Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Cerritos Vista Healthcare Center during CMS and state inspections, most recent first.
Inaccurate MDS Coding of Dental Findings: A resident with dementia, dysphagia, GERD, and a G-tube had an MDS that coded no broken teeth or abnormal gum tissue, even though the chart documented a broken incisor and moderate gingival inflammation. The MDSC confirmed the dental findings were present in the record and stated the MDS was coded inaccurately; the DON stated MDS assessments must be accurate to support appropriate interventions and ancillary services.
A resident with dysphagia, GERD, and a G-tube received EC ASA via G-tube once daily even though the order should have been for a chewable tablet rather than an EC formulation. Record review showed the medication was administered in the wrong form for the resident’s route, and the DON confirmed EC ASA must be given orally and not crushed for G-tube administration.
A resident with severe cognitive impairment, type 2 DM, and dry gangrene of a left index finger had physician orders for orthopedic and vascular specialist consultations, but the facility failed to obtain timely authorizations and appointments. Nursing identified that the initial orthopedic surgeon would not accept the resident’s insurance and notified the CM and SSD. The CM submitted an authorization request to the secondary insurer, received notice that Medicare was primary, and did not follow up, believing Medicare authorization was not the facility’s responsibility. The SSD was unaware of the referral and did not coordinate or track the needed consultations, and RN attempts to locate an accepting specialist were not documented. As a result of missed communication and lack of coordination among nursing, CM, and SSD, the ordered specialist referrals were delayed despite facility policies and job descriptions assigning social services responsibility for arranging medically related social services and outside referrals.
Improper Garbage and Refuse Disposal: Trash, including plastic, gloves, and paper, was observed in the bottom of the dumpster, and an uncovered trash can was found near a residents' refrigerator in Hall 1. The DS stated the trash should be cleaned up and covered to prevent cross-contamination and pest attraction, and facility policy required waste to be disposed of daily, trash bins to be covered at all times, and outside garbage bins to remain closed with the surrounding area kept clean.
Dignity and Meal Presentation: A resident was observed being served chili in a paper bowl, and dietary staff were also observed using paper plates for lunch items such as fruit salad and sandwich sides. During a test tray observation, the DS and RD stated the chili should have been served in a bowl, and the RD noted that disposable ware affected the meal’s appearance and home-like presentation. Facility policy required residents to be treated with dignity and respect and food tray setup to be neat.
Incomplete Advance Directive and POLST Documentation The facility failed to properly complete AD documentation for three residents. One resident had aphasia, cardiac arrhythmia, and severely impaired cognition, yet the AHDA was left blank except for the physician signature. Another cognitively intact resident had an incomplete AHDA that did not show whether an AD had been executed. A third resident with dementia had a POLST showing DNR, but the AD section was blank, written AD information was not provided to the RP, and the POLST was not updated after the code status changed.
Confidential resident meal tickets were observed being thrown into a trash can by a Dietary Aide instead of being shredded. The DS stated the tickets contained resident names, diets, room numbers, food preferences, and chart ID numbers, and that they should have been placed in the corodata for shredding to protect resident privacy and confidentiality.
Incorrect PASARR screenings were completed for three residents because an RN did not review the MDS and care plans when completing the assessments. One resident had schizoaffective disorder/schizophrenia, and two residents had depression, with one also having anxiety disorder, but the PASARRs did not identify serious mental illness or a Level II referral.
Failure to follow ordered treatments and hospice request: A resident with diabetes did not receive ordered lispro for an elevated blood sugar, a resident with HTN and ESRD did not receive PRN clonidine for elevated BP, and another resident with diabetes received insulin when it was not indicated by the MAR parameters. The facility also did not follow up on a family request for hospice for a resident with advanced cognitive impairment, despite the POA updating the POLST to DNR and staff acknowledging the request had not been addressed.
Failure to Complete ROM Screens and Follow AFO Order: The facility did not ensure proper ROM monitoring and therapy documentation for three residents. One resident with severe cognitive impairment, contractures, and ROM loss did not receive an annual lower-extremity joint mobility screen and did not have bilateral AFOs applied as ordered during RNA treatment. A second resident with aphasia and hemiplegia had an OT eval that lacked objective ROM measurements for the impaired wrist and hand and did not have a readmission OT joint mobility screen. A third resident with encephalopathy, hemiplegia, and contractures did not have a readmission upper-extremity joint mobility screen.
Enteral feeding and hydration bag management was not properly maintained for two residents with gastrostomy and dysphagia. One resident’s hydration bag was observed without a date/time label and the tube feeding had been running longer than ordered, which an LVN confirmed during interview. For another resident, the tube feeding formula was not labeled with the date and time it was hung or administered.
Failure to Provide Medically Related Social Services: The facility did not properly address decision-making and financial support needs for two residents. One resident with dementia, aphasia, CVA, and schizoaffective disorder was documented as lacking capacity, yet consent for treatment and psychotropic medication was obtained through a family member without clear authorized representative status, and no guardianship referral was initiated. Another resident with dementia, respiratory failure, and schizoaffective disorder reported not receiving Social Security checks, while the BOM and PG reported payment delays tied to address and personal information discrepancies, and the SSD was not aware of the issue.
Kitchen staff were not routinely trained or evaluated for key food service competencies. The DS could not verbalize IDDSI Level 4 testing for puree foods, and a puree item was observed with lumps during a test tray. Cooks were observed thawing food in the sink under running water, but could not explain safe thawing practices, and records showed no in-service training on thawing. A DA/Dishwasher also mixed QUAT sanitizer using an incorrect water-to-sanitizer ratio, and competency records did not include proper QUAT mixing.
Food was served at improper temperatures and with poor presentation during meal service. A dietary supervisor observed chili, cornbread, dessert, and salad items on regular and puree trays at temperatures below expected serving levels, and noted the chili was served on paperware that did not hold heat. A watery, soggy tossed salad was also observed, and the DS stated it should not have been watery and that the food temperatures and salad quality could reduce intake.
Puree Diet Foods Not Prepared to IDDSI Level 4 Texture: A facility failed to prepare puree foods in the proper consistency for residents on an IDDSI Level 4 diet. During a test tray observation, pureed chili was too sticky and left residue on a spoon tilt test, pureed tossed salad was too watery, and pureed Jello had lumps. The RD and DS stated puree foods should be smooth, hold shape, and pass IDDSI testing requirements.
Unsafe Food Storage, Thawing, and Sanitizer Preparation: Surveyors found rust, dirt, dust, food debris, spills, wet pans, dented cans stored with intact cans, and thawing practices that did not follow required time/temperature monitoring. Staff were thawing fish under running water at 77 F, and a Dietary Aide mixed QUAT sanitizer at an improper dilution, with the DS stating it would not reach the required concentration.
Infection Control Failures With PPE, Disinfection, Equipment Handling, and Hand Hygiene: A resident on EBP had a family member at the bedside without PPE, despite staff stating visitors should be educated and wear mask, gown, and gloves for high-contact care. Another resident’s padded siderails wrapped in porous foam were cleaned with a sanitizer intended for hard, nonporous surfaces. A third resident’s yankauer was observed on the floor instead of being kept bagged and dated, and a CNA was also observed moving between resident rooms without performing hand hygiene.
Failure to Obtain Valid Informed Consent for Psychotropic Medications: The facility did not obtain valid informed consent before starting Abilify for one resident whose H&P said she lacked decision-making capacity, and the consent was signed by her daughter even though she was not identified as the RP. The facility also did not obtain a new consent when another resident’s Cymbalta dose was increased, despite the resident having capacity and the facility policy requiring renewed consent for psychotherapeutic drug dose increases.
Failure to Monitor Adverse Effects of Cymbalta: A resident with diabetic neuropathy was prescribed Cymbalta 90 mg daily for neuropathic pain, but the MAR showed no monitoring for adverse effects over an extended period. The DON confirmed the lapse and stated that even when used for nerve pain, the antidepressant required monitoring for efficacy and adverse consequences per facility policy.
Failure to Assess and Report Open Skin Breakdown: A resident with severe cognitive impairment and dependence for ADLs had multiple open areas of skin breakdown on the upper arm. The TXN noticed the wounds but did not complete an assessment, measure them, or notify the MD, stating she thought notification was unnecessary because there was no active bleeding. The DON stated any identified open wound must be assessed and reported immediately as a change in condition.
Inaccurate MDS Coding for Suctioning Services: A resident with a G-tube, COPD, and HTN had a suction machine with canister and yankauer at the bedside, but the MDS did not indicate suctioning as scheduled or PRN. The MDS RN and DON stated the MDS should have reflected the suctioning service being provided and that the MDS is used to guide the resident’s care plan and staff care delivery.
Missing language barrier care plans and failure to follow care plans. Two residents who spoke Spanish did not have communication barrier care plans, and one resident’s communication board was missing. In addition, staff did not follow a diabetes care plan when lispro was not given for an elevated BG, and staff did not follow a BP care plan when PRN clonidine was not given for elevated BP readings.
A resident with ESRD and dialysis dependence had an AV shunt placed in the left upper arm, but the care plan was not revised to include no BP on that arm. The care plan listed no BP/IV/IM blood draw on the right arm and later noted the left upper arm s/p AV shunt placement, while the RNS and DON stated the plan should have included the left arm restriction.
A resident who preferred Spanish and needed an interpreter did not have a communication board available. During observation, the ADON was unable to communicate with the resident because she did not speak Spanish, and the resident was trying to ask for help while sitting in a wheelchair. The ADON later confirmed the resident speaks Spanish, and the facility policy stated communication needs should be identified and addressed.
Failure to identify and address a resident’s PTSD-related trauma triggers: A resident with PTSD, aphagia, and CVA had no trauma triggers identified on the TCE, and the SSD stated she did not obtain enough information from the resident and should have contacted the psychiatrist and family member. The MDS RN confirmed there was no care plan for PTSD or trauma, and the DON stated staff should have assessed the resident’s PTSD and developed individualized care based on the findings.
A resident admitted with lymphoma, hydrocephalus, HTN, and seizures did not have the physician H&P completed within the required 72 hours. The H&P was incomplete and noted the physician did not see the resident, while the physician communication log showed repeated notifications to the attending physician and later the Medical Director because the resident still had not been seen.
A resident’s alprazolam 0.5 mg count did not match the Controlled Drug Record on a medication cart. An LVN said she had given the missing dose earlier that morning but failed to sign it out, even though the facility policy requires the nurse to record the time of administration and sign the record upon giving a controlled substance.
A resident with depression, anxiety, insomnia, and moderately impaired cognition was started on quetiapine 50 mg at bedtime for depression with hopelessness and agitation, but staff did not obtain informed consent before administering the psychotropic medication. During interview and record review, an RN confirmed that informed consent was not obtained prior to starting the drug, and the DON acknowledged that consent should be secured before administering psychotropic medications. Facility policy requires that residents or their representatives be fully informed of benefits, risks, duration, side effects, and alternatives before initiating psychotherapeutic drugs, but this was not followed in this case.
A resident with depression, anxiety disorder, insomnia, moderately impaired cognition, and ADL assistance needs had physician orders for a psychological evaluation, follow-up treatment, and a psych consultation for depression and anxiety. Record review and interviews with an RN and the DON confirmed that the psych consultation was never completed despite the active orders and a facility policy requiring provision of needed behavioral health services.
