Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Grove Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to prevent non-consensual sexual contact between two residents with severely impaired cognition who were seated side by side in wheelchairs in a hallway. A visitor observed a male resident’s hand inside the front of a female resident’s pants and reported this to an LVN, while video footage later reviewed by the ADM and DON showed the male resident attempting to place his hand under and in front of the female resident’s pants and the female resident swaying his hand away. Another staff member in housekeeping was told by the visitor that one resident was touching the other but, not fully understanding, did not report the concern to nursing or other staff. The ADM acknowledged that the facility was not able to prevent the sexually inappropriate touching, that residents did not have consent for such contact, and that everyone is a mandated reporter, while facility policy stated that no form of resident abuse is condoned.
A resident with dementia, legal blindness, severe cognitive impairment, and significant physical limitations was identified as a fall risk with restlessness while in bed, yet the care plan interventions to monitor and document sleep patterns, notify the physician of insomnia or anxiety, and provide individualized fall-prevention measures were not implemented. Staff confirmed there was no documented sleep monitoring, no related orders on the MAR, and no sedative orders in place despite ongoing nighttime restlessness, moaning, and screaming. The resident, who could not use a call light or verbalize needs, did not have a bed alarm, even though nurses and the ADON stated a bed alarm should have been ordered and could have alerted staff when the resident was no longer in a safe position. On a night when the resident was noted to be especially restless and constantly moving in bed, the resident was later found on the floor beside the bed with a forehead abrasion, and the IDT attributed the fall to severe cognitive impairment, restlessness, and physical limitations.
The facility did not complete required antibiotic time-outs (ATO) within 48 to 72 hours for two residents who were prescribed antibiotics for infections, as mandated by facility policy. Medical records and staff interviews confirmed that ATOs were not documented within the specified timeframe after antibiotic initiation, despite both residents receiving their prescribed antibiotics. Staff acknowledged the omission and confirmed that the ATOs should have been completed according to the facility's antibiotic stewardship protocols.
The facility failed to maintain room temperatures between 71 to 81 degrees Fahrenheit for three residents, causing discomfort and potential negative impacts on their quality of life. Despite complaints from the residents and confirmation from maintenance staff, the rooms remained excessively hot, with temperatures recorded as high as 92 degrees Fahrenheit. The facility's policies to ensure a comfortable environment were not adequately followed.
The facility was found deficient in maintaining sanitary food handling and storage practices. A rusted can opener, uncovered non-stick spray oil, and improperly sealed and unlabeled cheese were observed in the kitchen. The dietary consultant and DON confirmed these practices were against the facility's policies, which require proper labeling, sealing, and sanitization to prevent contamination.
The facility failed to ensure dumpsters were closed and not overflowing, as required by its Waste Management Policy. Observations revealed dumpsters overflowing with PPE and kitchen trash, which the Dietary Supervisor acknowledged could attract pests and pose an infection control concern. The Administrator confirmed non-compliance with policies designed to reduce contamination risk.
The facility failed to maintain an effective water management program to prevent Legionnaire's disease, as they did not conduct initial or ongoing testing for legionella. Interviews with the Maintenance Supervisor and Infection Preventionist revealed a lack of testing, despite facility policies and national guidelines emphasizing the importance of environmental testing to validate control measures. This oversight placed residents at risk for severe respiratory infections.
The facility failed to ensure a safe and sanitary environment by not properly insulating bed control wires for two residents and allowing trash cans in three rooms to overflow with waste and PPE. Staff confirmed these issues, which could lead to safety and infection control problems.
A resident with multiple health conditions was unable to go outside for over a month due to the lack of a suitable wheelchair. The available wheelchair was too snug, ripped, old, and dusty, leading to the resident feeling sad and starting to get depressed. Despite staff acknowledgment of the issue, no appropriate wheelchair was provided, highlighting a deficiency in accommodating the resident's needs.
Two residents with language barriers were not provided with communication boards as required by their care plans. One resident, with dementia and muscle weakness, and another with a spinal fracture and muscle weakness, both lacked the necessary communication aids to express their needs. Observations confirmed the absence of communication boards, and staff interviews corroborated this deficiency, which contravened the facility's policy on accommodating residents' communication needs.
