan with measurable objectives and timeframes for all identified needs, including skin problems, but this was not done for this resident’s dry skin.
A resident with a history of stroke, DM, and heart failure was admitted with excessive dry skin on the face and bilateral lower extremities, but nursing staff did not obtain treatment orders or develop a care plan for this condition. Although the admission assessment documented dry skin, subsequent weekly head‑to‑toe assessments by CNs and LVNs failed to record it, and the ADON later confirmed these assessments were inaccurate. Staff interviews showed that CNs are expected to report skin abnormalities to charge nurses, LVNs typically obtain A + D ointment orders for dry skin, and RNs are responsible for comprehensive assessments and care plans, yet these processes did not result in an accurate assessment or care plan for the resident’s dry skin, contrary to facility policy and scope‑of‑practice requirements.
A resident with significant medical needs was found to have excessive dry skin on the face and overgrown toenails, despite requiring substantial assistance with ADLs. Staff observations and interviews confirmed the hygiene issues, and the care plan did not address the resident's specific skin care needs. Facility policy required support for hygiene and grooming, but this was not consistently provided.
A resident with multiple complex medical conditions, including OSA and use of BiPAP, was not accurately assessed in the MDS, as both the diagnosis of OSA and the BiPAP treatment were omitted. The ADON confirmed these omissions during review, despite facility policy requiring comprehensive and consistent documentation.
A resident with multiple diagnoses, including OSA and a history of hypercapnic respiratory failure treated with BiPAP, did not have a care plan developed for OSA or BiPAP use. The absence of this care plan was confirmed during record review and interview with the ADON, despite facility policy requiring comprehensive care planning for all identified needs.
A resident with multiple chronic conditions and at risk for pressure injuries was admitted with a physician's order for left foot treatment, but the facility did not develop a care plan to address this need. The DON confirmed that interventions for the left foot were not care planned, despite facility policy requiring comprehensive care planning and regular updates based on resident condition.
A resident with multiple risk factors for pressure injuries did not receive consistent skin monitoring or timely reporting of changes, as required by physician orders and facility policy. Staff failed to apply prescribed ointment and did not report redness and a developing wound on the resident's left heel, despite the resident voicing concerns and preventive measures being in place.
The facility did not ensure dietary cooks followed the menu and used a recipe for lunch, leading to potential food preparation errors. Observations revealed missing or incorrectly dated food items and a lack of a written recipe for the meal being prepared. Interviews confirmed that cooks were memorizing recipes, contrary to facility policy requiring standardized recipes.
The facility failed to maintain safe food storage and preparation practices, risking foodborne illness for 89 residents. Observations revealed improperly labeled food in the refrigerator and a lack of recipes for meal preparation. Interviews indicated inadequate staff training and improper cooling methods for leftovers, contrary to facility policies.
A facility failed to promote dignity during meal assistance when a CNA was observed feeding a resident while standing, contrary to the policy requiring staff to be seated at eye level. The resident, with a history of metabolic encephalopathy and other conditions, was dependent on assistance for eating. The facility's policy emphasizes maintaining resident dignity and ensuring safe eating practices.
A facility failed to complete and submit the annual MDS assessment within the required timeframe for a resident with multiple diagnoses, including epilepsy and bipolar disorder. The resident was totally dependent on staff for all ADLs and had severely impaired cognition. The last MDS assessment was completed months before the due date, and the facility's policies and job descriptions required timely completion and submission of assessments.
A facility failed to conduct a PASRR Level 1 assessment for a resident with schizophrenia and major depression, leading to potential inappropriate placement and management. The resident was admitted with these diagnoses, and the PASRR letter indicated no need for Level II screening. However, the facility did not follow up on the necessary PASRR Level II evaluation. Interviews revealed staff lacked experience and training in PASRR procedures, contributing to the oversight.
The facility failed to complete and maintain PASRR Level I evaluations for three residents, impacting their psychiatric care. A resident with bipolar disorder and another with schizophrenia did not have their mental illnesses indicated in their PASRR Level I, preventing necessary Level II evaluations. Another resident qualified for a Level II evaluation, which was not conducted. The Admission Director admitted to errors due to insufficient training.
The facility failed to maintain proper narcotic disposal procedures, as the DON did not keep records of medications collected for disposal, potentially leading to diversion. Additionally, an incorrect PASRR Level 1 screening was submitted for a resident with schizophrenia and major depression due to inadequate training of the Admission Director. These deficiencies highlight issues in the facility's adherence to policies, impacting resident care.