A resident with depression, anxiety, insomnia, homelessness, and moderately impaired cognition had a physician’s order for a one-time Permethrin/nit remover kit for head lice. The order was placed, but the medication was not dispensed and administered until three days later, despite facility policies and the DON’s expectation that medication orders be implemented within 24 hours. An RN acknowledged that the treatment should have been carried out right away, and the delay resulted in the resident not being treated for head lice in a timely manner, with the report noting potential for uncomfortable itching and loss of sleep.
The facility failed to prevent a cockroach infestation, resulting in the closure of the kitchen and sightings of cockroaches in the rooms of two residents with COPD. Despite pest control treatments and recommendations for repairs, the infestation persisted, and documentation of completed repairs was lacking. The issue was confirmed by city inspection, resident reports, and staff interviews.
A resident with cognitive impairment and high care needs reported being struck and was observed with facial bruising and redness. Multiple staff members witnessed or were informed of the resident's allegations and visible injuries, but failed to take protective action or initiate an abuse investigation, leaving the resident unprotected and at risk for further harm.
A resident with cognitive impairment and significant care needs was found with facial bruising and made statements indicating possible abuse. Multiple staff observed or were informed of the injuries and allegations, but failed to promptly report the suspected abuse to the DON and authorities as required by policy, resulting in delayed investigation.
A resident with significant cognitive and physical impairments was found with multiple facial bruises and alleged being hurt by an RN. Although a CNA submitted a statement regarding the allegation, the DSD did not review it and the DON did not interview the CNA or obtain her statement, resulting in an incomplete abuse investigation and failure to follow facility policy.
A resident with Alzheimer's disease and severe cognitive impairment was transferred to a GACH for behavioral evaluation and, after being cleared for discharge, was not allowed to return to the facility despite available beds. Facility staff, following direction from the psychiatrist and Administrator, declined readmission, citing behavioral concerns, and did not provide proper discharge notice or allow the resident a chance to improve. The resident remained in the hospital for 21 days before being transferred to another SNF.
A resident who required maximal assistance did not receive timely care during an overnight shift, with staff delaying rounds for several hours and providing care in a darkened room. As a result, staff were unable to properly assess the resident, who was later found with significant facial bruising. Facility policy required rounds and adequate lighting, but these procedures were not followed.
A resident with severe cognitive impairment and Alzheimer's disease was found with a discoloration on the left jaw by a CNA, who reported it to the charge nurse. Despite facility policy requiring reporting of injuries of unknown origin, the DON and Administrator did not report the incident to authorities, assuming it was due to the resident's behavior. This resulted in a delayed investigation and potential loss of information.
A resident admitted with pneumonia and moderate cognitive impairment did not have physician or NP progress notes readily accessible in the medical record. The DON confirmed that these notes, which are required for documenting prognosis and care plans, were missing despite facility policy requiring their inclusion.
A deficiency was identified when staff and signage at the facility enforced a two-person visitor limit per resident, despite the facility's policy supporting unlimited visitation. Interviews with staff, a family member, and a resident confirmed that this restriction was communicated and sometimes inconsistently enforced. Leadership acknowledged the error and noted that alternative spaces could be used for larger groups, but the practice of limiting visitors was not in line with residents' rights.
A resident with multiple medical conditions and cognitive impairment was placed in an abdominal binder restraint without documented attempts at alternative interventions, a complete informed consent, required 30-minute monitoring, or a care plan addressing the restraint. Nursing staff confirmed that facility policy was not followed regarding restraint use, monitoring, and documentation.
A resident with COPD and dysphagia who was dependent in multiple activities of daily living was placed in an abdominal binder restraint, but this was not documented as a restraint on the MDS. One RN did not consider the binder a restraint and omitted it from the MDS, while other staff and facility policy confirmed it should have been documented. This resulted in inaccurate assessment documentation.
A resident with diabetes and on anticoagulant therapy experienced a bleeding toenail detachment that was not comprehensively assessed or monitored for several days. Despite physician notification and facility policy requiring ongoing documentation, there was no follow-up assessment or treatment documentation by nursing staff, resulting in a lack of monitoring of the resident's condition.
Two residents with significant medical conditions and existing pressure ulcers were not consistently turned and repositioned every two hours or as needed, as required by facility policy and national guidelines. Documentation and staff interviews confirmed that these care tasks were not performed on several shifts, and neither resident was on a formal turning and repositioning program despite being at high risk for pressure injuries.
A resident with multiple complex medical conditions, including diabetes and heart failure, vomited and did not receive a comprehensive assessment or documentation of vital signs such as blood pressure, heart rate, temperature, or blood glucose. Staff interviews and record review confirmed that the required post-incident assessments were not completed or documented, contrary to facility policy.
A resident with multiple complex medical conditions and severe cognitive impairment experienced an episode of vomiting and was administered Ondansetron by an RN, but the administration was not documented in the MAR as required by facility policy. Both the RN and DON acknowledged that all medication administration must be recorded.
A resident dependent on staff for all ADLs was left in a soiled gown with dry blood on her nostril for an extended period due to staff workload and lack of timely communication between CNA and LVN. Both CNA and LVN observed the hygiene issue but did not address it promptly, resulting in the resident remaining unclean and uncomfortable.
A resident with significant medical needs did not receive prescribed pain medication or a pain assessment prior to wound care, resulting in unrelieved pain during treatment. The responsible LVN failed to follow physician orders and facility policy, and the resident was observed to be in distress during care.
A resident with muscle weakness and a pressure ulcer reported a broken bed with a burning smell, but maintenance did not promptly assess or document the issue, and staff lacked clear procedures for urgent equipment failures. Another resident with morbid obesity and skin issues was not provided with properly fitting adult briefs, leading to discomfort, skin irritation, and missed therapy sessions, despite her requests and facility policies requiring accommodation of individual needs.
The facility failed to ensure accurate completion and documentation of resident assessments in the MDS for two residents. One resident's discharge status was incorrectly coded, and another resident's bowel and bladder continence status was inconsistently documented, with assessments not reflecting the resident's actual condition or care plan. These inaccuracies had the potential to negatively impact care planning and service delivery.
Two residents with documented serious mental illnesses, including depressive disorder, bipolar disorder, and schizophrenia, were not accurately identified on their PASRR Level 1 screenings, resulting in the screenings being marked negative and not triggering required Level 2 assessments. Nursing staff confirmed that the screenings should have indicated the presence of serious mental disorders based on the residents' diagnoses and medication histories.
Inaccurate MDS Coding of Dental Findings
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident. The resident was recently re-admitted with diagnoses including dementia, dysphagia, GERD, and a G-tube. On the MDS dated 5/8/2026, the resident was coded as having severely impaired cognitive skills for daily decision-making and being dependent on staff for ADLs, but Section L indicated the resident did not have abnormal mouth tissue, did not have broken natural teeth, and did not have inflamed or bleeding gums. Record review showed the resident had a broken incisor tooth documented on the COC/Interact Assessment Form and localized moderate gingival inflammation involving three incisor teeth documented in dental notes. During interview, the MDSC stated the resident had a broken tooth and moderate gum inflammation documented in the chart and that the MDS was inaccurately coded. The DON stated MDS assessments should be accurate to ensure appropriate interventions and needed ancillary services, and the facility policy required the person completing the MDS to attest to the accuracy of the assessment.
Improper Administration of Enteric Coated Aspirin via G-Tube
Penalty
Summary
Pharmaceutical services failed to ensure that one resident’s enteric coated aspirin was administered in the correct form. The resident was recently re-admitted with diagnoses including dysphagia, gastroesophageal reflux disease, and a G-tube, and the MDS indicated severely impaired cognitive skills for daily decision-making and dependence on staff for ADLs. During record review and interview, the resident’s order history showed enteric coated aspirin had been ordered from 7/26/2024 until 5/27/2026, and the MDSC stated the resident had been receiving enteric coated aspirin while in the facility even though the order should have been for a chewable tablet rather than the enteric coated formulation. The MAR showed the enteric coated aspirin was administered via G-tube once daily from 5/1/2026 to 5/27/2026. The MDSC stated the resident had a G-tube inserted in 5/2025 and that enteric coated aspirin should not be crushed and administered through the G-tube. The DON stated enteric coated aspirin must only be administered orally and that medication orders need to be administered in the correct form for resident safety to prevent medication error. The facility’s policy on crushing medications stated medications shall be crushed when appropriate and nursing staff will notify the physician if a drug the manufacturer states should not be crushed, such as enteric coated medications, is ordered to be crushed.
Failure to Coordinate Specialist Referrals and Insurance Authorization for Resident With Gangrene
Penalty
Summary
The deficiency involves the facility’s failure to carry out physician orders for orthopedic and vascular specialist consultations and to ensure appropriate follow-up for a resident with dry gangrene of the left index finger. The resident was admitted and later readmitted with diagnoses including an open wound of the left index finger, type 2 DM, and epilepsy, and was documented as severely cognitively impaired and unable to make medical decisions. The resident’s H&P indicated the need for outpatient follow-up with an orthopedic specialist to determine the need for amputation, and physician orders dated 3/13/2026 and 3/16/2026 directed the facility to obtain authorizations for orthopedic and vascular specialist consultations. Despite these orders, the consultations were not obtained in a timely manner. On observation, the treatment nurse was performing wound care on the resident’s left index finger, which appeared darkened with blackened areas at the tip, discoloration along the finger, and an enlarged fingertip. A social service note documented that the CM notified the POA that the initially identified orthopedic surgeon did not accept the resident’s secondary insurance and that another provider would be sought. An insurance prior authorization determination dated 3/18/2026 showed that the request for outpatient consultation services was returned, indicating that the resident’s primary insurance was Medicare and instructing the facility to contact the primary insurer for coverage. Interviews and record review showed that no one assumed responsibility for coordinating and following up on the referrals after the insurance issue was identified. The SSD stated she was unaware of the referral and believed the CM was handling the authorization, and there was no documentation that the SSD coordinated, scheduled, or followed up on the referrals. The CM stated she submitted an authorization request to the secondary insurance, received a response indicating Medicare was primary, believed Medicare authorization was not the facility’s responsibility, and did not follow up after the denial. RN 1 reported attempting to schedule the appointment, being told the surgeon did not accept the resident’s insurance, and then referring the issue to the CM and SSD, but did not document these attempts. The DON explained that nursing, CM, and SSD each had defined roles in obtaining referrals and authorizations and that missed communication and coordination in this process resulted in a delay of care, contrary to the facility’s job description and social services policy requiring social services staff to make referrals, obtain needed services, and ensure medically related social services are provided.
