Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ararat Convalescent Hospital during CMS and state inspections, most recent first.
A high fall‑risk resident with dementia, prior rib fractures, and impaired mobility repeatedly reported pain and stated she had fallen, pointing to her right lower back and hip during morning care. A CNA notified an RN and LVN supervisor, who assessed the resident, but the RN did not believe a fall occurred due to lack of visible bruising, and no incident report or post‑fall protocol was initiated. The DON later confirmed that staff did not follow facility fall policies, which treat resident‑reported falls as falls and require post‑fall assessment, neuro checks for unwitnessed falls, incident reporting, and IDT review. The resident continued to report pain, and a later CT scan showed probable acute, nondisplaced right rib fractures, while documentation and interviews confirmed that the fall policies and required assessments were not implemented.
Food items in the kitchen were found without required use-by dates, including ground meat, leftover Armenian pizza, croissants, and glasses of milk. The DS stated some items were leftovers or used in residents' food and was unsure when the milk was prepared. The DON confirmed that facility policy requires food to be labeled with a use-by date, and the Food Storage policy and Food Code require date marking for ready-to-eat TCS food.
Failure to maintain resident privacy and dignity during feeding and personal care: two CNAs stood over a resident while feeding a resident with dementia, and a CNA did not fully draw the privacy curtain around another resident’s bed while providing grooming and shaving care. The DON stated standing over a resident during feeding and leaving the curtain partially open were not appropriate and did not protect resident dignity and bodily privacy.
Failure to Obtain Informed Consent for Antidepressant Treatment: A resident with major depressive disorder and severely impaired cognition was receiving Mirtazapine for depression and poor oral intake, but the chart lacked documented informed consent showing education to the resident and RP about the medication’s risks, benefits, side effects, and alternatives. RN and DON both confirmed there was no documented informed consent for the antidepressant treatment, despite facility policy requiring consent before administration.
Failure to ensure a bed alarm was working for a resident with severely impaired cognition and high fall risk. The resident had dementia, gait and mobility problems, and needed assistance with ADLs. The care plan and order called for a sensor pad alarm in bed for fall prevention, but during observation the alarm did not activate when tested, and the LVN stated it had not been checked. The DON confirmed the alarm was not functioning properly.
Kinked Catheter Tubing: A resident with an indwelling catheter, multiple cancers, dementia, CKD, hydronephrosis, DM2, and limited self-care ability was observed with catheter tubing coiled and kinked on the securement device, obstructing urine flow. RN and DON both acknowledged the tubing should not be kinked or coiled, and the facility policy required catheter tubing to remain free of obstruction and kinking.
A resident with FTT, dementia, depression, anemia, and Alzheimer’s disease experienced significant unplanned weight loss while requiring supervision with eating and daily monitoring of intake. The record showed repeated COC entries for weight loss without RD notification or follow-up, RD notes documenting poor and variable PO intake, and a nutritional supplement order for sugar-free ice cream that was not ensured as ordered. Staff also observed the resident eating less than 25% of lunch, and the DON and RD acknowledged the resident’s major weight loss.
Inaccurate Meal Intake Documentation by CNAs: CNAs failed to demonstrate consistent competency in documenting a resident’s meal intake. A resident with protein-calorie malnutrition, Alzheimer’s disease, and severe cognitive impairment had care plan interventions for meal percentage monitoring, but staff gave conflicting estimates of the resident’s lunch intake and used different methods to calculate breakfast and lunch/dinner percentages. The RD reviewed the facility’s standard intake guideline, and the DON stated the CNA inservice did not show that staff competency was evaluated.
Inaccurate Documentation of Urine Characteristics: A resident with AF, BPH, and Eliquis use had an order to monitor for discolored urine and a care plan to observe urine color. RN documented in the MAR that no discolored urine was present, but a CoC record showed CNA reported blood urine in the urinal bottle and RN did not enter that finding in the MAR because she created a CoC. The DON stated accurate urine documentation was important due to the resident’s BPH and anticoagulant use.
Infection Prevention and Control Failures: A resident receiving continuous oxygen had a nasal cannula without a label or date showing when it was last changed, and staff confirmed it was not identified as new or changed weekly per policy. A housekeeper entered and exited another resident’s room, handled dirty linens, and continued cleaning without hand hygiene, and an IP entered a third resident’s room without using hand sanitizer while assisting with breakfast trays and call lights. The DON stated hand hygiene is an important part of infection control and that oxygen tubing and cannulas are to be changed weekly.
Inaccurate Nurse Staffing Postings: The facility posted staffing information that showed scheduled RN, LVN, and CNA coverage and projected hours rather than the actual hours worked by nursing staff. The DON confirmed the postings did not reflect actual hours worked and stated that the daily nursing postings are meant to inform residents, responsible parties, and visitors about the type and hours of nursing care provided, while the facility policy required posting the total number and actual hours worked per shift.
Resident rooms exceeded the allowed bed capacity when four of 12 rooms were found to have five or six beds instead of no more than four. Surveyors observed rooms with six beds and four or six occupied beds, and rooms with five beds and three or five occupied beds. The ADM confirmed the occupancy remained the same, while residents and CNAs stated they were comfortable and had enough space for care. The facility’s P&P required resident rooms to accommodate no more than four residents.
Resident rooms in four areas did not meet the required square footage per resident under the facility’s room policy. A waiver and accommodation review showed some rooms were smaller than required, including rooms with multiple beds and residents, although staff and residents reported there was enough space for care and mobility devices and no complaints had been made about the room sizes.
