Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Bell Convalescent Hospital during CMS and state inspections, most recent first.
Ice Machine Not Cleaned and Sanitized Properly: During observation, the DSS found dark black/grey dots and pink slime under the ice dispenser, and Maintenance later observed black dots with a web-like substance on the ice maker cover and an unidentified substance on a steel plate above the ice container. The DSS said deep cleaning was handled by Maintenance, while the ice machine log showed monthly deep cleaning sign-offs and facility policy required ice to be handled and dispensed sanitarily per manufacturer guidelines.
Overflowing Trash and Open Dumpster Lids: The facility failed to dispose of garbage properly when the dumpster and nearby bins were observed overflowing with bags of waste on consecutive days. The dumpster lids were propped open or left unclosed, and the Administrator stated the facility’s daily trash production exceeded the current capacity available. Pest control reports had previously recommended keeping trash can lids closed to reduce pest attraction and breeding sources.
Failure to develop care plans for denture use, denture refusal, and hand tremors. A resident with ill-fitting dentures was observed eating without them, another resident with EPS-related hand tremors had no care plan despite visible shaking and assistance needs, and a third resident with dysphagia and dementia refused dentures and was observed eating without them. Staff and the DON acknowledged the missing care plans and the need for coordinated, person-centered care planning.
Failure to Train and Verify RNA Competency for ROM Exercises: The facility failed to ensure RNAs received training and demonstrated competency for ROM exercises for a resident receiving restorative care. An RNA said she received in-service only with new orders and special concerns, while the DOR, DON, and DSD stated ROM training and competency records were important but were not included in the CNA/RNA training log. The facility's training log did not include ROM training or a competency checklist, and the restorative ROM policy stated the PT or PTA would review the program with the RNA every other month.
A nurse failed to notify the MD when a resident’s BG was 436 mg/dL and administered insulin without the required documented call. In another case, a discontinued lorazepam dose remained in the med cart and a resident received the wrong lorazepam dose after the new order was not matched to the available medication. A third resident’s PRN hydrocodone-acetaminophen was given, but the RN did not document it on the MAR right away, leaving the controlled substance record and MAR out of sync.
Improper Disposal of Non-Controlled Medications: The facility failed to dispose of non-controlled meds with a witness as required by policy. Review of the disposal logs showed only one licensed nurse's initials, and the DON stated disposal was done by one person without a witness, despite the policy requiring destruction in the presence of a pharmacist or nurse and one witness.
Menu Recipes Not Followed and Ingredients Altered: A cook did not follow the Korean menu recipes during meal service. The DSS observed Korean pot stickers being served as chunky meat with cabbage and peppers instead of wrapped pot stickers, a zucchini dish that included carrots, red peppers, corn, and later cauliflower, and fish stew served as whole fish filets rather than soup. The DSS stated the cook did not check the menu, and no substitution log was available for documented or RD-approved menu changes.
Incorrect texture-modified diets were served to two residents with chewing and swallowing needs. One resident with dysphagia and dementia was given toasted garlic bread and chopped chicken despite an L5 minced and moist order, and another resident with DM and hemiplegia was served regular-texture items, including a full quesadilla, despite an L6 soft and bite sized order. The DS confirmed the food was not prepared to the ordered texture, and the DON stated that residents with swallowing problems require ordered texture diets as a safety measure.
Failure to inventory and track a resident's personal belongings resulted in the facility being unable to account for hearing aids and dentures. The resident had dementia with moderately impaired cognitive skills and fluctuating decision-making capacity, and staff did not complete inventory lists upon discharge and readmission despite multiple transfers. An RNA stated she did not complete the inventory because she knew the resident had a locked closet and bedside belongings, while the DON noted inventory lists should have been completed to account for valuable items.
PRN Lorazepam Order Lacked Required Stop Date: A resident with depression, anxiety, and epilepsy had a PRN order for Lorazepam 0.5 mg every 8 hours as needed for anxiety, but the order did not include a stop date. The DON confirmed the order was not aligned with the facility P&P, which limited PRN psychotropic medication orders to 14 days and required a specific time period.
Inaccurate MDS Oral/Dental Coding: A resident with DM and HTN was observed eating breakfast and stated she had no natural teeth and that her dentures did not fit. However, the MDS coded the resident as having no oral/dental issues. The MDSN later confirmed the assessment was coded incorrectly and should have reflected that the resident was edentulous.
Improper Handling of Finasteride During Medication Administration: An LVN was observed preparing finasteride for a resident without wearing gloves, despite the physician order and pharmacist review directing glove use when handling or administering the medication. The resident had BPH, urinary retention, CKD, and moderately impaired cognition, and the facility policy stated gloves are worn during medication administration when ordered by the prescriber.
Failure to Assist Resident With Hand Tremors During Meals: A resident with hand tremors was observed seated at a dining table with a meal tray and coffee but was not eating, and when the resident tried to drink, coffee spilled over the resident. The resident's record showed diagnoses including lack of coordination, DM, and EPS, and the MDS indicated moderately impaired cognitive skills and set up or clean up assistance for eating. CNA initially stated the resident did not need help, but later assisted with feeding after seeing the resident's hands shaking aggressively and the resident requested help; an LVN stated the resident should receive assistance, while the DON stated the resident was independent despite also acknowledging that residents with hand tremors would require staff assistance.
Failure to maintain nail hygiene for two residents. One resident with DM, HTN, and enterocolitis was observed with long fingernails and black substance under the nails despite needing ADL assistance and requesting nail care. Another resident with DM and dementia, dependent for all ADLs, was observed with long, thick toenails digging into adjoining toes after staff and SSD did not ensure podiatry follow-up, even though the care plan called for nail checks, trimming, and cleaning.
A facility failed to follow physician orders for three residents by not completing ordered monitoring and by giving medications without following hold parameters. One resident with HTN, dementia, and epilepsy did not have ordered HR and weight monitoring completed while receiving lisinopril. Another resident with HTN and heart failure received diltiazem even when SBP was below the ordered hold parameter. A third resident with HTN and ESRD did not receive ordered orthostatic BP checks in all positions, including standing.
Failure to Provide Ordered AAROM: A resident with cerebral ischemia, HTN, dysphagia, lack of coordination, and moderate cognitive impairment was ordered restorative nursing AAROM to BUE and BLE as tolerated 5 times a week. Staff observed the resident receiving PROM at times, and interviews confirmed the order called for AAROM, with the DSD, DON, and DOR stating the resident could initiate movement and should receive AAROM as ordered.
A resident with an indwelling Foley catheter had cloudy urine and visible sediment, and stated the catheter had not been flushed and that he had intermittent urinary pain and burning. RN staff could not find documentation that the catheter had been irrigated as ordered or that the physician had been notified of the abnormal urine findings and symptoms. The IP observed the same abnormal catheter findings and stated the physician's Foley care orders had not been followed.
Pain Rating Not Documented With PRN Tramadol Administration: A resident with low back pain, DM, and HTN received PRN Tramadol for moderate pain, but the MAR did not show a pain rating at the time of administration. RN stated the medication was given for pain without documenting the rating, while the order specified use for pain rated 4 to 6 on a 0 to 10 scale. The DON confirmed that a pain rating must be documented when giving pain medication, and facility policy required use of a pain scale for pain assessment.
Dialysis orders were not followed for one resident, who was sent to HD on the wrong days, and dialysis access sites were not assessed every shift for two residents. One resident had ESRD and a perma catheter, but the MAR showed access monitoring was discontinued after return from the hospital; staff stated the site had not been monitored since the resident returned. The DON confirmed dialysis access sites must be monitored and physician orders must be followed, and facility policy required shunt checks every shift.
Failure to Complete Required Physician Face-to-Face Visits: The facility did not ensure timely physician face-to-face visits for two residents during the first 90 days after admission. One resident with epilepsy, depression, anxiety, and HTN had monthly NP visits documented, but no documented in-person physician visit after admission/readmission. Another resident with enterocolitis, DM, and HTN had no documented physician visit after admission. The DON stated the facility’s expectation was for the physician to see newly admitted residents within 30 days and every 30 days thereafter for the first 90 days, consistent with the facility policy.
Incomplete documentation affected three residents when an RN failed to promptly record a hydrocodone-acetaminophen dose on the eMAR and delayed pain reassessments for two residents, while an LVN did not document a resident’s tremors in daily skilled charting. The residents had diagnoses including DM, pain, lack of coordination, and EPS-related movement symptoms, and the DON stated pain reassessments and tremor observations should be documented in the medical record.
Dialysis Binder Not Cleaned or Disinfected: A resident with ESRD on hemodialysis had a dialysis binder that was observed with brown staining on the exterior. The binder was used as a dialysis communication record and sometimes placed between the resident and the transport gurney. The IP stated the binder may have contained fecal matter and was not cleaned and disinfected after each dialysis return, despite the facility’s infection control policy requiring removal of visible soil from objects and surfaces.
Infection Preventionist Lacked Required Annual IPC Continuing Education: The facility failed to ensure the IP completed the required 10 hours of annual continuing education in infection prevention and control. The IP stated she could not provide documentation for 2025 and that her license renewal education hours were not obtained that year. The DON stated the IP was responsible for educating staff on current IPC practices, and a CDPH AFL stated the IP should complete 10 hours of IPC continuing education annually.
A resident with a history of cellulitis and recent toe amputation was not weighed on admission or weekly for four weeks as required by facility policy. Nursing staff and the DON confirmed that weights were missing from the records and that no explanations were documented for these omissions, despite the resident's care plan specifying weight monitoring.