A resident with multiple health issues, including fractures and mobility problems, missed a crucial orthopedic follow-up appointment due to the facility's failure to coordinate transportation and appointment scheduling. The case manager, responsible for these tasks, was absent, leading to the oversight. The facility's policy requires social services to manage such referrals and transportation, which was not followed.
The DON failed to properly store and discard medications, leaving them accessible in an unlocked container in his office. The medications were not dissolved as required, posing a risk for diversion. The facility's policy mandates secure storage and proper disposal methods, which were not followed.
A resident experienced a delay in receiving a substitute meal after expressing dissatisfaction with the breakfast served. Despite requesting an alternative at 7:15 am, the resident waited over two hours before receiving a substitute meal. Staff interviews indicated a delay in the kitchen's preparation of the substitute, contrary to the facility's policy on accommodating food preferences.
A resident was bitten by a spider due to the facility's failure to maintain a pest-free environment. Despite recent pest control measures, a CNA observed a spider near the resident's room. The Maintenance Supervisor confirmed scheduled fumigation, but the incident indicates a lapse in the pest control program's effectiveness.
A resident with a history of falls and cognitive impairments was left unattended by a CNA while sitting on the side of the bed, resulting in a fall and multiple rib fractures. The resident required substantial assistance with daily activities and was identified as a fall risk. Despite this, the CNA left the resident unsupervised, leading to the incident and subsequent hospital transfer.
A resident with a history of sepsis and diabetes, and an indwelling catheter, exhibited chills on two occasions, but the facility failed to notify the physician as required by the care plan. This led to the resident developing altered mental status and being transferred to a hospital, where she was diagnosed with sepsis and a UTI.
A resident with intact cognitive skills refused assistance from a specific CNA due to negative past interactions. Despite this, another CNA brought the refused CNA into the resident's room to assist with care, violating the resident's right to choose their caregiver. The facility's policies, which emphasize resident participation in care planning, were not followed.
The facility failed to protect a resident from abuse, resulting in one resident punching another, causing a cut to the lip. The incident involved a resident with dementia and another with major depressive disorder and anxiety. The investigation revealed a lack of behavioral monitoring and documentation for the resident with dementia, contributing to the incident.
The facility failed to obtain a physician's order for behavior monitoring and implement behavior monitoring for a resident with dementia, leading to an altercation where another resident punched the first resident in the face. The lack of monitoring and documentation contributed to the incident, despite the facility's policy on behavior management.
Failure to Provide Caregiver Orientation Prior to Discharge of High Fall-Risk Resident
Penalty
Summary
The facility failed to follow its Transfer or Discharge policy by not providing required orientation and caregiver training to the responsible party of a resident discharged home. The resident had diagnoses including HTN, DM, and CHF, and an MDS showing moderate cognitive impairment and a need for substantial/maximal assistance with most ADLs such as toileting hygiene, bathing, dressing, and footwear. Therapy documentation from OT and PT noted a history of falls, poor safety awareness, and the need for precautions. A physician’s order directed discharge to home on the day after the resident’s last covered day. Interviews with therapy staff and the ADON confirmed that no caregiver training or orientation was provided to the resident’s responsible party before discharge. The COTA stated the resident required minimal to moderate staff assistance for walking to ensure safety and positioning and could fall without that level of assistance, and confirmed no caregiver training or orientation was given. The PTA reported the resident was impulsive, confused, and required verbal and tactile cueing, with transfer assistance needs ranging from minimal to moderate, and confirmed he was not asked to provide caregiver training. The ADON stated that a proper and safe discharge included caregiver education and confirmed there was no documented evidence of such training, despite the facility’s policy requiring resident/representative notification, orientation, and documentation in the medical record for transfers and discharges.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
Facility staff failed to ensure that a resident and/or the resident’s responsible party were informed in advance of the risks and benefits of the antipsychotic medication Quetiapine (Seroquel), thereby not obtaining informed consent prior to its use. The resident was admitted with diagnoses including schizophrenia, hypertension, and major depressive disorder with psychotic features, and had a physician’s order dated 3/11/2026 for Quetiapine Fumarate 100 mg by mouth once daily for major depressive disorder with psychotic features. The resident’s Minimum Data Set dated 3/6/2026 documented severe cognitive impairment and a need for substantial/maximal assistance with most ADLs, indicating that the resident was not independently managing daily tasks. During an interview and concurrent record review with the ADON, it was stated that consents for antipsychotic medications are to be completed upon admission and whenever there is a new order, and that such consents must include the medication name, dosage, route, and frequency. The ADON confirmed there was no consent on file for Seroquel 100 mg for this resident, despite the existing order. The facility’s policy and procedure titled “Informed Consent for Psychotropic Drugs,” reviewed 2/2026, defined informed consent as disclosure of material information, including reasons for use, benefits, risks (including black box warnings), and alternatives, to allow the resident or representative to accept, refuse, or revoke consent. The absence of a documented consent for Seroquel showed that this process was not followed for the resident.
