Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Almond View Care Center during CMS and state inspections, most recent first.
Failure to Protect Residents from Abuse and Inappropriate Sexual Conduct: Multiple residents with dementia were involved in repeated resident-to-resident assaults and sexual misconduct, including one resident found performing oral sex on another resident and others being touched or stroked inappropriately. Staff also observed repeated physical altercations in rooms, hallways, and the dining room, resulting in injuries such as abrasions, bruising, a skin tear, and a cut. The DON stated incidents were discussed in morning meetings but were not tracked or trended for contributing factors, and the ADM said the QAPI team had not changed its plans since the increase in altercations was identified.
Insufficient CNA staffing and lack of dementia-specific training in a secured dementia unit led to repeated resident-to-resident altercations, including physical assaults and sexual behaviors. Staffing schedules showed missing dining room coverage and only one hall monitor on multiple shifts, while staff reported residents wandering, scratching, and needing frequent redirection. The DON and DSD confirmed the facility did not track or trend the incidents by time, location, injury, or staffing patterns, and staff working the unit had not received specialty dementia training.
The facility failed to maintain an effective QAPI program for repeated resident-to-resident altercations in the secured dementia unit. QAPI identified increased incidents and implemented staff in-services, a hall monitor, and added activity staffing, but the DON, ADM, and other staff stated the facility did not track or trend key data such as time, location, injuries, repeated involvement, or staffing patterns. The unit had frequent physical and sexual altercations involving the same residents, and staff reported that the long hallway, limited hall monitoring, and insufficient CNA activity staffing made observation and redirection difficult.
Inaccurate MDS Coding for Wandering Behavior: A resident with severe cognitive impairment, psychosis, Alzheimer’s disease, and dementia with behavioral disturbance was coded as not wandering on the MDS even though staff observed her pacing, entering other residents’ rooms, and needing repeated redirection. SS completed the behavioral section by reviewing the chart only and did not observe the resident or interview nursing staff, despite records showing she was out of her room and required redirection from other residents’ rooms. The DON confirmed the resident did exhibit wandering behavior and that the SS coding was inaccurate.
The facility did not comply with certification requirements for the dietary manager, as the current DM was not certified and had not passed the necessary test. The RD was present only once a month and had been in the role for two months, overseeing multiple facilities. The administrator was aware of the DM's lack of certification but believed the presence of the RD and another certified dietary manager, now serving as the Medical Records Director, would suffice.
The facility failed to promptly address resident grievances, as evidenced by a missing follow-up on a noise complaint from a Resident Council meeting and ongoing food quality issues reported by residents. The facility's policy requires documentation and resolution of grievances, but there was no record of efforts to resolve these issues. The Administrator confirmed that concerns should be addressed by Department Managers and discussed with the IDT.
The facility failed to serve food at an appetizing temperature and texture, as reported by 14 residents. Residents, including those with dementia, diabetes, and Alzheimer's, expressed dissatisfaction with the food being cold, bland, and having mushy vegetables. Complaints also included tough meat and cold soup, indicating a failure to adhere to food preparation guidelines.
Two residents experienced a lack of dignity and respect in their care. One resident's bed was frequently left unmade, despite her inability to make it herself due to age and fear of falling. Another resident overheard staff speaking disrespectfully about her, leading to feelings of fear and mistreatment. The facility's policy on maintaining resident dignity was not adhered to, and the Director of Staff Development had not yet addressed these issues.
The facility failed to maintain a safe and homelike environment, with issues such as missing tiles and exposed wood in the kitchen, extensive rust in tub and shower rooms, and disrepair in residents' rooms. These deficiencies were acknowledged by staff, including the Dietary Manager, Registered Dietician, and Maintenance Supervisor, who noted the need for repairs and the limited maintenance staff available.
A resident with dementia and diabetes was observed with long, dirty fingernails, indicating a failure to include nail care in their care plan. Despite being dependent on staff for personal hygiene, nail care was not documented, and staff confirmed the oversight. The facility's policy requires continuous assessment and updating of care plans, which was not followed.
A resident with dementia and diabetes was found with long, dirty fingernails, indicating a failure in maintaining personal hygiene. Despite being dependent on staff for care, the resident's nails were not properly maintained, as confirmed by a nurse. The facility's policy requires grooming for residents unable to perform ADLs, but this was not provided.