The facility failed to prevent falls and provide safety measures for two residents, leading to injuries and hospitalization. The facility did not conduct timely IDT assessments or implement person-centered interventions for fall prevention. Additionally, the facility did not provide padded siderails for residents at risk for seizures, increasing the potential for injury.
The facility did not act on the Medication Regimen Review (MRR) conducted for residents, resulting in delays in medication adjustments and care plans. The Consultant Pharmacist's recommendations for 35 residents were not communicated to physicians, as required by the facility's policy. The DON was unaware of these recommendations until months later.
The facility failed to ensure the cleanliness of the kitchen's ice machine, with yellow and white buildup observed on the inside gasket. The Dietary Supervisor and Maintenance Manager acknowledged the buildup, which could potentially be mold, posing a risk of contamination to the ice consumed by residents. The facility's policy required weekly cleaning of the gaskets to prevent such buildup.
The facility failed to maintain a sanitary garbage storage area, with trash bags and cardboard boxes on the ground and an overflowing dumpster with an open lid. The Maintenance Manager acknowledged the issue, which violated the facility's policy requiring closed dumpster lids to prevent pests and debris.
A LTC facility failed to implement infection control practices for three residents. A resident's nasal cannula tubing was not changed weekly, risking respiratory infection. Two residents had urinary catheter tubing and drainage bags touching the floor, contrary to care plans. One resident's catheter bag was encrusted with sediments, which staff failed to report, increasing infection risk. These deficiencies highlight lapses in adherence to infection control protocols.
The facility failed to maintain an effective pest control program, leading to an unresolved German cockroach infestation in the Admission's Office. Observations revealed clutter and water-damaged cardboard boxes, with live cockroaches seen over several days. The Administrator and Maintenance Manager acknowledged the inadequacy of current pest control measures, attributing the issue to the building's age and a neighboring carwash. Despite extermination efforts, the infestation persisted, indicating a failure to implement the facility's pest control policy effectively.
A resident received sertraline and aripiprazole without proper informed consent, as the facility obtained consent from an unauthorized family member instead of the resident, who had the capacity to make her own medical decisions. The resident was not informed about the medications or their potential side effects, violating her rights to be informed and make decisions about her care.
A resident with hemiplegia and other health issues was unable to reach or use the call light due to its inappropriate placement and type, leading to reliance on calling out for help. The facility's policy required the call light to be within reach, but this was not followed, resulting in a deficiency.
The facility failed to update the medical records of two residents to reflect their advance directive status. One resident's advance directive acknowledgment form was incomplete, missing essential signatures, while another resident's form was not obtained within the required 24 hours of admission. These deficiencies were identified during record reviews and interviews with staff, highlighting lapses in following the facility's policy on advance directives.
Two residents with severe cognitive impairments were involved in a verbal altercation, which was not reported to the State Agency in a timely manner. Despite facility policies requiring immediate reporting of abuse, the incident was delayed due to the alleged abuser's dementia diagnosis, leading to a delayed investigation and increased risk of further incidents.
A facility failed to ensure the accuracy of a PASRR Level I Screening for a resident with depression and psychosis. The screening did not reflect the resident's mental health diagnoses, leading to the omission of a necessary PASRR Level II Mental Health Evaluation. The DON acknowledged the inaccuracy, which contradicted the facility's policy to ensure appropriate placement and service provision for individuals with mental disorders.
The facility failed to develop comprehensive care plans for four residents, including those with mental health conditions, fall risks, and those using low air loss mattresses. This oversight led to potential risks and complications, as confirmed by staff interviews and record reviews.
Two residents with histories of falls and cognitive impairments experienced multiple falls without revisions to their care plans. Despite sustaining injuries, the facility did not update the fall prevention interventions, contrary to their policy. This deficiency in care planning led to repeated falls and injuries for the residents.
A facility failed to document medication administration and monitoring for a resident, including pantoprazole, insulin lispro, COVID-19 and vital signs, pain, and side effects of various medications. The resident, with conditions such as diabetes and hypertension, required these interventions as part of their care plan. The lack of documentation could delay necessary care, as acknowledged by RN 1.
The facility failed to adjust low air loss mattresses (LALMs) according to residents' weights, risking pressure ulcer development. A resident's LALM was set to 400 lbs despite weighing 224 lbs, and another's was set for 320 lbs while weighing 161 lbs. Staff lacked training on LALM setup, and care plans did not document necessary adjustments, leading to discomfort and potential injury.
A resident with multiple health conditions did not receive prescribed oxygen therapy due to a disconnection between the humidifier and the oxygen concentrator. An LVN confirmed the oversight, acknowledging it was her responsibility to ensure proper connection. The DON emphasized the importance of staff checking oxygen connections, as per facility policy.
The facility failed to provide dialysis emergency kits at the bedside for three residents requiring dialysis, placing them at risk for complications from uncontrolled bleeding. Observations revealed the absence of these kits, and interviews indicated staff were unaware of their necessity. The facility's policies did not adequately address the need for these kits, highlighting a systemic issue in ensuring resident safety during dialysis treatment.
The facility failed to implement a gradual dose reduction (GDR) for a resident on sertraline despite no depressive symptoms and did not obtain informed consent for trazodone administration to another resident. The sertraline GDR was recommended by the consultant pharmacist but not attempted, and the resident was unaware of receiving the medication. For trazodone, the resident's medical records lacked informed consent documentation, which is required by facility policy.
The facility failed to properly label and store food brought by visitors for four residents, including items like hot sauce, Popeyes food, desserts, and a sandwich, which were left at bedsides without labels or refrigeration. Staff were unsure of labeling requirements, leading to a deficiency in following the facility's policy.
A resident with a history of stroke and leg amputation was not screened for skilled therapy services upon readmission, despite physician orders. The resident did not receive passive range of motion exercises until months later, delaying necessary rehabilitative care. This failure prevented advocacy for skilled therapy services and could impact the resident's mobility and ADLs.
The facility failed to develop comprehensive Covid-19 care plans for three residents, including one with moderate cognitive impairment and another with severe cognitive impairment. Despite the facility's policy requiring care plans to address medical and psychosocial needs, the necessary interventions for Covid-19 were not identified or implemented.
The facility failed to implement proper Covid-19 infection control measures, including inadequate PPE use by staff, failure to test exposed staff, incomplete visitor screening, and not reporting an outbreak to the health department. These deficiencies were observed through staff actions and interviews, highlighting lapses in following established policies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and open wounds, despite the DON acknowledging the requirement. Additionally, the facility did not report three new Covid-19 cases during an outbreak, and staff were not trained or equipped with appropriate PPE. The ADM misunderstood EBP requirements, and the facility's outdated policies contributed to these deficiencies.
A resident received Hydrocodone-Acetaminophen (Norco) three hours earlier than prescribed due to a failure to follow the facility's medication administration policy. The resident, with a history of cerebrovascular disease and cognitive impairment, had already received a dose earlier for severe pain. The LVN did not document the early administration in the MAR, contrary to the facility's policy requiring documentation and adherence to prescribed times.
A resident with heart failure, asthma, and respiratory failure was observed receiving oxygen at a rate of four L/min instead of the physician-ordered two L/min. The DON confirmed the discrepancy, indicating a failure to follow the facility's policy for verifying and adjusting oxygen delivery according to physician orders.
A resident experienced inadequate pain management due to a nurse's failure to follow the facility's pain assessment policy. The nurse did not promptly address the resident's pain, use a standard pain assessment scale, or document the administration of pain medication. The resident, with a history of cognitive impairment and physical disabilities, expressed pain during a medication pass, but the nurse administered Norco without assessing the pain level. This led to the resident experiencing pain that interfered with daily activities.
Ice Machine Not Cleaned and Sanitized Properly
Penalty
Summary
The facility failed to ensure the ice machine was cleaned and sanitized properly. During a concurrent observation and interview, the Dietary Services Supervisor observed a combination of dark black/grey dots and a pink colored slime on a paper towel used to wipe underneath where the ice machine dispenses ice cubes. The DSS stated she did not know what the substance was and said it was the first time she had seen it. She also stated she was not aware of the deep cleaning procedures because Maintenance was responsible for deep cleaning, and she had emergency ice available for the remainder of the day. During a later observation and interview, Maintenance Staff demonstrated the deep cleaning procedure by removing screws from the ice maker housing and leaning back the cover. Black dots with a web-like substance were observed on the cover, and when the cover was removed further, a substance was seen on a steel plate fixed to the base of the ice maker directly above the container where ice is dispensed and held. The Maintenance Staff could not identify the substance and wiped the area with a paper towel, which resulted in a combination of dark black/grey dots and a pink colored slime. The Ice Machine Daily Cleaning log showed deep cleaning was signed off once per month, including 1/9/2026. Facility policy stated ice used in connection with food or drink shall be from a sanitary source and handled and dispensed in a sanitary manner, and the ice machine policy required Maintenance staff to clean the ice making mechanism per manufacturer guidelines. The manufacturer instructions reviewed directed removal of the evaporator cover, water pipe retaining cover, and water pipe for cleaning.
