Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 Pasadena Palace Tcu during CMS and state inspections, most recent first.
A resident with a feeding tube, who was totally dependent on staff and at risk for weight loss and dehydration, did not have their enteral feeding administration set changed every shift as ordered by the physician. Evidence from a family member and confirmation by the DON showed the set was not changed for three days, contrary to both physician orders and facility policy.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
A resident with multiple mental health and physical diagnoses was not readmitted to the facility after discharge from a GACH, despite being medically stable and beds being available. The facility's Administrator refused readmission, citing the resident's need for a private room due to a dog and prior behavioral issues, even though facility policy required residents to be allowed to return within the bed hold period.
A resident with depression, anxiety, and borderline personality disorder was identified as a danger to self and others after expressing intentions to cause harm. Despite physician orders for hospital transfer and psychiatric consultation, the resident refused these interventions, and the facility did not implement 1:1 observation, monitor or document behaviors, or develop a care plan to address the refusals. The lack of monitoring and intervention led to the resident being found unresponsive from an intentional medication overdose, requiring emergency hospitalization and intensive care.
A resident with a history of depression, anxiety, and borderline personality disorder was found unresponsive with opened prescription medications and alcohol in their possession, which were brought in from an outside pharmacy despite facility policy prohibiting such items. Staff interviews and records confirmed that required checks for contraband were not performed, resulting in the resident's hospitalization for an apparent overdose.
Two residents were administered antibiotics for UTIs without meeting the required McGeer criteria, as the facility failed to complete antibiotic stewardship assessments and did not document necessary clinical symptoms. Nursing staff confirmed that antibiotics were given based solely on positive urine cultures, without following established protocols for appropriate antibiotic use.
The facility did not have a designated Infection Preventionist (IP) with specialized training for nearly a month, with IP duties being performed by a registered nurse and other licensed nurses who lacked IP certification. The previous IP had left several months earlier, and current staff covering the role did not have the required training, contrary to facility policy.
A resident reported being physically abused by another resident, but staff failed to notify the State Survey Agency, ombudsman, and law enforcement within the required two-hour window. Although internal incident reports were completed and residents were separated and assessed, the event was not reported externally as required by facility policy. Staff interviews revealed misunderstandings about reporting obligations, and a review of policy confirmed that immediate reporting was necessary but not followed.
A resident with multiple mental health diagnoses and no cognitive impairment reported to staff that a male visitor had attempted to forcefully kiss her. Although the allegation was communicated up the chain of command, the Administrator did not report the incident to the State Survey Agency and ombudsman within the required 2-hour window, instead delaying notification for several days, contrary to facility policy.
A resident with a physician-ordered vegetarian diet and no cognitive impairment was served pizza containing chicken, despite clear documentation of her dietary preference and facility policy requiring adherence to such preferences. The incident was confirmed by both kitchen and nursing staff after the resident reported the issue.
A resident with significant mobility impairments and a history of heart disease and traumatic brain injury was transferred from a wheelchair to bed by a CNA without the required second staff member, despite clear assessments indicating a two-person assist was necessary. The resident slid to the floor during the transfer and was subsequently sent to the hospital. Staff interviews confirmed knowledge of the two-person assist requirement, but it was not followed at the time of the incident.
A resident with a documented vegetarian diet and food intolerances was repeatedly served meals containing meat, despite clear physician orders and care plan instructions. The resident experienced distress and physical symptoms after consuming or discovering meat in her food. Staff interviews confirmed that the dietary preferences were known and documented, but existing tray-checking procedures failed to prevent these incidents.
A resident with severe cognitive impairment and a history of anxiety-related leg kicking was not monitored or documented for this behavior, despite being at risk for fractures. The care plan did not include interventions to address the repetitive kicking, and staff confirmed that no monitoring or documentation occurred. The resident subsequently sustained multiple left foot fractures, likely due to repeated kicking of the bed's footboard, in violation of facility policy on resident safety and supervision.
A resident with severe cognitive impairment and multiple diagnoses was prescribed lorazepam and quetiapine at doses and for indications not aligned with federal guidelines. The consultant pharmacist’s recommendations to adjust these medications were not communicated to the physician for nearly two months, due to the facility’s lack of a defined timeframe in its policies and failure to follow procedures for timely action.
Two residents with unstageable pressure ulcers were not provided appropriate care as their Low Air Loss (LAL) mattresses were set to incorrect weight settings. Despite care plans indicating the use of LAL mattresses, staff were unaware of the residents' actual weights, leading to settings that were too high. This resulted in inadequate therapy from the mattresses, potentially worsening the residents' conditions.
A resident with dementia, Parkinson's disease, and ataxia was found with unexplained swelling on the right hand, which was not reported by the RN to the Administrator or DON as required. The facility's policy mandates reporting such incidents within two hours and to the state agency within 24 hours, but this was not followed, delaying medical evaluation and intervention.
A resident with dementia, Parkinson's disease, and ataxia experienced a fall, but the facility failed to update the Care Plan to include new fall prevention measures. Despite being at high risk for falls, the Care Plan had not been revised since a previous fall, contrary to facility policy. Staff interviews confirmed the oversight, highlighting a deficiency in care plan management.
A facility failed to coordinate with a resident's primary physician regarding medication orders, resulting in a 66-day lapse in seizure medication and unadministered supplements. The resident, with conditions including epilepsy and malnutrition, did not receive lacosamide due to a lack of communication between the facility and the neurologist. Additionally, new orders for N-Acetyl-L-Carnitine, Vitamin D3, and Zinc were not communicated to the primary physician, leading to deficiencies in care.
The facility did not adhere to menu and recipe guidelines, affecting the nutritional needs of 63 residents. The Cajun Country Rice lacked key ingredients, and the tarragon sauce was too salty due to the use of regular chicken broth instead of low sodium. The Dietary Supervisor confirmed these issues, noting potential impacts on residents' food intake and weight. The facility's policy on standardized recipes was not followed, leading to inconsistencies in food quality.
The facility failed to prepare food by methods that conserved flavor and appearance, affecting the quality of meals served to residents. Two residents expressed dissatisfaction with the food, leading them to order from outside. The dietary supervisor confirmed that recipes for tarragon sauce and Cajun rice were not followed, resulting in salty and altered flavors. The facility's policies emphasized the importance of following standardized recipes and tasting food before serving, which was not adhered to.
The facility failed to ensure safe food storage and preparation practices, with chipped refrigerator racks, expired dairy products, and dented cans improperly stored. A staff member did not wash hands after cleaning, risking cross-contamination. These deficiencies could lead to foodborne illnesses among residents.
Two residents in a facility were inadequately supervised, leading to harm. One resident, with a history of dementia, was not monitored as per their care plan and developed an infection from a ring they picked up. Another resident, with mental health conditions, was not checked on after a dental appointment and was later found hospitalized. The facility's failure to follow care plans and policies on supervision and wandering contributed to these incidents.
The facility failed to ensure call lights were within reach for four residents, violating its policy. Residents with various medical conditions, including hyperlipidemia, anemia, and chronic kidney disease, were observed with call lights either on the floor or not within reach. Staff confirmed these observations, acknowledging the risk of delayed care and potential injury. The facility's policy requires call lights to be accessible, which was not followed, resulting in this deficiency.
The facility failed to post No Smoking/Oxygen in Use signs for two residents receiving oxygen therapy, contrary to its policy. One resident with severe cognitive impairment and another with intact cognitive skills but requiring assistance were observed without the necessary signage. Both a Registered Nurse Supervisor and the Director of Nursing confirmed the oversight, acknowledging the importance of such signs due to the flammable nature of oxygen.
The facility failed to follow proper food handling practices, including improperly sealed food containers, an unclean and rusted can opener, and the use of a dirty potholder. Additionally, a resident's breakfast tray was not replaced with a clean one, and the kitchen had an overflowing trashcan in contact with clean items. These deficiencies were observed during a survey, indicating non-compliance with the facility's policies on food safety and infection control.
