Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay Crest Care Center during CMS and state inspections, most recent first.
A resident with type 2 DM, hemiplegia, hemiparesis, and severely impaired cognition had an order for glipizide with parameters to hold the dose if CBG was below 120, but an LVN repeatedly administered the medication despite CBG readings under that threshold and did not recognize the ordered parameters. Review of records showed multiple days where glipizide was given contrary to orders, with no documentation of a change in condition, no medication error report, and no notification to the physician or the resident’s responsible party, despite facility policies requiring immediate notification and reporting of such errors.
A resident with type 2 DM and severe cognitive impairment had a physician’s order for daily glipizide 2.5 mg with parameters to hold the dose if CBG was less than 120. Over multiple days, nursing staff documented CBG values below 120 yet still administered glipizide each time. An LVN acknowledged giving the medication outside the ordered parameters, stating he was unaware of and did not see the complete order, and was unfamiliar with glipizide having hold parameters. An RN confirmed the repeated administrations despite low CBG readings and the absence of documentation of these medication errors, while another RN confirmed the original telephone order included the hold instruction.
A resident with Alzheimer’s disease, dementia, dysphagia, and a GT order for Seroquel had a physician order entered without a documented dose. The MAR showed the antipsychotic was not given for eight consecutive days, while EMAR notes repeatedly stated it was on order or pending pharmacy delivery.
Unlabeled Open Food Items in Kitchen: Multiple open food items, including thickened water, pudding powder, donut holes, and pork chops, were observed in the kitchen without open dates. The DA, DS, and ADM all stated opened food must be dated, and the facility policy required foods to be labeled and dated.
Failure to Preserve Resident Dignity During Mealtime Assistance: A CNA was observed standing while assisting a resident with a spoon during a meal while the resident sat in a Geri chair and received a pureed diet. The resident had dx including Alzheimer's disease, dysphagia, dementia, depression, and a gastrostomy, and the MDS showed severe cognitive impairment and dependence on staff for multiple ADLs. The CNA stated she should have sat while assisting, and the DON stated staff should sit and be engaged with the resident during meals to support dignity and safety.
Failure to honor a resident's preferred morning shower time. A resident with osteoarthritis, quadriplegia, and major depressive disorder was dependent for ADLs and was scheduled for morning showers, but CNA delayed the shower until the afternoon after being occupied with another resident, taking a break, and returning after lunch trays were delivered. The resident stated she had been waiting all morning and preferred to shower as early as possible; the DON stated resident shower preferences should be honored.
A resident with Alzheimer's disease, dementia, dysphagia, and a GT was placed in an abdominal binder to prevent tube pulling. The binder was ordered before informed consent was obtained, and the RNS stated consent was missed when the device was first applied. The record also showed no monitoring system for the binder, while the care plan called for review of restraint-related adverse effects and the DON acknowledged the need for assessment and monitoring.
The facility failed to notify the LTC Ombudsman for one resident transferred to the GACH and failed to provide bed-hold information to two residents before transfer. One resident had schizophrenia, anxiety, and dementia with documented inability to make decisions, and the other had anemia, bone cancer, hypertension, and severe cognitive impairment with dependence in ADLs. Staff confirmed the Ombudsman was not notified and that the residents were not informed about the state bed-hold duration.
Failure to Provide Effective Communication Support: A resident with Alzheimer's disease, dementia, dysphagia, gastrostomy, depression, and severely impaired cognition did not receive an effective alternative means of communication in a language she could understand. Staff relied on hand signals, body gestures, occasional family translation, and a translator app on a personal phone, while no communication board or visual aids were available and no staff spoke the resident's language.
Inadequate Nail Care for a Dependent Resident: A resident who needed staff assistance with ADLs was observed with long fingernails containing visible dirt and black grime underneath while eating breakfast. The resident asked for the nails to be cleaned and trimmed, and a CNA confirmed they were dirty and needed care. The DON stated nails must be kept clean and trimmed, and the facility's nail care policy required cleaning under the nails and filing them to an appropriate length.
Failure to Provide Preferred Activities: A resident with PVD and anemia, who had decision-making capacity and needed substantial to maximal assistance with several ADLs, had a care plan and recreation assessment identifying exercise, reading, and walking as preferred activities. However, activity participation records showed no documentation that he was offered exercise, physical activity, or walking, despite the AD and DON acknowledging the importance of offering those activities.
Failure to obtain ENT follow-up for a resident with hearing loss. A resident admitted with hearing loss, HTN, and muscle weakness was noted by the ENT to have diminished hearing with a recommended follow-up in six months, but the appointment was not completed. The resident stated staff had to repeat themselves because she was hard of hearing and that hearing aids would help, while the CNA, RNS, and DON all acknowledged the resident’s hearing difficulty and the missed ENT follow-up.
A resident with severe protein-calorie malnutrition and nutritional anemia, who needed assistance with eating, told an RNA she was still hungry and wanted more chili on her potatoes. The RNA was observed cutting up the resident’s food and then leaving to assist other residents without providing additional food. The RNA later stated that residents who request another tray or say they are still hungry should be given additional food, and the DON said the issue had been addressed through inservice.
Hospice medication orders were not coordinated with the facility care plan for a resident receiving hospice services. The resident had diagnoses including hemiplegia, DM, and bipolar disorder, and was receiving opioids. The hospice RN said the care plans were on a laptop with no access for facility nurses, while the RNS and DON found no coordinated plan for fentanyl or morphine. The record also contained conflicting fentanyl orders, including different patch strengths and total doses.
Infection Control Failures With Hand Hygiene and COVID-19 Staff Testing: A resident with severe cognitive impairment and dependence on staff was observed eating lunch with bare hands while CNA did not provide hand hygiene before the meal. In a separate event, another resident with multiple medical conditions tested positive for COVID-19 after transfer to the GACH, and the IPN stated no COVID-19 testing was done for exposed staff despite the facility policy requiring serial testing of close contacts and exposed staff.
A resident with dementia, severe cognitive impairment, prior rib fractures, and a documented history of falls was identified as a high fall risk and required substantial/maximal assistance with ADLs. Despite a physician’s order for bed rails with fall precautions and repeated requests from the resident’s family, staff did not timely install bed rails or implement additional fall-prevention interventions such as bed alarms or floor mats after multiple falls. The care plan and facility policies on falls and bed rails called for identifying and implementing interventions to prevent subsequent falls, but no new interventions were added after repeated incidents, including a witnessed fall from bed. The resident ultimately sustained a possible nondisplaced lateral malleolus fracture of uncertain chronicity and was transferred to an acute care hospital.
A resident with dementia, prior rib fractures, and a documented history of falls was identified as having severely impaired cognition and multiple fall risk factors, including confusion, poor safety judgment, and impaired balance. After the resident was found on the floor and at the end of the bed on multiple occasions, a physician ordered side rails with fall precautions, and the family repeatedly requested bed rails. Despite this, staff did not complete a required bed rail assessment, did not obtain informed consent from the resident’s representative, and did not implement the physician’s order without delay. Interviews with a CNA, an LVN, an RN supervisor, the DON, and the maintenance director showed that maintenance was not notified to install the bed rails until several days after the order, and bed rails were not installed until after additional falls, contrary to facility policies on falls, restraints, and bed rail use.
A resident with dementia and atrial fibrillation, documented as having severely impaired cognition and needing maximal assistance with ADLs, repeatedly refused showers, meals, medications, and vital signs according to nursing notes and IDT documentation. Despite these ongoing refusals, staff did not develop an individualized care plan with measurable goals, timeframes, and interventions to address the refusal of care. An LVN and the DON both acknowledged that a care plan should have been created to guide staff response, and the facility’s own comprehensive care plan policy requiring inclusion of identified problem areas and related risk factors was not followed.
A resident with dementia, anxiety, prior left rib fractures, and moderately impaired cognition experienced a documented fall from her wheelchair, after which the existing fall risk care plan was not revised to reflect the actual fall or to add new interventions. Although the IDT noted the fall and discussed specific measures such as keeping the bed in the lowest position, implementing a toileting schedule, encouraging fluids while the resident self-propelled in a w/c, and educating staff on care plan adherence, these were not incorporated into an updated care plan. The IP and DON both acknowledged that the fall risk care plan remained unchanged after the fall, and the resident later sustained another unwitnessed fall resulting in multiple left rib fractures, despite facility policy requiring individualized, comprehensive, and updated care plans based on assessments.
Staff failed to follow infection prevention and control practices for mask use during an influenza outbreak. An LVN was observed administering medications with a face mask worn below the nose and did not adjust it to cover the nose and mouth, despite acknowledging this was improper and could expose a resident to respiratory droplets. A CNA was also observed wearing a mask below the nose and acknowledged this violated facility policy requiring masks to fully cover the nose and mouth while on duty. The IP and DON confirmed that all staff must wear PPE, including properly fitted masks, during resident care, and facility policy states that face masks must cover the nose and mouth while performing treatment or services.
A resident with intact cognition did not receive required monthly personal fund account statements, and the facility failed to obtain necessary authorization signatures for personal fund management. Several withdrawal receipts lacked witness signatures, and there was no documentation that the resident had been given her account statements as required by policy.
Two residents with physical and cognitive impairments were unable to access their call lights, forcing them to yell for assistance and causing delays in care. In both cases, the call lights were found out of reach—one wedged between the mattress and side rail, and the other placed on a bedside table. Staff confirmed that call lights should have been accessible, and care plans required this intervention for safety.
A LVN failed to directly supervise a student nurse during a medication pass, resulting in a resident receiving another resident's medications and missing their own prescribed medications. The LVN did not accompany the student nurse to the bedside or verify the resident's identity, and the five rights of medication administration were not followed. The resident required hospital evaluation after the error was discovered.
A resident with multiple medical conditions received another resident's medications after an LVN failed to directly supervise a student nurse during medication administration. The student nurse, instructed to give medications to a resident by bed assignment, did not verify the resident's identity and administered the wrong medications. The resident experienced low blood pressure and increased sleepiness, leading to transfer to a hospital for evaluation. Interviews confirmed that the LVN did not follow facility policy requiring direct supervision and proper resident identification.
A resident with moderate cognitive impairment received the wrong medications, resulting in increased sleepiness and low blood pressure. The responsible party was not promptly notified of the medication error or the resident's change in condition, despite facility policy requiring immediate notification. The omission was confirmed through staff interviews and record review.
A resident with a history of heart and lung conditions, who required minimal assistance with a walker, was able to leave the facility through an unsupervised, non-alarmed front door after being inaccurately assessed as low risk for elopement. Staff failed to monitor the door after the receptionist's shift, and the door was sometimes propped open, allowing the resident to exit unnoticed. The resident was later found at a restaurant, experienced shortness of breath, and died after being transported to a hospital. Staff also failed to respond promptly to exit door alarms, and there was confusion about responsibilities for monitoring and responding to alarms.