Overflowing Trash and Open Dumpster Lids
Penalty
Summary
The facility failed to dispose of garbage properly when the trash dumpster and smaller bins labeled Soiled Linen were observed overflowing with bags of waste on two consecutive days. During a concurrent observation and interview on 1/20/2026 at 9:30 a.m. with the Administrator, the dumpster and bins near the parking lot were filled beyond capacity, and the dumpster was located inside a wooden shed that was disheveled with broken roofing. The Administrator stated that trash was not picked up the day before because of a national holiday and that the trash company would dispose of all waste the next day. A review of the trash pickup schedule on the company’s website showed that if service falls on or after a holiday, pickup is delayed by one day. Monthly pest control reports also documented recommendations on 2/25/2025, 3/21/2025, and 5/22/2025 to keep trash can lids closed to reduce pest attraction and breeding sources. On 1/21/2026 at 10:30 a.m., nursing and kitchen staff were observed taking trash out to the dumpster and bins outside, and at 11:23 a.m. the dumpster was still filled with black trash bags beyond capacity with the lids propped open. A nearby wheeled trash bin contained bags protruding beyond capacity with the lid resting on top and unclosed. The Administrator stated that the facility’s daily trash production exceeded the current capacity available and that the trash could be a vector for pests, and noted they may require a second bin despite physical space and access obstacles.
Failure to Care Plan Denture Use, Denture Refusal, and Hand Tremors
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with identified needs related to dentures and hand tremors. For one resident, the record showed intact cognition, moderate assistance with ADLs, and no oral or dental issues on the MDS, yet the resident was observed eating breakfast without using dentures that were placed on the bedside table and stated the dentures were too big and loose. The MDSN confirmed the resident had dentures and stated a care plan should have been initiated on admission because the dentures were ill-fitting, but the care plans reviewed did not address denture use. For another resident, the admission record and psychiatric evaluation documented diagnoses including lack of coordination and EPS, and the resident was noted to have hand tremors. The MDS showed moderately impaired cognitive skills for daily decision making and varying levels of assistance with eating, oral hygiene, dressing, toileting, and personal hygiene. The electronic medical record did not contain a care plan for the hand tremors. The resident was observed with shaking hands while sitting on the bed and later while seated in the dining room. An LVN stated the tremors had worsened, the resident received medication for EPS, and a care plan should have been developed to guide care, monitor symptoms, and assist with mobility, ADLs, and eating. For a third resident, the admission record documented dysphagia, dementia, and abnormalities of gait and mobility, and the MDS showed moderately impaired cognitive skills with supervision needed for eating and partial assistance needed for oral hygiene, toileting, and footwear. The H&P noted fluctuating capacity to understand and make decisions. Staff knew the resident refused to wear dentures, and the resident was observed eating without dentures while a family member stated the resident had trouble eating because of the missing dentures. Review of the care plans showed no plan addressing refusal to wear dentures. The MDSN stated the resident should have had a care plan to address the refusal to use dentures.
Failure to Train and Verify RNA Competency for ROM Exercises
Penalty
Summary
The facility failed to ensure that all Restorative Nursing Aides (RNA) received training and demonstrated competency in performing range of motion (ROM) exercises for one sampled resident. During an interview, an RNA stated she received in-service education with new orders and residents with special concerns. The Director of Rehabilitation stated RNA in-service was based on the RNA referral form, which included the RNA order, instructions, and training for the activity to be completed, and that this process began on 12/05/2025. The DOR also stated that regular RNA competency in-service and a checklist with recordkeeping were important because RNAs needed to understand the orders, how to carry them out, and how the order affected the resident's ROM. The DON stated the importance of ROM training and competency was to monitor RNA skills and identify education needs that affected resident care, and that keeping records of trainings was important to keep skills updated and support residents' needs. The DSD stated ROM training was not included in the list of trainings and that ROM exercises should be part of CNA/RNA mandatory training. A review of the facility's In-service Training Program for CNA/RNA training log, dated 12/2019, showed that CNA in-service training did not include ROM training and a competency checklist. A review of the facility's Restorative Range of Motion policy, dated 2/2017, indicated the PT or PTA would review the program with the RNA at least every other month and advise on technique and documentation.
Medication Administration and Controlled Substance Documentation Failures
Penalty
Summary
The facility failed to ensure safe medication administration and accurate accountability of controlled medications for three residents. One resident with Type 2 DM, heart failure, and hypertension had repeated blood glucose readings over 400 mg/dL, including a reading of 436 mg/dL during a medication pass. The resident was given 15 units of insulin lispro per the sliding scale, but the nurse did not notify the physician at the time the elevated blood glucose was identified, even though the order required physician notification when blood glucose was greater than 400 mg/dL. The DON later confirmed there was no documentation that the physician had been notified for that reading, and the PCP stated he did not see a message from the facility about the 436 mg/dL result. A second resident with anxiety disorder had a lorazepam 0.5 mg order discontinued, but a medication card containing lorazepam 0.5 mg remained in the medication cart. The resident later had a lorazepam 1 mg order, but the facility did not have that dose in stock. The controlled drug record showed a dose of lorazepam 0.5 mg removed from the cart, while the MAR documented administration of lorazepam 1 mg at the same time. The DON stated the resident was transferred to the hospital and returned with the new lorazepam 1 mg order, but the charge nurse did not match the order and accidentally gave lorazepam 0.5 mg, which the DON identified as a medication error. A third resident with Type 2 DM, gout, polyneuropathy, and intact cognition had an order for hydrocodone-acetaminophen 10 mg/325 mg every 8 hours as needed for severe pain. The controlled drug record showed the medication was removed from the card in the morning, but the MAR was not completed at that time. RN 1 stated she forgot to document the administration immediately after giving the medication. The progress note later documented that the medication had been given, but the MAR entry was not made until several hours after administration. The DON stated licensed nurses must document medication administration on the MAR on time, especially for PRN controlled medications, and before going to the next resident.
Improper Disposal of Non-Controlled Medications
Penalty
Summary
The facility failed to dispose of non-controlled medications in the presence of a witness in accordance with its policy titled, Disposal of Medications. During a concurrent medication storage inspection and interview, the non-controlled medication disposal logs from 11/26/2025 through 1/15/2026 were reviewed in the DON's office, and the logs showed only one licensed nurse's initials on the forms. The DON stated that the non-controlled disposal log was used by both nursing stations and that non-controlled drug disposal was done by one person, either the DON or the RN Supervisor, and did not require a witness. During a later interview, the DON provided the facility policy, which stated that non-controlled medication disposal requires destruction in the presence of a pharmacist or nurse and one witness, and that medications may not be left in the original vials or container for disposal.
Menu Recipes Not Followed and Ingredients Altered
Penalty
Summary
The facility failed to ensure Cook 1 followed the Korean menu recipes and failed to ensure the zucchini recipe ingredients were not altered. During a concurrent observation, interview, and record review on 1/20/2026 at 12:05 p.m. with the Dietary Services Supervisor (DSS), the Weekly Korean Menu and the recipe for Korean Pot Stickers were reviewed. The menu indicated Korean Pot Stickers and Dipping Sauce, and the recipe directed that the meat mixture be wrapped into pot sticker or won ton wraps. Instead, a pan of chunky meat with cabbage and peppers was observed being served for lunch service. The DSS stated the food being served was from the Korean menu and said Cook 1 may have mistakenly followed Monday's menu, but also stated the food being served did not align with Monday's menu and corresponding recipe. During another concurrent observation, interview, and record review on 1/20/2026 at 12:10 p.m., the Weekly Menu indicated Seasoned Zucchini, but Cook 1 was observed serving a vegetable dish containing zucchini, carrots, red peppers, and corn. During lunch service, Cook 1 added boiled cauliflower to a pan on the steam table toward the end of lunch service. The DSS stated, "I don't know why she (Cook 1) added that," and Cook 1 stated the facility was out of zucchini and she chose to add cauliflower. On 1/21/2026 at 11:50 p.m., the Weekly Korean menu and recipe for Fish Stew were reviewed; the menu indicated Fish Stew and the recipe directed a soup using the fish, but Cook 1 was observed serving whole filets of fish for the Korean menu. The DSS stated Cook 1 baked it instead of making a stew and did not check the menu. The DSS was not able to present a substitution log showing any menu changes documented or revised and approved by a Registered Dietitian.
Incorrect Texture-Modified Diets Served
Penalty
Summary
The facility failed to provide the correct texture-modified diet for two sampled residents with swallowing and chewing needs. During observation, one resident with dysphagia and dementia was served lunch that included toasted garlic bread and chopped chicken with vegetables, even though the resident’s diet card, dietary profile, and order summary indicated an L5 minced and moist texture diet. The resident’s record also showed severe cognitive impairment and maximum assistance needed for eating. A CNA stated the chicken chunks were too big for the resident to chew and swallow and that the food had to be cut into smaller pieces before feeding. A second resident was observed eating lunch with toasted garlic bread, chicken with vegetables, and a full quesadilla, despite having a mechanical soft texture diet on the diet card and an L6 soft and bite sized texture diet in the order summary and dietary profile. The resident’s record showed diagnoses including DM and hemiplegia affecting the left non-dominant side, with moderately impaired cognitive skills and supervision required for eating. The Dietary Supervisor stated the food on the resident’s plate was regular texture food and not mechanical soft, and that the quesadilla should not have been served in full. The DON stated residents with chewing and swallowing problems had texture-modified diets as a safety measure to prevent choking, and that it was not acceptable for a resident to receive food texture that was not ordered. The DON also stated it was the dietary department’s responsibility to check food before it left the kitchen and the licensed nurses’ responsibility to check food before it was given to residents. The facility menu for the meal indicated that chicken for L6 and L5 textures had to be minced, and garlic bread for L6 had to be chopped, soaked, and drained, while garlic bread for L5 had to be minced and moist. The facility policy stated mechanically altered diets were for individuals with chewing or swallowing problems and that food must be served moist to facilitate chewing and swallowing.
