Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunny Hills Post Acute during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis post-stroke, syncope, and gait abnormalities was care planned as at risk for falls, with interventions including maintaining the bed in a low position at night. The MDS showed the resident had clear speech, was usually understood and understands, and needed substantial/maximal assistance with ADLs. Despite a fall risk assessment indicating fall risk and intermittent confusion, progress notes and staff interviews revealed the resident repeatedly raised the bed after staff lowered it and did not comply with instructions to keep the bed low. The DON and Charge Nurse acknowledged the resident’s non-compliance and the increased fall risk from the elevated bed, yet the care plan was not revised to reflect the resident’s non-compliance or to add individualized interventions, contrary to the facility’s Fall Prevention Program policy requiring monitoring of interventions and revision of the plan of care as needed.
A resident with severe cognitive impairment, malnutrition, and a recent UTI had STAT labs ordered, which returned an elevated WBC count significantly above the normal range. Documentation showed that the physician and family were notified only of the resident’s weight loss, with no evidence that the abnormal WBC result was reported or that a COC was completed. In interviews, an LVN, an RN, and the DON all confirmed that abnormal labs should be reported to the physician and responsible party and documented as a COC, and the facility’s policy required notification of significant changes in condition, but this did not occur for the elevated WBC.
A resident with a stage 4 sacrococcygeal pressure injury and osteomyelitis, who was cognitively intact but dependent on staff for ADLs, received wound care from an LVN while wearing a soiled incontinence brief containing feces. The LVN removed the old dressing, cleansed and redressed the wound per physician orders, then replaced the same soiled brief instead of cleaning the resident and applying a clean brief, despite facility care plan and policy requirements to keep skin clean, minimize moisture, and prevent fecal contamination of pressure injuries.
A resident with anemia, muscle weakness, severe cognitive impairment, and oropharyngeal dysphagia, who had physician orders and a nutritional care plan for 1:1 feeding assistance, was left with an open meal tray and no CNA present to help despite verbally stating a need for assistance. The tray remained unattended for about 20 minutes before a CNA not assigned to the resident briefly assisted, left to get water, and then returned to resume feeding. The assigned CNA later admitted she opened the tray, left to pass other trays, and did not return as planned, while staff interviews and facility policy confirmed that residents requiring 1:1 feeding should not have trays served until an attendant is ready to assist.
Two residents who required significant assistance with ADLs experienced a lack of clean linens, incontinent pads, towels, and blankets due to repeated shortages in linen storage and carts. Staff confirmed that these shortages led to delays in providing clean bedding and personal care, resulting in residents remaining in soiled or uncomfortable conditions until more linens were delivered. Facility policies required clean linens, but these were not consistently available, affecting resident comfort and care.
A resident with diabetes, anxiety disorder, and impaired cognition was not assessed or treated for scabies after exposure from a roommate who tested positive. Despite reporting persistent itching and rash to staff, no skin assessment was documented, and the resident was not isolated or tested. Staff interviews confirmed that required monitoring and infection control procedures were not followed, contrary to facility policy.
A resident with osteoporosis was administered Alendronate Sodium daily instead of the recommended weekly dose due to an incorrectly entered physician order. Nursing staff did not identify or clarify the error despite medication alerts and packaging instructions, resulting in the resident receiving the medication more frequently than intended.
A resident with Alzheimer's disease and dementia, identified as an elopement risk, was left unsupervised after being assisted to the restroom. The resident exited through an unmonitored, open front door while the receptionist was away from her post, and staff did not respond promptly to the door alarm. The resident was later found outside after falling from her wheelchair, sustaining multiple fractures and injuries. The facility did not follow its own policies for supervision and elopement prevention, leading to the incident.
The facility failed to provide a safe, clean, and homelike environment for residents, with observations of dusty vents, peeling paint, and broken fixtures in several rooms. Staff interviews confirmed that maintenance and cleaning issues were not addressed promptly, despite the facility's policies emphasizing the importance of a sanitary and safe environment.
A resident with moderate cognitive impairment and multiple diagnoses did not swallow scheduled stool softener medications, as observed when pills were left on the bedside table. An LVN confirmed the oversight, and the DON stated that nurses should ensure residents ingest all medications. Facility policy required observation of medication consumption.
A resident with a history of falls was admitted without a baseline care plan indicating fall risk or preventive interventions. The resident later experienced an unwitnessed fall, resulting in injuries and a hospital transfer. Facility staff confirmed the absence of a timely care plan increased fall risk, contrary to policy requiring a plan within 48 hours.
The facility failed to follow gastrostomy tube (GT) orders and protocols for four residents, leading to incorrect feeding formula administration and improper medication flushing. A resident received the wrong GT feeding formula, while others did not have their GT flushed as prescribed, risking medication errors and tube clogging. LVNs admitted to not following procedures due to insufficient training, and the facility's policies were not adhered to, posing risks to residents' health.
Two residents experienced medication administration errors due to improper GT flushing and inadequate training of nursing staff. The errors resulted in a medication error rate of 25.81%, significantly above the acceptable threshold.
Two residents in the facility experienced significant medication errors related to insulin administration. One resident received Humulin R insulin without the required coordination with meal times, while another was given Insulin Aspart significantly earlier than their meal. The facility failed to notify physicians or clarify orders, and there was a lack of insulin training for staff.
The facility failed to properly store and label medications for five residents, including unrefrigerated Insulin Lispro, expired Humulin R, and improperly stored Lorazepam Oral Solution. An oral inhaler was also not labeled with an open date. Additionally, the destruction of non-controlled medications was not witnessed as required, leading to potential health risks.
The facility failed to maintain safe food storage practices, as refrigerator temperatures were not logged for two days, a container of grated cheese was unlabeled, and an open bag of tortillas was improperly stored. These actions violated the facility's policies, risking food spoilage and contamination.
The facility failed to implement proper infection control practices, including not wearing appropriate PPE during G-tube handling, allowing medical tubing to touch the floor, and not labeling oxygen humidifier bottles. These actions put residents at risk of infection, as confirmed by staff interviews and observations.
A resident with severe cognitive impairment was observed with bedrails in use without a physician's order or informed consent from the responsible party (RP). The facility's policy required informed consent before using bedrails, but the RP was not informed of the risks and benefits, violating their right to make an informed decision.
A resident with severe cognitive impairment and multiple health issues was found with her call light out of reach, preventing her from communicating with staff. Despite care plan interventions requiring the call light to be accessible, it was positioned above her head, leading to distress as she was unable to request assistance. An LVN confirmed the importance of the call light being within reach to prevent frustration.
A facility failed to protect a resident's confidential information by not removing identifiable health information from an IV medication bag before disposal. An RN confirmed that RNs were responsible for managing IV therapy and should blacken out resident information before disposal. The facility's policy emphasized the importance of maintaining confidentiality.