Two residents in the facility, both dependent on staff for personal hygiene due to severe cognitive impairments and physical limitations, were observed with dirty and crusted fingernails. Despite facility policies requiring hand cleaning to prevent infection, these residents did not receive adequate grooming services, as confirmed by staff observations and interviews.
A resident with severe cognitive impairment and multiple health conditions did not receive their prescribed medications, amlodipine and Vitamin C, at the scheduled time due to a delay caused by the attending LVN. The medications were administered 1 hour and 18 minutes late, exceeding the facility's policy of a one-hour window for medication administration.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a med pass. A resident with cardiomegaly, heart failure, and diabetes received Amlodipine and Vitamin C 1 hour and 18 minutes late due to an LVN attending a call light. This was against the facility's policy of administering meds within one hour of the scheduled time.
An expired bottle of Osmolite 1.5 Cal was found in a medication room at nurse station 2, posing a risk to residents if administered. The DSD and DON acknowledged that licensed staff should ensure medications are not expired, as per facility policy, which requires immediate removal and disposal of outdated items.
A facility failed to coordinate care with hospice staff for a resident with a terminal prognosis, resulting in an inaccurate medical record. The resident's hospice binder lacked documentation of visits by hospice staff, including an RN and Spiritual Counselor, from December to February. This failure could potentially impact the resident's receipt of necessary hospice care.
The facility failed to ensure call lights were within reach for two residents, both with significant cognitive and physical impairments. One resident's call light was found hanging on the wall behind their bed, while another's was wrapped around a bed rail, both out of reach. This oversight could delay assistance and increase fall risk, contrary to facility policy.
The facility did not post accurate and complete nurse staffing information in a prominent location accessible to all residents and visitors. On one occasion, the information was only visible in the red zone for COVID-19 positive residents, and on another, the posted information was outdated. The administrator confirmed these deficiencies, which violated the facility's policy requiring daily, accurate postings.
The facility failed to meet the square footage requirement of 80 sq. ft. per resident in 13 rooms. Despite this, CNAs and residents reported no issues with space for care and mobility. A room waiver was recommended by the Department.
A resident with cognitive impairment and medical conditions was improperly restrained by a CNA using a white sheet as an abdominal binder to prevent self-scratching and pulling out a G-tube. This action violated the facility's policy, which requires restraints to be used only for medical necessity with proper authorization. Staff interviews confirmed the inappropriate use of the restraint.
A resident with cognitive impairment was subjected to physical restraint by a CNA, who wrapped a sheet around the resident's stomach to prevent access to their abdominal area. The incident was reported by an LVN to an RN, but the RN failed to inform the Administrator, delaying the required reporting to authorities. This breach of protocol violated the facility's policy on timely reporting of abuse and restraint incidents.
Failure to Prevent and Report Non-Consensual Sexual Contact Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent sexual abuse between residents in a hallway. Resident 1, who had dementia and severely impaired cognitive skills for daily decision-making, required partial to moderate assistance for mobility and was not self-responsible, with a representative designated as responsible party. On the date of the incident, Resident 1 was seated in a wheelchair in the hallway next to Resident 2. An SBAR and Change in Condition Evaluation completed that afternoon documented that Resident 1 was at risk for emotional distress related to alleged inappropriate touching and that a witness had reported Resident 1 was being touched inappropriately by Resident 2 while seated in the hallway. Resident 2 was also not self-responsible and had severely impaired cognitive skills for daily decision-making, with diagnoses including muscle weakness, gait mobility issues, and dysphagia. Resident 2 required partial to moderate assistance for sit-to-stand and walking. An SBAR and Change in Condition Evaluation for Resident 2 on the same date documented an allegation of inappropriate sexual behavior toward Resident 1, manifested by inappropriate touching, and that Resident 2 was being monitored for inappropriate behavior manifested by touching Resident 1. The Administrator later stated