Failure to Inventory and Track Resident Personal Belongings
Penalty
Summary
The facility failed to ensure a resident's personal belongings were inventoried and tracked upon discharge and readmission for one resident. Resident 48 had diagnoses including dysphagia, dementia, and abnormalities of gait and mobility, and the MDS indicated moderately impaired cognitive skills for daily decision making, with supervision needed for eating and partial assistance needed for oral hygiene, toileting, and putting on footwear. The H&P noted fluctuating capacity to understand and make decisions. A Theft and Loss Form documented that the resident reported her dentures were missing and could not recall where they were. Review of the resident's inventory lists showed only one list dated 5/30/2021, which identified a right and left hearing aid, despite the resident being discharged and readmitted five times between 10/2025 and 1/2026. During observation, the resident was eating without her dentures, and a family member stated the dentures were missing. Staff interviews indicated CNAs were responsible for completing inventory lists upon discharge and readmission, and one RNA stated she did not complete the inventory list on readmission because she knew the resident had a locked closet and belongings at bedside, and she did not try to locate the key. The DON stated there should have been at least one to two inventory lists completed during that timeframe to account for valuable belongings such as hearing aids and dentures. The facility policy required residents' personal possessions to be identified and inventoried upon admission and documented.
PRN Lorazepam Order Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure that a PRN order for Lorazepam, a psychotropic medication, included a stop date for one of six sampled residents. Resident 16 was originally admitted to the facility and later readmitted, and had diagnoses of depression, anxiety, and epilepsy. The resident’s MDS dated 12/11/2025 indicated cognition was intact and that the resident was dependent on staff for ADLs. A review of the order summary report dated 1/5/2026 showed that Resident 16 was ordered Lorazepam 0.5 mg, one tablet by mouth every eight hours as needed for anxiety, but the order did not include a stop date. During a concurrent interview and record review on 1/23/2026, the DON confirmed that the order lacked a stop date and stated the facility’s P&P required psychotropic medication orders to be written for a specific time period, with PRN psychotropic medication orders limited to 14 days. The DON stated the Lorazepam order was not in alignment with the facility’s P&P.
Inaccurate MDS Oral/Dental Coding
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident’s oral and dental status. The resident was admitted and later readmitted to the facility with diagnoses including DM and HTN, and the admission record and H&P indicated the resident had intact cognition and the capacity to understand and make decisions. In the MDS dated [DATE], the resident was assessed as requiring moderate assistance with ADLs and was coded as having no oral and/or dental issues. During a concurrent observation and interview, the resident was seen eating breakfast and stated it was difficult to chew because she did not have any teeth. She also stated she had dentures, but they did not fit because they were too big. During interview and record review with the MDSN, the MDS oral/dental status was reviewed and the MDSN stated it was coded incorrectly because it did not reflect the resident’s actual oral and dental status. The MDSN stated the resident should have been coded as edentulous because she did not have her natural teeth, and the facility policy required MDS accuracy for each resident’s status, needs, and strengths.
Improper Handling of Finasteride During Medication Administration
Penalty
Summary
The facility failed to ensure services met professional standards when finasteride was handled without gloves for one resident. Resident 63 was admitted with diagnoses including benign prostatic hyperplasia, urinary retention, and chronic kidney disease, and the MDS indicated moderately impaired cognitive skills for daily decision making as well as varying levels of assistance needed for personal care and dressing. During an observation in the resident’s room, an LVN was seen preparing finasteride for administration without wearing gloves. The resident’s physician order for finasteride 5 mg by mouth in the morning specifically directed staff to wear gloves when handling and administering the medication, and the consultant pharmacist’s medication regimen review also stated that gloves should be worn. The LVN stated she did not wear gloves when administering medications but should have followed the order to prevent absorption through the skin. The DON stated gloves must be worn when giving finasteride and that nurses should follow pharmacy recommendations and physician orders, and the facility policy stated examination gloves are worn during medication administration when ordered by the prescriber.
Failure to Assist Resident With Hand Tremors During Meals
Penalty
Summary
The facility failed to ensure that Resident 36, who had hand tremors, was assisted during mealtimes. During an observation in the dining room, Resident 36 was seated at a table with a cup of coffee and a food tray, but was not eating. The resident's hands were shaking, and when the resident grabbed the coffee cup and brought it toward her face, coffee spilled over the resident before the cup was returned to the table. Resident 36's record showed diagnoses including lack of coordination and diabetes mellitus. The H&P indicated the resident was oriented to person, place, and time, and the psychiatric evaluation noted the resident was alert and oriented to person and place and had EPS with involuntary movements, muscle stiffness, tremors, and restlessness. The MDS indicated the resident had moderately impaired cognitive skills for daily decision making and required set up or clean up assistance for eating. During interviews, CNA 5 initially stated the resident did not require help to eat, but later observed the resident's hands were aggressively shaking and assisted with feeding after the resident said yes when asked if help was needed. LVN 1 stated the resident would benefit from feeding assistance when tremors were more aggressive and should receive assistance to ensure adequate nourishment and avoid spillage. The DON stated the resident was independent and did not require assistance for eating, but also stated a resident with hand tremors would not be able to feed themselves and would require staff assistance.
Failure to Maintain Nail Hygiene for Two Residents
Penalty
Summary
The facility failed to maintain good grooming and personal hygiene for two sampled residents by not keeping their nails clean and neat. Resident 33, who had diagnoses including enterocolitis, DM, and HTN, was assessed as cognitively intact and required moderate assistance with ADLs. During observation, Resident 33 was seen with long fingernails and black substance underneath the nails, and the resident stated she wanted her fingernails cut and cleaned. A later observation again showed long fingernails with black substance under all ten fingernails. Resident 3, who had diagnoses including DM and dementia, was documented as lacking capacity to understand and make decisions and as being dependent on staff for all ADLs. The care plan directed staff to check nail length and trim and clean nails during baths/showers and as necessary. During observation, Resident 3 was found with long, yellow, thick toenails digging into adjoining toes. CNA 2 stated he reported the nails to the charge nurse and SSD, and also asked the podiatrist to cut them when the podiatrist was in the facility, but was told Resident 3 was not on the list to be seen. The SSD stated residents were seen by podiatry on admission and every two months after, but Resident 3 had not been seen since 7/19/2025 because of insurance issues, even though the facility offered the service without charge. The SSD acknowledged she did not place Resident 3 on the podiatry list and should have followed up to prevent injuries or complications from the long nails. The DON stated staff were expected to monitor and assist with nail hygiene, and that residents must see podiatry routinely for infection control and hygiene purposes.
Failure to Follow Medication Parameters and Ordered Monitoring
Penalty
Summary
The facility failed to follow physician orders for three residents by not carrying out ordered monitoring and by administering medications without following ordered parameters. Resident 84 had diagnoses including hypertension, dementia, and epilepsy, and was documented as moderately cognitively impaired and unable to make medical decisions. The physician ordered weekly weight monitoring for four weeks and ordered lisinopril 10 mg by mouth daily in the morning with instructions to hold the dose if systolic blood pressure was below 110 mm/Hg or heart rate was below 60 bpm. During record review and interview, the DON stated the MAR showed lisinopril was given from 11/9/2025 through 1/22/2026, but heart rate was not recorded before administration and there were no heart rate readings documented from 11/5/2025 to 1/22/2026. The DON also stated the last recorded weight was on 1/28/2025 even though the order required weekly weight monitoring for four weeks, and the facility did not implement the weight monitoring order as written. Resident 2 had diagnoses including hypertension and heart failure and was documented as having no capacity to understand and make decisions, with moderately impaired cognitive skills for daily decision making. The physician ordered diltiazem 60 mg by mouth three times daily for atrial fibrillation and to hold the medication if systolic blood pressure was less than 110. Review of the MAR showed that on multiple dates, Resident 2 received diltiazem when the systolic blood pressure was below 110. During interview, LVN 3 stated that a resident with systolic blood pressure less than 110 should not receive diltiazem because it could lower blood pressure to an unsafe level, and the DON stated nursing staff must follow medication parameters, retake the blood pressure, and hold the medication if it remained low. Resident 6 had diagnoses including hypertension and end stage renal disease and was documented as moderately cognitively impaired. The physician ordered orthostatic hypotension checks every Sunday. Review of the MAR and interview with LVN 3 showed that orthostatic blood pressure monitoring was not completed as ordered, including the standing position. LVN 3 stated she monitored lying and sitting blood pressures but did not monitor standing blood pressure, and stated the monitoring was inaccurate because there was no way of knowing whether there was a difference in blood pressures in different positions. The DON stated orthostatic blood pressures were monitored for changes when residents changed positions and that if they were not monitored, the doctor's orders were not followed.
Failure to Provide Ordered AAROM
Penalty
Summary
The facility failed to ensure Resident 38 received active-assist range of motion (AAROM) as ordered by the physician. Resident 38 was admitted with diagnoses including cerebral ischemia, HTN, dysphagia, and lack of coordination, and the MDS indicated moderate cognitive impairment and dependence on staff for ADLs. The history and physical stated the resident did not have capacity to understand and make medical decisions. The physician order dated 12/1/2025 directed restorative nursing aide services for AAROM to bilateral upper extremities and bilateral lower extremities as tolerated, 5 times a week. The care plan also identified the need for restorative nursing services and AAROM as ordered. During observation, Resident 38 was seen receiving PROM from an RNA and later PROM and AAROM from PT. Interviews with CNA 2, RNA 3, the DSD, the DON, and the DOR confirmed the order called for AAROM, and staff stated the resident could initiate movement and should receive AAROM to BUE and BLE. The facility's restorative ROM policy stated restorative ROM should be conducted as directed by the physician's order.