Three residents in a shared room experienced dissatisfaction due to old, yellow stains on the ceiling and an unfinished painted wall. Despite a previous water leak being repaired, the staining was not addressed, leading to an unappealing living space. The residents, with various medical conditions and cognitive impairments, expressed their unhappiness with the room's appearance.
The facility failed to conduct timely background criminal checks for four employees, as required by its policy. Interviews and record reviews revealed that checks were either delayed or not conducted at all, contrary to the facility's procedures. This lapse in protocol was acknowledged by the Director of Staff Development.
Two residents in an LTC facility were found to lack person-centered care plans addressing their specific needs. One resident, with severe cognitive impairment and using bedrails, had no care plan for monitoring safety and effectiveness. Another resident, whose primary language was Korean, had no care plan for overcoming language barriers, hindering effective communication. These deficiencies were contrary to the facility's policies on care planning and communication.
A facility failed to meet professional standards of care for three residents. A resident with sleep apnea and COPD did not receive BIPAP therapy as ordered, with nurses falsifying MAR entries. Another resident with multiple health issues did not receive medications and monitoring as prescribed, with missing documentation indicating non-compliance. A third resident's blood sugar was not checked as ordered, with no documentation to confirm the task was completed.
The facility failed to provide communication aids for two residents who did not speak English, impacting their ability to communicate needs. A resident who spoke Korean and another who spoke Spanish were not given communication boards, despite their medical conditions and care plans indicating the need for such aids. Staff interviews confirmed the absence of these aids, contrary to the facility's policy on effective communication.
A resident with a history of breast cancer reported a new bump under her breast and requested a mammogram, but the LTC facility failed to schedule the appointment despite a physician's order. The resident, who had chronic kidney disease, type 2 diabetes, and major depressive disorder, was frustrated by the lack of follow-up. The nursing department was responsible for scheduling the mammogram based on the resident's insurance, but this was not done, violating the facility's policy on assisting residents with follow-up appointments.
A long-term care facility failed to properly manage pressure ulcer prevention and care for three residents. One resident with a Stage IV pressure ulcer did not receive adequate interventions, as necessary padding was often missing, and the care plan lacked specific measures to prevent further skin breakdown. Additionally, two residents had their low air loss mattresses set incorrectly, making them too firm and increasing the risk of pressure ulcers. These deficiencies highlight a failure to adhere to the facility's pressure injury prevention policy.
The facility failed to ensure safe oxygen administration for three residents by not dating nasal cannulas, allowing tubing to touch the floor, and not posting precautionary signs outside rooms. These deficiencies posed risks of respiratory infection and fire hazards, contrary to facility policies.
A facility failed to properly assess and monitor the use of bedrails for a resident with severe cognitive impairment and multiple health conditions. The resident was observed with bilateral bedrails without a proper assessment or physician's order, contrary to the facility's policy. Interviews revealed that the necessary assessments and monitoring were not conducted, placing the resident at risk for entrapment and other safety issues.
A resident with obstructive sleep apnea and COPD did not receive prescribed BIPAP therapy due to the facility's failure to train nurses on the equipment's use. Interviews revealed that nurses were unaware of how to operate the BIPAP machine and falsely documented its use. The facility's policies required adherence to physician orders, but the lack of training led to the resident not receiving necessary respiratory support.
A resident with severe cognitive impairment was administered Seroquel without informed consent. Despite facility policy requiring consent for psychotropic medications, staff failed to obtain it before administration. Interviews confirmed the oversight, highlighting the need for informed consent in such cases.
Two residents with specific dietary needs and preferences were not offered alternative food choices, despite expressing dissatisfaction with their meals. Staff interviews revealed a lack of communication and action regarding the residents' meal preferences, contrary to the facility's policies.
A resident with prostate cancer and radiation proctitis did not receive prescribed Sucralfate enemas due to incorrect medication reconciliation and administration errors. The MAR showed discrepancies, and the medication was held despite physician orders. The facility's policies for medication orders and documentation were not followed, leading to potential worsening of the resident's condition.
A resident with severe cognitive impairment was verbally abused by a contracted X-ray provider, who used profanity and made threats during an X-ray procedure. The facility staff failed to protect the resident from this abuse, as confirmed by interviews with the DON, ADON, an LVN, and a CNA.
The facility failed to implement proper infection control practices, including timely placement of a resident on Novel Respiratory Precautions after COVID-19 exposure, lack of fit testing for CNAs, and inadequate training in PPE use. These deficiencies increased the risk of virus transmission within the facility.
Failure to Revise Fall Risk Care Plan for Non-Compliant Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to revise and individualize a fall risk care plan for a resident who was non-compliant with keeping the bed in the lowest position, as required by the facility’s Fall Prevention Program policy. The resident had diagnoses including hemiplegia and hemiparesis following a stroke, syncope and collapse, and other abnormalities of gait and mobility. An MDS dated 1/13/2026 documented that the resident had clear speech, was usually understood and understands, and required substantial/maximal assistance with toileting, bathing, and lower body dressing. The resident’s care plan, dated 1/20/2025, identified the resident as at risk for falls related to gait/balance problems and a fall at home, and included interventions such as anticipating and meeting needs, placing the call light within reach, encouraging use of the call light, maintaining a safe environment, and keeping the bed in low position at night. However, the care plan did not document that the resident was non-compliant with maintaining the bed in the lowest position, nor that education regarding safety precautions had been provided, despite evidence of ongoing non-compliance. A fall risk assessment dated 2/9/2025 indicated the resident was at risk for falls and had intermittent confusion. Progress notes dated 4/6/2026 at 2:52 p.m. recorded that the resident’s bed was observed elevated, the bed was lowered by staff, and the resident raised the bed again. During an observation and interview at the bedside with the DON, the bed height was approximately 30 inches from the floor, and the DON stated the height was too high and that the resident was non-compliant with instructions to keep the bed low. In a separate interview, the Charge Nurse also stated the resident did not comply with staff instructions and education to maintain the bed in the lowest position. Despite these findings and the facility policy requiring that interventions be monitored for effectiveness and the plan of care revised as needed, the resident’s care plan had not been updated to reflect the non-compliance or additional interventions.
