Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at City View Post Acute during CMS and state inspections, most recent first.
Food contact surfaces and kitchen areas were not maintained in sanitary condition. The dishmachine was found with chlorine sanitizer at 10 ppm, below the unit’s required minimum, and manual sanitizing in the 3-compartment sink did not meet the Quat manufacturer’s required 1-minute exposure time. Two refrigerators storing resident food had residue and dead insects inside, juice machine connectors had sticky residue, and the floor behind and under the ice machine had standing moisture, buildup, and debris.
Kitchen equipment was not maintained in safe working condition. Two refrigerators in an employee breakroom held resident food at temperatures above 41 degrees F, with one unit found to have a bad compressor and the other adjusted after its thermostat was turned up. An ice machine drainpipe was actively dripping water onto the floor, three ice machine drainpipes had black residue and were not clean, and a hotbox used for the lunch trayline showed a low display temperature with soup held below the facility's minimum hot-holding temperature.
A resident with contractures and neurologic impairment had a hand splint applied without a physician order, and staff did not identify or care plan for mycotic toenails or obtain a podiatry referral despite observing long, thick, yellow nails. Another resident received Tylenol in excess of the ordered 2-gram daily maximum on two occasions, and the DON acknowledged the order was not followed.
Medication administration errors exceeded the allowed rate when an LPN gave the wrong vitamin product to one resident, omitted ordered metformin and memantine for another resident, and crushed an extended-release metoprolol tablet during administration. The DON stated the medications should have been administered as ordered and that the extended-release tablet should not have been crushed.
Dietary staff were not competent in sanitizer testing and three-compartment sink procedures. Two Diet Aides incorrectly tested dishmachine sanitizer, three staff members were not competent with manual dishwashing and sanitizer exposure times, and one staff member incorrectly tested a red bucket Quat sanitizer. Observations showed staff using the wrong testing methods and incorrect contact times, while the DM demonstrated the proper dishmachine testing method and noted the Quat manufacturer instructions required a 1-minute exposure for food contact surfaces.
Incorrect pureed diet serving sizes were given during trayline when kitchen staff plated pureed broccoli, Tater tot casserole, and Texas toast using scoops that did not match the diet spreadsheet. The DM and RD later confirmed the serving sizes were incorrect after reviewing the trayline utensils and menu spreadsheet.
Food was served at an unpalatable temperature when multiple covered bowls were stored at room temperature before tray delivery and a test tray showed chicken noodle soup at 98 degrees F. During the meal service audit, the DM said the soup was only warm and the MRD said he would want it warmer. Facility policy stated hot foods on room trays are preferred to be 120 degrees F or greater to promote palatability.
A resident with schizophrenia continued receiving olanzapine and trazodone nightly without documented GDR attempts or resident-specific contraindications. Records showed no psychosis, no behavioral concerns, and minimal sleep disturbance, while the DON acknowledged GDRs were not performed. The CP recommended GDR review, but the physician denied the requests without individualized assessment.
Failure to Complete MDS After Readmission: A resident with aphasia, hemiplegia, hemiparesis, hypertension, and contractures was readmitted and receiving tube feeding, but the MDS was not initiated for re-entry within the required timeframe. The MDS Coordinator confirmed it was missed, and the DON stated the MDS should accurately reflect the resident’s clinical situation and services.
Inaccurate MDS coding affected two residents’ skin conditions. One resident with an unstageable sacral pressure injury was coded as having no pressure injury, while another resident whose sacral wound had been surgically repaired and documented as a surgical wound was coded as a stage 4 pressure injury. The MDS Coordinator and DON acknowledged the MDS did not match the nursing assessments and clinical records.
Failure to coordinate PASRR for a resident with psychotic disorder. The resident had vascular dementia and later developed paranoid delusions treated with routine quetiapine, and MDS assessments identified psychotic disorder with antipsychotic use. The AD confirmed only the original PASRR Level I screening was in the record and acknowledged no PASRR reassessment was completed after the new diagnosis and psychotropic medication use.
Baseline Care Plan Summary Not Provided: The facility failed to provide a written summary of the BCP to two residents or their representatives within the required timeframe. One resident had UTI and Alzheimer's disease, and the other was cognitively intact with spinal stenosis. In both cases, the BCP documentation left the summary-provided sections blank, progress notes had no record of delivery, and both residents or representatives stated they did not receive a copy.
Unsecured OTC medications were left on a resident’s bedside table and remained accessible to others in the room. The DON said the resident routinely bought many OTC meds and supplements and the facility treated them as personal belongings, while an LVN stated the meds in the room were not used for daily med administration. The DON also confirmed the meds were accessible near the resident’s bed while the resident was asleep and not using them.
Improper Disposal of Unidentified Medications: An LVN was observed placing two unidentified loose pills into a sharps container on a medication cart. The NUM and DON stated the pills should have been checked and disposed of in the designated pharmaceutical bins, and the facility policy allowed controlled and non-controlled substances to be disposed of in the collection receptacle.
A resident remained on olanzapine 15 mg HS and trazodone 50 mg HS for over 14 months after admission, with MARs showing nightly use throughout that period. The CP’s GDR recommendations for both psychotropic meds were denied without individualized physician assessment, resident-specific justification, or documented clinical contraindication, and IDT notes showed no documented behavioral concerns or sleep disturbances to support continued use.
Medication storage practices were not followed when a vial of brimonidine eye drops was found in the med refrigerator despite manufacturer instructions to store it at room temperature, and an expired vial of insulin glargine was left available in a med cart. The DON stated the eye drops should have been stored at room temperature and that the expired insulin should have been removed because expired medications may not be effective.
The facility failed to provide a nutritionally equivalent substitute entree when a resident declined the planned menu item, and it also failed to adequately support another resident with aphasia, hemiplegia, and poor oral intake. Staff served a grilled cheese in place of the planned entree, but the sandwich did not match the protein content of the menu item. For the second resident, staff observed repeated meal refusals and minimal intake, left the room after the resident did not respond, and did not consistently modify or assist with food items such as a whole hot dog that was too large for the resident to eat. Records showed ongoing low intake, repeated refusals, and unchanged dietary documentation over several months.
Arbitration Agreement Not Fully Explained to Resident with Cognitive Impairment A resident with moderately impaired cognition and Vietnamese as a primary language signed a 5-page arbitration agreement after it was reviewed with translation help from a Vietnamese-speaking nurse. Later, the resident said they did not remember signing the document and did not know what it was, and the record did not show a witness signature or detail how the complex admission packet was explained in a way the resident could understand.