that Residents 1 and 2 did not have consent to touch, especially in the private area or for any sexual interaction with another resident, and that if sexual inappropriate touching was not consensual, it was considered sexual abuse. The events leading to the deficiency were corroborated by witness interviews and video review. Visitor 1 reported seeing two wheelchairs side by side in the hallway, with Resident 1 closest to the wall and Resident 2 next to Resident 1, and observed Resident 2’s hand down the front inside of Resident 1’s pants, moving. Visitor 1 reported this to LVN 1 at the nurse’s station. The Administrator and DON reviewed surveillance footage from the hallway, which showed the two residents sitting side by side in wheelchairs, Resident 2 attempting to place a hand under and in front of Resident 1’s pants, and Resident 1 swaying Resident 2’s hand away; the exact hand location was not visible on the video. Housekeeping staff (HK1) stated that Visitor 1 told him something about Resident 2 touching Resident 1 and pointed toward the residents, but HK1 did not fully understand and did not report it to nursing or other staff. The Administrator acknowledged that the facility was not able to prevent Resident 2’s sexually inappropriate touching and stated that everyone is a mandated reporter required to report even alleged abuse. The facility’s abuse and neglect policy stated that the facility does not condone any form of resident abuse and that its purpose is to address the health, safety, welfare, dignity, and respect of residents.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate accident prevention interventions, including use of a bed alarm, monitoring and documentation of sleep patterns, and timely physician notification of insomnia or anxiety, for a resident assessed as at risk for falls. The resident was admitted with dementia, hypertension, and legal blindness, and was identified on a Fall Risk Evaluation as at risk for falls, with intermittent confusion, bedbound/incontinent status, and poor vision. The MDS documented severely impaired cognitive skills for daily decision making, bilateral upper extremity impairment, unilateral lower extremity impairment, and dependence or significant assistance needed for all ADLs, including rolling in bed. The care plan identified the resident as at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unawareness of safety needs, and restlessness while in bed, and also included a care plan for coronary artery disease with an intervention to monitor and document sleeping patterns, inform the physician of any insomnia or anxiety, and give sedatives as ordered. Despite these identified risks and care plan directives, the facility did not implement or document monitoring of the resident’s sleep pattern, and there was no sedative order in place. Multiple staff interviews, including with RN 1, LVN 2, and the ADON, confirmed there was no documented evidence that the resident’s sleep pattern had been monitored, even though it was listed as a care plan intervention. Staff also stated that if sleep monitoring was part of the care plan, it should have been ordered and reflected on the MAR so that licensed nurses could document hours of sleep. RN 1 acknowledged that the care plan was not resident-centered and that the intervention to monitor/document sleep pattern and notify the physician of insomnia or anxiety had not been carried out. The DON verified that the intervention to monitor and document sleep pattern was not implemented. The facility also failed to provide a bed alarm for this resident, despite the resident’s severe cognitive impairment, blindness, restlessness, and inability to use the call light or verbalize needs. LVN 1 stated the resident did not have a bed alarm and should have had an order for one to alert staff when the resident was no longer in a safe position in bed. LVN 2 and the ADON similarly stated that a bed alarm could have helped prevent a fall by alerting staff when pressure was off the bed. Staff interviews described the resident as usually restless at night, not sleeping like other residents, and moving or squirms frequently in bed. On the night of the incident, documentation and interviews indicated the resident was restless, screaming, moaning, and constantly moving in bed from around 1–2 AM, with repositioning and distraction attempts for comfort. At approximately 5:30 AM, the resident was found on the floor on the right side of the bed, face down between the bed and nightstand, with a 2 cm abrasion on the left forehead. The IDT progress notes identified the likely root causes of the fall as severe cognitive impairment, restlessness, and significant physical limitations, and the DON confirmed that the fall care plan did not include a specific intervention to address the resident’s restlessness while in bed and instead contained only a general directive to follow the facility fall protocol.