Failure to Notify Physician and Responsible Party of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and the responsible party of a change of condition related to abnormal lab results for one of five sampled residents. The resident had diagnoses including mild protein-calorie malnutrition and a urinary tract infection, and was documented as lacking capacity to make medical decisions, with severe cognitive impairment and dependence on staff for ADLs. A physician’s order directed that STAT labs, including a CBC, CMP, and urine culture and sensitivity, be obtained. The lab report from that testing showed an elevated WBC count of 15,200 cells/µL, above the normal reference range of 4,000–10,000 cells/µL. Review of the SBAR communication form for that date showed that the physician and family were informed of the resident’s weight loss, but there was no documentation that the physician or responsible party were notified of the elevated WBC or that a change of condition (COC) was completed. During interviews, an LVN acknowledged that the WBC was elevated, that no COC was completed, and that the physician and responsible party should have been notified. An RN stated that any abnormal lab results should be reported to the physician and documented as a COC, and that the resident had a change from baseline labs warranting such action. The DON stated that nurses must complete a COC when labs are abnormal and notify the physician and responsible party so all are aware of the abnormal results. The facility’s “Notice of Changes” policy indicated the facility must inform the physician and/or family or legal representative when there is a significant change in the resident’s condition, such as deterioration in health, mental, or psychosocial status, which did not occur in this case regarding the elevated WBC.
Failure to Maintain Cleanliness During Stage 4 Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves a failure to follow proper infection control practices during pressure injury wound care for Resident 2, who was admitted with a stage 4 pressure injury to the sacrococcygeal area and osteomyelitis of the vertebra, sacral, and sacrococcygeal region. During an observed wound care procedure, the LVN performed a dressing change while the resident was wearing a soiled incontinence brief containing a small amount of brown feces. The LVN removed the old dressing, cleansed the wound with normal saline, completed the wound care, and then replaced the same soiled brief on the resident, stating that the brief was dirty with stool but that she would wait for a CNA to change it later. Resident 2’s records showed that the resident had decision-making capacity, no cognitive impairment, and was dependent on staff for ADLs including toileting and personal hygiene. The care plan directed staff to keep the resident’s skin clean and provide skin care per facility guidelines, and the physician’s order specified daily cleansing and dressing of the stage 4 pressure injury. Facility staff, including the LVN, RN, and DON, acknowledged that residents should be cleaned of stool and urine and provided with a clean brief before wound care to prevent contamination of the pressure injury. The facility’s pressure injury prevention and management policy stated that treatment and services are to be provided to heal pressure injuries and prevent infection, including minimizing exposure to moisture and keeping skin clean, especially from fecal contamination.
Failure to Provide Timely 1:1 Feeding Assistance and Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide required 1:1 feeding assistance and timely meal support to a resident identified as being at risk for malnutrition. During a noon meal observation in the resident’s room, the resident was positioned in high Fowler’s with a towel placed around the chest and an open meal tray set on the bedside table. When asked, the resident opened his eyes, nodded that he wanted to eat, and verbally stated he needed help eating, but no CNA was present to assist. The tray remained open and unattended in front of the resident for approximately 16 minutes before any staff entered the room to help. When CNA 1, who stated the resident was not on her assignment, entered the room, she indicated she could assist and provided one spoonful of food before leaving to get water, then returned several minutes later to resume feeding. CNA 1 acknowledged that the resident required 1:1 feeding assistance and that leaving a tray open for a long time could cause the food to become cold, which she stated was not acceptable. Review of the resident’s records showed diagnoses including anemia, muscle weakness, and oropharyngeal dysphagia, with a history and physical indicating capacity to understand and make decisions, and an MDS documenting severe cognitive impairment and dependence on staff for ADLs, with partial/moderate assistance needed for eating. Physician’s orders and the nutritional care plan both specified that the resident was a 1:1 feeder and required 1:1 feeding assistance. CNA 3, who was assigned to the resident on the day of the observation, reported that her practice was to pass trays to other residents first and then bring trays to residents needing 1:1 feeding. She stated that she placed a towel on the resident, opened the meal tray in front of him, observed him open his eyes, and then left the room to pass other trays, intending to return in about 10 minutes but did not check back or return to see if he was eating. CNA 3 acknowledged that leaving the tray open could cause the food to get cold and that it was not acceptable to leave a tray unattended for 20 minutes in front of a resident who could not eat independently. RN 1 and the DON both stated that residents requiring 1:1 feeding should not have trays left in front of them without assistance, and the facility’s “Meal Supervision and Assistance” policy specified that meals should not be served until the attendant is ready to assist the resident.
Failure to Provide Adequate Linens and Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two of six sampled residents by not ensuring the availability of sufficient linens, incontinent pads, towels, and blankets. Multiple observations revealed that linen storage stations and carts were repeatedly found without essential items such as blankets, incontinent pads, towels, and sheets at various times of the day and night. Staff interviews confirmed that linen shortages occurred, particularly at the start of shifts and during nighttime hours, resulting in residents having to wait for clean linens to be delivered from the laundry department. One resident, with diagnoses including gait disturbance, spondylosis, and COPD, required substantial to maximum assistance with activities of daily living (ADLs) and reported that only their diaper was changed during nighttime care, not the sheets or blankets. The resident expressed a desire for fresh and clean blankets. Another resident, with hemiplegia, metabolic encephalopathy, and diabetes, was dependent on staff for ADLs and reported that nurses ran out of sheets and towels during the night, leading to situations where only the diaper was changed and not the sheets, resulting in discomfort from sweaty sheets. Staff interviews corroborated the residents' accounts, with laundry and nursing staff acknowledging the importance of having adequate linens available for resident care and comfort. The facility's policies required the provision and maintenance of clean bed and bath linens, but the observed and reported shortages indicated a failure to meet these standards, directly impacting the residents' environment and care.
Failure to Assess and Treat Resident After Scabies Exposure
Penalty
Summary
The facility failed to assess and treat a resident after exposure to scabies, following the positive diagnosis of the resident's roommate. Despite the resident's history of diabetes mellitus and anxiety disorder, as well as impaired cognitive skills and dependence on staff for personal care, there was no documented skin assessment in the medical record. The resident reported persistent itching and a rash, which she identified as scabies, and stated that staff did not assess her skin or address her symptoms. Observation confirmed the presence of a red rash, and the resident indicated she had informed staff of her condition. Interviews with staff revealed that the treatment nurse was not aware of the resident's skin issues and had not been notified of the rash, despite acknowledging that monitoring should have begun after the roommate's positive scabies result. The infection preventionist nurse admitted to not assessing or isolating the exposed resident, and the DON confirmed that exposed residents should be isolated and assessed. The facility's policy required assessment and isolation of residents exposed to scabies, but these procedures were not followed, resulting in the resident experiencing ongoing discomfort and an increased risk of transmission.
Medication Administration Exceeds Recommended Dose
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes mellitus, osteoporosis, and muscle weakness, was administered Alendronate Sodium at a dosage exceeding the manufacturer's recommended frequency. The physician's order was incorrectly entered as a daily administration of 70 mg, rather than the intended weekly dose. This error was not identified by the nursing staff, despite medication alerts and packaging instructions indicating the correct weekly dosing schedule. The resident received the medication on three separate days within a week, as documented in the Medication Administration Record. The error was further confirmed through interviews with the resident, who reported receiving the medication more frequently than prescribed, and with the pharmacist, who stated that the pharmacy only supplied four tablets and the packaging clearly indicated weekly dosing. The pharmacist also noted that exceeding the recommended dose could result in adverse effects. Interviews with the DON and a registered nurse revealed that the medication alert indicating the excessive dosage was overlooked, and the order was not clarified with the nurse practitioner or physician until after the error was discovered. The facility's policy required medications to be administered according to physician orders and manufacturer specifications, but this protocol was not followed in this instance.