A resident with an indwelling urinary catheter and diagnoses including dementia and urinary retention was observed with the catheter tubing and urine drainage bag touching the floor. Staff interviews confirmed the tubing clip was not anchored to the bed rail and that the tubing and drainage bag should be kept above the floor for infection control. The resident’s orders, care plan, facility policy, and CDC guidance all addressed securing the catheter and keeping the drainage bag off the floor.
Kitchen Window Screen Left Gap to Outside: The facility failed to maintain pest control when a kitchen window screen was not fully attached to the frame, leaving a gap to the outside. An open kitchen window was observed with the screen separated from the frame, and the DM confirmed the gap and stated no work order had been submitted because it had not been noticed. The MM stated the screen may have been broken during prior cleaning and acknowledged pests could probably fit through the opening.
Multiple staff and residents reported ongoing cockroach infestations in several rooms, with live and dead cockroaches observed in resident areas and food storage locations. Some rooms with reported infestations were not included in pest control or deep cleaning schedules, despite the facility's policy and pest control agreement indicating a need for ongoing and facility-wide pest management.
A resident with multiple medical and mental health conditions reported a black pouch containing cash missing after returning from the hospital. The resident had previously shown a CNA $1,000 in the pouch, but the cash was not documented in the inventory or secured as required by facility policy. The loss of the cash caused the resident significant emotional distress, including sadness and distrust toward staff.
A resident with multiple medical and mental health diagnoses reported a missing black pouch containing cash after a hospital transfer. Despite a CNA confirming the presence of $1,000 in the pouch and returning it to the resident prior to its disappearance, the facility did not document the cash in the resident's inventory or take further action after the CNA's verification. The resident experienced emotional distress, and the facility's required procedures for safeguarding and inventorying valuables were not followed.
A resident with moderate cognitive impairment and diagnoses of hypertension and pulmonary embolism was allowed to self-administer Eliquis and Metoprolol without an assessment or care plan from the interdisciplinary team, contrary to facility policy requiring such evaluation and approval.
A resident was found with visibly dirty fingernails containing black matter underneath, and reported that staff had not cleaned her nails despite her requests. An LVN confirmed the nails were dirty and noted the infection risk, while the DON stated that CNAs are responsible for daily nail care. Facility policy requires daily cleaning and regular trimming of nails to prevent infection.
Two residents experienced ongoing issues due to the facility's failure to assess, monitor, and implement care plans for sleep disturbances and behavioral symptoms. One resident with cancer and diabetes was unable to sleep because of another resident's persistent yelling, with no effective interventions or care planning provided. Another resident with dementia and encephalopathy exhibited frequent yelling, paranoia, and insomnia, but these behaviors were not addressed through care planning or accurately documented in the MDS.
The facility failed to refer two residents for a Level II PASARR evaluation after they were diagnosed with new mental illnesses. One resident, admitted in 2016, was diagnosed with a psychotic disorder with delusions in 2021, but no referral was made. Another resident, admitted in 2019, received multiple mental illness diagnoses, including psychotic disorder with hallucinations, but was not referred for evaluation. The facility's policy lacked procedures for handling new mental illness diagnoses, and the DON stated that a new PASARR would only be conducted if the mental illness caused a significant change in the resident's condition.
A facility failed to complete a new Level I PASARR screening for a resident with schizophrenia, as required by policy. The resident was admitted with a history of schizophrenia and was on antipsychotic medication, necessitating a Level II evaluation. The California DHCS could not complete the evaluation due to the facility's unresponsiveness to communication attempts. The DON admitted the facility missed calls and did not follow instructions to redo the Level I PASARR, leading to the deficiency.
A resident with severe cognitive impairment was discharged with another resident's medications due to a failure in medication reconciliation. The LVN did not verify the contents of the medication bag against the discharge list, leading to the error being discovered when the resident's sister returned the incorrect medications to the facility.
A resident with chronic pain syndrome experienced a delay in receiving an MRI due to a breakdown in communication and failure to follow facility policy. The physician's order was not promptly acted upon, leading to a re-order and delayed diagnostic imaging.
A resident with COPD did not receive their prescribed Trelegy Ellipta inhaler on multiple occasions due to the medication being out of stock. The DON confirmed that the medication was not reordered in a timely manner, despite facility policy requiring advance ordering. This created a risk for poor health outcomes for the resident.
The facility failed to ensure effective communication and proper care planning for a resident, leading to missed doctor's appointments and inadequate family communication. The resident's son reported unreturned calls and texts, and the facility mismanaged transportation arrangements, impacting the resident's clinical condition and well-being.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss due to being placed on a Controlled Carbohydrate Diet (CCHO) despite not being diabetic. The facility staff failed to adequately monitor and address the resident's nutritional needs, leading to a decline in the resident's health and well-being.
A resident without a diabetes diagnosis received unnecessary insulin and blood glucose monitoring. The facility's failure to follow its medication administration policy and mismanagement of the resident's drug regimen potentially compromised the resident's well-being.
Food Contact Surfaces and Kitchen Areas Not Kept Clean
Penalty
Summary
The facility failed to sanitize food contact surfaces and maintain kitchen equipment and food storage areas in accordance with professional food service standards. During observation in the kitchen, the chemical sanitizing dishmachine was being used with low sanitizer strength. A diet aide tested the dishmachine and found the chlorine sanitizer level at 10 ppm, and the dietary manager later confirmed the sanitizer strength was too low and that items processed at that level were not sanitized adequately. The dishmachine’s information plate indicated the minimum chlorine required for chemical sanitizing was 50 ppm. The facility also failed to follow manufacturer instructions for manual sanitizing in the three-compartment sink. A diet aide was observed sanitizing plates and pans in the third compartment and removing them after 27 to 28 seconds. The dietary manager confirmed the sanitizer used was Quat, and the manufacturer’s instructions showed food contact surfaces were to be exposed to a sanitizing solution of 150 to 400 ppm for not less than one minute. The observed contact time was shorter than the manufacturer’s required minimum. In addition, two refrigerators in the first-floor employee breakroom that stored resident food were not clean, with residue, dead insects, and buildup inside the freezer and refrigerator compartments. The juice machine syrup bag connectors had sticky pink and orange residue on them, and the dietary manager stated the connectors should be wiped down with warm water each night. The kitchen floor behind and under the ice machine also had water dripping from a pipe, wet dark brown residue, and debris, and the dietary manager stated the floors were to be cleaned daily.
