Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clara Baldwin Stocker Home For Women during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and dementia was transferred to GACH and then LTACH, where the discharge plan remained return to SNF. SNF staff said the resident needed a private room due to C. auris status and initially had no appropriate bed, but LTACH staff reported repeated attempts to arrange readmission and SNF leadership was unaware the resident was still pending return. Facility census and admission logs showed private room availability and other admissions during the period, while the facility policy stated residents may return upon the first available bed.
Surveyors found that the facility did not maintain a documented maintenance schedule for its two AC units and relied only on undocumented daily visual checks by maintenance staff. One AC unit was not working while a belt was being changed, and another had been nonfunctional previously. An AC technician reported that the units required monthly PM, including filter changes and testing of water valves and pneumatic controls, but these tasks were not part of the facility’s PM program. Review of the facility’s maintenance policy showed that the Maintenance Director was required to develop and maintain maintenance schedules for building systems, which was not done, creating the potential for residents in general to lack a comfortable environment.
A resident with encephalopathy, COPD, and dysphagia, who was cognitively impaired and dependent on staff for ADLs, had a physician order for weekly weights for four weeks after readmission. Review of the weight records showed the resident had not been weighed since an earlier documented date, and the resident’s name was missing from the facility’s weekly weight binder used to track residents needing weekly weights. The DON confirmed that weekly weights had not been obtained as ordered, despite a facility policy requiring weekly weights for newly admitted residents.
Missing Advance Directive Copies in Resident Charts: The facility failed to obtain and maintain copies of ADs for four residents. Records and staff interviews showed each resident had an AHCD/AHDA indicating an AD was in place, but the copies were not in the medical charts. The residents had varied conditions including intact or impaired cognition, dementia, metabolic encephalopathy, heart failure, and a recent fracture with fall history, and the SSD confirmed the facility did not have the AD copies.
Psychotropic Medication Orders Lacked Specific Behavioral Indications: The facility failed to ensure two residents had adequate, specific indications documented for antipsychotic use and behavior monitoring. One resident with dementia and psychosis had quetiapine ordered for agitation, and another resident with Alzheimer's disease had olanzapine ordered for manic episodes, but staff and the DON stated the orders did not identify specific behaviors for monitoring or clear indications for use. The facility policy stated antipsychotics should be used only for specific conditions and with documented information about the resident's behavior and symptoms.
A resident with Parkinson’s disease and other diagnoses remained on Diclofenac gel and Tizanidine after the pharmacist recommended MD assessment of effectiveness and possible dose reduction or adjustment, but the chart did not show the MD assessment. In a separate case, a resident with dementia, psychosis, and depression had an MRR recommending review of the risks and benefits of continuing Aricept and Seroquel, but although the physician disagreed, the record did not include the physician’s rationale. The DON confirmed the missing documentation.
Incomplete and Inaccurate Resident Diagnosis Documentation: The facility failed to keep accurate and complete diagnosis information in two residents’ records. One resident’s AR/facesheet did not include diabetes even though the H&P documented DM and staff confirmed the resident was receiving insulin for diabetes. Another resident’s AR and MDS listed BPD, but the H&P did not show BPD and the MD stated the resident did not have that diagnosis; the MDSC said the diagnosis was entered based on the resident’s olanzapine order.
Failure to notify MD of resident’s eye change in condition. A resident with Alzheimer’s disease and severely impaired cognition was observed with redness in the left eye, later with white discharge. The family member reported the redness to staff and was told it would be taken care of, but the MD was not notified and there was no documented evidence of physician notification before the SBAR note documented the eye findings.
Failure to update a resident’s care plan after G-tube removal. A resident admitted with dysphagia and a feeding tube had care plan entries for G-tube feeding and a G-tube site on the abdomen, but the care plan was not revised after the tube was removed. The OSR showed a diet change to regular with soft and bite-sized texture and double protein, and the LVN and DON stated the CP should have been updated to reflect the resident’s current nutrition status and to monitor the G-tube site for healing and infection.
A resident with Alzheimer's disease and dementia was given olanzapine for BPD, but the facility could not justify the diagnosis based on a comprehensive assessment. The resident had agitation, yelling, striking at staff, and resistance to care on admission, and an active UTI may have contributed to the behavior. The MD stated the resident did not have BPD and that the diagnosis may have been entered by mistake, while the DON said the admitting nurse incorrectly matched the medication to BPD.
A resident with severe cognitive impairment, total dependence for transfers and toileting, and diagnoses including Parkinson's disease and DM had an order for an LAL mattress to be monitored each shift for proper functioning and pressure relief. Staff found the mattress set and locked at 450 lbs instead of the indicated 150-lb setting, and an LVN stated the higher setting made the mattress too firm and could cause pressure injuries and redness.
Failure to administer ordered zinc ointment for a resident with a sacral PU. The resident stated the medication was not applied, yet the MAR was marked as given. An LVN confirmed the dose was documented as administered even though it was not actually provided.
A resident with arthritis, a R knee infection, muscle weakness, and morbid obesity had several ointments stored in the room closet, including bacitracin zinc, Activon, and clotrimazole cream. The resident said the meds were provided by the facility and kept in the closet, while an LVN stated meds are not supposed to be left in the room and did not know who provided them. The facility policy required drugs and biologicals to be stored in locked compartments.
A resident requiring moderate assistance with daily activities was discharged to an assisted living facility without being offered choices or adequate time to consider alternatives. The family was not provided with a list of options, and the only facility presented was identified shortly before discharge, contrary to facility policy and the resident's need for family support.