A resident with multiple serious medical conditions was admitted without timely initiation or implementation of physician orders. Licensed staff were unaware of the resident's presence for over two hours, and no admission packet or orders were processed during that time, contrary to facility policy requiring immediate action upon admission.
A resident with multiple medical conditions and a history of psychosis was inaccurately assessed as non-ambulatory for elopement risk, despite physical therapy documentation showing the ability to ambulate with assistance. The inaccurate assessment was based on limited observation and incomplete information, leading to the omission of appropriate interventions to address the resident's risk for elopement.
A resident admitted with multiple serious conditions, including heart failure and psychosis, did not receive eight prescribed medications on time because an LVN could not locate the admission packet and failed to enter medication orders into the electronic system. The delay was confirmed by a nurse supervisor and the administrator, and was not in accordance with facility policy requiring prompt medication ordering and administration.
The facility did not maintain or implement an ongoing QAPI program, as there was no documentation of QAPI activities, committee meetings, or performance improvement projects since the last recorded QA committee meeting. The Administrator confirmed that required monthly meetings had not occurred, and a review of facility policy showed that such meetings and documentation were mandated to monitor and improve care quality.
A resident with paraplegia and muscle weakness sustained a second-degree burn to the thigh after using an unauthorized egg cooker in their room. Facility staff, including an LVN, DON, and Administrator, were aware of the appliance at different times but did not ensure its removal, assess its safety, or provide written approval as required by facility policy. The lack of oversight and failure to enforce the electrical appliance policy led to the resident's injury.
A resident who required moderate assistance was transported from the shower room to their bedroom with only a towel covering the front of their body, leaving their buttocks exposed and visible through the shower chair in the hallway. The CNA was unaware of the exposure, and the resident later reported feeling embarrassed. Facility policy requires staff to maintain residents' bodily privacy during personal care, which was not upheld in this case.
A resident with severe cognitive impairment and a history of behavioral issues entered a roommate's space, yelled, and struck her with a water bottle. Despite being informed, staff did not separate or supervise the residents, leaving the affected resident feeling unsafe. Facility leadership later acknowledged that policy requiring immediate separation and supervision was not followed.
A resident with severe cognitive impairment and a history of aggressive behaviors struck her roommate multiple times with a water bottle. Despite the incident being witnessed by a CNA and reported by the victim to staff and her responsible party, the event was not reported to the DON or administrator within the required timeframe, resulting in a delay in notifying CDPH and other authorities as mandated by facility policy.
A resident with severe cognitive impairment and a history of delusions, wandering, and aggressive behaviors repeatedly entered roommates' personal spaces, took belongings, and displayed physical and verbal aggression. Despite staff and administration being aware of these behaviors, the care plan was not updated to include interventions addressing these specific risks, resulting in repeated incidents and distress among other residents.
A resident with COPD and muscle weakness did not receive requested copies of their medical records after a written request was submitted by a law office. The Medical Record Director delayed the release, believing more time was allowed, and was waiting for additional documentation from nursing. Interviews revealed the facility lacked a clear policy or timeframe for releasing records, and key staff were unaware of the request until surveyors intervened.
Staff failed to consistently monitor and document the temperature of a resident refrigerator containing personal food items, resulting in the refrigerator being found at 60°F, well above the required 41°F. The refrigerator contained various foods, including eggs without resident identification, and staff interviews revealed lapses in following temperature check protocols.
A resident with multiple complex medical conditions did not receive their scheduled morning medications on time, with administration delayed by over three hours. The LVN responsible did not notify the physician of the delay, as required by facility policy. The DON confirmed that such notification is necessary when medication administration is late, especially for residents with significant health risks.
A resident with multiple chronic conditions received ten scheduled medications three hours late when an LVN administered them outside the required one-hour window, citing workload as the reason for the delay. The facility's policy and the resident's care plans required timely medication administration, but these protocols were not followed.
A resident with hypertension and congestive heart failure was left waiting outside after returning from an appointment because a doorbell at one entrance was not working. The resident had to knock repeatedly before staff noticed and let her in. Staff confirmed the doorbell was non-functional and acknowledged its importance for timely resident access.
A resident with Full Code status was found unresponsive and not breathing, but CNA and LVN staff did not immediately check for a pulse, start CPR, place him flat, or call 911 right away. The CNA left to get help, the LVN left the room to retrieve a BP machine before starting compressions, and 911 was called several minutes later. EMS arrived and found the resident deceased, with signs including no pulse, no breath sounds, fixed pupils, rigor, and lividity.
Two residents with indwelling urinary catheters did not have individualized care plans addressing their catheter care, despite physician orders and facility policy requiring such plans. Staff confirmed that care plans should have included interventions for monitoring and reporting complications, but these were not documented, leaving catheter-related care needs unaddressed.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with quadriplegia and a sacral pressure ulcer was not turned or repositioned for about five hours, despite physician orders and the care plan requiring repositioning every two hours. Documentation was missing for the overnight shift, and a CNA reported not providing the care, while another CNA stated the resident never refused repositioning. Facility policy required regular repositioning for immobile residents to prevent skin breakdown.
The facility failed to maintain a plan that outlines the process for conducting QAPI and QAA activities, as required. Surveyors found no documentation or description of how these quality assurance activities are implemented.
A resident with orthopedic and mobility issues, requiring substantial assistance with hygiene, requested only female staff for personal care. Despite this preference being communicated by the family and supported by facility policy, male CNAs were assigned to the resident on multiple occasions, and staff confirmed the preference was not consistently honored.
A resident with mobility issues, muscle weakness, and a stage 3 pressure ulcer did not receive required toileting hygiene assistance every shift and as needed. Documentation and interviews confirmed that care was missed on multiple shifts, and the resident was left in soiled disposable underwear for an extended period, contrary to facility policy and standard practice.
A resident with multiple fractures and heart failure did not receive physician-ordered restorative nursing assistance (RNA) services, including active and assisted range of motion exercises, as documented in facility records and confirmed by staff interviews. The facility's policy required provision of these services to promote safety and independence.
A resident with a Foley catheter and a history of bladder dysfunction and UTIs did not have documented evidence of catheter care or urine monitoring for infection. Interviews with the treatment nurse and DON confirmed the lack of documentation, despite facility policies requiring such care for residents needing assistance with hygiene.
Two residents with special dietary needs did not receive meals at scheduled times or requested alternatives, resulting in missed or delayed meals. Documentation and staff interviews confirmed that meals were not consistently provided three times daily or within the facility's required timeframe.
Failure to Notify Physician and Responsible Party After Repeated Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and responsible party after repeated medication administration errors and a significant deviation from ordered treatment parameters. The resident, who had type 2 DM, hemiplegia, hemiparesis, and severely impaired cognition, had a physician’s order for glipizide 2.5 mg once daily with instructions to hold the medication if the capillary blood glucose (CBG) was less than 120. Review of the Medication Administration Record showed that on multiple dates in March, the resident’s CBG levels were below 120, yet glipizide was administered at 9 a.m. on each of those days contrary to the physician’s order. The resident’s History and Physical and MDS documented that the resident lacked capacity to understand and make decisions and required extensive assistance with activities of daily living. During interviews, the LVN who administered the glipizide acknowledged giving the medication when the CBG was less than 120 and stated he had not noticed the parameters on the order. He further stated he did not notify the physician of the medication administration errors. Review of the Order Summary Report, MAR, nursing progress notes, and change of condition reports confirmed there was no documentation of the errors, no change of condition report, and no notification to the physician or the resident’s family/responsible party. This failure occurred despite facility policies requiring immediate notification of the physician and resident representative for significant changes in condition or treatment, and immediate reporting and documentation of all medication errors, including notification of the attending physician, resident, and responsible party.
Failure to Follow Glipizide Hold Parameters for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to administer a hypoglycemic medication according to the physician’s ordered parameters for a resident with type 2 DM and severe cognitive impairment. The resident, who required significant assistance with activities of daily living and lacked decision-making capacity, had a care plan goal to remain free of signs and symptoms of hypoglycemia, with an intervention for staff to administer hypoglycemic medications as ordered. A physician’s order dated 3/4/2026 directed that the resident receive glipizide 2.5 mg once daily for DM, with instructions to hold the dose if the resident’s CBG was less than 120. Review of the MAR for the month showed that on eight separate days the resident’s CBG levels were below 120 (ranging from 96 to 119), yet glipizide 2.5 mg was administered at 9 a.m. on each of those days. During interview, the LVN who administered the medication acknowledged giving glipizide outside the ordered parameters multiple times, stated he was unaware the order included a hold parameter for CBG less than 120, and reported he did not see the complete order when administering the medication. He also stated he was not familiar with glipizide having parameters and that he should not have assumed the medication did not have parameters. RN 1 confirmed that glipizide was administered when CBG was less than 120 and that there was no documentation in nursing progress notes or change of condition reports regarding these medication errors. RN 2 confirmed that when the telephone order was taken, the hold parameter for CBG less than 120 was included and read back to the physician. The facility’s medication error policy defined a medication error as administration of a medication that is not currently prescribed or given at the wrong dose or time.
Failure to Administer Ordered Seroquel and Notify Physician of Missing Dose
Penalty
Summary
Resident 2, who had a history of Alzheimer’s disease, gastrostomy, dysphagia, unspecified dementia, and depression, was admitted and later readmitted to the facility. The resident’s MDS dated 2/6/2026 indicated severely impaired cognitive skills and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and transfer to and from a bed to a chair. A pharmacy delivery receipt dated 2/4/2026 showed Quetiapine Fumarate 25 mg tablets were received by the facility. On 2/24/2026, the Order Summary Report documented a physician telephone order for Quetiapine Fumarate one tablet via GT at bedtime for psychosis manifested by pulling out of the GT, but no dose was documented with the order. The MAR for March 2026 showed the medication was not administered on 3/5/2026 through 3/12/2026, and the EMAR progress notes during that period repeatedly stated the medication was on order, pending pharmacy delivery, awaiting pharmacy delivery, or on order.
Unlabeled Open Food Items in Kitchen
Penalty
Summary
The facility failed to store food items safely by not ensuring that a carton of thickened water, chocolate pudding powder, frozen donut holes, and frozen pork chops were labeled with open dates. During an observation in the kitchen, these multiple open food items were found without open dates. In interviews, the Dietary Aide stated that all food items must be labeled with an open date once opened to ensure they were served fresh, and the Dietary Supervisor acknowledged that the unlabeled items should have been dated to ensure freshness and resident satisfaction. The Administrator also stated that opened food must be dated to ensure freshness and visual appeal. The facility policy titled Food Storage stated that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination.