Failure to Follow Foley Catheter Orders and Notify Physician of Abnormal Urine Findings
Penalty
Summary
Resident 11, who had diagnoses including DM, neuromuscular dysfunction of the bladder, CKD, heart failure, and epilepsy, was admitted with no capacity to understand and make decisions and required substantial to maximal assistance with ADLs. The resident had an indwelling Foley catheter, and physician orders dated 12/04/2025 allowed irrigation with 100 cc normal saline as needed for tube clogging or to maintain patency, along with catheter bag changes and reinsertion as needed for malfunction or dislodgment. During observation on 1/20/2026, the Foley catheter was cloudy and clogged with sediment, and the resident stated the catheter had never been flushed and that he had on and off urinary pain and burning, with nurses aware but nothing done. On 1/21/2026, RN 2 stated the last catheter flush was 11/15/2025 and could not locate progress notes or change-in-condition notes showing physician notification about the urine sediment, cloudiness, or the resident's urinary pain and burning. The IP also observed visible sediment and cloudy urine and stated the physician's orders for Foley catheter care had not been followed.
Pain Rating Not Documented With PRN Tramadol Administration
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who was receiving Tramadol for pain. The resident was admitted and later readmitted with diagnoses including type II DM, HTN, and low back pain. The resident’s MDS dated 11/19/2025 indicated intact cognitive skills for daily decision making and varying levels of assistance with activities of daily living, including moderate assistance for oral and personal hygiene and upper body dressing, maximal assistance for toileting and lower body dressing, and dependence for showering/bathing. During review of the MAR and concurrent interview with RN 1, the Tramadol administration detail did not indicate a pain rating for the resident, and RN 1 stated that Tramadol was given for pain but a pain rating was not documented. The physician’s order for Tramadol indicated it was to be given as needed for moderate pain of 4 through 6 on a 0 to 10 scale. The DON stated that pain rating must be documented when administering a pain medication. Facility policy for Pain stated staff should assess for pain using a tool such as a pain scale, and the policy for Ordering and Implementing PRN Medications and Treatments stated PRN orders will clearly identify appropriate circumstances for a medication’s use.
Dialysis Orders Not Followed and Access Sites Not Monitored
Penalty
Summary
The facility failed to follow physician orders for dialysis treatment for one resident and failed to ensure dialysis access sites were assessed each shift for two residents. Resident 102 had diagnoses including dependence on renal dialysis and diabetes mellitus, and the admission record and MDS indicated the resident had intact cognitive skills and required varying levels of assistance with ADLs. The physician order summary directed staff to monitor the dialysis access site in the right upper chest every shift for signs and symptoms of infection, bleeding, redness, swelling, and discharge. For Resident 102, the MAR indicated the perma catheter was to be monitored every shift for signs of infection such as redness, swelling, soreness, pain, warmth, and bleeding, but the monitoring was discontinued after the resident returned from the hospital. During interview and record review, LVN 1 stated she was not aware the order was not renewed and stated the site had not been monitored since the resident returned to the facility. The DON stated dialysis access sites have to be monitored to make sure they are in working condition. Resident 90’s record showed diagnoses including diabetes mellitus, hyperlipidemia, ESRD, and dependence on renal dialysis. The physician order indicated hemodialysis every Sunday, Tuesday, and Friday, but the resident was being sent for dialysis every Monday, Wednesday, and Friday. LVN 2 stated the dialysis order was not being followed, and the DON stated all physician orders must be followed and that residents do not all have the same dialysis schedule. The facility policies on dialysis care and hemodialysis also stated shunt sites would be checked every shift and that orders for follow-up dialysis appointments and shunt care would be reviewed and ensured.
Failure to Complete Required Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure physician face-to-face visits were completed at least once every 30 days for the first 90 days after admission for two sampled residents, Residents 16 and 33. Resident 16 was originally admitted and later readmitted to the facility, and had diagnoses including epilepsy, depression, anxiety, and hypertension. The resident’s H&P dated 6/8/2025 indicated the resident had capacity to understand and make decisions and was signed by an NP. The resident’s progress notes showed monthly visits by an NP on 7/4/2025 and 8/2/2025. During interview and record review, the MRD stated the H&P was where physicians documented their initial face-to-face visit and comprehensive assessment of newly admitted residents, but the H&P and progress notes reviewed did not show any in-person physician visit after admission and/or readmission. Resident 33 was originally admitted and later readmitted to the facility and had diagnoses including enterocolitis, diabetes mellitus, and hypertension. The resident’s MDS indicated cognition was intact and that the resident required moderate assistance with ADLs. During record review, the MRD stated there was no documented evidence that Resident 33 was seen by a physician following admission. The DON stated the expectation was for the physician to conduct an in-person visit for newly admitted residents within the first 30 days and then every 30 days thereafter for the first 90 days, and acknowledged the facility did not follow its policy or federal requirements. The facility policy titled Physician Services stated residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter.
Incomplete documentation of medication administration, pain reassessment, and tremors
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three sampled residents by not ensuring licensed staff documented care events in a timely manner. Resident 12 was admitted and readmitted with diagnoses including type II DM, a disorder of muscle, and gout. The resident’s MDS indicated intact cognitive skills for daily decision making and varying levels of assistance with eating, hygiene, dressing, toileting, and bathing. During record review and interview, RN 1 stated she administered hydrocodone-acetaminophen to Resident 12 at 9:48 a.m. but forgot to document it on the eMAR until later, and the progress note showed the medication was given at 9:48 a.m. but not recorded until 4:27 p.m. Resident 33 was admitted and readmitted with diagnoses including DM, hypertension, and low back pain. The resident’s MDS indicated intact cognitive skills for daily decision making and assistance needs for eating, hygiene, dressing, and bathing. The record showed a pain reassessment was completed at 8:00 a.m. but not entered into the medical record until 4:01 p.m., and another pain reassessment dated at 10:27 a.m. was not recorded until 4:28 p.m. RN 1 stated she had not documented the pain reassessments for Resident 12 or 33, and stated pain reassessments should be documented after 30 minutes of giving pain medication. The DON stated pain reassessments should be documented within an hour of receiving pain medication. Resident 36 was admitted and readmitted with diagnoses including lack of coordination and DM. The resident’s records included an H&P noting orientation to person, place, and time, a psychiatric evaluation noting the resident was alert and oriented to [NAME], place, and EPS with involuntary movement symptoms, and an MDS showing moderately impaired cognitive skills and assistance needs with eating, hygiene, toileting, dressing, and shoes. Daily Skilled Charting for 1/13/2026 through 1/23/2026 did not address tremors in the neurological/sensory/communication section. LVN 1 stated Resident 36 had tremors on 1/22/2026 and 1/23/2026 but she did not document them because she was not aware there was a section to acknowledge tremors. The DON stated nursing staff must document observations of tremors.
Dialysis Binder Not Cleaned or Disinfected
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program when Resident 90’s dialysis binder was found with brown-colored staining on the back exterior surface. Resident 90 was admitted with diagnoses including DM, hyperlipidemia, and ESRD with dependence on hemodialysis, and the resident’s H&P indicated the resident had the capacity to understand and make decisions. The resident’s physician orders directed hemodialysis every Sunday, Tuesday, and Friday, and the binder was used as a dialysis communication record that accompanied the resident to and from dialysis appointments. During a concurrent observation, interview, and record review, the Infection Preventionist stated the binder was assigned solely to Resident 90 and was sometimes placed between the resident and the transportation gurney during transport. The Infection Preventionist stated the staining might have been fecal matter and that the binder should have been cleaned and disinfected after each return from dialysis, but this did not occur. The facility policy on infection control stated that prevention of infection includes policies and procedures that enhance the practice and prevention of the spread of infection, and that cleaning includes removal of visible soil from objects and surfaces with detergents or enzymatic products.
Infection Preventionist Lacked Required Annual IPC Continuing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) completed ten hours of continuing education in infection prevention and control on an annual basis. During an interview, the IP stated she was unable to provide documentation showing completion of ten hours of continuing education in infection prevention and control for 2025. She stated that she had completed continuing education hours when she renewed her nursing license, but those hours were not obtained in 2025, and that it was her responsibility to complete the required annual infection prevention and control education to stay informed on new guidance, evidence-based practices, and emerging infectious disease threats. During an interview, the DON stated the IP was responsible for educating staff on current infection prevention and control practices and that the IP needed to remain current on infection prevention and control updates in order to do so effectively. The DON stated that failure to complete the required annual ten hours of training could result in the IP missing critical changes in infection control practices, which could lead to inconsistent implementation of current infection prevention measures. A review of the California Department of Public Health AFL dated 11/4/2020 indicated that the IP should complete 10 hours of continuing education in infection prevention and control on an annual basis.