A resident with severe cognitive impairment and multiple health conditions was observed with new discoloration and redness on the arm after reporting that a CNA had grabbed them during a transfer, causing pain. Two LVNs noted the resident's distress and reported the incident to the DON, who recognized it as a possible abuse case. Despite facility policy requiring abuse allegations to be reported to the State Agency within two hours, the report was delayed by two days.
The facility did not follow its policy for N95 fit testing, failing to test a newly hired CNA, which is required upon hire and annually. This oversight was acknowledged by the DSD and highlighted by the IPN as crucial for preventing airborne disease transmission.
Two residents with severe cognitive impairment had their call lights out of reach, leading to delayed assistance. One resident's call light was tucked under the mattress, while another's was hooked around a dresser. A CNA and the DON confirmed the importance of accessible call lights for safety and communication, as per facility policy.
The facility failed to adhere to physician orders and document care for three residents. A resident with seizures did not have padded side rails as ordered, hospice staff did not consistently document visits for another resident, and a STAT chest x-ray was delayed for a third resident. These deficiencies highlight lapses in following care plans and ensuring timely medical interventions.
The facility failed to prevent employee beverages from being stored in a kitchen refrigerator alongside resident food items, as observed during an inspection. The Dietary Supervisor confirmed that the beverages belonged to employees and acknowledged the risk of cross contamination. This practice was against the facility's policy, which prohibits storing employee food in the kitchen refrigerator.
The facility failed to maintain its infection prevention and control program, with unlabeled urinals in shared restrooms, a lack of disinfection of a pill counting tray by an LVN, insufficient hand hygiene supplies in the laundry area, and a Housekeeping Supervisor not performing hand hygiene after touching the dumpster. These deficiencies could lead to cross-contamination and increased infection risk among residents and staff.
A facility failed to conduct a comprehensive communication assessment for a resident who primarily spoke Arabic, as required by policy. The resident, with multiple medical conditions, needed an interpreter to communicate effectively. Staff attempted to communicate using non-verbal cues without any tools, which was inadequate. A nurse confirmed the necessity of a communication assessment to provide proper care.
A facility failed to implement a person-centered care plan for a resident who only spoke Arabic, despite the resident's need for an interpreter being documented. The resident, with conditions including hemiplegia and dysphagia, was observed attempting to communicate with staff who did not use any communication tools. The absence of a communication care plan was confirmed by a Registered Nurse, highlighting a deficiency in meeting the facility's policy for effective and person-centered care.
A resident who spoke Arabic was not provided with communication tools, hindering effective communication of care needs. Despite the facility's policies on language access, staff relied on gestures and limited English, failing to use appropriate resources to assist the resident, who had multiple medical conditions requiring clear communication.
A resident receiving hemodialysis did not have an emergency kit at their bedside, which is crucial for addressing potential bleeding emergencies. The resident, with end-stage renal disease and type 2 diabetes, required dialysis thrice weekly. An LVN could not find the kit during an inspection, and the DON confirmed the facility's policy did not explicitly require it, despite its necessity for immediate response.
A resident with an indwelling foley catheter was observed with dark amber urine containing sediments, indicating a potential infection. Despite daily catheter care, the abnormal urine appearance was not reported to the physician, contrary to the facility's policy. The resident had a history of Alzheimer's, psychosis, and hypertension, and the catheter was ordered due to uropathy.
A facility failed to provide an emergency kit at the bedside of a resident requiring hemodialysis, potentially delaying emergency treatment. The resident, with end-stage renal disease and diabetes, needed dialysis thrice weekly. An LVN could not find the kit, which is crucial for addressing bleeding from the dialysis site. The DON confirmed the policy did not specify the need for a bedside kit, leading to the deficiency.
A facility failed to justify the use of fluoxetine for a resident with dementia and mild depression, lacking documentation for a gradual dose reduction (GDR) and non-pharmacological interventions. Staff interviews indicated the resident did not show depressive symptoms, and the prescriber did not document why GDR was contraindicated, contrary to facility policy.
The facility failed to properly label and discard medications in Med Cart 2, including a bottle of Geri Care Stool Softener and a box of Alka-Seltzer, which were not marked with an opened date. Staff interviews revealed inconsistencies in following the facility's protocol, which required labeling to ensure medications were not used past the recommended due date. The facility's policy required proper labeling in accordance with guidelines, indicating a lapse in adherence.
The facility failed to secure its premises, leaving the back door unlocked after dark and allowing unauthorized access. Observations showed the staff parking area gate was open, and several LVNs were unaware of how to lock the facility doors. The DON acknowledged the broken gate chain and emphasized the importance of locking doors for safety. Despite policies on safety, staff lacked training on securing the facility, putting 37 residents at risk.
The facility failed to provide adequate isolation supplies for two residents with C. diff infection, as they did not have their own package of incontinent wipes during the night shift. Staff interviews revealed a lack of sufficient wipes and uncertainty about obtaining more supplies, contrary to the facility's policy requiring dedicated equipment for isolated residents.
A resident with severe cognitive impairment was not readmitted to the first available bed at the facility after hospitalization, violating the facility's policy. Staff interviews confirmed the refusal was against policy, and the Administrator later acknowledged the error.
Failure to Readmit Resident to First Available Private Room
Penalty
Summary
SNF 1 failed to ensure Resident 1 was permitted to return to the first available private room after the resident was transferred to GACH 1 and then to LTACH 1. Resident 1 had been admitted to SNF 1 with diagnoses including hemiplegia, hemiparesis following cerebral infarction, and dementia. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS later described the resident as severely cognitively impaired and needing partial/moderate assistance with most ADLs. The record showed LTACH 1 identified Resident 1 as appropriate for return to SNF 1 and initiated a request for readmission, with the discharge goal remaining transfer back to a SNF. SNF 1's ACD stated the resident needed a private room because of C. auris status and that no appropriate bed was available at the time of the initial inquiry. However, LTACH 1's SW stated multiple attempts were made to contact the facility after the initial request, and SNF 1's DON stated she was unaware the resident remained pending return. Facility census and admission logs showed multiple beds, including private room availability, became available during the period in question, and other residents were admitted into available beds. The facility policy stated residents may return after hospitalization and are to be permitted to return immediately upon the first availability of a bed, with another area of the facility offered if the previous room was unavailable.