Failure to Complete Timely Antibiotic Time-Outs for Two Residents
Penalty
Summary
The facility failed to ensure that an antibiotic time-out (ATO), a structured process for reviewing and assessing the need for ongoing antibiotic therapy, was completed within 48 to 72 hours for two residents who were prescribed antibiotics. According to the facility's policy, an ATO should be performed within this timeframe to reassess the necessity of the antibiotic based on clinical and laboratory data, and to communicate findings with the prescribing physician. However, record reviews and interviews confirmed that ATOs were not completed for these residents within the required period after antibiotic initiation. One resident was admitted with chronic kidney disease, urinary tract infection, and enterocolitis due to Clostridium difficile, and was prescribed metronidazole. The medication administration records showed that the resident received the antibiotic as ordered, but there was no documentation of an ATO being completed within the 48 to 72-hour window. Another resident, admitted with heart failure, bacteremia, and end-stage renal disease, was prescribed ciprofloxacin following a surgical procedure. Similarly, the records indicated the antibiotic was administered as ordered, but an ATO was not documented within the required timeframe. Interviews with the Infection Preventionist, Registered Nurse Supervisor, and Director of Nursing confirmed that the ATOs for both residents were not completed as per facility protocol. The staff acknowledged that the ATOs should have been performed within 48 to 72 hours after starting the antibiotics, as outlined in the facility's policies on antibiotic stewardship and ATO procedures. The absence of timely ATOs was verified through both electronic medical chart reviews and staff statements.
Failure to Maintain Appropriate Room Temperatures
Penalty
Summary
The facility failed to maintain the room temperatures within the required range of 71 to 81 degrees Fahrenheit for three residents, leading to discomfort and potential negative impacts on their quality of life. Resident 126, who was in an isolation room, experienced excessive heat, causing her to sweat profusely and have difficulty sleeping. Despite her complaints about the room being too hot, the temperature was recorded at 92 degrees Fahrenheit by the maintenance staff. Resident 126 expressed that the heat exacerbated her insomnia, and she was unable to sleep due to the uncomfortable conditions. Resident 63 also reported discomfort due to the high temperature in his isolation room. He expressed that the room was too hot, which was confirmed by the maintenance staff who measured the temperature. Similarly, Resident 36, who had a history of polyneuropathy and other medical conditions, complained about the persistent heat in his room. Despite having the window partially open, he felt the room was excessively hot and had repeatedly informed various staff members, including the Maintenance Supervisor, about the issue without any resolution. The maintenance staff and Infection Control Nurse acknowledged the residents' complaints but failed to effectively address the temperature issues. The Maintenance Supervisor stated that he could control the thermostat remotely and was not notified of any extreme temperatures by the monitoring app. However, the residents continued to experience discomfort, and the facility's policies and procedures aimed at providing a comfortable environment were not adequately followed, resulting in the deficiency.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain the food service area in a clean and sanitary manner, as observed during a survey. A can opener in the kitchen was found to be rusted, which was acknowledged by the dietary consultant (DC) as a potential source of cross-contamination. Additionally, a non-stick spray oil was observed without a lid, and cheese in the refrigerator was not properly sealed or labeled with an open or use-by date. These observations were confirmed by the DC, who noted the importance of sealing and labeling to prevent contamination. The Director of Nursing (DON) reviewed the facility's policies and procedures (P&P) and confirmed that the observed practices were not in compliance. The P&P required that all food items be labeled and dated, and that open products be stored in containers with tight-fitting lids. The can opener was also required to be sanitized between uses according to the manufacturer's guidelines. The DON emphasized that these measures are crucial to prevent food contamination and ensure resident safety.
Improper Waste Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure that three dumpsters in the parking lot were closed and not overflowing, as required by the facility's Waste Management Policy and Procedure. During observations and interviews conducted on two separate days, the dumpsters were found to be overflowing with personal protective equipment (PPE) and kitchen trash. The Dietary Supervisor acknowledged that the dumpsters should not be overflowing, as this could attract insects and rodents, posing an infection control concern. The facility's Administrator confirmed that the facility was not compliant with its Policies and Procedures, which were designed to reduce the risk of contamination from regulated waste. The policy indicated that biohazard containers should have closed lids and that food waste should be placed in covered garbage cans. The Administrator noted that when dumpsters are left open and overflowing with kitchen waste, it could lead to unpleasant odors and attract pests, further emphasizing the infection control issues.
Failure to Implement Effective Water Management Program for Legionella
Penalty
Summary
The facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease. During interviews, the Maintenance Supervisor (MS) admitted that the facility does not conduct any testing for legionella, neither initially nor on an ongoing basis, to confirm the effectiveness of their control measures. The Infection Preventionist (IP) also acknowledged the lack of testing for legionella or other waterborne pathogens, despite suggesting that testing would validate the effectiveness of the facility's control measures. A review of the facility's policy and procedure on Water Management indicated that the facility should develop and utilize water management strategies to reduce the risk of legionella and other water-borne pathogens. However, the facility did not follow through with environmental testing for pathogens as part of their verification and validation process. The CMS and CDC guidelines, as well as ASHRAE standards, emphasize the importance of environmental testing for legionella to validate the effectiveness of control measures, especially in healthcare facilities serving at-risk populations. The facility's failure to implement these testing protocols placed residents at risk for developing severe respiratory infections.