Kitchen equipment not maintained at safe temperatures or in clean, working condition
Penalty
Summary
The facility failed to maintain two refrigerators used to store resident food in safe working condition. In the first-floor employee breakroom, one refrigerator contained food labeled for a resident, including packaged string cheese and an unsealed jar of homemade pickled eggs, and the other contained a bag of food labeled for another resident, including packaged fruit salad with cut melon. Both refrigerators had internal temperatures above 41 degrees F, with surveyor measurements showing one at 50.9 degrees F and the other at 47.3 degrees F. The Housekeeping Director confirmed the temperatures, and the Maintenance Director stated one refrigerator had a bad compressor and the other had been adjusted because the thermostat dial was turned up. The Maintenance Director also stated he could not produce the original temperature logs for the refrigerators and confirmed the refrigerator with the broken compressor was not taken out of service until later that evening. The facility also failed to maintain an ice machine drainpipe in the kitchen. During observation, water was actively dripping from a pipe behind the ice machine onto the floor, and pools of water were present underneath it. The pipe end was jagged and had black, slimy residue on the outer surface and visible inner surface. In a concurrent interview, the Maintenance Director stated the pipe was broken, should be repaired as soon as possible, and should have another pipe attached leading to the floor sink drain. In addition, three drainpipes attached to the back of the ice machine and ice machine bin were not maintained clean. One short drainpipe was jagged and had black, slimy residue on the outside and visible inside surface, and two longer drainpipes leading to a floor sink also had black residue on their outer surfaces. The Maintenance Manager stated the short drainpipe was cracked and that the longer drainpipes were for the ice machine condenser and draining during the cleaning cycle. He confirmed the drainpipes were not clean and stated they should be cleaned. The facility also failed to maintain a hotbox used for the lunch trayline in adequate working condition. The hotbox temperature display showed 108 degrees F, and the soup held inside measured 119 degrees F, 117 degrees F, and 126 degrees F, all below the facility's stated minimum acceptable hot holding temperature of 140 degrees F. A vendor quote dated earlier in the month stated the unit was not heating, the temperature gauge was not working, the temperature display was cracked, and the gasket was ripped affecting temperatures.
Unordered splint use, missed podiatry assessment, and excess Tylenol administration
Penalty
Summary
A hand splint was applied to Resident 194 without a physician’s order. Resident 194 was readmitted with diagnoses including aphasia, hemiplegia, hemiparesis, hypertension, and contracture, and was observed with contractures of both hands and lower extremities. During observation, the resident had a blue fabric support device on the right hand, which staff identified as a hand splint. The electronic health record showed no physician order for the hand splint, although restorative nursing documentation indicated a right resting hand splint with a wearing schedule of at night and during rest as tolerated, off for ROM and hand hygiene. RNA staff stated the splint had been verbally ordered by the PT after evaluation and was applied the day after admission. Resident 194’s mycotic toenails were not identified in the admission/readmission assessment, were not addressed in the basic care plan, and no care plan was developed for the condition. Staff observed and described the toenails as long, thick, and yellowish on multiple toes, and RN staff stated the fungal condition and nail length could cause skin damage. LVN staff confirmed the condition was not noted in the assessment, progress notes, or care plan, and stated it should have been part of the assessment. The record also showed no referral to podiatry, and the Social Services Director confirmed there had been no podiatry referral. The DON stated the mycotic nails should have been identified in the assessment. Resident 114 had a physician order for Tylenol 500 mg, two tablets by mouth every six hours as needed for mild pain, not to exceed 2 grams in 24 hours from all sources. The MAR showed that 3 grams of Tylenol were administered on two separate days, with three doses given on each of those days. The DON reviewed the record and acknowledged that the order not to exceed 2 grams was not followed, resulting in 3 grams being administered. The physician stated the facility was expected to notify the provider when pain medications were ineffective. The medication regimen reviews did not address the Tylenol order.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with 4 errors identified out of 29 observed medication administration opportunities for a rate of 13.79%. During observation, a LVN administered Resident 139’s morning medication using folic acid from the wrong bottle instead of the ordered Nephro-Vite. The resident had a physician order dated 3/12/25 for Nephro-Vite, 1 tablet by mouth daily, but the nurse stated she believed the order was only for folic acid and used the folic acid bottle instead of Nephro-Vite. For Resident 199, the LVN did not administer ordered metformin 850 mg twice daily and did not administer ordered memantine 5 mg twice daily during the observed medication pass, and both medications were documented as not administered on the MAR for that date. The LVN stated both medications were not available in the cart. In addition, the LVN administered metoprolol succinate extended-release 25 mg, one-half tablet, after crushing it and mixing it with applesauce, despite the medication being an extended-release formulation that should not be crushed. The LVN acknowledged the label said not to crush, and the DON stated the medication should not have been crushed.
Dietary Staff Not Competent in Sanitizer Testing and Sink Procedures
Penalty
Summary
The facility failed to ensure staff competency for food and nutrition service tasks involving the dishmachine, the three-compartment sink, and sanitizer testing. The report states that 6 of 27 staff were not competent in these duties, including two Diet Aides who were not competent testing the dishmachine sanitizer, three staff members who were not competent in three-compartment sink procedures, and one staff member who was not competent testing the red bucket food contact surface sanitizer. The Dietary Supervisor job summary stated the supervisor was responsible for overseeing food service operations, managing dietary staff, and training kitchen staff on proper food handling and dietary regulations. During observation, a Diet Aide tested the low temperature dishmachine sanitizer with chlorine test strips and reported a 10 ppm chlorine level, while the information plate on the machine showed the minimum chlorine required for chemical sanitizing was 50 ppm. Another Diet Aide demonstrated dishmachine testing by dipping a chlorine sanitizer strip in standing water on the counter and stated it needed to be held in water for 10 seconds. The Dietary Manager stated the strip should be touched to the surface of an item in the dishmachine after the rinse cycle and not dipped in standing water, and demonstrated that method. The directions on the chlorine test paper container said to dip and remove quickly. For manual dishwashing in the three-compartment sink, a Diet Aide stated items sanitized in the third compartment had to be submerged for 10 seconds, while the Dietary Manager stated items only needed to be submerged for 20 to 30 seconds and did not realize the Quat manufacturer instructions required exposure for no less than 1 minute at 150 to 400 ppm active quat. Another Diet Aide tested sanitizer in the three-compartment sink but held the strip in the solution for only four seconds, then seven seconds on retest, although the test strip container directed that it be dipped in the sanitizer solution for 10 seconds. A Diet Aide also tested a red bucket of Quat sanitizer by dipping a strip into the solution and removing it after several seconds, stating it should remain in the solution for five seconds, while the Dietary Manager stated the strip was not held long enough to accurately test the sanitizer strength.