Failure to Preserve Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to maintain respect and dignity for one of two sampled residents when a CNA was observed standing while feeding the resident during a meal. The resident was seated in a Geri chair and was receiving assistance with a spoon at lunchtime. The resident's meal tray ticket indicated a regular diet with pureed texture. The resident's admission record showed diagnoses including Alzheimer's disease, gastrostomy, dysphagia, unspecified dementia, and depression. The MDS dated 2/6/2026 indicated the resident had severely impaired cognitive skills and was dependent on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and transfer from bed to chair. The resident also had an order for enteral feeding of Jevity 1.2 calorie via pump at 45 milliliters per hour for 12 hours, from 8:00 p.m. to 8:00 a.m., and a separate order for a regular diet with pureed texture. During interview, the CNA stated she had been standing while assisting the resident with a spoon during lunchtime and said she was expected to sit while assisting so the resident would not feel intimidated and for safety reasons. The DON stated staff should sit and be engaged with the resident during meals and that standing over the resident could affect dignity and safety. The DON also stated sitting while assisting supports dignity and helps staff better observe whether the resident was chewing and swallowing food. The facility's dignity policy stated each resident should be cared for in a manner that promotes individuality, well-being, self-worth, and self-esteem.
Failure to Honor Resident's Preferred Morning Shower Time
Penalty
Summary
The facility failed to ensure that one of four sampled residents, Resident 25, received a morning shower as requested and preferred. Resident 25 was admitted with osteoarthritis, quadriplegia, and major depressive disorder, and the record showed the resident was alert, oriented, and able to express ideas and wants. The care plan identified that Resident 25 was dependent for ADLs including bathing, and the facility assignment sheet scheduled the resident for showers on Wednesdays and Saturdays in the morning on the day shift. During interview, Resident 25 stated she had been waiting all morning to shower and preferred to shower as early in the morning as possible. CNA 5 stated the resident was showered at 1:30 p.m. and that the preferred morning shower time was not followed because she was assisting another resident, took a break, and returned after lunch trays had been delivered. CNA 5 stated she should have asked another nurse for assistance before taking her break, and the DON stated residents have the right to choose their shower preferences and have those preferences honored. The facility policy stated resident goals, choices, preferences, values, and beliefs are respected and honored to the extent possible.
Failure to Obtain Consent and Monitor Abdominal Binder Use
Penalty
Summary
The facility failed to ensure Resident 2 was free from the use of a physical restraint when an abdominal binder was applied to prevent the resident from pulling out a gastrostomy tube. Resident 2 had diagnoses including Alzheimer's disease, gastrostomy, dysphagia, unspecified dementia, and depression. The physician order dated 5/28/2025 directed use of the abdominal binder every shift for gastrostomy tube displacement prevention. The record showed the device informed consent for the abdominal binder was not obtained until 2/17/2026, although the binder order had been initiated months earlier. During interviews, the RNS stated consent had not been obtained when the binder was first applied and that this was missed by the facility. The RNS also stated CNAs applied the binder and licensed nurses were responsible for correct placement, and that the binder was removed only during personal care and brief changes. The report also showed there was no monitoring system in place for the abdominal binder. The care plan identified the resident as at risk for complications of restraint use and included monitoring for adverse effects, but the RNS stated ongoing assessment and monitoring were not being done to identify complications such as skin breakdown or impaired circulation. The DON stated the facility expected informed consent before applying the binder and acknowledged that failing to assess and monitor the binder could result in skin breakdown and bruising.
Failure to Notify Ombudsman and Offer Bed-Hold Information During Transfers
Penalty
Summary
The facility failed to ensure a safe discharge and transfer for two sampled residents by not notifying the LTC Ombudsman when one resident was transferred to the GACH and by not offering bed-hold information before transfer for either resident. Resident 7’s record showed diagnoses including schizophrenia, anxiety, and dementia, and the H&P stated the resident did not have the ability to understand and make decisions. The MDS later indicated cognition was intact and that the resident needed partial/moderate assistance with ADLs such as toileting, bathing, and dressing. Transfer forms showed Resident 7 was transferred to the GACH on two occasions. Resident 11’s record showed diagnoses including anemia, bone cancer, and hypertension, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severe cognitive impairment and dependence with ADLs such as toileting, bathing, and dressing. Transfer forms showed Resident 11 was transferred to the GACH. During interview and record review, the RNS stated the Ombudsman was not notified for Resident 7’s transfer and that Resident 7 and Resident 11 were not provided information on the duration of the state bed hold before transfer. The DON stated the Ombudsman should be notified when a resident is discharged to the GACH and that residents should be provided bed-hold information at discharge.
Failure to Provide Effective Communication Support
Penalty
Summary
The facility failed to provide an alternative means of communication in a language the resident could understand for one sampled resident who had diagnoses including Alzheimer's disease, unspecified dementia, dysphagia, gastrostomy, and depression. The resident's MDS showed severely impaired cognitive skills and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and transfers. The care plan identified impaired communication related to cognitive impairment, dementia, Alzheimer's disease, impaired hearing in the left ear, and use of another language, with a goal of meeting the resident's daily communication needs. During observation, the resident was seen seated in a Geri chair in the lobby speaking and later yelling in a foreign language. Staff interviews showed the resident did not speak English and that communication was handled with hand signals, body gestures, and occasional help from a family member to translate. Staff stated there were no visual aids or communication boards in the resident's room, and no staff spoke the resident's language. One LVN used a translator app on a personal phone during an interaction, but stated this was not an appropriate method because it was unclear whether the resident understood what was being communicated. The DON stated the resident needed a communication board and that using a translator app on a personal phone was not a good way to communicate with the resident.
Inadequate Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to ensure Resident 7, who was dependent on staff for activities of daily living, received appropriate personal care. Resident 7 was admitted with diagnoses including schizophrenia, anxiety, and dementia. The H&P stated Resident 7 did not have the ability to understand and make decisions, while the MDS indicated cognition was intact and that Resident 7 needed partial/moderate assistance with ADLs such as toileting, bathing, and dressing. During a concurrent observation and interview, Resident 7 was seen eating breakfast with long fingernails that had visible dirt and black grime underneath, and the resident stated a desire to have the fingernails cleaned and trimmed. A CNA at the bedside stated the fingernails were dirty and long and needed to be cleaned and trimmed, and the DON stated residents' fingernails need to be kept clean and trimmed to prevent the possibility of ingesting bacteria and developing stomach issues. The facility policy for nail care required cleaning under the nails and filing nails to an appropriate length.
Failure to Provide Preferred Activities
Penalty
Summary
The facility failed to ensure that Resident 41 received ongoing activities in accordance with his comprehensive assessment, preferences, and interests, and that supported his physical, mental, and psychosocial well-being. Resident 41 was admitted with diagnoses including PVD and anemia, and his H&P indicated he had the capacity to understand and make decisions. His MDS showed he needed substantial to maximal nursing assistance with transferring, toileting, showering, and dressing. The care plan dated 1/16/2025 stated that Resident 41 liked to exercise and that it was important for him to engage in his favorite activities and exercise. The Recreation Comprehensive Assessment also identified reading and exercise as activities he liked currently and in the past. During interview, Resident 41 stated he used to be active and likes to walk. However, review of his participation records for January, February, and March 2026 showed no documentation that he was offered exercise, physical activity, or walking. The AD stated that if the activities Resident 41 likes were not offered it could lead to depression, and the DON stated the AD needed to be offering Resident 41 activities he likes to decrease depression and for good comradery with other residents.
Failure to Obtain ENT Follow-Up for Resident With Hearing Loss
Penalty
Summary
The facility failed to ensure Resident 67 received a recommended follow-up appointment with an ENT specialist for diminished hearing after the ENT physician noted the resident had diminished hearing and recommended a follow-up in six months. Resident 67 was admitted on 1/14/2025 and readmitted later, with diagnoses including hearing loss, hypertension, and muscle weakness. The resident’s H&P dated 1/31/2025 stated she did not have the capacity to understand and make decisions, while the MDS dated 1/21/2026 indicated cognition was intact and that she was dependent with ADLs such as toileting, bathing, and dressing. During interview, Resident 67 stated she needed staff to repeat themselves because she was hard of hearing and said hearing aids would help her hear better. A CNA stated the resident had difficulty hearing and could benefit from hearing aids, and believed there was a possibility the resident’s needs might not be met because of her hearing loss. The RNS reviewed the ENT progress note and stated the resident should have been seen by ENT in October 2025, adding that difficulty hearing could make it hard for the resident to express her needs and increase the potential for miscommunication. The DON also stated the resident should have had the ENT follow-up last year and was at risk of having her needs unmet due to her hearing loss.
Resident not given additional food after stating she was still hungry
Penalty
Summary
The facility failed to ensure that one sampled resident was provided additional food after telling the RNA she was still hungry. Resident 25 was admitted with severe protein-calorie malnutrition, nutritional anemia, and hypertension. Her MDS indicated she could express her ideas and wants, could understand others, and needed nursing supervision and touching assistance with eating. Her H&P described her as alert and oriented to name, place, and time, with normal speech, and dependent on nursing staff for care. Resident 25 had an order for a regular no-salt, regular-textured diet. During an interview, she stated she wanted more chili on her potatoes and would request more chili from RNA 1. During observation, Resident 25 told RNA 1 she was still hungry and wanted more chili, while RNA 1 was observed cutting up her baked potatoes into multiple tiny pieces and then leaving to assist two other residents. RNA 1 later stated that when a resident requests another tray or indicates they are still hungry, he should provide additional food. The DON stated she had inserviced RNA 1 on offering residents additional food or appropriate alternatives to ensure they have enough to eat and to help prevent weight loss. The facility policy on dignity and resident rights stated residents are encouraged to eat and conduct ADLs as they choose.