The facility did not report a COVID-19 outbreak involving three symptomatic residents to CDPH as required by policy and regulation. Staff interviews revealed miscommunication and lack of clarity regarding reporting responsibilities, and no documentation was provided to confirm that public health authorities were notified.
A CNA found a resident with severe cognitive impairment and high fall risk on the floor, moved her back to bed without notifying a nurse, and delayed reporting the incident for about 20 minutes. When a nurse assessed the resident, she was found to have a swollen, discolored foot and was later diagnosed with a metatarsal fracture. Facility policy required immediate nurse notification and assessment before moving any resident after a fall, which was not followed in this case.
A resident with dementia and a history of wandering was found tied to a wheelchair with a sheet by a CNA, who recorded the incident but failed to report it immediately. The resident's care plan allowed for safe wandering, but the restraint was not in line with facility policies. The delay in reporting the incident to the Administrator and DON resulted in a situation of immediate jeopardy.
The facility experienced a gastrointestinal illness outbreak due to failures in infection control practices. Staff did not consistently use PPE or perform hand hygiene, and there was a delay in reporting the outbreak to health authorities. These deficiencies contributed to the spread of the illness, affecting residents and staff.
A facility failed to ensure a call light was within reach for a resident with a history of falls and high fall risk. The resident required assistance with ADLs and had a care plan emphasizing the need for accessible call lights. On observation, the call light was found wedged and inaccessible, confirmed by multiple staff members. Facility policies required call lights to be within reach to accommodate resident needs.
A resident with severe cognitive impairment sustained an unknown injury, resulting in swelling on the left cheek. The facility failed to conduct neurological assessments or develop a care plan, as confirmed by staff interviews and a review of the resident's medical records. Facility policies required these actions for head or facial injuries, but they were not documented, potentially leading to inadequate care.
A resident's MDS assessment was found to be inaccurate as it failed to include an active diagnosis of depression, despite the resident's medical records indicating this condition. The DON confirmed that the MDS should reflect a comprehensive assessment, including medical history, but acknowledged the discrepancy could lead to a care plan mismatch.
The facility failed to properly administer oxygen therapy for two residents, as their oxygen tubing and nasal cannulas were observed on the floor, contrary to infection control standards. Both residents had significant medical conditions requiring oxygen therapy, and the facility's policy required weekly changes of oxygen equipment, which was not followed.
The facility did not ensure that three LVNs completed their annual competency assessments, relying on self-evaluation without verifying proficiency. The DON provided a skills checklist but did not confirm skill proficiency, and the facility lacked a policy for staff skills validation.
The facility failed to follow proper food labeling and storage practices. A container of sugar in the dry goods area had multiple dates without clear indication of its status, and a Styrofoam cup of Baba ghanoush in the refrigerator was unlabeled and undated. The Dietary Supervisor acknowledged that all food items should be labeled with the name and preparation date to prevent foodborne illnesses.
A resident with a history of CHF, acute respiratory failure, and COPD experienced a severe weight loss of 10.13% over three months. The facility failed to notify the physician of this significant change, as required by their policy. The DON confirmed the absence of documentation and communication regarding the weight loss, leading to delayed care and intervention.
A resident experienced a severe weight loss of 10.13% over three months, which the facility failed to report to the physician or address with a care plan. Despite the resident's diagnoses of CHF, acute respiratory failure, and COPD, the facility did not consult with a dietician or develop a care plan to mitigate the weight loss. The DON acknowledged the lack of documentation and adherence to facility policies regarding physician notification and care planning.
The facility did not meet the required minimum of 80 square feet per resident in four rooms, affecting space for residents and potentially impacting care. Despite this, observations showed adequate space for mobility and care, and no complaints were reported.
A resident with severely impaired cognition and requiring assistance for daily activities experienced an unwitnessed fall, resulting in a head laceration. The CNA on duty had informed the RN of the resident's confusion and agitation, but the RN claimed no prior notification before the fall. The facility's fall risk policy was not followed, leading to the incident.
A resident with severe cognitive impairment and a history of confusion and agitation experienced an unwitnessed fall in an LTC facility due to the lack of a Side Rail Utilization Assessment. The facility did not assess the need for bed rails, resulting in the resident sustaining injuries. Staff interviews revealed a misunderstanding of regulations regarding bed rail use, and the facility's policy requiring such assessments was not followed.
Failure to Implement Fall Response Protocol After Resident Reported Fall and Pain
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and investigate a potential fall after a high fall‑risk resident reported pain and stated she had fallen. The resident had multiple right‑sided rib fractures, pneumonia, dementia, moderate cognitive impairment, used a wheelchair and walker, and required supervision and moderate assistance with ADLs. A Morse Fall Risk assessment identified the resident as high risk for falls with a score of 80 and a history of falls and overestimation of functional abilities. On the morning in question, a CNA reported the resident pointed to her right lower back and hip indicating pain during morning care. An RN and LVN supervisor assessed the resident, who again indicated pain and told the LVN supervisor she had fallen. Despite this, the RN did not believe a fall occurred because there was no visible bruising, and the DON later confirmed that no fall incident report was completed because the fall was unwitnessed and the CNA had not observed it. The facility’s own investigation summary documented that the resident had reported to multiple staff, including a CNA and therapy staff, that she had experienced a fall, and later that evening the resident reported pain while being assisted to the bathroom with a front‑wheel walker. A CT scan performed subsequently showed probable acute, nondisplaced fractures of the right 5th and 10th ribs, and progress notes documented that the resident stated she had fallen when asked about her pain. The DON acknowledged that staff did not implement the facility’s fall policies, which defined a fall as one that may be witnessed or reported by the resident or any observer and required post‑fall assessments, neurological monitoring for unwitnessed falls, incident reporting, reassessment of mobility status, and IDT review. As a result, required post‑fall assessments, 72‑hour neurological checks, incident reporting, and interdisciplinary review were not initiated when the resident first reported a fall and pain.