Incorrect Pureed Diet Serving Sizes During Trayline
Penalty
Summary
The facility failed to follow the planned menu when incorrect serving sizes were given to residents on pureed diets. During observation and interview, the Dietary Manager provided the trayline diet spreadsheet used to show foods and serving sizes for prescribed diets. While lunch trayline was being prepared, kitchen staff plated pureed broccoli and Tater tot casserole on ceramic plates using a number 16 scoop, and pureed bread (Texas toast) was plated using a number 6 scoop after the cook reviewed the tray cards listing each resident’s prescribed diet, food preferences, and allergies. During a later interview with the Dietary Manager and Registered Dietician, the serving utensils used during trayline were reviewed and the Dietary Manager confirmed that the pureed serving sizes were incorrect. The diet spreadsheet showed that pureed Tater tot casserole should have been served with a number 6 scoop, while pureed broccoli and Texas toast should have been served with number 12 scoops. Record review confirmed that the serving sizes used did not match the spreadsheet and that incorrect serving sizes were given to residents receiving pureed diets.
Food Served at Unpalatable Temperature
Penalty
Summary
The facility failed to serve food at a palatable temperature. During an observation, multiple individual plastic bowls with plastic lids were stored on a metal cart at room temperature before being placed on resident trays. During a concurrent test tray audit after the last lunch tray was served, pureed and regular foods were tested with a calibrated thermometer, and the chicken noodle soup measured 98 degrees F and did not feel warm in the mouth when tested. During the test tray assessment, the Dietary Manager stated the soup was just warm after tasting, and the Medical Records Director stated he would want the soup to be warmer after tasting it. The facility policy for In-Room Dining stated that hot foods on room trays at the point of service are preferred to be at 120 degrees F or greater to promote palatability for the resident.
Failure to Attempt GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDRs) were attempted for psychotropic medications for one resident who continued to receive olanzapine 15 mg at bedtime and trazodone 50 mg at bedtime without documented clinical contraindications to not attempting GDRs. The resident was admitted in February 2025 with diagnoses including schizophrenia, and the hospital transfer documents listed olanzapine for mood disorder manifested by constant yelling and/or screaming and trazodone for insomnia manifested by an inability to sleep. Review of the resident’s monthly MARs showed the medications were given nightly throughout the review period. Behavioral monitoring records from August 2025 through April 2026 showed no documented hallucinations, delusions, or verbal or physical behaviors directed toward others. The same records showed only seven nights of inability to sleep out of approximately 270 documented nights. A psychiatry note stated the resident had trouble maintaining attention and nearly fell asleep during the visit, and later notes stated the resident did not have behavioral problems and did not exhibit anxiety, irritability, agitation, or anger. The IDT meeting notes dated 2/11/25, 5/5/25, 7/23/25, 8/10/25, 10/24/25, 1/28/26, and 4/29/26 contained no documentation of behavioral concerns, sleep disturbances, or other symptoms that would contraindicate a GDR. The DON stated the resident had no documented inability to sleep during the prior three months and no behaviors during that period, and acknowledged that GDR was not performed. The consultant pharmacist recommended GDRs for trazodone and olanzapine, but the physician did not evaluate or address the trazodone recommendation and only selected a pre-populated denial option without individualized assessment; the olanzapine GDR was also denied without documented consideration of resident-specific risks, benefits, or clinical factors.
Failure to Complete MDS After Readmission
Penalty
Summary
The facility failed to ensure the MDS was completed for one sampled resident after readmission. Resident 194 was readmitted with diagnoses including aphasia, hemiplegia, hemiparesis, hypertension, and contracture. During observation, the resident was sleeping in bed with a blanket covering the resident and was receiving tube feeding, with a small white rolled washcloth placed on the contracted left hand. A signage for Enhanced Barrier Precautions was posted outside the room. During a concurrent observation and interview, Resident 194 was noted to have contractures on both hands and lower extremities and long, thick yellowish toenails. The CNA stated the toenails were for podiatry. During record review and interview with the MDS Coordinator, it was confirmed that the resident had been readmitted and that the last MDS had been completed when the resident left for hospital leave. The MDS Coordinator confirmed the MDS was not initiated for the resident's re-entry and stated it should have been completed within 14 days of readmission, noting, "It was missed. It should be done timely." The DON stated that the MDS accurately reflects the clinical situation of the patient and the services being provided.
Inaccurate MDS Coding of Resident Skin Conditions
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the skin conditions of two residents. For one resident admitted with rhabdomyolysis, weakness, and severe malnutrition, a concurrent wound treatment observation on the sacral area showed an unstageable pressure injury, and the resident’s Skin Assessment also documented an unstageable pressure injury on the sacrum. However, the MDS dated 4/18/26 coded the resident as having 0 pressure injuries. The MDS Coordinator acknowledged the coding was incorrect and stated it should have been coded as one unstageable pressure injury. For another resident admitted with an unstageable pressure injury, the Skin Assessment documented a surgical incision in the sacrum, and the Physician Assistant’s Progress Note stated the resident had a wound closure procedure and a surgical wound in the sacrum. Despite this, the MDS coded the resident’s skin condition as a stage 4 pressure injury instead of a surgical wound. The MDS Coordinator stated it should have been coded as a surgical wound, and the DON stated the MDS should match the nursing assessments and evaluations provided.
Failure to Reassess PASRR After New Psychotic Disorder Diagnosis
Penalty
Summary
The facility failed to coordinate PASRR for one sampled resident with a diagnosis of psychotic disorder. The resident was admitted with diagnoses including vascular dementia and urinary retention, and the face sheet later showed a diagnosis of psychotic disorder with delusions due to a known physiological condition with an onset during the stay. The resident’s MAR showed routine antipsychotic use, including quetiapine 25 mg daily for paranoid delusions and quetiapine 100 mg at bedtime for paranoid delusions, with behavior monitoring for paranoid delusions documented every shift. The resident’s MDS assessments identified psychotic disorder as an active psychiatric/mood disorder and noted antipsychotic medication use on a routine basis only. During interview and record review, the Admissions Director confirmed that only one PASRR Level I screening was in the record from the resident’s initial hospital admission and acknowledged there was no PASRR reassessment after the new psychotic disorder diagnosis and psychotropic medication use. The Admissions Director stated that PASRR should have been completed for the new diagnosis and psychotropics, but no new screening was found.