The facility failed to follow infection control protocols, including improper use of PPE by CNAs and LVNs, inadequate water management to prevent Legionnaire's disease, and improper handling of contaminated materials. Staff did not wear gloves when handling dirty linen and trash, and a resident's nasal cannula was found on the floor, increasing the risk of infection spread.
A facility failed to maintain a resident's dignity during meal assistance when a CNA stood over a resident while feeding them, contrary to the care plan and facility policy. The resident, who required full assistance with eating, was admitted with conditions including lack of coordination and chronic kidney disease. Staff interviews confirmed the requirement to maintain eye level with residents during feeding to ensure respect and dignity.
A facility failed to ensure a resident's Advance Health Care Directive was readily retrievable by staff. Despite the resident having an advance directive, a copy was not available in the medical chart, contrary to the facility's policy. This was confirmed by a nurse supervisor and acknowledged by an LVN, highlighting the importance of having the directive accessible to honor the resident's wishes in emergencies.
A resident with mild protein calorie malnutrition and adult failure to thrive was not provided with the necessary assistance during meals, as required by their care plan. Observations revealed the resident ate without staff help, with their bed not elevated to the recommended angle, consuming only 10-15% of their meal. Interviews with staff confirmed the need for assistance to prevent aspiration and ensure adequate nutrition, highlighting a deficiency in following the facility's policy on Activities of Daily Living.
A facility failed to follow its infection control policy by not labeling a resident's nebulizer tubing with the date of change and the resident's name. The resident, who had moderate cognitive impairment and required assistance for daily activities, was prescribed albuterol sulfate for wheezing. The oversight was confirmed by the IP and DON, who noted the tubing should have been labeled as per the facility's policy.
A facility failed to provide proper dialysis care for a resident by not having a dialysis emergency kit at the bedside and lacking warning signage to prevent the use of the resident's left arm for medical procedures. The resident, with end-stage renal disease, required hemodialysis, and the absence of these safety measures was confirmed by facility staff, highlighting a deviation from standard practice.
The facility failed to maintain an effective pest control program, resulting in an ant infestation observed on multiple occasions along the door frames of several residents. Staff interviews confirmed the presence of ants was unacceptable due to safety and infection control concerns. The facility's policy emphasizes providing a safe and clean environment, which was not upheld.
A resident experienced verbal abuse from an LVN who told her to "shut up" during a medication preparation interaction. The resident, who was cognitively intact and had anxiety disorder, felt disappointed and confronted by the LVN's aggressive behavior. The facility's policies emphasize an abuse-free environment, but this incident highlighted a failure to protect the resident's rights.
The facility failed to post accurate Daily Staffing Reports, leading to discrepancies between reported and actual staffing levels. On several occasions, the number of CNAs and RNAs listed did not match the Facility Staffing Assignment. Interviews with the DSD and DON confirmed the need for accurate staffing data to reflect Direct Care Service Hours Per Patient Per Day (DHPPD).
The facility failed to ensure timely physician visits for two residents, as required by regulations. One resident, with conditions like muscle wasting and anxiety disorder, experienced significant gaps in physician visits, with only five visits over two years. Another resident, with cerebral infarction and diabetes, had no documented physician visits for over two months. The DON acknowledged the outdated policy and the need for revision to meet current standards.
A resident with limited mobility and range of motion was discharged from PT services but experienced a delay in starting RNA services, which were recommended for continued ambulation. The RNA services were ordered a week after PT discharge, resulting in a gap in care. The resident, who had conditions like lumbago and spinal stenosis, did not walk for about a week due to this delay. Facility staff acknowledged the delay and the need for timely RNA initiation to ensure continuity of care.
The facility failed to properly disinfect cloth gait belts used for resident transfers, using disinfectant wipes instead of laundering them as required for porous surfaces. This practice, confirmed by the Director of Rehabilitation and the Infection Prevention Nurse, did not align with the facility's policy and posed a risk of infection transmission.
A resident who underwent hip surgery was not provided with an abduction pillow as required by their care plan, leading to a deficiency in care. The resident's care plan did not include specific interventions for the use of the pillow, despite physician orders. Staff interviews confirmed the care plan was incomplete, failing to meet the facility's policy for comprehensive, person-centered care plans.
A resident who underwent right hip hemiarthroplasty was not consistently provided with an abduction pillow as ordered by the physician, leading to internal rotation of the leg. Staff interviews revealed a lack of communication and documentation regarding the use of the pillow, and facility policies were found to be incomplete in ensuring adherence to physician orders.
A facility failed to document the required 72-hour monitoring for a resident after an alleged verbal abuse incident. The resident, with severe cognitive impairments and multiple diagnoses, was not monitored for two shifts on consecutive days as per facility policy. Interviews with the DON and an LVN confirmed the lapse in documentation, which is crucial for resident safety and compliance with the facility's standards.
The facility failed to ensure call lights were accessible and responded to promptly for four residents, leading to potential delays in care. Residents with cognitive impairments and those requiring assistance were observed with call lights out of reach or unanswered, despite facility policies emphasizing prompt response. This deficiency highlights lapses in adhering to established guidelines for resident care.
A resident with dementia and depression did not receive privacy during perineal care, as a CNA failed to close the privacy curtain, making the resident visible from outside the room. This action violated the facility's policies on maintaining resident dignity and privacy.
A facility failed to implement its COVID-19 infection control protocols, as a designated COVID-19 room lacked appropriate droplet isolation signage, and staff did not wear required PPE while assisting a COVID-19 positive resident. The resident's isolation cart was not stocked with face shields, and the room door was left open, contrary to facility policy. Interviews with staff confirmed these deficiencies, highlighting the importance of correct PPE usage and signage to prevent virus transmission.
A resident with diabetes and hyperlipidemia did not receive meals according to their prescribed low sodium and carb-controlled diet. Despite physician orders, the resident reported receiving sweet foods, and an observation confirmed the presence of inappropriate items like bread and apple crumble on their tray. The RN Supervisor and Dietary Supervisor acknowledged the non-compliance with the diet order, highlighting a need for staff training.
A resident found a wire in their corn bread muffin, and the facility failed to assess or monitor the resident for complications. Additionally, utensils and dishware provided to the resident had visible residue, indicating a failure to follow proper sanitation procedures.
A resident experienced extreme pain and complications due to the facility's failure to change an indwelling urinary catheter monthly as ordered by the physician. Despite the resident's diagnoses and the physician's order, the catheter was not changed for five and a half months, leading to significant discomfort and medical issues.
Failure to Change Enteral Feeding Set per Physician Order
Penalty
Summary
The facility failed to follow physician orders and facility policy regarding the changing of enteral feeding administration sets for a resident with a feeding tube. Specifically, the order required that the enteral administration set be changed with every bottle of formula, every shift. However, evidence from a family member's screenshot and interview confirmed that the resident's enteral feeding set was not changed for three consecutive days. The Director of Nursing acknowledged that the licensed nurse did not change the enteral feeding bottle and hydration water bag every shift as ordered. The resident involved had a history of dysphagia, a gastrostomy, and adult failure to thrive, and was totally dependent on staff for care, including tube feeding. The resident's care plan identified risks for significant weight loss and dehydration, with interventions requiring staff assistance for tube feeding and water flushes. Facility policy also required formula and administration set changes within specified timeframes. The failure to adhere to these protocols resulted in the resident not receiving the prescribed nutrition and hydration support.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.
Failure to Readmit Resident After Hospitalization in Accordance with Bed Hold Policy
Penalty
Summary
The facility failed to readmit a resident following discharge from a General Acute Care Hospital (GACH), despite the resident being medically stable and the facility having available beds. The resident, who had diagnoses including spondylosis, anxiety disorder, depression, and borderline personality disorder, was originally transferred to the hospital due to being a danger to herself. Upon discharge from the hospital, the GACH contacted the facility to arrange for the resident's return, but the facility refused readmission by order of the Administrator, even though the facility's policy and procedure on Bed Holds and Returns required that residents be permitted to return following hospitalization within the bed hold period. Record review and staff interviews confirmed that the facility's Director of Admissions and Administrator were aware of the policy but chose not to readmit the resident. The Administrator cited the resident's need for a private room due to having a dog and previous behavioral issues as reasons for the refusal. The facility's own policy, however, indicated that all residents, regardless of payer source, should be allowed to return to their previous room if available within the bed hold period. This action resulted in the resident being unable to return to the facility after hospital discharge.