Food Items Left Unlabeled With Use-By Dates
Penalty
Summary
The facility failed to follow its food storage policy and professional food service standards by not labeling several food items with a used-by date. During a kitchen tour and interview with the Dietary Supervisor, surveyors observed ground meat in a plastic container, three pieces of Armenian pizza, five croissants in a clear plastic bag, and five glasses of milk that did not have a label with a used-by date. The Dietary Supervisor stated that the ground meat was normally added to residents' food, the pizza and croissants were leftovers, and she was not sure when the milk had been prepared. During an interview, the DON stated that per facility policy, food in the kitchen should be labeled with a use-by date. The DON explained that the date marking is used to ensure food freshness, help staff know when to discard expired items, and prevent serving unsafe food to residents. A review of the facility's Food Storage policy indicated that all food items and storage products should be labeled and dated with a used-by date, and a review of the Food Code 2022 included requirements for date marking ready-to-eat time/temperature control for safety food held for more than 24 hours.
Failure to Maintain Resident Privacy and Dignity During Feeding and Personal Care
Penalty
Summary
The facility failed to follow its Resident Rights policies by not promoting privacy and dignity for two residents during personal care and feeding. One resident had diagnoses including dementia, heart disease, and chronic kidney disease, and the record stated the resident did not have the capacity to understand and make decisions. During a mealtime observation, two CNAs were standing while feeding the resident, and one CNA stated she should have sat at the resident’s eye level because standing over the resident violated the resident’s rights to be treated with dignity and respect. The DON later stated that assisting and feeding a resident while standing over the resident was not appropriate and violated resident rights. A second resident had diagnoses including a nontraumatic acute subdural hemorrhage, dementia, agitation, and generalized muscle weakness, and the record stated the resident did not have the capacity to understand and make decisions. During an observation in the resident’s room, a CNA was preparing to groom and shave the resident while the privacy curtain was not drawn fully around the bed. The curtain was drawn only from the right side of the bed to the foot of the bed in front of the open doorway, leaving the resident exposed to other residents in the room. The CNA stated she had not closed the curtain fully while providing ADL care and acknowledged that privacy should be provided during care such as grooming, shaving, oral care, and brief care. The DON stated the privacy curtain should be drawn all the way around the bed, covering both sides, while providing ADL care or procedures so the resident is not exposed to other residents, visitors, or staff. The facility policies titled Privacy and Dignity, Resident Rights – Quality of Life, and Resident Rights stated that residents must be treated with respect and dignity and that privacy, including bodily privacy, must be protected during personal care and treatment procedures.
Failure to Obtain Informed Consent for Antidepressant Treatment
Penalty
Summary
The facility failed to implement its Informed Consent policy for one resident who was receiving Mirtazapine for depression and decreased oral intake. The resident was admitted with diagnoses including major depressive disorder and unspecified mood disorder, and the MDS indicated the resident’s cognition was severely impaired and that the resident was receiving an antidepressant. The order summary showed Mirtazapine 15 mg at bedtime for depression manifested by less than 25% oral intake, and the care plan noted the medication was related to depression with decreased oral intake and weight loss of 13 lb in 6 months. During a concurrent interview and record review, the RN stated there was no documented evidence of an Informed Consent for the resident’s use of Mirtazapine showing education to the resident and the RP about the risks, benefits, and side effects. The RN stated antidepressants require an Informed Consent form signed by the resident or RP. The DON also stated the facility’s practice was to complete an Informed Consent for antidepressant or antianxiety medication, with two licensed nurses as witnesses if the RP could not come to the facility within 24-48 hours, and confirmed there was no documented evidence of informed consent for the resident’s Mirtazapine treatment. The facility’s policy stated the physician or licensed healthcare practitioner would obtain informed consent and inform the resident or RP of the nature of the proposed treatment, risks and benefits, alternatives, and the right to decline, and that staff would verify the consent was obtained and signed before administration.
Failure to Ensure Bed Alarm Functioned for High-Fall-Risk Resident
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan for a resident with severely impaired cognitive skills who was assessed as a high fall risk. The resident had diagnoses including dementia, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. The resident's HPE stated the resident did not have the capacity to understand and make decisions. The MDS showed severely impaired cognitive skills and dependence or substantial assistance with multiple activities of daily living, and the facility's fall assessment documented a Morse Fall score of 75, indicating high risk for falling. The resident's care plan included an intervention to assure that the bed alarm sensor pad was working properly, and the order summary directed staff to apply the sensor pad alarm in bed for fall prevention related to trying to get out of bed unassisted. During observation and interview, the bed alarm was in place but the on light indicator was off and it did not alarm when the LVN attempted to trigger it by removing it from under the resident. The LVN stated the bed alarm was not functioning properly and had not been checked. The DON stated the facility did not implement a care plan for the resident by not ensuring the bed alarm was functioning properly, and that a nonfunctioning bed alarm was not acceptable for a resident assessed as high risk for falls.