A resident reported rough care by night shift staff to a Licensed Nurse, who informed the Director of Staff Development. Despite the resident's emotional distress and the facility's policy requiring notification to the California Department of Public Health (CDPH), the allegation was not reported. The Director of Nursing was aware but did not consider it abuse, and the Administrator confirmed no report was made.
A resident with severe cognitive impairment was exposed to an outside courtyard during personal care due to an open window shade. The CNA providing care did not close the shade, compromising the resident's dignity. Facility staff, including an LVN and the Activity Director, confirmed the issue, and the CNA acknowledged the oversight.
A resident with Parkinson's and a history of falls was improperly restrained by pillows placed under their mattress, preventing independent movement. The facility's policy on restraint-free care was violated, as the resident could not remove the pillows and was restricted in bed. A CNA confirmed the issue, and the DON acknowledged the pillows should not have been there.
The facility failed to provide necessary assistive devices for two residents, leading to potential fall risks. One resident did not have a call light or urinal within reach, and another lacked anti-rollback brakes on her wheelchair, despite both being at high risk for falls. Staff confirmed the absence and malfunction of these devices, which were required by the residents' care plans.
A resident with dementia and a history of aggression was involved in multiple altercations due to the facility's failure to update and implement an effective care plan. The resident's territorial nature and sensitivity to personal space violations were not adequately addressed, leading to physical confrontations with other residents who entered his room or disturbed him.
A resident with severe cognitive impairment was injured after being pushed by another resident with a history of aggressive behavior. The incident occurred when the injured resident entered the other's room, prompting the push. The facility's policy on preventing resident-to-resident altercations was not effectively implemented, leading to the injury.
Failure to Protect Residents from Abuse and Inappropriate Sexual Conduct
Penalty
Summary
The facility failed to protect vulnerable residents with dementia from physical abuse and inappropriate sexual behaviors involving multiple resident-to-resident incidents. The report describes repeated episodes in which residents were physically assaulted or subjected to nonconsensual sexual conduct, including one resident found on top of another resident with his penis in her mouth, another resident holding a peer’s hand over his penis and stroking it, and another resident using a peer’s hand to stroke his penis. The report also documents multiple physical altercations involving one resident who repeatedly struck, pushed, grabbed, or slapped other residents, causing injuries such as abrasions, bruising, a skin tear, and a knocked-off pair of glasses. The residents involved had diagnoses including Alzheimer’s disease, vascular dementia, psychosis, anxiety, major depressive disorder, and behavioral disturbances. After the sexual incident, the resident who was assaulted stated that the man had come into her room, talked about sex, seduced her, and put his penis into her mouth. She later expressed increased anxiety, said she was raped, stated she hated being there, and told social services she was not sure she felt safe. In the other incidents, residents reported being hit, and staff observed injuries including a forehead abrasion, a cheek skin tear, a bruise under an eye, and a cut to the forehead. The report also shows that the facility had multiple resident-to-resident altercations over several months, including incidents involving the same aggressive resident and repeated conflicts among residents in the dining room, hallways, and resident rooms. Staff interviews and record reviews confirmed that residents were checked shortly before several of the incidents occurred. The administrator stated the QAPI team identified an increase in altercations on the dementia secure unit, but the facility had not changed its plans and interventions since they began and had not reached out to corporate clinical consultants. The DON stated the facility received information about the incidents in morning meetings but did not track or trend the data to analyze contributing factors such as location, time of day, injury type, staffing, or repeated resident involvement.
Insufficient CNA staffing and lack of dementia-specific training in secured dementia unit
Penalty
Summary
The facility failed to provide sufficient and competent nursing staff in the secured dementia unit to meet resident needs. The unit had an average daily census of 41 residents out of 42 possible beds, yet staffing schedules showed repeated shortages in the expected CNA coverage for the dining room and hall monitoring roles. The scheduler confirmed that the unit was supposed to have four CNAs on day shift, four CNAs on evening shift, two hall monitor CNAs, and two CNAs assigned to the dining room, but the schedules did not consistently fill those assignments. Facility records showed a pattern of resident-to-resident abuse and altercations in the secured dementia unit from June 2025 through March 2026, including 25 allegations reported to CDPH and three allegations involving sexual abuse. The incidents included residents engaging in sexual contact with other residents, residents striking, pushing, and grabbing one another, and multiple episodes involving one resident who repeatedly assaulted others. Nursing notes showed that this resident was involved in nine resident-to-resident altercations between July 2025 and January 2026, including an incident where he struck another resident with a closed fist and another where he pushed a resident to the floor, causing that resident to be sent to the hospital for evaluation. Staffing records showed that on multiple evenings there was no dining room CNA assigned and only one hall monitor CNA instead of the expected two, including on dates when resident altercations occurred. Staff interviews described residents wandering into rooms, taking food, scratching others, and requiring frequent redirection. Staff also stated that the unit needed more eyes, that call-offs left the unit short-staffed, and that two CNA activity staff were not enough to meet resident care and supervision needs. The DON and DSD confirmed that the facility did not track or trend the repeated altercations by time, location, injury, or staffing patterns, and that no specialized dementia training had been provided to staff working on the secured unit.
