Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Catered Manor Care Center during CMS and state inspections, most recent first.
Failure to Maintain ROM and Apply Ordered Hand Splints: Two residents with hand contractures experienced decline when ordered hand rolls and bilateral resting hand splints were not applied consistently and changes in condition were not communicated to RN/OT staff. One resident with dementia and right-hand osteoarthritis had pain and worsening contracture after staff used inconsistent hand-roll materials and did not report intolerance or pain; another resident with paraplegia and bilateral upper-extremity impairment was observed without splints and progressed from needing assistance with eating to being fully dependent, while OT was not informed of the decline.
A resident with active shingles and immunocompromised status was managed under contact and droplet precautions, but staff did not use airborne precautions or an N95, and the lesions were not always covered during care. In addition, a CNA did not offer or provide hand hygiene to two residents before lunch, despite staff interviews and facility policy stating that residents should be assisted with hand hygiene before meals.
A resident with dementia, psychosis, depression, and fluctuating capacity to make medical decisions was given Buspirone, Escitalopram, and Quetiapine, but signed the informed consents despite lacking the capacity to do so. RN and DON stated the resident should not have signed because the resident would not understand the risks, benefits, or side effects, and the facility policy required informed written consent from the resident or resident representative before psychotherapeutic drugs were prescribed.
A facility gave conflicting and inaccurate information about smoking during admission, with the ADM saying it was non-smoking while the admission packet and written policy indicated residents had smoking rights and designated smoking areas. The DON stated the facility was not providing accurate smoking information and was not following its own policy. The facility also failed to honor a blind resident's stated preference for a Sunday bed bath; instead, a CNA brought the resident to the bathroom sink and gave towels for self-care, despite the care plan and posted instructions indicating a bed bath was to be provided.
A resident with dementia, anxiety, depression, and unspecified psychosis was receiving Buspirone, Escitalopram, and Quetiapine for schizophrenia-related anger outbursts, but the record had no documented schizophrenia diagnosis. Staff stated the resident was sleepy in the morning, had no behavioral problems, and had not received a psychiatric evaluation or IDT review of psychotropic use. The DON acknowledged no psychiatric assessment was completed, while facility policy required antipsychotics to be based on a comprehensive assessment and reevaluation when psychotropic orders were present.
PASRR Level II screening was not completed or accurately reflected for two residents with documented mental health conditions. One resident had schizophrenia, severe cognitive impairment, lacked decision-making capacity, and was receiving multiple antipsychotics, while the PASRR Level I showed a positive screen for serious mental illness and a Level II eval was required. The other resident had anxiety, depression, a psychotic disorder, moderate cognitive impairment, total dependence with ADLs, and was receiving buspirone, escitalopram, and quetiapine, but the PASRR Notice of Attempted Evaluation stated no serious mental illness or functional limitations. The MDSA and DON stated PASRR Level I and Level II information should have been reviewed for correct follow-up and coding.
Failure to Arrange Audiology Referral for a Resident with Hearing Loss: A resident with dementia and other diagnoses was documented as having diminished/decreased hearing, no hearing aid, and an audiogram showing hearing loss significant enough to qualify for hearing aids under Medi-Cal. The resident stated she could not hear and wanted hearing aids, while CNA and SSD interviews confirmed she had hearing difficulty and that an audiology referral should have been made after ENT wax removal; the SSD also stated the hearing loss affected communication with staff and the resident's ability to communicate needs effectively.
Inconsistent skin assessments and wound documentation for a resident with pressure ulcers. A resident with encephalopathy, sepsis, protein calorie malnutrition, malignant neoplasm of the endometrium, and dysphagia had orders for wound care and a care plan calling for weekly skin checks, monitoring during care, prompt MD notification for skin breakdown, and wound consults as needed. Records showed Stage III pressure ulcers to the coccyx and bilateral buttocks, but Shower Day Skin Inspections later documented the skin as intact/clear. The TN stated no skin assessments were documented in 2/2026, and the DON stated weekly skin assessments were not being completed.
The facility failed to keep documentation of annual performance evaluations in the personnel files of four of eight employees, including CNAs, a TN, and an RN. During record review, the DSD confirmed the missing evaluations, and both the DSD and DON stated that annual evaluations are important for assessing employee performance and ability to provide safe resident care. The facility policy required each employee's job performance to be reviewed and evaluated at least annually.
Missing RN Co-Signatures on Controlled Substance Destruction Records: The facility failed to properly document destruction of six controlled substances when the pharmacist signed the disposition records but an RN did not co-sign them. The DON said she counted the meds with the pharmacist and was supposed to sign the records, but forgot to do so. The medications included tramadol, zolpidem, temazepam, lorazepam, and hydrocodone-acetaminophen, and the facility policy required witness signatures on the medication disposition record.
A dietary aide incorrectly read the dishwasher chlorine test strip as 200 ppm during the final rinse, despite facility P&P requiring a lower chlorine range for proper sanitizing. The aide later stated the correct range was 50-100 ppm, and the DS confirmed staff competency in testing the dishwasher chlorine level was important because improper levels could affect dish sanitizing.
A resident with left-sided hemiplegia, muscle weakness, HTN, and hyperlipidemia reported that the food was horrible and that his African American cultural food preferences were not being honored; he wanted Soul Food. A CNA did not know the resident’s cultural food preferences, and the DON found no documentation of those preferences in the nutritional screen. The facility policy required staff to identify resident food preferences on admission and document them in the care plan.
Improper Quaternary Sanitizer Concentration in Kitchen: A dietary aide observed that the quaternary sanitizer in a red bucket used for kitchen surface cleaning tested below the required level, with the test strip color not matching the expected chart result. The DS later confirmed the solution did not have the correct concentration, and the facility policy required testing at least every shift and replacement when below 200 ppm.
Incomplete Documentation of Ordered Restorative Nursing Services: A resident with DM, depression, and generalized muscle weakness had care plan interventions and MD orders for restorative nursing aide services, including PROM to the BLE and AAROM to the BUE five times per week with minutes documented. During observation, the resident reported staff did not come every day for exercises and said she became stiff and weak when she missed them. Review of restorative nursing records showed no documentation that the services were provided on multiple days, and the RNA and DON acknowledged the missing documentation and the need to record all restorative services in the medical record.
A resident with multiple health conditions fell while transferring from bed to wheelchair after staff failed to lock the wheelchair and did not respond to a call for assistance. No fall risk assessment or comprehensive care plan was documented or implemented following the incident, despite facility policy requiring individualized safety interventions.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment contained hazards and lacked sufficient oversight, increasing the risk of accidents for residents.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
A resident with COPD and DM experienced increased confusion and poor food intake, leading to lab tests that revealed abnormal blood glucose, sodium, and chloride levels. Although earlier abnormal results were reported, the physician was not notified of subsequent abnormal findings, contrary to facility policy, resulting in a delay in care and treatment.
A resident with DM and COPD was given Prednisone without a care plan or interventions to monitor for hyperglycemia, despite the medication's known risk of raising blood sugar. The resident's b/s was not monitored, resulting in a critical hospitalization for DKA and HHS after presenting with altered consciousness, hypotension, and an unmeasurably high b/s level.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
A deficiency was cited when a resident was found to have been prescribed or administered unnecessary drugs, with no adequate clinical justification documented in the medical record.
A resident with significant physical dependencies was not provided the required two-person assistance during incontinent care, as indicated in the MDS and facility policy. A CNA attempted to reposition the resident alone, resulting in the resident falling from the bed and sustaining severe neck and spinal injuries. The resident was hospitalized, placed on a ventilator, and later passed away due to complications from the injuries.
A resident with multiple medical conditions and mild cognitive impairment was assessed as fully dependent on staff for toileting hygiene and turning in bed, requiring a two-person assist. However, the care plans did not document this specific need, and interventions were limited to general safety measures. The MDS Nurse acknowledged the omission, stating she assumed CNAs would understand the resident's dependency without explicit instructions.
A resident with diabetes and hypoglycemia, who was cognitively intact and required assistance with daily activities, was not included—nor was their family—in the IDT care conference following a fall. Staff interviews and facility policy confirmed that the resident or family should have participated in the care planning process, but only staff attended the meeting.
A family member requested a resident's medical records, but the facility did not provide access within the required two-day timeframe as outlined in its policy. The resident had diabetes and hypoglycemia, with intact cognition and some assistance needs. The DON confirmed the delay in fulfilling the records request.
A resident with diabetes and hypoglycemia did not have their blood glucose rechecked after insulin administration, as required by their care plan. Nursing staff administered insulin on several occasions but did not perform the follow-up blood sugar checks specified in the care plan. This failure was confirmed by both the RN and DON, and was not in accordance with facility policy for comprehensive care planning.