Kinked Catheter Tubing
Penalty
Summary
The facility failed to ensure appropriate catheter care for one resident with an indwelling catheter. The resident was admitted with multiple diagnoses including bladder cancer, liver cancer, bile duct cancer, prostate cancer, dementia, chronic kidney disease, hydronephrosis, diabetes type 2, and dysphagia. The resident’s record showed dependence in several self-care activities, and the history and physical stated the resident did not have the capacity to understand and make decisions. The care plan for the indwelling catheter related to prostate cancer, bladder cancer, and chronic failure included securing the tubing with an anchor and providing catheter care. During observation, the resident’s indwelling catheter tubing was found coiled and kinked on the right upper thigh securement device, obstructing urine flow to the drainage bag. RN 1 acknowledged the tubing was coiled and kinked and stated this could lead to urine backflow and increase the risk of infection or bladder rupture. The DON later reviewed a photo of the tubing and stated it should not be kinked or coiled. The facility policy titled Care of Catheter stated the catheter and collection tubing should be free of obstruction and kinking, and the DON stated the coiling and kinking could cause backflow of urine and infection or sepsis.
Failure to Monitor and Support Resident Weight Loss
Penalty
Summary
The facility failed to prevent unplanned weight loss for one resident who was admitted with failure to thrive, dementia, depression, anemia, and Alzheimer’s disease, and who was documented as lacking capacity to understand and make decisions. The resident required supervision or touching assistance with eating and was admitted at 106 lbs. The care plan noted the resident refused food and required daily monitoring and documentation of food intake. Over the following months, the resident’s weight declined to 103 lbs., then 97 lbs., 96 lbs., 94 lbs., and 90 lbs., reflecting a 15.09% loss over six months. The record showed repeated changes of condition for weight loss, including a 3-lb. loss in early July and additional weight loss later in July, August, and October. Several change-of-condition notes documented that there were no new physician orders and that the RD was not notified. RD notes from July through October did not show follow-up visits in response to the weight-loss changes. The nutritional assessment documented that the resident had lost 10 lbs. since admission, and later notes documented 9 lbs. and 8.7% weight loss since early July, with oral intake ranging from 25-100% and at times less than 25%. The resident was ordered a nutritional supplement of sugar-free ice cream twice daily between meals on 10/3/2025, but the report states the facility failed to ensure the supplement was provided from 8/6/2025 through 10/3/2025 as ordered. During observation, the resident ate less than 25% of lunch. The DS described the resident as a picky eater, the RD stated the resident refused Magic Cup and preferred ice cream, and the DON stated the ice cream nourishment may not be helping the resident gain weight. The RD and DON both acknowledged the resident had significant weight loss, and the RD stated the resident had a major weight loss of 16 lbs. and that the facility had not been able to do much for the weight loss issue.
Inaccurate Meal Intake Documentation by CNAs
Penalty
Summary
The facility failed to ensure that three CNAs demonstrated sufficient competency and skills to accurately document meal intake for Resident 7 in accordance with the facility’s Documentation - Nursing policy and the Guidelines for Percentage of Meal Intake. Resident 7 was admitted with diagnoses including protein-calorie malnutrition, Alzheimer’s disease, and adult failure to thrive. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated cognition was severely impaired and that the resident needed supervision when eating. Resident 7’s care plan identified nutritional risk and weight loss risk, with interventions to monitor and record intake every meal and to monitor dietary intake by percentage at each meal. During observation and interview, CNA 5 stated Resident 7 ate less than 25% of lunch, while CNA 6 later reviewed the intake record and stated she documented that Resident 7 ate about 50% of the tray. CNA 6 stated she was not aware of the discrepancy and acknowledged the importance of accurate meal percentage documentation. Interviews with CNA 5 and CNA 2 showed that staff used different methods to estimate meal percentages for breakfast and lunch/dinner trays. The RD reviewed the facility’s standard guideline for percentage of meal intake, which assigned specific percentages to individual food items on breakfast and lunch/dinner trays. The DON reviewed the inservice training report and stated the training did not indicate an evaluation was performed to verify CNA compliance with documentation of meal intake, and stated she assumed staff would know how to calculate the percentages.