QAPI Failure to Track Repeated Resident Altercations in Dementia Unit
Penalty
Summary
The facility failed to maintain an effective QAPI program because the committee did not monitor, evaluate, or track the outcomes of its performance improvement efforts related to repeated resident-to-resident altercations in the secured dementia unit. The facility’s QAPI policy required a data-driven program that identifies quality deficiencies, analyzes information from multiple sources, and monitors corrective action plans, including at least one annual performance improvement project in a high-risk or problem-prone area. Despite this, the facility identified an increase in resident-to-resident incidents in November 2025 and implemented interventions, but the plan was not changed or expanded as the problem continued. Facility-reported incidents showed 25 resident-to-resident abuse allegations from June 2025 through March 2026, including three allegations of sexual abuse. The secured dementia unit had an average daily census of 41 residents out of 42 possible beds. The incidents included sexual conduct between residents, physical assaults, and repeated altercations involving the same residents. One resident was involved in eight resident-to-resident altercations as the perpetrator and one as a victim, and another resident was the victim of three altercations. QAPI meeting minutes showed the facility recognized the increase in incidents and identified contributing factors such as insufficient staff education, a higher number of residents who ambulated and paced in the hallways, and the need for enhanced dementia-specific activities. The facility implemented measures including staff in-services, a hall monitor, and increased activity staffing, but interviews with the ADM, AD, DSD, LN, and DON showed the facility did not track or trend key data such as time of day, location, injuries, repeated involvement, or staffing patterns. Staff stated the unit had a long hallway, one hall monitor was not enough, two CNA activity staff were insufficient, and additional direct care staffing had helped, but the facility had not reached out to corporate clinical consultants for further assistance.
Inaccurate MDS Coding for Wandering Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded for wandering behavior for one resident. The resident had diagnoses including unspecified psychosis, Alzheimer’s disease, dementia with behavioral disturbance, and a history of falls. Her BIMS score was 3 out of 15, indicating severely impaired cognition. The admission MDS indicated that she did not exhibit wandering behavior in Section E, even though her care plan directed staff to monitor and document wandering behaviors and included interventions for behavioral symptoms. During observation, the resident was seen pacing in the hallway, entering another resident’s room, and lying on that resident’s bed. When redirected by a CNA, she refused to cooperate and later entered another resident’s room again. The CNA stated that the resident did this all the time and that staff had to keep trying to redirect her. The CNA also explained that the resident’s behavior of entering other residents’ beds could lead to an altercation because the other resident was hospitalized. The MDS Nurse stated that Social Services completed the behavioral sections of the MDS and acknowledged that the resident may not have demonstrated wandering during the 7-day look-back period. The Social Services staff member stated she assessed wandering by reviewing the chart and behavior monitoring records only, without observing the resident or interviewing nursing staff, and said she had been taught that this was sufficient. The behavior monitoring records and a nursing progress note documented the resident being out of her room throughout the shift and requiring redirection from other residents’ rooms, which the Social Services staff member confirmed. After reviewing the CMS RAI Manual definition of wandering, she still stated she would code no wandering unless the word wandering was explicitly written in the record.