Baseline Care Plan Summary Not Provided
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan within 48 hours of admission to two sampled residents, Resident 198 and Resident 197, or their representatives. Resident 198 was admitted with diagnoses including urinary tract infection and Alzheimer's disease. During observation and interview, Resident 198's representatives stated they did not receive a copy of the baseline care plan. Review of Resident 198's baseline care plan dated 4/23/26 showed the sections for resident and/or representative participation, written summary provided, recipient, date, and method were left blank, and progress notes from 4/23/26 through 4/25/26 contained no documentation that a written summary was given. An LVN stated there was no documentation that the team had given Resident 198 a copy of the baseline care plan. Resident 197 was admitted with spinal stenosis and was documented as cognitively intact on the MDS. Resident 197 stated they make decisions for themselves and said they did not receive a copy of the baseline care plan. Review of Resident 197's baseline care plan dated 4/20/26 showed the sections for resident and/or representative participation, written summary provided, recipient, date, and method were left blank, and progress notes from 4/19/26 through 4/21/26 contained no documentation that a written summary was provided. An LVN stated that a copy of the baseline care plan was not given to Resident 197 and that providing a written copy is important so there is a clear path of the plan of care and understanding of what was discussed.
Unsecured OTC Medications Left Accessible in Resident Room
Penalty
Summary
The facility failed to maintain a safe resident environment when Resident 147’s over-the-counter medications were left unsecured in the resident’s room and accessible to other residents. During observation on 4/28/26 at 9:46 AM, three bottles of OTC medications were seen on the bedside table, including folic acid, zinc, and a men’s multivitamin. These items were not secured and were accessible in the room. During interview, the DON stated that the resident had a habit of buying many OTC medications and supplements and that the facility treated them as the resident’s personal belongings. The DON later observed the room and confirmed the OTC medications were accessible near the resident’s bed while the resident was asleep and not using them. LVN 5 stated that the resident’s OTC medications in the room were not used for daily medication administration and that only the medication cart was used to supply the resident’s OTC medications. On 5/1/26 at 10:34 AM, the three bottles were still accessible and unsecured in the room.
Improper Disposal of Unidentified Medications
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not maintained when non-controlled medications were improperly disposed of in a sharps container. During observation of medication cart 3A, an LVN was seen finding and placing two unidentified loose pills into the sharps container on the side of the cart. The NUM stated that staff should have checked and properly disposed of unidentified loose tablets to reduce the risk of medication errors and drug diversion. The DON stated that unidentified loose pills should not have been disposed of in the sharps container and should have been placed in the designated pharmaceutical bins. The facility policy titled, Discarding and Destroying Medications, stated that both controlled and non-controlled substances may be disposed of in the collection receptacle.
Failure to Address GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified, recommended, and followed up on needed medication regimen changes for one resident who had been receiving olanzapine 15 mg at bedtime and trazodone 50 mg at bedtime since admission from an acute care hospital in February 2025. The resident’s hospital transfer documents listed olanzapine for mood disorder with constant yelling and/or screaming and trazodone for insomnia, and monthly MARs showed both psychotropic medications were continued nightly for over 14 months. The record showed that the Consultant Pharmacist’s 9/9/25 recommendation for trazodone GDR was not evaluated or addressed by the physician, and only a pre-populated denial option was selected without individualized assessment, clinical contraindication, resident-specific justification, or rationale. The Consultant Pharmacist’s 9/9/25 recommendation for olanzapine GDR was also denied without documented physician consideration of risks, benefits, or resident-specific clinical factors. IDT meeting notes dated 2/11/25, 5/5/25, 7/23/25, 8/10/25, 10/24/25, 1/28/26, and 4/29/26 contained no documentation of behavioral concerns, sleep disturbances, or other symptoms that would contraindicate a GDR of psychotropic medications, and the CP stated during interview that she had not made any recommendations for the resident and that the number of hours of sleep was not documented.
Medication Storage and Expired Insulin
Penalty
Summary
The facility failed to ensure medications were stored according to manufacturers’ specifications. During an inspection of the third-floor medication room, a 10 mL vial of brimonidine 0.1% eye drops was observed stored in the medication refrigerator at 38 degrees F, even though the manufacturer’s printed storage instructions on the box indicated the medication should be stored between 68 and 77 degrees F. The Nursing Unit Manager stated the eye drops should have been stored at room temperature, and the Director of Nursing stated that cold temperature could denature the medication and that the eye drops needed to be discarded and the pharmacy notified. The facility also had an expired 10 mL vial of insulin glargine available for use in medication cart Mod #1 on the second floor. The vial had been opened on 3/25/26 and had an expiration date of 4/22/26. The Director of Nursing stated the expired insulin glargine should have been removed from the medication cart because expired medications may not be effective, and stated the expectation was to check expiration dates at the beginning of each shift and remove expired medications. The prescribing information for insulin glargine stated used vials should be thrown away after 28 days, even if insulin remains.
Failure to Provide Nutritionally Equivalent Substitute Meals and Adequate Mealtime Support
Penalty
Summary
The facility failed to provide an entree of similar nutritive value to a resident who chose not to eat the planned menu entree. On 4/27/26, the lunch menu for a regular, consistent carbohydrate diet included Beef Tater Tot Casserole, which had a total protein content of 29.61 grams. During trayline observation, the resident’s tray ticket showed a standing order for a grilled cheese sandwich instead of the menu entree. The sandwich was prepared with two slices of American cheese, and the Registered Dietitian later confirmed the grilled cheese served did not equal the nutritional value of the planned entree. The facility’s own recipe analysis showed the grilled cheese recipe contained 20.40 grams of protein, while the sandwich actually served contained 11 grams of protein, which was less than the planned entree. The facility also failed to ensure adequate nutritional intake and individualized meal support for a second resident with significant communication and mobility limitations. This resident had a history of cerebral infarction with right-sided hemiplegia and hemiparesis, aphasia, and was documented as nonverbal and communicating by head nods. During observation, staff asked whether the resident wanted to eat, covered the tray, and left the room when there was no response. On another observation, the resident ate fries, pudding, fruit, and the bun but left a whole hot dog untouched; an LVN offered to cut the hot dog but did not do so and stated it was too large for the resident to eat. The Speech Pathologist stated the resident could swallow liquids and solid foods and was not at risk for choking, while the RD stated the resident’s intake was better when family visited and that the resident consumed only about 25 percent of meals. Facility records showed repeated poor intake and meal refusals over several months for this resident. Monthly follow-up reports documented that many meals were eaten at 0% to 25% or refused, including nearly half of meals in January and February 2026, nearly three-quarters in March 2026, and two-thirds in April 2026. The monthly dietary notes repeated the same language, including that family or friends were not always present to encourage intake and that the plan of care would continue, while also documenting that the resident refused food and pushed the tray away. The care plan identified nutritional risk related to aphasia, but the intervention to determine food and beverage preferences had last been revised in 2023. The resident’s diet orders included regular texture, thin liquids, enteral feedings, and protein modular supplements, and speech therapy documentation continued to describe finger foods and inconsistent response to encouragement while attributing poor intake to the resident’s behavior. The facility policy stated staff should interview the resident to determine food preferences and create a care plan if the resident refused or was unhappy with the diet, and that documenting meal refusal due to non-compliance with diet orders was not appropriate.