Inaccurate Documentation of Urine Characteristics
Penalty
Summary
The facility failed to accurately document one resident’s urine characteristics in the MAR for October 2025 in accordance with its Documentation - Nursing policy. The resident was admitted in 2022 and readmitted in June 2025 with diagnoses including atrial fibrillation and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s order summary included Eliquis 5 mg for chronic atrial fibrillation and an order to monitor every shift for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, and nose bleeds related to anticoagulant use. The care plan also directed staff to observe the resident’s urine color, and the resident’s H&P stated he had the capacity to understand and make decisions; the MDS indicated intact cognition and substantial assistance with toileting hygiene. During interview and record review, RN 2 stated the MAR documented that the resident did not experience discolored urine or other listed symptoms in October 2025. However, the same review showed a Change in Condition evaluation dated 10/24/2025 after CNA 5 notified RN 2 that blood urine was noted in the urinal bottle. RN 2 stated she did not document the discolored urine in the MAR because she created a CoC. The DON stated it was important to accurately document the resident’s urine characteristics because of his history of BPH and anticoagulant use to ensure proper monitoring for change of condition, and that inaccurate documentation created an inaccurate assessment of the resident and may lead to missed CoC.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program for three sampled residents by not following required hand hygiene and oxygen tubing practices. The report states that Resident 13 had diagnoses including COPD and heart failure, lacked capacity to understand and make decisions, and had severely impaired cognition. Resident 13 was receiving oxygen continuously via nasal cannula for shortness of breath, but during observation the nasal cannula was found without a label or date showing when it was last changed. The LVN stated the cannula was not labeled to identify whether it was new or old and whether it had been changed weekly as required by policy. The DON also stated there was no way to identify when it had last been changed. The facility also failed to ensure proper hand hygiene by Housekeeper 1 while cleaning Resident 23's room and handling dirty linens. Resident 23 had Type 2 DM and severely impaired cognition. During observation, Housekeeper 1 entered the room without performing hand hygiene, exited with a bag of dirty linens without gloves, walked through the hallway to the laundry room, dropped off the linens, did not perform hand hygiene, and then re-entered the room without hand hygiene to continue cleaning. Later, Housekeeper 1 was observed leaving the room and going to the staff lounge to continue environmental cleaning without performing hand hygiene. In interview, Housekeeper 1 stated she did not use hand sanitizer or wash her hands before entering or after exiting the resident's room. The facility further failed to ensure proper hand hygiene by IP 1 when entering and exiting Resident 35's room. Resident 35 had diagnoses including hemiplegia, hemiparesis following a cerebral infarction, dementia, and protein-calorie malnutrition, and was documented as lacking capacity to understand and make decisions with severely impaired cognition. During observation, IP 1 entered the room without using hand sanitizer while helping pass breakfast trays and answer call lights. IP 1 stated staff were supposed to use hand sanitizer before entering and after exiting resident rooms, but said she did not use it because she did not touch the resident and believed hand hygiene was not necessary if nothing was touched. The DON stated hand hygiene was an important part of infection control and that all staff should use hand sanitizer when entering or exiting resident rooms, especially when touching the resident or the resident's environment.
Inaccurate Nurse Staffing Postings
Penalty
Summary
The facility failed to post accurate nurse staffing information showing the actual hours worked by RN, LVN, and CNA staff per shift from 9/1/2025 through 9/28/2025, as required by its policy and procedure titled Nursing Department - Staffing, Scheduling & Posting. A review of the Daily Staff Record used for staffing postings showed the number of scheduled licensed staff and CNAs per shift, but it did not show the actual hours worked by the nursing staff. During a concurrent interview and record review on 9/30/2025, the DON stated that the posting reflected scheduled staff and projected hours per shift, not actual hours worked. The DON also stated that actual hours worked were recorded through payroll and were not posted. On 10/1/2025, the DON stated that the daily nursing postings are intended to inform residents, responsible parties, and visitors about the type and hours of nursing care provided in the facility, and that the postings must be accurate to prevent misinformation and confusion. The facility policy stated that the total number and actual hours worked by licensed and licensed nursing staff directly responsible for resident care per shift must be posted.
Resident Rooms Exceeded Allowed Bed Capacity
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents in four of 12 rooms. A review of the facility’s request for an additional room waiver dated 11/19/2025 showed that some rooms were designated for five beds and others for six beds. The Client Accommodation Analysis form submitted the same day also identified rooms that did not meet the federal requirement of no more than four beds per multiple-resident room. During observations from 9/30/2025 to 10/1/2025 and 11/17/2025 to 11/19/2025, surveyors found one room with six beds and four occupied beds, one room with six beds and six occupied beds, one room with five beds and five occupied beds, and one room with five beds and three occupied beds. The ADM stated the bed occupancy in those rooms remained the same. Residents and CNAs interviewed in the rooms stated they were comfortable and had enough space for care, and surveyors observed enough space for individualized beds, bedside tables, overbed tables, and resident care equipment. The facility’s P&P titled Resident Rooms and Environment, dated 11/1/2017, stated resident rooms must accommodate no more than four residents.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that resident bedrooms measured at least 80 square feet per resident in four of 12 rooms, specifically Rooms 1, 3, 4, and 5, in accordance with its policy titled Resident Rooms and Environment. The deficiency was identified during observation, interview, and record review, and the report states that the room size issue had the potential to negatively impact the care and services of staff to provide safe nursing care and privacy to residents. A review of the facility’s request for an additional room waiver dated 11/19/2025 showed that some rooms were approximately 456 square feet and others were approximately 348 square feet. The Client Accommodation Analysis form dated 11/19/2025 indicated that four rooms did not meet the required square footage per resident, including one room with 6 beds and 4 residents and another room with 5 beds and 3 residents. During multiple observations, residents in Rooms 1, 3, 4, and 5 were seen to have adequate room for wheelchairs, walkers, or canes, and staff were observed providing care without the room variance affecting services. Interviews with the ADM, residents, CNA, and LVN reflected that they felt there was enough space and no complaints had been made about the room sizes.