Hospice Medication Orders Were Not Coordinated With Facility Care Plan
Penalty
Summary
The facility failed to ensure a coordinated hospice plan of care was integrated with the facility plan of care and accessible to nursing staff for one resident receiving hospice services. The resident was admitted with diagnoses including right sided hemiplegia, diabetes mellitus, and bipolar disorder. The history and physical stated the resident did not have the capacity to understand and make decisions, while the MDS dated 1/7/2026 indicated the resident’s cognition was intact, the resident was dependent with ADLs, was taking opioids, and was receiving hospice services. The hospice Patient Care Order dated 1/26/2026 included morphine 20 mg/ml oral solution, 1 ml every 4 hours as needed for severe pain, and fentanyl 25 mcg/hr transdermal patch every 72 hours for severe pain, discontinued on 2/16/2026. The facility Order Recap Report showed conflicting fentanyl orders, including fentanyl 50 mcg/hr patches with a 25 mcg/hr patch for a total dose of 75 mcg/hr, and later fentanyl 50 mcg/hr patches, 2 patches every 72 hours for a total dose of 100 mcg/hr. During interview, the hospice RN stated the resident’s fentanyl dose had been increased multiple times and the hospice care plans were on the RN’s laptop with no access for facility nurses. The RNS and DON stated no coordinated plan of care was found for fentanyl or morphine, and the facility policy stated hospice care plans should include the most recent hospice plan of care and the care and services provided by the facility.
Infection Control Failures With Hand Hygiene and COVID-19 Staff Testing
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when hand hygiene was not provided to a resident before lunch service. Resident 2 had diagnoses including Alzheimer's disease, gastrostomy, dysphagia, unspecified dementia, and depression. The MDS dated 2/6/2026 indicated the resident had severely impaired cognitive skills and was dependent on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and transfers. During observation on 3/12/2026 at 12:37 p.m., CNA 1 brought the lunch tray while Resident 2 was seated in a Geri chair and eating with bare hands and fingers, and hand hygiene was not offered or provided before the resident began eating. During interview, CNA 1 stated it was important to offer and provide hand hygiene to Resident 2 before eating to remove germs from the resident's hands and prevent illness. The IPN stated CNA 1 should have provided hand sanitizer before eating to help prevent illness caused by dirty hands and fingers. The DON stated not providing hand hygiene to Resident 2 could affect dignity and had the potential to cause infection. The facility also failed to perform COVID-19 testing for staff who cared for Resident 9 after the resident tested positive for COVID-19. Resident 9 was admitted with diagnoses including depression, HTN, chronic kidney disease, and cerebral infarction. The H&P stated the resident did not have the capacity to understand and make decisions but could make decisions for ADLs. The MDS dated 3/3/2026 indicated the resident needed partial to moderate assistance with oral hygiene, toileting, showering, sitting, and lying down, and was not up to date on COVID-19 vaccination. The COC dated 3/3/2026 indicated the resident went to the GACH for evaluation of septic arthritis of the right knee, tested positive for COVID-19 on 3/4/2026, returned to the facility on 3/5/2026, and contact isolation started on 3/6/2026. The IPN stated the facility's COVID-19 management policy required serial testing of close contacts and exposed staff on days 1, 3, and 5 after the last exposure, but no COVID-19 testing was done for exposed staff because they did not have symptoms.
Failure to Implement Ordered Bed Rails and Fall-Prevention Measures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow fall-prevention measures, including timely installation of ordered bed rails, for a resident with severe cognitive impairment and a high fall risk. The resident was admitted with dementia, multiple rib fractures, a history of falls, and was documented as lacking capacity to understand and make decisions. The care plan identified confusion and decreased safety awareness related to dementia, with goals for the resident to remain free of falls and return to a previous level of activity. Interventions listed included cueing for safety and educating the resident and representative on proper ambulation and transfer techniques. Nursing documentation and the MDS showed the resident had multiple fall risk factors, including a history of falls in the last six months, disorientation/confusion, poor safety judgment, impaired balance, and a need for substantial/maximal assistance with toileting, bathing, and showering. On one date in February, a change of condition note documented that the resident was found lying on her back at the end of the bed, reporting that she had hit her left ribs and back and was experiencing pain, for which pain medication was given. A physician’s order for side rails with fall precautions was entered a few days later. A PT evaluation indicated the resident required moderate assistance to ambulate 10 feet with a two-wheeled walker. Subsequently, another change of condition note indicated the resident was found sitting on the floor near her doorway after attempting to get up without assistance. An IDT care conference note recorded that the resident had a recent fall resulting in a rib fracture, as well as another fall, and that the resident had decreased safety awareness and attempted to ambulate independently. During one of these incidents, a CNA placed the resident on a shower chair and briefly left to gather supplies, returning to find the resident on the floor. Interventions noted at that time included cueing for safety and placing bilateral mats at the bedside. Despite the physician’s order for bed rails and the resident’s repeated falls, interviews and record reviews showed that bed rails and other fall-prevention interventions were not implemented in a timely manner. A CNA stated the resident was dependent in ADLs, used a wheelchair, was considered a fall risk, and did not have bed rails installed until after the resident was admitted to the hospital. The CNA and LVN both indicated that residents at fall risk should have interventions such as low beds, floor mats, side rails, bed alarms, and frequent monitoring, and the LVN confirmed that the resident’s family member had repeatedly requested bed rails since the initial fall. The LVN reported witnessing the resident fall from the bed to the floor on a later date, noting that at that time the resident had no floor mats, bed rails, or bed alarm, and that no new interventions were implemented after that incident. The RN supervisor and DON both acknowledged that a physician’s order for bed rails with fall precautions existed, that bed rails should be installed without delay after assessment, order, and consent, and that no new interventions or physician orders were implemented following the resident’s subsequent falls. The maintenance director stated he was first informed to install the bed rails at a stand-up meeting in early March, and installed them that same day. The facility’s policies on Falls-Clinical Protocol and Bed Rails required staff and physicians to identify and implement interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling, but these were not followed for this resident, who ultimately sustained a possible nondisplaced lateral malleolus fracture of uncertain chronicity and was transferred to a general acute care hospital.
Failure to Assess, Obtain Consent, and Timely Implement Physician-Ordered Bed Rails for a High-Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete required assessments, obtain informed consent, and timely implement physician-ordered bed rails for a resident identified as a high fall risk. The resident was admitted with dementia, multiple rib fractures, and a history of falls. A History & Physical dated 9/28/2025 documented that the resident lacked capacity to understand and make decisions. The care plan dated 1/13/2026 identified confusion and decreased safety awareness secondary to dementia, with goals for the resident to be free of falls and return to previous activity level, and interventions including cueing for safety and education on ambulation and transfer techniques. A nursing evaluation dated 2/12/2026 documented fall risk factors including a history of falls in the last six months, disorientation/confusion, poor safety judgment, and impaired balance. An MDS dated 2/20/2025 indicated severely impaired cognition and a need for substantial/maximal assistance with toileting, bathing, and showering. On 2/20/2026, a change of condition note documented that the resident was found lying on her back at the end of the bed, reporting that she hit her left ribs and back, with pain rated 4/10 and pain medication administered. An order summary dated 2/23/2026 showed a physician’s order for side rails with fall precautions. Despite this order, a subsequent change of condition on 2/27/2026 recorded that the resident was found sitting on the floor near the doorway after attempting to get up without assistance. An IDT care conference note on 2/27/2026 documented that the resident had a recent fall on 2/20/2026 resulting in a rib fracture and another fall on 2/27/2026, and that the resident had decreased safety awareness and attempted to ambulate independently. On 3/1/2026, an x-ray of the left tibia and fibula showed a possible nondisplaced lateral malleolus fracture of uncertain chronicity. On 3/6/2026, surveyors observed bed rails present on both sides at the head of the bed, but no floor mats at the bedside, and the resident was reported to have been admitted to an acute care hospital. Staff interviews and record reviews showed that the facility did not follow its own process and policies for bed rail use. A CNA stated the resident was a fall risk and did not have bed rails installed until after hospital admission. An LVN reported that the resident’s family member had repeatedly requested bed rails since the initial fall on 2/20/2026, that staff had asked for the necessary paperwork, and that she did not know why bed rails were not installed after the 2/20/2026 fall or after the 2/23/2026 physician order. The LVN described the facility’s process as requiring a bed rail assessment, a physician’s order, and informed consent after education on risks, benefits, and alternatives, with immediate installation once consent and order were obtained, and physician notification if there was any delay; she confirmed these steps were not completed in a timely manner and could not explain the delay. The RN supervisor similarly stated that the process required a bed rail assessment, physician order, and consent prior to implementation, and that bed rails should be installed without delay and the physician notified of any delay, but could not explain why side rails were not installed until 3/2/2026. The DON stated the family had requested bed rails since the initial fall, that the resident was a fall risk due to dementia and prior falls, and that additional interventions such as a bed alarm and bed rails should have been implemented; she stated policy required a bed rail assessment, physician order, and consent, and that bed rails should be installed within 24 hours, but maintenance was not contacted until 3/2/2026. The maintenance director confirmed he first learned of the need for bed rails on 3/2/2026 and installed them that day. Review of facility policies on falls, restraints, and bed rails showed requirements for pre-restraint assessment, identification of interventions to prevent subsequent falls, and assessment-based decisions regarding bed rail use, which were not carried out for this resident prior to bed rail installation.
Failure to Develop Care Plan for Resident’s Refusal of Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop an individualized comprehensive care plan addressing a resident’s refusal of care and treatment. The resident was admitted with dementia and atrial fibrillation, and an MDS dated 1/5/2026 documented severely impaired cognition and a need for maximal assistance with toileting, bathing, and showering. Nursing documentation showed that on 11/15/2025 the resident refused to be showered, an IDT care conference note on 11/24/2025 recorded refusals of meals and medications, and a follow-up note on 12/26/2025 documented refusal of vital signs. Despite these documented refusals across multiple care areas, there was no corresponding care plan problem, goal, or interventions developed to address the resident’s refusal of care. During an interview and concurrent record review on 2/20/2026, an LVN confirmed that there was no care plan in place for the resident’s refusal of care and stated that such a care plan should have been developed so staff would be aware of the resident’s needs and know how to respond appropriately. The LVN also stated that a care plan addressing refusal of care was important because the lack of one could place the resident at risk for skin breakdown and that the care plan serves as a communication tool for staff. In a separate interview, the DON stated that when a resident refuses care, a care plan should be developed to guide staff in directing care. The facility’s written policy on comprehensive care plans indicated that each resident’s care plan is to incorporate identified problem areas and associated risk and contributing factors, with interventions designed after consideration of the relationship between the resident’s problem areas and their causes, which was not followed in this case.