Deficiencies in Environmental Safety and Waste Management
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for two residents by not ensuring that the bedside control wires for their beds were properly insulated. The exposed wires were observed in the rooms of two residents, one of whom had severe cognitive impairment and a history of falling, while the other had moderate cognitive impairment and a history of falling and depression. The Director of Nursing confirmed the presence of exposed wires, which could pose a risk of fire, shocks, and accidents. Additionally, the facility did not manage waste disposal effectively, as observed in three rooms where trash cans were overflowing with trash and used personal protective equipment. This was confirmed by interviews with staff, including a certified nursing assistant, an infection preventionist, and a licensed vocational nurse, who acknowledged that overflowing trash cans could lead to infection control issues. The facility's policies and procedures required trash cans to be closed and waste bags to be removed when three-quarters full, but these guidelines were not followed, contributing to an unsanitary environment.
Failure to Provide Suitable Wheelchair for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences regarding a wheelchair that was comfortable for his size and in good condition. The resident, who was admitted with multiple diagnoses including polyneuropathy, type 2 diabetes with diabetic polyneuropathy, end-stage renal disease, anemia, and dysphagia, expressed his desire to go outside for fresh air and sunlight. However, he was unable to do so because the facility did not have a wheelchair that fit him properly, and the available wheelchair was described as too snug, ripped, old, and dusty. The resident reported feeling sad and starting to get depressed due to being confined to his bed for over a month. Despite his requests and the facility staff's acknowledgment of the issue, no suitable wheelchair was provided. Interviews with various staff members, including the Director of Nursing, Certified Nursing Assistant, Social Service Director, and Occupational Therapy staff, confirmed the lack of an appropriate wheelchair and the resident's inability to be transferred safely and comfortably. The facility's policies and procedures, including those related to maintenance, resident rights, and infection control, emphasize the importance of maintaining equipment in good condition and accommodating residents' needs. However, the failure to provide a suitable wheelchair for the resident highlights a deficiency in adhering to these policies, potentially impacting the resident's psychosocial well-being and safety.
Failure to Provide Communication Boards for Residents with Language Barriers
Penalty
Summary
The facility failed to provide communication boards to two residents, Residents 66 and 225, who had language barriers and were dependent on staff for communication. Resident 66, diagnosed with dementia and muscle weakness, was admitted to the facility and was noted to be dependent on staff for various activities of daily living. The care plan for Resident 66 indicated the need for adaptive equipment, such as a communication board, to address the language barrier. However, during multiple observations, no communication board was found in Resident 66's room, and staff confirmed the absence of such a device. Similarly, Resident 225, who had a wedge compression fracture and muscle weakness, was also identified as having a language barrier. The care plan for Resident 225 included the provision of a communication board or translator to facilitate communication. Observations revealed that no communication board was present in Resident 225's room, and the resident reported frequent misunderstandings with staff due to the lack of communication aids. Staff interviews confirmed the absence of communication boards for Resident 225. The facility's policy on accommodating residents' communication needs requires the provision of adaptive devices like communication boards for residents with language barriers. The Director of Nursing acknowledged that the absence of communication boards for these residents placed them at risk of being unable to express their needs effectively. This deficiency highlights the facility's failure to adhere to its own policy and ensure that necessary communication aids are readily accessible to residents with language barriers.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide adequate grooming services for two residents who were dependent on staff for activities of daily living (ADLs), specifically personal hygiene. Resident 53, who was admitted with diagnoses including sepsis, dysphagia, and muscle weakness, was observed with dirty and crusted fingernails. The resident's cognitive skills were severely impaired, and they were totally dependent on staff for personal hygiene, as indicated in their care plan. Despite these needs, observations revealed that the resident's nails were not maintained, which was confirmed by a licensed vocational nurse who noted the potential for bacteria harboring under the nails. Similarly, Resident 57, who had diagnoses including dysphagia, muscle weakness, and paraplegia, was also observed with unkempt fingernails. This resident required substantial assistance with eating and was dependent on staff for personal hygiene. During an observation, the resident's fingernails were noted to have a dry, crusted, yellowish-blackish substance. The facility's administrator acknowledged that it was unacceptable for residents to have dirty fingernails and that the facility's policy was to clean residents' hands when dirty, especially before and after meals, to prevent the spread of infection.