A cook prepared pumpkin pie for a puree diet without following the required recipe, adding milk and resulting in a mixture that was too loose. The Dietary Manager and DON confirmed that recipes must be followed to ensure correct consistency, especially for residents on puree diets, as improper preparation can compromise food quality and safety.
Staff failed to follow the standardized recipe for a puree diet when a cook added milk to a pumpkin pie mixture, resulting in a consistency that did not meet dietary requirements. The Dietary Manager and DON confirmed that the correct procedure was not followed, and facility policies require adherence to recipes for resident safety.
A resident's MDS assessment was not accurately documented, with the middle initial entered in the wrong field and the assessment being 120 days overdue. The resident, who had multiple chronic conditions and required assistance with daily activities, was affected by this documentation error, which was identified during a record review and confirmed by the MDS Nurse.
A resident with schizophrenia and dementia was admitted without a properly documented Level 1 PASRR, despite exhibiting behavioral symptoms and a history of mental illness. The PASRR screening was incorrectly marked as negative, and no Level II PASRR was conducted, which was acknowledged by the case manager. The DON confirmed that inaccurate PASRR screening would lead to an incorrect care plan.
Two residents experienced significant changes in condition—one passing out and another developing a toe infection—without appropriate documentation of the events or development of care plans. Nursing staff did not complete required COC documentation or initiate care plans, despite facility policies mandating these actions for acute changes. This resulted in a lack of guidance for staff and insufficient monitoring of the residents' conditions.
A resident with diabetes, heart failure, and chronic kidney disease did not receive timely referral and follow-up for ophthalmology services as ordered, despite documented need for cataract management and further evaluation. The resident waited a year for new glasses and used inadequate over-the-counter glasses. Staff interviews and record reviews revealed a breakdown in communication and follow-through, with the social service director unaware of the eye doctor’s recommendations until the survey. Facility policy required prompt arrangement of such services, but this was not followed.
A resident with diabetes, dementia, and depression did not receive a timely podiatry consult for a left big toe infection as ordered by a PA. Although an appointment was initially scheduled, it was missed due to the resident having COVID-19 and was not rescheduled, resulting in a lack of appropriate foot care.
A resident with chronic respiratory and heart failure was ordered to receive continuous oxygen at 8 LPM via re-breathable mask, but was instead observed receiving 3 LPM via nasal cannula. An LVN admitted to not checking the physician's order, resulting in the resident not receiving the prescribed oxygen therapy.
The facility did not perform or document required annual competency and performance evaluations for a CNA working the night shift over multiple years, as confirmed by record review and staff interviews. This failure was attributed to oversight due to the CNA's shift schedule, and was not in accordance with facility policy requiring annual assessments and documentation.
A resident with diabetes, dementia, and moderate cognitive impairment was prescribed and administered topical bacitracin for a toe infection without the required assessment using McGeers criteria. Interviews with the IP and DON confirmed that the facility's antibiotic stewardship policy, which mandates use of McGeers criteria to define infections before starting antibiotics, was not followed.
The facility failed to ensure the Infection Preventionist (IP) had the required specialized training and certification in infection prevention and control. The IP, responsible for staff training on infection control practices, could not provide her IP certificate. Interviews with the Director of Staff Development, Registered Nurse Supervisor, and Administrator highlighted the importance of certification to prevent infection spread, as mandated by federal regulations.
A resident with a history of chest pain and hypertension experienced a significant change in condition, including low oxygen saturation and chest pain. Despite these symptoms, the resident was not transferred to a hospital for eight hours due to inadequate monitoring and communication by the nursing staff. The delay resulted in the resident's condition worsening, leading to their death after unsuccessful resuscitation efforts at the hospital.
The facility failed to provide recommended restorative nursing care for three residents with limited ROM and/or mobility. One resident did not receive the prescribed left-hand splint and RNA services, another received RNA services inconsistently, and a third had no documentation of RNA services or joint mobility assessments. The facility lacked a system to track and assess residents' progress.
The facility failed to ensure that two cartridges of morphine tablets were properly stored in the cubex machine after delivery by the pharmacy. The morphine tablets were found in unlabeled red containers with plastic locks in the medication storage room, leading to potential drug diversion and theft. Interviews and record reviews confirmed that the facility's policies for controlled substance storage were not followed.
The facility failed to inform five residents about their right to develop an advance directive, despite their various medical conditions and the facility's policy requiring such information to be provided upon admission and periodically thereafter.
The facility failed to ensure that two residents with mental illnesses had proper PASARR assessments prior to admission. Both residents were admitted with incorrect PASARR Level I screenings that did not reflect their diagnoses of schizophrenia, resulting in a lack of necessary mental health support and services.
The facility failed to ensure that the consultant pharmacist's recommendations were communicated to the physician for four residents, resulting in the administration of unnecessary medications. The recommendations included dose adjustments, taking medication with food, reassessing the need for a medication, and clarifying the indication for use. These recommendations were not followed up, leading to potential adverse effects for the residents.
The facility failed to ensure that over-the-counter medications were not expired in a medication storage room and that a resident's medications were not left unattended on a bedside table by an LVN. The expired medications included multivitamins, Vitamin B12, nasal decongestants, Aspirin, and Vitamin D. The LVN signed off on the medications as administered without waiting for the resident to take them, contrary to the facility's policy.
The facility failed to ensure safe and sanitary food storage practices, as expired banana puree, egg puree, lettuce, and eggs were found in the kitchen. Staff interviews revealed that cooks were responsible for labeling and dating food, while all kitchen staff were responsible for removing expired items. The facility's policy indicated that food should be stored to minimize contamination and bacterial growth, and expiration dates should be checked to ensure they are within acceptable parameters.
The facility failed to assess the mental capacity of two residents before having them sign arbitration agreements. Both residents, who were documented as unable to make decisions, signed the agreements without the signature of an authorized agent or a witness. The Admission Coordinator and her assistant were unsure about the requirements, and the facility's policy on informing residents about their rights was not followed.
The facility failed to observe proper infection control practices by allowing dietary staff to store personal food items in the kitchen refrigerator and by not ensuring proper use of PPE when providing care for a resident on Enhanced Standard Precaution. These actions had the potential to result in cross-contamination and the spread of infection.
The facility failed to ensure that a resident and/or their responsible party were informed in advance of the risks and benefits of psychoactive medications. Despite the resident's moderately impaired cognitive skills and need for assistance with daily activities, informed consent was not obtained for the use of Ativan and ABHR cream. The consent was only obtained after the medications had already been administered, violating the resident's right to make an informed decision.
The facility failed to ensure that the call light was within reach for a resident with multiple medical conditions, leading to feelings of helplessness and incidents of falls. Despite care plan interventions and facility policies emphasizing the importance of call light accessibility, the call light was found placed out of reach, impacting the resident's dignity and ability to receive timely care.
The facility failed to accurately assess and code the MDS for a resident, leading to potential issues in care planning and service provision. The MDS did not reflect the resident's lower extremity impairments, including ankle contractures and footdrop, until after the deficiency was identified.
Failure to Maintain ROM and Apply Ordered Hand Splints
Penalty
Summary
The facility failed to provide appropriate ROM-related care and splinting services for two residents with hand contractures and functional decline. Resident 13 was admitted with dementia, osteoarthritis of the right hand, muscle weakness, and hypertension. A Joint Mobility Assessment on 1/16/2026 showed minimal loss and stiffness in the right hand digits 3 through 5, and OT discharge documentation indicated a hand roll was recommended to keep the right palm open. The resident’s care plan and RNA splinting program directed staff to apply a right hand roll, monitor tolerance, observe for pain, and notify rehab if function declined. During the survey, Resident 13 was observed without a hand roll in place, with the middle, ring, and little fingers held in a fist-like position. RNA documentation showed the resident refused the hand roll and complained of pain, and staff interviews confirmed that the RNA applied a towel-made hand roll on one occasion, noted pain and tension, but did not notify the licensed nurse. Other staff also used a rolled-up gauze hand roll because the resident could not tolerate the towel roll, but this change was not reported as a change in condition. The DOR later stated the resident’s JMA entry showing full ROM on the right hand was a mistake and did not reflect the resident’s actual status. The DOR and DON both stated the resident’s pain and inability to tolerate the appropriate hand roll should have been communicated to nursing and rehab, and the report states these failures resulted in pain and increased contracture of the right hand’s third through fifth digits. Resident 70 had diagnoses including spinal stenosis, paraplegia, intervertebral disc degeneration, and contractures of both knees and ankles, and had upper extremity impairment. OT records showed the resident previously needed supervision or touching assistance for eating, while later documentation showed dependence for eating. Physician orders required bilateral resting hand splints to be applied five times per week for two to four hours per day, and the care plan directed staff to notify rehab if function declined. During observation, Resident 70 was seen without splints on either hand while being fed by CNA staff, and later was again observed without splints with contracted fingers. The resident stated she had been able to use both hands and feed herself when she first came to the facility, but was getting worse and was supposed to have splints for both hands. Staff interviews confirmed the splints had not been applied regularly, nursing had not notified OT of the decline in eating function, and OT was not aware the resident had become dependent for eating. The report states these failures resulted in decline in bilateral hand function, increased dependence with eating, and worsening contractures.