Plan Of Correction
Corrective Action for Deficient Practice: On 2/25/26, the Director of Nursing (DON) developed the care plan for Resident 1 on refusal of care and treatment and included goals and interventions. Identification of Other Affected Residents: On 2/24/26, the DON conducted staff interviews to identify residents who had exhibited episodes of refusal of care. 8 residents were identified as having instances of refusal of care. On 2/25/26, the DON developed/updated a care plan for the identified residents to address the refusal of care. Systemic Changes: On 3/2/26, the DON initiated an in-service to licensed nurses on the policy and procedure titled "Care Plan Comprehensive" with a focus that each resident's care plan is designed to incorporate identified problem areas and incorporate risk and contributing factors associated with identified problems. Interventions in the care plans are designed in relationships between the residents' problem areas and their causes. Monday through Friday, during the Clinical Meeting, the clinical team (Director of Nursing, Director of Staff Development, Infection Preventionist, Director of Rehab, Social Service Director) will review Change of Conditions as well as the progress notes from the day prior to identify any episodes of refusal of care. The clinical team will conduct an audit of the resident's care plans for refusal of care. Negative findings will be corrected immediately. Monitor to Ensure Ongoing Compliance and Responsible Individuals:DON and/or designee will report findings of the care plan audits monthly x 3 months to QAA committee for further evaluation and recommendations.Compliance Date: 3/2/26
Failure to Revise Fall Risk Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s fall risk care plan after an actual fall and change in condition. The resident was admitted with diagnoses including multiple left rib fractures, dementia, and anxiety. A History and Physical dated 9/28/2025 documented that the resident did not have capacity to understand and make decisions. A Minimum Data Set dated 2/8/2026 showed moderately impaired cognition and a need for substantial/maximal assistance with ADLs such as toileting and bathing. A Change of Condition evaluation dated 1/11/2026 documented that the resident was found sitting on the floor next to her wheelchair, indicating an actual fall. The resident’s existing care plan, titled "Risk for Falls secondary to confusion/decreased safety awareness and history of falls," dated 1/13/2026, included general interventions such as determining the resident’s ability to transfer, educating the resident/representative on ambulation and transfer techniques, ensuring call light availability, evaluating the environment for fall risks, and notifying the provider and initiating neuro checks and bleeding evaluation if a fall occurred. An Interdisciplinary Care Conference note dated 1/16/2026 recorded that the resident had a fall on 1/11/2026 and continued to be at risk for falls due to cognitive changes and dementia, and it identified specific measures such as keeping the bed in the lowest position, providing a toileting schedule, providing a cup with holder to encourage fluids as the resident propelled herself in the wheelchair, and educating staff to adhere to the care plan. Despite these findings and discussions, the fall risk care plan dated 1/13/2026 was not revised to reflect that the resident had an actual fall on 1/11/2026 or to incorporate new or adjusted interventions following that event. The Infection Preventionist stated that the care plan should have been revised after the 1/11/2026 fall and acknowledged that it was not. The DON also confirmed that the resident had an actual fall on 1/11/2026, that the fall risk care plan had not been revised to reflect this incident, and that no new interventions were added after the fall. Subsequently, a Change of Condition report dated 2/20/2026 documented that the resident was found lying on her back on the floor in front of her bed, and a General Acute Care Hospital record for the same date indicated the resident was admitted after an unwitnessed fall that resulted in multiple fractures to the left ribs. The facility’s own care plan policy required individualized comprehensive care plans with measurable objectives and timeframes, developed and implemented by the IDT and revised based on identified needs from assessments.
Plan Of Correction
Corrective Action for Deficient Practice: On 2/23/26, the Director of Nursing (DON) revised Resident 1's care plan to reflect the resident's current physical and cognitive status. On 2/23/26, the DON revised the "At risk for fall" care plan for Resident 1. Identification of Other Affected Residents: On 3/2/26, the DON reviewed the care plans for 5 residents with recent falls. There were no other residents identified to have been affected by the alleged deficient practice. Systemic Changes: On 3/2/26 the DON initiated an in-service to licensed nurses on the policy and procedure titled "Care Plan Comprehensive" with a focus on developing an "individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs." In addition, care plan interventions should be designed after careful consideration between the problem and it's cause. Interventions should address the underlying source of the problem rather than addressing only the symptoms. Monday through Friday, during the Clinical Meeting, the clinical team will review Change of Conditions from the day prior to identify any incidents of fall. The clinical team (Director of Nursing, Director of Staff Development, Infection Preventionist, Director of Rehab, Social Service Director) will conduct an audit of each resident's care plan that both the "Actual Fall" and the at "Risk for Fall" care plan are present and reflective of the resident's current condition and needs. The audit will also verify that a new intervention has been added as appropriate to address the relationship between the resident's problem areas and the cause of the fall. Negative findings will be corrected immediately. Monitor to Ensure Ongoing Compliance and Responsible Individuals: DON and/or designee will report findings of the care plan audits monthly x 3 months to QAA committee for further evaluation and recommendations. Compliance Date: 3/2/26
Improper Mask Use During Influenza Outbreak
Penalty
Summary
The deficiency involves staff failure to follow the facility’s infection prevention and control practices for mask use during an influenza outbreak. During an observation and interview on 1/30/2026 at 8:20 a.m., an LVN was seen administering medications while wearing a face mask positioned below her nose and did not adjust it to fully cover her nose during the medication pass. The LVN acknowledged that the mask was worn improperly and stated that it should fully cover both the nose and mouth during resident care, and that not wearing it properly could potentially expose residents to respiratory droplets and increase the risk of infection transmission. At 8:33 a.m. the same day, a CNA was observed wearing a face mask positioned below her nose, leaving her nose exposed. The CNA acknowledged that her mask was worn improperly and stated that wearing the mask below the nose could potentially expose residents to respiratory droplets and increase the risk of infection transmission if she entered a room or interacted with a resident, and confirmed that facility policy requires masks to fully cover both the nose and mouth while on duty. In interviews later that morning, the IP and DON both stated that all staff are required to wear PPE, including masks that fully cover the nose and mouth, while providing resident care, and that improper mask use increases the risk of influenza transmission. Review of the facility’s 2025 PPE policy for face masks indicated that masks must cover the nose and mouth while performing treatment or services for residents.
Failure to Provide Required Personal Fund Statements and Obtain Authorization Signatures
Penalty
Summary
The facility failed to properly manage and document a resident's personal funds by not providing the required monthly personal fund account statements and by failing to obtain the necessary authorization signatures. Record review showed that the resident, who had intact cognition and was able to make herself understood, did not receive periodic statements detailing deposits, withdrawals, and current balances. Additionally, the personal funds authorization form was incomplete, lacking both the resident's and the required staff witness signatures. Several personal fund withdrawal receipts were also missing witness signatures, and there was no documentation that the resident had been given her account statements as required by facility policy. During interviews, the resident reported that she had repeatedly requested her account statements and was dissatisfied with the facility's response, leading her to contact law enforcement. The Office Manager confirmed that the resident had the right to receive monthly and quarterly statements, especially given her cognitive status, but was unable to provide documentation that these statements had been provided or that proper authorization procedures had been followed. The facility's policy required that residents be presented with a copy of their ledger, sign for receipt, and have the signed copy placed in their trust folder, but this process was not followed for this resident.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of three sampled residents, resulting in both residents being unable to use their call lights to request assistance. For one resident with convulsions and muscle weakness, the call light was found wedged between the mattress and side rail, out of reach, causing the resident to yell for help and experience frustration due to difficulty moving and inability to reposition himself. The resident reported that this was a recurring issue and that he had to yell to get staff attention. A CNA confirmed that staff should have checked the call light's accessibility before leaving the room. Another resident, with diagnoses including fibromyalgia, back pain, and dementia, was observed sitting on the edge of her bed with her call light placed on a bedside table out of her reach. This resident also reported having to yell for assistance and expressed frustration both at her own inability to access the call light and at the frequent yelling from a neighbor, which disrupted her rest. The care plan for this resident specifically required the call light to be within reach due to her fall risk. Staff interviews confirmed that call lights should be accessible and that failure to do so could increase the risk of residents attempting to get up on their own.
Failure to Supervise Student Nurse Leads to Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to provide direct supervision to a student nurse (SN) during a scheduled medication pass, resulting in a significant medication error. The LVN prepared medications at the medication cart and handed a cup containing multiple tablets to the student nurse, instructing the student to administer all the medications to a specific resident. The LVN did not accompany the student nurse to the resident's bedside and did not observe the administration of the medications. The student nurse administered the medications without verifying the resident's identity or reviewing the medications with the resident, and the LVN was not present to ensure the five rights of medication administration were followed. As a result of this lack of supervision and failure to follow established medication administration protocols, the resident received medications intended for another resident, including Valsartan, multivitamin and minerals, Guaifenesin ER, Eliquis, Carvedilol, Keppra, and Magnesium Oxide. The resident did not receive his prescribed medications, which included Glipizide, Metformin, Baclofen, vitamin D, Iron, Finasteride, and Lacosamide. The error was discovered after the resident exhibited symptoms, and it was reported that the resident's wife noticed something was wrong. The resident was subsequently transferred to a general acute care hospital for evaluation, where he underwent blood tests and radiological studies. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the LVN did not follow facility policy or professional standards, which require direct supervision of student nurses and verification of resident identity using at least two identifiers. The facility's consultant pharmacist also confirmed that the five rights of medication administration were not followed, and the LVN failed to supervise the student nurse during the medication pass. The facility's policies and job descriptions require licensed nurses to provide nursing services in accordance with professional standards and to verify resident identity before administering medications.
Failure to Supervise Student Nurse Results in Significant Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to provide direct supervision to a student nurse (SN) during a scheduled medication pass, resulting in a significant medication error. The LVN prepared medications at the medication cart and handed them to the student nurse, instructing the student to administer them to a resident identified only by bed assignment. The LVN did not accompany the student nurse to the resident's bedside or verify the resident's identity, and the student nurse administered the medications without confirming the resident's name or identity. As a result, the resident received another resident's medications, including Valsartan, multivitamin and minerals, Guaifenesin ER, Eliquis, Carvedilol, Keppra, and Magnesium Oxide, instead of their prescribed medications such as Glipizide, Metformin, Baclofen, vitamin D, Iron, Finasteride, and Lacosamide. The resident involved had a history of hemiplegia, hemiparesis, atrial fibrillation, and type 2 diabetes, and was assessed as having moderate cognitive impairment. Following the medication error, the resident became unusually sleepy, had low blood pressure, and was unable to recall events from the day. The resident's responsible party noticed the change in condition and requested a blood pressure check, which revealed hypotension. The Director of Nursing (DON) was notified and assessed the resident, who was then transferred to a general acute care hospital for evaluation, where blood tests and radiological studies were performed to rule out adverse drug effects. Interviews with the student nurse, another student nurse, the LVN, and the DON confirmed that the LVN routinely failed to provide direct supervision during medication administration by student nurses and referred to residents by bed assignment rather than by name. The facility's policy required verification of resident identity and direct supervision of student nurses during medication administration, which was not followed. The failure to adhere to these protocols led to the resident receiving the wrong medications and being exposed to unnecessary medical interventions.