Improper Garbage and Refuse Disposal
Penalty
Summary
Garbage and refuse were not disposed of properly in two observed areas of the facility. During an observation of the dumpster area with the Dietary Supervisor, trash consisting of plastic, gloves, and paper was seen in the bottom of the dumpster, and the Dietary Supervisor stated that the plastic trash on the ground of the dumpster surroundings should be cleaned. The Dietary Supervisor also stated that trash attracts pests such as cockroaches and rodents, which could potentially go to the kitchen and make residents sick. During a separate observation of the residents' refrigerator area in Hall 1 with the Dietary Supervisor, a trash can was observed without a lid near the refrigerator. The Dietary Supervisor stated the trash was not covered and should not be near the residents' refrigerator, and that trash should be covered to prevent cross-contamination. Facility policy titled Waste Control and Disposal stated that all waste will be disposed of daily and as needed throughout the day, trash bins should be covered at all times, and outside garbage bins should be kept closed at all times with the surrounding area kept clean.
Dignity and Meal Presentation
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity and respect by not ensuring residents were served in China wares during lunch time. During an observation on 2/23/2026 at 12:06 p.m., [NAME] 2 was observed using paper bowls for chili. During another observation on 2/23/2026 at 12:20 p.m., dietary staff were observed using paper plates for fruit salad and sandwich sides for lunch. During a concurrent observation and interview on 2/23/2026 at 1:06 a.m. with a test tray of the regular diet meal, the chili was observed served on paperware. The Dietary Supervisor stated the chili should be in a bowl and that insulated bowls were available, but she was unsure why the cooks did not use them. The Registered Dietitian stated the presentation could improve by using a regular bowl instead of a disposable bowl, and noted that serving in bowls would better support a home-like appearance. The facility's Dignity policy stated residents shall be cared for in a manner that promotes well-being, satisfaction with life, self-worth, and self-esteem, and that residents are treated with dignity and respect at all times. The Food Preparation policy stated food is to be prepared to maximize flavor, appearance, and nutritional value, and that tray set up must be neat.
Incomplete Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to correctly formulate Advance Directives (AD) in the medical records for three sampled residents. For Resident 7, the admission record showed diagnoses including aphasia and cardiac arrhythmia, and the H&P noted fluctuating capacity to understand and make decisions. The MDS indicated severely impaired cognition and need for assistance with multiple activities of daily living. During interview and record review, the Social Services Director stated the Advance Healthcare Directive Acknowledgement (AHDA) form was left blank except for the physician’s signature, was not discussed or completed by the resident or representative, and was not compliant practice. The DON stated the AHDA should be completed on admission, and if an AD was executed, a copy should be obtained and maintained in the chart. For Resident 15, the admission record showed diagnoses including perforation of intestines, muscle weakness, chronic pain, and hypertension. The MDS indicated the resident was cognitively intact and able to make decisions. During interview and record review, Registered Nursing Supervisor 1 reviewed the AHDA form and stated it did not indicate whether the resident had executed an AD. The RNS stated the form was incomplete and should be completed because it expresses the resident’s wishes regarding end-of-life care and who may make decisions if the resident becomes unable to do so. For Resident 126, the admission record showed diagnoses including dementia and anxiety disorder, and the H&P indicated the resident did not have capacity to understand and make decisions. The MDS showed dependence for eating, hygiene, shower/bath, dressing, bed mobility, and transfer. During interview and record review, the POLST showed a DNR order, but Section D for AD was left blank and not completed. The RNS stated the POLST was not completed because information was missing and that, if not completed, the resident would be treated as full code and receive all life-sustaining measures during an emergency. The SSD stated there was no AD acknowledgement, she did not provide written materials regarding AD to the resident’s responsible party, and she did not complete and update the POLST after the code status changed from full code to DNR.
Confidential Resident Meal Tickets Discarded in Trash
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when meal tickets containing protected resident information were discarded in a trash can instead of being shredded. During observation in the dishwashing area, a Dietary Aide was seen throwing meal tickets into a grey trash can. During a concurrent observation and interview, the Dietary Supervisor observed the Dietary Aide throw the meal tickets in the trash and stated the trash would go to the dumpster. The Dietary Supervisor stated the meal tickets should have been separated and placed in the corodata to be shredded. The supervisor identified that the meal tickets contained residents' names, diets, room numbers, food preferences, and identification numbers from the chart. The supervisor stated the tickets needed to be shredded for privacy because someone could access residents' charts through the ID number, and that residents' identities could be stolen if the meal tickets were thrown in the trash. The facility policy titled Confidentiality of Information and Personal Privacy stated the facility would protect and safeguard resident confidentiality and personal privacy and limit access to resident personal and medical records to authorized staff and business associates.
Incorrect PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
PASARR screenings were completed incorrectly for three sampled residents because the nurse who performed the screenings did not review the residents’ MDS assessments and care plans. Resident 9 was admitted with diagnoses including diabetes, anemia, chronic kidney disease, and schizoaffective disorder; the MDS showed an active diagnosis of schizoaffective disorder and the care plan identified schizophrenia, but the PASARR dated 1/31/2026 did not indicate serious mental illness or a referral for a Level II PASARR. Resident 46 was admitted with end stage renal disease, dialysis, hypertension, and depression; the MDS and care plan identified depression, but the PASARR dated 1/31/2026 did not indicate serious mental illness or a Level II PASARR. Resident 56 was admitted with type 2 diabetes mellitus, seizures, depression, and anxiety disorder; the MDS showed active diagnoses of depression and anxiety disorder, but the PASARR dated 1/31/2026 did not indicate serious mental illness or a referral for a Level II PASARR. During interview, the RN supervisor stated she completed the PASARR screens for Residents 9, 46, and 56 and did not review the MDS and care plans when completing them, resulting in incorrect screenings. The MDS supervisor stated the screenings had discrepancies and that the nurse should review the MDS and care plan to ensure accurate assessment.
Failure to Follow Physician Orders and Hospice Request
Penalty
Summary
The facility failed to implement physician orders and resident care plans for two residents with chronic medical conditions. One resident with diabetes had an order for 6 units of lispro before meals and at bedtime when blood sugar was 200-249 mg/dL, and the MAR showed a blood sugar of 243 mg/dL on 2/16/2026 at 6:30 a.m. with no lispro given. Another resident with hypertension, hypertensive heart failure, end stage renal disease, and dialysis had an order for clonidine 0.2 mg every 6 hours as needed for systolic blood pressure greater than 160 mmHg, and the care plan included administering PRN clonidine for elevated blood pressure. The MAR showed blood pressures of 197/112 mmHg on 2/2/2026 and 168/88 mmHg on 2/21/2026, and clonidine was not given on either occasion. A third resident with diabetes had orders for Lantus 20 units twice daily, to be held if blood sugar was less than 120 mg/dL, and HumaLOG was not to be given before meals if blood sugar was 50-149 mg/dL. The MAR showed blood sugars of 110 mg/dL on 2/7/2026 with Lantus given and HumaLOG also given 30 minutes later, 114 mg/dL on 2/13/2026 with Lantus given, and 118 mg/dL on 2/23/2026 with Lantus given. During interview, the RNS stated the nurse did not follow the physician orders for the first two residents and stated the insulin given to the third resident when it was not indicated could further lower blood sugar and cause hypoglycemia. The facility also failed to follow up on a resident representative's request for hospice care. The resident had metabolic encephalopathy and Alzheimer's disease, was severely cognitively impaired, and was dependent for eating, oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. The resident's FM/POA requested hospice care and updated the POLST to reflect DNR status, but family members stated the facility did not follow up on the request despite multiple conversations. The SSD stated the request for hospice was expressed on 2/12/2026, that nursing staff were expected to notify the physician to obtain an order for hospice care, and that 12 days had passed with no documentation regarding hospice care in the medical record. The DON stated the facility failed to follow up on the request for hospice services.
Failure to Complete ROM Assessments and Follow AFO Order
Penalty
Summary
The facility failed to ensure appropriate care to maintain or improve ROM and mobility for three sampled residents. For Resident 9, the record showed diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and contractures of both elbows. The resident’s MDS indicated severe cognitive impairment, ROM limitations in both upper and lower extremities, and dependence for eating, dressing, hygiene, bathing, and chair-to-bed transfers. The care plan identified risk for decreased ROM and strength, and the order summary included RNA services for PROM, splints, and bilateral AFOs. During review, the resident’s joint mobility screens showed ROM loss in the upper and lower extremities, but there was no annual lower-extremity joint mobility screen completed in 6/2025. For Resident 9, the facility also did not follow the ordered use of bilateral AFOs during RNA treatment. The order summary dated 1/23/2026 directed RNA to apply both AFOs for three hours a day, five times a week or as tolerated. The report states the deficiency involved failing to put on the right and left AFOs during RNA treatment for no more than three hours as ordered by the physician. The Director of Rehabilitation and therapy staff stated joint mobility screens were to be completed on admission, annually, and with change in condition, and that the annual lower-extremity screen had not been completed. For Resident 6, the record showed diagnoses including aphasia, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side. The resident had moderate cognitive impairment, ROM impairment in one upper extremity, and dependence for dressing, hygiene, bathing, and chair-to-bed transfers. The OT evaluation dated 2/20/2026 identified impaired ROM in the left shoulder, elbow, wrist, and hand, but did not include objective ROM measurements for the left wrist or left hand. The resident also did not have a readmission OT joint mobility screen completed in 7/2025, even though the facility’s rehab staff stated joint mobility screens were to be completed on admission or readmission, annually, and with change in condition. For Resident 136, the record showed diagnoses including encephalopathy, hemiplegia, hemiparesis following cerebral infarction affecting the left non-dominant side, and contractures of the left elbow, left hand, and left knee. The resident had moderate cognitive impairment, ROM limitations in both upper and lower extremities, and required moderate to dependent assistance with ADLs and transfers. The care plan identified risk for decline in ROM and included restorative nursing PROM to both lower extremities. The resident had a readmission lower-extremity joint mobility screen in 7/2025 and annual upper- and lower-extremity screens in 12/2025, but there was no readmission upper-extremity joint mobility screen completed in 7/2025.
Enteral Feeding and Hydration Bag Management Deficiencies
Penalty
Summary
Safe and appropriate management of enteral tube feeding was not ensured for Resident 11, who had diagnoses including gastrostomy and dysphagia and was severely cognitively impaired and dependent for eating, oral hygiene, toileting hygiene, showering, and personal hygiene. The resident had orders for an open bag system with gastrostomy tube feeding every night shift and for the hydration bag to be changed every 24 hours. During observation, the hydration bag was connected without a label showing the date and time it was started, and the tube feeding bag was labeled with a date and time indicating it had been initiated the prior day at 2:30 a.m. During interview and record review, the LVN confirmed the tube feeding had remained running for more than 24 hours and confirmed the hydration bag had not been labeled. Safe and appropriate management of enteral tube feeding was also not ensured for Resident 129, who had diagnoses including gastrostomy and dysphagia and was severely cognitively impaired and dependent for oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. The record review showed an enteral feeding order, but the report states the facility failed to ensure Resident 129's tube feeding was labeled with the date and time the formula was hung or administered. These deficient practices were identified through observation, interview, and record review and were cited as having the potential to increase the risk of infection prevention and compromised resident health.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for two residents. For Resident 2, the record showed diagnoses including dementia, aphasia, cerebrovascular accident, and schizoaffective disorder. The History and Physical stated Resident 2 had no capacity to understand and make decisions. Despite this, the Consent for Medical Treatment was signed by Resident 2, and the Psychotherapeutic Drug Informed Consent for aripiprazole was verbally consented to by a family member identified as an emergency contact. The Social Service Director stated she was not aware of the situation and that there had been no discussion in the IDT meeting, and she stated public guardianship or conservatorship would have been initiated if staff had notified her that there was no responsible party. Resident 2’s record also showed a care plan for cognitive deficit and moderately impaired decision making related to dementia, with interventions to use yes/no questions and encourage choices of care. The Director of Nursing stated the staff and SSD should have identified the family member as the authorized representative before obtaining consent, and that having someone who was not an authorized representative sign for informed consent increased the risk that Resident 2 may not be able to exercise the right to opt out of treatment. The facility’s guardianship referral policy stated that if a resident does not have capacity and there is no responsible party, family member, or interested party with legal authority to make decisions, the Social Worker or Social Service Designee will make a referral to the Public Guardian. For Resident 8, the record showed diagnoses including dementia, respiratory failure, and schizoaffective disorder. The H&P stated Resident 8 was able to make her own medical decisions. Resident 8 stated she had not received her social security check since 11/2025 and was worried about bills not being paid on time. The Business Office Manager stated the facility had not received Social Security benefit money from the Public Guardian since 11/2025, and the Public Guardian reported discrepancies involving mailing address and other personal information that were delaying the checks. The SSD stated she was not aware of the issue, had not been informed about the missed payments, and would have helped Resident 8 out of Public Guardianship and taken her to the Social Security Office to correct the problem. The facility’s social services policies stated that staff are responsible for assisting residents with medically related social services, including financial needs and problems.
