Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Claremont Heights Post Acute during CMS and state inspections, most recent first.
Two cognitively intact residents who required staff assistance with toileting and mobility had urinals partially or fully filled with urine left on top of their dressers despite their requests for assistance to have them emptied. One resident, with COPD, heart failure, and morbid obesity, reported repeatedly asking staff to empty the urinal and expressed embarrassment and concern about overflow, while another resident with a UTI and mobility issues asked that the urinal be emptied before family arrived due to embarrassment. An LVN confirmed both urinals contained about 240 cc of urine and acknowledged they should be emptied and concealed for dignity, and facility leadership stated that urinals should be empty and that residents must be treated with respect and dignity in accordance with resident rights policies.
Surveyors found that two residents who required staff assistance with toileting had urinals left on their dressers partially or completely filled with urine, despite one having a history of UTI and both having intact cognition. One resident reported asking staff multiple times to empty the urinal. An LVN confirmed the urinals contained about 240 cc of urine and acknowledged they should be emptied promptly to prevent bacterial growth. The DSD and DON both stated staff were instructed to empty urinals as soon as possible for infection control, and the facility’s infection control policy emphasized maintaining a safe, sanitary environment, but these practices were not followed.
A resident with hemiplegia and dependence for most ADLs was left uncovered in bed with the privacy curtain only partly drawn, and the resident stated this felt uncomfortable and naked. Another resident with dementia was fed at lunch while a CNA stood in front of the resident instead of remaining at eye level. A third resident with dysphagia and hemiplegia was fed by an ST who stood during feeding, despite staff statements and an in-service indicating staff should sit while feeding residents for dignity.
Advance directives were not properly maintained for two residents. One resident had capacity and intact cognitive skills, but the SSD stated the AD was not in the medical record even though the SSA noted it was on file in the EHR. Another resident had severe cognitive impairment and no capacity, but the record contained only a financial DPOA, not a healthcare DPOA or AD, despite the POLST stating it does not replace an AD. The facility policy required staff to obtain and file a copy of the AD in the medical record.
Missing care plans were identified for three residents with significant needs. One resident with Parkinson's disease, dysphagia, and a GT had a history of repeatedly pulling out the tube and used an abdominal binder and mittens, but no CP addressed the behavior. A second resident with macular degeneration and cranial nerve disorders used tape to keep the eyelids open by preference, yet no CP addressed the tape, skin integrity, or infection risk. A third resident with severe cognitive impairment was admitted to hospice, but the DON could not find a hospice CP.
A resident with ESRD and DM received Tresiba under an order that lacked blood sugar monitoring and hold parameters, and staff reported blood sugar was not always checked before administration. Two other residents had OTC topical products at the bedside without physician orders for bedside storage or self-administration, and staff confirmed there were no such orders or consents.
Improper Storage of Food Brought in by Visitors: Two residents had food brought in from family or visitors left unlabeled and not stored in the refrigerator. An unlabeled container of grapes was found on one resident's dresser, and an unlabeled bag with cookies was found in another resident's bedside drawer. Staff stated outside food should be labeled with the resident's name and date received and refrigerated, and a family member said the facility had not informed them of the policy.
Unlabeled and improperly stored personal care items were found in a shared room and restroom occupied by two residents. One resident had diagnoses including HF and HTN and a care plan addressing MDRO transmission risk, while the other had a history of sepsis and required assistance with ADLs. During observation, multiple personal care items, wipes, toiletries, and a container of grapes were left unlabeled on shared surfaces, and staff stated these items should be labeled and kept in the resident’s personal space for infection control and to prevent sharing and cross contamination.
Unclean Resident Room Wall: A resident with significant cognitive impairment and extensive ADL assistance needs was observed with a red tinged substance on the wall next to the bed. The DSD said it looked like old food and noted the dirty wall was potential for infection, while the DON stated the wall should be clean and the resident deserved a clean, homelike environment.
A resident with Parkinson’s disease, severe cognitive impairment, and a GT repeatedly pulled out the tube and later removed a Foley catheter used to keep the stoma open, leading to hospital transfer. The resident was then placed in bilateral mittens, but the record did not show that less restrictive measures were tried first or that the physician order specified when the restraints should be applied or removed. Staff and the DON stated the resident used the restraints all day, there was no IDT meeting, and there was no documented plan to reduce restraint use.
Care Plan Not Updated After Significant Weight Loss: A resident with cerebral palsy and severe protein-calorie malnutrition had severely impaired cognition, was dependent for ADLs including eating, and experienced significant weight loss documented on the MDS, NRA, COC, and weight records. RN stated the CP should have been revised when the weight loss began, but it was not revised until later, despite facility policy requiring the CP to be updated after significant weight loss and after each assessment.
The facility failed to document that nursing staff had been trained in the use of physical restraints while a resident with Parkinson's disease, dysphagia, severe cognitive impairment, and a G-tube was observed wearing bilateral mittens and an abdominal binder to prevent tube dislodgement. Staff interviews showed restraint training was informal or not clearly documented, and the DON stated there was no documentation that staff had previously been trained. In a separate finding, a CNA's personnel file lacked a pre-hire background check and a current CPR card, and the DSD acknowledged the missing documentation.
Incomplete Annual CNA Performance Review: The facility failed to complete an annual performance review for a CNA, and the CNA's personnel file showed the last EPR on file was incomplete. The DSD stated annual reviews were important so CNAs would know how they were doing with their skills and what to improve on to support quality of care. The facility handbook stated performance evaluations may be done annually and are intended to help employees understand progress, areas for improvement, and future goals.
A resident with intact cognition and no approval to self-administer had calcium carbonate (Tums) left in a medicine cup on the bedside table. CNA identified the pill as the resident’s daily Tums, while the LVN said it had not been given that day and did not know how long it had been there. The resident said it had been requested the night before to keep nearby for nighttime reflux, and the RN and DON stated bedside medication storage was not acceptable without a self-administration assessment.
Antibiotic Stewardship Not Followed for Pneumonia Treatment: A resident with quadriplegia and pneumonia-related findings had a chest x-ray showing right upper lung opacities and was prescribed levofloxacin for pneumonia. The IP later stated the resident did not meet McGeer's criteria, but the physician was not informed, and the facility's antibiotic stewardship policy required the IP to track whether McGeer's Criteria were met when the antibiotic was ordered.
A resident with dementia, severe cognitive deficit, and significant mobility impairment was care-planned for fall risk with interventions that included keeping the bed in a low position and using bilateral floor mats at the bedside. A fall risk evaluation identified the resident as high risk for falls, and the care plan directed that floor mats be applied next to the bed. During observation, the resident was found in bed with only one floor mat on the right side, while the other mat was placed against the wall instead of on the floor beside the bed. An LVN and the DON both confirmed that the care plan required floor mats on both sides of the bed, but this intervention was not implemented as written.
A resident with impaired cognition, muscle weakness, and dependence for transfers repeatedly called out from a wheelchair for help to use the bathroom. A CNA entered the room, looked around, and left without speaking to or assisting the resident, and another CNA later entered and left without providing toileting assistance or communication. An LVN remained at a nearby med cart and focused on medication preparation while the resident continued to call out. The facility’s policy on resident rights and quality of life requires staff to promptly respond to toileting requests and prohibits practices that compromise dignity, but this was not followed in this incident.
A resident with traumatic brain injury, muscle weakness, lack of coordination, moderately impaired cognition, and dependence for transfers was observed seated in a wheelchair repeatedly calling out for help to use the bathroom while the call light button, taped to the bed rail next to the resident, failed to activate any light or audible signal outside the room. A CNA confirmed the call light was not functioning, and maintenance staff later identified a non-working corridor light bulb and reported they had not previously been notified of the problem, despite facility policy requiring a maintained call system and immediate reporting of defective call alerts.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall. The LPN who responded did not notify the physician or family, nor document the incident, as no injury was observed at the time. Required notifications were only made days later after further changes in the resident's condition were identified, contrary to facility policy.