Isolation Precautions and Pre-Meal Hand Hygiene Not Followed
Penalty
Summary
The facility failed to follow appropriate isolation precautions for a resident with active shingles who was also immunocompromised due to multiple myeloma. The resident’s record showed diagnoses including multiple myeloma, CVA, and hemiplegia, and the MDS indicated substantial to maximal assistance was needed with toileting, lower body dressing, and footwear. The MAR and SBAR documented suspected shingles with a rash on the left buttock and left inner thigh, and the resident was moved to a single room. During observation, contact precaution signage was posted outside the room and the PPE instructions listed gowns and surgical masks. A CNA stated he was not aware the resident required airborne precautions and provided care using a gown, gloves, and surgical mask rather than an N95 respirator. The CNA also stated the shingles were not always covered during care. The IPN and NP both stated the resident was immunocompromised and that the lesions were not covered. The facility policy on transmission-based precautions stated that airborne precautions require an AIIR, and if one is not available, a resident suspected of having an airborne infectious disease shall be masked and transported to a facility with an AIIR. The facility also failed to offer and provide hand hygiene to two residents before mealtime. During dining observations, a CNA brought a lunch tray to one resident in her room and to another resident seated in a wheelchair outside his room, and hand hygiene was not offered or provided to either resident before they ate. One resident’s record showed legal blindness, thoracogenic scoliosis, history of falling, anxiety disorder, and hypertension, and the H&P indicated he made his own medical decisions. His MDS showed intact cognition and independence with eating, with severely impaired vision. The other resident’s record showed ascites, heart failure, cirrhosis of the liver, and hyperlipidemia, and the MDS indicated moderately impaired cognitive skills and set-up or clean-up assistance with eating. Interviews with staff confirmed that hand hygiene was expected before meals. A CNA stated she would practice hand hygiene before passing out trays and would provide residents with a washcloth with soap and water or hand sanitizer before mealtime. The IPN stated residents are encouraged to use wet towels or ABHR and could get sick if they are not offered hand hygiene before and after meals. The DON stated staff were expected to provide wipes, wet towels, and alcohol gel to residents before meals, and that residents could get sick if their hands were not sanitized or cleaned before meals. The facility policy on handwashing/hand hygiene stated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections.
Informed consent for psychotropic medications obtained from resident with impaired decision-making capacity
Penalty
Summary
The facility failed to accurately assess the mental capacity of one resident before obtaining informed consent for psychotropic medications. The resident was admitted with diagnoses including anxiety disorder, unspecified dementia, unspecified psychosis, depression, and diabetes mellitus. The H&P documented memory loss and fluctuating capacity to make medical decisions, and the MDS showed moderately impaired cognitive skills with dependence on staff for toileting hygiene, bathing, and transfers. The resident’s order summary included Buspirone for anxiety, Escitalopram for depression, and Quetiapine for schizophrenia-related behaviors. During interview and record review, RN 1 stated the resident signed the informed consents for Buspirone, Escitalopram, and Quetiapine, but should not have signed because the resident lacked the capacity to make medical decisions. RN 1 stated informed consent should have been provided to the family representative or resident so they could understand the risks, benefits, and possible side effects. The DON also stated legal documents such as informed consent should be signed by a family representative because the resident would not understand the risks or benefits of the psychotropic medication or recognize side effects. The facility policy required the physician to personally examine the resident and obtain informed written consent signed by the resident or resident representative before prescribing a psychotherapeutic drug.
Inaccurate Smoking Information and Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to provide residents with accurate information needed to make informed choices about smoking preferences and failed to follow its own smoking-related policies. During interviews, the Administrator stated the facility had been non-smoking since 2010 and that residents and families were told this before admission. However, the admission Coordinator reviewed the admission packet and found a Smoking Policy and Guidelines section stating the facility recognized residents' right to smoke and complied with local and state smoking regulations. The admission Coordinator stated he told residents the facility was non-smoking, even though the packet and policy indicated otherwise. The DON stated the facility was not providing accurate information about smoking and was not following its own policy, and that there was no documentation showing the facility was non-smoking. The facility's written policy also stated residents were informed of the smoking policy, including designated smoking areas, prior to and upon admission, and another policy stated that if the facility policy changed to prohibit smoking, residents currently allowed to smoke would be provided an area to smoke and residents admitted after the no-smoking policy was adopted would be informed on admission. The facility also failed to honor a resident's expressed preference for personal care. Resident 47 was admitted with legal blindness, thoracogenic scoliosis, a history of falling, anxiety disorder, and hypertension. Her H&P indicated she could make medical decisions, and her MDS showed intact cognition, severely impaired vision, and need for set-up or clean-up assistance with bathing, toileting hygiene, and transfers. Her care plan stated CNAs would provide care in accordance with her wishes, and a sign posted above her bed indicated she was to receive a bed bath every Sunday morning. During observation and interviews, Resident 47 stated CNA 4 did not provide the bed bath and instead brought her to the bathroom sink, gave her towels, and had her clean herself. Resident 47 stated she felt like she was going to fall and had pain when she stood up, and said she was disappointed and sad with her care. CNA 4 confirmed she did not provide the bed bath and said she was not familiar with the resident's level of assistance. CNA 5, the DSD, and the DON all stated staff should follow resident preferences and that CNA 4 should have provided the bed bath as indicated. The facility's policy stated each resident is allowed to choose options consistent with his or her interests, values, assessments, and plan of care.
Unnecessary Psychotropic Medication Use Without Documented Psychiatric Evaluation
Penalty
Summary
The facility failed to ensure one sampled resident was free of unnecessary psychotropic medications and chemical restraint concerns. Resident 6 was admitted with diagnoses including anxiety disorder, unspecified dementia, unspecified psychosis, depression, and diabetes mellitus. The resident’s records showed moderately impaired cognitive skills, dependence on staff for toileting hygiene, bathing, and transfers, and use of antipsychotic, antianxiety, and antidepressant medications. Resident 6’s medication orders included Buspirone for anxiety, Escitalopram for depression, and Quetiapine Fumarate 100 mg every 12 hours for schizophrenia manifested by recurrent outbursts of anger. The record review also showed no documented diagnosis of schizophrenia. The care plan for behavior problems and anger outbursts related to schizophrenia was initiated with a goal that the resident would have no evidence of behavior problems, and the interventions included providing medications as appropriate. During interviews, a CNA stated Resident 6 was always sleepy in the morning and had to be awakened for breakfast, and that the resident did not refuse care and had no behavioral problems. An RN stated Resident 6 did not have a psychiatric evaluation addressing behaviors and psychotropic medication use, and that the interdisciplinary team met without discussing the resident’s behaviors or psychotropic medication use. The DON stated there was no psychiatric evaluation or assessment for Resident 6 and that a psychiatric referral should have been done. Facility policies stated antipsychotic medications should only be used when indicated and necessary to treat specific conditions based on a comprehensive assessment, and that admission, readmission, new medications, or renewal of orders should prompt evaluation or reevaluation.
PASRR Level II Not Completed or Correctly Reflected for Two Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that PASRR Level II screening was completed and accurately reflected the medical conditions of two sampled residents, both of whom had documented mental health diagnoses and related treatment needs. One resident had diagnoses including schizophrenia, diabetes mellitus, and hypertension, was documented as lacking capacity to understand and make decisions, had severe cognitive impairment on the MDS, and required substantial to maximal assistance with ADLs. That resident was also receiving multiple antipsychotic medications, including aripiprazole, haloperidol, and ziprasidone, with care plans identifying schizophrenia-related behaviors such as angry outbursts, auditory hallucinations, and disorganized thinking. For that resident, the PASRR Level I screening notice identified a positive screen for serious mental illness and stated that a PASRR Level II mental health evaluation was required, with the facility to be contacted to arrange the evaluation. The record reviewed did not show that the Level II evaluation was completed. The facility also failed to ensure the second resident’s PASRR information was correctly followed up. That resident had diagnoses including anxiety and depression, fluctuating capacity to make medical decisions, moderate cognitive impairment, total dependence with ADLs, and documentation of a psychotic disorder on the MDS. The second resident’s medication regimen included buspirone for anxiety, escitalopram for depression, and quetiapine for schizophrenia with recurrent angry outbursts, and the care plan documented use of medication for schizophrenia and anti-anxiety medication for an anxiety disorder. However, the PASRR Notice of Attempted Evaluation stated the PASRR office was unable to complete a Level II evaluation because the resident had no serious mental illness and no functional limitations in the last six months. During interviews, the MDS Assistant and DON stated PASRR Level I and Level II information should have been reviewed to ensure correct follow-up and coding because both residents had mental illness, and that treatment and services could be affected if not coded correctly.