Medication Administration Delay for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 64 by not administering medications as prescribed. Resident 64, who was admitted with diagnoses including cardiomegaly, heart failure, and diabetes, had a physician's order for amlodipine 5 mg and Vitamin C 250 mg to be administered at 9 AM. However, during a medication pass observation, it was noted that the medications were administered at 10:18 AM, which was 1 hour and 18 minutes after the scheduled time. The Licensed Vocational Nurse (LVN) responsible for administering the medications stated that the delay was due to attending to another resident's call light. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but the administration in this case exceeded that window. The facility's administrator confirmed that the medications should have been administered between 8 AM and 10 AM, indicating a failure to adhere to the facility's medication administration policy.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69% during a medication administration observation. This deficiency was identified when two medication errors occurred out of 25 opportunities, specifically involving a resident who was administered medications outside the prescribed time frame. The medications, Amlodipine 5 mg and Vitamin C 500 mg, were given 1 hour and 18 minutes after the scheduled 9 AM administration time, which was beyond the facility's policy of administering medications within one hour before or after the scheduled time. The resident involved had significant medical conditions, including cardiomegaly, heart failure, and diabetes, which required careful management of their medication regimen. The Licensed Vocational Nurse (LVN) responsible for the medication pass attributed the delay to attending to a call light during the medication administration process. The facility's policy and procedures emphasized the importance of adhering to the scheduled administration times to ensure compliance with dose guidelines, but this was not followed in this instance, leading to the identified deficiency.
Expired Osmolite 1.5 Cal Found in Medication Room
Penalty
Summary
The facility failed to remove expired Osmolite 1.5 Cal, a therapeutic nutrition product, from one of its medication rooms, specifically at nurse station 2. During an observation with the Director of Staff Development (DSD), a bottle of Osmolite 1.5 Cal was found with an expiration date that had already passed. The DSD acknowledged that expired enteral feeding bottles should not be present in the medication room, as their administration could lead to residents becoming ill and potentially requiring hospitalization. The Director of Nursing (DON) confirmed that licensed staff are responsible for checking expiration dates before administering any medication or enteral feeding bottles to residents. The facility's policy on medication storage mandates the immediate removal and proper disposal of expired, contaminated, or deteriorated medications. However, the presence of the expired Osmolite 1.5 Cal in the medication room indicates a lapse in adherence to this policy, posing a risk to resident health.
Lack of Coordination and Documentation in Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident, resulting in an inaccurate medical record. The resident, who was admitted with a terminal prognosis and under hospice care, did not have hospice staff visit progress notes maintained in their medical record. Additionally, hospice staff did not sign in on their flow sheet in the resident's hospice binder, which is considered part of the medical record. This lack of documentation could potentially lead to the resident not receiving the necessary hospice care and services. The resident, identified as having severe cognitive impairment and being dependent on assistance for daily activities, was admitted to the facility with serious health conditions, including a dissection of the ascending aorta and type 1 diabetes. Despite the care plan indicating the need for cooperation with the hospice team to meet the resident's needs, the hospice binder lacked documentation of visits by the hospice RN and Spiritual Counselor from December 2024 to February 2025. The Director of Nursing confirmed the absence of required documentation, which was against the facility's policy and procedure for hospice care of residents.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for two residents, leading to a potential delay in receiving assistance. Resident 8, who was admitted with type 2 diabetes and dementia, was observed with their call light hanging on the wall behind the head of their bed, out of reach. This resident was noted to have severe cognitive impairment and was dependent on staff for daily activities, making the accessibility of the call light crucial for their safety and communication needs. Certified Nursing Assistant 1 confirmed the call light's placement was not within the resident's reach. Similarly, Resident 44, diagnosed with metabolic encephalopathy and multiple sclerosis, was found with their call light wrapped around the back part of their bed's side rail, also out of reach. This resident's care plan specifically indicated the need for the call light to be within reach due to their risk of falls and dependency on staff for assistance. Licensed Vocational Nurse 2 acknowledged the call light's improper placement and its importance for resident communication. The Director of Nursing emphasized the risk posed by inaccessible call lights, as residents might attempt to move independently, increasing the risk of falls or unmet needs. The facility's policy mandates that call lights be placed within residents' reach, which was not adhered to in these cases.