Non-compliance with Dietary Manager Certification Requirements
Penalty
Summary
The facility failed to comply with federal regulations regarding the certification qualification requirements for the dietary manager as outlined in the California Health and Safety Code (HSC 1265.4). The dietary manager (DM) at the facility was not certified, as required by the state, and had not passed the necessary test to obtain certification. Despite having been in the role for three years, the DM was scheduled to take the certification test in January 2024. The facility's job description for the dietary manager indicated that certification was a minimum requirement, yet this was not met. The registered dietitian (RD) employed by the facility was present only once a month and had only been in the role for two months, overseeing four other facilities. The administrator acknowledged the lack of certification for the DM and believed that the presence of the RD and another certified dietary manager, who was now serving as the Medical Records Director, would suffice. This oversight had the potential to impact the accuracy of resident assessments, meal distribution, safe food handling, and adherence to sanitation guidelines.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to act promptly to resolve resident grievances in a timely manner and demonstrate their response and rationale for their response, potentially violating residents' rights. The facility's policy on Resident and Family Grievances, dated January 24, 2024, outlines that grievances can be voiced verbally during resident or family council meetings. The policy requires staff to record the grievance details, take steps to resolve it, and document the actions taken. The Social Service Designee (SSD) is responsible for keeping residents informed about the progress and resolution of grievances and issuing a written decision. However, during an interview with the Activities Director, it was revealed that there was a missing follow-up from a resident council meeting grievance, specifically regarding a noise complaint from September 17, 2024, which lacked documentation of efforts to resolve it or a conclusion of the investigation. Additionally, during a confidential interview, five residents expressed dissatisfaction with the food quality, stating that hot food was not served hot, cold food was not cold, and the meat was tough and hard to chew. One resident mentioned difficulty swallowing the meat due to its toughness. These food-related grievances had been ongoing and were reportedly brought up in previous council meetings, yet there was no documentation of these complaints in the Resident Council minutes from June to November 2024. The Administrator acknowledged that the facility is supposed to follow up on all concerns raised by Resident Council members and that these concerns should be addressed by Department Managers and discussed with the Interdisciplinary Team (IDT).
Facility Fails to Serve Food at Appetizing Temperature and Texture
Penalty
Summary
The facility failed to ensure that the food served to residents was at an appetizing temperature and palatable texture, as required by their policy and procedure titled 'Food Preparation Guidelines.' This deficiency was observed in 14 out of 21 sampled residents who expressed dissatisfaction with the temperature and texture of the food. The residents reported that the food was often cold, bland, and the vegetables were mushy, which did not meet their expectations for palatability. Several residents with varying degrees of cognitive impairment and medical conditions, such as dementia, diabetes, chronic kidney disease, and Alzheimer's disease, were interviewed. These residents consistently reported issues with the food being served cold and lacking in taste. For instance, one resident with intact cognition expressed that the food was bland and mostly cold, while another resident with severely impaired cognition stated that the food was cold. Additionally, a resident with moderately impaired cognition also mentioned that the food was cold. The dissatisfaction with the food was not limited to its temperature but also included complaints about the texture and quality. Residents mentioned that the meat was tough and hard to chew, and one resident was particularly disappointed when served cold tomato soup, which they had been looking forward to on a cold evening. These observations and interviews highlight the facility's failure to adhere to its own guidelines for food preparation, potentially impacting the residents' nutritional intake and overall well-being.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents, Resident 80 and Resident 92, as observed through various interactions and interviews. Resident 80, who was admitted with hypertensive heart disease, anxiety, and a history of falling, expressed distress over her bed not being made daily. Despite being unable to make her own bed due to age and fear of falling, Resident 80 often found her bed unmade and had to request staff assistance. Observations confirmed that her bed was frequently left stripped of linen, and staff interviews corroborated the resident's claims, indicating a lapse in the facility's adherence to its policy on maintaining resident dignity. Resident 92, diagnosed with hypertension, anxiety, and requiring assistance with personal care, reported overhearing staff speaking disrespectfully about her. During an interview, Resident 92 expressed feeling that staff were reluctant to provide care and treated her with a lack of respect, which was corroborated by her roommate. The roommate noted a difference in how staff interacted with them, describing the communication with Resident 92 as short and sharp. This behavior led Resident 92 to feel afraid to voice her concerns, fearing further mistreatment. The facility's policy on promoting and maintaining resident dignity was not followed, as evidenced by the staff's failure to make Resident 80's bed and the disrespectful communication overheard by Resident 92. The Director of Staff Development acknowledged awareness of these issues but had not yet addressed them, indicating a gap in the facility's response to maintaining a respectful and dignified environment for its residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations of disrepair and uncleanliness. In the kitchen, a drain was found with missing tiles and exposed, water-damaged wood. This issue was acknowledged by the Dietary Manager and Registered Dietician, who confirmed that maintenance had ordered tiles to address the problem. Additionally, two tub and shower rooms were observed to have extensive rust on metal baskets and handrails, as well as corrosion on floor drains and capped-off spigots. These conditions were confirmed by a Licensed Vocational Nurse and the Administrator, who both agreed that the environment was unsatisfactory and required repairs. Further observations revealed that several residents' room doors and walls were in disrepair, with gouges and scrapes exposing wood and drywall. The Maintenance Supervisor acknowledged these findings and noted that repairs were needed. He also mentioned that there was only one full-time maintenance person and a recently hired part-time assistant, which may have contributed to the delay in addressing these issues. The report highlights the facility's failure to provide a homelike environment, as required by their policy, which could potentially lead to injuries and discomfort for the residents.