Failure to Arrange Audiology Referral for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure Resident 65 received proper assistive devices to maintain hearing abilities by not assisting with arranging an audiologist referral consult. Resident 65 was admitted and readmitted with diagnoses including ataxia, spinal stenosis, dementia, and major depressive disorder, and the H&P stated she was not able to make her own medical decisions. The MDS indicated she did not have a hearing aid or other hearing appliances, and she required substantial to maximal assistance with multiple activities of daily living. Record review showed an ENT note documented diminished hearing and recommended an audiogram, another ENT note documented decreased hearing with wax removed from both ears, and an audiogram showed hearing loss significant enough to qualify for hearing aids and that she was eligible for them under Medi-Cal. During interview, Resident 65 stated she was not able to hear, wanted hearing aids, and said no one had come to check her hearing. CNA 11 stated Resident 65 had a hearing problem and did not have hearing aids, and the SSD stated she was responsible for hearing-related referrals and should have made a referral to the audiologist because Resident 65 still had hearing loss after ear wax removal. The SSD also stated Resident 65's hearing loss affected communication with staff and her ability to communicate needs effectively.
Inconsistent skin assessments and wound documentation for a resident with pressure ulcers
Penalty
Summary
The facility failed to ensure Resident 7 received necessary care and services to prevent the development and progression of avoidable pressure injuries. Resident 7 had multiple relevant diagnoses, including encephalopathy, sepsis, protein calorie malnutrition, malignant neoplasm of the endometrium, and dysphagia. The resident’s records showed orders for treatment of bilateral buttocks MASD and later orders for coccyx and left buttocks pressure ulcers after transfer to a GACH for dehydration and failure to thrive. The resident’s care plan identified a goal to prevent pressure ulcers and directed weekly skin evaluation, monitoring during care, prompt notification of the MD for any skin breakdown, and wound consults as needed. The record review showed inconsistent and incomplete skin monitoring and wound documentation. GACH records dated 2/26/2026 and 3/2/2026 documented Stage III pressure ulcers to the coccyx and bilateral buttocks, and nursing progress notes on 3/2/2026 documented pressure injury on the bilateral buttocks and coccyx upon readmission. However, Shower Day Skin Inspections dated 3/7/2026, 3/11/2026, and 3/18/2026 documented the skin as intact/clear, despite the known pressure ulcers. The Treatment Nurse stated she did not see or document any skin assessments for Resident 7 in 2/2026, and the DON stated the facility was not completing weekly skin assessments for Resident 7. The facility’s records also showed progression of the resident’s wounds over time. The MDS dated 4/3/2026 identified three Stage III pressure ulcers and no other skin problems. The Weekly and Monthly Pressure Ulcer Management Report showed measurements for Stage III sacrococcyx and bilateral buttocks wounds on 4/7/2026, resolution of the left and right buttock wounds by 4/14/2026, continued Stage III sacrococcyx measurements on 4/21/2026, and an unstageable full thickness sacrococcyx wound measuring 5.0 cm by 7.0 cm on 4/28/2026. During interview, the DON stated Resident 7 had been admitted in 2017 with no pressure ulcers, developed a Stage IV sacral pressure ulcer in 2/2023, and that the pressure ulcer reopened in 6/2024 and resolved in 11/2024.
Missing Annual Employee Performance Evaluations
Penalty
Summary
The facility failed to ensure that personnel files contained documentation of completed performance evaluations for four of eight employees: CNA 1, CNA 3, TN 1, and RN 1. During concurrent interview and record review with the DSD, employee files were reviewed and it was confirmed that these four employees did not have documentation of their employee performance evaluations. The DSD stated that annual performance evaluations were important to assess whether employees can fulfill their roles and responsibilities for residents in their care and that residents can be harmed if employees' strengths and weaknesses were not assessed. During interview, the DON also stated that annual performance evaluations were important to assess employees' ability to deliver safe resident care in accordance with facility policies and procedures, and that residents were at risk for harm if employees' performance were not evaluated in a timely manner. The facility policy titled Performance Evaluation stated that the job performance of each employee shall be reviewed and evaluated at least annually.
Missing RN Co-Signatures on Controlled Substance Destruction Records
Penalty
Summary
The facility failed to ensure proper documentation of the destruction of controlled substances for six medications in the month of 4/2026 when the pharmacist's signature was not co-signed by a registered nurse. During a concurrent interview and record review on 5/11/2026 at 3:48 p.m. with the DON, the controlled substance binder was reviewed and six controlled substance medication documents were identified with a pharmacist signature but no RN co-signature. The medications listed without an RN signature were Tramadol HCL 50 mg tablet, Zolpidem Tartrate 10 mg tablet, Temazepam 15 mg capsule, a second Zolpidem Tartrate 10 mg tablet, Lorazepam 0.5 mg tablet, and Hydrocodone-acetaminophen 5-325 mg, all dated disposed on 4/15/2026. The DON stated she counts the medication with the pharmacist for destruction and then signs the controlled substance document, and acknowledged that both the DON and pharmacist must sign the documents but she forgot to sign them. The facility's policy titled 'Discarding and Destroying Medications,' dated February 2026, stated that Schedule II, III, and IV controlled substances are disposed of in accordance with state regulations and federal guidelines and that the medication disposition record contains signatures of witnesses.
Dietary Staff Incorrectly Tested Dishwasher Chlorine Level
Penalty
Summary
Food and nutrition service staff were not competent in testing the chlorine level of the dishwashing machine for one dietary aide. During a concurrent observation and interview, the dietary aide used a test strip during the final rinse of the dishwashing machine and read the result as 200 parts per million, stating that 200 ppm was the correct chlorine level to use. This was inconsistent with the facility's own policy and procedure, which identified the proper chlorine range for the dishwasher's final rinse as 50-100 ppm, and another policy stated the final rinse should be 50 ppm. During a later interview, the dietary aide stated the chlorine in the dishwashing machine should read 50-100 ppm, not 200 ppm, and acknowledged that the correct chlorine amount was important to properly sanitize dishes. The dietary supervisor stated she had provided in-service education to kitchen staff on testing the chlorine in the dishwashing machine and confirmed that staff competency was important because incorrect chlorine levels could affect dish sanitizing. The report identified this as a failure to ensure food service staff were competent to safely and effectively carry out food and nutrition service functions.
Failure to Document and Honor Cultural Food Preferences
Penalty
Summary
The facility failed to identify and honor the cultural food preferences of Resident 76, who was admitted with diagnoses including left-sided hemiplegia, muscle weakness, HTN, and hyperlipidemia. The resident’s MDS indicated he needed partial to moderate assistance with toileting, showering, dressing, and transferring, and his H&P stated he had the capacity to understand and make medical decisions. His order summary showed a NAS diet with regular texture and thin liquids. During interview, Resident 76 stated the food was horrible and that he did not receive food honoring his African American culture; he said he wanted Soul Food. A CNA stated she did not know what cultural foods the resident liked and did not know whether the facility honored cultural food preferences. The DON reviewed the resident’s nutritional screen and found no documentation of his cultural meal preferences, while stating the facility honors cultural preferences upon admission and that the preferences should have been documented in the chart and honored to provide the food wishes and nutritional needs of the resident. The facility’s policy required staff to identify resident food preferences upon admission and document them in the care plan.