Failure to Notify Responsible Party After Medication Error
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident when there was a significant change in the resident's condition following a medication error. The resident, who had diagnoses including hemiplegia, hemiparesis, atrial fibrillation, and type 2 diabetes mellitus, was assessed as having moderate cognitive impairment and lacked capacity to make certain decisions. On the day of the incident, the resident was administered multiple medications that were not prescribed for him by a new nurse who did not verify his identity or review his medications with him. As a result, the resident became unusually sleepy and had low blood pressure, which was first noticed by his RP during a visit. Despite facility policy requiring immediate notification of the resident and responsible party in the event of a medication error or significant change of condition, the assigned LVN did not inform the RP after being instructed to do so by the DON. The LVN stated she was focused on monitoring the resident and forgot to call the RP. The RP only learned of the medication error when the DON entered the room later that day. Facility records and staff interviews confirmed that the required notification was not made in a timely manner, contrary to facility policy.
Resident Elopement Due to Inadequate Door Monitoring and Risk Assessment
Penalty
Summary
A deficiency occurred when a resident who required minimal assistance with ambulation using a front wheel walker was able to exit the facility through an unsupervised, non-alarmed front door without staff knowledge. The facility did not have a system in place to monitor the front door after the receptionist left for the day, and the door could be freely opened from the inside, allowing residents to leave undetected. Staff were observed propping the front door open with a box of gloves to facilitate staff entry, leaving the entrance unsupervised and accessible to residents and unauthorized individuals. Multiple staff interviews confirmed that the front door was not consistently monitored, and there was no alarm system to alert staff if someone exited through it. The resident in question had a medical history including acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis. Despite being assessed as low risk for elopement due to an assumption of non-ambulatory status, therapy records and staff interviews indicated the resident was able to ambulate with minimal assistance using a walker. The resident was last seen in his room in the evening and was later found at a local restaurant approximately one mile away, after which he experienced shortness of breath, was transported to a hospital, and subsequently died from cardiac arrest. The inaccurate assessment of the resident's mobility and elopement risk, as well as the lack of appropriate interventions and monitoring, directly contributed to the resident's ability to leave the facility unnoticed. Additional observations revealed that staff did not respond promptly to exit door alarms, with alarms sounding for several minutes without investigation. Staff interviews indicated confusion about responsibilities for responding to alarms and a lack of clear procedures for monitoring exit doors, especially during times when the front lobby was unsupervised. The facility's policy required identification and care planning for residents at risk of elopement, but this was not followed in the case of the resident who eloped. The combination of inadequate assessment, lack of monitoring systems, and failure to respond to alarms resulted in a serious lapse in resident safety.
Removal Plan
- The Elopement Evaluation for active residents was completed by the Director of Staff Development (DSD), Infection Prevention Nurse (IPN) and Case Manager (CM). Residents identified to be at risk for elopement. The Elopement Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed by the Minimum Data Set Nurse (MDSN)/ Designee. Upon completion of elopement evaluation by the licensed nurse, the Director of Nursing (DON)/Designee will review for accuracy. Resident centered care plans with emphasis on elopement interventions will be reviewed, updated, and completed to ensure resident safety upon completion of the Elopement Evaluation. After completion of Elopement Evaluation, the Licensed Nurse will initiate interventions/measures such as one to one (1:1) monitoring, sitter, hourly rounding, place resident in a supervised area when in wheelchair, re-route resident when attempting to seek exit, engage resident in activities of choice.
- The care plan for residents identified to be at risk for elopement was reviewed and updated by DON/Designee. The care plan interventions included measures such as: hourly rounding, placed in supervised area, redirection / rerouting. Residents placed on 1:1 monitoring for 24 hours and will be evaluated by the Interdisciplinary Team (IDT) for continuation or discontinuation. Residents in the same room were placed on a sitter for 24 hours and will be evaluated by the IDT for continuation/discontinuation.
- The IDT initiated a care plan meeting for residents identified to be at risk for elopement with a follow up call to the resident's representative by the IP Nurse.
- The Maintenance Director checked facility egress doors and tested all audible door alarms for functionality. There were no negative findings identified in all exit doors. Egress tests and checks will be maintained daily for four weeks then weekly thereafter by the Maintenance Director. Exit Door Audit logs will be completed by Maintenance Director /Designee daily. The Administrator will perform validation rounds on door and alarm testing once a week. If the alarm is not working, maintenance will be notified via TELS, Maintenance department will fix and if more time needed, a staff member will be assigned to monitor door until it is fully operational. If a resident is observed attempting to leave using the egress door, staff will redirect and prevent the resident from leaving and notify the Licensed Nurses for further action / interventions.
- The DON/Designee initiated skills competency to licensed nurses on resident admission and elopement with emphasis on identifying risks, prevention, interventions, and door security procedures to ensure all exit doors are attended and checked for resident safety. The DSD/Designee initiated in-service training to Certified Nursing Assistant (CNA) on elopement policy with emphasis on prevention, interventions, monitoring of all exit doors and alarm system, identification of elopement risk residents, location of elopement binders and pink wristbands as elopement identifier. Staff training provided by the DSD/Designee on monitoring all exit doors and ensuring all exit doors are secured and alarm in place. Staff training with emphasis on ensuring all exit doors are secured and an alarm in place: a. The front door will be unlatched, and the alarm will be turned off by the receptionist on duty to allow entrance and exit of facility staff and visitors. b. The front door activity will be monitored by the receptionist on duty. c. The receptionist, before leaving for the day, will inform the licensed nurse to ensure continuity of monitoring of the front door. The licensed nurse will ensure the front door is fully latched, and the alarm is turned on. d. An assigned staff from 3p.m. to 11 p.m., and 11-7 p.m., will monitor the exit doors. The DSD/Designee is responsible for preparing the daily assignment for checking the exit doors that are latched and alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of all doors and alarms as assigned hourly. e. Any licensed nurse on leave will receive training on their next scheduled workday prior to their shift.
- The DON/Regional Clinical Resource initiated an in-service to the nursing staff regarding the updated resident elopement binder which is located at each nurse's station and reception area that has the following information: a. List of residents that are elopement risk b. Guide for staff on steps to take in case of elopement: Refer to Elopement Policy included in the binder as well as the list of the local police and fire department, and nearby acute hospitals in the area. c. Each resident packet includes demographic information which includes a copy of the resident's latest photograph, face sheet, elopement risk identification, most recent elopement evaluation, and updated elopement care plan.
- The DON/Designee is responsible for updating the content of the Elopement Binder for any newly identified and or changes in resident elopement evaluation and plan of care. Any new information, updates or changes with the list of residents in the Elopement Binder will be communicated by the DON / Designee with the nursing staff during the shift huddle and Point Click Care Communication Home Page. A pink wristband will be applied to a resident by the DON/Designee and to be worn by a resident determined to be an elopement risk based on evaluation. The pink wristband will include the resident name, date of birth identification, facility address, and telephone number. The department managers will check out the resident pink wristband during the daily Patient Centered Rounds to ensure wristbands are in place and worn per plan of care. Registered Nurse (RN) Supervisors responsible for checking the wristbands on weekends. If pink wristbands are not in place, Department Managers will notify the DON/Designee for replacement. On weekends, the Registered Nurse Supervisor (RNS) will replace the pink wristbands which are available at Station 1.
- The Medical Director was informed by DON regarding the incident. No new orders were given.
- The Elopement Binder was reviewed and updated by the DSD/Designee and placed at each nursing station and the reception area.
- The DSD/Designee placed pink wristbands to residents as an elopement identifier.
- The Maintenance Director initiated daily checks on all exit doors to ensure they were properly latched and alarms functioning.
- Nursing staff from 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m., shifts. The DSD/ Designee is responsible for preparing the daily assignment for checking the egress doors and alarms of exit doors and if properly latched with alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of exit doors as assigned hourly.
- The facility installed an alarm on the front lobby door, with a key in a red key holder located inside the reception area.
- The receptionist hours were increased, with the expectation to monitor the front door lobby for residents leaving or attempting to leave unattended. In case of receptionist is not available during break, another staff will cover to ensure continuity of monitoring is in place.
- The Administrator and Regional Nurse Consultant provided 1:1 in service training to RNS 1 and reviewed elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures. Inservice and education with the licensed nurses was also initiated regarding accurate assessment and elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures.
- The Administrator will report findings to the Quality Assurance and Performance Improvement (QAPI) Committee on the outcome of resident elopement evaluation and system implementation status update for review and further action as needed.
- The facility's policies and procedures regarding elopement and wandering residents were reviewed by IDT. Interventions such as 1:1 monitoring, providing a sitter, and hourly safety checks as needed.
- The facility revised its facility's new admission decision tree to include questions about history and frequency of wandering and elopement prior to resident admission to the facility. The admissions coordinator will inquire about additional information regarding elopement, history of wandering- and will be discussed with the team: Administrator, DON, and Social Service Director (SSD). DON will audit new admissions daily.
- DSD/Designee will train new hires in wandering, elopement, and resident safety procedures during orientation.
- All findings will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of three months or until the pattern of compliance is maintained.
Failure to Timely Initiate Admission Orders for New Admission
Penalty
Summary
The facility failed to ensure that admission orders were entered and implemented in a timely manner for a newly admitted resident with multiple serious medical conditions, including acute myocardial infarction, coronary angioplasty implant and graft, heart failure, COPD, and psychosis. Upon arrival at approximately 9:00 p.m., the resident was not acknowledged or assessed by licensed staff for over two hours. The assigned LVN was unaware of the resident's admission until discovering the individual in bed during rounds at approximately 11:30 p.m. No admission packet or hospital orders were available or processed during this time, and no admission orders were entered into the electronic system. Interviews with staff revealed that admissions frequently occurred during shifts without an RN supervisor present, contributing to lapses in the admission process. The facility's policy required immediate initiation of admission orders and assessment upon a resident's arrival, including reconciliation of medications and communication with the attending physician. The administrator confirmed that the expectation was for admission orders to be initiated within 30 minutes of arrival and acknowledged that this protocol was not followed in this instance.
Failure to Accurately Assess Elopement Risk
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's risk for elopement. A review of the resident's physical therapy assessment indicated the resident was alert and able to ambulate with a front-wheeled walker, though with a slow gait and complaints of fatigue. The resident's medical history included acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis. The joint mobility screening showed full range of motion in all extremities. However, the elopement risk assessment documented that the resident could not walk or self-propel a wheelchair independently. Interviews with the Physical Therapy Director confirmed the resident could walk to the bathroom with minimal assistance but required frequent safety cues due to impulsivity. The Registered Nurse Supervisor, who completed the elopement risk assessment, based her assessment on limited observation and the resident's selective responsiveness, concluding the resident was non-ambulatory. The nurse later acknowledged the assessment was inaccurate and that the resident was at high risk for elopement. The facility's policy required comprehensive assessment upon admission to inform care planning, but this was not followed, resulting in the failure to identify and address the resident's elopement risk.