Failure to Obtain and Document Admission and Weekly Weights
Penalty
Summary
The facility failed to weigh one of three residents on admission and weekly for four weeks as required by its policy and procedure titled 'Weight Assessment and Interventions.' Specifically, the resident was not weighed upon readmission, and there were no recorded weights for the required weekly intervals following readmission. The resident's care plan included an intervention to monitor weight per policy due to a diagnosis of cellulitis of the right lower limb and acquired absence of other right toe(s). Despite this, the weight records did not include a weight taken on the day of readmission, nor were there documented reasons in the progress notes for missing weights on subsequent required dates. Interviews with facility staff, including an LVN, RN, and the DON, confirmed that the facility's policy was not followed, as weights were not obtained or documented as required. The DON acknowledged the absence of weight records and progress notes explaining the missed weights, and confirmed the importance of obtaining weights on admission to monitor residents' health status. The facility's policy clearly stated that weights should be measured on admission, the next day, and weekly for four weeks, and recorded in the appropriate records, which was not done in this case.
Failure to Prevent Falls and Provide Safety Measures
Penalty
Summary
The facility failed to ensure that two residents, Resident 17 and Resident 44, were free from avoidable accidents and hazards. For Resident 17, the facility did not conduct an Interdisciplinary Team (IDT) assessment following a fall on June 14, 2024, and failed to develop or implement person-centered interventions to prevent repeated falls on June 21, 2024, and August 3, 2024. As a result, Resident 17 sustained significant injuries, including a laceration, hematoma, and fractures, leading to hospitalization. The IDT assessments were not completed in a timely manner, and the interventions suggested were not appropriate given Resident 17's cognitive impairments. Resident 44 also experienced multiple falls due to the facility's failure to conduct timely IDT assessments and develop new, person-centered fall prevention interventions. Despite a history of falls, the IDT assessment did not address the cause of the falls or implement new interventions. Resident 44 sustained a forehead abrasion and complained of moderate pain after subsequent falls. The facility's policy required staff to assess and identify residents at risk for falls and develop appropriate care plans, which was not adhered to in this case. Additionally, the facility failed to provide padded siderails for Residents 44, 6, and 35 as ordered by their physicians. Observations revealed that these residents, who were at risk for seizures, did not have the necessary padded siderails to prevent injury. Staff interviews confirmed the absence of padded siderails, which increased the potential for injury. The facility's policy on safety and supervision required targeted interventions to reduce individual risks, which were not implemented correctly or consistently in these cases.
Failure to Act on Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on the Medication Regimen Review (MRR) conducted for all residents between 8/19/2024 and 8/20/2024. The MRR, which is a thorough evaluation of a resident's medication regimen aimed at promoting positive outcomes and minimizing adverse consequences, was not reviewed or acted upon by the facility staff. The Consultant Pharmacist made recommendations for 35 out of 91 residents, but these recommendations were not communicated to the residents' physicians, resulting in delays in medication adjustments and care plans. During an interview and record review on 12/4/2024, the Director of Nursing (DON) acknowledged that the recommendations from the MRR were not reviewed or reported to the physicians. The DON was unaware of the recommendations until the interview date. The facility's policy and procedure, dated 4/2018, required that any offsite MRR recommendations be communicated to the physician, with the DON or their designee responsible for enforcing this policy. The Consultant Pharmacist emphasized the importance of timely acknowledgment and action on his recommendations to allow physicians to make informed decisions about residents' care plans.
Ice Machine Contamination Risk
Penalty
Summary
The facility failed to maintain the cleanliness of the kitchen's ice machine, specifically the inside gasket, which was found to have yellow and white buildup. During an observation and interview with the Dietary Supervisor, it was noted that the buildup could potentially be mold, which should not be present inside the ice machine. The Dietary Supervisor acknowledged that ice is considered food and that the presence of such buildup could contaminate the ice, posing a risk of foodborne illnesses to residents. The responsibility for cleaning the internal parts of the ice machine was attributed to the maintenance department. Further observation and interview with the Maintenance Manager confirmed the presence of dirty calcium buildup inside the ice machine, which was deemed inappropriate. The facility's policy and procedure on sanitation and infection control, dated 2018, indicated that ice should be produced, stored, and dispensed in a manner to avoid contamination. It also specified that the inside gaskets or seals should be wiped down weekly by the Department of Food and Nutrition Services to prevent mold or calcium buildup.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary condition, as observed during a survey. Trash bags and cardboard boxes were found on the ground, and the outside trash dumpster was overflowing with trash and had its lid open. During interviews, the Dietary Supervisor did not comment on the garbage area, indicating that maintenance was responsible. The Maintenance Manager acknowledged the unacceptable condition, noting that it could lead to disease and infection. The facility's policy and procedure on sanitation and infection control, dated 2018, required that dumpster lids be kept closed to prevent pests, animals, or debris from entering.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices for three residents, leading to potential health risks. For Resident 66, the nasal cannula tubing used for oxygen therapy was not changed every seven days as required. Observations on multiple occasions revealed that the tubing was dated 11/25/2024, indicating it had not been replaced in accordance with the facility's policy. Licensed Vocational Nurse 3 confirmed that the tubing should be changed weekly to prevent respiratory infections, as microorganisms could enter the respiratory tract through the nasal cannula. Resident 38's indwelling urinary catheter tubing and drainage bag were observed touching the floor on two separate occasions. This practice is against the facility's care plan, which aims to prevent urinary tract infections by ensuring the catheter bag and tubing are placed below the bladder level and away from the floor. Resident 38's cognitive skills were severely impaired, making them dependent on staff for personal hygiene and other activities, further emphasizing the need for staff vigilance in maintaining infection control standards. Resident 84's urinary catheter drainage bag was found to be encrusted with sediments and touching the floor, which was observed over several days. The presence of sediments in the urine and on the drainage bag was not reported by the staff, despite the facility's policy requiring such findings to be communicated to the charge nurse. The Infection Preventionist Nurse and other staff members acknowledged the potential for infection due to the dirty and improperly maintained catheter equipment. Resident 84's cognitive impairment and dependency on staff for personal care necessitated strict adherence to infection control protocols, which were not followed in this case.
Unresolved German Cockroach Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective, ongoing pest control program, resulting in an unresolved infestation of German cockroaches. Observations revealed that the Admission's Office, located next to the kitchen, was cluttered with desks, a couch, a refrigerator, a microwave, Christmas decorations, and cardboard boxes filled with paper documents. These boxes were stored on the floor and showed signs of water damage. A square hole with an uncovered electrical outlet and exposed wires was also noted on the wall adjacent to the kitchen. Live adult German cockroaches were observed in the Admission's Office, crawling from under a desk and hiding among the clutter. Interviews with the Administrator and Maintenance Manager revealed that the facility had ongoing issues with cockroaches, attributed to the building's age and a neighboring carwash, which allegedly contributed to the pest problem and excess moisture. The Administrator acknowledged the inadequacy of the current pest control measures and expressed the need for a more effective solution. Despite extermination efforts and the placement of roach baits, live cockroaches continued to be observed in the office over several days. The facility's policy on pest control, dated April 2018, indicated that employees should report any signs of pests, and the Maintenance Supervisor should take immediate action, which was not effectively implemented in this case.
Failure to Obtain Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications from the responsible party of a resident, identified as Resident 45. Instead, consent was obtained from a family member who was not designated to make medical decisions on behalf of the resident. This resulted in the resident receiving sertraline and aripiprazole without her knowledge or explicit consent, which is a violation of the resident's rights to be informed and make decisions about her own care. Resident 45 was admitted to the facility with diagnoses of depression and psychosis and had the capacity to understand and make medical decisions, as indicated in her medical records. Despite this, the facility obtained consent from a family member who was not authorized to act on her behalf. The resident's admission agreement indicated she had decision-making capacity, and she had signed her own consent for treatment upon admission. However, the informed consents for the medications were signed by the unauthorized family member. Interviews with the resident and the family member confirmed that neither was aware of the consent process or the administration of the medications. The Director of Nursing acknowledged that the resident should have been informed and provided consent herself. The facility's policy on informed consents emphasizes the importance of upholding residents' rights to make informed decisions, which was not adhered to in this case.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident 23 by not providing an appropriate call light device within reach, which prevented the resident from effectively communicating with staff. Resident 23, who was admitted with conditions including hemiplegia, hemiparesis, and other health issues, required maximal assistance for daily activities and was dependent on a wheelchair for mobility. The resident's care plan specifically indicated that the call light should be within reach to ensure prompt assistance and prevent falls. During an observation, Resident 23 was found unable to reach the call light, which was placed at ear level on the left side of the pillow. The resident was observed calling out for help, and a CNA confirmed that the call light was not accessible to the resident. The CNA placed the call light on the resident's chest, but Resident 23 struggled to use it due to limited mobility. The CNA acknowledged that the resident typically yelled for help and was unaware of the resident's inability to use the call light, suggesting the need for a paddle call light. The facility's policy required staff to assess residents' ability to use the call light and ensure it was within easy reach. However, this was not adhered to in Resident 23's case, as the resident was not provided with a suitable call light device. The Director of Nursing later acknowledged the need for reassessment and appropriate accommodation for Resident 23's call light needs.