Arbitration Agreement Not Fully Explained to Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure Resident 133 entered into a legally binding arbitration agreement only after fully understanding its terms, and the required explanation of the agreement was not provided in a form and manner the resident could understand. During an observation and interview in the resident’s room, Resident 133 and the resident’s friend were shown a paper copy of the arbitration agreement that had been signed earlier, and Resident 133 stated they did not remember signing it and did not know what the document was. The friend stated that Resident 133 does not have a good memory. Record review showed the arbitration agreement for Resident 133 was signed by the resident and later by the Admissions Assistant. The Admissions Assistant stated that Resident 133’s primary language is Vietnamese and that a Vietnamese-speaking nurse helped translate and review the five-page arbitration agreement with the resident, but there was no witness signature documented. The Marketing-Admissions Note stated that the admissions packet was reviewed at the bedside with translation assistance and that Resident 133 verbalized understanding, but it did not describe how the extensive and complex packet, including the arbitration agreement, was reviewed with a resident who had a BIMS score of 10, indicating moderately impaired cognition.
Urinary Catheter Tubing and Drainage Bag Left on Floor
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a resident with an indwelling urinary catheter had the catheter tubing and urine drainage bag touching the floor. Resident 195 was admitted with diagnoses including dementia and urinary retention. During the initial tour on 4/27/2026 at 10:05 AM, the resident was in bed with a urinary catheter attached to an uncovered urine drainage bag positioned under the bed and touching the floor. During a later observation on 04/29/2026 at 1:02 PM, the resident was sitting at the edge of the bed eating lunch, and the urinary catheter tubing was resting on the floor with the catheter tube clip not anchored on the bed rail. During interviews on 4/29/2026, CNA 4 acknowledged the catheter tubing clip was not anchored on the bed rail and stated that clipping the tubing to the bed rail prevents the catheter from pulling out and keeps it in place when in bed, and that the tubing and drainage bag should be above the floor. LVN 4 stated the clip should be secured to prevent dislodgement and to prevent the tubing from touching the floor for infection control. The Infection Preventionist stated the tubing and urine drainage bag should not touch the floor because of germs on the ground and said it was an infection control concern. The resident's order summary required the indwelling catheter to be in a privacy bag and secured with an anchoring device, and the care plan included using a catheter anchor and keeping the catheter anchored for security and to prevent trauma. The facility policy also stated the catheter tubing and drainage bag should be kept off the floor.
Kitchen Window Screen Left Gap to Outside
Penalty
Summary
The facility failed to maintain a pest control program to prevent or deal with mice, insects, or other pests when a kitchen window screen was not fully attached to the window frame, leaving a gap to the outside. Facility policies reviewed stated that defective or bent screens should be replaced or repaired and that windows are to be screened at all times. During an observation in the kitchen, a window was open and the screen was not completely attached, creating an opening. The Dietary Manager confirmed the gap between the open window and the screen and stated he had not submitted a work order because he had not noticed it before. The Maintenance Director stated the screen may have been broken the last time it was removed for cleaning and acknowledged that pests could probably fit through the gap. The Dietary Manager later stated the gap between the window frame and the broken screen was at least 1/2 inch.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and staff and resident reports of cockroach infestations in several resident rooms. During an observation, live and dead cockroaches were found in a resident's room, including on the floor, trash bin, nightstand, and inside a nightstand drawer containing food items. Food particles and brownish discolorations were also noted on the floor. Staff, including CNAs and LVNs, acknowledged the ongoing presence of cockroaches throughout the facility, with one CNA stating that every room had roaches. Housekeeping staff confirmed that some rooms had been fumigated and cleaned, but sightings persisted, and not all affected rooms were included in the cleaning or fumigation schedule. A resident reported seeing multiple cockroaches in his room and stated that his room had not been fumigated or inspected by pest control after he raised the issue during a resident council meeting. Review of pest control service reports and facility cleaning schedules confirmed that certain rooms with reported infestations were not serviced or deep cleaned. The facility's pest control agreement indicated a primary concern of active cockroach infestation with facility-wide risk, but documentation showed that only a limited number of rooms were serviced per visit, and some affected rooms were omitted. The facility's policy required ongoing pest control, but the observed and reported conditions demonstrated a failure to implement an effective program.
Failure to Safeguard Resident's Personal Property and Document Valuables
Penalty
Summary
The facility failed to safeguard the personal property of a resident who reported a black pouch containing cash missing after being readmitted from the hospital. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, stated that the pouch with $2,000 was left in his room prior to hospitalization. The resident had previously shown a CNA $1,000 in the pouch, and the CNA confirmed witnessing this amount. However, the pouch and cash were not documented in the resident's inventory of personal effects as required by facility policy. Upon the resident's return, he reported the missing pouch and cash, expressing significant emotional distress, including sadness, tearfulness, and feelings of distrust toward staff. Multiple staff interviews and record reviews confirmed that the CNA had seen the pouch and cash but failed to update the inventory or ensure the valuables were secured in the facility's safe, as per policy. The resident continued to experience emotional distress related to the loss, requiring ongoing support from the social worker and referral to a psychologist. The facility's investigation did not find evidence of wrongdoing by staff, residents, or visitors, and the missing items were not recovered. The CNA involved received in-service training on the proper process for documenting resident property and the facility's procedures for safeguarding valuables. Despite these measures, the initial failure to document and secure the resident's cash resulted in its loss and ongoing emotional impact on the resident.