Failure to Timely Administer Admission Medications Due to Order Processing Delay
Penalty
Summary
The facility failed to ensure that a newly admitted resident received timely and appropriate medication administration upon admission. The resident, who was admitted with multiple serious medical conditions including acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis, had physician orders for eight prescribed medications to address these conditions. Upon arrival, the Licensed Vocational Nurse (LVN) on duty was unable to locate the resident's admission packet containing hospital orders and did not enter any of the resident's medications into the electronic system. As a result, the resident's medication orders were not processed or administered as required. The delay in entering and processing the medication orders was confirmed by the Registered Nurse Supervisor (RNS), who began entering the orders the following day, and by the facility Administrator, who acknowledged that medications should be ordered immediately upon a resident's arrival. Review of the facility's policy indicated that medications are to be ordered and received from the pharmacy on a timely basis, with accurate records maintained. The failure to follow this policy resulted in a delay in administering essential medications for the resident's serious medical conditions.
Failure to Maintain Ongoing QAPI Program and Documentation
Penalty
Summary
The facility failed to maintain and implement an ongoing Quality Assurance and Performance Improvement (QAPI) program as required. Documentation and evidence of QAPI activities, committee meetings, or performance improvement projects were not available for review since 07/17/2025. The last recorded meeting of the Quality Assurance (QA) committee was on that date, and no subsequent meetings or activities were documented. During an interview, the Administrator confirmed that the QA committee was expected to meet monthly to review concerns, discuss current issues, and revise care plans as needed, but acknowledged that no meetings had occurred since the last documented date. A review of the facility's QAPI policy and procedure indicated that the facility was required to develop, implement, and maintain an ongoing, facility-wide QAPI plan, with the QA committee meeting monthly to monitor and evaluate the quality and safety of resident care. The policy outlined objectives such as identifying and resolving negative outcomes, correcting deficiencies, and maintaining documentation of QAPI activities. The lack of ongoing QAPI activities and documentation demonstrated noncompliance with the facility's own policy and regulatory requirements.
Failure to Prevent Burn Injury Due to Unauthorized Appliance
Penalty
Summary
A resident with paraplegia and generalized muscle weakness sustained a second-degree burn to the left thigh after using an unauthorized egg cooker in their room. The resident, who was cognitively intact and required partial to moderate assistance with activities of daily living, reported burning themselves while cooking eggs. The burn was not immediately reported to staff, and the resident waited several days before seeking treatment, at which point a partial thickness wound was identified and treated per physician order. Facility staff, including an LVN, DON, and Administrator, were aware at various times that the resident possessed an egg cooker in their room. The LVN observed the egg cooker during routine care but did not report its presence until after the burn occurred. The DON believed the egg cooker had been removed but did not verify this, and the Administrator instructed the resident not to keep the appliance but did not confirm its removal due to the resident's behavior and concealment of the device. No staff member assessed the egg cooker for safety, provided written approval for its use, or ensured the resident received instruction on safe operation of the appliance. The facility failed to follow its own policy and procedure regarding electrical appliances, which required written authorization and safety checks for any such devices in resident living areas. The policy specifically prohibited residents from maintaining heating or cooking devices in their rooms unless approved in writing by the Administrator or designee. The lack of enforcement and oversight of this policy directly contributed to the resident's injury.
Resident Exposed During Post-Shower Transfer
Penalty
Summary
A resident with a diagnosis of generalized weakness, who required partial to moderate assistance with showering and toilet hygiene, was observed being transported by a CNA in a shower chair from the shower room to his bedroom. During this transfer, the resident had a bath towel covering the front of his body, but his uncovered buttocks was visible and hanging through the shower chair as they moved through the hallway. The CNA stated he usually wrapped a towel around the resident's entire body but was unaware that the resident's buttocks was exposed during this instance. The resident later reported feeling something cold on his buttocks and realized it was uncovered, expressing concern and embarrassment about the possibility of being seen. The DON confirmed that the resident should have been fully covered after the shower to prevent exposure. Facility policy requires staff to promote and protect residents' privacy, including bodily privacy during personal care, but this was not followed in this instance.
Failure to Separate and Supervise Residents After Alleged Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by not separating, supervising, or monitoring after an incident involving another resident with a known history of delusions, severe cognitive impairment, and behavioral disturbances. The resident with dementia and major depressive disorder had a documented pattern of wandering, invading others' personal spaces, and exhibiting both verbal and physical aggression. On the evening in question, this resident entered her roommate's space, yelled, and struck her multiple times on the leg with a water bottle. The affected resident reported feeling unsafe and fearful, and stated that previous complaints to staff about similar behaviors had not resulted in any action. Despite being informed of the incident, the CNA and LVN who responded did not remove the aggressive resident from the shared room or provide additional supervision. The LVN did not consider the event to be abuse since there were no visible injuries, and left the residents unsupervised together after the incident. Other residents in the room also expressed fear and concern about the aggressive resident's behavior, noting a pattern of wandering and intruding into their spaces. The responsible party for the affected resident called the police due to concerns about the facility's lack of response. Interviews with facility leadership confirmed that the facility's policy requires immediate separation and supervision following allegations of abuse, but this was not followed. The DON and Administrator both acknowledged that the aggressive resident should have been moved and provided with one-on-one supervision after the incident. The facility's own policies and procedures, as well as federal and state regulations, guarantee residents' rights to be free from abuse and to be treated with dignity and respect, which were not upheld in this situation.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after an incident involving two residents. One resident, who had severe cognitive impairment, a history of delusions, and physical and verbal behaviors directed toward others, reportedly approached her roommate, yelled at her, threw water, and struck her with a water bottle multiple times while the roommate was in bed. The incident was witnessed by a CNA, who heard yelling and observed the resident standing close to the roommate, with a water pitcher on the ground nearby. Despite these observations and the roommate's report of being hit, the CNA did not report the incident, believing no one was hurt and assuming the administrator was already aware of ongoing issues between the two residents. The roommate, who was the victim in this incident, stated that she had previously informed nursing staff about repeated invasions of her personal space and taking of her belongings by her roommate, but no action had been taken. On the night of the incident, she used her call light and yelled for help, but no staff responded. She also contacted her responsible party, who, upon hearing the commotion over the phone, called the police for a wellness check. The police report confirmed the details of the incident, including the physical altercation and the lack of immediate staff intervention. The Director of Nursing (DON) only became aware of the incident the following day during a staff huddle and confirmed that the incident should have been reported immediately to the administrator, police, Ombudsman, and CDPH. The administrator was present in the building at the time of the incident but was not informed until the next day. The facility's policy required reporting all allegations of abuse within two hours, but this protocol was not followed, resulting in a delay in notifying authorities and initiating an investigation.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with measurable goals and interventions for a resident with severe cognitive impairment, a history of delusions, and behavioral symptoms such as wandering, hitting, threatening, and screaming. The resident was known to enter roommates' personal living spaces, take their belongings, and display aggressive behaviors, but the care plan only addressed the risk of elopement and did not include interventions specific to these behaviors. Multiple incidents were reported where the resident invaded the personal space of roommates, leading to feelings of violation, anxiety, and, in one case, an allegation of bodily harm when the resident hit a roommate with a water bottle. Interviews and record reviews revealed that staff and administration were aware of the resident's behaviors but did not update the care plan to address the specific risks posed to other residents. Roommates and their responsible parties reported these incidents to staff and administration, but no effective measures were taken to prevent recurrence. Staff members described difficulty redirecting the resident and noted that the behaviors persisted over time, affecting multiple roommates and requiring intervention from more than one staff member on several occasions. The facility's own policy required the interdisciplinary team to develop and revise care plans as residents' conditions changed, including the implementation of person-centered interventions with measurable objectives. However, the care plan for this resident was not revised to address the ongoing behavioral issues, resulting in repeated incidents where the resident's actions negatively impacted the safety and well-being of other residents.
Failure to Timely Release Medical Records Upon Written Request
Penalty
Summary
The facility failed to provide a copy of a resident's medical records upon written request, violating the resident's right to access their own records. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and muscle weakness, had a record release request submitted by a law office on their behalf. The Medical Record Director (MRD) received the request and forwarded it to the facility's legal department, but did not release the records, believing she had additional time to fulfill the request. The MRD was still waiting for the nursing department to complete their section of the records and had not yet provided the requested documents. Interviews with facility staff revealed a lack of clear policy and procedure regarding the timeframe for releasing medical records. The Administrator and Director of Nursing (DON) both acknowledged that there was no specific policy guiding the release of records or the associated costs, and were unaware of the delay until it was brought to their attention by surveyors. The DON also indicated that requests for records typically go through the front office and administration, and he was not informed of the request until the day of the survey.
Failure to Monitor and Maintain Resident Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor and maintain the temperature of the resident refrigerator containing personal food items, as required by its policy and procedure. Review of the Resident Refrigerator Temperature Log showed that temperature checks were not documented on multiple days throughout the month. During an observation, the refrigerator thermometer was found to read 60 degrees Fahrenheit, significantly above the policy requirement of 41 degrees Fahrenheit or below. The refrigerator contained various food items, including a carton of eggs without resident identification, cake, and other bagged or sealed foods. Interviews with staff revealed that the charge nurse responsible for checking the refrigerator had forgotten to do so and was unsure of the appropriate temperature standard. The DON confirmed the elevated temperature and that the food items were present in the refrigerator at the time of the check. The facility's policy specified that refrigerator temperatures should be checked daily when first opening and closing in the evening, and that refrigerators should be maintained in good working condition.
Failure to Notify Physician of Delayed Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered a resident's scheduled 9 a.m. medications at 12:08 p.m., resulting in a delay of over three hours. The LVN did not notify the resident's physician about the late administration, despite facility policy requiring immediate consultation with the physician when there is a significant need to alter treatment. The LVN acknowledged that medications should be administered as ordered due to their time-sensitive nature and admitted that the physician should have been informed of the delay, as the resident might require further treatment or monitoring. The resident involved had multiple complex medical conditions, including hemiplegia, hemiparesis, diabetes, hypertension, a history of cerebrovascular accident (CVA), and was at risk for cardiovascular complications, hypo/hyperglycemia, and bleeding due to anticoagulant therapy. The resident's care plans specifically required medications to be administered as ordered, with monitoring for effectiveness and side effects, and prompt reporting of abnormalities to the physician. The medications delayed included those for stroke prophylaxis, diabetes management, hypertension, and supplements. During interviews, the LVN explained that the delay was due to being occupied with other residents' needs, and confirmed that no notification was made to the physician regarding the late administration. The Director of Nursing (DON) stated that in cases of late medication administration, the nurse should complete a change in condition report, update the care plan, monitor the resident, and notify both the physician and the resident's family. Review of facility policy confirmed the requirement for immediate physician notification when treatment is significantly altered.