Improper Quaternary Sanitizer Concentration in Kitchen
Penalty
Summary
The facility failed to ensure the quaternary sanitizer solution in the red bucket used to clean kitchen surfaces was at 200 parts per million. During an observation in the kitchen, a red bucket containing quaternary solution was seen in a kitchen sink with a dish towel submerged in the solution. During a concurrent observation and interview, a Dietary Aide tested the solution with a quaternary test strip and compared it to the color chart; the strip was observed to be teal, and the aide stated it should have been green. The aide stated the quaternary solution needs the correct amount to ensure kitchen surfaces are sanitized properly. During an interview, the Dietary Supervisor stated she was made aware the quaternary solution in the red bucket did not have the correct amount of quaternary solution. She stated that when the solution does not have the correct amount, there is a possibility residents could develop a food borne illness because kitchen surfaces would not be properly sanitized. The facility policy titled Quaternary Ammonium Log Policy stated the solution is used for sanitizing clean work surfaces in the kitchen, is to be tested at least every shift or when cloudy, and is to be replaced when the reading is below 200 ppm.
Incomplete Documentation of Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one sampled resident by not documenting restorative nursing services as ordered. Resident 11 had diagnoses including diabetes and depression, and the care plan identified a risk for decline in self-care and ADLs related to generalized muscle weakness. The care plan called for restorative nursing aide services five times per week as tolerated, including active assistive range of motion to both upper extremities and passive range of motion to both lower extremities. Resident 11’s physician orders dated 3/2/2026 directed restorative nursing aide services for PROM to both lower extremities and AAROM to both upper extremities five times per week, with documentation of the number of minutes provided. During observation and interview, Resident 11 was seated in a wheelchair with edema to both upper extremities and stated staff did not come every day to provide exercises and that she became stiff and weak when she did not receive them. On later observations, the resident was lying in bed and no restorative nursing services were observed being provided. Review of the restorative nursing documentation for 5/11/2026, 5/12/2026, and 5/13/2026 showed no evidence that restorative nursing services were provided on those dates, and the documentation did not include the required minutes. The RNA acknowledged the missing documentation and stated staff should document all restorative nursing services on the RNA form. The DON stated the resident had orders for PROM and AAROM, and that failure to document restorative services prevented verification that the resident received the ordered care and treatment. The facility policy required all services provided to the resident and progress toward care plan goals to be documented in the medical record.
Failure to Develop and Implement Comprehensive Fall Care Plan After Resident Fall
Penalty
Summary
A resident with a history of acute respiratory failure, muscle weakness, type 2 diabetes, and dependence on renal dialysis experienced a fall while attempting to transfer from bed to wheelchair after returning from dialysis. The resident, who had intact cognitive function and required moderate assistance for activities of daily living and transfers, reported that staff did not respond to her call for help because they were occupied elsewhere. The wheelchair had not been locked by staff, causing it to slide and resulting in the resident falling face down. The resident sustained a slight swelling on the right forehead, which later resolved. Upon review, there was no documentation of a fall risk assessment or a comprehensive, resident-centered care plan addressing falls in the resident's electronic health record following the incident. Staff interviews confirmed that neither a fall assessment nor appropriate care plan interventions were initiated after the fall. The facility's policy required individualized safety interventions and risk assessments, but these were not implemented or documented for the resident after the fall event.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents among residents. Specific actions or inactions leading to this deficiency include the presence of hazards and insufficient oversight in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's physician of abnormal laboratory results, specifically a high blood glucose level, low sodium, and low chloride, as indicated in lab results dated 5/22/2025. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM), was experiencing increased confusion and poor food intake, prompting the physician to order a series of lab tests. While the physician was notified of earlier abnormal results and ordered further testing, there was no documented evidence that the subsequent abnormal results were communicated to the physician. Interviews confirmed that the physician was not made aware of the abnormal lab findings from 5/22/2025, and the Director of Nursing acknowledged that the physician should have been notified. The facility's policy required prompt notification of lab results outside clinical reference ranges, but this was not followed in this instance, resulting in the physician being unaware of the resident's condition and a delay in care and treatment.
Failure to Develop and Implement Care Plan for Prednisone Use in Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of Prednisone for one resident with a history of diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD). Despite the known risk of Prednisone to increase blood sugar (b/s) levels and induce hyperglycemia, there was no care plan created to monitor for risk, side effects, or adverse reactions related to this medication. As a result, the resident's b/s levels were not monitored from 4/11/2025 through 5/16/2025, and no interventions were documented to ensure b/s remained within an acceptable range. This lack of monitoring and absence of a care plan led to the resident experiencing an altered level of consciousness, hypotension, high heart rate, and a b/s level too high to register on the facility's glucometer. The resident was subsequently transferred to a general acute care hospital, where she was diagnosed with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), requiring admission to the intensive care unit in critical condition. Facility policy required comprehensive, person-centered care plans with measurable objectives and monitoring for medication effects, but these were not followed in this case.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its established policies and procedures for reporting irregularities identified during the drug regimen review process. These actions resulted in noncompliance with regulations regarding pharmaceutical services and oversight.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Provide Required Two-Person Assistance During Incontinent Care Results in Resident Fall and Fatal Injuries
Penalty
Summary
A deficiency occurred when a resident, who was assessed as totally dependent on staff for toileting hygiene and for turning and repositioning in bed, was not provided the required two-person assistance during incontinent care. The resident's Minimum Data Set (MDS) indicated that he was unable to assist in turning himself and required two staff members for safe repositioning. Despite this, a Certified Nursing Assistant (CNA) attempted to turn and reposition the resident alone, without the help of another staff member, contrary to the resident's care plan and facility policy. During the incident, the CNA raised the resident's bed to her waist level and attempted to pull the resident towards her using a draw sheet. As she did so, the resident slid out of bed and landed face down on a floor mat. The CNA called for help, and a Licensed Vocational Nurse (LVN) responded, finding the resident unresponsive. The resident was subsequently transferred to a general acute care hospital, where he was diagnosed with multiple traumatic injuries to his neck and spine, including ligamentous injuries, spinal cord compression, hemorrhage, and suspected fractures. The resident's medical history included a left humerus fracture, congestive heart failure, generalized muscle weakness, and myasthenia gravis. Following the fall, the resident required intubation and mechanical ventilation, and after consultation with neurosurgery and the family, comfort care was initiated. The resident passed away as a result of sequelae from blunt traumatic injuries sustained in the fall. Interviews with facility staff confirmed that the CNA was not aware of the two-person assistance requirement, and the facility's policy required the appropriate number of staff for safe turning and repositioning.
Failure to Document Two-Person Assist for Dependent Resident in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to document necessary interventions to prevent falls and injuries for a resident with multiple medical conditions, including a left humerus fracture, congestive heart failure, generalized muscle weakness, and myasthenia gravis. The resident was assessed as having mild cognitive impairment and was dependent on nursing staff for toileting hygiene and for rolling to either side while lying in bed, requiring a two-person assist for these activities. Despite this, the care plans reviewed did not specify the resident's dependency or the need for two-person assistance for turning and repositioning. The care plans in place addressed impaired physical mobility and risk for falls, listing general interventions such as allowing adequate response time, assessing toileting needs, and encouraging use of the call light. However, they lacked documentation of the resident's specific need for two-person assistance during turning and repositioning. The MDS Nurse confirmed that this level of dependency was identified during assessment but was not included in the care plan, as she assumed that CNAs would understand the implications of the term "dependent" without explicit instructions.
Resident and Family Not Included in Post-Fall Care Planning
Penalty
Summary
The facility failed to involve a resident and/or their responsible party in the Interdisciplinary Team (IDT) conference following a fall incident. The resident, who had diagnoses including hypoglycemia and type 2 diabetes mellitus, was cognitively intact according to the Minimum Data Set (MDS) and required varying levels of assistance with daily activities. After the resident experienced a fall in front of the bathroom door, the IDT meeting was conducted with participation from nursing, rehabilitation, dietary, and activities staff, but without the involvement of the resident or their family. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed that the resident or family should have been included in the care conference. Review of facility policy also indicated that care plans are to be developed collaboratively with the resident and the IDT team. The omission of the resident and/or responsible party from the care planning process after the fall constituted a deficiency in person-centered care planning.
Delay in Providing Resident Medical Records to Family Member
Penalty
Summary
The facility failed to provide a family member with timely access to a resident's medical records as required by facility policy. The family member requested the records on 3/21/2025, but the records were not made available until 3/28/2025, exceeding the facility's policy of providing records within two calendar days of a valid request. The resident involved had diagnoses including hypoglycemia and type 2 diabetes mellitus, with intact cognition and requiring varying levels of assistance with daily activities. The Director of Nursing acknowledged that the records should have been provided sooner.