Failure to Maintain AC Preventative Maintenance Schedule and Critical Component Testing
Penalty
Summary
The facility failed to maintain a documented maintenance schedule for its two air conditioning (AC) units and did not include testing of water valves and pneumatic controls in its preventative maintenance program. During interviews, the Maintenance Supervisor (MS) reported that the facility had two AC units, with the front unit currently working and the back unit not working due to a belt change. The MS stated that the front unit had not been working approximately two months earlier. The MS explained that the only preventative maintenance performed on the AC units was a daily visual inspection, and that the facility did not keep any log or documentation of these daily checks. In a telephone interview, the AC technician stated that they had been called to the facility a few weeks earlier for AC issues and indicated that the facility’s AC units required monthly preventative maintenance, including changing filters, testing water valves, and testing pneumatic controls. The MS reported that the AC technician had previously informed them that the problem with the AC unit was related to water valves on the roof that needed to be exercised (opened and closed). Review of the facility’s Maintenance Service policy, revised December 2009, showed that the Maintenance Department was responsible for maintaining buildings, grounds, and equipment in a safe and operable manner, providing routinely scheduled maintenance service, and that the Maintenance Director was responsible for developing and maintaining a schedule of maintenance service and maintaining maintenance schedules. The failure to maintain such schedules and to include testing of water valves and pneumatic controls in preventative maintenance had the potential for residents in general not to have a comfortable environment while at the facility.
Failure to Obtain Ordered Weekly Weights for Newly Admitted Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to obtain weekly weights as ordered and as required by its own policy. A resident was admitted with diagnoses including encephalopathy, COPD, and dysphagia, and was documented on the MDS as having moderately impaired cognitive skills and being dependent on staff for bathing, dressing, and toileting hygiene. The physician’s order summary dated 3/31/2026 directed that the resident be weighed weekly for four weeks following readmission. However, review of the Weights and Vitals Summary on 4/28/2026 showed that the resident had not been weighed since 4/3/2026, despite the active weekly weight order. During a concurrent interview and record review with the DON on 4/28/2026, the facility’s Weekly Weight Binder, which lists all residents requiring weekly weights, was examined. The resident’s name was not included in this binder, and the DON acknowledged that the resident should have been weighed weekly for four weeks due to the recent readmission. The DON confirmed that the resident had not been weighed weekly since readmission. The facility’s undated Weight Change Protocol policy stated that residents are to be weighed monthly and weekly for newly admitted residents, but this protocol was not followed for this resident.
Missing Advance Directive Copies in Resident Charts
Penalty
Summary
The facility failed to obtain and maintain copies of advance directives for four sampled residents. Resident 3 was admitted with diagnoses including arthritis, right knee infection, muscle weakness, and morbid obesity, and the MDS dated 12/11/2025 indicated cognition was intact. During review of the clinical record and an interview with the SSD, the resident’s AHCD form showed an advance directive existed, but no copy was present in the chart. The SSD stated the AHCD indicated the resident had an AD, but it was not in the clinical record. Resident 43 was admitted with diagnoses including fibromyalgia and dementia, and the MDS dated 1/8/2026 indicated impaired cognition and dependence on staff for bathing and toileting. During interview and record review, LVN 5 reviewed the resident’s AHDA dated 10/24/2024 and stated it indicated the resident had a current advance healthcare directive, but no copy was found in the medical chart. The AHDA also stated that if a client has an Advance Health Care Directive, a copy should be inserted into the clinical record. Resident 6 was admitted with diagnoses including metabolic encephalopathy and heart failure, and the MDS indicated intact cognition with partial or moderate assistance needed for toileting and bathing. LVN 3 reviewed the resident’s AHDA dated 12/3/2025 and stated it indicated the resident had a current advance health care directive, but the copy was not in the medical chart. Resident 44 was admitted with diagnoses including a displaced fracture of the upper end of the right humerus and a history of falling; the H&P indicated decision-making capabilities, while the MDS showed moderately impaired cognitive skills for daily decision making. The resident stated having an AD and that no one at the facility had asked for a copy, and the SSD confirmed the facility did not have a copy of the resident’s AD. The facility policy stated advance directives would be respected and that information about whether a resident had executed an advance directive should be displayed prominently in the medical record.
Psychotropic Medication Orders Lacked Specific Behavioral Indications
Penalty
Summary
The facility failed to ensure adequate indications for psychotropic medication use and failed to ensure specific psychotropic medication behavior monitoring was completed for two residents. The report states these failures involved Resident 7 and Resident 64 and were identified through interview and record review. Resident 7 was admitted with diagnoses including unspecified dementia and unspecified psychosis not due to a substance or known physiological condition. The H&P stated the resident did not have decision-making capacity, and the MDS showed moderately impaired cognitive skills for daily decision making with substantial assistance needed for multiple ADLs. The OSR listed quetiapine 25 mg for psychosis manifested by agitation and an order to monitor behavior for psychosis manifested by agitation and tally by hashmark. During interview, an LVN stated agitation should be tracked through specific behaviors such as pacing, fidgeting, irritability, restlessness, muscle tension, shouting, or hostility, and the DON stated the order was not a specific indication for psychotropic medication use for Resident 7. Resident 64 was admitted with multiple diagnoses including Alzheimer's disease. The MDS showed severely impaired cognition and dependence on staff for ADLs. The OSR listed olanzapine 1 tablet daily for bipolar disorder manifested by manic episodes. During interview, an LVN stated manic episodes could mean screaming, striking, and acting out of control, but the order did not identify a specific behavior presented by Resident 64, and the DON stated the order did not indicate a specific behavior or indication for use to monitor. The facility policy stated residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective, and that staff would gather and document information to clarify a resident's behavior, mood, function, medication condition, specific symptoms, and risks.