Failure to Care Plan and Monitor Antipsychotic Therapy and Psychotic Behaviors
Penalty
Summary
The facility failed to develop and implement an individualized, comprehensive care plan with measurable objectives and timetables for a resident receiving Quetiapine (Seroquel) for major depressive disorder with psychotic features manifested by inconsolable screaming. The resident was admitted with diagnoses including schizophrenia, hypertension, and major depressive disorder, and had severe cognitive impairment requiring substantial to maximal assistance with most ADLs. Physician orders directed Quetiapine administration, including a dose increase associated with psychotic features manifested by inconsolable screaming, and the resident was to be monitored for psychotic behaviors. However, review of the resident’s care plans showed there was no care plan addressing the use of Seroquel or the monitoring of psychotic behaviors. During an interview and concurrent record review with the ADON, it was confirmed that care plans are required for residents being monitored for behavioral issues such as aggressive behaviors and yelling, and for medications so staff know what interventions to carry out. The ADON acknowledged that there was neither a behavior monitoring care plan nor a medication care plan for Seroquel for this resident. This omission occurred despite facility policies requiring an individualized comprehensive care plan with measurable objectives and timetables to meet residents’ medical, physical, mental, and psychosocial needs, and a behavior management policy requiring evaluation of behavioral symptoms, use of non-pharmacologic interventions as first-line approaches, and inclusion of behaviors and interventions in the care plan. As a result, the resident’s psychotic behaviors and potential adverse drug reactions were not monitored.
Failure to Care Plan for Resident with Documented Dry Skin
Penalty
Summary
Surveyors identified that the facility failed to develop and implement an individualized, person-centered care plan for a resident who was admitted with documented dry skin to the face and bilateral lower extremities. The resident’s admission assessment, completed in the evening on the date of admission, recorded excessive dry skin under the body check section. Despite this documented skin abnormality, a review of the resident’s care plans showed there was no care plan addressing dry skin. The facility’s Assistant Director of Nursing (ADON) stated in interview that dry skin is considered a skin abnormality that must be care planned and confirmed that the resident was admitted with dry skin to the face and both legs but had no corresponding care plan. The resident’s medical record indicated admission with diagnoses including sequelae of cerebral infarction, diabetes mellitus, and heart failure. The Director of Nursing (DON) stated that not accurately assessing the resident’s dry skin could have resulted in broken skin or infection. Review of the facility’s policy and procedure titled “CARE PLAN COMPREHENSIVE” showed that the Interdisciplinary Team, in coordination with the resident and/or representative, is required to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified needs from the comprehensive assessment, including incorporation of identified problem areas and associated risk factors. The failure to create a care plan for the resident’s dry skin was inconsistent with this policy and represented the cited deficiency.