Failure to Recheck Blood Glucose After Insulin Administration
Penalty
Summary
The facility failed to follow the care plan for a resident with diabetes mellitus and hypoglycemia by not rechecking blood glucose levels after administering insulin, as required by the resident's care plan. The care plan specified that blood sugar should be rechecked 30 to 45 minutes after insulin administration to monitor for hypo- or hyperglycemia. Record review and interviews confirmed that on multiple occasions, insulin was administered to the resident for elevated blood sugar levels, but no subsequent blood glucose checks were performed as directed in the care plan. The resident had intact cognition and required assistance with daily activities, including eating, oral hygiene, toileting, and showering. The failure to recheck blood glucose was acknowledged by both the RN and the DON during interviews, and the facility's policy required comprehensive, person-centered care plans with measurable objectives to be implemented. The omission of post-insulin blood glucose monitoring was directly contrary to the established care plan and facility policy.
Failure to Follow Recipe Results in Improper Puree Food Consistency
Penalty
Summary
A deficiency occurred when a cook prepared pumpkin pie without following the prescribed recipe, specifically by adding milk to the mixture, resulting in a loose consistency. The cook acknowledged not following the recipe and recognized the importance of adhering to recipes, especially for residents on puree diets, as improper consistency could pose a risk. The Dietary Manager observed the incident, confirmed the mixture was too loose, and stated that cooks are responsible for reading and following recipes to ensure correct food preparation, particularly for puree diets. The Director of Nursing also confirmed the importance of following recipes, noting that improper preparation could compromise food quality and resident health. Review of the cook's job description indicated a requirement to prepare food according to planned menus, diet plans, recipes, and portions. Facility policy further stated that all special diets must be prepared and served as planned. The failure to follow the recipe had the potential to affect the quality and safety of meals, particularly for residents requiring puree diets.
Failure to Follow Puree Diet Recipe Results in Improper Food Consistency
Penalty
Summary
A deficiency occurred when staff failed to prepare a puree diet according to the facility's standardized recipes and menus. During an observation, a cook was seen adding milk directly to a pumpkin pie mixture in a food processor, resulting in a loose consistency. The cook confirmed that this action was not in accordance with the recipe, which did not call for milk to be added. The cook acknowledged the importance of following recipes, especially for residents on puree diets, as improper consistency could pose a risk to residents with swallowing difficulties. The Dietary Manager observed the incident and agreed that the mixture was too loose, stating that puree diets must have the correct consistency to prevent risks for residents. The Director of Nursing also emphasized the importance of following recipes, noting that improper preparation could compromise resident health. Review of the job description and facility policies confirmed that staff are required to prepare food according to planned menus, diet plans, and recipes. The facility's recipe for pumpkin pie specified the correct preparation method, which was not followed in this instance.
Inaccurate and Overdue MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately documented and completed in a timely manner. Specifically, the resident's middle initial was incorrectly entered in the section intended for the first name, and the middle initial field was left blank. This error was identified during a review of the resident's records and confirmed by the MDS Nurse, who acknowledged responsibility for providing accurate assessments. The MDS for this resident was also found to be 120 days overdue. The resident involved had a medical history including rheumatoid arthritis, diabetes, and a right artificial hip joint. The MDS indicated the resident was able to express ideas and understand others clearly, and required supervision or assistance with certain activities of daily living such as toileting, showering, and dressing. Facility policies reviewed stated that documentation must be complete and accurate, and that MDS coding should reflect an accurate assessment of each resident's functional capacity and health status.
Failure to Accurately Complete PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Level 1 Preadmission Screening and Resident Review (PASRR) for one resident was documented correctly. The resident was admitted with diagnoses including schizophrenia and dementia, and exhibited behavioral symptoms such as verbal outbursts, use of foul language, and physical aggression towards others. Despite these diagnoses and behaviors, the PASRR Level 1 screening was marked as negative, indicating no mental illness, intellectual disability, or related conditions, and the case was closed without a Level II PASRR being conducted. This incorrect documentation was confirmed by the Case Manager, who acknowledged the resident's diagnosis of schizophrenia and agreed that the PASRR screening was completed incorrectly. Further review of the resident's records showed ongoing behavioral issues, including an incident where the resident hit another resident and could not recall the reason for the action. The Director of Nursing stated that improper or inaccurate PASRR screening would result in an incorrect plan of care for the resident. The facility's policy requires proper PASRR screening for individuals with major mental illness, intellectual disability, or developmental disabilities prior to admission and throughout their stay, in compliance with federal regulations.
Failure to Document Change of Condition and Develop Care Plans for Acute Events
Penalty
Summary
The facility failed to ensure comprehensive care planning and appropriate documentation of change of condition (COC) for two residents. For one resident, who had diagnoses including acute respiratory failure, muscle weakness, and type 2 diabetes, there was an incident where the resident passed out while sitting on a shower chair and was assisted to the floor. Despite the event, there was no care plan or COC documentation completed regarding the incident. The charge nurse present at the time did not document the incident, assuming the Registered Nurse Supervisor (RNS) would handle the assessment, physician notification, and care plan initiation, but this was not done. The Director of Nursing (DON) confirmed that the RNS should have assessed and documented the COC and implemented a care plan to monitor the resident's status after the incident. For another resident with diagnoses including type 2 diabetes, dementia, and depression, there was a documented infection of the left big toe, for which bacitracin ointment was ordered and administered. However, there was no COC documentation or comprehensive care plan developed for the infection. The Infection Preventionist (IP) and DON both acknowledged that a care plan should have been initiated to guide staff in providing appropriate care and monitoring the resident's condition. The absence of a care plan meant that staff lacked guidance on interventions and monitoring for potential decline related to the infection. Review of facility policies confirmed that changes in condition require prompt assessment, documentation, physician notification, and care plan development. The policies also require that all services, changes in condition, and progress toward care plan goals be documented in the resident's medical record to facilitate communication among the interdisciplinary team. In both cases, the facility did not follow its own policies regarding COC documentation and care planning for acute changes in residents' conditions.
Failure to Arrange Timely Ophthalmology Referral and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received timely referral, appointment, and follow-up for ophthalmology services as ordered by the physician. The resident, who had a history of diabetes, heart failure, and chronic kidney disease, was documented as needing an ophthalmology consultation for diabetic eye examination and cataract management. Despite physician orders and an eye doctor consultation recommending follow-up for cataracts and referral for occult macular dystrophy, the necessary arrangements for these services were not made. Record reviews showed that the resident had been waiting for new glasses for a year and was using inadequate over-the-counter glasses, which did not sufficiently address her vision needs. Interviews with staff revealed that the process for arranging such appointments required communication between licensed nurses, case managers, and the social service director (SSD). However, the SSD was unaware of the eye doctor consultation and its recommendations until the time of the survey, indicating a breakdown in communication and follow-through on the referral process. Facility policy required that social services or their designee assist with appointments, referrals, and transportation for ancillary services, and that orders for such services be relayed promptly. Despite these policies, the resident's referral and follow-up for vision care were not completed, and staff acknowledged that failure to arrange these services could result in worsening vision for the resident.
Failure to Provide Timely Podiatry Care for Foot Infection
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, dementia, and depression was not seen by a podiatrist for a left big toe infection as ordered. The resident was admitted with multiple diagnoses that increase the risk of complications from foot infections. Medical documentation showed that a physician assistant ordered bacitracin ointment and a podiatry consult for toenail care due to a skin infection on the left big toe. The facility's policy required that ancillary services, including podiatry, be scheduled within 1-3 weeks of referral unless it was an emergency. Despite the order for a podiatry consult, the resident's appointment was not completed as scheduled. The social services staff reported that the resident was scheduled to see the podiatrist, but the appointment was missed due to the resident having COVID-19. The appointment was not rescheduled, and both the social services staff and the DON acknowledged that the resident should have been seen by podiatry as soon as possible after the initial referral. This lapse resulted in the resident not receiving timely podiatric care for the toe infection.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A resident with chronic respiratory failure and congestive heart failure was admitted to the facility and required continuous oxygen therapy as indicated in their Minimum Data Set assessment. The physician's order specified that the resident should receive oxygen at eight liters per minute via a re-breathable mask to maintain oxygen saturation at 92% or above. However, during an observation, the resident was found to be receiving only three liters per minute of oxygen via a nasal cannula, which did not match the physician's order. Interviews with the LVN responsible for the resident's care revealed that she had not checked the physician's order and was unaware of the correct oxygen administration method and flow rate. The Director of Nursing confirmed that all licensed staff are responsible for following physician orders and that failure to do so could result in inadequate care. Review of facility policy and the LVN job description further emphasized the requirement to check physician orders and administer treatments as prescribed.