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information in a prominent location accessible to residents and visitors, as required by their policy and procedure. On February 4, 2025, the nurse staffing information was only posted in the red zone, which is designated for residents who tested positive for COVID-19, and was not visible to other residents or visitors outside this area. This oversight was confirmed during an observation at the facility's entrance and lobby, where the staffing information was not accessible to those in the yellow and green zones. Additionally, on February 5, 2025, the Daily Nurse Staffing form posted in the lobby was found to be outdated, displaying the previous day's date, thus rendering it inaccurate. The facility's administrator acknowledged that the staffing information was not updated and confirmed that the posting did not comply with the facility's policy, which mandates that the information be accessible to all staff, residents, and visitors, and must be accurate. The facility's policy, revised in July 2018, requires daily posting of the facility name, current date, and total number of actual hours worked by licensed and unlicensed nursing staff per shift in a clear, readable format in a prominent location.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 of 35 resident rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. During an initial observation, it was noted that rooms 5, 7, 8, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23 did not meet this requirement. Despite this, residents were able to ambulate and move around in their wheelchairs freely, and nursing staff had enough space to provide safe quality care. The facility had a room waiver indicating that the rooms with three beds were in accordance with the needs of the residents and did not adversely affect their health and safety. Interviews with Certified Nursing Assistants (CNAs) and residents revealed that there were no concerns regarding the room sizes. CNAs stated that there was enough room to provide proper and safe care to the residents. Additionally, residents did not express any concerns about the size of their rooms. The Department recommended the room waiver for the specified rooms as requested by the facility.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. A Certified Nurse Assistant (CNA) wrapped the resident's torso with a white sheet, using it as an abdominal binder, which restricted the resident's normal access to their body. This action was taken to prevent the resident from self-scratching and pulling out their gastrostomy tube (G-tube) or incontinent brief. The resident, who was cognitively impaired and required substantial assistance for daily activities, was unable to understand or make decisions due to their medical conditions, including hemiplegia and dementia. The facility's policy mandates that restraints should only be used when necessary for medical treatment and require a physician's order, assessment, and consent. The CNA's action was not in compliance with this policy, as it was done for convenience rather than medical necessity. Interviews with the staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that the use of the sheet as a restraint was inappropriate and not authorized. The facility administrator also emphasized that restraints should only be used as a last resort and in accordance with the resident's assessment and plan of care.
Failure to Timely Report Suspected Abuse and Restraint
Penalty
Summary
The facility failed to report a suspected case of abuse and physical restraint involving a resident to the appropriate authorities within the required timeframe. The incident involved a resident who was cognitively impaired and required substantial assistance for daily activities. The resident was found with a white sheet wrapped around their stomach, which was used by a CNA to prevent the resident from accessing their abdominal area. This action was reported by an LVN to an RN, but the RN failed to report the incident to the facility's Administrator as required by the facility's policy. The Administrator was only informed of the incident during a staff meeting several days later, which delayed the reporting to the State Survey Agency, Law Enforcement, and the LTC Ombudsman. The facility's policy mandates that such incidents be reported within two hours, but this was not adhered to, potentially placing the resident at risk for further abuse and delaying the investigation. The facility's policies on restraint and abuse prevention clearly outline the procedures for reporting such incidents, which were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadway Healthcare Center | 0.7 mi | — | 18 | 0 |
| Mission Care Center | 0.9 mi | — | 25 | 0 |
| Ivy Creek Healthcare & Wellness Centre | 1.1 mi | — | 1 | 0 |
| San Gabriel Valley Medical Ctr D/p Snf | 1.1 mi | — | 3 | 0 |
| Live Oak Rehab Center | 1.2 mi | — | 30 | 1 |
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