Failure to Assess and Care Plan Dry Skin for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with documented dry skin was properly assessed and care planned by nursing staff with the appropriate competencies and within their scope of practice. On admission, Resident 2’s initial assessment documented excessive dry skin on the face and bilateral lower extremities. The resident had significant medical diagnoses including sequelae of cerebral infarction, diabetes mellitus, and heart failure, and the MDS later documented mild cognitive impairment and a need for assistance with multiple ADLs. Despite the documented dry skin at admission, there were no physician orders for skin ointments or protectants for dry skin in the resident’s record over several months. Review of Resident 2’s care plans showed there was no care plan addressing dry skin, even though the ADON stated that dry skin is considered a skin abnormality that must be care planned. The ADON confirmed that Resident 2 was admitted with dry skin to the face and both legs but that this condition was not reflected in the care plan. Additionally, weekly head‑to‑toe assessments completed by night shift charge nurses on multiple dates did not indicate the presence of dry skin, which the ADON acknowledged was inaccurate. This demonstrated that the ongoing assessments did not accurately capture the resident’s skin condition. Interviews with staff further clarified the facility’s assessment and reporting processes. An LVN stated that A + D ointment is typically ordered for residents with dry skin and that CNs report skin abnormalities to charge nurses, who then assess residents and report changes in condition to the RN Supervisor. The RN Supervisor stated that full body assessments are completed on admission, readmission, or change of condition. Facility job descriptions for LVNs and RNs emphasized providing nursing care within the scope of practice and ensuring baseline and periodic comprehensive assessments and care plans are completed. The facility’s care plan policy required that identified problem areas and risk factors be incorporated into comprehensive care plans and that assessments be ongoing with care plans reviewed and revised as new information emerges. The Board of Vocational Nursing and Psychiatric Technicians guidance indicated that LVNs cannot perform certain types of assessment, underscoring that a licensed nurse with the appropriate skill set did not complete or document an accurate assessment and care plan for Resident 2’s dry skin.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene and grooming for one resident with multiple medical conditions, including Type 2 Diabetes Mellitus, sequelae of cerebral infarction, and dysphagia. Upon admission, the resident was noted to have excessive dry skin on the face and both lower legs, and required substantial to maximal assistance with showers and baths. The resident's care plan addressed self-care performance deficits related to impaired balance and limited mobility, but did not include interventions for the excessive dry skin. Observations revealed the resident had visible dry, white/gray flakes of skin on the face and overgrown toenails. Staff interviews confirmed these findings, with a nurse acknowledging the condition was unacceptable and a CNA admitting the toenails should have been reported to the charge nurse. Further review indicated that although the resident was scheduled for a shower and had reportedly received one, the issues with dry skin and overgrown toenails persisted. The facility's policy required that residents unable to perform activities of daily living independently receive appropriate support for hygiene and grooming, but this was not consistently implemented for the resident in question. The lack of timely intervention and communication among staff contributed to the ongoing issues with the resident's personal hygiene and grooming.
Failure to Accurately Document Diagnoses and Treatments in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment in the Minimum Data Set (MDS) for one resident. The resident was admitted with multiple diagnoses, including heart failure, cellulitis, muscle weakness, morbid obesity, hypertension, and obstructive sleep apnea (OSA). The resident's hospital history and physical also documented hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy. However, upon review of the resident's MDS, it was found that the diagnosis of OSA was not included in Section I - Active Diagnoses, and the use of BiPAP was not documented in Section O - Special Treatments, Procedures, and Programs. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that both the OSA diagnosis and BiPAP treatment were missed in the MDS assessment. The facility's policy and procedures require that comprehensive assessments reflect information from progress notes, care plans, and resident observations/interviews, but this was not followed in this case. This omission had the potential to affect the resident's plan of care and delivery of services.
Failure to Develop Care Plan for OSA and BiPAP Use
Penalty
Summary
The facility failed to develop a care plan addressing obstructive sleep apnea (OSA) for a resident who was admitted with multiple diagnoses, including OSA, heart failure, cellulitis, muscle weakness, morbid obesity, and hypertension. The resident's hospital history indicated she experienced hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy, resulting in improvement. Despite these significant medical issues, a review of the resident's care plans confirmed that no care plan was created for OSA or the use of BiPAP. The resident was assessed as having intact cognition but required staff assistance for bed mobility, bathing, dressing, personal hygiene, and supervision for eating and oral hygiene. During an interview and record review, the ADON verified the absence of a care plan for OSA or BiPAP and acknowledged that this could impact the resident's overall health. The facility's own policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to address all identified needs, but this was not done for the resident's OSA.
Failure to Develop Care Plan for Left Foot Treatment
Penalty
Summary
The facility failed to develop a care plan addressing left foot treatments for a male resident admitted with multiple diagnoses, including peripheral vascular disease, Type 2 diabetes mellitus, atherosclerosis, and other chronic conditions. The resident was identified as being at risk for developing a pressure injury and was dependent on staff for activities such as toileting, personal hygiene, and transfers. Despite a physician's order to apply A&D ointment to the resident's left foot and toes for excessive dryness and to monitor for skin breakdown, no care plan was created to address these specific needs. During an interview and record review, the DON confirmed that the left foot treatment order should have been care planned, especially given the resident's risk factors for pressure injuries. The facility's own policies required comprehensive, interdisciplinary care planning for prevention and wound treatments, as well as regular review and updates to care plans based on changes in resident condition. However, the care plan for this resident did not include interventions for the left foot, and the omission was acknowledged by facility leadership.