Kitchen Staff Lacked Competency in Puree Diet Testing, Food Thawing, and QUAT Mixing
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency in food and nutrition service functions. During a puree diet test tray observation with the Dietary Supervisor (DS) and Registered Dietitian (RD), the puree Jello was observed to have lumps. The DS stated puree foods should be an applesauce-like consistency and smooth to swallow, and said the consistency was determined by seeing and tasting the food. The DS could not identify any other test used to confirm proper texture and consistency, and stated she was the one providing in-services to staff with the RD. The facility’s diet manual stated IDDSI Level 4 pureed foods must be smooth, free of lumps, hold their shape, and pass IDDSI Level 4 testing requirements, including appearance, fork drip, and spoon tilt tests. The DS’s competency checklist did not specifically indicate competency in IDDSI testing methods. The facility also failed to ensure staff were trained and competent in safe thawing of food. Dietary staff were observed thawing chicken, tilapia, turkey, and fish in the kitchen sink under running water. One cook stated chicken had been thawed in the sink with running water after being moved from the refrigerator, and said she did not check the temperature during thawing or before cooking and had not attended in-services on thawing food. Another cook stated tilapia and turkey had been out for 45 minutes and were for that day’s use. The DS described thawing as placing food in the sink under room temperature running water, while the RD stated the safest method was under refrigeration and that thawing in the sink should be done with cold running water at 70 F or below for a maximum of 2 hours. During observation, the RD measured the running water used for thawing fish at 77 F and stated it should be below 70 F; the fish temperature was observed at 69 F. The facility’s thawing policy required food to be thawed under potable running water at 70 F or lower, and the record review showed no in-service training about the thawing process during the reviewed period. The facility further failed to ensure proper mixing of QUAT sanitizer. During observation, a Dietary Aide/Dishwasher stated the red bucket contained QUAT sanitizer for sanitizing the cart and said he mixed it using 5 liters of water to 75 milliliters of sanitizer. The DS stated the correct ratio was 4 quarts of water to 7.5 milliliters of sanitizer based on manufacturer guidance, and stated the ratio used by the aide would be diluted and would not achieve the required 200-400 ppm concentration. The facility’s red bucket policy required QUAT sanitizer to be prepared according to manufacturer instructions and maintained at 200-400 ppm. The aide’s competency checklist did not include how to mix QUAT sanitizer to water, and the record review showed no in-service training about mixing QUAT sanitizer during the reviewed period.
Food Served at Improper Temperature and Watery Salad
Penalty
Summary
Food and drink were not served in a palatable, attractive, and safe appetizing temperature during lunch service for residents on regular and therapeutic diets. During a test tray observation, the dietary supervisor took temperatures of the regular diet tray and found chili at 120 F, cornbread at 84 F, citrus chiffon delight at 60 F, and tossed green salad at 64 F. On the puree diet tray, the dietary supervisor found puree chili at 94 F, puree salad at 56 F, and puree citrus chiffon delight at 52 F. The facility’s cook spreadsheet for the winter menu showed that residents on these diets were to receive three bean chili, tossed green salad with salad dressing, cornbread with green chilis, citrus chiffon delight, and milk. During interview, the dietary supervisor and registered dietitian stated the chili was served on paperware and did not hold heat, and that the food temperatures were affected because the food was not hot. During a concurrent observation, the tossed green salad was observed to be drenched with liquid. The dietary supervisor stated the salad recipe called for mixing the tossed green salad with dressing during preparation, but the salad was watery and should not have been soggy. The facility’s food preparation policy stated food is to be prepared to maximize flavor, appearance, and nutritional value and served at the proper temperature, and the menu policy stated menus are to be prepared as written using standardized recipes.
Puree Diet Foods Not Prepared to IDDSI Level 4 Texture
Penalty
Summary
The facility failed to prepare puree foods in a form designed to meet individual needs for residents on an IDDSI Level 4 puree diet. During a test tray observation with the Dietary Supervisor and Registered Dietitian, pureed chili was observed to be too sticky and left a thick film during a spoon tilt test, pureed tossed salad was observed to be too watery, and pureed Jello had lumps in it. The Dietary Supervisor stated puree foods should be applesauce-like, smooth to swallow, and free of lumps, and the Registered Dietitian stated puree foods should have no clumps or grains and little to no residue on the spoon. The facility’s menu, diet manual, and standardized recipes identified that residents on the puree diet were to receive foods prepared to IDDSI Level 4 specifications and that finished puree items must pass IDDSI testing requirements, including spoon tilt and fork drip tests. The Registered Dietitian performed a spoon tilt test for the puree chili and stated there was a lot of puree chili sticking on the spoon, and stated the puree salad was a bit runny and should not look like it was lying flat on the plate. The Dietary Supervisor stated residents on puree diets could have aspirated and choked if the puree food was not on the right texture and consistency.
Unsafe Food Storage, Thawing, and Sanitizer Preparation
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During observations, surveyors found a walk-in refrigerator rack with amber discoloration that the Dietary Supervisor identified as rust, along with dirt, dust, and food debris on kitchen equipment and utensils. The walk-in refrigerator vent had dust buildup, the refrigerator wall had dressing spills, and the walk-in freezer wall had a black dirt spill coming from the ceiling with dirt, dust, and food particles on the racks. Corn starch was spilled into a lentil container, pans had burnt plastic debris and sticker residue, and two of three food warmers had food and dirt debris. Six dented cans were stored with non-dented cans, and pots and pans were stacked wet in the storage area. Surveyors also observed unsafe food handling practices during thawing. Dietary staff were thawing fish under running water measured at 77 F, while the fish was at 67 F, and there was no temperature or time monitoring during thawing. Staff described thawing food by moving it from the freezer to the refrigerator and then to the sink under running water, but one staff member stated she did not take temperatures during thawing or before cooking and had not attended in-services on thawing food. The Dietary Supervisor and Registered Dietitian stated the water used for thawing should be 70 F or below, and the report documented that the fish was not safe to cook because the water temperature was above 70 F. The report also identified improper sanitizer preparation. A Dietary Aide stated the QUAT sanitizer in the red bucket was mixed using 5 liters of water to 75 ml of sanitizer, while the Dietary Supervisor stated the manufacturer-based ratio was 4 quarts of water to 7.5 ml and that the reported mixture would be too diluted to reach the required concentration. The facility’s policies and Food Code references cited in the report required clean and sanitary food-contact surfaces, proper storage of canned goods, air-drying of utensils and pans before storage, safe thawing under running water at 70 F or lower, and QUAT sanitizer prepared at the proper concentration.
Infection Control Failures With PPE, Disinfection, Equipment Handling, and Hand Hygiene
Penalty
Summary
The facility failed to implement infection control measures for multiple residents and staff interactions. Resident 35 was admitted with sepsis, ESBL infection, and cellulitis of the left lower extremities, and had Enhanced Barrier Precautions ordered for colonized ESBL. The care plan directed staff to post EBP signage and provide gloves, gowns, and masks. During observation, the resident’s family member was at the bedside holding the resident’s hands and stroking the resident’s hair without wearing PPE such as gloves, mask, or gown. The family member stated he did not see EBP signage at the entrance and did not realize the signage was on the wall. The LVN stated she should have educated the family member about wearing PPE, that there was no signage outside the room, and that staff forgot to wear PPE. The IPN and DON stated that staff and visitors should wear mask, gown, and gloves for high-contact care under EBP, and that visitors should be educated and provided PPE. Resident 59 was admitted with seizure disorder and UTI, and had padded siderails ordered for safety. The resident’s side rails were observed wrapped with porous foam and electrical tape. A housekeeping staff member was observed cleaning the side rail foam with a sanitizer and stated she cleaned resident equipment including the foam with that sanitizer. The IPN stated the sanitizer manufacturer’s instructions indicated it was for hard, nonporous surfaces, and that using it on porous foam was not appropriate because it could prevent proper cleaning and break down the foam. The facility policy required following manufacturer instructions for disinfecting, and the sanitizer guidelines specified use on hard, non-porous surfaces. Resident 37 was admitted with a G-tube, COPD, and HTN, and was dependent for self-care and mobility. During observation, the resident’s suction machine, canister, and tubing with the yankauer device were at the bedside, and the yankauer device was observed on the floor. CNA 2 stated the yankauer should be in a dated bag and that if it was used after being on the floor, the resident could get an infection. LVN 3 stated the yankauer and other breathing treatment supplies should be placed in a plastic bag with the date opened or replaced, and that a yankauer on the floor was an infection control issue and should be changed out. In addition, CNA 1 was observed exiting one resident’s room and entering and exiting another resident’s room without performing hand hygiene. CNA 1 stated she did not wash her hands after leaving the room, and the ADON stated staff should perform hand hygiene when entering and exiting resident rooms because failure to do so increases the risk of spreading infection among residents.
Failure to Obtain Valid Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before starting Abilify for one resident with schizoaffective disorder. The resident’s admission record identified her as self-responsible and without an authorized responsible party, but her H&P stated she did not have the capacity to understand and make decisions. The physician ordered Abilify 5 mg by mouth twice daily for delusions interfering with daily care, and the facility’s informed consent form for Abilify was signed by the resident’s daughter even though the daughter was not listed as the responsible party. The DON stated there was no record of a conference to identify the daughter as the resident’s responsible party before obtaining the consent. The facility also failed to obtain a new informed consent when Cymbalta was increased for another resident with diabetes mellitus due to underlying condition with diabetic neuropathy. The resident’s H&P stated he had the capacity to make healthcare decisions, and the order summary showed Cymbalta was increased to 90 mg once daily for neuropathic pain. The most recent informed consent on file was for Cymbalta 30 mg twice daily, and the DON stated the facility did not obtain a new consent when the dosage was increased in August 2025. The facility’s policy stated informed consent for psychotherapeutic drugs must be renewed whenever there is an increase in dosage, and the psychotropic medication policy stated residents and/or representatives have the right to decline treatment with psychotropic medications.