Failure to Report COVID-19 Outbreak to Public Health Authorities
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) as required by its own policy and state regulations. The outbreak involved three residents who tested positive for COVID-19 over a span of several days. Each resident had varying degrees of cognitive and physical impairment, and all were symptomatic at the time of testing. Documentation confirmed the positive test results and the presence of symptoms such as runny nose, cough, and weakness among the affected residents. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for reporting the outbreak. The Infection Preventionist (IP) believed another IP had reported the cases, while the Administrator assumed the IP had completed the notification. The Director of Nursing (DON) stated that the Department of Public Health had been notified, but was unable to provide documentation to support this claim. Another IP admitted to not knowing that reporting to CDPH was required and acknowledged that failing to report would result in a lack of outbreak support. A review of the facility's policy and procedure on communicable disease outbreaks indicated that the Administrator was responsible for reporting outbreaks to public health authorities. The policy defined an outbreak as one or more facility-acquired COVID-19 cases in a resident or three or more suspect, probable, or confirmed cases. Despite these clear guidelines, the facility did not notify CDPH of the outbreak, resulting in a failure to comply with both internal policy and regulatory requirements.
Failure to Notify Nurse and Improper Movement of Resident After Fall
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow facility policy and procedure regarding the response to resident falls. Upon finding a resident with severe cognitive impairment, muscle weakness, osteoporosis, and a history of falls lying on the floor, the CNA lifted the resident and returned her to bed without notifying a licensed nurse or waiting for a nurse's assessment. The CNA did not immediately report the incident to the licensed nurse, delaying notification by approximately 20 minutes. During this time, the resident was not assessed for injuries by a licensed nurse as required by facility policy. When the licensed nurse was finally notified and assessed the resident, she found the resident in bed, shivering and shaking in pain, with a swollen and discolored left foot. Subsequent X-ray imaging confirmed an acute nondisplaced distal fourth metatarsal neck fracture, with a possible additional fracture. The resident's care plans and assessments indicated she was at high risk for falls and fractures, required maximal assistance for mobility and transfers, and was to be handled gently to prevent injury. The facility's policy and CNA job description both required immediate notification of a licensed nurse and that residents not be moved after a fall until assessed by a nurse. Interviews with staff, including the CNA, licensed nurses, and the Director of Nursing, confirmed that the CNA did not follow established procedures. The CNA admitted to moving the resident without assistance and without notifying a nurse, stating he did not observe pain at the time and did not seek help because other staff were busy. The Director of Nursing and other nursing staff emphasized that moving a resident after a fall without a nurse's assessment could worsen injuries, and that the CNA's actions were not in accordance with facility policy.
Failure to Prevent and Report Resident Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. On a specific date, a Certified Nurse Assistant (CNA) observed a resident tied to a wheelchair with a white sheet during her shift. Instead of immediately addressing the situation or reporting it to a licensed vocational nurse (LVN) or other facility staff, the CNA recorded a video of the incident. The CNA did not untie the resident or report the incident to the appropriate authorities until two days later, which delayed the facility's response to the abuse. The resident involved had a history of dementia, anxiety disorder, and a history of falling, and was identified as a wandering risk. The care plan for the resident included interventions to allow safe wandering and to monitor the resident's whereabouts for safety. Despite these measures, the resident was found restrained in a manner that was not in line with the facility's policies, which require a restraint-free environment unless necessary for medical treatment. The delay in reporting the incident was compounded by the CNA's failure to inform the Administrator or the Director of Nursing (DON) immediately, as required by the facility's abuse prevention policy. The Administrator was informed of the incident only after the CNA showed the video in person, which was three days after the initial observation. This delay in reporting and addressing the abuse incident resulted in a situation of immediate jeopardy, as identified by the California Department of Public Health.
Removal Plan
- Staff including but not limited to license nurses, certified nursing assistants, office staff, kitchen staff, and housekeeping staff will have in-service education regarding elder abuse, reporting abuse and the use of physical restraints, conducted by the Director of Staff Development [DSD], DON and/or Administrator. The in-services are based on facility Policies and Procedures titled Restraints, Abuse Prevention and Prohibition Program, and Definitions.
- 50 out of 61 facility employees will have received in-service education regarding elder abuse, reporting abuse and the use of physical restraints.
- A posttest was created to verify staff competency on abuse and use of restraints. The post test will be given to all staff to determine understanding of in-service. Staff will be given repeat in-service on areas found to be lacking in knowledge until 100% score is received.
- Charge nurses were assigned to complete Abuse Rounds on a minimum once per shift to ensure there are no signs or symptoms of abuse or restraints. Rounds will continue once per shift for a minimum of three months.
- If a suspected abuse or improper restraint is identified charge nurse will immediately notify the Administrator and DON.
- The facility's Social Services Consultant will provide staff in-service regarding abuse.
- All charge nurses will be in-serviced on use of SOC 341 [a form used to report suspected abuse or neglect of dependent adults and elders].
- The Administrator will review facility's current Abuse Prevention Plan with DSD to develop a new yearly in-service schedule with increased abuse training. New employee Orientation abuse and neglect training will be reviewed and updated as needed during the facility's Quality Assurance and Performance Improvement (QAPI).
Infection Control Failures Lead to GI Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to a gastrointestinal illness outbreak affecting 15 residents and 7 staff members. Several instances of non-compliance with infection control protocols were observed. Certified Nurse Assistants (CNAs) and other staff members did not consistently use personal protective equipment (PPE) or perform proper hand hygiene. For example, CNA 1 did not remove PPE before leaving an isolation room, and CNA 2 failed to use hand sanitizer between resident interactions. Additionally, a kitchen assistant was observed handling food without gloves, and a family visitor entered the facility without a mask, despite clear signage indicating the need for masks due to the outbreak. The facility's staff also failed to adhere to contact precautions. CNA 7 entered a contact isolation room without donning PPE and did not perform hand hygiene after handling a resident's food tray. Housekeeping staff did not change gloves between tasks, potentially spreading contaminants. Furthermore, CNA 4 did not wear a gown when handling a resident's food tray in a contact isolation room, and a family member visiting a resident under contact precautions did not wear a gown, as required. The facility delayed reporting the gastrointestinal outbreak to the appropriate health authorities. The Director of Nursing (DON) initially considered the cases isolated and did not report them promptly, leading to a delay in implementing control measures. The facility's policies and procedures for infection control and reporting were not followed, contributing to the spread of the outbreak. The lack of timely communication and adherence to established protocols resulted in a failure to contain the outbreak effectively.