Failure to Investigate and Safeguard Resident's Missing Cash
Penalty
Summary
The facility failed to thoroughly investigate a resident's report of missing personal property, specifically a black pouch containing cash. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, reported that the pouch with approximately $2,000 was missing following a transfer to the hospital. The resident had previously shown a Certified Nursing Assistant (CNA) $1,000 in the pouch, and the CNA confirmed seeing and returning the pouch to the resident in the weeks prior to its disappearance. However, the pouch and cash were not documented in the resident's inventory, and the facility did not take further action after the CNA verified the presence of the cash. The investigation conducted by the facility included interviews with staff and review of documentation, but no evidence or report of wrongdoing by staff, residents, or visitors was found. The interdisciplinary team determined that the allegation was unverified, and the missing items were not recovered. The CNA involved received training on the proper process for documenting resident property and the facility's policy for safeguarding valuables, but this was after the incident had occurred. Throughout the process, the resident experienced significant emotional distress, including tearfulness, sadness, and feelings of distrust toward staff. The resident continued to express sadness and depression related to the loss of the cash, and social services provided ongoing support and referred the resident to a psychologist. The facility's policies required inventorying resident belongings and safeguarding valuables, but these procedures were not followed in this case, contributing to the loss and the resident's emotional response.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
A resident with a history of hypertension and pulmonary embolism, and documented moderate cognitive impairment, was observed self-administering medications without the required assessment and approval from the interdisciplinary care planning team. The resident had an unlabeled transparent medicine cup containing two tablets, which she identified as Eliquis and Metoprolol, on her overbed table. She reported that a nurse had left the medications for her earlier so she could take them later. Review of the resident's clinical records by the Director of Nursing confirmed that there was no documented evaluation or care plan for self-administration of medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary team have determined the resident has the decision-making capacity to do so safely. This policy was not followed in this instance.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
A deficiency was identified when a resident's fingernails were observed to be unclean, with black-colored matter present under all fingernails. The resident reported that no one had come to clean her nails despite her repeated requests, expressing dissatisfaction with the condition of her nails. During the observation, an LVN confirmed the presence of dirt under the nails and acknowledged that this could be an infection issue, emphasizing the need to keep nails clean to prevent infection. The DON stated that CNAs are responsible for daily cleaning of residents' fingernails to prevent infection. Review of the facility's policy indicated that daily cleaning and regular trimming of nails are required to prevent infections and skin problems around the nail bed.
Failure to Address Sleep Disturbances and Behavioral Symptoms
Penalty
Summary
The facility failed to provide appropriate care and treatment for two residents with significant needs. One resident, admitted with diagnoses including squamous cell carcinoma and diabetes, reported ongoing difficulty sleeping due to another resident's persistent yelling and screaming at all hours. Despite repeated complaints to nursing, social work, and management, the only intervention provided was a headphone, which was ineffective. There was no assessment, monitoring, or care plan developed to address the resident's sleep difficulties, and the grievance was not documented or addressed according to facility policy. Another resident, diagnosed with dementia and encephalopathy, exhibited ongoing behavioral disturbances including yelling, screaming, paranoia, and insomnia. Staff interviews and record reviews confirmed that these behaviors were persistent and disruptive, occurring day and night, and were documented in multiple psychiatry notes. Despite this, there was no care plan or interventions implemented to address the resident's insomnia and paranoia, and the behaviors were not accurately reflected in the Minimum Data Set (MDS) assessments. The facility's interdisciplinary team did not evaluate or monitor these behavioral symptoms as required by policy. Facility policies reviewed indicated requirements for accommodating resident needs, providing a homelike environment, addressing grievances, and developing comprehensive, person-centered care plans based on thorough assessments. However, these policies were not followed in the cases of the two residents, resulting in unaddressed sleep disturbances for one and unmanaged behavioral symptoms for the other. The lack of assessment, care planning, and intervention contributed to ongoing issues for both residents.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer two residents to the appropriate state-designated authority for a Level II PASARR evaluation after they were diagnosed with newly evident mental illnesses. Resident #56, admitted in 2016, was diagnosed with a psychotic disorder with delusions in 2021, but there was no evidence of a referral for a Level II PASARR. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and the care plan included the diagnosis of psychotic disorder. Similarly, Resident #86, admitted in 2019, received multiple mental illness diagnoses, including psychotic disorder with hallucinations, psychosis, and adjustment disorder with anxiety, but was not referred for a Level II PASARR. The resident's MDS showed severe cognitive impairment, and the care plan noted the use of psychotropic medication for the psychotic disorder. The facility's policy on admissions criteria did not specify procedures for staff to follow when a resident is diagnosed with a new or possible serious mental disability. During interviews, the Director of Nursing (DON) stated that a new Level I PASARR would be conducted if a resident received a new mental illness diagnosis. However, the DON indicated that a new PASARR would only be done if the severe mental illness caused a significant change in the resident's condition, which was not the case for Residents #56 and #86. This lack of referral for a Level II PASARR evaluation represents a deficiency in the facility's compliance with regulatory requirements for preadmission screening and resident review.
Failure to Complete PASARR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to complete a new Level I PASARR screening for a resident with a diagnosis of schizophrenia, as required by the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. If the Level I screening suggests the presence of such conditions, a referral for a Level II evaluation is necessary. The resident in question was admitted with a medical history of schizophrenia and was receiving haloperidol, an antipsychotic medication, indicating the need for a Level II evaluation. The California Department of Health Care Services (DHCS) attempted to conduct a Level II evaluation but was unable to complete it due to the facility's lack of response to multiple communication attempts. A letter from DHCS indicated that the facility staff did not respond to two or more separate attempts within 48 hours following the resident's Level I screening. The Director of Nursing acknowledged that the facility missed the calls and failed to follow the instructions in the letter to redo the Level I PASARR, resulting in the deficiency.
Medication Reconciliation Error at Discharge
Penalty
Summary
The facility failed to accurately reconcile post-discharge medications for a resident, leading to the resident being discharged with another resident's medications. This incident involved a resident with a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The discharge summary note indicated that the resident was discharged with a Post-Discharge Plan of Care form filled out and signed by the patient, with all medications and follow-up appointments reviewed. However, the Licensed Vocational Nurse (LVN) responsible for the discharge did not open the bag of medications to verify its contents against the discharge medication list. The error was discovered when the resident's sister returned to the facility with a bag of medications labeled for a different resident. The Nurse Manager confirmed that the returned medications were intended for another resident, as evidenced by the labels on the blister packs. The Director of Nursing stated that the expectation was for nursing staff to verify the medications against the discharge list before discharge, which was not done in this case.