Plan Of Correction
Determines that the disputed findings are relied upon in a manner adverse to the interests of the provider either by the governmental agencies or third party. Corrective action for residents found to have been affected by this deficiency: - The Physician and/or NP of resident #1 was notified of the medication administration error on May 18, 2025, and the order was clarified. - The Physician was contacted on May 18, 2025, and labs were ordered for resident #1 to rule out any abnormality. Resident's Calcium level was normal, and no other abnormalities were noted. - An order was also obtained for monitoring of Dysphagia. - DON provided 1:1 education with the licensed nurse on May 19, 2025. Identification of others at risk: - DON and/or Designee audited residents with Alendronate 70 mg on May 20, 2025, and no other resident was affected by this practice. Measures that will be put into place to ensure that this deficiency does not recur: - Starting on May 19, 2025, the Director of Nursing initiated in-service with Licensed Nurses on the facility's policy titled "Medication Errors" and "Medication Administration." - Med Pass competency was initiated by the DON/Designee on May 29, 2025, and will be continued by the DSD/Designee on med pass observation to at least one (1) licensed nurse per month for three (3) months. Findings will be reported to the Director of Nursing for follow-up. - Pharmacy Nurse Consultant will perform med pass observation during their monthly scheduled visit. Findings will be reported to the Director of Nursing for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: - The Director of Nursing will review all new residents with Alendronate orders to ensure orders are transcribed accurately for three (3) months. - The Director of Nursing will provide a summary trend analysis of the facility's compliance on a monthly basis for three months to the QA committee for further evaluation and recommendations until substantial compliance is sustained.
Failure to Prevent Elopement and Provide Supervision Results in Resident Injury
Penalty
Summary
A facility failed to provide adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease and dementia and was assessed as lacking capacity for decision-making, had a documented history of wandering and previous attempts to leave the facility without informing staff. The resident's care plan specifically identified the risk for elopement and included interventions such as anticipating needs, encouraging activity participation, and frequent visual checks for safety. Despite these documented risks and interventions, the resident was left unsupervised in a wheelchair in the hallway after being assisted to the restroom, and staff did not maintain the required level of monitoring. On the day of the incident, the resident was observed propelling herself down the hallway and was later seen in the front lobby. The facility's front exit door was left wide open and unmonitored when the receptionist left her post unattended to use the restroom. No staff were present to observe or redirect the resident, and the door alarm was not responded to in a timely manner. The resident exited the facility unsupervised, traveled to an adjacent property, and fell from her wheelchair onto the street. The incident was not immediately noticed by staff, and the resident was found by a passerby who called emergency services. As a result of the elopement and fall, the resident sustained multiple injuries, including fractures to the nose, jaw, and ribs, a laceration to the lip, a hematoma, and damage to dental implants. Interviews with staff and review of records confirmed that the facility did not follow its own policies and procedures regarding supervision, elopement prevention, and door monitoring. The lack of supervision and failure to ensure the function and monitoring of exit doors directly led to the resident's elopement and subsequent injuries.
Removal Plan
- Resident 1 was placed on 1:1 supervision with staff educated on supervision until a safe plan is determined by the IDT.
- In-service education was provided to the weekend and evening receptionist regarding not leaving their post unattended.
- In-service education regarding monitoring/supervision, wandering, and elopement policy was provided to the receptionist and facility staff on shift, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel.
- Facility doors were checked for appropriate function by the Maintenance Director.
- A head count of all in-house residents was initiated and all residents were accounted for.
- Elopement assessments were completed on all residents by the DON/designee.
- Two residents identified at risk for elopement were reviewed by the DON/designee for appropriate care plan interventions.
- In-service education regarding wandering and elopement was provided to facility staff, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel. Staff on leave or PRN will be in-serviced on their next scheduled shift.
- An IDT meeting was conducted for the two residents identified as at risk for elopement.
- The DON or designee will audit new admissions with elopement risks and ensure appropriate interventions are in place.
- The SSD or designee will review all new admissions to ensure an elopement risk assessment has been completed, and those residents identified at risk are updated in the Elopement binder. Audits will be conducted until substantial compliance is achieved.
- New hires will receive education on wandering, elopement, and resident safety by the DON, SSD, or designee(s) upon hire and annually thereafter. Ongoing in-service trainings regarding wandering, elopement, resident safety, and resident monitoring/supervision will be performed.
- Elopement risk binders were reviewed and updated by the DON and Administrator. Binders are available at each nursing station and reception area, updated by the SSD with oversight by the DON.
- Elopement code drills were initiated on all shifts and will continue by Administrator/DON and/or DSD.
- A check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. Frequency increased.
- A check of facility doors and alarms will be performed by the Maintenance Department until substantial compliance is achieved. Any findings will be corrected immediately and trends reported to the QA/QAPI Committee.
- The QAPI Committee will review and discuss elopement and supervision for all residents during QAPI meetings to determine effectiveness and provide feedback and program modification until compliance is maintained.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for 8 out of 9 residents in the affected rooms. Observations revealed that the activity room had ceiling vents covered in dust, with strands hanging over them, and walls with dried food spots. In several residents' rooms, paint was peeling off the walls behind headboards, and one room had a plastic baseboard sticking out from the wall. These conditions were confirmed by interviews with housekeeping and maintenance staff, who acknowledged the importance of cleanliness and maintenance for resident safety and hygiene. Interviews with staff revealed that deep cleaning was conducted monthly, but issues such as dirty walls and broken fixtures were not addressed promptly. The housekeeping staff stated that they informed the supervisor about maintenance issues, but these were not resolved in a timely manner. The maintenance supervisor and director of nursing both emphasized the need for a clean and safe environment, as outlined in the facility's policies and procedures. However, the facility's failure to adhere to these policies resulted in unsanitary conditions and potential safety hazards for the residents.
Failure to Ensure Resident Swallowed Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, swallowed scheduled stool softener medications during medication administration. This oversight was observed when two small, white, circular pills were found inside a plastic cup on Resident 3's bedside table. Resident 3, who was admitted with diagnoses including primary generalized osteoarthritis and chronic obstructive pulmonary disease, had moderate cognitive impairment and required substantial assistance with activities of daily living. The physician's orders for Resident 3 included taking Docusate Sodium Oral Tablet 100 mg, two tablets by mouth twice a day for bowel management. During an interview, a Licensed Vocational Nurse (LVN) confirmed that Resident 3 did not take the pills and acknowledged that the facility did not ensure the resident took all her medications. Another LVN stated that it was inappropriate to leave medication at a resident's bedside, as it could lead to missed doses or other residents taking medication not prescribed to them. The Director of Nursing (DON) confirmed that nurses should ensure residents ingest or swallow all medications during administration and that it was not acceptable to leave pills at a resident's bedside. The facility's policy on medication administration required licensed nurses to observe residents consuming their medication.