A resident with severe cognitive impairment was subjected to rough handling and verbal aggression by a CNA, including being placed forcefully into a wheelchair and having hair brushed roughly. Witnesses, including another resident and a CNA, observed and reported the mistreatment, which led to discomfort and distress for the resident. Facility staff and records confirmed the incident and noted that the actions violated the facility's abuse prevention policy.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
CNAs failed to maintain the dignity of two residents by leaving one uncovered during care and by not addressing the needs of another when responding to a call light in a shared room. Both residents, who were dependent on staff for daily care and had intact cognitive skills, reported feeling neglected and upset by these actions.
A resident admitted with a history of a sacral pressure injury was not accurately assessed for pressure ulcer risk, and the initial skin assessment missed additional wounds. Within a day, the resident developed new pressure injuries on the buttocks and both heels. The care plan did not include offloading interventions for the heels, and facility policies for skin assessment and individualized care planning were not fully followed.
A resident with a nephrostomy tube experienced two incidents of tube dislodgement, requiring hospital transfer for reinsertion, due to staff lacking proper training and competency assessment in nephrostomy tube care. Neither CNAs nor licensed nurses had received specific skills checks or education on managing nephrostomy tubes, despite the facility's policy requiring such evaluations when new procedures are introduced.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols for two residents with wounds and indwelling urinary catheters. In both cases, CNAs provided care without wearing required protective gowns, and in one instance, did not perform hand hygiene after care. Staff interviews confirmed knowledge of the requirements, but lapses occurred due to forgetting or not seeing signage, contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses refused ordered blood tests on two occasions, but the physician was not notified as required by facility policy. The DON confirmed that the refusals were not communicated to the physician, despite the need for regular CBC and valproic acid level monitoring due to psychotropic medication use.
A resident with severe cognitive impairment and multiple diagnoses was prescribed psychotropic medications requiring weekly blood tests, but the care plan did not include interventions for the required labs or address the resident's refusal of these tests. The DON confirmed these omissions during review.
Three residents with end stage renal disease and diabetes who required regular dialysis did not have complete pre- and post-dialysis assessments or documentation in their medical records as required by facility policy. Nursing staff failed to ensure that communication forms were fully completed by the dialysis center, resulting in missing or incomplete records of dialysis treatments and resident condition before and after dialysis.
A resident with severe cognitive impairment and on a scheduled morphine sulfate regimen had multiple doses documented as administered on the MAR, but the corresponding entries were missing from the Individual Narcotic Record. The ADON confirmed these discrepancies, which were not in accordance with facility policy requiring regular reconciliation of controlled substance inventories to the MAR.
Two residents' prescribed medications were left unsupervised on a nurse station desk by an LVN, rather than being properly disposed of according to facility policy. The medications included treatments for dementia, peripheral vascular disease, and hypertension. An RN confirmed that the medications should not have been left unattended and that the facility's policy requires proper documentation and destruction of discontinued medications.
The facility failed to implement its vaccination program for four residents. One resident refused the flu vaccine without documented education or a signed declination. Another received a flu vaccine without a documented lot number or informed consent. Two residents did not receive pneumococcal and flu vaccines despite signed consents. The facility did not adhere to its policies requiring education, consent, and documentation of vaccinations.
The facility failed to implement its COVID-19 immunization program for three residents and all staff. A resident was not offered the latest vaccine, another did not receive the vaccine despite consent, and a third had no documentation of education or consent for vaccination. Additionally, the facility lacked a system to track staff vaccination status, contrary to its policies.
The facility failed to designate a qualified Infection Preventionist (IP) during a COVID-19 outbreak, as the previous IP resigned and was reassigned to other duties. Interviews and staffing logs confirmed the absence of a designated IP, leaving the Infection Prevention and Control program unimplemented during a critical period.
During a COVID-19 outbreak, a facility failed to ensure proper infection control practices. An Activity Assistant removed their N95 mask in a resident care area, and a CNA wore their mask incorrectly. Another CNA did not perform hand hygiene after glove removal and before entering resident rooms. The DON acknowledged the need for staff education on proper mask usage and hand hygiene.
A resident with metabolic encephalopathy was discharged without a documented skin assessment, despite having a known wound on the right leg. The facility failed to document or communicate the resident's skin condition to the receiving facility, contrary to its discharge policy. Interviews confirmed the lack of required documentation and communication.
Two residents in an LTC facility experienced deficiencies in care and documentation. One resident with metabolic encephalopathy sustained a leg wound, but the treatment order was not properly documented or followed. Another resident with hemiplegia underwent a teeth extraction, but the procedure was not documented, and the family was not informed. Staff interviews revealed lapses in documentation and communication, contributing to these deficiencies.
The facility failed to maintain complete and accurate clinical records for three residents, leading to potential inappropriate care. A resident's leg wound treatment was not documented timely, another resident's tooth extraction location was unspecified, and a third resident's dental procedure was not recorded, with incorrect transcription of a physician's order. These documentation lapses could hinder care evaluation and communication among staff.
The facility failed to maintain resident dignity during meal assistance by not ensuring staff were at eye level with residents while feeding them. Observations showed that an LVN and a CNA fed residents from elevated positions, contrary to facility policies that emphasize promoting dignity and communication. This practice affected residents with conditions like dementia and dysphagia.
The facility failed to specify target behaviors for psychotropic medications for two residents, leading to potential overuse and inappropriate administration. A resident's Lorazepam order lacked specific behaviors and a duration limit, while another's Ziprasidone order used a broad term 'agitation' without clarification. This non-compliance with facility policy could result in adverse drug events.
A facility failed to maintain sanitary conditions in a resident's restroom, leaving a toilet uncleaned despite the resident's notification to staff. Additionally, two residents shared a restroom where an unlabeled peri cleanser was improperly stored, risking cross-contamination. These actions violated the facility's infection control policies, as confirmed by staff interviews and observations.
The facility failed to document and administer flu vaccinations for three residents during the flu season. Despite having signed consents, the immunization reports showed discrepancies: one resident's vaccine was marked as refused without a date, another's was pending consent, and the third was marked as not eligible without a date. The IPN planned to contact the health department for a vaccination clinic but lacked proof of communication.
The facility failed to educate and document COVID-19 vaccination information for 9 residents upon admission, who had various medical conditions. The IPN did not have access to the California Immunization Registry and failed to maintain a vaccination log, contrary to the facility's policy.
A resident left the facility Against Medical Advice (AMA) without the physician being informed, contrary to the facility's policy. The resident, who required supervision for certain activities, left without a discharge order. A registered nurse confirmed the lack of notification to the physician, which was necessary for ensuring appropriate post-care recommendations and medication adjustments.
A resident in an LTC facility felt uncomfortable and nauseated after witnessing another resident regurgitate and spit into a trashcan in the dining room without staff intervention. The incident involved residents with severe cognitive impairments and required assistance with daily living activities. Staff observed the incident but did not provide immediate assistance, failing to maintain a homelike environment as per facility policy.
A facility failed to develop a baseline care plan for a resident readmitted with a gastrostomy tube and on oxygen therapy. The resident's records did not reflect these needs, and no specific care plan was created to address them, contrary to the facility's policy requiring a care plan within 48 hours of admission. This oversight was confirmed by the RN Supervisor, highlighting a potential risk to the resident's health and safety due to inadequate communication among staff.
A facility failed to develop a care plan for a resident with impaired vision, despite the resident's history of worsening eye health and conditions such as diabetic retinopathy and cataracts. Interviews with nursing staff confirmed the absence of a care plan, which was contrary to the facility's policy on comprehensive person-centered care planning.
A resident with multiple health conditions, including diabetes and a foot ulcer, was found with soiled fingernails, indicating a failure in personal hygiene care. The facility's policy required referral to a podiatrist for nail care in such cases, but this was not done, increasing the risk of infection. The Infection Preventionist Nurse and a Registered Nurse confirmed the deficiency, highlighting the importance of proper nail hygiene in infection control.