Failure to Timely Execute Physician's Order for MRI
Penalty
Summary
The facility failed to provide necessary care and services to a resident when a physician's order for an MRI was not carried out in a timely manner. The resident, who suffers from chronic pain syndrome, expressed severe pain and a desire to understand the cause of their condition, including concerns about potential cancer. Despite the physician ordering an MRI on 3/25/24, the order was not acted upon promptly. The night nurse saw the order on 3/26/24 but did not inform the social worker responsible for outpatient referrals. This oversight led to the MRI not being scheduled, and the physician had to re-order it on 4/17/24. Interviews with the resident, LVN, SW, and DON revealed that the breakdown in communication and failure to follow the facility's policy on medication and treatment orders contributed to the delay. The DON confirmed that the physician's order should have been communicated to the appropriate staff and carried out as soon as possible. The facility's policy requires licensed nurses to record and act on physician orders immediately, but this protocol was not followed, resulting in a delay in the resident receiving the necessary diagnostic imaging.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure that prescribed medication was available for administration to a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who relies on a Trelegy Ellipta inhaler to manage their condition, reported experiencing chronic shortness of breath. A review of the resident's Medication Administration Record (MAR) revealed that the inhaler was not administered on multiple occasions in February 2024 due to the medication being out of stock. The Director of Nursing (DON) confirmed that the medication was not given because it had not been reordered in a timely manner by the licensed nurses, despite the facility's policy requiring medications to be ordered in advance based on the pharmacy's lead time. During an interview, the DON acknowledged that the failure to have the Trelegy Ellipta inhaler available could worsen the resident's respiratory symptoms and emphasized the importance of communication with the doctor. The resident's progress notes indicated that the medication was out of order on several dates, and although it was reordered, it was not available for administration. This lapse in medication management created a risk for poor health outcomes for the resident.
Communication and Transportation Failures
Penalty
Summary
The facility failed to ensure effective communication and proper care planning for Resident-A, leading to significant deficiencies. Resident-A's son reported that the social worker did not return his calls or texts on five different occasions, which hindered communication about his father's care. Additionally, the facility mismanaged transportation arrangements, resulting in the cancellation of Resident-A's doctor's appointments on two separate dates. This lack of coordination and communication potentially impacted Resident-A's clinical condition and psychosocial well-being. Resident-A was admitted with multiple diagnoses, including cerebral infarction, enterocolitis due to clostridium difficile, urinary tract infection, type 2 diabetes, and frequent falls. His cognitive skills were moderately impaired, as indicated by a BIMS score of 9. Despite these complex medical needs, the facility failed to ensure that Resident-A's appointments were kept and that his family was adequately informed about his care. The social worker's failure to return calls and the facility's disorganized transportation scheduling contributed to these deficiencies. Interviews with facility staff, including the social worker and the director of nursing, revealed a lack of accountability and documentation regarding the missed appointments and communication failures. The transportation company also indicated that they were not solely responsible for the missed appointments, as the facility used multiple transportation providers and often made last-minute requests. The facility's policies on transportation and resident rights were not effectively implemented, leading to the observed deficiencies in Resident-A's care and communication with his family.
Failure to Meet Nutritional Needs of Non-Diabetic Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident who was not diabetic but was placed on a Controlled Carbohydrate Diet (CCHO) since admission. This resident, who had severe cognitive impairment and multiple diagnoses including burns, hyperkalemia, and dysphagia, experienced a significant weight loss of almost 10 lbs. from September 24, 2023, to November 17, 2023. The resident's clinical record did not indicate diabetes mellitus as a diagnosis, and the CCHO diet order was carried over from the hospital without proper verification by the facility staff. The resident's poor appetite and significant weight loss were not adequately addressed by the facility's dietary and medical staff, leading to a decline in the resident's clinical health and well-being. Interviews with various staff members, including the unit managers, social worker, dietary manager, and registered dietitian, revealed a lack of awareness and coordination regarding the resident's dietary needs and weight loss. The dietary manager and registered dietitian were new to the facility and were not fully informed about the resident's condition and dietary requirements. The registered dietitian noted that the resident had a poor appetite and was on a puree texture diet with Boost supplements three times a day, but the resident's meal intake was only about 51%. The resident's daughter also confirmed that her mother was placed on a diabetic diet despite not being diabetic and that her mother's weight and appetite improved after being discharged and cared for at home. The facility's policies on weight assessment and intervention were not effectively implemented, as evidenced by the lack of timely and appropriate actions to address the resident's significant weight loss. The care plan for the resident included multiple focus areas such as nutritional risk, nausea and vomiting, dehydration, and weight loss, but the interventions were not adequately followed. The facility's failure to monitor and address the resident's nutritional needs and weight loss in a timely manner resulted in a decline in the resident's health and well-being.
Unnecessary Drug Administration and Mismanagement of Resident's Drug Regimen
Penalty
Summary
The facility failed to ensure that a resident, who had no diagnosis of diabetes mellitus, was free from unnecessary drugs and interventions. The resident was admitted with diagnoses including burns, hyperkalemia, and dysphagia, but not diabetes. Despite this, the resident had an order for a sliding scale of insulin Lispro and received it multiple times. Additionally, the resident's blood glucose was checked three times a day over a period of nearly a month, with levels ranging from 112 to 188. The resident was also placed on a Controlled Carbohydrate diet, which was later discontinued by a new registered dietitian who noted the resident's poor appetite and weight loss. The resident's daughter confirmed that her mother was not diabetic and questioned the blood sugar checks and diabetic diet. The facility's medical doctor acknowledged that the resident's hemoglobin A1C was 6, which is considered pre-diabetic according to the American Diabetes Association, and not diabetic. The MD stated that the sliding scale insulin was discontinued because the resident was well-controlled, but it was unclear who had initially ordered it. The facility's policy on administering medications emphasizes that medications should be administered as prescribed and that any concerns about inappropriate or excessive dosages should be discussed with the prescriber. However, this policy was not followed in the case of this resident. The facility's failure to adhere to its own medication administration policy and the mismanagement of the resident's drug regimen potentially compromised the resident's mental, physical, and psychosocial well-being. The care plan for the resident included a diagnosis of diabetes, which was incorrect according to the resident's daughter and the medical records. This misdiagnosis led to unnecessary interventions, including insulin administration and blood glucose monitoring, which were not clinically indicated for the resident's actual medical condition.
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What surveyors actually found near you
We read the 976 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Francisco Towers | 0 mi | ★★★★★ | 12 | 0 |
| Victorian Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Sequoias San Francisco Convalescent Hospital | 0.6 mi | ★★★★★ | 13 | 0 |
| Chinese Hospital D/p Snf | 0.7 mi | ★★★★★ | 19 | 0 |
| Central Gardens Post Acute | 0.7 mi | ★★★★★ | 0 | 0 |
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