Failure to Monitor Adverse Effects of Cymbalta
Penalty
Summary
The facility failed to monitor for adverse effects related to Cymbalta use for one resident. Resident 111 was admitted and later readmitted to the facility with diagnoses including diabetes mellitus due to underlying condition with diabetic neuropathy. His H&P dated 10/23/25 indicated he had the capacity to make healthcare decisions. Physician orders dated 8/1/25 showed the attending physician prescribed Cymbalta 30 mg and Cymbalta 60 mg, for a total daily dose of 90 mg, to be taken together once daily for neuropathic pain. A review of Resident 111's MAR showed the facility did not monitor for adverse effects related to Cymbalta between 11/2/25 and 2/24/26. During interview, the DON stated the facility failed to monitor the adverse effects of Cymbalta during that period and explained that even when an antidepressant is used to manage nerve pain, it must be monitored for adverse effects to ensure the medication is safe and effective. The facility's policy on Psychotropic Medication Use stated that psychotropic medication management includes adequate monitoring for efficacy and adverse consequences, and that residents receiving psychotropic medications are monitored for adverse consequences.
Failure to Assess and Report Open Skin Breakdown
Penalty
Summary
The facility failed to assess and report a change in condition for Resident 89 after the Treatment Nurse identified multiple open areas of skin breakdown on the resident’s left upper arm. During observation, the resident had multiple open skin breakdown areas on the left upper arm, and the next day there were blood-tinged stains on the left upper sleeve over those areas. Resident 89 had been admitted and readmitted to the facility with diagnoses including metabolic encephalopathy and Alzheimer’s disease, and the MDS dated 2/15/2026 indicated severely impaired cognitive skills for daily decision making and dependence with eating, oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. During interview and record review, the Treatment Nurse stated she first noticed the areas about two days earlier, but did not complete an assessment, including measuring the areas, and did not notify the physician. She stated she believed physician notification was not necessary because there was no active bleeding. The DON stated staff must assess and report any identified open wound immediately because it is a change in condition that requires prompt physician notification, and that the Treatment Nurse could not independently determine the severity of the condition or the risk of infection without notifying the physician.
Inaccurate MDS Coding for Suctioning Services
Penalty
Summary
The facility failed to provide accurate information in the MDS for one sampled resident who had a suction machine at the bedside. During observation, the resident was resting in bed with eyes closed, and a suction machine with a canister and attached tubing with a yankauer device was present on the bedside dresser. The resident’s admission record showed diagnoses including a G-tube, COPD, and HTN. The MDS dated [DATE] indicated the resident was rarely/never understood, was dependent for self-care and mobility, and did not require suctioning as scheduled or as needed. During a concurrent interview and record review, the MDS RN stated the MDS should have indicated the resident had a suctioning machine at bedside and was receiving suctioning as needed, and that the services provided by the facility should be reflected on the MDS. The DON also stated the MDS should have been coded as yes for suctioning on an as-needed schedule, and explained that the MDS is used to initiate the comprehensive care plan and to show the care staff are to provide. The facility policy on resident assessments stated the interdisciplinary team is responsible for timely and appropriate assessments and that those completing portions of the MDS must sign attesting to the accuracy of the information.
Missing Language Barrier Care Plans and Failure to Follow Diabetes and Blood Pressure Care Plans
Penalty
Summary
The facility failed to develop communication barrier care plans for two residents whose preferred or primary language was Spanish. Resident 42’s admission record and MDS identified Spanish as the resident’s primary/preferred language, and a registered nurse supervisor stated there was no communication barrier care plan in the medical record. The MDS RN stated the care plan should have been added within 21 days of admission per facility policy and that it was important for effective communication with staff. Resident 112’s admission record and MDS also identified Spanish as the preferred language and indicated the resident needed an interpreter to communicate with health care staff, but the care plan did not include a language barrier care plan. During a concurrent observation and interview, the ADON was in the resident’s room, stated she did not speak Spanish, and noted the resident’s communication board was missing. The ADON later stated that Resident 112 speaks Spanish, and the MDS RN stated a language barrier care plan was essential for the resident. The facility also failed to implement existing care plans for two residents. Resident 9 had diabetes, and the care plan directed staff to monitor for hypoglycemia and hyperglycemia related to diabetes mellitus; however, on 2/16/2026, the MAR showed a blood sugar of 243 mg/dL and lispro was not given as ordered. Resident 46 had hypertension, hypertensive heart failure, end stage renal disease, and dialysis, and the care plan directed PRN clonidine for elevated blood pressure; however, on 2/2/2026 and 2/21/2026, the MAR showed elevated blood pressure readings and clonidine was not given as ordered. The MDS RN stated the nurses did not follow the care plans on those dates.
Care plan not updated for AV shunt arm restriction
Penalty
Summary
The facility failed to ensure the comprehensive person-centered care plan was revised to include the intervention of no blood pressure on the left arm for Resident 16 after the resident received an AV shunt for hemodialysis. During observation on 02/23/2026 at 3:25 p.m., Resident 16 was seen at the bedside with dialysis access on the left upper arm and right chest. Resident 16’s admission record showed diagnoses including hypotension, end stage renal failure, and dependence on dialysis, and the MDS dated 2/6/2026 indicated moderate cognitive impairment. Review of the care plan showed that on 1/16/2026 it included no blood pressure, IV, or IM blood draw on the right arm, and on 2/19/2026 it included left upper arm status post AV shunt placement. During interview, RNS 1 stated the care plan should include no blood pressure on the left arm because taking blood pressure there could impede blood supply and delay treatment causing risk of harm. The DON stated the care plan was a guide for nurses to provide safety and cause no harm, and that failing to update the care plan could lead to blood pressure being taken on the left arm, which could cause injury such as clotting and bleeding. The facility policy stated care plans are revised as resident assessments and conditions change, and the interdisciplinary team reviews and updates the care plan when there has been a significant change in condition.
Missing Communication Board for Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure that Resident 112 had a communication board available. Resident 112 was initially admitted on 9/23/2024 and later readmitted with diagnoses including thrombocytopenia, diabetes, and muscle weakness. The resident's MDS dated 12/23/2025 indicated that Spanish was the preferred language and that an interpreter was needed to communicate with doctors or health care staff. During a concurrent observation and interview on 2/23/2026 at 9:20 a.m., the ADON was in Resident 112's room while the resident was sitting in a wheelchair and trying to ask for help. The ADON stated she did not speak Spanish and that Resident 112's communication board was missing. During a later interview on 2/25/2026 at 3:30 p.m., the ADON stated that Resident 112 speaks Spanish. The facility policy on accommodation of communication deficits stated that residents' communication needs would be identified and appropriate intervention developed for each resident.
Failure to Identify PTSD Triggers and Trauma-Informed Care Needs
Penalty
Summary
The facility failed to identify and intervene for one of three sampled residents, Resident 6, who had a history of trauma and PTSD with potential triggers that could cause re-traumatization. Resident 6’s admission record showed diagnoses including PTSD, aphagia, and CVA. The H&P stated Resident 6 was able to make decisions for activities of daily living, and the MDS showed the resident required dependent assistance from two or more staff for showering, bed mobility, dressing, transfer, hygiene, and eating. During interview, the resident’s family member stated Resident 6 was a war veteran with PTSD, had nightmares about war, and startled with loud noises. The SSD reviewed the Trauma Care Evaluation and stated no trauma or triggers had been identified, and that she should have assessed PTSD triggers and the severity of possible re-traumatization by contacting the resident’s psychiatrist and family member for more information. The MDS RN reviewed the care plan report and stated there was no care plan regarding PTSD or trauma, and the DON stated staff should have assessed the resident’s PTSD and developed the plan of care based on the findings. The facility policy stated trauma survivors may be re-traumatized in an institutional setting, triggers are individualized, and assessments should identify symptoms and triggers for individualized care planning.
Physician Did Not Complete H&P Within Required Timeframe
Penalty
Summary
The facility failed to ensure Resident 140’s physician completed the History and Physical (H&P) within 72 hours of admission, as required by facility policy. Resident 140 was admitted with diagnoses including lymphoma, hydrocephalus, hypertension, and seizures, and later died in the facility. A review of the resident’s H&P dated 12/10/2025 showed it was incomplete and documented that the physician did not see the resident. The physician communication log showed the attending physician was notified on 12/10/2025 that Resident 140 needed to be seen, notified again on 12/11/2025, and the Medical Director was notified on 12/16/2025 that the resident still had not been seen by the attending physician. The MR stated the attending physician did not complete the H&P and that it is usually done within 72 hours after admission. The DON stated the H&P was not completed within the required 72 hours and that if the attending physician was unavailable, the facility should have notified the Medical Director to ensure timely completion.
Controlled Medication Not Properly Documented
Penalty
Summary
The facility failed to accurately account for one dose of alprazolam 0.5 mg for Resident 117 on Medication Cart 3. During a concurrent observation and interview, the Controlled Drug Record for the resident’s alprazolam showed 11 doses remaining, while the medication card contained 10 doses. The discrepancy was identified during review of the controlled medication supply and the corresponding record for the resident. During the interview, LVN 2 stated that she had administered the missing dose of alprazolam to Resident 117 earlier that morning but did not sign the dose out on the Controlled Drug Record. LVN 2 stated that the record must be signed immediately after each dose is administered. The facility’s policy on Controlled Substances, revised March 2023, states that upon administration the nurse is responsible for recording the time of administration and the signature of the nurse administering the medication.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent prior to initiating a psychotropic medication for a resident. The resident was admitted with diagnoses including depression, anxiety disorder, insomnia, and homelessness. An MDS assessment dated 12/30/2025 documented moderately impaired cognition, with the resident needing setup assistance for eating and partial assistance for other ADLs. The physician’s orders, covering 12/24/2025 to 12/31/2026, included a new order starting 12/25/2025 for quetiapine fumarate 50 mg by mouth at bedtime for depression manifested by verbalized feelings of hopelessness and agitation. During a concurrent interview and record review, RN 1 confirmed that staff did not obtain informed consent before administering the quetiapine, and that administration began on 12/25/2025. In a separate interview, the DON stated that informed consent should be obtained prior to the administration of psychotropic medications. Review of the facility’s policy titled “Psychotherapeutic drug informed consent,” revised 1/2026, showed that the facility policy requires residents and/or their representatives to be fully informed of the benefits, risks, frequency/duration, possible side effects, and alternative approaches before starting psychotherapeutic drugs. Despite this policy, informed consent was not obtained for this resident before the psychotropic medication was administered.