A resident at risk for pressure ulcers was found to have their low air loss (LAL) mattress incorrectly set to static mode with a pressure setting of 350 pounds, despite weighing 137 pounds. This was confirmed by the Director of Staff Development and Treatment Nurse 1, who adjusted the pressure to 100 pounds. The resident's care plan required a LAL mattress for wound management due to their risk factors, and the facility's policy emphasized the importance of proper mattress settings to prevent pressure injuries.
Failure to Maintain Resident Dignity by Leaving Full Urinals in Rooms
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity and respect by leaving urinals partially filled with urine on top of dressers for two cognitively intact residents. Resident 1, admitted with COPD, heart failure, and morbid obesity, had documented capacity to understand and make decisions and required maximal assistance with toilet hygiene and moderate assistance with transfers. On 4/15/2026 at 12:55 PM, Resident 1’s urinal was observed to be halfway full of urine on the dresser. Resident 1 reported having asked staff several times to empty the urinal and expressed embarrassment and concern about it overflowing. At 1:27 PM the same day, during an observation with an LVN, the urinal was again observed on the dresser, now full, containing 240 cc of urine. The LVN acknowledged that, for Resident 1’s dignity, urinals should not be left with urine inside. Resident 4, admitted with diagnoses including UTI, difficulty walking, and lack of coordination, also had documented capacity to understand and make decisions and required moderate assistance with toilet hygiene and bathing and maximal assistance with certain mobility tasks. On 4/15/2026 at 1:24 PM, during an observation with the same LVN at the bedside, Resident 4’s urinal was found full of urine on top of the dresser, with the resident requesting that it be emptied due to embarrassment about family visiting later. The LVN confirmed the urinal contained 240 cc of urine and stated urinals should be emptied and concealed for resident dignity. The Director of Staff Development and the DON both stated that urinals should be empty and that residents must be treated with respect and dignity, consistent with facility policies on Resident Rights – Accommodation of Needs and Quality of Life, which emphasize maintaining residents’ dignity and well-being.
Improper Handling of Urinals Undermines Infection Control
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the handling of urinals for two residents. For Resident 1, who had COPD, heart failure, morbid obesity, intact cognition, and required maximal assistance with toilet hygiene and moderate assistance with transfers, observations on the same day showed the resident’s urinal first half full and later full of urine, both times left on top of the dresser in the room. Resident 1 reported having asked staff several times to empty the urinal. During an observation with an LVN, the urinal was noted to contain approximately 240 cc of urine, and the LVN acknowledged that urinals should be emptied because bacteria could grow inside them and for infection control. For Resident 4, who had a history of UTI, difficulty walking, lack of coordination, intact cognition, and required moderate assistance with toilet hygiene and bathing and maximal assistance with certain mobility tasks, the resident’s urinal was observed at the bedside on top of the dresser containing about 240 cc of urine. During interviews, the LVN, the Director of Staff Development, and the DON each stated that urinals should be emptied as soon as possible and not left with urine because they could grow bacteria and posed an infection control issue. Review of the facility’s infection control policy indicated it was intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections, but the observed handling of urinals for these two residents did not align with those practices.
Residents Left Exposed or Fed in a Dignity-Lacking Manner
Penalty
Summary
The facility failed to ensure three sampled residents were treated with dignity during care and feeding activities. Resident 54 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and contractures, and was dependent for most ADLs with moderately impaired cognitive skills. During an observation, CNA 6 left Resident 54 lying in bed uncovered, wearing only a sweater over a shirt, a diaper, and socks, with the privacy curtain only partially drawn so the resident was not visible from the hallway. Resident 54 stated feeling uncomfortable while lying in bed uncovered and later stated that being left in only a shirt and underwear without a blanket would make the resident feel naked. Resident 1 had diagnoses including type 2 diabetes mellitus, muscle weakness, and unspecified dementia, and was assessed as moderately cognitively impaired and needing partial/moderate assistance with eating and oral hygiene. During lunch in the dining room, CNA 12 fed Resident 1 while seated across from the resident, but stood up in front of Resident 1 each time the milk had to be tipped for drinking. CNA 10 observed this and stated CNA 12 was not supposed to stand up and should sit at Resident 1's side while feeding. CNA 12 later stated the staff member should have been at eye level with Resident 1 while feeding for dignity. Resident 6 had diagnoses including dysphagia following cerebral infarction and flaccid hemiplegia affecting the right dominant side, and was cognitively impaired and dependent on staff for ADLs. During an observation in Resident 6's room, the ST was seen standing while feeding Resident 6. The ST stated standing while feeding was personal preference and that residents had not asked the ST to sit down, but also stated the ST had attended an in-service instructing staff to sit while feeding residents. Facility staff interviewed stated staff should sit down while feeding residents to ensure they can see the residents' faces and make sure they are not choking. The facility policy stated employees are to treat residents with kindness, respect, and dignity and honor resident rights, including privacy and confidentiality.
Advance directives not properly filed in resident records
Penalty
Summary
The facility failed to implement its Advance Directives policy for two residents when copies of their advance directives were not properly maintained in the medical record as required. For one resident, the Social Services Assessment documented that an advance directive was on file and uploaded in the EHR, but during interview the SSD stated the document was not in the resident’s medical record. The resident had been admitted with diagnoses including a right femur fracture and UTI, and the H&P and MDS indicated the resident had capacity and intact cognitive skills for daily decision making. For the second resident, the record showed severe cognitive impairment and no capacity to understand and make decisions. The resident’s POLST stated that it complements an advance directive and is not intended to replace it, but the medical record did not contain an advance directive or a healthcare DPOA. The only DPOA in the record, dated 12/13/1991, granted the responsible party authority over financial affairs only and did not appoint anyone to make medical or healthcare decisions. During interview and record review, the SSD stated that an advance directive identifies who a resident wants to decide for them if they cannot make medical decisions, and that the POLST was not intended to replace an advance directive. The SSD also stated that admissions or social services staff were responsible for obtaining the resident’s advance directive on admission and that the DPOA should have been reviewed to ensure it covered medical decisions. The facility policy required staff to obtain a copy of the resident’s advance directive upon admission and place it in the medical record.
Missing Care Plans for GT Pulling, Eyelid Taping, and Hospice Admission
Penalty
Summary
Failure to develop comprehensive care plans was identified for three residents with distinct needs and conditions. Resident 13 was admitted and readmitted with Parkinson's disease with dyskinesia, dysphagia, and a gastrostomy tube, and the MDS showed severely impaired cognition and dependence for toileting with partial to moderate assistance for mobility. Staff interviews confirmed Resident 13 had a history of repeatedly pulling out the GT, wore an abdominal binder and mitten restraints to prevent removal, and had reportedly removed the GT multiple times over the past year, yet the facility did not develop a care plan for this behavior. Resident 67 was admitted with macular degeneration and multiple cranial nerve disorders, and the MDS showed impaired cognition with partial to moderate assistance needed for toileting hygiene and bathing. Optometry notes documented complete ptosis with lids taped up two to three times per day. During observation, Resident 67 was seen with tape placed vertically from the right eyelid to the forehead and the left eye closed, and the resident stated the tape was used to keep the eye open and that it was their preference. RN 2 stated there was no care plan for the eyelid tape, and that one should have been developed to address skin integrity around the eyes, infection potential, and the resident's preference. Resident 103 was admitted with anoxic brain damage and had severely impaired cognitive skills. The IDT note documented the daughter requested hospice involvement, the MD and NP were notified, and an order was received for a hospice evaluation; the order summary then indicated admission under hospice care at routine level of care. The H&P described the resident as declining, with a history including cerebral atherosclerosis, vascular dementia, hyperlipidemia, anoxic brain injury, and psychosis, and noted the resident did not have capacity to understand and make decisions. The DON stated she could not find a hospice care plan and had missed it, while also stating hospice and the facility should collaborate on a care plan.