Failure to Initiate Baseline Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to initiate a baseline care plan for a resident with a history of falls, which is a requirement to be completed within 48 hours of admission. The resident, who was admitted with diagnoses including contusion, laceration, hemorrhage of the brainstem, and repeated falls, did not have a baseline care plan indicating a high risk for falls or interventions to prevent further incidents. This omission was identified during a review of the resident's records, which showed that the baseline care plan dated several days after admission lacked necessary fall prevention measures. The deficiency was further highlighted when the resident experienced an unwitnessed fall in the bathroom, resulting in skin tears and a hospital transfer for evaluation. Interviews with facility staff, including an LVN and the DON, confirmed that the absence of a baseline care plan for a resident with a history of falls placed the resident at risk for repeated falls. The facility's policy mandates the development of a resident-centered baseline care plan within 48 hours of admission, which was not adhered to in this case.
Failure to Implement Gastrostomy Tube Orders and Protocols
Penalty
Summary
The facility failed to implement gastrostomy tube (GT) orders in accordance with its policy for four residents. Resident 56 received the incorrect GT feeding formula, Glucerna 1.2 instead of the prescribed Glucerna 1.5, which was intended to manage their diabetes and nutritional needs. This error was identified during an observation and confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the mistake and the potential impact on the resident's blood sugar and nutritional status. For Residents 81, 41, and 35, the facility did not adhere to the prescribed protocol for flushing the GT before and after medication administration. Observations revealed that medications were administered without the required flushing, which could lead to medication errors and potential clogging of the GT. LVNs involved in the administration process admitted to not following the correct procedures, citing insufficient training as a reason for the oversight. The facility's policies and procedures were not followed, as evidenced by the discrepancies between the prescribed orders and the actual practices observed. The Director of Staff Development and the Regional Nurse Consultant confirmed that the standard practice was not adhered to, and there was a lack of proper training documentation for some of the LVNs involved. This failure to follow established protocols and ensure staff competency in GT management posed significant risks to the residents' health and safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 25.81% error rate during medication administration for two residents. Resident 81 and Resident 41 were both affected by improper medication administration through their gastrostomy tubes (GT). The errors were identified during observations and interviews with the nursing staff responsible for administering the medications. Resident 81, who has a history of hemiplegia, hemiparesis, and dysphagia, was not administered medications as per the physician's orders. The Licensed Vocational Nurse (LVN) responsible for Resident 81's care did not flush the GT before and after each medication, as required. Additionally, the medications were not mixed adequately, leading to residual medication remaining in the cups. The LVN admitted to insufficient training in GT medication administration, which contributed to the errors. Similarly, Resident 41, diagnosed with epilepsy and dysphagia, also experienced medication administration errors. The LVN did not flush the GT before or after administering medications, contrary to the facility's policy and physician's orders. The LVN acknowledged the oversight and the need for additional water to ensure proper medication delivery. The Regional Nurse Consultant confirmed that the standard practice was not followed, which could lead to clogged GTs and incomplete medication delivery.
Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 36 and Resident 55, were free from significant medication errors, specifically concerning the administration of insulin. Resident 36, who has Type II diabetes mellitus and hypertension, was administered Humulin R insulin at 11:30 AM daily, despite the resident's enteral feeding being turned off from 9 AM to 1 PM. This administration was not in accordance with the physician's order to administer the insulin before meals, nor was it aligned with the manufacturer's specifications. The facility did not document any notification to the physician regarding this discrepancy, nor was there any clarification of the order, leading to repeated administration errors over a period of time. Resident 55, also diagnosed with Type II diabetes mellitus, was administered Insulin Aspart before meals as per a sliding scale. However, the insulin was given significantly earlier than the meal was provided, with an observed instance where the insulin was administered over an hour before the resident received lunch. This was contrary to the manufacturer's instructions to administer Insulin Aspart within 5-10 minutes before a meal. The facility's failure to coordinate insulin administration with meal times was not documented or addressed, and there was no evidence of physician notification or order clarification. The facility's policy on the timely administration of insulin was not adhered to, as evidenced by the lack of coordination between insulin administration and meal times for both residents. Interviews with staff, including the Director of Staff Development and the Regional Nurse Consultant, highlighted the importance of administering fast-acting insulins like Humulin R and Insulin Aspart in conjunction with meals to prevent hypoglycemia. The absence of insulin training on the facility's checklist for licensed nurses further contributed to the medication errors observed.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals for five residents, leading to potential health risks. An unopened vial of Insulin Lispro for Resident 2 was found unrefrigerated in a medication cart, contrary to the manufacturer's requirement to refrigerate until opened. Additionally, a vial of Humulin R for Resident 17 was stored past its expiration date, which should have been discarded according to the manufacturer's guidelines. Controlled medications requiring refrigeration, such as Lorazepam Oral Solution for Residents 15 and 42, were improperly stored at room temperature instead of being refrigerated as per the manufacturer's instructions. Furthermore, an oral inhaler, Trelegy Ellipta, for Resident 92 was opened without being labeled with an open date, which is necessary to track its shortened expiration period once opened. The facility also failed to follow its policy for the destruction of discontinued and expired non-controlled medications. The process was not witnessed by a second nurse, as required, and documentation was incomplete, with only one nurse's initials recorded. This lack of adherence to proper procedures for medication storage and disposal increased the risk of residents receiving ineffective or potentially harmful medications.