Failure to Provide Treatment and Monitoring for Resident with Mental Health Crisis
Penalty
Summary
A resident with diagnoses of depression, anxiety, and borderline personality disorder was identified as being a danger to self and others (DTSO) after verbalizing intentions to harm self and others. Despite a physician's order for transfer to a general acute care hospital (GACH) and recommendations for psychiatric and psychological consultations, the resident refused these interventions. The facility failed to implement 1:1 sitter observation, did not monitor or document the resident's behavior after being identified as DTSO, and did not develop or implement a care plan to address the resident's refusal of transfer or psychiatric consultation. There was no evidence in the medical record that the facility monitored the resident's behavior or provided additional interventions after the resident refused psychiatric consultation. Staff interviews confirmed that no hourly monitoring, documentation, or care planning was initiated following the resident's refusal of transfer and ongoing verbalizations of self-harm or harm to others. The interdisciplinary care team did not meet to address the situation, and there was no documentation of behavioral observations or safety interventions in the resident's chart during the period of risk. As a result of these failures, the resident was later found unresponsive in their room with opened prescription medication containers not dispensed by the facility. The resident was transferred to the hospital via emergency services, where toxicology confirmed an intentional overdose of tricyclic antidepressants. The resident required intubation and admission to the intensive care unit. The facility's lack of assessment, supervision, monitoring, and care planning for a resident identified as DTSO directly preceded this critical incident.
Removal Plan
- The charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist.
- If a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior, and refused to be transferred to the hospital licensed nurse will immediately notify MD.
- The Director of Social Services completed a Psychosocial Assessment of identified residents who has a diagnosis of depression, reviewed and updated Care Plan as necessary.
- Licensed staff were instructed to document behavioral observations in the monitoring log such as DTSO every hour and notify the nurse or RN supervisor and/or designee.
- The Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis.
- The Director of Social Services completed a psychosocial assessment of all residents with a diagnosis of depression to identify residents who may be DTSO and no other residents were identified at risk of harming themselves or others.
- Situation, Background, Assessment, and Recommendation (SBAR) / Change in Condition (COC) was implemented, and in-service was conducted by Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental condition and/or status.
- 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations.
- The care plan was reviewed and updated for identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer for resident's safety.
- The Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety.
- Crisis Intervention Plan included: Provide safe and clean environment; Visual check and document monitoring of resident behavior every hour for resident safety; Administer medication as ordered; Diet as ordered; Encourage to verbalize feelings; Always approach in calm and friendly manner and unhurriedly; To ensure all needs are met; Provide emotional support; Maintain comfort and dignity; To call doctor of medicine (M.D) for any noted change of condition.
- Social Services will re-evaluate and update initial psychosocial assessment of the resident when a resident refused for psychiatric consult and licensed nurse will inform MD.
- Social services will make daily visits to re-engage the resident and residents who are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in the progress notes and provide resident's education on the importance of psychiatric evaluation.
- Behavioral and Crisis intervention care plan will be implemented to reflect ongoing risk for harm to self and others. Interventions included: PRN and scheduled psychiatric medication management; Behavior tracking and psychiatric consultation follow-up; Staff re-education on management of residents with psychosocial adjustment difficulties; Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques.
- The ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition.
- Licensed staff in-services will continue until compliance is met.
- All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant regarding the existing policies and procedures: Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others; Requesting, Refusing and/or Discontinuing Care or Treatment; Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy.
- The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x 4 weeks, then monthly x 3 months.
- All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician.
- Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Prevent Resident Possession of Contraband Medications and Alcohol
Penalty
Summary
The facility failed to provide a safe environment for a resident by not preventing the possession of a bottle of alcoholic beverage and multiple prescription medication bottles from an outside pharmacy, despite having a policy prohibiting such items. The resident, who had diagnoses including depression, anxiety, and borderline personality disorder, was admitted with cognitive intactness and required some assistance with daily activities. The facility's policy clearly stated that restricted items, including non-facility prescribed medications and alcohol, were not allowed, and staff were responsible for monitoring for such items. On the day of the incident, the resident was found unresponsive in their room by an LVN, with opened containers of doxepin and ondansetron at the bedside, both labeled from an outside pharmacy. Further investigation by local police and facility staff revealed additional bottles of prescription medications and a bottle of wine among the resident's belongings. Interviews with staff confirmed that medications from outside pharmacies were not permitted and that the facility's procedures for checking residents' belongings for contraband were not followed. Staff acknowledged that the resident was able to bring in alcohol and medications without detection, which was against facility policy. Medical records from the hospital indicated that the resident was admitted with altered mental status, a Glasgow Coma Scale of 3, and was intubated for a suspected intentional overdose of tricyclic antidepressants and possibly clonazepam. The resident remained in intensive care before being discharged home. The presence of unauthorized medications and alcohol in the resident's possession, and the lack of adequate supervision and enforcement of the facility's contraband policy, directly led to the resident's medical emergency.
Failure to Implement Antibiotic Stewardship Protocol for UTI Treatment
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship by not ensuring that antibiotics were only administered when the established criteria, specifically the McGeer criteria, were met. For two sampled residents, antibiotics were given for urinary tract infections (UTIs) without documented evidence that both required clinical and microbiological criteria were satisfied. In both cases, the residents received antibiotics based on positive urine cultures, but there was no documentation of the necessary clinical symptoms as outlined in the McGeer criteria. One resident, with a history of cerebral infarction, epilepsy, and paraplegia, was prescribed and administered Keflex via gastrostomy tube for a UTI. The medical record showed a positive urine culture for Escherichia coli, but there was no evidence that the resident exhibited the required clinical signs or symptoms for UTI treatment per the McGeer criteria. Nursing staff confirmed that the antibiotic stewardship process was not completed and acknowledged that the resident did not meet the criteria for antibiotic therapy. Another resident, diagnosed with atherosclerotic heart disease, hyperlipidemia, and dementia, was prescribed Bactrim DS for a UTI following a positive urine culture for Klebsiella pneumoniae. The resident's care plan included monitoring for UTI symptoms, but there was no documentation that the resident met both the clinical and microbiological criteria for antibiotic use. Nursing staff confirmed that the antibiotic stewardship protocol was not followed, and the required Nurse to Physician Report was not completed prior to administering the antibiotic.
Lack of Designated, Trained Infection Preventionist
Penalty
Summary
The facility failed to employ a designated Infection Preventionist (IP) with specialized training, as required for the infection prevention and control program. According to interviews, the facility had been without a designated IP for almost a month, and the responsibilities were being covered by a registered nurse and other licensed nurses, none of whom had IP certification. Record review confirmed that the previous IP's last day was several months prior, and staff currently performing IP duties lacked the required specialized training. The facility's policy indicated that the IP is responsible for coordinating infection prevention and control policies and practices.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State Survey Agency, ombudsman, and local law enforcement within the required two-hour timeframe, as mandated by facility policy. The incident occurred when one resident reported being kicked by another resident at the nursing station. The resident who experienced the incident immediately informed the Assistant Director of Nurses (ADON), who assessed both residents and separated them but did not escalate the report to the appropriate authorities. Interviews with facility staff, including the ADON, Medical Record Nurse, and social worker, revealed that although incident reports were filed internally, the event was not reported externally as required. Staff members indicated a lack of understanding or misinterpretation of the reporting requirements, with the ADON stating she did not consider the kick to be an allegation of physical abuse and the Medical Record Nurse expressing unawareness of the need to report to external agencies. A review of the facility's policy confirmed that all allegations of abuse must be reported immediately, defined as within two hours for abuse or serious bodily injury. The policy also specifies that such reports must be made to the administrator, state agency, ombudsman, law enforcement, and other relevant parties. Despite this, the required notifications were not made, and the incident was not thoroughly investigated in accordance with policy.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required 2-hour timeframe to the State Survey Agency and the state ombudsman, as mandated by the facility's abuse policy. The incident involved a resident with a history of spondylosis, anxiety disorder, depression, and borderline personality disorder, who was cognitively intact and required some assistance with daily activities. The resident reported that a male visitor had tried to forcefully kiss her, and this was communicated to a CNA and then to an RN, who subsequently informed the Administrator. Despite the facility's policy requiring immediate reporting of abuse allegations, defined as within 2 hours, the Administrator acknowledged that the incident was not reported to the appropriate authorities until several days after the initial allegation was made. The delay in reporting was confirmed through interviews and record reviews, and the facility's own policy and procedure documentation was reviewed during the investigation. The failure to promptly report the allegation had the potential to compromise the resident's protection from further abuse.
Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor the food preferences of a resident who had a physician's order for a vegetarian diet. The resident, who had diagnoses including spondylosis, anxiety disorder, depression, and borderline personality disorder, was cognitively intact and able to make daily decisions. Despite documentation in the care plan and physician's orders specifying a vegetarian diet, the resident was served pizza containing a small piece of chicken. This incident was confirmed by both the cook and a registered nurse after the resident reported the issue. The facility's policy required that individual food preferences be assessed upon admission, communicated to the interdisciplinary team, and documented in the care plan. The policy also stated that if a resident is unhappy with their diet, a care plan should be created to address their satisfaction. In this case, the resident's food preference was not honored, as evidenced by the presence of meat on her meal tray, contrary to her dietary restrictions and documented preferences.
Failure to Provide Required Two-Person Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) attempted to transfer a resident from a wheelchair to bed without the required assistance of a second staff member. The resident had a history of atherosclerotic heart disease and traumatic brain injury, and was assessed as non-ambulatory and dependent for transfers, requiring two-person assistance according to the Minimum Data Set (MDS) and physical therapy evaluation. Despite this, the CNA proceeded alone after the resident requested to return to bed, resulting in the resident sliding to the floor in an assisted fall. The resident's care plan and physical therapy assessment both indicated a need for two-person assistance for all transfers due to decreased strength, impaired lower extremity function, and high risk for falls. On the day of the incident, the CNA was aware of the two-person assist requirement, having been informed by a licensed nurse at the start of the shift. However, when the resident requested to go back to bed, the CNA attempted the transfer alone, leading to the resident's gradual slide to the floor and subsequent contact of the resident's head with the floor. Following the fall, the resident was transferred to a general acute care hospital for further evaluation. Interviews with facility staff, including the CNA, registered nurse, and director of nursing, confirmed that the resident required two-person assistance and that the CNA did not follow this protocol at the time of the incident. The facility's fall risk assessment policy also emphasized the need for individualized prevention plans based on resident assessments, which in this case were not adhered to during the transfer.
Failure to Accommodate Resident's Vegetarian Diet Preferences
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's documented vegetarian preference and food intolerances. The resident, who was cognitively intact and independent in daily activities, had a physician's order and care plan specifying a vegetarian diet, with additional notes indicating a dislike for milk, eggs, and meat. Despite these clear dietary instructions, the resident was served meals containing meat on at least two separate occasions. On one occasion, the resident received a lunch tray with beef mixed into her rice, which led to her becoming upset and vomiting twice. The incident was documented in the nursing notes, and it was confirmed that the kitchen staff was aware of her vegetarian status. On another occasion, the resident found two pieces of chicken in her soup during dinner, which was witnessed by both a CNA and an LVN. The resident retained the chicken pieces as evidence and reported that this was not the first time such an incident had occurred. Interviews with facility staff, including the Administrator, DON, kitchen staff, and direct care staff, confirmed that the resident's vegetarian preference was known and documented on her meal tickets. The kitchen had a process for double-checking trays, and CNAs performed additional checks before distribution, but these measures failed to prevent the errors. Facility policies required that individual food preferences be assessed and accommodated, but these were not effectively implemented in this case.
Failure to Monitor and Address Repetitive Leg Kicking Resulting in Foot Fractures
Penalty
Summary
Facility staff failed to monitor and document a resident's behavior of constant leg kicking during episodes of severe anxiety or agitation, despite the resident's known history of this behavior and associated risk for pathologic fractures. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, and a prior left foot fracture, was dependent on staff for most activities of daily living and had a care plan identifying risk for spontaneous fractures related to severe anxiety and agitation. However, the care plan did not include specific interventions to monitor or address the resident's repetitive leg kicking behavior. Over a period from January to March, there was no documented evidence that staff monitored or recorded the resident's leg kicking, even though the behavior was known to occur when the resident was agitated, particularly in relation to discomfort with a gastrostomy tube. Staff interviews confirmed that monitoring and documentation of this behavior were not performed, and this omission was not reflected in the Treatment Administration Record or other documentation systems. The Director of Nursing acknowledged that monitoring and documentation should have been implemented as part of a resident-centered approach to prevent injury, in accordance with facility policy. The resident was eventually found to have multiple fractures in the left foot, which were determined to be most likely caused by repetitive kicking of the bed's footboard, despite a protective barrier being in place. The lack of monitoring and documentation of the resident's behavior, as well as the absence of targeted interventions in the care plan, directly contributed to the failure to prevent this accident, contrary to the facility's policy on safety and supervision of residents.
Failure to Timely Communicate Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the consultant pharmacist’s recommendations regarding the use of lorazepam (Ativan) and quetiapine (Seroquel) for a resident were communicated to the attending physician in a timely manner. The pharmacist’s drug regimen review, dated 2/4/2025, identified that the resident was prescribed Ativan at a dosage exceeding the maximum daily allowable dose for individuals over a certain age, and recommended a dose reduction or a risk-benefit assessment. The review also noted that Seroquel was being used for anxiety disorder, which is not an approved indication for elderly patients, and recommended discontinuation or substitution with an appropriate medication. Despite these recommendations, there was no documentation that the physician was informed or had reviewed the pharmacist’s suggestions until nearly two months later, on 3/30/2025. The resident involved had a history of Alzheimer’s disease, anxiety disorder, and a fracture of the left foot, and was assessed as having severely impaired cognitive skills and requiring significant assistance with daily activities. The resident was receiving antipsychotic and antianxiety medications, including quetiapine and lorazepam, through a gastrostomy tube. The orders for these medications did not specify a discontinuation date and were carried over from previous months, with the lorazepam order being changed to allow administration every four hours as needed. The facility’s policies and procedures required that findings and recommendations from the drug regimen review be reported to the appropriate staff and acted upon, but did not specify a timeframe for action. The Director of Nursing acknowledged that the policy was not followed, and that the lack of a defined timeframe contributed to the delay in communicating the pharmacist’s recommendations to the physician. This failure to promptly address the consultant pharmacist’s recommendations constituted the deficiency identified in the report.