Failure to Update Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the medical records of two residents were updated to reflect their advance directive status, which is a legal document indicating a resident's preferences on end-of-life treatment decisions. For one resident, the facility did not complete the advance directive acknowledgment form (ADAF), which is part of the advance directive process. The form was missing essential signatures, including those of the resident's representative or witnesses, rendering it inactive. This oversight was identified during a review of the resident's admission record and confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the incomplete form could affect the resident's care. In the case of another resident, the facility did not obtain the ADAF within 24 hours of admission, as required by the facility's policy and procedure on advance directives. The resident's medical records, both physical and electronic, lacked the ADAF, which could potentially delay necessary care. The LVN confirmed the absence of the ADAF and stated that it was the charge nurse's responsibility to ensure its availability. The Director of Staff Development also noted that the ADAF should be readily accessible in the resident's chart for emergencies. The facility's policy on advance directives mandates that an acknowledgment of the resident's right to an advance directive be completed and included in the resident's medical file within 24 hours of admission. If the acknowledgment is not completed within this timeframe, the Admissions Coordinator or designee must document the reasons for the delay. The policy further states that any incomplete acknowledgment after five days should be forwarded to the facility Administrator for necessary actions. The failure to adhere to these procedures resulted in the deficiencies noted in the report.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to report an incident of resident-to-resident verbal abuse to the State Agency in a timely manner. On 12/29/2024, an unidentified staff member observed Resident 30, who has severe cognitive impairments and a mood disorder, throw a blanket at Resident 3 and yell at her. Resident 3, who also has severe cognitive impairments and is dependent on staff for all activities of daily living, was unable to understand or make decisions. Despite the observation of this altercation, the incident was not reported to the State Agency until 1/15/2024. The facility's policies and procedures require that all allegations of abuse, including verbal abuse, be reported immediately to the State Agency, regardless of the alleged abuser's cognitive condition. The Administrator acknowledged that the incident was not reported because Resident 30 had a diagnosis of dementia, which is not an acceptable reason for failing to report according to the facility's policies. This delay in reporting resulted in a delayed investigation by the State Agency and increased the potential for further incidents of abuse.
Inaccurate PASRR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident with mental health disorders. The resident, who was admitted and readmitted to the facility, had diagnoses of depression and psychosis. However, the PASRR Level I Screening conducted upon their readmission did not reflect these diagnoses and was marked as negative. Consequently, a PASRR Level II Mental Health Evaluation was not deemed necessary, potentially impacting the resident's access to required services and care. During an interview and record review, the Director of Nursing acknowledged that the PASRR Level I Screening was inaccurate and should have included the resident's mental health diagnoses. The facility's policy and procedure on PASRR, dated December 2017, emphasized the importance of accurate screenings to prevent inappropriate placements in nursing homes for individuals with mental disorders or intellectual disabilities. The deficiency was identified as the facility did not review and correct the PASRR for accuracy, which is crucial for determining the necessity of additional services and ensuring appropriate admission.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks and complications. Resident 45, who was admitted with diagnoses of depression and psychosis, did not have a care plan addressing these mental health conditions. The Director of Nursing (DON) acknowledged the absence of care plans for these diagnoses, which would have included goals and interventions to manage the resident's conditions effectively. Resident 58, who had severe cognitive impairment and was at risk for falls, did not have a fall risk care plan despite evaluations indicating the need for one. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) both confirmed the lack of fall risk indicators and care plans, which posed a safety risk to the resident. The RN stated that the absence of a fall risk care plan was a significant oversight, as it would have included necessary interventions to prevent falls. Residents 32 and 77, both using low air loss (LAL) mattresses, did not have care plans addressing the use of these mattresses. The Licensed Vocational Nurse (LVN) and RN involved in their care confirmed the lack of documentation and care plans for the LAL mattresses, which are crucial for pressure injury prevention and skin maintenance. The facility's policy required that the use of such mattresses be documented in the care plan, but this was not done, potentially affecting the residents' care and comfort.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise the care plans for two residents following multiple falls, which is a deficiency in care planning and risk management. Resident 44, who has a history of falling and severe cognitive impairment, experienced three falls after the initiation of a fall risk care plan. Despite these incidents, the care plan was not updated to address the falls on 5/19/2024, 8/22/2024, and 9/14/2024. The resident sustained injuries, including a forehead wound and reported moderate pain, yet the care plan interventions remained unchanged. Similarly, Resident 17, who has osteoarthritis, osteoporosis, dementia, and a history of falls, experienced three falls without subsequent revisions to her care plan. The resident's falls on 6/14/2024, 6/21/2024, and 8/3/2024 resulted in injuries, including a puncture wound to the scalp and broken bones in the sacral region. Despite these significant events, the care plan interventions were not updated to prevent further falls and injuries. The facility's policy and procedure for fall risk and prevention assessment require the interdisciplinary team to develop and update care plans to address fall risks. However, the care plans for both residents did not reflect these requirements, as they were not revised following significant changes in the residents' conditions. This lack of action contributed to the residents' repeated falls and injuries, highlighting a failure in the facility's care planning process.
Failure to Document Medication Administration and Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality care for Resident 62 by not documenting the administration of medications and monitoring as required. Specifically, the Medication Administration Record (MAR) lacked documentation for the administration of pantoprazole and insulin lispro on multiple occasions. Additionally, there was no documentation for COVID-19 and vital signs monitoring, pain monitoring, and significant side effects monitoring for anticoagulant and sedative/hypnotic medications on several dates. Resident 62, who was admitted with diagnoses including diabetes mellitus, hypertension, anemia, and depression, required various medications and monitoring as part of their care plan. The resident's Minimum Data Set (MDS) indicated they had intact cognitive skills but required varying levels of assistance with daily activities. Despite these needs, the facility's records showed gaps in documentation, which could potentially delay necessary care and services for the resident. During an interview, RN 1 acknowledged the missing documentation and stated that it was unacceptable, as it could delay necessary care. The facility's policies required immediate documentation of medication administration and monitoring, but these were not adhered to in Resident 62's case. The lack of documentation could lead to prolonged unnecessary medication usage and increased risk of side effects, as well as potential issues with blood sugar management for the resident.
Improper Adjustment of Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALMs) were adjusted according to the residents' weights, which is crucial for preventing and treating pressure ulcers. For Resident 32, the LALM was set to 400 lbs, despite the resident weighing 224 lbs. This discrepancy was observed during an interview and record review, where it was noted that the LALM should have been adjusted according to the resident's weight or comfort level, especially after the resolution of a Stage III pressure injury. The Licensed Vocational Nurse (LVN) acknowledged that there was no care plan or intervention documented for the LALM, which could lead to errors and potential injury. Similarly, for Resident 77, the LALM was set for a person weighing 320 lbs, while the resident's actual weight was 161 lbs. The resident expressed discomfort and difficulty moving in bed, indicating that the mattress was not set correctly. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), revealed a lack of knowledge and training regarding the proper setup and adjustment of LALMs. The facility's policy and procedure, as well as the user manual for the LALM, emphasized the importance of setting the mattress according to the resident's weight and comfort, which was not adhered to in these cases. The deficiency highlights a failure in the facility's processes to ensure that LALMs are used effectively for pressure injury prevention and resident comfort. The Director of Nursing (DON) confirmed that the LALM settings should be documented and care planned, but this was not done for the residents involved. The lack of proper documentation and training on LALM usage contributed to the potential risk of pressure ulcer development or worsening for the residents.
Failure to Administer Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received the prescribed oxygen therapy as ordered by the physician. The resident, who had a history of atrial fibrillation, heart failure, hypertension, asthma, and obstructive sleep apnea, was supposed to receive oxygen at 2 liters per minute via nasal cannula continuously. However, during an observation, it was found that the nasal cannula was connected to a humidifier, but the humidifier was not connected to the oxygen concentrator, resulting in the resident not receiving any oxygen. A Licensed Vocational Nurse (LVN) confirmed the disconnection and acknowledged that it was her responsibility to ensure the oxygen tubing was properly connected during her shift. The Director of Nursing (DON) also confirmed that the resident did not receive oxygen if the humidifier was not connected to the concentrator and emphasized that all staff were instructed to check and ensure oxygen was connected to residents. The facility's policy indicated that oxygen must be administered according to the physician's order and monitored by licensed nurses and the Respiratory Therapist.
Failure to Provide Dialysis Emergency Kits at Bedside
Penalty
Summary
The facility failed to provide dialysis emergency kits at the bedside for three residents who required dialysis, which is a treatment to cleanse the blood of wastes and extra fluids when the kidneys have failed. This deficiency was observed during multiple visits to the rooms of the residents, where it was noted that the necessary emergency kits were absent. The absence of these kits placed the residents at risk for ineffective emergency treatment and complications from uncontrolled bleeding, which could result in hospitalization or death. Resident 66, who was admitted with diagnoses including end-stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), heart failure, and hypertension, was observed without a dialysis emergency kit at the bedside on two separate occasions. The resident's care plan indicated a goal to avoid complications from dialysis, yet the necessary emergency supplies were not provided. Similarly, Resident 36, with diagnoses of ESRD, diabetes mellitus, hypertension, and anemia, also lacked a dialysis emergency kit at the bedside. Interviews with staff revealed a lack of awareness about the necessity of these kits, indicating a gap in training and policy implementation. Resident 63, who had a perm-a-cath for dialysis, was also found without an emergency kit at the bedside. The facility's Director of Nursing acknowledged the oversight and the absence of a policy requiring these kits at the bedside. The facility's existing policies and procedures did not adequately address the need for dialysis emergency kits, highlighting a systemic issue in ensuring the safety and preparedness for residents undergoing dialysis treatment.