Deficient Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. The temperature for Refrigerator 1 was not logged for two consecutive days, which was confirmed by the Dietary Supervisor (DS) during an interview. The DS acknowledged that refrigerator temperatures were supposed to be checked daily to ensure they were functioning correctly and to prevent food spoilage. The absence of temperature records for those days meant that any potential issues with the refrigerator's temperature could go unnoticed, risking the spoilage of produce stored inside. Additionally, a container of grated cheese inside Refrigerator 2 was found without a label indicating the product name, open date, and use by date. The DS admitted that the cheese had been transferred into the container without proper labeling, which could lead to confusion and the use of expired products. Furthermore, an open bag of tortillas was observed to be ripped and not stored in a tight-lidded container, as required. The DS stated that such items should be placed in sealable containers to prevent contamination. These practices were in violation of the facility's policies and procedures, which require daily temperature logging and proper labeling and storage of food items.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices for several residents, leading to potential risks of infection. Licensed nurses did not adhere to Enhanced Barrier Precautions when handling a gastrostomy tube for a resident. Despite signage indicating the need for gowns and gloves, a nurse only wore gloves and failed to don a gown while administering medication through the G-tube. This oversight was confirmed through interviews with various staff members, including the Infection Preventionist Nurse and the Director of Staff Development, who emphasized the necessity of wearing gowns during such procedures to prevent infection transmission. In another instance, the facility did not maintain proper hygiene standards for medical equipment. The nasal cannula tubing for a resident was repeatedly observed touching the floor over several days, posing a risk of contamination. Similarly, the indwelling urinary catheter tubing for two residents was also found touching the floor, which could lead to infections. Staff interviews highlighted the importance of ensuring that such tubing does not contact the floor as part of infection prevention practices. Additional deficiencies included an unlabeled oxygen humidifier bottle for a resident, which should have been dated to ensure timely changes for infection control. Furthermore, a resident's bed linens were placed back on the bed after falling to the floor, contrary to the facility's policy on handling soiled linens. These practices were inconsistent with the facility's infection prevention and control program, which mandates proper handling and separation of clean and soiled linens, as well as adherence to enhanced barrier precautions for high-contact resident care activities.
Failure to Obtain Informed Consent for Bedrail Use
Penalty
Summary
The facility failed to ensure that the responsible party (RP) of a resident was informed in advance about the risks and benefits of using bedrails. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed with bilateral bedrails up. However, there was no physician's order for the use of bedrails, nor was there any documentation indicating that the RP had consented to their use. This lack of informed consent violated the RP's right to make an informed decision regarding the resident's care. Interviews with the registered nurse (RN) and the Director of Nursing (DON) revealed that the facility's policy required informed consent from the resident or their RP before bedrails could be used. The RN acknowledged that the bedrails should not have been applied without a physician's order and the RP's consent. The DON confirmed that an assessment for the need and risk of bedrails should have been completed, and the RP should have been informed of the associated risks. The facility's policy on the proper use of bedrails also emphasized the necessity of obtaining informed consent prior to their installation and use.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which prevented the resident from effectively communicating with staff. The resident, who had multiple diagnoses including muscle weakness, anxiety disorder, dementia, and functional quadriplegia, was observed lying in bed with the call light positioned above her head, out of reach. The resident expressed distress by yelling that she was cold and needed to be covered up, indicating her inability to use the call light to request assistance. The resident's care plan included interventions to anticipate and meet her needs, including having a call light within reach, but this was not adhered to. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependence on assistance for daily activities. The facility's policy on fall prevention required that call lights and frequently used items be within reach, but this was not followed in the resident's case. An interview with an LVN confirmed the importance of having the call light within reach to prevent the resident from becoming frustrated and angry when her needs were unmet. The failure to ensure the call light was accessible was a deficiency in the facility's care for the resident.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by not removing identifiable health information from an intravenous (IV) medication bag before disposing of it in the trash. During an observation, an empty IV medication bag with identifiable health information was found in the trash can in a resident's room. This oversight was noted for a resident who had been admitted with multiple diagnoses, including diabetes mellitus, dysphagia, sepsis, and dementia. The resident's cognitive skills for daily decision-making were severely impaired, as indicated in their Minimum Data Set (MDS). A registered nurse (RN) confirmed that only RNs were responsible for managing IV therapy and were required to blacken out the resident's information on the IV medication bag before disposal. The RN acknowledged that it was unacceptable to find the IV medication bag with identifiable information in the trash and emphasized the importance of protecting the resident's dignity and confidentiality. The facility's policy on confidentiality, revised in December 2022, stated the importance of securing and maintaining the confidentiality of residents' personal and medical records.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for three residents who shared a room with visible old, yellow stains on the ceiling and an unfinished painted wall. During observations, the ceiling near the door had a yellow stain, and the wall had an uneven surface and paint color. Interviews with the residents revealed dissatisfaction with the appearance of their living space, with one resident describing the stain as an 'eye sore' and another expressing dislike for the 'ugly' ceiling and wall. The residents involved had various medical conditions, including chronic kidney disease, depression, type 2 diabetes mellitus, and dementia, with varying levels of cognitive impairment. The Regional Maintenance Director acknowledged that a previous water leak had been repaired, but the staining was not painted over by the former Maintenance Director. The facility's policy on providing a safe and homelike environment was not adhered to, as the necessary repairs were not completed in a timely manner.
Failure to Conduct Timely Background Checks on Employees
Penalty
Summary
The facility failed to conduct background criminal checks for four randomly selected employees prior to hire and upon completion of orientation, as required by the facility's policy. This deficiency was identified during interviews and record reviews conducted with the Director of Staff Development (DSD). The review revealed that a Registered Nurse (RN) hired in 2003 did not have a background check until 2007. Additionally, a Licensed Vocational Nurse (LVN) hired in 2023 had their background check completed after their orientation, and two other LVNs hired in 2024 had no background checks conducted upon hire. The facility's policy, revised in January 2024, mandates that criminal conviction record checks be conducted on all personnel applying for employment, in compliance with state and federal regulations. These checks are to be completed after a contingent offer of employment but before the conclusion of the employee's orientation. The DSD acknowledged that background checks should be done prior to hiring to ensure that individuals with criminal backgrounds are not employed, highlighting a lapse in adherence to the facility's established procedures.