Inadequate Pressure Ulcer Management Due to Incorrect LAL Mattress Settings
Penalty
Summary
The facility failed to provide appropriate pressure ulcer management for two residents by not ensuring that their Low Air Loss (LAL) mattresses were set to the correct weight settings. Resident 2 was admitted with diagnoses including an unstageable pressure ulcer in the sacral region and was at risk for pressure ulcer development due to constant skin moisture and limited mobility. Despite having a care plan that included the use of a LAL mattress, the mattress was observed to be set at a weight range significantly higher than Resident 2's actual weight of 101 lbs. Similarly, Resident 3, who was admitted with a cerebral infarction and had severely impaired cognitive skills, also had an unstageable pressure ulcer. The care plan for Resident 3 included the use of a LAL mattress, but the mattress was set at a weight range much higher than Resident 3's actual weight of 114 lbs. Observations and interviews revealed that the staff, including the Certified Nurse Assistant and Treatment Nurse, were unaware of the residents' current weights and had not adjusted the LAL mattress settings accordingly. The Director of Nursing confirmed that the LAL mattresses should be set according to the residents' current weights to prevent pressure ulcers effectively. The facility's policy indicated that pressure-reducing devices should be set to the resident's weight to optimize effectiveness. The failure to adjust the LAL mattress settings to the residents' actual weights resulted in inadequate therapy from the mattresses, potentially worsening the residents' pressure ulcers.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was observed with unexplained swelling on the right hand. The resident, who had been admitted with diagnoses of dementia, Parkinson's disease, and ataxia, was noted to have severely impaired cognition and required varying levels of assistance for daily activities. On the date of the incident, the resident's wife informed a Registered Nurse (RN) about the swelling and pain in the resident's hand, which was visibly larger than the other hand. Despite this, the RN did not report the unusual occurrence to the Administrator or the Director of Nursing (DON) as required by the facility's policy. The facility's policy mandates that any injury with an unknown cause should be reported within two hours to the Administrator and DON, and within 24 hours to the state agency. However, the Administrator confirmed that she was not informed about the incident, and no investigation was conducted to determine the cause of the injury. The facility's policy also requires a written report detailing the incident and actions taken to be sent to the state agency within 48 hours, which was not done in this case. This failure compromised the resident's safety and well-being by delaying appropriate medical evaluation and intervention.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise and update the Care Plan for a resident who experienced a fall on February 11, 2025. The resident, who was admitted with diagnoses of dementia, Parkinson's disease, and ataxia, had severely impaired cognition and required varying levels of assistance for daily activities. Despite being identified as high risk for falls, the Care Plan was not updated following the fall incident, which was necessary to implement new fall prevention interventions. Interviews with facility staff revealed that the Care Plan had not been revised since September 4, 2024, after a previous fall. The Licensed Vocational Nurse confirmed the absence of an updated Care Plan post-fall, and the Assistant Director of Nursing emphasized the importance of revising Care Plans following any change in a resident's condition. The facility's policies require Care Plans to reflect current standards and be revised with any change in the resident's condition, yet this was not adhered to, resulting in a deficiency.
Failure to Coordinate Medication Orders with Primary Physician
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for a resident by not notifying and coordinating with the resident's primary physician regarding the continuation of lacosamide medication. The resident, who was admitted with diagnoses including cerebral infarction, epilepsy, and moderate protein-calorie malnutrition, had a neurologist's order to continue lacosamide to manage seizures. However, the medication was stopped on November 2, 2024, without notifying the neurologist or the primary physician, leading to a 66-day period without the medication until it was restarted on January 8, 2025. Additionally, the facility failed to communicate new medication orders from the resident's Doctor of Osteopathic Medicine to the primary physician. These orders included starting N-Acetyl-L-Carnitine and increasing Vitamin D3 and Zinc, which were not reflected in the resident's Physician Order Sheet. The licensed staff did not inform the primary physician of these new orders, resulting in the resident not receiving the prescribed medications. The facility's policy and procedure on medication therapy emphasize the importance of consistent medication use with an individual's condition and the need for staff and practitioners to review medication regimens periodically. However, the lack of communication and coordination with the primary physician regarding the resident's medication orders led to deficiencies in the delivery of necessary care and services, potentially causing adverse health outcomes for the resident.
Failure to Follow Menu and Recipe Guidelines
Penalty
Summary
The facility failed to adhere to its menu and recipe guidelines, impacting the nutritional needs of 63 out of 67 sampled residents on both regular and therapeutic diets. During a review, it was found that the recipe for Cajun Country Rice was not followed, as it lacked celery, diced red and green peppers, and thyme. Additionally, the tarragon sauce prepared for the fish was too salty because the cook used regular chicken broth instead of the specified low sodium chicken broth and omitted cornstarch in water. This deviation from the recipe resulted in a sauce that was not suitable for serving to residents. The Dietary Supervisor confirmed these discrepancies during an observation and interview, noting that the failure to follow recipes could lead to residents not eating the food due to its taste, potentially resulting in decreased calorie intake and weight loss. The facility's policy on food preparation emphasizes the use of standardized recipes to ensure consistency and quality, which was not adhered to in this instance. The failure to follow these guidelines was observed during a test tray evaluation, where the tarragon sauce was deemed too salty and unacceptable for resident consumption.
Failure to Follow Recipes Leads to Poor Food Quality
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance, specifically during breakfast service. Cook 1 did not follow the recipes for tarragon sauce and Cajun rice, resulting in a salty food product and altered flavors, respectively. These failures had the potential to result in unplanned weight loss for 63 of 67 residents, including two residents who expressed dissatisfaction with the food quality and presentation. Resident 2, admitted with diagnoses including spinal stenosis, muscle wasting, atrophy, and chronic kidney disease, reported ordering food from outside due to the poor quality of meals served at the facility. Resident 2 stated that the chicken with sauce tasted bad and bitter, and no food substitute was offered. Similarly, Resident 1, with diagnoses including spinal stenosis, muscle wasting, atrophy, and gastro-esophageal reflux disease, also expressed dissatisfaction with the facility's food, preferring to buy food from outside. Resident 1 reported being served raw fish, which was then overcooked upon request. The facility's dietary supervisor confirmed that the Cajun rice lacked essential ingredients like celery, diced red and green peppers, and thyme, and the tarragon sauce was too salty. Cook 1 admitted to not using low sodium chicken broth and cornstarch in water as per the recipe, leading to the excessive saltiness. The facility's policies and procedures emphasized the importance of following standardized recipes and tasting food before serving to ensure quality, which was not adhered to in this instance.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a survey. The walk-in refrigerator contained racks with chips, which the Dietary Supervisor acknowledged could lead to bacterial growth and food contamination. Additionally, several dairy products, including Greek yogurts and cottage cheeses, were found to be past their expiration dates, posing a risk of foodborne illness to residents. The facility's policy and procedure for refrigerated storage and labeling were not adhered to, as expired items were not discarded as required. In the dry storage area, dented cans were stored alongside non-dented cans, contrary to the facility's policy that requires dented cans to be separated and returned to the vendor. The Dietary Supervisor confirmed that dented cans could be hazardous due to the risk of botulism, which could cause gastrointestinal issues in residents. The facility's failure to properly manage canned goods storage was a significant oversight in maintaining food safety standards. Furthermore, a staff member was observed not washing hands after wiping the food preparation sink and then touching scoops used for the lunch trayline. This action violated the facility's handwashing policy and increased the risk of cross-contamination. The Dietary Supervisor acknowledged the importance of hand hygiene in preventing food contamination and the potential for residents to suffer from foodborne illnesses as a result of such lapses in protocol.
Inadequate Supervision Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents. Resident 1, who has a history of dementia, osteoporosis, and anxiety disorder, was not monitored every two hours as required by their care plan. This resident, known for picking up and hiding items, was found with a ring on their left middle finger, which was not theirs. The ring caused swelling and pus formation, leading to an infection that required hospital intervention, including IV antibiotics and ring removal via an electric saw. Resident 4, diagnosed with bipolar disorder, major depressive disorder, and anxiety disorder, was not adequately monitored during a dental appointment. Despite being independent in activities of daily living, Resident 4 was at risk for elopement or wandering. After leaving for a dental appointment, the resident did not return within the expected timeframe. The facility failed to check on the resident's whereabouts until nine hours later, by which time the resident had been admitted to a hospital with nausea, vomiting, and low oxygen saturation. The facility's policies on safety and supervision, as well as wandering and elopement, were not effectively implemented. The care plans for both residents indicated the need for specific interventions to prevent accidents, but these were not followed. The lack of timely monitoring and follow-up on the residents' whereabouts contributed to the deficiencies observed, placing both residents at risk of harm.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, which is a violation of the facility's policy. Resident 6, who was admitted with conditions such as hyperlipidemia, anemia, and muscle atrophy, required substantial assistance with daily activities. Observations revealed that Resident 6's call light was wrapped around the side rails and later found on the floor, both times verified by staff members who acknowledged it should have been within reach. Resident 20, diagnosed with lack of coordination, hyperlipidemia, and chronic kidney disease, was dependent on staff for daily activities. During an observation, Resident 20's call light was found on the floor, confirmed by the Director of Nursing, who stated it should have been accessible. Similarly, Resident 171, with diagnoses including type 2 diabetes and hypertension, required assistance with daily activities. Observations on multiple occasions showed Resident 171's call light on the floor, which was verified by staff who acknowledged the risk of delayed care and potential injury. Resident 34, who had aphasia, generalized muscle weakness, and an ataxic gait, was at high risk for falls and required assistance with daily activities. Observations indicated that Resident 34's call pad was not within reach, confirmed by family and staff members who noted the resident's inability to call for help. The facility's policy mandates that call lights be accessible to residents, but this was not adhered to, leading to the deficiency.