Failure to Ensure Call Light Accessibility for High-Risk Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident with a history of falls and a high risk for falling by not ensuring the call light was within reach. The resident, who was originally admitted on October 2, 2023, and readmitted later, had diagnoses including osteoporosis, generalized muscle weakness, and a history of falling. The Minimum Data Set (MDS) assessment indicated the resident required various levels of assistance with activities of daily living (ADLs), including supervision or touching assistance with toileting and personal hygiene, and partial/moderate assistance with bathing and dressing. The resident's care plan, revised on January 6, 2024, and August 6, 2024, emphasized the importance of having the call light within easy reach due to the resident's poor balance and potential for falls. On November 7, 2024, during an observation and interview, it was noted that the call light cord was wedged between the resident's mattress and headboard, making it inaccessible. Multiple staff members, including a certified nurse assistant, social service director, registered nurse, licensed vocational nurse, occupational therapist, and director of nurses, confirmed that the call light should be within reach to prevent falls and ensure the resident could request assistance when needed. The facility's policies on resident rights and communication systems also stipulated that call lights should be within residents' reach to accommodate their needs and ensure prompt communication with nursing staff.
Failure to Conduct Neurological Assessments and Develop Care Plan for Resident Injury
Penalty
Summary
The facility failed to meet professional standards of practice for a resident who sustained an unknown injury, specifically swelling on the left cheek. Despite the resident's severe cognitive impairment and inability to understand and make decisions, the facility did not conduct neurological assessments (NA) or develop a care plan in response to the injury. The resident's medical records lacked documentation of these necessary actions, which are crucial for monitoring potential head injuries and ensuring appropriate care. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Staffing Development (DSD), confirmed that NA should have been conducted for head or facial injuries, and a care plan should have been developed. The facility's policies and procedures also indicated that NA is required following falls or injuries involving head trauma, and care plans are essential for addressing residents' medical and psychosocial needs. The absence of these assessments and care planning could lead to inadequate monitoring and care for the resident.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, which is a federally mandated assessment tool. Specifically, the MDS for a resident did not include an active diagnosis of depression, despite the resident's face sheet indicating a diagnosis of depression along with other conditions such as chronic obstructive pulmonary disease (COPD) and chronic congestive heart failure. This omission was identified during a review of the resident's records, which showed that the resident lacked the capacity to understand and make decisions. During an interview with the Director of Nursing (DON), it was confirmed that the MDS assessments should include a comprehensive evaluation of the resident, incorporating direct observation, interviews, and a review of the resident's medical history. The DON acknowledged that an inaccurate MDS could lead to a mismatch between the resident's plan of care and their actual care needs. The facility's policy requires licensed nursing staff to complete an admission assessment using the Resident Assessment Instrument (RAI) specified by CMS, but this was not accurately reflected in the resident's MDS.
Oxygen Therapy Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy according to accepted standards of clinical practice and its own policy for two residents. Resident 4, who was admitted with diagnoses including encephalopathy, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD), was observed with oxygen tubing on the floor. This observation was confirmed by a licensed vocational nurse (LVN), who acknowledged that the tubing should not be on the floor due to infection control concerns. The Director of Nursing (DON) also stated that oxygen tubing should not be on the floor to prevent bacterial contamination. Similarly, Resident 20, admitted with chronic obstructive pulmonary disease with acute exacerbation and chronic congestive heart failure, was observed with both oxygen tubing and nasal cannula on the floor. This was confirmed by another LVN, who stated that the tubing should never be on the floor due to potential infection control issues. The facility's policy, dated 8/1/2014, indicated that all oxygen delivery equipment should be changed weekly and when visibly soiled, which was not adhered to in these cases.
Failure to Complete Annual Competency Assessments for LVNs
Penalty
Summary
The facility failed to ensure that three out of five Licensed Vocational Nurses (LVNs) completed their annual competency assessments and evaluations, as required by the facility's assessment to determine necessary resources and services for resident care. The LVNs' employee records included an Orientation & Annual Evaluation Skills Check List, which was signed by both the employee and the Director of Nursing (DON). However, the DON admitted that the competency skills were not completed upon hire or annually, and the facility relied on self-evaluation by the nurses without verifying proficiency in the skills listed. During interviews, the DON stated that she provided the skills checklist to the nurses at the beginning of their shifts and discussed skills with those who rated themselves as somewhat experienced or not experienced. However, there was no verification of demonstrated proficiency. Additionally, the facility administrator confirmed the absence of a policy and procedure for staff skills validation and evaluation of competencies. The facility assessment, which was undated, indicated that staff competency evaluations were necessary to maintain and improve residents' well-being, but these evaluations were not effectively conducted.