Failure to Include Nail Care in Resident's Care Plan
Penalty
Summary
The facility failed to include nail care in the comprehensive care plan for a resident, identified as Resident 8, who was observed with long, dirty fingernails while eating with his fingers. This oversight was noted during observations and interviews, where it was confirmed that the resident's nails were approximately one inch in length with a brown substance underneath. The resident, who has diagnoses including dementia and diabetes, was admitted to the facility with a need for assistance with personal care and was assessed as severely impaired for decision-making and dependent on staff for personal hygiene. Interviews with facility staff, including Licensed Nurses C and D, and the Director of Nurses, revealed that nail care was typically performed weekly during showers and activities, but was not included in the resident's care plan. The Activity Director also noted that the resident was usually resistant to care and was unaware of the nail care issue. A review of the facility's care planning policy indicated that care plans should be continuously assessed and updated to meet residents' needs, which was not adhered to in this case.
Failure to Maintain Personal Hygiene for Resident
Penalty
Summary
The facility failed to maintain personal hygiene for a resident who was unable to perform activities of daily living independently. Resident 8, who has diagnoses including dementia and diabetes, was observed with long, dirty fingernails containing black particles. The resident was noted to be severely impaired in decision-making and dependent on staff for personal hygiene, as indicated in the Minimum Data Set assessment. Despite this, the resident's nails were not properly maintained, leading to a deficiency in care. Observations on two separate occasions confirmed the poor condition of Resident 8's nails, with a licensed nurse acknowledging the issue and stating that nail care is typically performed weekly during showers and activities. The Activity Director, who conducts rounds to observe residents, was unaware of the concern regarding the resident's nails, citing the resident's resistance to care. The facility's policy on Activities of Daily Living mandates grooming and personal hygiene for residents unable to perform these tasks, yet this was not adequately provided for Resident 8.
Failure to Report Alleged Abuse to CDPH
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) concerning a resident who reported rough care by night shift staff. The resident, who was capable of making her own decisions and had a good memory score, informed a Licensed Nurse (LN A) about the incident. Despite the resident's emotional distress during an interview, the allegation was not reported to CDPH as required by the facility's policy. Interviews with facility staff revealed that LN A had informed the Director of Staff Development (DSD) about the resident's concerns, who in turn stated that the Director of Nursing (DON) was aware of the situation. However, the DON did not consider the incident as abuse and did not report it. The facility's Administrator confirmed that no report was made to CDPH, indicating a breakdown in communication and adherence to reporting protocols within the facility.
Resident Dignity Compromised Due to Open Window During Personal Care
Penalty
Summary
The facility failed to honor the dignity of a resident when a Certified Nursing Assistant (CNA) provided personal care with the window covering open, exposing the resident to an outside courtyard accessible to staff and other residents. This incident involved a resident with severe cognitive impairment due to Alzheimer's Disease and dementia, who was dependent on staff for toileting needs and was always incontinent. During the observation, the CNA was seen changing the resident's brief with the window shade fully open, allowing visibility from the outside. The deficiency was confirmed through interviews and observations with facility staff, including a Licensed Vocational Nurse (LVN) and the Activity Director, who acknowledged the dignity issue. The CNA admitted to not closing the window shade before providing care, recognizing it as a dignity issue. The Administrator and Director of Nursing also concurred that window shades should be closed to maintain privacy during personal care activities.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as observed when a staff member placed two pillows under the resident's mattress. This action tilted the mattress, preventing the resident from getting out of bed independently. The facility's policy on maintaining a restraint-free environment was not adhered to, as the use of pillows to restrict movement was not justified by any medical treatment or condition. The resident, who had a history of falls and required supervision for transfers, was unable to remove the pillows on his own, which restricted his movement and access to the bed's exit. The resident involved had multiple diagnoses, including Parkinson's disease, diabetes, and a history of falls, which necessitated careful supervision and the use of the least restrictive measures to prevent falls. During an observation, the resident's bed was found with pillows stuffed under the mattress, causing a tilt that forced the resident to roll towards the center of the bed. A CNA confirmed the presence of the pillows and the resident's inability to remove them, while the resident mentioned that a night nurse placed them there to prevent falls. The Director of Nursing acknowledged that the pillows were not supposed to be there.