Failure to Post Oxygen Precautionary Signs
Penalty
Summary
The facility failed to post precautionary and safety signs indicating the use of oxygen for two residents, as required by the facility's oxygen administration policy. Resident 120, who has severe cognitive impairment and is dependent on assistance for daily activities, was observed receiving oxygen therapy without a No Smoking/Oxygen in Use sign posted outside their room. This oversight was confirmed by a Registered Nurse Supervisor, who acknowledged the importance of such signage for safety reasons, as oxygen is flammable and poses a fire risk if smoking occurs nearby. Similarly, Resident 121, who has intact cognitive skills but requires assistance with daily activities, was also observed receiving oxygen therapy without the necessary precautionary signage. The Director of Nursing confirmed that the absence of a No Smoking/Oxygen in Use sign was against the facility's policy, which aims to ensure safe oxygen administration. The facility's policy, revised in October 2010, explicitly requires the posting of such signs to alert everyone of the potential fire hazard associated with oxygen use.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to proper food handling practices, as observed during a survey. Several issues were identified, including improperly sealed food containers in the refrigerator, such as a cracked lid on a jelly container and a loose lid on a ham container. Additionally, a can opener was found to be unclean and rusted, which the dietary supervisor acknowledged as a potential source of foodborne illness. These observations indicate a lack of compliance with the facility's policies and procedures regarding food storage and equipment sanitation. Further deficiencies were noted in the handling of meal trays and kitchen cleanliness. A dietary aid was observed using a dirty potholder, which had fallen on the floor, to handle food trays. This action was confirmed by the dietary aid, who admitted the potholder was contaminated. Additionally, a breakfast tray returned by a resident was not replaced with a clean tray and plate before being redelivered, and the staff used the clean entrance instead of the dirty entrance, violating infection control protocols. The kitchen environment also presented issues, with an overflowing trashcan in contact with clean plate covers, as observed by a dietary aid. This situation was acknowledged as a risk for food contamination. The facility's policies emphasize the importance of maintaining cleanliness and proper food handling to prevent foodborne illnesses, yet these practices were not consistently followed, as evidenced by the observations and interviews conducted during the survey.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in multiple deficiencies. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) did not don personal protective equipment (PPE) before entering the room of a resident under enhanced barrier precautions (EBP) due to a gastrostomy tube site, which increased the risk of multidrug-resistant organism (MDRO) transmission. Observations revealed that staff entered the resident's room without wearing gowns and gloves, despite the presence of signage indicating the need for PPE. Interviews with staff confirmed the lack of compliance with EBP protocols, and the Infection Preventionist acknowledged the expectation for all staff to follow these precautions. The facility also failed to maintain an effective water management program to prevent Legionnaire's disease. After receiving a positive test result for legionella in the water, the Maintenance Supervisor did not retest the water as advised by the testing company, citing being too busy. This oversight placed all residents at risk for severe respiratory infections. The facility's policies and procedures, as well as external guidelines, emphasize the importance of retesting and maintaining control measures to prevent the spread of waterborne microorganisms. Additional deficiencies included improper handling of dirty linen and trash, with staff observed not wearing gloves while handling potentially contaminated materials. Housekeeping staff were seen transporting trash without gloves, contrary to infection control policies. Furthermore, a resident's nasal cannula was found on the floor, not stored in a clean plastic bag, posing a risk of contamination. These actions and inactions by the facility staff contributed to the potential spread of bacteria and viruses within the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care that maintained or enhanced a resident's dignity and respect. This deficiency was observed when a Certified Nursing Assistant (CNA) was seen standing over a resident while assisting them during a meal. The resident, identified as Resident 20, was dependent on assistance for eating, as indicated in their Minimum Data Set (MDS). The CNA stated that there were no chairs in the room, which led to the CNA standing over the resident during the feeding process. Resident 20 was admitted to the facility with diagnoses including lack of coordination, hyperlipidemia, and chronic kidney disease. The resident's care plan specified that staff should sit at eye level when feeding the resident to ensure respect and dignity. Interviews with facility staff, including a Registered Nurse Supervisor and another CNA, confirmed that the facility's policy required staff to maintain eye level with residents during feeding to avoid making residents feel scared or intimidated. The facility's policies on dignity and assistance with meals emphasized the importance of treating residents with respect and ensuring their comfort and dignity during meals.
Failure to Maintain Readily Retrievable Advance Directive
Penalty
Summary
The facility failed to ensure that the Advance Health Care Directive for one of the sampled residents was readily retrievable by any facility staff. This deficiency was identified during a review of the resident's admission record and medical chart. The resident, who was admitted with diagnoses including hypertension, Parkinson's disease, and dyskinesia, had an Advance Directive Acknowledgement Form indicating the presence of an advance directive. However, a copy of this directive was not available in the resident's medical chart, as confirmed by a Registered Nurse Supervisor during a concurrent interview and record review. The facility's Policies and Procedures on Advanced Directives, revised in September 2022, state that if a resident has an advance directive, copies should be maintained in the same section of the resident's medical record and be readily retrievable by any facility staff. Despite this policy, the advance directive for the resident was not accessible, which was acknowledged by a Licensed Vocational Nurse who emphasized the importance of having the directive available to honor the resident's wishes in case of an emergency.
Failure to Assist Resident with Eating as per Care Plan
Penalty
Summary
The facility failed to provide necessary assistance to Resident 12 during meal times, as outlined in the resident's care plan and the facility's policy. Resident 12, who was admitted with diagnoses including mild protein calorie malnutrition and adult failure to thrive, was observed eating without assistance from facility staff. The care plan indicated that Resident 12 was at risk for weight loss due to poor intake and required assistance with meal consumption to prevent aspiration. However, during an observation, it was noted that the resident's head of bed was not elevated to the recommended 30 degrees while eating, and the resident consumed only 10 to 15 percent of the food provided. Interviews with facility staff, including a CNA, RN Supervisor, and LVN, confirmed that Resident 12 should have been assisted while eating to ensure adequate calorie intake and to prevent aspiration. The facility's policy on Activities of Daily Living emphasized the importance of providing care to maintain or improve residents' ability to perform ADLs. Despite this, the facility did not adhere to the care plan's directives, resulting in a deficiency that could potentially impact Resident 12's nutritional status and overall wellbeing.
Failure to Label Nebulizer Tubing for Infection Control
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding respiratory infection control for a resident, identified as Resident 220. The deficiency was observed when Resident 220's nebulizer tubing was found stored in a plastic bag on the nightstand without a label indicating the date the tubing was changed or the resident's name. This oversight was confirmed during an observation and interview with the Infection Preventionist and the Director of Nursing, who acknowledged that the tubing should have been labeled to ensure proper infection control measures were followed. Resident 220 was admitted to the facility with diagnoses of atrial fibrillation and pleural effusion and was noted to have moderate cognitive impairment, requiring various levels of assistance for daily activities. The resident had an order for albuterol sulfate nebulization as needed for wheezing. The facility's policy, revised in November 2011, clearly stated that nebulizer circuits should be stored in a plastic bag marked with the date and resident's name between uses, a protocol that was not followed in this instance, potentially putting the resident at risk for infection.
Failure to Provide Dialysis Care and Safety Measures
Penalty
Summary
The facility failed to provide appropriate dialysis care and services to a resident on hemodialysis by not ensuring the availability of a dialysis emergency kit at the resident's bedside. The resident, who was admitted with diagnoses including type 2 diabetes, end-stage renal disease, and hypertension, required hemodialysis three times a week. During an observation, it was noted that there was no dialysis e-kit in the resident's room, which was confirmed by the Director of Nursing and a Registered Nurse Supervisor. The absence of the e-kit, which is essential for managing potential bleeding from the dialysis access site, was against the facility's normal process for residents on dialysis. Additionally, the facility did not have visible warning signage at the resident's bedside to prevent the use of the resident's left arm for blood pressure checks, blood draws, or finger sticks, which could damage the arteriovenous shunt. The lack of signage was confirmed during interviews with the Registered Nurse Supervisor and the Treatment Nurse, who emphasized the importance of such signage for safety. The Director of Nursing acknowledged the absence of specific policies and procedures regarding the placement of dialysis e-kits and warning signage, although it was considered standard practice for safety.