Failure to Implement GDR and Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) for a resident receiving sertraline, a medication used to treat depression, despite the absence of depressive symptoms. The resident, who had been admitted with diagnoses including depression and psychosis, was monitored from May to October 2024, during which no episodes of depression were recorded. Despite recommendations from the facility's consultant pharmacist to attempt a GDR within the first year of medication use, no such reduction was attempted. Interviews with the resident and facility staff revealed that the resident was unaware of receiving sertraline and its associated side effects, and there was no documentation indicating that a GDR was contraindicated. Another deficiency involved the administration of trazodone to a different resident without obtaining informed consent. The resident, who had intact cognitive skills and required assistance with daily activities, began receiving trazodone for depression in October 2024. However, a review of the resident's medical records showed no evidence of informed consent for the medication. Interviews with nursing staff confirmed that informed consent was not obtained, which is a requirement for administering psychotropic medications. The facility's policy mandates that informed consent be documented in the patient's record, but this was not adhered to in this case. These deficiencies highlight the facility's failure to adhere to protocols regarding medication management and informed consent. The lack of a GDR for sertraline and the absence of informed consent for trazodone administration indicate lapses in ensuring that residents are not subjected to unnecessary medications and are fully informed about their treatment options and potential side effects.
Improper Storage and Labeling of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure that leftover food brought by family members or visitors for four residents was stored according to the facility's policy and procedure. The policy required that food be labeled with the resident's name, the item, and the use-by date, and that perishable foods be stored in resealable containers in a refrigerator. However, observations revealed that food items such as hot sauce, Popeyes food, desserts, and a sandwich were left at residents' bedsides without proper labeling or refrigeration. Resident 69, who had diagnoses including diabetes mellitus, heart failure, hypertension, and chronic kidney disease, was observed with a used bottle of hot sauce on the bedside table without any labeling. Similarly, Resident 66, with conditions such as chronic obstructive pulmonary disease and end-stage renal disease, had outside food from Popeyes and desserts on the bedside table without labels. Both residents confirmed that the food was brought in by family members or themselves, and staff members were unsure about the labeling requirements. Resident 73, diagnosed with diabetes mellitus, dysphagia, heart failure, and hypertension, also had a bottle of hot sauce on the bedside table without labeling. Additionally, Resident 63, with end-stage renal disease and type 2 diabetes mellitus, had a half-eaten sandwich in a brown paper bag on the nightstand, which was not refrigerated. Staff interviews confirmed that the food should have been labeled and stored properly to prevent spoilage and potential illness, but this was not done, leading to the deficiency.
Failure to Provide Rehabilitation and Restorative Services
Penalty
Summary
The facility failed to conduct a rehabilitation screening and provide necessary rehabilitative and restorative nursing services for a resident who was readmitted with significant medical conditions, including a cerebral infarction and a below-knee amputation. Despite physician orders for skilled therapy evaluations upon readmission, the resident was not evaluated or screened for these services. This oversight prevented the Case Manager from advocating for the resident to receive skilled therapy services, which could have been beneficial given the resident's prior therapy history and discharge assessment. Additionally, the resident did not receive passive range of motion exercises until several months after readmission, despite active physician orders. The Director of Rehabilitation Services acknowledged that the restorative nursing services should have commenced upon the resident's readmission, as they did not require prior authorization. The delay in providing these services could potentially contribute to a decline in the resident's mobility and ability to perform activities of daily living.
Failure to Develop Covid-19 Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents diagnosed with Covid-19, which is a highly contagious respiratory disease. This deficiency was identified during a review of the residents' records and interviews with the Director of Nursing (DON). Resident 1, who had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs), did not have a Covid-19 care plan in place. Similarly, Resident 3, who was cognitively intact and required assistance for certain ADLs, and Resident 4, who had severe cognitive impairment and required substantial assistance for ADLs, also lacked Covid-19 care plans. The absence of these care plans meant that the necessary nursing care interventions to address the residents' Covid-19 infections were not identified or implemented. The facility's policy and procedure on care plans emphasized the importance of developing comprehensive care plans to meet the medical, nursing, and psychosocial needs of each resident, especially following significant changes in their status or condition. However, the facility did not adhere to this policy, as evidenced by the lack of Covid-19 care plans for the affected residents.
Inadequate Covid-19 Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control measures for Covid-19, as evidenced by several observations and interviews. Staff did not adhere to proper PPE protocols when entering and exiting Covid-19 positive rooms. Specifically, a Licensed Vocational Nurse entered a Covid-19 positive room without donning PPE, and a Maintenance Supervisor exited a Covid-19 positive room without doffing PPE. These actions were contrary to the facility's policy, which required staff to wear appropriate PPE, including gloves, isolation gowns, eye protection, and respirators, when dealing with Covid-19 positive residents. The facility also failed to conduct close contact testing of exposed staff after a resident tested positive for Covid-19. The Director of Nursing admitted that staff testing was not initiated promptly, and the facility's policy required testing of all staff and residents with higher-risk exposure. This oversight was confirmed by a Public Health Nurse, who emphasized the importance of testing staff to prevent the spread of the virus. Additionally, the facility did not adequately screen visitors during a Covid-19 outbreak. The Visitor Screening Log was incomplete, with some sections left blank, which meant the facility could not determine if visitors had symptoms or exposure to Covid-19. Furthermore, the facility failed to report the Covid-19 outbreak to the California Department of Public Health, as required by their policy, which could have hindered their ability to receive assistance in controlling the outbreak.
Failure to Implement Infection Control Measures and Report Covid-19 Cases
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for 15 out of 16 residents who met the criteria for EBP implementation. These residents had various medical conditions, including the presence of indwelling medical devices such as gastrostomy tubes and urinary catheters, as well as open wounds. Despite the Director of Nursing (DON) acknowledging the requirement for EBP, the facility did not have a policy or procedure in place, and staff were not trained to implement EBP. The Administrator (ADM) was aware of EBP but mistakenly believed it was not mandatory, leading to a lack of implementation. Additionally, the facility failed to report three new cases of Covid-19 to the local health department during an active outbreak. Two staff members and one resident tested positive, but these cases were not reported, which would have extended the outbreak period. The facility's DON was aware of the positive cases but did not report them, and the facility did not conduct the required testing for new admissions or after identifying positive cases. This failure to report and test created a risk for further transmission of Covid-19 within the facility. Interviews with staff revealed a lack of understanding and adherence to infection control protocols. The DON and ADM did not ensure that staff wore appropriate personal protective equipment (PPE), such as N95 respirators, during the outbreak. The facility's policies and procedures for Covid-19 were outdated and not followed, contributing to the deficiencies in infection prevention and control.
Medication Administration Timing Error
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering medications, resulting in a deficiency. Specifically, a Licensed Vocational Nurse (LVN) administered Hydrocodone-Acetaminophen (Norco) to a resident three hours earlier than the prescribed time. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified. During an observation, the LVN was seen retrieving and administering the medication to the resident at 9:58 a.m., which was not documented in the Medication Administration Record (MAR). The resident involved, identified as Resident 19, had a history of convulsions, hemiplegia, and hemiparesis following cerebrovascular disease, and was moderately impaired in cognitive skills for daily decision-making. The resident's care plan indicated a focus on managing pain and comfort, with interventions to assess pain levels and administer medications as ordered. However, the MAR showed that the resident had already received Norco at 12:50 a.m. for severe pain, and the subsequent administration at 9:58 a.m. was not recorded. The Director of Nursing confirmed that licensed nurses must adhere to the five rights of medication administration, which was not followed in this instance.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer supplemental oxygen as ordered by the physician for a resident, identified as Resident 5. Resident 5 was admitted with diagnoses including heart failure, asthma, and respiratory failure, and required substantial assistance for daily activities due to impaired short-term memory and mild cognitive impairment. During an observation, it was noted that Resident 5 was receiving oxygen at a rate of four liters per minute, contrary to the physician's order of two liters per minute. The Director of Nursing confirmed the discrepancy between the observed oxygen delivery rate and the physician's order. The facility's policy and procedure for oxygen administration required staff to verify and review physician orders and adjust the oxygen delivery device to ensure the proper flow. However, this protocol was not followed, leading to the deficiency in care for Resident 5.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, identified as Resident 19, by not adhering to its pain assessment policy and procedure. Licensed Vocational Nurse (LVN 5) did not promptly address the resident's pain when it was verbalized, nor did she use a standard pain assessment scale to determine the pain level. Additionally, LVN 5 did not ensure a thorough assessment of the resident's pain, including its location, frequency, quality, intensity, and duration, before administering pain medication. Resident 19, who was moderately impaired in cognitive skills and had a history of convulsions, hemiplegia, and hemiparesis, expressed pain during a morning medication pass. Despite the resident's request for pain relief, LVN 5 administered Norco without assessing the pain level or documenting the administration. The resident's care plan required pain to be controlled to their comfort level, with interventions including pain assessment and non-medication measures, which were not followed. The facility's policy required pain to be assessed with vital signs and documented using a standard scale, which was not done by LVN 5. The Director of Nursing confirmed that licensed nurses should know the medications they administer and always ask residents about their pain levels. The failure to follow these procedures resulted in Resident 19 experiencing pain that interfered with daily activities and had the potential for unrelieved pain.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarcrest Nursing Center | 0.8 mi | ★★★★★ | 17 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 1.2 mi | ★★★★★ | 25 | 0 |
| Villa Del Rio | 1.7 mi | ★★★★★ | 14 | 0 |
| Greenfield Care Center Of South Gate | 1.9 mi | ★★★★★ | 10 | 0 |
| Huntington Park Nursing Center | 2.4 mi | ★★★★★ | 2 | 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.