Failure to Document Physician Follow-Up on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to follow up with the physician on a pharmacist’s medication regimen review recommendation for one resident who was admitted with diagnoses including palliative care, Parkinson’s disease, malaise, and neuromuscular dysfunction of the bladder. The resident’s H&P indicated the resident had decision-making capability, while the MDS later indicated severe impairment in cognitive skills for daily decision making and extensive dependence on staff for care. In the December 2025 MRR, the pharmacist noted the resident was receiving Diclofenac gel 1% 4 grams twice daily for pain management and Tizanidine 2 mg twice daily for muscle spasms and recommended that the MD assess effectiveness and evaluate whether dose reduction or adjustment was warranted. The resident’s January 2026 MAR showed continued administration of Diclofenac Sodium External Gel 1% to affected joints twice daily and Tizanidine HCL 2 mg by mouth twice daily. A progress note dated 12/18/2025 stated the MD was made aware of the pharmacist’s recommendation and would assess the resident for effectiveness of therapy and evaluate whether dose reduction or adjustments were warranted, with no new orders at that time. During observation and interview, the DON was unable to find documentation of the MD assessment for effectiveness or evaluation of whether dose reduction or adjustment was warranted as recommended by the pharmacist. The facility also failed to document the physician’s rationale for not following a pharmacist’s recommendation for another resident. That resident’s H&P indicated the resident was not competent and not able to enter into contract, and the MRR recommended that the physician review the risk and benefits of continuing Aricept 5 mg and Seroquel 100 mg due to the risk of mortality in the elderly population. The physician disagreed with the recommendation, but the record did not include a rationale for that decision. The DON stated the response to the pharmacist’s recommendation should have included the physician rationale, and the facility policy stated the physician’s response is documented in the resident’s chart.
Incomplete and Inaccurate Resident Diagnosis Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical record documentation for two residents. For one resident, the admission record did not include a diagnosis of diabetes even though the history and physical documented diabetes mellitus, and staff confirmed the resident was receiving Humalog Lispro on a sliding scale for diabetes. During interviews, the LVN, DON, and MDS coordinator all reviewed the resident’s facesheet and history and physical and acknowledged that the diabetes diagnosis was missing from the facesheet and that the diagnosis should have been reflected in the resident’s record and plan of care. For another resident, the admission record and MDS listed bipolar disorder as a diagnosis, but the resident’s history and physical signed by the MD did not include bipolar disorder. The resident’s order summary showed an order for olanzapine with bipolar disorder documented as the indication, but the MD stated the resident did not have a diagnosis of bipolar disorder and that the diagnosis was likely entered by the admitting nurse in error. The MDS coordinator stated the bipolar disorder diagnosis had been included in the MDS and admission record based on the resident’s active olanzapine medication and that the coordinator was acting in good faith that the MD had reviewed the medications and agreed with the diagnosis. The facility policy titled Charting and Documentation required documentation in the medical record to be objective, complete, and accurate. The record review and interviews showed that the diagnosis information for both residents was not verified or accurately reflected in the medical record, resulting in incomplete and inaccurate documentation for the residents.
Failure to Notify Physician of Resident’s Eye Change in Condition
Penalty
Summary
The facility failed to inform the resident’s physician and resident representative of a change in condition when a resident with Alzheimer’s disease and severely impaired cognition was observed with redness in the left eye. The resident was dependent on staff for activities of daily living. On 1/27/2026, the resident’s left eye was observed with redness, and the family member stated it looked more red than ever before. The family member also reported the eye had been pink and/or red a few months earlier when the resident had shingles on the left side of the face. The family member told staff about the eye redness on 1/27/2026 and was told it would be taken care of, but later stated no updates had been provided and there was no known treatment plan. On 1/29/2026, the resident’s left eye was still red and had white discharge. A nurse stated the physician had not been notified of the eye redness and that the nurse who first received the report from the family member should have notified the doctor to rule out a potential infection. Review of the progress notes showed no documented evidence that the physician was informed before the SBAR note on 1/29/2026 documented redness and white discharge in the left eye.
Failure to Update Care Plan After G-Tube Removal
Penalty
Summary
The facility failed to revise Resident 6’s care plan related to the gastrostomy tube and nutrition after the resident’s G-tube was removed. Resident 6 was admitted with diagnoses including dysphagia, oropharyngeal phase, and heart failure. The Minimum Data Set indicated the resident had intact cognition, required partial or moderate assistance with toileting and bathing, had a feeding tube on admission, and received 26-50% of total calories through the feeding tube. The care plan report initiated for Resident 6 identified a nutritional problem related to G-tube feeding and other co-morbidities, with interventions for staff to explain and reinforce the importance of maintaining the ordered diet. A later care plan report stated the resident was admitted with a G-tube site on the abdomen and included a goal to maintain it without complications until the next review date. The order summary showed a physician order for a regular diet with soft and bite-sized texture, regular consistency, and double protein, as well as an order for skilled wound care to remove the gastrostomy tube. During interview, the LVN stated the care plan should have been revised when the G-tube was removed to monitor the site for healing and signs of infection and because the resident’s diet had changed. The DON stated the care plans should have been revised when the G-tube was removed to reflect the resident’s current nutritional status and direct treatment.