Deficient Pest Control Program Leads to Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as per its policy and procedure, resulting in the presence of ants within the facility. Observations were made on multiple occasions where more than ten black ants were seen crawling along the door frames of two residents. Further observations noted ants on the doorways of additional residents. Interviews with staff, including a Certified Nursing Assistant and a Maintenance Supervisor, confirmed that the presence of ants was unacceptable due to safety and infection control concerns. A Licensed Vocational Nurse also acknowledged the risk of cross-contamination posed by the ants. The facility's policy titled 'Homelike Environment' emphasizes providing a safe, clean, and comfortable environment for residents, which was not upheld in this instance.
Verbal Abuse Incident Involving LVN and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically Licensed Vocational Nurse 4 (LVN 4). The incident involved LVN 4 using inappropriate language towards Resident 123, telling her to "shut up" during an interaction. This exchange occurred while LVN 4 was preparing medication for Resident 123, who was discussing something with Certified Nursing Assistant 10 (CNA 10) in her room. LVN 4 perceived the conversation as disrespectful and responded with verbal aggression. Resident 123, who was cognitively intact and required assistance with daily activities, was admitted to the facility with diagnoses of spondylosis and anxiety disorder. During the incident, Resident 123 expressed her surprise and disappointment at being told to "shut up" by LVN 4, which she found aggressive and confrontational. The resident's account of the event highlighted that LVN 4 threatened to call the police if she felt disrespected, further escalating the situation. The facility's policies on abuse prevention clearly state that residents have the right to be free from all forms of abuse, including verbal abuse. The policy outlines the importance of maintaining an abuse-free environment and includes training for staff on recognizing and preventing abuse. Despite these policies, the incident with LVN 4 demonstrated a failure to adhere to these standards, resulting in a deficiency in protecting the resident's rights.
Inaccurate Daily Staffing Report
Penalty
Summary
The facility failed to ensure the accuracy of the Daily Staffing Report, which is supposed to reflect the correct total number and actual hours of unlicensed nursing staff directly responsible for resident care. On multiple occasions, discrepancies were found between the posted Daily Staffing Report and the Facility Staffing Assignment. For instance, on 10/29/2024, the report indicated a different number of Certified Nursing Assistants (CNAs) and Restorative Nursing Assistants (RNAs) than what was actually assigned. Similar discrepancies were noted on 10/30/2024 and 11/1/2024, where the number of RNAs listed did not match the actual staffing assignment. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the posted staffing information should have matched the actual staffing assignments to ensure an accurate reflection of Direct Care Service Hours Per Patient Per Day (DHPPD). The facility's policy, revised in August 2022, mandates that nurse staffing data, including the number of non-licensed nursing staff, be posted accurately for each shift. The failure to adhere to this policy resulted in inaccurate staffing information being posted, which could potentially misrepresent the actual care provided to residents.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physicians visited residents at the required intervals, specifically once every thirty days for the first ninety days after admission and at least once every sixty days thereafter. This deficiency was identified for two residents. Resident 1, who was admitted with diagnoses including muscle wasting, polyneuropathy, and anxiety disorder, had significant gaps in physician visits. The records showed that the physician did not visit Resident 1 for extended periods, such as from December 2023 to April 2024, and the resident reported only five visits over two years. Similarly, Resident 4, admitted with conditions such as cerebral infarction, end-stage renal disease, and type 2 diabetes mellitus, also experienced a lack of timely physician visits. The records indicated that after an initial examination in July 2024, there were no documented physician visits for over two months. During an interview, Resident 4 confirmed not having met the doctor despite being in the facility for nearly three months. The Director of Nursing acknowledged the lapses in physician visits and noted that the facility's policy did not specify the required frequency of visits. The policy, last updated in 2001, was outdated and did not align with the current standards set by the Omnibus Budget Reconciliation Act (OBRA) regulations. The DON recognized the need for policy revision to ensure compliance with the required frequency of physician visits to improve the quality of care for residents.
Delay in Restorative Nursing Aide Services Post-PT Discharge
Penalty
Summary
The facility failed to provide timely restorative nursing aide (RNA) services to a resident following the discontinuation of physical therapy (PT) services. The resident, who had limited range of motion and functional mobility, was discharged from PT on 9/12/24 with a recommendation for RNA ambulation. However, the RNA services were not ordered until 9/19/24, resulting in a delay of approximately one week before the resident began receiving RNA treatments. This delay in initiating RNA services was acknowledged by the physical therapist and the Director of Rehabilitation, who admitted that the RNA order was completed late. The resident, who had diagnoses including lumbago with sciatica and spinal stenosis, required assistance with various activities of daily living and had impairments in the range of motion in the lower extremities. The resident expressed that RNA services did not start immediately after PT discharge, leading to a period where she did not walk for about a week. The Director of Nursing confirmed that RNA services should commence immediately after PT discharge to ensure continuity of care, which did not occur in this case.
Inadequate Disinfection of Cloth Gait Belts
Penalty
Summary
The facility failed to implement appropriate infection control measures regarding the use of cloth gait belts, which are safety devices used to assist in transferring residents. During an observation, a Restorative Nursing Aide (RNA) was seen using a cloth gait belt on a resident without proper disinfection between uses. The Director of Rehabilitation confirmed that staff used disinfectant wipes on the cloth gait belts after each resident use, despite the belts being porous surfaces that require laundering for proper disinfection. Interviews with the Infection Prevention Nurse and the Director of Nursing revealed that the facility's practice of using disinfectant wipes on cloth gait belts was inadequate, as these wipes are only effective on non-porous surfaces like plastic gait belts. The facility's policy indicated that gait belts should be cleaned after each use, but the current practice did not align with this policy, posing a risk of infection transmission among residents and staff.
Failure to Implement Individualized Care Plan for Post-Surgery Resident
Penalty
Summary
The facility failed to initiate an individualized resident-centered care plan for a resident who required an abduction pillow to prevent hip dislocation after surgery. The resident, who had undergone a right hip hemiarthroplasty and had a history of right hip fracture and end-stage renal disease, was observed without the necessary abduction pillow between his legs. This oversight was noted during an observation on 9/23/2024, when a Licensed Vocational Nurse (LVN) did not check for the presence of the pillow, and the resident's right leg was slightly internally rotated. The care plan for the resident, who was at risk for falls due to recent surgery, was incomplete and did not include specific interventions for the use of the abduction pillow, despite it being part of the physician's orders. Interviews with the Director of Staff Development (DSD) and a Registered Nurse Supervisor (RNS) confirmed that the care plan lacked the necessary details to ensure proper use of the abduction pillow. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and timetables, and be updated as the resident's condition changes, which was not adhered to in this case.
Failure to Follow Physician Orders for Abduction Pillow Use
Penalty
Summary
The facility failed to adhere to physician orders for the use of an abduction pillow for a resident who underwent a right hip hemiarthroplasty. The resident, who had a history of right hip pain and falls, was supposed to use the abduction pillow three times daily to prevent internal rotation and potential dislocation of the hip. However, during observations, it was noted that the resident's right leg was internally rotated, and the abduction pillow was not in use. Interviews with the resident and staff revealed that the abduction pillow was not consistently used as ordered. The resident expressed awareness of the need for the pillow to prevent internal rotation, yet it was found stored in the closet rather than in use. A Certified Nursing Assistant (CNA) confirmed that there was no endorsement regarding the use of the pillow, and the Registered Nurse Supervisor (RNS) acknowledged the absence of the pillow and the risk it posed for dislocation. Further review of the facility's policies and procedures indicated gaps in documentation and implementation of physician orders. The Director of Staff Development noted that the policies did not specify the need for licensed staff to document and implement treatments as ordered. This lack of adherence to physician orders and facility protocols contributed to the deficiency in care for the resident, potentially risking further complications.