Failure to Monitor and Report Skin Changes Leading to Pressure Injury Risk
Penalty
Summary
A deficiency occurred when staff failed to monitor and report changes in a resident's skin condition, specifically redness on the left heel, to the attending physician. The resident, an older male with significant medical history including peripheral vascular disease, diabetes, atherosclerosis, and a partial foot amputation, was identified as being at risk for pressure injuries and was dependent on staff for most activities of daily living. Despite physician orders to apply A&D ointment to the left foot for excessive dryness and to monitor for skin breakdown every shift, staff inconsistently applied the ointment and did not consistently monitor or report changes in the skin condition. The resident reported concerns about developing a pressure ulcer on the heels to both facility staff and the physician, but felt these concerns were not addressed. Observations revealed that heel protector boots, intended as a preventive measure, were not consistently used as ordered. Staff interviews confirmed that the ointment was not applied on the day of observation and that the CNA did not notice or report any redness. When the LVN finally assessed the left heel, a reddened area with a black scab was found, and the resident exhibited pain upon palpation. Facility policy required staff to observe for signs of potential or active pressure injury daily and to notify the physician of any significant changes. However, the lack of timely reporting and intervention for the observed skin changes on the resident's left heel constituted a failure to follow these protocols, resulting in a deficiency related to pressure ulcer prevention and care.
Failure to Follow Menu and Recipe in Food Preparation
Penalty
Summary
The facility failed to ensure that dietary cooks followed the menu and used a recipe for lunch on a specific date. During an initial kitchen observation, it was noted that several food items in the walk-in refrigerator were either not labeled with a date or were dated incorrectly. Additionally, during an observation of the food recipe binder, it was found that there was no recipe for the lunch being prepared, which was chicken noodle casserole. The Dietary Supervisor admitted that the menu was in their office and that the cooks were memorizing the recipe instead of following a written one. Interviews with the Dietary Supervisor and a dietary cook revealed that the lack of a written recipe could lead to food being prepared incorrectly, potentially making residents sick. The facility's policy and procedures, reviewed prior to the incident, stated that menus should meet the nutritional needs of residents and that standardized recipes should be developed and used in food preparation. However, these policies were not followed, as evidenced by the absence of a recipe for the meal being prepared.
Deficiency in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, which had the potential to result in harmful bacteria growth and foodborne illness for all 89 medically compromised residents. During an initial kitchen observation, several containers of cooked food in the walk-in refrigerator were noted to be improperly labeled or unlabeled, with some items not having a date. Additionally, the food recipe binder lacked a recipe for the chicken noodle casserole being prepared, and the Dietary Supervisor admitted that the menu was not available to the cooks, who were instead relying on memorization. Interviews with dietary staff revealed further issues, including a lack of recent skills competency assessments for the cooks and improper cooling methods for leftover food. The night shift cook did not follow the cooling down method for food cooked the previous day, and the leftover food was already stored in the refrigerator without proper cooling. The Registered Dietician confirmed that storing leftover cooked foods improperly could lead to foodborne illnesses. The facility's policy and procedures emphasized the importance of adhering to safe food handling practices, including rapid cooling of potentially hazardous foods, which was not followed in this instance.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff promoted dignity while assisting a resident during meals. Specifically, a Certified Nursing Assistant (CNA) was observed feeding a resident while standing, rather than sitting at eye level as required by the facility's policy. This practice was noted during a meal observation, where the CNA was standing to the right side of the resident while feeding them. The CNA acknowledged that she was supposed to be seated beside the resident to assist with feeding, which is in line with the facility's policy to maintain resident dignity and ensure safe eating practices. The resident involved had a medical history that included metabolic encephalopathy, paralytic syndrome following cerebral infarction, hypertension, and contractures of both knees. The resident was dependent on assistance for eating, oral hygiene, and dressing, among other personal care needs. The facility's policy on dignity emphasizes caring for residents in a manner that promotes their well-being and self-esteem. The Assistant Director of Nursing confirmed that CNAs are required to be seated at eye level when assisting residents with eating to ensure proper chewing and swallowing, as well as to uphold the resident's dignity.