Failure to Complete Ordered Psychological Consultation for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with diagnosed mental health conditions received a psychologist consultation as ordered by the physician. The resident was admitted with diagnoses of depression, anxiety disorder, and insomnia. An MDS assessment dated 12/30/2025 documented moderately impaired cognition and a need for setup assistance with eating and partial assistance with other ADLs such as bathing, dressing, and toileting. Physician orders dated 12/24/2025 and 12/26/2025 directed that the resident receive a psychological evaluation, follow-up treatment as indicated, and a psych consultation for depression and anxiety. Record review and staff interviews confirmed that the ordered psychological services were not completed. During an interview and concurrent record review, an RN acknowledged that a psych consultation had been ordered for the resident but was not carried out, and stated that the order should have been completed as written. The DON similarly stated that a psych consult should be completed if ordered by the physician. The facility’s Behavioral Assessment, Intervention, and Monitoring policy, revised 3/2019, indicated that the facility will provide behavioral health services as needed for residents to attain or maintain their highest practicable mental, physical, and psychosocial well-being, but this was not followed for this resident.
Delay in Dispensing and Administering Ordered Lice Treatment
Penalty
Summary
The facility failed to ensure timely dispensing and administration of a prescribed medication for head lice for one resident. The resident was admitted with diagnoses including depression, anxiety disorder, insomnia, and homelessness, and had a Minimum Data Set indicating moderately impaired cognition, requiring setup assistance with eating and partial assistance with other ADLs. A physician’s order dated 12/26/2025 directed the use of a Permethrin/Nit Remover combination kit to be applied to the scalp one time for head lice, with instructions to reorder after seven days. Facility policies on administering medications and on ordering and receiving medications from the pharmacy both indicated that medications would be administered and received in a timely manner. During an interview and record review, an RN confirmed that although the lice medication was ordered on 12/26/2025, it was not administered until 12/29/2025, three days later. The RN stated that not administering the Permethrin as soon as it was ordered was unacceptable and that it should have been carried out right away. The DON stated that medication orders with instructions need to be implemented within 24 hours. As a result of this delay, the resident was not treated for head lice until three days after the infestation was identified, which the report states has the potential to cause uncomfortable itching and loss of sleep for the resident.
Cockroach Infestation Leads to Kitchen Closure and Resident Exposure
Penalty
Summary
The facility failed to maintain sanitary conditions by not preventing a cockroach infestation, resulting in the closure of the kitchen and sightings of cockroaches in resident rooms. Multiple reports and interviews documented that at least two residents observed cockroaches in their rooms on several occasions, with one resident noting repeated sightings over a period of months. Both residents had chronic obstructive pulmonary disease (COPD), a condition that can be exacerbated by environmental contaminants. The facility's Concern Records and Resident Council Departmental Response forms confirmed these observations, and the Ombudsman also witnessed cockroaches in resident rooms and reported them to facility leadership. A city inspection of the facility's kitchen found live adult German cockroaches near the handwashing area and on the wall, leading to the suspension of the facility's public health permit and the closure of the kitchen. The Environmental Health Specialist (EHS) had previously instructed the facility to eradicate the pests by a set deadline, but upon re-inspection, the infestation persisted. The EHS explained that cockroaches can carry germs from garbage and sewage, contaminating food and surfaces, particularly in kitchen and food storage areas. Interviews with facility staff revealed that pest control services were provided monthly and more frequently as needed, with treatments occurring at least three times in the past month. The pest control company gave recommendations for repairs to prevent pest entry, which the Maintenance/Housekeeping Director claimed to have completed, but no documentation was maintained to verify these repairs. The DON acknowledged being informed of the infestation and noted that residents keeping food in their rooms could contribute to the problem. The facility's policy required an effective pest control program to keep the building free of insects and rodents.
Failure to Protect Resident Following Allegation and Signs of Abuse
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for assistance with daily activities and lacked capacity to make decisions, reported being struck to a CNA after bruising was observed on her face. The CNA relayed the resident's statement to an RN, but there was no evidence that immediate protective measures or a thorough investigation were initiated at that time. Later, another CNA witnessed an RN roughly handling the resident and observed redness on both cheeks. Despite reporting the resident's allegations and observed rough handling to another RN, no action was taken to protect the resident or escalate the concern, as the RN did not perceive the resident's behavior as a concern and did not seek translation or further assessment. The facility's failure to act on the resident's allegations and visible injuries resulted in the resident being left unprotected after making an abuse allegation. The staff did not follow the facility's policy to report and investigate suspected abuse, and the resident remained at risk for continued abuse. The deficiency was identified through interviews, record reviews, and direct observations of the resident's injuries and staff interactions.
Failure to Timely Report Suspected Abuse and Facial Injuries
Penalty
Summary
Facility staff failed to report suspected abuse involving a resident who was found with multiple facial bruises. The resident, who had diagnoses including anemia, generalized muscle weakness, depression, and lacked decision-making capacity, required substantial assistance with daily activities. On the morning of the incident, a CNA discovered the resident with red and purple bruises on her face and reported that the resident stated in Spanish that she had been hit. The CNA relayed this information to an RN. Earlier, another CNA had witnessed the resident expressing fear and alleging that a male staff member had hurt her, and later observed the same staff member handling the resident roughly and covering her face with a sheet. Despite these observations and allegations, the initial reports to nursing staff did not result in immediate action or escalation as required by facility policy. Interviews with staff revealed confusion and lack of follow-through regarding mandated reporting procedures. One CNA admitted uncertainty about what to do after her initial report was not acted upon, and the RN on duty did not seek translation services to better understand the resident's statements. The facility's policy requires immediate reporting of suspected abuse to the DON and appropriate authorities, but this process was not followed, resulting in a delay that hindered the ability of regulatory authorities to conduct a timely and effective investigation.
Failure to Thoroughly Investigate Allegation of Abuse and Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was found with multiple facial bruises. The resident, who had diagnoses of generalized muscle weakness and depression and lacked decision-making capacity, was discovered with significant discoloration on both cheeks, jawline, temple, and orbital area. A CNA reported that the resident alleged being hurt by an RN and submitted a written statement to the Director of Staff Development (DSD). However, the DSD did not review the statements and only passed them to the Director of Nursing (DON). The DON acknowledged that the investigation into the resident's bruises was incomplete. Although statements were collected from staff assigned to the resident, the DON did not interview the CNA who reported the allegation and did not have her statement. The facility's policy required extensive efforts in investigating unusual occurrences or injuries of unknown origin, but these procedures were not fully followed in this case.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with Alzheimer's disease and severe cognitive impairment, who was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of uncontrollable singing and refusal of activities of daily living, was allowed to return to the facility after being cleared for discharge by the hospital. The resident's records indicated that she was admitted to the facility with significant cognitive decline and behavioral disturbances. Upon transfer to the GACH, the facility provided a bed hold notice and a Notice of Proposed Transfer and Discharge, but the discharge notice was not properly signed by the resident or her family member, and did not specify the required advance notice period. After the resident was stabilized and ready for discharge from the GACH, the hospital's social worker contacted the facility to arrange for her return. The facility's Admissions Coordinator, following direction from the facility's psychiatrist and Administrator, declined to readmit the resident, stating that she required placement in a facility better equipped to handle behavioral issues. This decision was made without giving the resident an opportunity to demonstrate improvement. Despite available beds at the facility, the resident remained in the hospital for 21 days while alternative placement was sought. Facility policy indicated that residents seeking to return after hospitalization should be allowed to return to their previous room or the first available bed, provided they still required the facility's services and met eligibility criteria. However, the facility did not follow this policy in the resident's case, as documented in interviews with facility staff and the GACH social worker. The resident was ultimately transferred to another skilled nursing facility after an extended hospital stay.
Delayed and Inadequate Night Shift Care Due to Improper Rounding and Lighting
Penalty
Summary
Staff failed to provide timely and appropriate care to a resident who required substantial assistance with daily activities, including eating, personal hygiene, and transfers. On the overnight shift, rounds were not completed and care was not provided to the resident until approximately four hours after the shift began. When care was eventually given at around 3 a.m., it was performed with the lights off or dimmed, preventing staff from adequately assessing the resident's condition. Multiple staff members, including a CNA and an RN, reported not seeing the resident's face during their rounds due to the darkened room. The resident, who had diagnoses of generalized muscle weakness and depression and lacked decision-making capacity, was later found to have multiple facial bruises and discolorations. Facility policy required staff to make rounds at the beginning of each shift to ensure residents' safety and to provide care under appropriate conditions, including turning on lights to properly assess residents. The failure to follow these procedures resulted in delayed care and an inability to recognize changes in the resident's condition.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with severe cognitive impairment and Alzheimer's disease. A Certified Nursing Assistant (CNA) discovered a discoloration on the resident's left lower jaw while providing care and reported it to the charge nurse. The Change of Condition form documented the injury, and both the Administrator and Director of Nursing (DON) were notified. Despite this, the injury was not reported to the California Department of Public Health (CDPH) as required by facility policy and regulations. Interviews revealed that the DON and Administrator assumed the discoloration was due to the resident's agitated behavior and therefore did not consider it necessary to report the incident to CDPH. The facility's policy clearly states that all injuries of unknown origin must be reported to appropriate authorities and thoroughly investigated. The failure to report resulted in a delayed investigation by CDPH and created the potential for important information or facts to be lost or forgotten.
Physician Progress Notes Not Accessible in Medical Record
Penalty
Summary
The facility failed to ensure that physician progress notes for one resident were readily accessible in the medical record. During a review of the resident's admission record and Minimum Data Set, it was found that the resident had been admitted with pneumonia and had moderately impaired cognition, requiring full assistance with activities of daily living. When the Director of Nursing (DON) was interviewed and the resident's medical record was reviewed, the DON was unable to locate completed copies of the physician or nurse practitioner visit notes for the resident. The DON confirmed that these notes should have been present in the medical record, as they are essential for documenting the resident's prognosis, plan of care, and treatment. The facility's policy and procedure on physician services indicated that physician orders and progress notes are to be maintained in accordance with regulatory requirements and facility policy. However, the absence of these notes in the resident's record demonstrated noncompliance with the requirement to maintain complete and readily accessible medical records. This deficiency was identified through direct observation and interview, with no evidence provided that the required documentation was available at the time of the survey.
Plan Of Correction
F 842 Immediate Corrective Action The Medical Records Director immediately contacted the physician's office to request the progress notes for Resident 1. Identification of Others at Risk The Medical Records designee audited all resident charts on 7/24/25 to ensure the physicians' progress notes were in the chart. No other residents were identified with the same deficiency. Process to Prevent Recurrence On 8/1/25, the Medical Records Consultant gave an in-service to the Medical Records staff regarding the policy for physicians' visits, specifically ensuring that the physicians' progress notes are readily accessible to prevent a delay in the delivery of care and necessary services. The Medical Records Designee will audit physicians' progress notes several times a week for six weeks to ensure they are readily available and monthly thereafter for 3 months. All findings will be reported to the Administrator. Monitoring Performance The Medical Records consultant will visit monthly for three months and quarterly thereafter for six months to ensure physicians' progress notes are readily accessible. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved.