Failure to Document 72-Hour Monitoring After Alleged Abuse
Penalty
Summary
The facility failed to document the required 72-hour monitoring for a resident following an alleged incident of verbal abuse. The resident, who was admitted with diagnoses including dementia, muscle wasting, atrophy, and major depressive disorder with psychotic features, was supposed to be monitored every shift for 72 hours as per the facility's standard practice. However, the documentation for the monitoring was incomplete, missing records for the 3PM-11PM and 11PM-7AM shifts on two consecutive days following the incident. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) confirmed that the facility's practice was to conduct and document 72-hour monitoring after any alleged abuse. The DON acknowledged that if monitoring was not documented, it was not completed, which could potentially place the resident at risk. The facility's policy on Charting and Documentation, which was reviewed during the investigation, mandates that all services and changes in a resident's condition be documented comprehensively in the medical record.
Failure to Ensure Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure that the call lights, a critical communication tool for residents to request assistance, were accessible and responded to in a timely manner for four residents. Resident 2, admitted with diagnoses including muscle weakness and severe cognitive impairment, had a care plan that required the call light to be within reach. However, during an observation, the call light was found hanging on the bed rail, out of reach. Similarly, Resident 3, also with severe cognitive impairment and dependent on assistance for daily activities, had a care plan specifying the call light should be within reach. Yet, it was observed to be inaccessible. Resident 4, who had intact cognitive skills but required assistance for certain activities, was observed with an active call light that went unanswered for several minutes. The resident expressed distress over the delay, as she needed her diaper changed. Staff members present in the vicinity did not respond promptly, highlighting a lapse in addressing the resident's needs. Resident 5, with moderately impaired cognitive skills, also experienced a delay in response to an active call light. Despite an overhead announcement, none of the nurses at the station attended to the call light promptly, leaving the resident in discomfort due to a wet diaper. The facility's policy and procedure for answering call lights emphasize the importance of ensuring call lights are within easy reach and responding to them as soon as possible. However, the observations and interviews indicate a failure to adhere to these guidelines, resulting in potential delays in care and services for the residents involved.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy for a resident during perineal care, which is a violation of the resident's rights to dignity and privacy. The incident involved a resident who was admitted with diagnoses including dementia, depression, and a history of falling. The resident's Minimum Data Set indicated that they required substantial assistance with personal hygiene. During an observation, a Licensed Vocational Nurse (LVN) witnessed a Certified Nurse Assistant (CNA) changing the resident's diaper without closing the privacy curtain, making the resident visible from outside the room. Interviews with the LVN, CNA, and a Registered Nurse (RN) confirmed that the privacy curtain should have been closed to ensure the resident's dignity and privacy. The CNA admitted to not fully closing the curtain because they were in a hurry. The facility's policies and procedures emphasize the importance of maintaining resident privacy and dignity during personal care. However, these policies were not followed in this instance, leading to the deficiency.
Failure to Implement COVID-19 Infection Control Protocols
Penalty
Summary
The facility failed to implement its COVID-19 infection control policy and procedures, as evidenced by several deficiencies observed during a survey. A designated COVID-19 room lacked appropriate signage indicating droplet isolation, which is necessary to prevent transmission of the virus through speaking, sneezing, or coughing. Instead, a contact precaution sign was posted, which does not require the use of an N95 mask and face shield or goggles, as required for droplet precautions. Additionally, facility staff did not adhere to the required personal protective equipment (PPE) protocols while assisting a COVID-19 positive resident. A certified nurse assistant (CNA) was observed assisting the resident without wearing a face shield or goggles, despite acknowledging that such PPE was required per facility protocol. Furthermore, the isolation cart outside the resident's room was not stocked with face shields, which are necessary for staff protection. The resident in question had been readmitted to the facility with several diagnoses, including dementia and hypertension, and was dependent on staff for daily activities. The resident had tested positive for COVID-19, and the facility's policy required the room door to remain closed, which was not adhered to, as the door was observed to be fully open. Interviews with the Infection Prevention Nurse and the Director of Staff Development confirmed the discrepancies in signage and PPE usage, emphasizing the importance of following the correct protocols to prevent the spread of COVID-19.
Failure to Follow Prescribed Diet for Diabetic Resident
Penalty
Summary
The facility failed to adhere to the prescribed diet order for a resident, identified as Resident 2, who was on a low sodium and carbohydrate-controlled diet with large portions and thin liquids. Despite the physician's orders, the resident reported receiving meals that included sweet foods such as bread, rice, and potatoes, which are not suitable for a diabetic diet. This discrepancy was confirmed during an observation of the resident's lunch tray, which contained bread, stuffing, and apple crumble, items that should not have been included in a carb-controlled diet. The Registered Nurse Supervisor acknowledged that the meal did not comply with the dietary requirements, which could potentially worsen the resident's condition by increasing blood sugar levels. Resident 2, who has diagnoses of diabetes and hyperlipidemia, was found to lack the capacity to make decisions, according to a review of their History and Physical. However, the Minimum Data Set indicated that the resident was independent in cognitive skills for daily decision-making but required varying levels of assistance with personal care tasks. The Dietary Supervisor confirmed that the meal provided did not align with the carb-controlled diet and recognized the need for an in-service training for dietary staff to ensure compliance with meal tickets and physician orders. The facility's policy, dated 2011, mandates serving diets as ordered by the physician, which was not followed in this instance.
Improper Food Handling and Utensil Sanitation
Penalty
Summary
The facility failed to adhere to proper food handling practices, resulting in a resident finding a non-edible item, specifically a wire, in their corn bread muffin. This incident occurred during dinner, and the resident almost swallowed the wire but managed to cough it out. Despite the seriousness of the situation, there was no documented evidence that the resident was assessed or monitored for potential complications following the incident. Additionally, there was no immediate investigation into how the wire ended up in the muffin, nor were other residents' meals checked for similar contamination. Furthermore, the facility did not ensure that the utensils and dishware provided to the resident were free from residue. The resident reported seeing residue on bowls, utensils, and cups, which was corroborated by a Certified Nursing Assistant and observed during a test tray inspection by the RN Supervisor. The facility's policies on food preparation and sanitation were not followed, as utensils and equipment were not adequately cleaned and sanitized after use, leading to the presence of residue on items served to residents.
Failure to Change Indwelling Catheter Monthly
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter was changed monthly as indicated in the physician's order. The resident, who had diagnoses including benign prostatic hyperplasia, hypertensive chronic kidney disease, and peripheral vascular disease, experienced extreme pain when the catheter was finally changed five and a half months after the order was placed. The resident's admission record and physician orders indicated the catheter should be changed monthly, but this was not adhered to, resulting in significant discomfort and complications for the resident. Interviews and record reviews revealed that the resident's catheter was not changed from the time of admission until it was removed in March 2024, despite the physician's order for monthly changes. The resident reported severe pain during the catheter change, and subsequent nursing notes documented mild pain, skin abrasion, and early signs of penile erosion. The resident's family member expressed concerns about the lack of catheter changes and the resulting pain and bleeding experienced by the resident. The facility's Licensed Vocational Nurse and Director of Nursing confirmed that the catheter should have been changed monthly according to the physician's order. However, the facility's policy and procedure for catheter care were not followed, leading to the resident's prolonged discomfort and potential complications. The Director of Nursing acknowledged the failure to adhere to the physician's order and the facility's policy, which contributed to the resident's pain and medical issues.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 5,374 citations issued within 25 miles in the last 12 months — including the 30 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Californian Pasadena Healthcare | 0.2 mi | — | 17 | 0 |
| The Bellefontaine Healthcare Center | 0.2 mi | — | 2 | 0 |
| South Pasadena Care Center | 1.4 mi | — | 6 | 0 |
| Villa Gardens Health Care Unit | 1.8 mi | — | 16 | 0 |
| York Healthcare & Wellness Centre | 2.5 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.