Failure to Justify Bipolar Disorder Diagnosis for Antipsychotic Use
Penalty
Summary
The facility failed to justify a diagnosis of bipolar disorder for one resident based on a comprehensive assessment, as required by its policy on antipsychotic medication use. The resident was admitted with diagnoses including Alzheimer's disease, dementia, and bipolar disorder, and the Minimum Data Set dated 1/23/2026 also listed bipolar disorder. The History and Physical dated 1/17/2026 described dementia/Alzheimer's with worsening behavioral issues, and the Order Summary Report showed an order for olanzapine 1 tablet by mouth daily for bipolar disorder manifested by manic episodes, starting 1/19/2026. During interview, the LVN stated the resident had agitation on admission, including screaming, yelling out, striking at staff, and resistance to care, and also had an active UTI that could have contributed to the behavior. The physician stated the resident did not have a diagnosis of bipolar disorder and that the facility may have added it by mistake; the physician said the resident had been taking olanzapine at home and the medication was continued due to a history of Alzheimer's with psychosis. The DON stated the admitting nurse tried to find a diagnosis to match medications when one was not already listed and acknowledged that bipolar disorder had been written as the indication for olanzapine by mistake.
Incorrect LAL Mattress Setting for Resident at Risk for Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with a low air loss (LAL) mattress. The resident was admitted with diagnoses including palliative care, Parkinson's disease, malaise, neuromuscular dysfunction of the bladder, and diabetes mellitus. The MDS indicated the resident was severely impaired in cognitive skills, totally dependent on staff for transfers and toilet use, and required extensive assistance with bed mobility, dressing, and hygiene. The resident had a physician's order for the LAL mattress to be monitored every shift for proper functioning and for offloading and pressure relief. During observation, the resident was asleep in bed and the LAL mattress was on and set at 450 lbs. During interview and record review, an LVN stated the mattress had not been checked and then found it locked at 450 lbs.; the red sticker on the machine indicated the correct setting was 150 lbs. The LVN changed the setting to 150 lbs. The facility policy on prevention of pressure injuries directed staff to select appropriate support surfaces based on resident risk factors.
Failure to Administer Ordered Zinc Ointment
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when staff failed to administer zinc ointment as ordered for Resident 3's sacral pressure ulcer. Resident 3 was admitted with diagnoses including arthritis, right knee infection, muscle weakness, and morbid obesity, and the MDS dated 12/11/2025 indicated the resident required partial assistance with bathing, dressing, and using the toilet. During interview on 1/29/2026, Resident 3 stated the medication was not applied to the sacral area the previous day. During concurrent interview and record review, the MAR dated 1/28/2026 showed the LVN documented the zinc ointment as administered to the sacral area, but the LVN stated the medication was not actually given and that checking off medications that are not given is not appropriate.
Resident Kept Facility-Provided Medications in Closet
Penalty
Summary
The facility failed to ensure that medications were not stored in a resident’s room for one of three residents reviewed, Resident 3. Resident 3 was admitted with diagnoses including arthritis, right knee infection, muscle weakness, and morbid obesity. A review of the MDS dated 12/11/2025 showed Resident 3 required partial assistance from nursing staff with bathing, dressing, and using the toilet. During a concurrent observation and interview on 1/28/2026 at 12:15 PM, several medication ointments were found in Resident 3’s closet, including bacitracin zinc, Activon, and clotrimazole cream. Resident 3 stated the medications were provided by the facility and were kept in the closet. On 1/29/2026 at 9:42 AM, an LVN stated medications left in the resident’s room are not supposed to be there and did not know why they were there or who provided them. The facility policy titled, Storage of medications, dated November 2020, stated drugs and biologicals used at the facility are to be stored in locked compartments and only authorized staff may have access to locked medications.
Failure to Ensure Resident Discharge Location Met Needs and Preferences
Penalty
Summary
The facility failed to ensure that a resident's discharge location met the resident's needs for family support and resources. The resident, who had a history of pneumonia and falls, required partial to moderate assistance with activities of daily living and mobility, as documented in the Minimum Data Set and Physical Therapy Discharge Summary. Despite these needs, the discharge planning process did not provide the resident or their family member with choices regarding potential discharge locations. The family member reported that no options were offered and that the only assisted living facility (ALF) presented was provided on the day of discharge, leaving insufficient time to evaluate alternatives or appeal the decision due to external circumstances. Interviews with facility staff, including the case manager, social services director, and director of nursing, confirmed that the resident and family were not given a list of ALFs to consider and that there was no documentation of other options being discussed. The case manager indicated that the ALF was found within 48 hours before discharge, and the family was informed that if they did not agree to the transfer, they would need to pay for additional days until a safe placement was found. The facility's policy required assisting residents in selecting a post-acute care provider relevant to their goals and preferences, but this was not followed in this case.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy by not reporting an allegation of staff-to-resident physical abuse to the State Agency within the required two-hour timeframe. A resident with severely impaired cognitive skills and multiple medical diagnoses, including hypertensive heart disease with heart failure and rheumatoid arthritis, was observed by two LVNs to have discoloration and redness on the right forearm. The resident indicated that a CNA had grabbed their arm during a transfer, causing pain and visible marks. Both LVNs noted the resident appeared upset and frustrated, and one LVN confirmed the discoloration was not present earlier that same morning. The incident was reported by the LVN to the DON on the same day it occurred, and the DON acknowledged that the situation constituted a possible case of physical abuse, which should have been reported to the State Agency within two hours according to facility policy. However, the allegation was not reported until two days later. The facility's policy, reviewed by surveyors, clearly states that all allegations of abuse must be reported within the federal requirement timeframe, which was not adhered to in this case.