Failure to Complete Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete and submit the annual comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe for a resident. The resident was originally admitted on November 3, 2023, and readmitted on May 17, 2024, with diagnoses including epilepsy, bipolar disorder, hemiplegia, and hemiparesis. The resident was totally dependent on staff for all activities of daily living and had severely impaired cognition. The last MDS assessment for the resident was completed on July 30, 2024, and the annual assessment was overdue as it should have been completed by November 1, 2024. During a review with the MDS Coordinator, it was confirmed that the annual MDS assessment was overdue, and the coordinator acknowledged that the MDS is a complete record of the resident's care. The Director of Nursing also stated that the MDS should be completed and submitted according to CMS timeframes. The facility's policy and procedures, as well as the MDS/RAI Coordinator's job description, indicated that assessments should be completed and transmitted within required timeframes, which was not adhered to in this case.
Failure to Conduct PASRR Level 1 Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct a Preadmission Screening and Resident Review (PASRR) Level 1 assessment for a resident diagnosed with mental illness, specifically schizophrenia and major depression. The resident was admitted with these diagnoses, and the PASRR letter indicated a negative result for Level I screening, suggesting no need for Level II screening. However, the facility did not follow up on the PASRR Level II for the resident, which was necessary given the resident's mental health conditions and medication regimen, including Trazadone, Risperdal, Aripiprazole, and Clozaril. Interviews with facility staff revealed a lack of experience and training in PASRR procedures. The Admission Director, who was responsible for ensuring PASRR Level 1 was received upon admission, had minimal training and relied on licensed nurses to review the PASRR Level 1. The Assistant Director of Nursing and the Director of Nursing acknowledged the oversight and the need for a PASRR Level II evaluation, which was not conducted. This oversight was attributed to a failure in the facility's process to ensure proper PASRR assessments were completed, potentially leading to inappropriate placement and management of the resident's mental health condition.
Failure to Complete PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening Resident Review (PASRR) Level I was obtained and maintained in the residents' charts for three sampled residents. Resident 1 was readmitted with diagnoses including bipolar disorder, anxiety, and depression, yet the PASRR Level I did not indicate a diagnosis of mental illness, leading to a lack of a Level II evaluation. Similarly, Resident 2, who was readmitted with schizophrenia and major depression, also did not have a PASRR Level I indicating a mental illness, resulting in no Level II evaluation. Resident 74, admitted with schizophrenia and depression, qualified for a PASRR Level II evaluation, but it was not conducted upon admission. The Admission Director admitted to submitting incorrect PASRRs due to a lack of training, which was only received after the errors occurred. The Assistant Director of Nursing acknowledged that Resident 74 should have been rescreened for PASRR Level II upon admission. The Director of Nursing confirmed that incorrect completion of PASRRs could affect psychiatric treatment for residents. The facility's policy stated that the Admissions Director or Social Worker should ensure PASRR completion for all potential residents, but this was not adhered to, leading to the deficiency.
Deficiencies in Narcotic Disposal and PASRR Screening
Penalty
Summary
The facility failed to maintain proper procedures for the disposal of narcotics, as the Director of Nursing (DON) did not keep a log or records of medications collected for disposal by a medication waste management company. During an interview, the DON admitted to not knowing the process of preventing diversion once the medications are picked up, nor did he have an answer for preventing theft of narcotics from an unlocked bucket in his office. This lack of knowledge and procedure could potentially lead to the diversion of medications. Additionally, the facility submitted an incorrect Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident who was admitted with diagnoses including schizophrenia and major depression. The Admission Director (AD) acknowledged submitting the incorrect PASRR and admitted to not receiving adequate training on completing and submitting PASRR Level 1 or Level 2. This error in the PASRR process could affect the necessary and required treatment for the resident. The facility's policies and procedures require the Director of Nursing to be knowledgeable and competent in their duties, including overseeing nursing practices and developing staff training programs. However, the DON's lack of knowledge regarding narcotic disposal and the AD's insufficient training on PASRR processes highlight deficiencies in the facility's adherence to these policies, potentially impacting the quality of care provided to residents.
Failure to Coordinate Orthopedic Follow-Up for Resident
Penalty
Summary
The facility failed to provide necessary social services to Resident 244 by not following up on an orthopedic evaluation appointment. Resident 244, who was admitted with multiple diagnoses including fractures, gout, hyperlipidemia, prostate cancer, and mobility issues, had an intact cognition and required varying levels of assistance with daily activities. Despite having a scheduled orthopedic follow-up appointment, it was canceled without informing the resident of the reason or who canceled it. This oversight was identified during an initial tour when the resident mentioned the missed appointment. The case manager, responsible for coordinating referrals and appointments, acknowledged the missed appointment, citing her absence as the reason. She explained her usual process of arranging transportation and negotiating costs for private pay residents like Resident 244, who lacked transportation insurance. The Director of Nursing emphasized the importance of follow-up appointments for assessing treatment progress and adjusting care plans. The facility's policy indicated that social services should coordinate referrals and transportation for medical services based on physician evaluations and orders, which was not adhered to in this case.