Deficiency in Resident Visitation Rights Due to Visitor Limitation Policy
Penalty
Summary
Surveyors identified a deficiency related to the facility's failure to respect residents' rights to receive visitors without limitation. Reception staff reported and signage indicated a policy limiting visitors to two per resident per visit, a practice that had been in place for several years. Observations confirmed the presence of this signage at the receptionist's desk, and interviews with staff and family members corroborated that this visitor limit was communicated and enforced, despite the facility's own policy encouraging visiting by family and friends. A family member reported awareness of the two-visitor guideline but noted that the facility did not consistently enforce it, as evidenced by a group celebration for a resident's birthday. On another occasion, the visitor limit sign was not posted at the receptionist's desk, and staff could not account for its absence. A resident also stated that their family had been informed of the two-person visitor limit, indicating that the restriction was communicated to residents and their families. Interviews with the Social Service Director and the Administrator revealed that both were aware residents have the right to unlimited visitors and acknowledged that the signage was incorrect. They stated that alternative spaces, such as the patio or activity room, could be used if resident rooms became overcrowded, rather than limiting visitor numbers. The facility's written policy supported the right to visitation and the provision of comfortable visiting areas, but the observed and reported practices did not align with this policy.
Plan Of Correction
F 550 Immediate Corrective Action The signage at the receptionist desk was immediately removed. On 7/9/25, the Administrator gave a 1-1 in-service to Receptionist 1 and Receptionist 2 regarding the policy for resident rights, specifically regarding visitation. Identification of Others at Risk Social Services Director visited with residents on 7/10/25 to ensure they are able to have visitors with no restrictions. No other residents were identified with the same deficient. Process to Prevent Recurrence On 7/9/25, the DSD gave an in-service to staff regarding the policy for resident rights, specifically regarding visitation. The Social Service designee will visit residents randomly weekly for six weeks to discuss whether they had any concerns with visitation. All findings will be reported to the Administrator. Monitoring Performance The Activity Designee will discuss monthly at resident council for three months whether residents had any concerns with visitation. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved. The Social Service designee will visit residents randomly weekly for six weeks to discuss whether they had any concerns with visitation. All findings will be reported to the Administrator. Monitoring Performance The Activity Designee will discuss monthly at resident council for three months whether residents had any concerns with visitation. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved.
Failure to Follow Restraint Policy for Resident Using Abdominal Binder
Penalty
Summary
A deficiency occurred when the facility failed to follow its own restraint policy for a resident who was using an abdominal binder as a physical restraint. The facility did not attempt alternative interventions prior to the application of the abdominal binder, as indicated in the restraint-physical initial evaluation. Additionally, the required informed consent for the restraint was incomplete, lacking a physician's signature and date. The resident's medical records also did not include a care plan addressing the use of the abdominal binder as a restraint. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease (COPD), dysphagia, type 2 diabetes mellitus, and a gastrostomy. The resident was cognitively impaired and dependent on staff for all activities of daily living. Despite these complex needs, staff did not document monitoring of the resident every 30 minutes while the abdominal binder was in use, as required by facility policy. Observations confirmed that the resident was wearing the abdominal binder, and interviews with nursing staff revealed that monitoring and assessment for comfort, tolerance, and breathing difficulties were not performed or documented. Interviews with facility staff, including an LVN, RN, and the Assistant Director of Nursing, confirmed that the facility's procedures were not followed. Staff acknowledged that alternatives to restraint were not tried, informed consent was not properly obtained, and ongoing monitoring and care planning for the restraint were not completed. The facility's policy required that restraints only be used after unsuccessful alternatives, with ongoing documentation, physician orders, and care plans reflecting the use and need for restraints, none of which were fully implemented in this case.
Plan Of Correction
Corrective action: On 7/11/25, the physician's order for the use of abdominal binder for Resident 2 was discontinued and carried out. An individualized care plan to address the use of the abdominal binder was developed on 07/10/2025 for Resident #2. An in-service to the MDS nurses was done by the Regional MDS nurse on 07/9/2025 to discuss the completion of care plans for residents with abdominal binder orders, individualized to address resident needs, clinical conditions, and medical necessity for use. **Identification of others:** On 7/11/25, the DON/ADON conducted a chart audit and reviewed residents with current orders for abdominal binders/physical restraints to ensure that less restrictive interventions were attempted or tried prior to applying a physical restraint. No other residents were identified with the same deficient practice. The Medical Records designee conducted a health records audit on 7/11/25 to ensure residents with an abdominal binder/physical restraint have a complete informed restraint consent. No other residents were identified with the same deficient practice. On 7/11/25, the DON/ADON and Medical Records designee reviewed MAR/TAR records on residents with current orders for abdominal binders/physical restraints to ensure that residents are monitored every 30 minutes while the abdominal binder is in use. No other residents were identified with the same deficient practice. The Lead MDS nurse completed an audit on residents who currently have an abdominal binder/physical restraint order and reviewed to ensure an individualized care plan for abdominal binder/physical restraint use is addressed/updated. No other residents were identified for this deficient practice. **Process to prevent recurrence:** An in-service to all licensed nurses was conducted by the DON on 7/11/25 to discuss trying alternatives prior to the use of an abdominal binder/physical restraint. An in-service to all licensed nurses was conducted by the DON on 7/10/25 to discuss the completion of informed restraint consent when a resident has an order for an abdominal binder/physical restraint. Also, staff must monitor every 30 minutes. An in-service to all licensed nurses was conducted by the DON on 7/9/25 to discuss the completion of care plans for residents with abdominal binder orders, individualized to address resident needs, clinical conditions, and medical necessity for use. The Medical Records designee will conduct a weekly audit for six weeks and monthly thereafter for three months to ensure there is an informed restraint consent completed for residents with an abdominal binder/physical restraint. She will also check the MARS/TARS to ensure the residents are being monitored every 30 minutes. All findings will be reported to the DON. The DON/ADON will ensure care plans for abdominal binder use are addressed for all residents with current abdominal binder orders/physical restraints. Furthermore, the MDS nurses will review/update restraint care plans quarterly and as needed, per protocol. **Monitoring performance:** The DON/ADON will review residents with current orders for abdominal binder application several times a week for six weeks and weekly thereafter for 3 months to ensure that less restrictive interventions were attempted and/or other alternative options prior to abdominal binder/physical restraint. The Director of Nursing will discuss findings at the Quality Assurance and Improvement Committee monthly for evaluation and further action. The DON/ADON and Medical Records designee will check resident records MAR/TAR weekly for six weeks and monthly thereafter for 3 months to ensure residents are being monitored every 30 minutes. An in-service to all licensed nurses was conducted by the DON on 7/9/25 to discuss the completion of care plans for residents with abdominal binder orders, individualized to address resident needs, clinical conditions, and medical necessity for use. The Medical Records designee will conduct a weekly audit for six weeks and monthly thereafter for three months to ensure there is an informed restraint consent completed for residents with an abdominal binder/physical restraint. She will also check the MARS/TARS to ensure the residents are being monitored every 30 minutes. All findings will be reported to the DON. The DON/ADON will ensure care plans for abdominal binder use are addressed for all residents with current abdominal binder orders/physical restraints. Furthermore, the MDS nurses will review/update restraint care plans quarterly and as needed, per protocol. **Monitoring performance:** The DON/ADON will review residents with current orders for abdominal binder application several times a week for six weeks and weekly thereafter for 3 months to ensure that less restrictive interventions were attempted and/or other alternative options prior to abdominal binder/physical restraint. The Director of Nursing will discuss findings at the Quality Assurance and Improvement Committee monthly for evaluation and further action. The DON/ADON and Medical Records designee will check resident records MAR/TAR weekly for six weeks and monthly thereafter for 3 months to ensure residents are being monitored every 30 minutes. The Director of Nursing will discuss findings at the Quality Assurance and Improvement Committee monthly for evaluation and further action. The Regional MDS nurse shall conduct chart audits monthly for 3 months with a focus on care plans for residents with current restraint orders and will provide a report of findings to the Administrator/QA committee for review and further recommendations.
Inaccurate MDS Documentation of Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment entries accurately reflected a resident's use of restraints. Specifically, for a resident admitted with chronic obstructive pulmonary disease and dysphagia with a gastrostomy, the MDS dated 5/15/2025 indicated that the resident did not have any restraints. However, a review of the resident's physical restraint evaluation dated 5/10/2025 showed that staff had initiated an abdominal binder restraint for the resident. During interviews and record reviews, one registered nurse stated that she did not mark the abdominal binder as a restraint on the MDS because she did not consider it to be a restraint. Another registered nurse and the Assistant Director of Nursing both confirmed that the abdominal binder used for the resident was considered a restraint and should have been documented as such on the MDS. The staff acknowledged the importance of accurate MDS entries, as they reflect the care provided and are essential for identifying the correct status of the patient. Facility policy and procedure documents reviewed indicated that any person completing any portion of the MDS assessment is required to sign and certify the accuracy of that portion. The failure to accurately document the use of a restraint on the MDS for this resident resulted in a deficiency related to the accuracy of assessments, as required by federal regulations.
Plan Of Correction
F 641 Corrective action: A. Resident #2's Admission/Medicare 5-day assessment with an Assessment Reference Date (ARD) of 05/15/2025 has been modified on 07/10/2025 to correct coding for Section P0100D. Other Restraint, to code use of the abdominal binder. This assessment was transmitted and accepted on 07/11/2025 accordingly. B. In-service was done by the Regional MDS consultant re: Section P coding accuracy on 07/9/2025. Identification of Others at Risk: The Lead MDS nurse did a chart audit on 7/10/25 and reviewed residents with current order for abdominal binder use to check if they were correctly coded on the MDS assessment/s: Section P. A copy of this audit was provided to the DON/Administrator for review. One other resident was identified for this deficient practice and MDS assessment was modified accordingly. Measures to prevent recurrence: The Lead MDS nurse will ensure all residents with (new) abdominal binder order that meet the definition of restraint are coded accurately. The Regional MDS consultant shall perform random chart audits, focusing on coding Section P accurately, monthly for three months and present inaccuracy findings to the DON and the Administrator for corrective actions. Monitoring Performance: The Director of Nursing will present a recapitulation of findings of the random monthly audits at the Monthly Quality Assessment and Assurance Committee meeting for review with corrective actions, as indicated. Measures to prevent recurrence: The Lead MDS nurse will ensure all residents with (new) abdominal binder order that meet the definition of restraint are coded accurately. The Regional MDS consultant shall perform random chart audits, focusing on coding Section P accurately, monthly for three months and present inaccuracy findings to the DON and the Administrator for corrective actions. Monitoring Performance: The Director of Nursing will present a recapitulation of findings of the random monthly audits at the Monthly Quality Assessment and Assurance Committee meeting for review with corrective actions, as indicated.
Failure to Assess and Monitor Toenail Detachment in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident's toenail detachment after it began bleeding for five days. The resident, who had multiple diagnoses including diabetes, chronic obstructive pulmonary disease, dysphagia, and was on long-term anticoagulant therapy, was dependent on staff for all activities of daily living and had impaired cognitive skills. The resident's daughter reported bleeding from the resident's toe, and an RN noted dried blood under the left fifth toe. The RN notified the physician, who ordered the treatment nurse to assess and evaluate the situation. Despite this order, there was no documentation of ongoing assessment or monitoring of the toe's condition in the days following the initial report. The RN who first assessed the resident was not present for six days, and upon return, found the toenail had completely detached. The treatment nurse only assessed the resident after the toenail was fully removed, and there was no follow-up treatment documentation regarding the bleeding or the status of the toe during the intervening period. The Director of Nursing confirmed that there was no documentation regarding the status of the toenail's detachment after the initial change of condition assessment. Interviews with nursing staff, including the LVN and Assistant Director of Nursing, confirmed that the resident's condition warranted close monitoring and documentation due to the risk factors of diabetes and anticoagulant use. Facility policies required documentation of changes in condition for at least 72 hours or longer if warranted, including objective, complete, and accurate records of assessments and treatments. However, these policies were not followed, as there was no documentation of the source of bleeding, circulation, signs of infection, or the progress of the toenail detachment for several days.