Failure to Conduct N95 Fit Testing for New Staff
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding N95 fit testing, as outlined in their document titled 'N95 Fit Testing.' This policy mandates that all employees must be fit tested for an N95 respirator upon hire and annually, in accordance with OSHA's Respiratory Protection Standard. However, one of the four sampled staff members, a Certified Nurse Assistant (CNA 4), was not fit tested upon hire. CNA 4 began working at the facility on February 3, 2025, and confirmed during an interview on February 25, 2025, that they had not been fit tested for the N95 mask. The Director of Staff Development (DSD) acknowledged during a concurrent interview and record review that CNA 4 should have been fit tested before starting work, as per the facility's policy. The Director of Nursing (DON) reiterated the requirement for fit testing upon hire and annually. The Infection Prevention Nurse (IPN) emphasized the importance of fit testing to prevent the transmission of airborne diseases between employees and residents. The failure to conduct the fit testing had the potential to result in the spread of COVID-19 and other airborne diseases within the facility.
Plan Of Correction
F 880 It is the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicated disease and infections. Corrective Action for Resident found to have been affected by this deficiency: No Resident was identified to have been affected by this deficiency. Identification of Other Residents having the potential to be affected by the same deficient practice and corrective action that will be taken: All Residents have the potential to be affected by this deficiency. On 2/25/2025, the IP Nurse designee completed N95 Fit Testing for CNA 4. What measures will be put into place to ensure that the deficient practice does not recur: On March 14, 2025, the DON inserviced the IP LVN Designee on the facility's policy and procedure on N95 Fit Testing; including that all new hire employees must have N95 Fit Testing upon hire and before being assigned to work with any Resident(s) and annually thereafter. On February 25, 26, and 27, 2025, the IP LVN Designee completed an N95 Fit Testing Audit on all current Employees. There were no additional employees identified as not having been N95 Fit Tested upon hire. There were 15 current employees identified as not being current with annual N95 Fit Testing. On February 28, 2025, the IP LVN Designee completed N95 Fit Testing on the identified 15 employees. On March 14, 2025, the DON gave a 1:1 inservice to the IP LVN Designee on the facility's policy and procedures on N95 Fit Testing; including that all new hires must have N95 Fit Testing upon hire and before being assigned to any Resident(s), and annually thereafter. Measures that will be implemented to ensure that solutions are sustained: The IP LVN Designee will conduct monthly audits X 3 months on all new hire employees and all employees due for the prior months' annual N95 Fit Testing to ensure that all current employees are compliant with the facility's policy and procedures on N95 Fit Testing. Results of the monthly audits will be documented on the Quality Improvement Audit Tool. The documented results will be forwarded to the QA & A Committee monthly X 3 months for review and action planning as indicated or until the QA & A Committee determines compliance.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of two residents by not ensuring that their call lights were within reach. Resident 21, who was admitted with diagnoses including anxiety disorder and failure to thrive, had severe cognitive impairment and required substantial assistance with activities of daily living. During an observation, it was noted that Resident 21's call light was tucked below the bed mattress, making it inaccessible. The resident expressed being wet and unable to call for assistance, highlighting the deficiency in care. Similarly, Resident 25, who had severe cognitive impairment and was dependent on assistance for daily activities, also had an inaccessible call light. The call light was found hooked around a small dresser drawer, out of the resident's reach. Interviews with a CNA and the DON confirmed the importance of call lights for resident safety and communication, emphasizing that they should always be within reach. The facility's policy on call lights, which mandates their accessibility, was not adhered to, resulting in delayed service provision and potential negative impacts on the residents' well-being.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and professional standards for three residents. Resident 15, who had a history of seizures, was not provided with bilateral padded side rails as ordered by the physician to prevent injury during seizure episodes. Despite the care plan and physician orders indicating the need for padded side rails, observations confirmed their absence, and staff interviews highlighted the importance of adhering to such orders for resident safety. Resident 23, who was receiving hospice care, did not have consistent documentation of hospice staff visits as required. The hospice staff were supposed to sign in during each visit, but the sign-in sheets did not reflect the frequency of visits as per the staff assignment. Interviews with facility staff emphasized the necessity of proper documentation to ensure coordinated care and communication between hospice and facility staff, which is crucial for providing end-of-life care. Resident 38, who had severe cognitive impairment and multiple health issues, did not receive a STAT chest x-ray as ordered by the physician. The x-ray was intended to address respiratory concerns, but due to delays with the diagnostic imaging company, the x-ray was not performed in a timely manner. The Director of Nursing acknowledged the issue and stressed the importance of following STAT orders promptly to allow for immediate medical interventions if necessary.
Improper Storage of Employee Beverages in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure that personal beverages for employees were not stored in one of the kitchen refrigerators, specifically Refrigerator 1. During an observation and interview with the Dietary Supervisor, two Starbucks beverages with plastic open tops were found in the refrigerator next to resident food items. The Dietary Supervisor acknowledged that the beverages belonged to employees and should not have been stored in the refrigerator due to the potential for cross contamination. A review of the facility's policy and procedure titled 'Employee Meals,' dated 2018, indicated that food brought by employees from outside the facility should not be kept in the facility's refrigerator in the kitchen.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain its infection prevention and control program, as evidenced by several deficiencies observed during the survey. In shared restrooms used by residents, urinals were found unlabeled, which could lead to cross-contamination. Certified Nurse Assistant (CNA) 3 and the Infection Preventionist Nurse (IPN) confirmed that urinals should be labeled with the resident's initials and room number to prevent the spread of infectious diseases. This oversight was noted in restrooms shared by residents with severe cognitive impairments and those requiring assistance with activities of daily living. Additionally, a Licensed Vocational Nurse (LVN) did not disinfect the pill counting tray before and after use, which is a critical step in infection control. The LVN acknowledged the failure to clean the tray, which could result in drug residue and potential cross-contamination. The Infection Preventionist Nurse emphasized the importance of disinfecting the tray to prevent drug interactions and allergies. The facility also lacked sufficient hand hygiene supplies in the laundry area, which did not have a sink, soap, paper towels, or alcohol-based hand sanitizer. The Housekeeping Supervisor (HS) failed to perform hand hygiene after touching the dumpster, acknowledging the need for at least an alcohol-based hand sanitizer in the area. The facility's policy on hand hygiene stresses the importance of readily accessible supplies to prevent the spread of infections, highlighting the deficiency in the laundry area.