Improper Storage and Disposal of Medications
Penalty
Summary
The Director of Nursing (DON) failed to store and discard controlled and non-controlled medications according to the facility's policy and procedures. During an observation and interview, it was noted that medications were stored in a large blue and white bucket with an unlocked screw-on top in the DON's office, which was shared with the Assistant Director of Nursing (ADON). The medications were whole, intact, and retrievable, and were not mixed in any solution to dissolve them, making them easily accessible. The DON stated that the narcotics are disposed of with the pharmacist once a month, but there was no log for the medication waste management company to sign upon pickup, and the DON was unaware of the process to prevent diversion once the medications were picked up. The facility pharmacist confirmed that the medications should be destroyed by adding a solution called drug buster to dissolve them, but he never witnessed the DON using this solution. The pharmacist emphasized that the container should be closed and locked to prevent drug diversion. The facility's policy requires that all unused controlled substances be retained in a securely locked area until disposal, and staff should contact the provider pharmacy if unsure of proper disposal methods. The failure to follow these procedures posed a risk for medication diversion and potential harm to residents.
Failure to Provide Timely Meal Substitutes
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences, resulting in a significant delay in meal service. Resident 294, who was admitted with medical diagnoses including hypertension and muscle weakness, was observed on the morning of December 9, 2024, with a breakfast tray containing oatmeal that appeared watery and unappetizing. The resident, whose cognition was intact and could make decisions regarding medical care, expressed dissatisfaction with the meal, stating it was not hot and tasted bad. After requesting a substitute meal at 7:15 am, the resident waited over two hours before receiving an alternative meal of two sausage patties at 9:15 am. Interviews with staff revealed that the delay was due to the kitchen not promptly preparing the substitute meal. A Certified Nursing Assistant confirmed the resident's request for a substitute and noted the prolonged wait time. The Dietary Supervisor acknowledged the delay and stated that typically, substitutes do not take two hours to prepare. The facility's policy requires the Dietary Manager to discuss food preferences with residents and provide suitable substitutes if preferred items are unavailable, which was not adhered to in this instance.
Pest Control Deficiency Leads to Resident Spider Bite
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in a spider bite incident involving Resident 294. The resident, who was admitted with medical diagnoses including hypertension and muscle weakness, was bitten by a spider, highlighting the facility's inability to ensure a homelike environment free of pests. During an observation, a Certified Nursing Assistant (CNA) reported seeing a spider on the wall near the resident's room, although she mentioned not having seen other insects except for occasional gnats. The Maintenance Supervisor stated that the facility's pest control company was scheduled to fumigate soon and that the facility had been treated two weeks prior. Despite these measures, the presence of spiders persisted, indicating a lapse in the effectiveness of the pest control program. The facility's policy mandates an ongoing pest control program to keep the building free of insects and rodents, yet the incident with Resident 294 suggests a failure in implementation. The Administrator acknowledged the expectation of a pest-free environment and indicated that immediate action would be taken upon spotting pests.
Resident Left Unattended Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a known history of falls and cognitive impairments. On 11/5/2024, a Certified Nursing Assistant (CNA) left the resident unattended while sitting on the side of the bed, which led to the resident falling and sustaining multiple rib fractures. The resident was subsequently transferred to a General Acute Care Hospital for further evaluation and treatment. The resident had been identified as a fall risk due to impaired mobility and cognitive decline, requiring substantial assistance with activities of daily living. Despite these known risks, the CNA left the resident unsupervised, contrary to the facility's fall management policy, which mandates appropriate interventions for residents at risk of falls. Interviews with staff and family members confirmed the resident's fall risk status and the inappropriate action of leaving the resident unattended, which directly contributed to the incident.
Failure to Notify Physician of Resident's Condition
Penalty
Summary
The facility failed to implement its policy and procedure by not ensuring prompt physician notification for a resident who exhibited symptoms of chills on two separate occasions. The resident, who had a history of sepsis and diabetes mellitus, was admitted with an indwelling catheter and a care plan that required monitoring and reporting of signs and symptoms of urinary infection, including chills. Despite this, the resident's physician was not notified when the resident was observed shaking and was only provided with blankets and hot packs. As a result of this oversight, the resident later developed altered mental status and was found to be hypotensive with low oxygen saturation. The resident was subsequently transferred to a General Acute Care Hospital, where she was diagnosed with sepsis and a urinary tract infection. The Assistant Director of Nursing confirmed that the physician should have been notified promptly, as chills were a symptom that should have been monitored according to the resident's care plan.