Failure to Complete Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations and competency assessments for a Certified Nursing Assistant (CNA) who had been employed since 2013 and worked the night shift. Record review and interviews with the Director of Staff Development (DSD) revealed that there were no records of annual competency training for this CNA for the years 2022, 2023, and 2024. The DSD acknowledged missing the required evaluations, attributing the oversight to the CNA's night shift schedule. The CNA could not recall the last time an annual skills performance training was completed. Further interviews with the DSD and the Director of Nursing (DON) confirmed the importance of annual competency and skills evaluations for CNAs to ensure they are competent in their duties. Review of the facility's policy and procedure indicated that departmental training and competency assessments are to be repeated annually, with the DSD responsible for maintaining appropriate records. The lack of documented annual evaluations for the CNA constituted a failure to follow facility policy and regulatory requirements.
Failure to Use McGeers Criteria Before Initiating Topical Antibiotic
Penalty
Summary
The facility failed to ensure that McGeers criteria were used to assess a resident prior to the initiation of a topical antibiotic for a left big toe infection. The resident, who had diagnoses including type 2 diabetes mellitus, dementia, and depression, was admitted with moderate cognitive impairment and required substantial assistance with activities of daily living. Medical documentation showed that a physician assistant ordered bacitracin ointment to be applied to the resident's left big toe for a skin infection, and this order was carried out as documented in the Treatment Administration Record. Interviews with the Infection Preventionist and the Director of Nurses confirmed that McGeers criteria, which are required by facility policy to define infections and guide antibiotic use, were not utilized before starting the antibiotic treatment. The facility's policy on antibiotic stewardship specifies that nursing staff should assess residents using McGeers criteria prior to notifying the physician and that antibiotic orders should be reviewed for appropriateness. Despite these protocols, the required assessment was not performed in this case.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had specialized training in infection prevention and control, as required by federal regulations. During an interview, the Director of Staff Development (DSD) emphasized the necessity for the IP to be full-time and possess an IP certificate to ensure adequate training. The IP, who works full-time at the facility, confirmed her responsibility for training staff on infection control practices but was unable to provide her IP certificate. The IP acknowledged the importance of proper training to equip staff with the necessary knowledge and skills to prevent the spread of infections. Further interviews revealed that the Registered Nurse Supervisor (RNS) and the Administrator were also aware of the requirement for the IP to have the necessary training. The RNS stated that without proper training, both staff and residents are at risk of infection. The Administrator, who was new to the facility, admitted he was unaware of the IP's certification status but confirmed that certification is a regulatory requirement. A review of the job description for the IP position indicated that training in infection prevention and control is mandatory according to federal requirements.
Delayed Transfer to Hospital Leads to Resident's Death
Penalty
Summary
The facility failed to promptly transfer a resident to a general acute care hospital (GACH) after a significant change in condition was observed. The resident, who had a history of chest pain, hypertension, and anemia, experienced a sudden drop in oxygen saturation to 86% on room air, accompanied by chest and abdominal pain, and fluctuating blood pressure. Despite these alarming symptoms, the resident was not transferred to the hospital until eight hours later, during which time the resident's condition deteriorated further. The nursing staff, including Licensed Vocational Nurses (LVNs) and a Registered Nurse Supervisor (RNS), did not adequately monitor or assess the resident's vital signs, nor did they inform the resident's physician of the continuous oxygen desaturation and other symptoms. Text messages sent to a Nurse Practitioner (NP) failed to mention the resident's chest pain and shortness of breath, and there was a lack of timely communication and documentation regarding the resident's condition. The facility's policy to call 911 in such situations was not followed, leading to a delay in transferring the resident to a higher level of care. Interviews with staff revealed a lack of urgency and communication breakdowns, with some staff members unsure why the resident was not transferred sooner. The Director of Nursing (DON) eventually instructed the staff to call 911, but by then, the resident's condition had worsened significantly. Upon arrival at the hospital, the resident experienced severe complications, including bradycardia and respiratory failure, and ultimately passed away despite resuscitation efforts.
Failure to Provide Recommended Restorative Nursing Care
Penalty
Summary
The facility failed to ensure that three residents with limited range of motion (ROM) and/or limited mobility received restorative nursing care as recommended by physical and occupational therapists. For Resident 16, the facility did not apply the left-hand splint as recommended, and there was no documentation of the resident receiving the prescribed RNA services. Despite the resident's request for more therapy, the RNA services were inconsistently provided, and the left-hand splint was not found in the resident's room. The Director of Rehabilitation confirmed that the RNA services were not documented, and the nursing staff did not follow through with the recommended care plan. Resident 34 also did not receive the recommended RNA services, including the use of a right-hand splint and specific ROM exercises. The resident reported receiving RNA services only twice in three weeks, contrary to the therapist's recommendation of five times a week. The RNA services were not documented, and the facility's RNA Program Binder showed incomplete records and meetings. The Director of Nursing acknowledged that the RNA services were not provided as recommended, and there was no system to track the residents' progress. Resident 3, who had severe cognitive impairment and hemiplegia, did not receive the prescribed RNA services for bilateral upper and lower extremities. The resident's medical records lacked documentation of RNA services, and there was no evidence of joint mobility assessments. During an observation, the RNA was unable to perform the exercises due to the resident's pain, but there was no record of pain medication being administered. The Director of Nursing confirmed that the RNA services were not provided as recommended, and the facility did not have a system to assess the residents' progress.
Failure to Properly Store Morphine Tablets
Penalty
Summary
The facility failed to ensure that two cartridges of morphine tablets were properly stored in the cubex machine after delivery by the pharmacy. During a medication storage room observation, two red containers with plastic locks, not labeled, were found inside the medication storage room. Each container had a cartridge containing four morphine extended-release 15 mg tablets. The Registered Nurse Supervisor (RNS) confirmed that the morphine tablets were not properly stored, which could lead to drug diversion. The facility's Delivery Reconciliation Form indicated that the morphine tablets were received on two separate occasions, but they were not stored in the cubex machine as required. Interviews with the RNS and the Director of Nursing (DON) revealed that it was the responsibility of the licensed nurses to store the morphine in the cubex machine upon receiving it from the pharmacy. The facility's policy and procedure for medication ordering and receiving from the pharmacy, as well as controlled substance storage, were not followed. These policies required that controlled substances be signed for, inspected, reconciled, and stored in a permanently affixed double lock compartment. The failure to adhere to these procedures resulted in the potential for drug diversion and theft of the controlled substances.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to ensure that five of 14 sampled residents were informed of their right to develop an advance directive. This deficiency was identified through interviews and record reviews, revealing that the residents or their responsible parties were not provided with information regarding advance directives upon admission or during their stay. The residents involved had various medical conditions and required different levels of assistance from the staff, but the facility did not fulfill its obligation to inform them about their rights to formulate advance directives. Resident 35, who was admitted with multiple fractures and hypertension, did not have the mental capacity to make decisions. The Social Services Director (SSD) confirmed that no information about advance directives was provided to Resident 35's responsible party. Similarly, Resident 24, who had COPD and an abdominal aortic aneurysm, was capable of making medical decisions but was not offered information on advance directives as per the facility's policy. Resident 5, with diagnoses including rheumatoid arthritis, schizoaffective disorder, and dementia, was alert and oriented but was not provided with advance directive information. The SSD mistakenly believed that offering a Durable Power of Attorney (DPOA) was sufficient. Resident 49, who had metabolic encephalopathy and end-stage renal disease, was also not given information about advance directives. The SSD only documented whether the resident had an advance directive without offering further information. Resident 1 and Resident 3, both with significant medical conditions, were similarly not informed about their rights to formulate advance directives, despite the facility's policy requiring such information to be provided upon admission and periodically thereafter.
Failure to Conduct Proper PASARR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that two residents, Resident 24 and Resident 5, had a Preadmission Screening and Resident Review (PASARR) assessment done when diagnosed with a mental illness prior to admission. Resident 24, who was diagnosed with schizophrenia, was admitted and readmitted to the facility without a proper PASARR Level II screening. The PASARR Level I screening incorrectly indicated that Resident 24 did not have a diagnosis of schizophrenia. This error was not caught by the facility staff, and as a result, Resident 24 did not receive the necessary PASARR Level II assessment for appropriate mental health support and services. Similarly, Resident 5, who was diagnosed with schizoaffective disorder, was admitted to the facility without a proper PASARR Level II screening. The PASARR Level I screening incorrectly indicated that Resident 5 did not have a diagnosis of schizophrenia. The Assistant Director of Nursing (ADON) acknowledged that both residents had mental disorders and that the PASARR screenings from the hospital were incorrect. The facility's policy and procedure indicated that the Level I Screening should always reflect the individual's current condition, which was not adhered to in these cases.