Missing insulin parameters and OTC medications kept at bedside without orders
Penalty
Summary
Resident 58 had diagnoses including end stage renal disease and diabetes mellitus. The resident’s record showed a physician order for Tresiba, 70 units subcutaneously once daily for diabetes, but the order did not include administration parameters such as when to check blood sugar, when to hold the medication, or what to do if blood sugar was low. The resident’s care plan identified a goal to maintain normal blood glucose levels and included an intervention to check fasting blood sugar as ordered by the physician. A review of the medication administration record showed Tresiba was administered on multiple dates, while the blood sugar summary showed blood sugar had only been checked four times during the resident’s stay. During interview, the resident stated staff did not always check blood sugar before giving Tresiba and expressed concern because staff were supposed to do so. RN staff confirmed the Tresiba order lacked parameters and stated there were no orders indicating blood sugar should be checked before administration. The RN staff also stated the physician was not notified about the missing parameters. Resident 105 and Resident 29 each had OTC topical products at the bedside without physician orders for bedside storage or self-administration. Resident 105 had Amlactin Daily Healing 12% Lactic Acid Lotion in a bedside drawer and stated it had been obtained from a warehouse club and kept for about 30 days. Resident 29 had Eucerin Original Healing Cream in a bedside drawer and stated it had been given by a family member for dry skin. LVN and RN staff identified both products as OTC topical creams and stated they should have been stored at the medication cart unless there were physician orders for bedside storage and self-administration. Staff also stated there were no physician orders or consents for self-administration for either resident.
Improper Storage of Food Brought in by Visitors
Penalty
Summary
The facility failed to ensure foods brought in from outside the facility were stored properly for two residents. Resident 105 was admitted with diagnoses including heart failure and essential hypertension, and the H&P dated 2/18/2026 indicated the resident had the capacity to understand and make decisions. During observation on 2/24/2026, an unlabeled 3-pound container of green seedless grapes was found on Resident 105's dresser. RN 2 observed the grapes and stated the grapes should have been labeled with the resident's name and stored in the refrigerator for infection precautions. Resident 105 later stated the son brought the grapes and cherries and that they should have been refrigerated to prevent bacteria from getting in and making the resident sick. Resident 4 was admitted with diagnoses including sepsis and unspecified protein-calorie malnutrition, and the H&P dated 1/15/2026 indicated the resident had the capacity to understand and make decisions. The MDS dated 1/20/2026 indicated cognitive skills for daily decision making were intact, but the resident required substantial to maximal assistance with eating, oral hygiene, and personal hygiene and was dependent on toileting, showering, and dressing. During observation on 2/24/2026, an unlabeled and undated plastic grocery bag containing an undated plastic container with Spanish labeling and three cookies was found inside Resident 4's bedside drawer. CNA 9 stated the food's age was unknown and that foods brought in from outside were supposed to be labeled with the resident's name, room number, and date received and stored in the refrigerator. The resident's family member stated the food was brought in from home and that the facility did not inform the family of its policy regarding bringing food from home.
Unlabeled and Improperly Stored Personal Care Items
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when two sampled residents sharing a room had personal care items that were not labeled and were not stored properly. Resident 105 was admitted and readmitted to the facility with diagnoses including heart failure and essential hypertension, and the history and physical indicated the resident had the capacity to understand and make decisions. Resident 105’s care plan included interventions to reduce the risk of MDRO transmission and to use EBP during care activities such as dressing, bathing, transferring, hygiene, linen changes, brief changes, and toileting. Resident 50 was admitted and readmitted with diagnoses including sepsis and a personal history of other infectious and parasitic diseases. The minimum data set indicated the resident’s cognitive skills for daily decision making were intact, and the resident required substantial to maximal assistance or supervision/touching assistance with activities of daily living. The history and physical indicated Resident 50 had the capacity to understand and make decisions. During observation of the shared room and restroom, an unlabeled 3-pound container of green seedless grapes was seen next to multiple unlabeled personal care items, including deodorant, mouthwash, toothpaste, toothbrush, and a wash basin with diapers, stored on the shared dresser across from Resident 105’s bed. In the shared restroom, an unlabeled pack of XL wipes and two unlabeled packs of wipes were on top of the toilet tank, along with body lotion, perineal/body wash + shampoo, baby lotion, toothpaste, and a bar of bath soap stored on the top of the pony wall. RN 2 stated the residents ideally share half of everything, and later stated personal care items should be labeled and stored in the resident’s personal space for infection control. The infection preventionist stated personal care items should be labeled with the resident’s name and stored close to the resident’s side of the room, and CNA 14 stated labeling and bedside storage were important to prevent residents from sharing and to avoid cross contamination.
Unclean Resident Room Wall
Penalty
Summary
The facility failed to ensure a safe and clean environment for Resident 76 when the wall on the right side of the resident’s bed was observed with a red tinged substance. Resident 76 was admitted with diagnoses including nontraumatic intracerebral hemorrhage in the cerebellum and acute respiratory failure with hypoxia. The resident’s history and physical indicated the resident could make needs known but could not make medical decisions, and the MDS showed severely impaired cognitive skills for daily decision making, with substantial assistance needed for eating, oral hygiene, showering, and lower body dressing, and dependence for toileting and personal hygiene. During an observation, the wall in Resident 76’s room was seen with the red tinged substance. During a concurrent interview and observation, the DSD stated the substance looked like old food and said the dirty wall was potential for infection, adding that it was important to maintain a clean room for a comfortable and homelike environment. The DON later stated the wall next to Resident 76’s bed should be clean and that Resident 76 deserved a clean and homelike environment. Facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment, and housekeeping policy stated all surfaces in long-term resident rooms, including walls and ceilings, are to be thoroughly cleaned quarterly.
Failure to Show Restraints Were Last Resort for GT Protection
Penalty
Summary
The facility failed to provide evidence that the use of physical restraints for one resident was a measure of last resort to protect the resident’s safety. The resident had multiple diagnoses including Parkinson’s disease with dyskinesia, adult failure to thrive, and a gastrostomy tube (GT), and the MDS indicated severely impaired cognition, dependence for toileting, and partial/moderate assistance for mobility. The record showed the resident dislodged the GT on multiple occasions, including an event where the resident pulled out the GT while in bed and later pulled out a Foley catheter that had been inserted to keep the stoma from closing, resulting in transfer to a general acute care hospital for further evaluation and treatment. After these events, the resident was placed in bilateral mittens to prevent accidental GT dislodgement. The restraint evaluation documented that an abdominal binder had worked in the past to control or limit the behavior, but the resident was still able to access the GT site even when wearing the binder. The resident’s family requested the restraints, and the care plan and order summary reflected bilateral mittens and skin monitoring related to restraint use. Staff interviews stated the resident was impulsive, had repeatedly pulled the GT over the past year, and used the restraints all day, while the physician order did not specify when the restraints should be applied or removed. The DON stated the facility attempted to monitor behavior and redirect the resident when seen playing with tubing, but there was no interdisciplinary team meeting about the behavior and no documentation showing interventions attempted before restraints were implemented. The DON also stated there was no documented evidence that the least restrictive method had been used and no current plan to reduce restraint use. The facility policy stated restraints are to be used only as a last resort, with the least restrictive alternative for the least amount of time and under carefully monitored circumstances.
Care Plan Not Timely Revised After Significant Weight Loss
Penalty
Summary
The facility failed to ensure that Resident 35’s care plan was revised after the resident experienced significant weight loss. Resident 35 was originally admitted and later readmitted with diagnoses including cerebral palsy and unspecified severe protein-calorie malnutrition. The history and physical indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills, dependence for ADLs including eating, and a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Record review showed Resident 35 was identified as being at increased nutritional risk, with a 15-pound weight loss in one month and 14-pound weight loss in three months, and a change in condition evaluation documented a 16-pound weight loss in one month. The weights and vitals summary showed a decline from 114 pounds to 99 pounds over the documented period and a significant 14.04% weight loss in the last 6 months. During interview and record review, RN 1 stated the resident had significant weight loss and that the care plan should have been revised when the resident started losing weight in 12/2025, but the care plan was not revised until 2/24/2026. The facility policy stated comprehensive care plans must be reviewed and revised after each assessment, and that weight loss of 5 pounds or more in 30 days or 10% or more in 6 months required the care plan to be updated to reflect the resident’s current status.