Violation of Resident's Right to Choose Caregiver
Penalty
Summary
The facility failed to respect a resident's right to make informed decisions regarding their care, specifically in choosing who provides that care. The resident, who had intact cognitive skills and the capacity to make medical decisions, explicitly refused assistance from a particular CNA due to previous negative interactions. Despite this, CNA 1 brought CNA 2 into the resident's room to assist with hygiene care, against the resident's wishes. The resident expressed dissatisfaction with CNA 2's presence and behavior, stating that CNA 2 was rude and irritating. The resident's care plan emphasized the importance of providing consistent and trusted caregivers, as well as seeking the resident's input to make their stay meaningful. The facility's policies also supported the resident's right to participate in care planning and treatment decisions. However, these policies were not adhered to in this instance, as CNA 1 involved CNA 2 in the resident's care despite the resident's clear refusal. This action violated the resident's rights and the facility's own policies, as confirmed by interviews with the resident, CNA 2, and the Director of Nursing.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in an incident where one resident punched another in the face, causing a cut to the lip. Resident 1, who has unspecified dementia and lacks the capacity to understand and make decisions, was found with redness on the right side of the face and a minor skin tear on the upper lip after being punched by Resident 2. Resident 2, who has major depressive disorder and anxiety disorder, claimed that Resident 1 was going through his personal belongings and scratched him, prompting Resident 2 to defend himself by punching Resident 1. The investigation revealed that Resident 1's care plan did not include specific timeframes, initiation dates, or revision dates, and there were no orders to monitor Resident 1's behavior despite his dementia diagnosis. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that there were no behavioral monitoring orders for Resident 1, and his behavior was not documented in his medical chart or electronic medical record (eMAR). The DON acknowledged the importance of monitoring residents with dementia to prevent such incidents and stated that the charge nurse could initiate a care plan without a doctor's order. The facility's policies and procedures for behavior management and abuse prevention were reviewed, indicating that the interdisciplinary team should identify underlying causes of residents' behavior and ensure appropriate treatment. However, the lack of monitoring and documentation for Resident 1's behavior contributed to the incident, highlighting a deficiency in the facility's ability to protect residents from abuse and ensure their safety.
Failure to Monitor Resident with Dementia Leads to Altercation
Penalty
Summary
The facility failed to obtain a physician's order for behavior monitoring and implement behavior monitoring for signs and symptoms of dementia for Resident 1. Resident 1, who was diagnosed with unspecified dementia and exhibited agitated and disruptive behavior, did not have a physician's order for behavior monitoring documented in their medical records. This lack of monitoring led to an incident where Resident 2, who had major depressive disorder and anxiety disorder, punched Resident 1 in the face, resulting in a cut to Resident 1's lip. Resident 1 was found on Resident 2's bed, which triggered the altercation. Resident 1's care plan indicated a goal to reduce behavioral problems but lacked specific timeframes, initiation dates, or revision dates. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that there were no orders to monitor Resident 1's behavior, and no documentation of Resident 1's behavior was found in the medical chart or electronic medical record (eMAR). The DON and LVN both acknowledged the importance of behavior monitoring for residents with dementia to ensure safety and prevent incidents like the one that occurred. Resident 2's records showed that they had a physician's order to monitor for episodes of agitation, screaming, and aggressive behaviors. However, the lack of similar monitoring for Resident 1, who had dementia and was prone to wandering and confusion, contributed to the altercation. The facility's policy on behavior management emphasized the need for appropriate treatment and services for residents diagnosed with mental disorders, but this was not adequately implemented for Resident 1, leading to the deficiency identified in the report.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Overland Terrace Healthcare & Wellness Centre, Lp | 0.1 mi | — | 2 | 0 |
| Southern California Hosp At Culver City D/p Snf | 0.6 mi | — | 9 | 0 |
| Meadowbrook Behavioral Health Center | 1.6 mi | — | 14 | 0 |
| Vista Del Sol Care Center | 1.9 mi | — | 3 | 0 |
| Mar Vista Country Villa Healthcare & Wellness | 1.9 mi | — | 3 | 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.