Failure to Communicate Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations in the Medication Regimen Review (MRR) were communicated to the physician for four residents, resulting in the administration of unnecessary medications. Resident 2 was on Ativan at a dose exceeding the daily threshold for anxiolytics, and the pharmacist recommended reducing the dose. However, this recommendation was not communicated to the physician, and the resident continued to receive the higher dose despite minimal episodes of anxiety. Similarly, Resident 56 was prescribed Metformin, and the pharmacist recommended taking it with food, but this recommendation was not followed up with the physician, and the resident continued to take the medication without the advised precaution. Resident 24 was prescribed metoclopramide, and the pharmacist recommended assessing the ongoing need for the medication due to the risk of tardive dyskinesia with long-term use. This recommendation was not communicated to the physician, and the resident continued to receive the medication without reassessment. Resident 1 was prescribed tamsulosin, and the pharmacist recommended clarifying the indication for its use, as it is typically used for stone expulsion in females. This recommendation was also not communicated to the physician, and the resident continued to receive the medication without clarification. Interviews with the Director of Nursing (DON) and Registered Nurse Supervisor (RNS) revealed that the facility did not have a consistent process for following up on the pharmacist's recommendations. The DON admitted that the MRR forms for February and March 2024 were blank, indicating that the recommendations were not followed up. The Pharmacist Consultant confirmed that he did not receive feedback from the facility regarding the implementation of his recommendations. The facility's policy and procedure on pharmacy services emphasized the importance of addressing unnecessary medications, but this was not adhered to in these cases.
Expired Medications and Improper Medication Administration
Penalty
Summary
The facility failed to ensure that seven over-the-counter medications were not expired in one of the two sampled medication storage rooms. During an observation and interview, it was found that multiple bottles of multivitamins, Vitamin B12, nasal decongestants, Aspirin, and Vitamin D were expired and stored in an open cabinet. The Registered Nurse (RNS 2) acknowledged that these medications should have been discarded and not left in the cabinet uncovered, as they could mistakenly be used to administer to residents. The interim Director of Nursing (DON) confirmed that expired medications are not effective and could affect residents' health. Additionally, the facility failed to ensure that a resident's medications were not left on the bedside table by an LVN. Resident 22, who had diagnoses including paraplegia, dementia, and heart failure, was observed with a medicine cup filled with medications on her bedside table. The LVN admitted to signing the medications as administered without waiting for the resident to take them, contrary to the facility's policy. Both the LVN and the DON acknowledged that medications should not be left unattended and should be administered in the presence of a licensed nurse to ensure they are taken by the resident.
Failure to Ensure Safe and Sanitary Food Storage Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen. During an observation, it was found that banana puree, egg puree, lettuce, and eggs with use-by dates that had already passed were still present in the kitchen. An interview with a dietary aide revealed that cooks were responsible for labeling and dating food, while all kitchen staff were responsible for removing expired items. The facility's policy and procedure on food safety indicated that food should be stored to minimize contamination and bacterial growth, and expiration dates should be checked to ensure they are within acceptable parameters.
Failure to Assess Mental Capacity Before Signing Arbitration Agreements
Penalty
Summary
The facility failed to assess the mental capacity of two residents, Resident 60 and Resident 45, before having them sign arbitration agreements. Resident 60, who had diagnoses including traumatic brain injury and cerebral infarction, was documented as unable to make his own medical decisions. Despite this, Resident 60 signed an arbitration agreement without the signature of an authorized agent or a witness. Resident 60's family member was unaware of the arbitration agreement and believed that Resident 60 could not understand its content. Similarly, Resident 45, who had diagnoses including Parkinson's disease and metabolic encephalopathy, was also documented as lacking the mental capacity to make decisions. Resident 45 signed an arbitration agreement without the signature of an authorized agent or a witness. The Admission Coordinator and her assistant, who were still in training, were unsure about the requirements for the arbitration agreement and did not ensure that the residents understood the agreement. Interviews with the Director of Nursing and the Administrator revealed that the facility's policy required that residents or their designated representatives be fully informed about the arbitration agreement and their right to refuse it. However, this policy was not followed, leading to the deficiency. The facility's policy also stated that the arbitration agreement should not be a condition for admission or continued care, and residents had the right to rescind the agreement within 30 days.
Infection Control Deficiencies in Dietary and PPE Practices
Penalty
Summary
The facility failed to observe proper infection control practices and procedures in two key areas. Firstly, dietary staff stored personal food items in the kitchen refrigerator, which had the potential to result in cross-contamination of resident food. During an observation, a dietary aide was found to have a personal cup with an undated and unlabeled thick brown substance in the refrigerator. Both the dietary aide and the registered dietician confirmed that staff were not supposed to keep personal food items in the refrigerator due to infection control policies. The facility's policy on kitchen sanitation and cleaning schedules emphasized maintaining a clean, sanitary, and safe kitchen environment. Secondly, the facility failed to ensure proper use of personal protective equipment (PPE) when providing care for a resident. An LVN was observed wearing an isolation gown improperly while performing a fingerstick to check the resident's blood sugar. The gown was untied at the front and back, covering only half of the body and touching the floor. The resident was on Enhanced Standard Precaution due to dialysis access, and the improper use of the gown had the potential to spread infection. Both the Director of Nursing and the Infection Preventionist Nurse confirmed that the gown should be tied at the back and front to completely cover the body, as per the facility's policy on donning PPE.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that Resident 56 and/or their responsible party were informed in advance of the risks and benefits of psychoactive medications. Resident 56, who was admitted with diagnoses including unspecified dementia, depression, diabetes, and anxiety disorder, had moderately impaired cognitive skills and required partial or moderate assistance with daily activities. Despite this, the facility did not obtain informed consent for the use of Ativan and ABHR cream, both of which contain psychoactive components. The Ativan was ordered to be administered every 12 hours for anxiety, and the ABHR cream was to be used every four hours as needed for agitation or restlessness when the resident refused Ativan. The lack of informed consent was confirmed during interviews and record reviews with the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the consent was obtained only after the medications had already been administered. The Pharmacist Consultant also confirmed that these medications could affect the resident's behavior and should have required informed consent before administration. The facility's policy and procedure on 'Psychotropic Medication Management' dated 2/2017 indicated that informed consent for psychoactive medicines must be verified before use. However, this policy was not followed in the case of Resident 56. The Director of Nursing noted a discrepancy in the consent form, which was signed by a licensed nurse instead of a physician, and confirmed that the consent was obtained after the medications had already been administered. This failure to obtain informed consent before administering psychoactive medications violated the resident's right to make an informed decision regarding their treatment.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 60, who was admitted with diagnoses including traumatic brain injury, cerebral infarction, muscle weakness, history of falling, and acute respiratory distress syndrome. Resident 60 required maximal assistance for various activities and was unable to make his own medical decisions. Despite the care plan intervention indicating that the call light should be kept within reach, an observation revealed that the call light was placed on top of a nightstand behind a radio, making it inaccessible to the resident. Interviews with staff confirmed that the call light should always be within reach to ensure timely assistance and maintain the resident's dignity and self-worth. Resident 60 expressed feelings of helplessness and sadness due to the inability to reach the call light, which led to incidents of falls and attempts to get up unassisted to use the bathroom. The facility's policies on residents' rights, dignity, and call light accessibility were reviewed, all of which emphasized the importance of keeping the call light within reach to accommodate residents' needs and ensure timely responses. Despite these policies, the facility failed to adhere to them, resulting in a deficiency that impacted Resident 60's self-determination, dignity, and ability to receive necessary care promptly.
Inaccurate MDS Coding for Resident with Lower Extremity Impairments
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for one resident, leading to potential issues in care planning and service provision. Specifically, the MDS for Resident 24 was not correctly coded to reflect the resident's lower extremity impairments, including ankle contractures and footdrop. This discrepancy was identified during a review of the resident's records, which showed that the MDS indicated no impairment to the lower extremities on multiple dates, despite the resident's documented conditions. Interviews with the MDS nurse revealed that the MDS had been updated to reflect the resident's current condition only after the deficiency was identified. The facility's policy and procedure for MDS Standard of Practice, which mandates accurate coding and delivery of services, was not followed in this case. The failure to accurately assess and code the MDS had the potential to result in delayed or missed identification of joint range of motion changes, leading to inadequate care planning and provision of services for Resident 24.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 6,535 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bixby Towers Post-acute Rehab | 0.4 mi | ★★★★★ | 6 | 1 |
| Pacific Villa, Inc | 0.9 mi | ★★★★★ | 35 | 0 |
| Long Beach Healthcare Center | 1 mi | ★★★★★ | 8 | 0 |
| Pacific Care Nursing Center | 1.1 mi | ★★★★★ | 6 | 0 |
| North Long Beach Post Acute | 1.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.