Missing restraint training documentation and incomplete CNA personnel file
Penalty
Summary
The facility failed to ensure nursing staff had the appropriate competencies and skill sets to care for residents when it did not provide documentation that nursing staff had been trained in the use of physical restraints. Resident 13 was admitted with diagnoses including Parkinson's disease, dysphagia, and need for gastrostomy tube care. The resident's MDS indicated severely impaired cognition and dependence on staff for toileting hygiene, with supervision or touching assistance needed for personal hygiene. Resident 13 had a physician order allowing bilateral mittens to prevent accidental G-tube dislodgement. During a concurrent observation and interview, the resident was seen wearing bilateral mitten restraints and an abdominal binder, and the DSD stated the resident had a behavior of pulling out the gastrostomy tube and wore the mittens and binder to prevent access to the tube. Staff interviews showed CNA 8 had received an informal restraint in-service from the DSD, while LVN 2 and LVN 4 stated they had received restraint training in the past but could not recall when, and LVN 4 stated restraints were not covered during the annual skills fair. The DSD stated no restraint in-services had been given in the past month, and the DON stated there was no documentation showing staff had previously been trained in restraint use. The facility assessment listed topics covered at the annual nursing skills competency fair, but restraints were not included. In a separate finding, CNA 15's personnel file did not contain a background check dated before hire and did not contain a current CPR card. The DSD stated the background check was used to verify eligibility and criminal history, and acknowledged CNA 15's CPR card on file was expired and that a current CPR card should have been filed. The TI stated CNA 15 had taken a CPR class and received an e-card directly, and the DSD stated that current card should have been in the employee file.
Incomplete Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure that one of three CNA 15's employee performance reviews was completed at least once every 12 months. During a concurrent interview and record review with the Director of Staff Development, CNA 15's personnel file was reviewed and the last performance review on file was dated 6/8/2024. The Employee Performance Review dated and signed 6/8/24 was incomplete. The Director of Staff Development stated that completing a performance review annually was important to ensure CNAs were aware of how they were doing with their skills and what to improve on to ensure they provided quality of care. The facility's Employee Handbook stated employees may receive periodic performance reviews, generally conducted by their supervisor, and that performance evaluations may be conducted annually on or around their anniversary date to help employees become aware of progress, areas for improvement, and future work performance goals.
Medication Left at Bedside Without Self-Administration Approval
Penalty
Summary
The facility failed to ensure medication was not left at the bedside for one sampled resident. Resident 73 was admitted with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The resident’s MDS dated 1/19/2026 indicated intact cognition and that the resident required supervision or touching assistance for toileting and personal hygiene. The resident’s active order included calcium carbonate oral tablet, one tablet by mouth every six hours as needed for heart burn. During a concurrent observation and interview on 2/24/2026, a large white round pill imprinted with G 127 was observed in a medicine cup on top of Resident 73’s bedside table, and CNA 8 identified it as Tums that the resident took every day. LVN 5 stated the medication had not been administered that day, did not know how long it had been left there, and stated medications are not kept at the bedside unless a resident is approved to self-administer; Resident 73 did not have that approval. Resident 73 later stated the Tums had been requested the night before to have nearby in case of nighttime acid reflux. RN 2 stated it was never acceptable to keep medication at the bedside unless an assessment showed the resident could self-administer, and the DON stated Resident 73 should not have had medication at the bedside for safety reasons. The facility policy on medication storage stated only authorized staff may access medications and that medications dispensed by the pharmacy are stored in their labeled container.
Antibiotic Stewardship Not Followed for Pneumonia Treatment
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for one resident who was screened for pneumonia and prescribed levofloxacin without meeting the required criteria. The resident was admitted with multiple diagnoses including quadriplegia, pneumonia, and a solitary pulmonary nodule. A chest x-ray showed opacities in the right upper lung concerning for pneumonia, and a physician ordered levofloxacin 500 mg by mouth in the evening for 5 days. Progress notes documented abnormal x-ray results, that the chest x-ray was provided to MD 2, and that the antibiotic was ordered for pneumonia after the resident reported right upper chest pain and feeling short of breath at times. During review of the Surveillance Data Collection Form, the Infection Preventionist stated the form used McGeer's criteria to determine whether a resident met infection criteria and needed an antibiotic, and that the resident did not meet McGeer's criteria. The IP stated the physician was not informed that the resident did not meet criteria, and the DON stated the doctor should be informed when a resident does not meet McGeer's criteria to avoid unnecessary medication. The facility policy titled Antibiotic Stewardship stated the IP is responsible for tracking whether the resident's condition met McGeer's Criteria when the antibiotic was ordered.
Failure to Implement Care-Planned Bilateral Floor Mats for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention requiring bilateral floor mats at the bedside for a resident assessed as high risk for falls. The resident was admitted with dementia and lack of coordination, and a subsequent MDS assessment documented severe cognitive deficit and a need for maximal assistance with walking, transfers, and toileting. The resident’s care plans for risk of falls related to impaired mobility and weakness, initiated on 10/26/2025, specified that the bed may be in the lowest position with bilateral floor mats while in bed and that floor mats should be applied next to the bed as appropriate. A Fall Risk Evaluation dated 12/10/2025 showed a score of 16, indicating the resident was at high risk for falls. During observation on 1/23/2026, the resident was found lying in bed with the bed in a low position, a bed alarm in place, and only one fall mat located on the right side of the bed. In a concurrent interview and record review, an LVN confirmed that the resident’s fall risk care plan called for bilateral fall mats and stated the resident needed mats on both sides of the bed to prevent injuries in the event of a fall. The DON also stated that fall mats needed to be in place on both sides of the bed and, upon entering the room, found the left fall mat placed against the wall toward the right side of the bed rather than positioned on the floor beside the bed. The facility’s policy on Person Centered Care Planning required development and implementation of a comprehensive person-centered care plan, but the specified intervention of bilateral floor mats was not implemented as written.
Failure to Promptly Respond to Resident’s Repeated Toileting Requests
Penalty
Summary
The deficiency involves staff failing to promptly respond to a resident’s repeated requests for toileting assistance, resulting in unmet needs. The resident had been admitted with traumatic hemorrhage of the cerebrum, muscle weakness, lack of coordination, and had moderately impaired cognition. The resident’s MDS indicated dependence for rolling and chair/bed-to-chair transfers. During an observation period, the resident was seated in a wheelchair at the foot of the bed, facing away from the door, and repeatedly yelled, “Can I go to the bathroom,” a total of 16 times, and also stated, “I would make a mess and you going to be stuck with it.” During this time, CNA 1 entered the room while the resident was calling out but only looked around and left without communicating with or assisting the resident. CNA 2 later entered the room but also did not assist with toileting or communicate with the resident and then left. LVN 1 was observed standing by the medication cart near the resident’s room while the resident continued to call out, and then began preparing medications before entering the room to administer them. Staff interviews confirmed that LVN 1 was preoccupied with the medication pass and that CNA 1 was taking out meal trays and described the resident as very persistent. The facility’s “Resident Rights – Quality of Life” policy stated that demeaning practices and standards of care that compromise dignity are prohibited and that staff are to promote dignity by promptly responding to residents’ requests for toileting assistance.