Deficiencies in Care Planning for Residents with Special Needs
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in their care. Resident 331, who was admitted with severe cognitive impairment and multiple diagnoses including sepsis, dementia, and COPD, was observed using bedrails without a corresponding care plan. The absence of a care plan meant there were no documented interventions to monitor the resident's skin, assess the risk of entrapment, or evaluate the effectiveness of the bedrails, potentially compromising the resident's safety and care. Similarly, Resident 66, whose primary language was Korean and who had moderately impaired cognitive skills, did not have a care plan addressing her language barrier. Despite her difficulty in communicating and understanding verbal messages, no communication board or other aids were provided to facilitate effective communication. This oversight could hinder the staff's ability to provide appropriate care and support to the resident, as they might not fully understand her needs or concerns. The facility's policies on the proper use of bedrails and effective communication were not adhered to, as evidenced by the lack of care plans for these residents. The policies required that care plans include measurable objectives and timeframes to meet the residents' needs, which were not implemented in these cases. The failure to develop and implement these care plans could delay the delivery of necessary care and services to the affected residents.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents due to the actions and inactions of licensed nurses. For Resident 14, who was diagnosed with obstructive sleep apnea and COPD, the nurses did not follow the physician's order to provide BIPAP therapy at bedtime. Despite the Medication Administration Record (MAR) indicating that the BIPAP machine was used on several dates, interviews with the resident and nurses revealed that the machine was not provided. The nurses admitted to falsifying the MAR entries, citing reasons such as being in a hurry or not knowing how to use the machine. This failure to provide necessary respiratory support could have led to negative outcomes for the resident. For Resident 30, who had multiple diagnoses including diabetes mellitus, dysphagia, and dementia, the facility failed to administer medications and monitor vital signs as ordered. The MAR for October 2024 showed missing documentation for several physician-ordered tasks, such as evaluating pain, monitoring temperature and oxygen saturation, and administering medications like melatonin and atorvastatin. Interviews confirmed that these tasks were not completed, and the lack of documentation indicated non-compliance with physician orders. This inconsistency in care could have delayed necessary treatment and affected the resident's health. Resident 49, who was diagnosed with diabetes mellitus, hypertension, and anemia, also experienced a lapse in care. The facility did not perform a blood sugar check as ordered on a specific date, and there was no documentation to indicate that the task was completed. The facility's policies and procedures emphasized the importance of accurate and timely documentation, yet these were not followed. The failure to monitor blood sugar levels as ordered could have put the resident at risk for complications related to diabetes management.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure effective communication for two residents who did not speak the dominant language, English. Resident 66, whose primary language is Korean, was admitted with several medical conditions including a fracture, dysphagia, and end-stage renal disease. Despite her moderately impaired cognitive skills and difficulty communicating, no communication board or device was provided to assist her in expressing her needs. Observations revealed that Resident 66 struggled to communicate with staff, leading to frustration and unmet needs, such as requesting orange juice instead of cranberry juice. Similarly, Resident 92, who primarily speaks Spanish, was not provided with a Spanish language communication board as indicated in their care plan. Resident 92 has a history of pulmonary mycobacterial infection, COPD, and chronic respiratory failure, and requires an interpreter for effective communication. Despite these needs, staff were observed speaking English to Resident 92, and no communication board was present at the bedside, potentially delaying necessary care. Interviews with facility staff, including CNAs, LVNs, and RNs, confirmed the absence of communication aids for both residents. Staff acknowledged the importance of providing communication boards to facilitate understanding and prevent delays in care. The facility's policy on effective communication emphasizes accommodating residents' communication needs, yet this was not adhered to in the cases of Residents 66 and 92.
Failure to Schedule Mammogram for Resident with Breast Cancer History
Penalty
Summary
The facility failed to follow up on a mammogram appointment for a resident, resulting in a deficiency. The resident, who had a history of breast cancer, noticed a hard bump under her right breast and informed her healthcare team about it. Despite the physician ordering a mammogram screening in August 2024, the nursing department did not set up an appointment, leaving the resident without the necessary diagnostic follow-up. This oversight led to the resident feeling frustrated with her healthcare team. The resident's medical history included chronic kidney disease stage four, type 2 diabetes mellitus, and major depressive disorder. The resident's cognition was intact, and she had the capacity to understand and make decisions. The Director of Nursing confirmed that the nursing department was responsible for scheduling the mammogram based on the resident's insurance. The facility's policy required staff to assist residents in scheduling and attending follow-up appointments as ordered by the physician, which was not adhered to in this case.
Inadequate Pressure Ulcer Management in LTC Facility
Penalty
Summary
The facility failed to adequately implement pressure ulcer interventions for three residents, leading to deficiencies in care. Resident 82, who was at high risk for pressure ulcer development due to quadriplegia and other conditions, had a Stage IV pressure ulcer that was not properly managed. Despite being educated on the importance of repositioning and using padding to protect bony prominences, Resident 82 preferred to remain in a Geri chair for extended periods, which contributed to the pressure ulcer's persistence. Observations revealed that the necessary padding was often not provided, and the care plan lacked specific interventions to prevent further skin breakdown. Resident 331's low air loss mattress (LALM) was not set to the correct weight, which compromised its effectiveness in preventing pressure ulcers. The mattress was observed to be set at a significantly higher weight than the resident's actual weight, making it too firm and increasing the risk of skin breakdown. The treatment nurse acknowledged the incorrect setting and the potential risk it posed to the resident, who was already at high risk for pressure ulcer development. Similarly, Resident 92's LALM was also set incorrectly, with the weight setting far exceeding the resident's actual weight. This error resulted in a mattress that was too hard, potentially contributing to the resident's existing moisture-associated skin damage. The facility's policy on pressure injury prevention was not adequately followed, as evidenced by the failure to ensure that the LALM settings matched the residents' weights, thereby compromising the intended protective measures against pressure ulcers.
Deficient Oxygen Administration Practices
Penalty
Summary
The facility failed to implement safe oxygen administration practices for three residents, leading to several deficiencies. Resident 14's nasal cannula was not dated with an open date, and the tubing was observed touching the floor on multiple occasions. Additionally, there was no precautionary sign indicating oxygen use outside Resident 14's room. These practices were not in line with the facility's policy, which requires oxygen equipment to be dated and changed weekly, and for precautionary signs to be posted. Resident 54's nasal cannula was also observed touching the floor on several occasions, and there was no sign indicating oxygen use outside their room. Resident 54 had a history of chronic kidney disease and cardiomegaly and was dependent on staff for various activities of daily living. The lack of precautionary signage and improper handling of oxygen equipment posed a risk of respiratory infection and fire hazards. Similarly, Resident 99's room lacked a precautionary sign despite the presence of an oxygen concentrator at the bedside. Resident 99 had a history of respiratory failure, COPD, pulmonary edema, and dementia, and required continuous oxygen for shortness of breath. The absence of a no-smoking sign was acknowledged by a registered nurse as a potential fire risk. The facility's policy mandates that oxygen warning signs be placed on the doors of rooms where oxygen is in use, which was not adhered to in these cases.
Failure to Properly Assess and Monitor Bedrail Use
Penalty
Summary
The facility failed to ensure the proper use of bedrails for a resident, identified as Resident 331, as per the facility's policy and procedure. The deficiency was identified through observation, interview, and record review. The facility did not assess Resident 331's risk for entrapment or the need for bedrails, nor did it conduct monitoring specific to the resident's use of bedrails. This oversight had the potential to result in accidents such as entrapment or falls. Resident 331 was initially admitted to the facility with diagnoses including sepsis, dementia, and chronic obstructive pulmonary disease. The Minimum Data Set indicated that the resident's cognition was severely impaired, and they were dependent on staff for various activities of daily living. The History and Physical report noted that Resident 331 lacked the capacity to understand and make decisions. Despite these conditions, the resident was observed with bilateral bedrails up, without a proper assessment or physician's order. Interviews with RN 1 and the Director of Nursing revealed that the facility did not follow its process for assessing the need for bedrails, the risk of entrapment, and performing close monitoring. The facility's policy required an evaluation of alternatives before installing bedrails and documentation of monitoring during their use. However, these steps were not followed for Resident 331, placing them at risk for entrapment and other safety issues.