Improper Food Labeling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and safe food handling practices as per their policy and procedure. During an observation, a plastic container containing sugar was found in the dry goods storage area with a label displaying three different dates, none of which indicated the received, opened, or expiration date. This lack of proper labeling could lead to confusion about the freshness and safety of the food product. Additionally, a Styrofoam cup containing Baba ghanoush was found in the refrigerator without any label indicating the contents or the date it was prepared. The Dietary Supervisor confirmed that all opened food items should be labeled with the name and preparation date to prevent foodborne illnesses. The facility's policy, dated November 1, 2014, requires that all storage products be labeled and dated, which was not followed in these instances.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced severe weight loss. The resident, who was cognitively intact and had a history of congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease, lost 10.13% of their body weight over three months. This weight loss was not communicated to the physician as required by the facility's policy, which mandates notification for a weight change of five pounds or more within a 30-day period. The Director of Nursing (DON) confirmed that there was no documented evidence of a nutritional assessment addressing the resident's weight loss from July to August, nor was there documentation in the progress notes indicating that the physician was notified. The facility's policy requires that such changes be documented and communicated to the physician, but this was not done, resulting in delayed necessary care and intervention for the resident.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to assess, evaluate, and determine the cause of severe weight loss for a resident, identified as Resident 23, who experienced an unplanned severe weight loss of 10.13% over three months. The facility did not report the severe weight loss to the physician from July to August 2024, which was necessary to determine if the weight loss was related to the resident's disease process. Additionally, the licensed staff did not consult with the dietician for an assessment or any new dietary recommendations. Resident 23 was readmitted to the facility with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. Despite being cognitively intact, the resident experienced a significant weight loss of 7.72% from July to August 2024, which was not addressed in the nutritional assessment. The facility's policy required notifying the physician and conducting a nutritional assessment upon significant weight loss, but these actions were not documented. Furthermore, the facility did not develop a care plan to address Resident 23's severe weight loss in August 2024. The Director of Nursing acknowledged the lack of documentation for notifying the physician, conducting a nutritional assessment, and developing a care plan. The facility's policies outlined the need for timely physician notification, comprehensive care planning, and nutritional assessments upon changes in condition, but these were not followed in this case.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in four out of twelve resident rooms, specifically Rooms 1, 3, 4, and 5. These rooms included two six-bed capacity rooms and two five-bed capacity rooms, which did not meet federal requirements for space per resident. The deficiency was identified through observation, interviews, and record reviews, revealing that the rooms measured less than the required space, with some rooms accommodating more residents than the space allowed. Despite this, the facility's administrator indicated that they intended to request a room waiver, asserting that the room sizes had not changed and that there were no complaints from residents, families, or staff regarding the room sizes. Observations conducted over several days showed that the affected rooms provided adequate space for residents to move freely and for the use of mobility aids such as wheelchairs, walkers, and canes. The rooms were equipped with beds and bedside tables, and the nursing staff was observed providing care without any apparent hindrance due to space constraints. The facility's policy, dated 2017, required resident rooms to measure at least 80 square feet per resident in multiple resident rooms, which was not adhered to in the identified rooms.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who experienced an unwitnessed fall, resulting in a laceration on the head and above the right eye that required medical attention. The resident, admitted with diagnoses including congestive heart failure, had severely impaired cognition and required moderate to maximum assistance for daily living activities. On the night of the incident, the resident was found on the floor by a CNA after returning from a break, indicating a lack of supervision during that time. Interviews revealed that the CNA had informed the RN at the beginning of the shift that the resident was awake, confused, and agitated. However, the RN stated that she was not informed of the resident's condition prior to the fall. The facility's policy on fall risk assessment mandates adequate supervision and assistance to prevent accidents, which was not adhered to in this case, leading to the resident's fall and subsequent injury.
Failure to Assess Bed Rail Need Leads to Resident Fall
Penalty
Summary
The facility failed to assess the medical need for the use of a bedside rail for a resident, which resulted in an unwitnessed fall. The resident, who was admitted with diagnoses including congestive heart failure, had severely impaired cognition and required moderate to maximum assistance for daily living activities. Despite these needs, the facility did not conduct a Side Rail Utilization Assessment during the resident's stay, which is a necessary step to determine if the use of side rails is appropriate. On the night of the incident, a CNA found the resident on the floor next to her bed with a laceration above her right eye and on her head, requiring medical attention. The CNA had been on a break and discovered the fall upon returning. The resident was known to have episodes of confusion and agitation, yet there was no care plan in place to address these behaviors. Additionally, the Fall Risk Assessment conducted after the incident was inaccurately completed, failing to reflect the resident's previous fall and predisposing conditions, which would have indicated a high risk for falls. Interviews with facility staff revealed a misunderstanding of regulations regarding the use of side rails, with some staff believing they were against regulations. The facility's policy required a Side Rail Utilization Assessment to determine the appropriateness of bed rail use, but this was not completed for the resident. The lack of assessment and care planning contributed to the resident's fall and subsequent injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,181 citations issued within 25 miles in the last 12 months — including the 40 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solheim Senior Community | 0.1 mi | ★★★★★ | 17 | 0 |
| College Vista Post-acute | 0.7 mi | ★★★★★ | 0 | 0 |
| Glendale Adventist Medical Center Dp/snf | 0.9 mi | ★★★★★ | 16 | 0 |
| Ararat Post Acute | 1.2 mi | ★★★★★ | 20 | 0 |
| Glendale Post Acute Center | 1.3 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.