Failure to Maintain Functional Call Light System for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a functioning call light system for a resident. The resident had been admitted with diagnoses including traumatic hemorrhage of the cerebrum, muscle weakness, and lack of coordination, and an MDS assessment documented moderately impaired cognition and dependence for rolling and chair/bed-to-chair transfers. During observation, the resident was seated in a wheelchair at the foot of the bed, facing away from the door, and repeatedly yelled, “Can I go to the bathroom,” 16 times. The call light button was taped on top of the bottom bed rail next to the resident. When the resident pressed the call light button, the call light bulb outside the room did not illuminate and there was no audible sound outside the door. A CNA confirmed that the call light did not activate any light or sound and stated they would call maintenance. Maintenance staff later entered the room and stated the light bulb outside the door was not working and that they had not previously received a report that the resident’s call light needed to be checked. The facility’s policy on the call system stated that the facility would maintain a communication system to allow residents to call for staff assistance from rooms and toileting/bathing areas, and that any defective call alert system would be reported to maintenance for immediate repair.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
Licensed Vocational Nurse 4 (LVN 4) failed to immediately notify the physician and family after a resident experienced an unwitnessed fall. The resident, who had diagnoses including osteoarthritis, dementia, and Alzheimer's disease, was severely cognitively impaired and dependent on staff for activities of daily living. On the evening of the incident, the resident was found on the floor mat by the bed and was assisted back to bed by LVN 4, LVN 3, and a CNA. LVN 4 did not document the fall or notify anyone, stating that there was no injury or distress observed at the time. Subsequent reviews of the resident's records showed that neither the physician nor the family were informed of the fall until several days later, after further changes in the resident's condition were noted, including swelling, discoloration, and eventually fractures requiring surgical intervention. The facility's policy required immediate notification of the physician and family in the event of an incident or accident involving a resident. The Director of Nursing confirmed that the policy applied to this situation and that the required notifications were not made at the time of the fall.
Failure to Protect Resident from Physical Abuse and Mistreatment by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide a safe environment and protect a resident with severe cognitive impairment from physical abuse and mistreatment. The resident, who had diagnoses of Alzheimer's disease and dementia and required moderate assistance with activities of daily living, was subjected to rough handling and verbal aggression by the CNA. Multiple witnesses, including the resident's roommate and another CNA, observed the CNA speaking loudly and firmly to the resident, grabbing the resident tightly by the arms, and placing the resident into a wheelchair in a fast and rough manner. The CNA was also seen brushing the resident's hair roughly, causing concern for the resident's comfort. The roommate, who was cognitively intact, reported that the CNA's actions were forceful enough to cause discomfort and that the CNA yelled at the resident not to get up. Another CNA corroborated these observations, stating that the resident appeared uncomfortable and that the CNA's tone of voice was inappropriate. The incident was reported to facility leadership, and interviews with staff and residents confirmed the rough treatment and verbal mistreatment by the CNA. The resident, when interviewed, did not recall the incident, but later described the CNA as rude and stated that the CNA had yelled and handled them harshly. The roommate refused further care from the CNA due to these actions. Facility records and interviews with the Director of Staff Development and Director of Nursing confirmed that concerns about the CNA's behavior were reported by both residents and staff, and that the facility's abuse prevention policy prohibits any form of resident abuse or mistreatment.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's condition at the time, are not provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision practices were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Resident Dignity and Address Needs During Care and Call Light Response
Penalty
Summary
Certified Nursing Assistants (CNAs) on the night shift failed to maintain the dignity of a resident with functional quadriplegia and multiple pressure ulcers by leaving the resident uncovered and with their gown up when they left to assist another resident. This occurred while the resident was dependent on staff for all activities of daily living, including bed mobility and transfers, and had intact cognitive skills. The resident reported feeling upset and neglected when left in this vulnerable state, as the CNAs did not focus on their care during these incidents. In a separate incident, staff failed to address the needs of a resident with diabetes, dysphagia, and an indwelling urinary catheter when responding to a call light in a shared room. Both a male staff member and a CNA only inquired about the needs of the roommate and did not check on the resident, despite the resident's repeated use of the call light. The resident expressed feeling bad about being overlooked, and the CNA later acknowledged that both residents in a shared room should be asked if they need assistance when a call light is activated.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to implement its policies and procedures for pressure injury prevention and skin and wound management for a resident who was admitted with a history of a sacral pressure injury. Upon admission, the resident's risk for developing pressure ulcers was not accurately assessed, as the Braden Scale completed indicated no impairment in sensory perception or mobility, despite the resident being dependent on staff for most activities and having decreased movement in both lower extremities. The initial skin assessment performed by the admitting nurse did not identify any pressure injuries other than the sacral wound, and it was later revealed that the assessment may have been incomplete, as the nurse admitted to possibly not removing the resident's socks during the examination. Within approximately 22.5 hours of admission, the resident developed additional pressure injuries on the left buttocks/ischium and both heels, which were not present upon discharge from the hospital or noted during the initial skin check. A subsequent assessment by the treatment nurse identified a Stage 4 pressure injury on the left ischium, a Stage 3 pressure injury on the right gluteus, and deep tissue injuries on both heels. The discrepancies between the initial and follow-up assessments made it difficult to determine whether these injuries were acquired prior to or after admission, but the facility's own staff acknowledged that a lapse in turning and repositioning could result in the development of pressure injuries within a single shift. The resident's care plan did not include specific interventions to offload pressure from the heels, despite the presence of deep tissue injuries in those areas. The facility's policies required a comprehensive skin assessment upon admission, accurate risk assessment, and individualized care planning to prevent pressure injuries, including offloading and use of pressure-redistributing devices. These steps were not fully implemented, resulting in the resident developing additional pressure injuries and being at risk for further skin breakdown.
Failure to Ensure Staff Competency in Nephrostomy Tube Care
Penalty
Summary
Licensed nurses and CNAs failed to demonstrate appropriate competencies in caring for a resident with a nephrostomy tube, resulting in two separate incidents where the tube became dislodged. The resident, who had a history of urinary tract infection and hydronephrosis, required substantial assistance with mobility and hygiene. On both occasions, the nephrostomy tube was found dislodged, with urine leaking from the insertion site and the resident's back wet, necessitating transfer to an acute care hospital for evaluation and reinsertion of the tube. Interviews and record reviews revealed that neither the CNAs nor the licensed nurses had received specific training or skills checks related to nephrostomy tube care prior to the incidents. Several CNAs confirmed they had not been trained on how to care for residents with nephrostomy tubes, and the Director of Staff Development acknowledged that skills evaluations for nephrostomy tube care were not conducted at the time of the resident's admission. The facility's own policy required competency evaluations when new procedures or equipment were introduced, but this was not followed in the case of nephrostomy tube care. Observations and interviews with the resident and family member indicated that the nephrostomy tube had not previously become dislodged at home, and the resident expressed concerns about staff awareness and handling of the tube during care activities such as turning and repositioning. The lack of staff competency assessment and training directly contributed to the improper handling of the nephrostomy tube, leading to its repeated dislodgement and the need for hospital intervention.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program for two of five sampled residents by not ensuring staff followed Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. Certified Nursing Assistant 1 (CNA 1) removed splints from a resident with multiple pressure ulcers and an indwelling urinary catheter without wearing a protective gown, despite being aware of the requirement due to the resident's wounds and catheter. CNA 1 acknowledged forgetting to don the gown during the care activity. In a separate incident, two other CNAs (CNA 2 and CNA 3) provided dressing care to another resident who had surgical wounds and an indwelling urinary catheter, also without wearing protective gowns. After completing care, both CNAs removed their gloves and exited the resident's room without performing hand hygiene. CNA 2 later stated that they were aware of the EBP requirements but did not see the EBP sign by the resident's room and therefore did not wear the gown. CNA 2 also confirmed the importance of hand hygiene and PPE use for residents with wounds or indwelling devices. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that EBP and hand hygiene are required for residents with wounds or indwelling medical devices, and that staff must don PPE and perform hand hygiene before and after resident care. Facility policies reviewed also indicated that EBP applies to all residents with wounds and/or indwelling medical devices, and that hand hygiene must be performed before donning and after doffing PPE, as well as upon entering and exiting resident rooms.