Failure to Provide BIPAP Therapy Due to Lack of Staff Training
Penalty
Summary
The facility failed to ensure that licensed nurses were trained on the use of a BIPAP machine, which is essential for providing respiratory support to residents with conditions such as obstructive sleep apnea and COPD. This deficiency was identified for one resident, who had a physician's order for BIPAP therapy at bedtime. Despite the order, the resident did not receive the BIPAP therapy due to the nurses' lack of training and familiarity with the equipment. Interviews with the resident revealed that she was aware of her need for the BIPAP machine and expressed concern about not receiving it. The resident reported that the nurses did not provide the machine because they did not know how to operate it. Further interviews with two licensed vocational nurses confirmed that they had not been trained on the BIPAP machine and had falsely documented its use. One nurse mentioned a missing piece of the equipment but did not report it or notify the physician. The facility's policies and procedures required the provision of physician-ordered services, including noninvasive ventilation, according to professional standards. However, the lack of in-service training for the nurses on the BIPAP machine led to the resident not receiving the necessary therapy, as documented in the facility's policy and procedure reviews.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering Seroquel, a psychotropic medication, to a resident. The resident, who was admitted with diagnoses including sepsis, dysphagia, depression, and dementia, lacked the capacity to understand and make decisions, as indicated in their History and Physical and Minimum Data Set. Despite this, Seroquel was ordered and administered without informed consent, as confirmed by a review of the resident's Medication Administration Record and an interview with a registered nurse. Interviews with nursing staff revealed that informed consent is required before administering antipsychotic medications, and the absence of such consent should prompt the nurse to contact the resident's family or responsible party. The facility's policy mandates obtaining informed consent for complex decisions, including the administration of psychotherapeutic medication. The failure to secure informed consent for Seroquel administration was acknowledged by the nursing staff, who stated that the medication should not have been given without it.
Failure to Provide Alternative Food Choices
Penalty
Summary
The facility failed to provide alternative food choices and an alternative menu for two residents, impacting their nutritional status and quality of life. Resident 77, who has diabetes mellitus, dysphagia, Parkinson's disease, and hyperlipidemia, was observed to have a meal tray that did not align with her preferences. Despite having a care plan that required honoring her food preferences and offering substitutes if meals were less than 50% consumed, Resident 77 was not offered an alternative meal when she expressed dissatisfaction with her food. She reported not being aware of the alternative menu available in the hallway. Similarly, Resident 24, who has congestive heart failure, hyperlipidemia, hypertension, gastroesophageal reflux disease, and dysphagia, also expressed dissatisfaction with the meals provided. Despite having a care plan that required offering substitutes if meals were less than 50% consumed, Resident 24 was not offered an alternative meal. She was observed eating from a container of cashews instead of the meal provided, indicating a lack of awareness of the alternative menu. Interviews with staff, including CNAs and LVNs, revealed a lack of communication and action regarding the residents' dissatisfaction with their meals. Staff members acknowledged that residents should be offered alternative options if they do not like the food provided, but this was not done for Residents 24 and 77. The facility's policies and procedures require staff to offer suitable nourishing alternatives when meals are refused, but these were not followed, leading to the deficiency.
Medication Reconciliation and Administration Failure
Penalty
Summary
The facility failed to ensure that the nursing staff correctly reconciled the medication list for a resident upon admission. The resident, who was admitted with diagnoses including malignant neoplasm of the prostate and hemorrhage of the anus and rectum, was supposed to receive Sucralfate enemas twice daily for radiation proctitis. However, the medication was ordered incorrectly for constipation, and the nursing staff did not administer the medication as prescribed. The resident reported not receiving the enemas for about a week, which led to significant rectal bleeding. The Medication Administration Record (MAR) showed discrepancies in the documentation of Sucralfate administration. The MAR indicated that the medication was held on certain days due to bleeding, despite the physician's order to administer it for radiation proctitis. The Director of Nursing confirmed that the medication was ordered with the incorrect indication and that the documentation was inaccurate, with two doses unaccounted for. This discrepancy suggested that the medication was documented as given when it was not. The facility's policies and procedures for medication orders and administration were not followed. The policies required verification of medication orders and accurate documentation in the medical record. The failure to adhere to these procedures resulted in the resident not receiving the necessary treatment, potentially leading to a decline in their condition.
Verbal Abuse by Contracted X-ray Provider
Penalty
Summary
The facility staff failed to protect a resident from verbal abuse by a contracted X-ray provider. The incident involved the X-ray provider using profanity and making threatening remarks towards the resident during an X-ray procedure. Interviews with the Director of Nursing, Assistant Director of Nursing, a Licensed Vocational Nurse, and a Certified Nursing Assistant confirmed that the X-ray provider verbally abused the resident by calling them derogatory names and threatening physical harm. The resident, who was admitted with diagnoses including metabolic encephalopathy and unspecified psychosis, was unable to make their own medical decisions and was dependent on staff for all activities of daily living. The facility's policy on abuse, neglect, and exploitation defines verbal abuse as the use of disparaging and derogatory terms towards residents. The staff's failure to ensure the resident was treated with dignity and respect by the X-ray provider led to the deficiency.
Inadequate Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to implement proper infection control practices as evidenced by several deficiencies. Resident 1, who was exposed to COVID-19, was not placed on Novel Respiratory Precautions promptly on 7/9/2024, despite being reported to the Infection Preventionist Nurse (IPN). It was only after Resident 1 tested positive for COVID-19 on 7/12/2024 that the precautions were initiated. This delay in implementing necessary precautions could have contributed to the potential spread of the virus within the facility. Additionally, the facility did not conduct fit testing for Certified Nursing Assistants (CNAs) 1 and 2, who were in direct contact with Resident 1. Both CNAs were observed entering the room of another COVID-19 positive resident without proper fit-tested N95 masks. CNA 1 had been working at the facility for only two days and was not aware of the requirement for fit testing, while CNA 2 had been employed for six months without being fit tested. This lack of fit testing compromised the effectiveness of the protective equipment, increasing the risk of virus transmission. Furthermore, the CNAs were not adequately trained in the proper donning and doffing of personal protective equipment (PPE). Observations revealed that CNA 1 and CNA 2 were double masking incorrectly and not using goggles or face shields as required. The PPE bin outside the resident's room lacked necessary protective equipment, such as goggles or face shields, further indicating lapses in infection control practices. These deficiencies in training and equipment availability posed a significant risk of a widespread COVID-19 outbreak within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near La Mirada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Imperial Healthcare Center | 0.2 mi | — | 1 | 0 |
| Whittier Hills Health Care Ctr | 2.3 mi | — | 35 | 0 |
| Dept Of State Hospitals - Metropolitan Snf | 2.9 mi | — | 28 | 2 |
| Whittier Hospital Medical Ctr D/p Snf | 3 mi | — | 1 | 0 |
| Bonita Hills Post Acute | 3 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.