Failure to Provide Assistive Devices for Fall Prevention
Penalty
Summary
The facility failed to ensure that two residents received necessary assistance devices to prevent accidents, as outlined in their fall prevention care plans. For the first resident, staff did not ensure that the call light and urinal were within reach, which was crucial given the resident's high risk for falls due to conditions such as Parkinson's disease, diabetes, and a history of falling. Observations revealed that the call light was under the bed and out of reach, and the urinal was not present. Interviews with staff confirmed that the call light clip was broken, preventing it from being secured within reach, and the urinal was not provided as required by the care plan. The second resident, who had a history of falling and was severely cognitively impaired, did not have anti-rollback brakes on her wheelchair as required by her fall prevention care plan. This resident had previously sustained a fracture from a fall in the facility and was at high risk for falls. An observation confirmed that the wheelchair next to her bed lacked the necessary anti-rollback brakes, which was corroborated by staff during interviews. These deficiencies in providing essential safety devices and ensuring their proper use placed both residents at risk for falls and potential injuries. The facility's failure to adhere to the residents' fall prevention care plans and ensure the availability and functionality of assistive devices contributed to these safety hazards.
Failure to Implement Effective Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dementia, paranoid schizophrenia, and anxiety disorder, leading to multiple altercations with other residents. The resident, who had a history of aggressive behavior, was involved in several incidents where he physically confronted other residents who entered his room or disturbed his personal space. Despite the resident's known territorial nature and history of aggression, the care plan was not adequately updated to address these specific behavioral issues. The first altercation occurred when another resident accessed the resident's room through a shared bathroom, resulting in a physical confrontation. Subsequent incidents involved the resident reacting aggressively to perceived intrusions or disturbances by other residents, including an instance where he slammed another resident's face into a door and another where he threatened violence if his roommate was not removed from his bed. These incidents highlight the resident's sensitivity to personal space violations and the facility's failure to implement effective interventions to prevent such occurrences. Interviews with staff and observations revealed that the resident was easily agitated by noise and territorial about his room. Despite these known triggers, the care plan lacked recent updates to address the resident's specific needs and preferences, such as his dislike for others entering his room. The facility's inaction in updating the care plan and implementing effective strategies to manage the resident's behavior contributed to the repeated altercations, placing both the resident and others at risk of harm.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident pushed him, resulting in a rib fracture. The incident occurred when the resident entered another resident's room and began flipping the light switch on and off, prompting the second resident to push him, causing a fall. This incident was reported to the California Department of Public Health, and the injured resident was diagnosed with a new rib fracture and an old rib fracture. The resident who was pushed had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. He was known to wander into other residents' rooms, which was a behavior observed by multiple staff members. The resident who pushed him had a history of behavioral disturbances, including previous altercations with other residents, and was known to be territorial and easily upset when others entered his room. The facility's policy on resident-to-resident altercations was not effectively implemented, as evidenced by the repeated incidents involving the resident who pushed others. Despite the known history of aggressive behavior and the cognitive impairments of both residents involved, the facility did not adequately prevent the altercation that led to the injury. Interviews with staff and observations confirmed that the resident who was pushed frequently wandered into rooms, and the resident who pushed him had a history of aggressive responses to such intrusions.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Williams
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colusa Medical Center - Snf | 9.4 mi | ★★★★★ | 0 | 0 |
| Willows Post Acute | 25.8 mi | ★★★★★ | 1 | 0 |
| River Valley Care Center | 27.8 mi | ★★★★★ | 1 | 0 |
| Fountains, The | 28.4 mi | ★★★★★ | 1 | 0 |
| Meadowood Nursing Center | 28.6 mi | ★★★★★ | 32 | 0 |
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