Failure to Conduct Communication Assessment for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a comprehensive communication assessment for a resident who primarily spoke Arabic, as required by the facility's policy and procedure. The resident was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss. The Minimum Data Set (MDS) indicated that the resident needed or wanted an interpreter to communicate with healthcare staff due to Arabic being the resident's preferred language. However, the resident was not assessed regarding their ability and preferred way of communication upon admission, which was a requirement according to the facility's policy. Observations and interviews revealed that staff members, including a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), attempted to communicate with the resident without using any communication tools, despite acknowledging the resident's language barrier. The staff relied on non-verbal cues such as facial expressions and pointing, which was inadequate for understanding the resident's needs. A Registered Nurse (IPN) confirmed that a communication assessment should have been conducted to address the resident's preferred language, emphasizing the importance of such an assessment for providing proper care.
Failure to Implement Person-Centered Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop or implement an individualized person-centered care plan for a resident who only spoke and understood Arabic. This deficiency was identified during a review of the resident's admission record, which indicated the resident was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss. The Minimum Data Set (MDS) assessment noted that the resident needed or wanted an interpreter to communicate with healthcare staff due to Arabic being the preferred language. Despite this, the facility did not have a communication care plan in place for the resident, which was confirmed during an interview with the Registered Nurse (IPN) who reviewed the resident's charts and acknowledged the absence of such a plan. Observations and interviews with facility staff further highlighted the communication barriers faced by the resident. A Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN) both attempted to communicate with the resident without using any communication tools, relying instead on gestures and facial expressions. The LVN acknowledged the importance of providing a form of communication to understand the resident's needs and wants. The facility's policy on baseline care plans, which was revised in 2016, requires the inclusion of instructions needed to provide effective and person-centered care, yet this was not adhered to in the case of the resident in question.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool or resources for a resident who spoke Arabic, which hindered effective communication of the resident's needs. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss, was noted to require an interpreter to communicate with healthcare staff. Despite this, the facility did not provide any communication aids, and staff attempted to communicate using non-verbal cues such as facial expressions and pointing, which were inadequate for the resident's needs. Observations and interviews revealed that staff, including a CNA and an LVN, did not utilize any communication tools when interacting with the resident, relying instead on gestures and limited English. The facility's policies on language access and interpreter services were not followed, as staff did not provide the necessary resources to ensure meaningful communication. This deficiency had the potential to impact the resident's ability to convey care needs effectively, as highlighted by the staff's acknowledgment of the importance of communication in determining the resident's needs.
Failure to Provide Emergency Kit for Hemodialysis Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis had an emergency kit available at their bedside, which is necessary for immediate response in case of bleeding from the dialysis site. The resident, who was admitted with end-stage renal disease and type 2 diabetes mellitus, required hemodialysis three times a week. During an observation and interview, a Licensed Vocational Nurse (LVN) was unable to locate the emergency kit in the resident's room, acknowledging that it should have been present to quickly address any potential bleeding emergencies. The Director of Nursing (DON) confirmed that the facility's policy on Hemodialysis Access Care did not specifically mention the need for an emergency kit at the bedside, but emphasized its importance due to the resident's condition. The policy outlined the steps to take in case of major bleeding, including applying pressure to the site and contacting emergency services, but did not explicitly require the presence of an emergency kit. This oversight had the potential to delay critical treatment for the resident during an emergency.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling foley catheter, which was observed to have dark amber urine with sediments. This observation was made during an interview with an LVN, who acknowledged that the presence of sediments could harm the resident and indicated a potential infection. The LVN stated that the resident's physician should have been informed to determine the cause of the abnormal urine appearance. The resident, who was admitted with diagnoses including Alzheimer's Disease, psychosis, and hypertension, had a physician's order for an indwelling foley catheter due to uropathy, with instructions to change the catheter or bag as needed. Further interviews with a Registered Nurse revealed that catheter care was performed daily, and the presence of sediments was a sign of infection. The resident's care plan aimed to prevent urinary infections and included monitoring and reporting symptoms such as pain, burning, blood-tinged urine, and cloudiness to the physician. However, the facility's policy on catheter care, which was intended to prevent catheter-associated urinary tract infections, was not adequately followed, as the abnormal urine appearance was not reported to the physician or supervisor immediately.
Failure to Provide Emergency Kit for Dialysis Resident
Penalty
Summary
The facility failed to provide an emergency kit at the bedside of a resident who required hemodialysis, which could potentially delay treatment during an emergency. The resident, who was admitted with end-stage renal disease and type 2 diabetes mellitus, required hemodialysis three times a week. During an observation, a Licensed Vocational Nurse (LVN) was unable to locate the emergency kit in the resident's room, which is necessary to quickly address any bleeding from the dialysis site. The Director of Nursing (DON) confirmed that the facility's policy did not specifically mention the need for an emergency kit at the bedside, but acknowledged its importance in case of major bleeding post-dialysis. The policy outlined the steps to take in the event of major bleeding, including applying pressure to the site and contacting emergency services, but did not explicitly require an emergency kit to be readily available. This oversight in policy and practice led to the deficiency noted by the surveyors.