Late Medication Administration by LVN
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) administered ten medications to a resident three hours after the scheduled 9 a.m. administration time, with the medications being given at 12:08 p.m. The medications included treatments for diabetes, hypertension, stroke prophylaxis, and supplements, all of which were ordered to be administered at specific times according to the resident's physician orders and care plans. The LVN stated the delay was due to being occupied with other residents' needs, including addressing family concerns and managing a gastrostomy tube for another resident. The resident involved had a medical history of hemiplegia, hemiparesis, diabetes, hypertension, hyperlipidemia, congestive heart failure, and a history of cardiac arrest and stroke. The resident was cognitively intact but dependent on staff for activities of daily living. The care plans for this resident specifically required timely administration of medications to manage risks related to blood pressure, blood sugar, and anticoagulant therapy, with interventions including administering medications as ordered and monitoring for side effects. Facility policy and the LVN's job description both required medications to be administered within one hour of the prescribed time unless otherwise specified. The Director of Nursing confirmed that late administration should be documented, and the physician and family should be notified. However, in this instance, the medications were administered late without adherence to these protocols, resulting in a failure to meet the pharmaceutical service needs of the resident as required.
Non-Functioning Doorbell Delays Resident Re-Entry
Penalty
Summary
The facility failed to ensure that one of three doorbells, specifically at hallway 2's entrance, was functioning properly. This deficiency was identified when a resident, who had diagnoses including hypertension and congestive heart failure and was cognitively intact, returned from an appointment and attempted to use the doorbell to gain entry. The doorbell did not work, resulting in the resident having to knock several times and wait several minutes outside before staff heard and let her in. The resident expressed frustration about the wait and the non-functioning doorbell. Multiple staff members, including an LVN, the Registered Nurse Supervisor, the Maintenance Director, and the Director of Nursing, confirmed through observation and interviews that the doorbell was not working and acknowledged its importance for resident access. The Maintenance Director was unaware of the doorbell's existence prior to the incident. Review of facility policy indicated that the maintenance department is responsible for keeping equipment in safe and operable condition at all times.
Delayed CPR and 911 Response for Unresponsive Full Code Resident
Penalty
Summary
The facility failed to ensure timely basic life support and CPR when a resident was found unresponsive and not breathing. The resident had been admitted with diagnoses including cervical spine fracture, quadriplegia, and COPD. His records showed intact cognition, full dependence for ADLs, capacity to make decisions, Full Code status, and a POLST indicating resuscitation/CPR if he had no pulse and was not breathing. According to the nurses’ notes and staff interviews, CNA 1 found the resident unresponsive during rounds and did not check for a pulse. CNA 1 left the resident unattended to get LVN 1 because she wanted a witness and it was her first time experiencing an unresponsive resident. LVN 1 entered the room, found the resident unresponsive and without a pulse, but left the room to retrieve her personal BP machine from the medication cart before initiating CPR. LVN 1 also did not direct CNA 1 to begin CPR while she was out of the room. LVN 1 later checked the resident’s BP twice and received error readings before starting chest compressions. The record further showed that the resident was in an upright position in bed when found, and LVN 1 did not lower the head of the bed to place him flat before performing compressions. CNA 1 and LVN 1 did not call 911 immediately when the resident was found unresponsive and pulseless; the call was placed seven minutes later. EMS arrived and found the resident deceased. The EMS report documented no pulse, no breath sounds, fixed pupils, rigor, lividity, pallor, and cold skin. The PM stated the staff were attempting CPR but not providing effective chest compressions, and the resident appeared to have been deceased for several hours.
Failure to Develop Care Plans for Residents with Indwelling Urinary Catheters
Penalty
Summary
The facility failed to develop and implement care plans with specific interventions for two residents who had indwelling urinary catheters in place. For both residents, medical records and physician orders documented the presence of indwelling urinary catheters, including details such as catheter size, reason for use, and instructions for changing the catheter and drainage bag. However, a review of their care plans revealed no documentation or individualized plans addressing the care and monitoring of the catheters. This omission meant that care needs related to catheter use, such as monitoring for infection, displacement, or blockage, were not formally identified or documented in the residents' care plans. Interviews with facility staff, including an LVN and the DON, confirmed that care plans should have been created to guide staff in monitoring, documenting, and reporting any signs of infection or complications associated with catheter use. The facility's own policy required comprehensive care plans with measurable objectives and timetables to address each resident's needs, but this was not followed for the two residents with indwelling catheters. As a result, the care needs related to the use of these catheters were unknown and undocumented.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Reposition Resident with Pressure Ulcer as Ordered
Penalty
Summary
A resident with a history of cervical spine fracture, quadriplegia, and a sacral pressure ulcer was not turned or repositioned for approximately five hours, contrary to physician orders and the resident's care plan, which required repositioning every two hours. Documentation for turning and repositioning during the overnight shift was missing, and a CNA reported not providing this care after midnight, citing the resident being asleep and claiming the resident always refused to be turned. However, another CNA stated the resident never refused repositioning and was always willing to participate in care. The facility's policies required regular repositioning for immobile residents to prevent skin breakdown and maintain skin integrity. The Director of Nursing confirmed that turning and repositioning are essential for both comfort and assessment of skin condition, and that care should have been provided and documented. The lack of adherence to the care plan and physician's orders resulted in the resident not receiving necessary care to prevent complications related to pressure injuries.
Lack of Documented QAPI/QAA Process
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or a described process outlining how QAPI and QAA activities are to be carried out within the facility.
Failure to Accommodate Resident's Gender Preference for Personal Care Staff
Penalty
Summary
The facility failed to accommodate a resident's request to have only female staff provide personal hygiene care. The resident, who was admitted with orthopedic aftercare needs, abnormalities of gait and mobility, muscle weakness, and a stage 3 pressure ulcer in the sacral region, had intact cognitive skills and required substantial assistance with toileting hygiene and showering. The resident's family member communicated the preference for female caregivers for personal hygiene tasks. Despite this request, a review of assignment sheets showed that male CNAs were assigned to the resident on several occasions. Staff interviews confirmed that the resident's preference was not consistently honored. The facility's policy stated that residents' preferences would be accommodated to the extent possible, but this was not followed in practice for this resident.
Failure to Provide Toileting Hygiene Assistance Every Shift
Penalty
Summary
A deficiency occurred when a resident who was admitted with orthopedic aftercare needs, mobility issues, muscle weakness, and a stage 3 pressure ulcer in the sacral region did not receive assistance with toileting hygiene at least every shift and as needed. The resident's Minimum Data Set indicated intact cognitive skills and a requirement for substantial assistance with toileting hygiene and showering. Documentation reviewed by a registered nurse showed that toileting hygiene was not provided on all three shifts on multiple days, and on one specific day, the resident received assistance on only one shift instead of the required three. A family member reported that the resident was left in soiled disposable underwear without personal care until the afternoon on a particular day. Both the registered nurse and the Director of Nursing confirmed that facility policy and standard practice require toileting hygiene to be provided every shift and as needed. The facility's policy on supporting activities of daily living also states that residents unable to perform these tasks should receive necessary services to maintain good grooming and personal hygiene.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
A deficiency was identified when a resident with multiple fractures of the pelvis, orthopedic aftercare, and heart failure did not receive Restorative Nursing Assistance (RNA) services as ordered by the physician. The resident's Minimum Data Set indicated intact cognitive skills and independence in all activities of daily living. Physician orders specified that the resident was to receive active assisted and active range of motion exercises to the right lower extremity and bilateral upper extremities every day, three times a week or as tolerated. Record review and staff interviews confirmed that the resident did not receive the ordered RNA services during the months reviewed. The Registered Nurse acknowledged that the restorative services were not provided as ordered, and the Director of Nursing stated that all residents should receive RNA services as ordered, with refusals documented and addressed. The facility's policy required that residents receive restorative nursing services as needed to promote optimal safety and independence.
Lack of Documented Foley Catheter Care and Urine Monitoring
Penalty
Summary
A deficiency was identified when a resident with a history of neuromuscular bladder dysfunction and previous urinary tract infections was admitted with a Foley catheter. Review of the resident's admission record and Minimum Data Set indicated the resident required substantial assistance with toileting hygiene. However, there was no documentation in the medical record of Foley catheter care being provided or of monitoring the urine for signs and symptoms of infection. During interviews, the treatment nurse confirmed the absence of documentation regarding Foley care and urine monitoring. The Director of Nursing also stated that residents with Foley catheters should receive catheter care and have their urine assessed every shift for infection indicators. Facility policies reviewed indicated that residents unable to perform activities of daily living should receive necessary services to maintain hygiene, but there was no evidence these services were documented or provided in this case.
Failure to Provide Timely and Appropriate Meals to Residents
Penalty
Summary
The facility failed to provide scheduled meals and requested alternatives to two out of three sampled residents, resulting in missed or delayed meals. One resident, admitted with orthopedic aftercare, muscle weakness, and a stage 3 pressure ulcer, required set-up assistance for eating and had a regular diet order with a large portion of protein for breakfast. This resident did not receive a requested alternative sandwich after disliking the breakfast meal and ultimately received the sandwich much later than the scheduled mealtime. Another resident, admitted with multiple fractures and heart failure, was independent in eating and had a regular diet order with the option for double portions upon request. Record reviews and staff interviews confirmed that both residents did not consistently receive three meals per day as required, and that meals were not always provided within the facility's policy timeframe of 45 minutes from request or scheduled mealtime. The DON acknowledged that all residents should receive their scheduled meals, and documentation showed that the deficiency occurred over a period of time, affecting the residents' access to timely and appropriate nutrition.
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 5,007 citations issued within 25 miles in the last 12 months — including the 21 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 Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Driftwood Healthcare Center | 0.6 mi | ★★★★★ | 2 | 0 |
| The Earlwood | 0.6 mi | ★★★★★ | 31 | 0 |
| Providence Little Co Of Mary Transitional Care Ctr | 0.6 mi | ★★★★★ | 17 | 0 |
| Torrance Care Center West, Inc | 0.7 mi | ★★★★★ | 7 | 0 |
| Del Amo Gardens Care Center | 1.4 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.