Plan Of Correction
Immediate Corrective Action Upon notification, the RN Supervisor immediately assessed the toenail of Resident 2 and notified the Physician and family. The treatment nurse was informed and assessed the resident. On 7/9/25, the DON gave a 1-1 in-service to RN 1 regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. On 7/9/25, the DON gave a 1-1 in-service to LVN 1 regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. Identification of Others at Risk The Director of Nursing and Medical Records conducted a health records review on 7/9/2025 to ensure all residents with a change of condition were assessed and monitored and follow-up was completed. No other residents were identified with the same deficient. Process to Prevent Recurrence On 7/9/25, the DON gave an in-service to Licensed nurses regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. Medical Records will audit change of condition assessments daily for six weeks and weekly thereafter for three months to ensure compliance. All findings will be reported to the DON. Monitoring Performance The DON or designee will randomly check residents' change of condition assessments several times a week for six weeks and weekly thereafter for three months to ensure licensed nurses have assessed and monitored after the residents' change of condition.
Failure to Consistently Turn and Reposition Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care by not consistently turning and repositioning two residents with existing pressure ulcers every two hours or as needed. Both residents had significant medical conditions that increased their risk for pressure injuries, including functional quadriplegia, diabetes, muscle weakness, and end stage renal disease for one resident, and acute kidney failure, diabetes, muscle weakness, and a Stage IV pressure ulcer for the other. Documentation and interviews confirmed that the required turning and repositioning tasks were left blank on several shifts, indicating the care was not performed as required. Resident records and assessments showed that both individuals were dependent on staff for mobility and at high risk for developing or worsening pressure ulcers. One resident had multiple pressure ulcers, including an unstageable ulcer on the sacrum and deep tissue injuries on the right gluteus and left heel. The other resident had a Stage IV pressure ulcer on the sacral region. Despite these conditions, neither resident was on a formal turning and repositioning program according to their Minimum Data Set assessments. Interviews with facility staff, including an LVN and the DON, confirmed that the lack of documentation meant the turning and repositioning was not done. Facility policy and national guidelines both require regular repositioning of residents at risk for pressure injuries, but this was not followed for these two residents, as evidenced by incomplete documentation and staff statements.
Failure to Assess and Document After Resident Vomiting Episode
Penalty
Summary
The facility failed to complete and document a comprehensive assessment, including a head-to-toe physical evaluation, blood pressure, heart rate, temperature, and blood glucose measurements, after a resident experienced vomiting. The resident in question had multiple significant diagnoses, including pneumonia, diabetes, gastrostomy status, dependence on supplemental oxygen, and heart failure, and was noted to have severely impaired cognition and total dependence on all activities of daily living. Despite these complex medical needs, after the resident vomited, the responsible nurse did not perform or document the required assessments and vital sign checks. Interviews with facility staff confirmed that the expected protocol following a change in condition, such as vomiting, was not followed. The Director of Nursing stated that staff should conduct a head-to-toe assessment and check vital signs after such events to identify and address potential problems early. Review of facility policy also indicated that a detailed observation and collection of pertinent information should occur after a significant change in a resident's condition. However, documentation and staff statements confirmed that these steps were not taken in this instance.
Failure to Document Medication Administration in MAR
Penalty
Summary
A deficiency occurred when the facility failed to ensure that medication administration was properly documented in the Medication Administration Record (MAR) for a resident. The resident, who was admitted with multiple diagnoses including pneumonia, diabetes, gastrostomy status, dependence on supplemental oxygen, and heart failure, had severely impaired cognition and was dependent on staff for all activities of daily living. The resident had an active order for Ondansetron 4 mg via G-tube every eight hours as needed for nausea and vomiting. On a day when the resident experienced vomiting, a registered nurse stated that Ondansetron was administered but this administration was not documented in the MAR for that month. Both the registered nurse and the Director of Nursing confirmed that medication administration should always be documented according to facility policy. Review of the facility's policy confirmed that licensed personnel are required to document all medication administration.
Failure to Provide Timely Personal Hygiene and ADL Assistance
Penalty
Summary
A resident with significant physical and cognitive impairments, including muscle wasting, multiple pelvic fractures, contractures, and memory problems, was observed in bed with a soiled gown and dry blood on her right nostril for an extended period. The resident was dependent on staff for all activities of daily living (ADLs), including bed mobility, eating, oral hygiene, and personal hygiene. During the observation, the resident appeared uncomfortable, contracted in both lower extremities, and expressed that she was waiting to be cleaned and was in pain. The assigned CNA reported a heavy workload, stating that she was responsible for multiple residents requiring showers and was unable to perform ADLs for the resident in a timely manner. The CNA noticed the dry blood but did not immediately notify the charge nurse, believing it was outside her scope and due to being busy. The LVN also observed the dry blood but did not clean it, assuming it would be addressed during the resident's scheduled shower. The DON confirmed that both CNAs and licensed staff are responsible for ensuring residents are clean and comfortable, and that delays in care can occur when residents require more time for ADLs. Facility policy requires staff to provide appropriate support and assistance with hygiene for residents unable to perform ADLs independently.
Failure to Provide Timely Pain Management Prior to Wound Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including muscle wasting, pelvic fractures, and contractures, did not receive appropriate pain management prior to wound care treatment. The resident was dependent on staff for all activities of daily living and had documented memory problems. Despite physician orders for scheduled and as-needed pain medications, including Tramadol and Tylenol, the resident did not receive Tramadol prior to wound care as ordered, and there was no evidence of pain assessment or administration of pain medication before the procedure. The resident was observed to be in significant discomfort, reporting pain throughout her body and stating she had not received pain medication that morning. During wound care, the resident exhibited clear signs of pain, including screaming when touched and turned, leading the treatment nurse to stop the procedure. The responsible LVN admitted to not assessing the resident's pain or administering pain medication as required, citing an intention to wait until just before wound care, but ultimately failing to do so. The facility's policy required pain assessment and timely administration of analgesics, but these steps were not followed, resulting in the resident experiencing unrelieved pain during wound treatment and personal care.
Failure to Timely Address Malfunctioning Equipment and Provide Properly Fitting ADL Supplies
Penalty
Summary
The facility failed to assess and repair a malfunctioning bed in a timely manner for a resident who was admitted with muscle weakness and a sacral pressure ulcer. The resident reported to nursing staff that her bed was broken and emitted a smoke odor, but no maintenance staff evaluated the bed until several days later. The maintenance request log did not specify who checked the bed or when, and there was no immediate response to the report of a burning smell. Interviews with staff revealed that there was no clear process or training for handling malfunctioning equipment, and the bed was not prioritized for immediate inspection despite the potential risk. Additionally, the facility did not provide properly fitting adult briefs for another resident with morbid obesity, muscle weakness, and heart failure. The resident reported discomfort and skin irritation due to being supplied with briefs that were too small, despite her requests for a larger size. She also refused therapy sessions out of concern for exposure due to the ill-fitting briefs. The social service director was unaware of the complaint and stated that no authorization was needed to order the correct size, while the DON acknowledged that staff should have assessed and accommodated the resident's needs promptly. Review of facility policies indicated that maintenance is responsible for keeping equipment safe and operable, and that staff are expected to accommodate residents' individual needs and preferences, including adaptive devices and modifications. The policies also require ongoing assessment and intervention to support residents' activities of daily living and well-being, but these were not followed in the cases described.
Inaccurate Resident Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments and that assessment statuses were properly reflected in the medical records for two of three sampled residents. For one resident, the Minimum Data Set (MDS) assessment was inaccurately coded regarding the resident's discharge status. The MDS indicated the resident was discharged to a short-term general hospital, while the discharge summary and staff interviews confirmed the resident was actually discharged to home with family and home health services. Both the Registered Nurse Supervisor and the Director of Nursing acknowledged that the MDS should have been coded to reflect the actual discharge destination, as this information is essential for accurate reporting and follow-up by CMS. For another resident, the facility failed to ensure that bowel and bladder assessment entries on the MDS were accurately documented. The resident's care plan included a scheduled toileting program, and physician orders required monitoring and documentation of bowel elimination. However, the MDS and related documentation contained conflicting information regarding the resident's continence status. The resident reported being continent and able to sense the need to use the bathroom, but the MDS and Bowel and Bladder Program Screener reflected varying levels of incontinence. The MDS Coordinator admitted that the assessments were based on CNA documentation and that resident interviews were not conducted, leading to inaccurate coding. Facility policies and procedures require that MDS assessments be completed accurately, using information from multiple sources including resident interviews, record reviews, and communication with staff and family. The failure to accurately code and document resident assessments in the MDS had the potential to negatively affect the residents' plans of care and the delivery of necessary services, care, and treatment.
Failure to Accurately Complete PASRR Screenings for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that two out of five sampled residents had their Level 1 Preadmission Screening and Resident Review (PASRR) completed accurately. For both residents, the PASRR Level 1 screenings were marked as negative, indicating no serious mental illness, and therefore did not trigger a Level 2 screening. However, both residents had documented diagnoses of serious mental illnesses, including depressive disorder, bipolar disorder, and schizophrenia, as well as histories of psychotropic medication use. For one resident, the admission record and medical documentation showed diagnoses of depressive disorder, bipolar disorder, and schizophrenia, with significant cognitive and functional impairments. Despite these diagnoses, the PASRR Level 1 screening indicated 'no' to the presence of a serious mental disorder, which was inconsistent with the resident's medical history. The Registered Nurse Supervisor confirmed during interview and record review that the PASRR should have been marked 'yes' to trigger a Level 2 screening based on the resident's diagnoses and medication regimen. Similarly, another resident with diagnoses of depressive disorder, bipolar disorder, and dementia was also marked as negative for serious mental illness on the PASRR Level 1 screening. The Registered Nurse Supervisor acknowledged that, given the resident's medical diagnoses and history of psychotropic medication use, the screening should have indicated the presence of a serious mental disorder. The Director of Nursing emphasized the importance of accurate PASRR screenings to ensure appropriate assessment and care planning for residents with mental health needs. The facility's policy requires a new Level 1 PASRR if there is a significant change in condition or any error in previous screenings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,686 citations issued within 25 miles in the last 12 months — including the 29 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 Bellflower
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bellflower Post Acute | 0.6 mi | ★★★★★ | 20 | 0 |
| Villa Del Sol Post Acute | 0.7 mi | ★★★★★ | 28 | 0 |
| Rose Villa Health Care Center | 1.2 mi | ★★★★★ | 6 | 0 |
| Artesia Christian Home Inc. | 1.8 mi | ★★★★★ | 24 | 0 |
| Bay Vista Healthcare & Wellness Centre, Lp | 1.8 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cerritos Vista Healthcare Center.
100% money-back within 48 hours.
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.