Lack of Clinical Justification for Fluoxetine Use in Resident
Penalty
Summary
The facility failed to ensure that a resident's use of fluoxetine, a medication for depression, was clinically justified and that a gradual dose reduction (GDR) was not contraindicated. The resident, who was diagnosed with dementia and mild, recurrent major depressive disorder, was receiving fluoxetine without clear documentation of the necessity for its continued use or evidence of non-pharmacological interventions prior to its initiation. The resident's care plan indicated interventions for resistance to care due to dementia, but there was no documentation of depressive symptoms or behaviors that would justify the use of fluoxetine. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that the resident did not exhibit signs of depression, such as sadness or crying, and often complied with care after initial refusal. The consultant pharmacist recommended a GDR, but the prescriber did not provide documentation to justify why a reduction was contraindicated. The facility's policy required determining the cause of behaviors before using psychotropic medications, but this was not documented in the resident's case.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure that all drugs and medications used were labeled properly and discarded according to professional standards. During an observation, it was found that Med Cart 2 contained multiple opened house supply medications, including a bottle of Geri Care Stool Softener and a box of Alka-Seltzer Buffered aspirin, which were not marked with an opened date. This was contrary to the facility's protocol, which required labeling with an opened date to ensure medications were not used past the recommended due date, typically ninety days from opening. Interviews with staff revealed inconsistencies in the application of the facility's protocol. LVN 2 indicated that staff followed the manufacturer's expiration date rather than labeling with an opened date, while the Director of Nursing emphasized the importance of labeling to ensure medication effectiveness. LVN 6 acknowledged that the opened pouch of Alka-Seltzer should have been discarded for infection control. The facility's policy, revised in April 2019, required all medications to be properly labeled in accordance with state and federal guidelines, highlighting a lapse in adherence to these standards.
Facility Security Lapses Lead to Safety Risks
Penalty
Summary
The facility failed to ensure that unauthorized individuals did not enter the premises undetected, as the back door remained unlocked after dark. Observations revealed that the gate to the staff parking area was wide open, providing easy access to the facility's back door, which was also unlocked. Interviews with several Licensed Vocational Nurses (LVNs) indicated that they were unaware of how to lock the facility doors, and the back door had been left unlocked consistently during the night shifts for weeks. The Director of Nursing (DON) acknowledged that the chain to the gate of the staff parking area had broken, and the gate was supposed to be locked with a passcode. However, the DON was unaware of the exact date when the chain broke. The DON emphasized the importance of locking the facility doors for the safety of the property, residents, and employees. Despite this, the LVNs and Certified Nursing Assistants (CNAs) interviewed did not know how to lock the facility doors, and some were not shown how to do so when they started working at the facility. The facility's policy and procedure on safety and supervision of residents highlighted the importance of making the environment free from accident hazards and ensuring resident safety through employee training and monitoring. However, the lack of knowledge among staff about locking the facility doors and the broken gate chain indicated a failure to adhere to these policies. The facility's failure to secure the premises placed all 37 residents at risk for accident hazards and harm.
Failure to Provide Adequate Isolation Supplies for C. diff Patients
Penalty
Summary
The facility failed to implement its policy and procedure for isolation and transmission-based precautions, specifically for two residents diagnosed with Clostridium difficile (C. diff) infection. Both residents were placed on contact isolation, but during the night shift, they did not have their own package of incontinent wipes in their isolation rooms. This oversight was identified during interviews with staff, including CNAs and LVNs, who reported a lack of sufficient wipes for the entire shift and uncertainty about how to obtain more supplies during the night shift. The facility's policy required that non-critical resident-care equipment be dedicated to a single resident when possible, which was not adhered to in this case. Interviews revealed that the housekeeper typically provided one package of wipes per shift and placed one package in each isolation room in the morning. However, during the night shift, there was no clear process for obtaining additional wipes, leading to a potential risk of infection spread. The Director of Nursing and the Infection Prevention Nurse confirmed the necessity of having dedicated wipes in isolation rooms to prevent cross-contamination.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident to the first available bed after hospitalization, as required by their policy. The resident, who had severe cognitive impairment and was initially admitted with diagnoses including Parkinson's Disease and hyperlipidemia, was transferred to a General Acute Care Hospital (GACH) due to refusal of all oral intake. Upon being ready for discharge from the GACH, the facility's case manager refused to accept the resident back, citing the absence of a bed hold, despite the facility's policy allowing for readmission to the first available bed. Interviews with various staff members, including the Administrator, Director of Nursing (DON), and Director of Staff Development (DSD), confirmed that the refusal to readmit the resident was against the facility's policy. The DON and DSD both stated that the facility should not refuse readmission unless the resident's condition is severe and imminently dangerous or if the resident poses a threat to themselves or others. The Administrator acknowledged the error and instructed the case manager to accept the resident back, but the initial refusal constituted a violation of the resident's rights to resume residency at the facility.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near West Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Haven Healthcare | 0.6 mi | ★★★★★ | 17 | 0 |
| West Covina Medical Center D/p Snf | 0.7 mi | ★★★★★ | 15 | 0 |
| West Covina Healthcare Center | 1.2 mi | ★★★★★ | 17 | 0 |
| Victoria Care Center | 1.4 mi | ★★★★★ | 13 | 0 |
| Garden View Post Acute Rehabilitation | 1.7 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.