Failure to Notify Physician of Resident's Refusal of Blood Tests
Penalty
Summary
The facility failed to notify a resident's physician when the resident refused ordered blood tests on two separate occasions. The resident, who had diagnoses including metabolic encephalopathy, schizoaffective disorder, and Alzheimer's disease, was severely cognitively impaired and required significant assistance with daily activities. Physician orders were in place for weekly complete blood counts due to Clozapine use and for regular valproic acid level monitoring. Documentation showed that the resident refused blood draws on two dates, but there was no evidence in the medical record that the physician was informed of these refusals. During interviews and record reviews, the Director of Nursing confirmed that the physician was not notified each time the resident refused the blood draws, despite the facility's policy requiring timely notification of changes in a resident's condition to physicians, family, or legal representatives. The facility's policy also required updating the care plan to reflect the resident's current status, but this was not documented in relation to the refusals.
Failure to Develop and Implement Comprehensive Care Plan for Blood Test Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident by not including interventions to address the resident's refusal of ordered weekly blood tests. The care plan also did not document the required weekly blood tests, despite physician orders for a complete blood count every Monday due to Clozapine use and a valproic acid level every Wednesday. These omissions were identified during a review of the resident's care plan and order summary report, which showed that the care plan did not reflect the necessary interventions for the resident's specific needs. The resident involved had a history of metabolic encephalopathy, schizoaffective disorder, and Alzheimer's disease, and was severely impaired in cognitive skills, requiring varying levels of staff assistance for daily activities. The resident was prescribed psychotropic medications, including Clozapine and Depakote (valproic acid), which necessitated regular blood monitoring. The Director of Nursing confirmed that the care plan should have included interventions for both the required blood draws and the resident's behavior of refusing these tests.
Failure to Ensure Complete Dialysis Assessment and Documentation
Penalty
Summary
The facility failed to ensure that three residents who required dialysis services were properly assessed before, during, and after their dialysis treatments, and that all required documentation was maintained in their medical records according to facility policy. Specifically, the care plans for these residents indicated that nurses were to document the time, date, and general condition of the residents before transport to dialysis, as well as upon their return. However, reviews of the residents' medical records revealed missing or incomplete documentation, including absent pre- and post-dialysis evaluations and missing treatment records from the dialysis center. Resident 10, who had diagnoses including type 2 diabetes mellitus, respiratory failure, and dependence on renal dialysis, was admitted and readmitted to the facility and was scheduled for dialysis three times a week. The care plan required documentation of the resident's condition before and after dialysis, but the pre-dialysis evaluation form was found incomplete, with the section to be filled by the dialysis unit left blank. Similarly, Resident 11, with diagnoses of type 2 diabetes mellitus and end stage renal disease, was also scheduled for regular dialysis, but their medical record was missing post-dialysis evaluations for several dates, and the dialysis unit's section on the pre-dialysis evaluation forms was not completed. Resident 12, who had type 2 diabetes mellitus, end stage renal disease, and muscle weakness, was also scheduled for dialysis three times a week. The medical record for this resident did not include any documentation from the dialysis center for two treatment dates. Interviews with facility staff confirmed that the required documentation was either incomplete or missing, and that the dialysis center's nurse had not completed the necessary sections of the forms as required by facility policy. The facility's policy and procedure on dialysis management specified that all documentation concerning dialysis services and care should be maintained in the resident's medical record, and that communication forms should be sent to and completed by the dialysis center for each treatment.
Failure to Accurately Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to accurately inventory and reconcile a resident's controlled medication, morphine sulfate, with the Medication Administration Record (MAR). The resident, who was admitted with diagnoses including type 2 diabetes mellitus, dementia, and was receiving palliative care, was severely cognitively impaired and dependent on staff for daily activities. The resident had a physician's order for scheduled morphine sulfate for pain management. Record reviews and interviews revealed that while the resident's MAR indicated morphine sulfate was administered daily at 6:00 p.m. on several dates, the Individual Narcotic Record (INR) was missing corresponding entries for those administrations. The Assistant Director of Nursing confirmed these omissions. Facility policy required that controlled substance inventory be regularly reconciled to the MAR, but this was not done, resulting in incomplete documentation of the use and removal of the resident's morphine sulfate.
Unsecured Medications Left Unattended at Nurse Station
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services for two residents by not properly securing physician-ordered medications. For one resident with diagnoses including peripheral vascular disease, dementia, and Parkinsonism, medications Cilostazol and Memantine HCI were found unsupervised on the desk at the nurse station. This resident was severely cognitively impaired and dependent on staff for most activities of daily living. For another resident with type 2 diabetes, hypertension, and anemia, Metoprolol was also found unsupervised on the same desk. Both residents' medication orders were confirmed through record review. During an observation and interview, an LVN admitted to placing the medications on the desk while changing them out from the medication cart, acknowledging that they should have been disposed of in the medication room according to facility policy. The LVN further stated that the medications were not disposed of properly and that other residents could have accessed them. An RN confirmed that the medications should not have been left on the desk and reiterated the facility's policy for medication destruction, which requires documentation and proper disposal in the incineration container. Review of the facility's policy supported these procedures for medication destruction.
Failure to Implement Vaccination Program
Penalty
Summary
The facility failed to implement its influenza and pneumococcal immunization program for four of seven sampled residents. For one resident who refused the flu vaccination, the facility did not document that education was provided regarding the risks and benefits of the vaccination, nor was there a signed declination in the medical record. Another resident received a flu vaccination, but the facility failed to document the lot number of the vaccine and did not have a signed informed consent in the medical record. Additionally, the facility did not administer a pneumococcal vaccine to a resident despite having a signed informed consent from the resident's representative. Similarly, another resident who had signed informed consents for both the pneumococcal and flu vaccinations did not receive either vaccine. These failures indicate a lack of adherence to the facility's policies and procedures regarding vaccination documentation and administration. The facility's policies require that residents or their representatives be educated on the risks and benefits of vaccinations, and that informed consent be obtained and documented. The policies also mandate that the vaccine type, dose, route, and lot number be recorded. The deficiencies observed in the facility's vaccination program highlight a failure to follow these established protocols, potentially impacting resident safety and care.
Failure to Implement COVID-19 Immunization Program
Penalty
Summary
The facility failed to implement its COVID-19 immunization program effectively for three residents and all facility staff. Resident 2 was not offered the latest COVID-19 vaccination, as confirmed by the Director of Nursing (DON) during a review of the resident's medical records. Resident 4, who had signed an informed consent to receive the COVID-19 vaccination, did not receive the vaccine. The DON confirmed that the facility staff did not administer the vaccination to Resident 4. For Resident 5, the facility administered a COVID-19 vaccination but failed to document whether education regarding the benefits and potential risks associated with the vaccination was provided. Additionally, there was no signed consent in Resident 5's medical record for the vaccination administered. The DON acknowledged the lack of documentation regarding the education and consent for Resident 5. The facility also failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for the facility's staff. The newly hired Infection Preventionist (IP) stated that there was no system or documentation in place to track the COVID-19 vaccination status of the staff. The facility's policies and procedures required offering vaccinations to all residents and staff, along with maintaining records of consent or declination, but these were not followed as per the findings.
Failure to Designate Infection Preventionist During COVID-19 Outbreak
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for overseeing the Infection Prevention and Control program during a COVID-19 outbreak. The previous IP, a Licensed Vocational Nurse (LVN), had resigned from the position on 2/21/2025, and the facility did not appoint a replacement. Instead, the LVN was reassigned to pass medications and work as a charge nurse on 2/24/2025 and 2/25/2025, leaving the IP role unfilled during a critical time. Interviews with the Public Health Nurse (PHN) and the Director of Staff Development (DSD) confirmed that the facility was experiencing a COVID-19 outbreak, with at least three positive cases within a seven-day period. The PHN was unaware of who would assume the IP responsibilities, and the facility's staffing logs indicated that the LVN was not performing IP duties on the specified dates. The facility's job description for the IP role emphasized the importance of having a designated individual to oversee infection prevention and control, highlighting the deficiency in maintaining this critical position during an outbreak.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of infections during a COVID-19 outbreak. An Activity Assistant was observed pulling down their N95 mask to drink from a bottle while standing in a hallway near the COVID-19 isolation zone, despite being trained to go to the break room for such activities. Additionally, a Certified Nursing Assistant was seen wearing their N95 mask incorrectly, with the bottom strap hanging loosely under their chin, and admitted to discomfort from the mask straps. This improper use of personal protective equipment could contribute to the spread of infections. Furthermore, another Certified Nursing Assistant failed to perform proper hand hygiene after removing gloves and before entering and exiting resident rooms. This CNA was observed discarding gloves and then interacting with a Licensed Vocational Nurse and entering a resident room without sanitizing or washing their hands. The Director of Nursing acknowledged the need for staff education on proper N95 mask usage and hand hygiene to control the COVID-19 outbreak. The facility's policies on respiratory protection and hand hygiene were reviewed, indicating the necessity for staff to adhere to these protocols to prevent infection spread.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident by not conducting and documenting a skin assessment upon discharge. The resident, who was admitted with metabolic encephalopathy and had significant cognitive and physical impairments, was discharged without a documented assessment of their skin condition. This oversight occurred despite the resident having a known wound on the right lower leg, which was not properly documented or treated as per the physician's orders prior to discharge. Additionally, there was no evidence that the resident's skin condition was communicated to the receiving facility. The facility's policy required a skin assessment to be conducted and documented before discharge to ensure appropriate treatment orders could be obtained and communicated. Interviews with facility staff, including the Director of Nursing, confirmed the absence of the required documentation and communication, highlighting a failure to adhere to the facility's discharge and transfer policy.
Deficiencies in Documentation and Care for Two Residents
Penalty
Summary
The facility failed to provide necessary care and services to two residents, leading to deficiencies in their treatment and documentation. Resident 2, who was admitted with metabolic encephalopathy and had limited capacity to understand and make decisions, sustained a wound on the right leg. The clinical record did not document how the wound occurred, and the treatment order for the wound was not transcribed in the resident's clinical record or Treatment Administration Record (TAR) until the following day. There was no evidence that the wound treatment was provided according to the physician's order. Resident 4, who had hemiplegia and hemiparesis following a cerebral infarction, underwent a teeth extraction procedure at the bedside. However, there was no documentation in the clinical record to indicate the procedure took place, nor was there evidence of monitoring for 72 hours post-extraction or that the family was informed. Additionally, the physician's order was incorrectly documented as a treatment for an excoriation instead of a teeth extraction, and there was no clarification of this order with the physician or the registered nurse who took it down. Interviews with staff revealed a lack of proper documentation and communication regarding the residents' care. Licensed nurses failed to transcribe physician's orders into the clinical records and TAR, and there was a misunderstanding about the process for documenting treatment orders. The Director of Nursing acknowledged the importance of documenting incidents and treatments to inform care plans and interventions, but the facility's policies and procedures were not followed, leading to these deficiencies.
Incomplete and Inaccurate Clinical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, leading to potential inappropriate care and evaluation issues. Resident 2's clinical record lacked documentation on how a right leg wound was sustained and the treatment order for the wound was not transcribed in the clinical record or the Treatment Administration Record (TAR) in a timely manner. This oversight was compounded by the fact that the treatment order was not documented in the Medication Administration Record (MAR) from the date it was ordered until the end of the month. Resident 3's clinical record was incomplete as it did not specify the location where a tooth extraction was performed. The Dental Progress Notes and Change in Condition Evaluation failed to provide this critical information, which is necessary for ensuring proper follow-up care and communication among care providers. This lack of documentation could hinder the evaluation of the care provided and the need for staff education. Resident 4's clinical record was missing documentation of a teeth extraction procedure, monitoring post-procedure, and family notification. Additionally, a physician's order was incorrectly transcribed, indicating treatment for an excoriation instead of the dental procedure. These documentation failures could lead to inadequate care and communication, as well as hinder the development of appropriate care plans and interventions.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff promoted dignity while assisting three residents during meals. Observations revealed that staff members were not maintaining eye level with the residents while feeding them, which is a practice that could affect the residents' self-worth and dignity. Specifically, Licensed Vocational Nurse 1 (LVN 1) was observed feeding Resident 55 while seated on a chair with her face about one foot higher than the resident's face. LVN 1 acknowledged that residents should be fed at eye level to observe how they tolerate the feeding. Resident 19, who has a diagnosis of contracture, dementia, and dysphagia, was observed being fed by LVN 1 while sitting in a wheelchair. LVN 1 was seated on an elevated chair, looking down on the resident, which was not at eye level. LVN 1 admitted that she was not at eye level with Resident 19, which was necessary to respect the resident's dignity. Similarly, Resident 52, diagnosed with Parkinson's disease, dementia, and dysphagia, was fed by CNA 1, who was seated on an elevated stool, not at eye level with the resident. CNA 1 acknowledged the importance of sitting at eye level to observe the resident chewing. The facility's policy and procedure on Resident Rights - Accommodation of Needs, last revised in 2012, and Resident Rights - Quality of Life, revised in 2017, emphasize the importance of maintaining residents' dignity and well-being. The policies indicate that staff should interact with residents in a manner that accommodates their physical or sensory limitations and promotes communication. The failure to adhere to these policies during meal assistance was identified as a deficiency in promoting resident dignity.
Failure to Specify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, Resident 54 and Resident 286, were free from unnecessary drugs by not specifying targeted behaviors for the administration of antipsychotic medications. For Resident 54, the facility did not include specific target behaviors for the use of Lorazepam, a medication prescribed for anxiety/agitation. The Licensed Vocational Nurse (LVN) and Registered Nurse (RN) both indicated that the absence of specific target behaviors in the medication order could lead to inappropriate administration and potential harm. Similarly, Resident 286's order for Ziprasidone lacked specific behavioral manifestations, with the term 'agitation' being too broad, which could result in overuse or inappropriate use of the medication. Additionally, the facility did not ensure that Resident 54's physician order for Lorazepam included a duration for the use of the medication. The LVN noted that there should be a 14-day limit on PRN psychoactive medication orders to promote responsible medication use and ensure regular reassessment of the resident's condition. The RN reiterated the importance of a 14-day window to prevent potential misuse or overuse of the medication, emphasizing that PRN orders should not exceed this period without a physician's reassessment. The facility's policy and procedure on Behavior/Psychoactive Medication Management required that any order for psychoactive medications include a specific behavior manifestation and that PRN orders not exceed 14 days unless justified by the physician. The failure to adhere to these guidelines resulted in the potential for overuse of antipsychotic medications without proper monitoring for effectiveness or ineffectiveness, which could lead to adverse drug events for the residents involved.
Infection Control Deficiencies in Resident Restrooms
Penalty
Summary
The facility failed to maintain sanitary conditions in the restroom of Resident 72, leading to an unsanitary environment. Resident 72's toilet was observed to have fecal-like matter around the rim and inside the bowl, with a strong odor present. Despite the resident notifying the night-shift staff, the toilet remained uncleaned, causing discomfort and embarrassment for the resident. Interviews with the Infection Preventionist Nurse and Housekeeper revealed that immediate cleaning should have been conducted by available staff to maintain sanitary conditions, but this was not done. In another instance, the facility did not ensure proper labeling and storage of personal toiletry items in the shared restroom of two residents, Resident 4 and Resident 58. An unlabeled peri cleanser was found stored on top of the toilet paper holder, which should have been labeled with the resident's name and date and kept at the resident's bedside. This oversight was confirmed by a Certified Nursing Assistant and the Infection Preventionist, who acknowledged the risk of cross-contamination due to the improper handling of personal care items. The facility's policies and procedures for infection control and prevention of cross-contamination were not adhered to, as evidenced by the unsanitary restroom conditions and the improper storage of personal care items. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to maintain a safe, sanitary, and comfortable environment for the residents.
Failure to Document and Administer Flu Vaccinations
Penalty
Summary
The facility failed to provide and document influenza vaccinations for three residents during the flu season, as required by their policy. Resident 22, admitted with hemiplegia, hemiparesis, and colon cancer, had a signed consent for the influenza vaccine, but the immunization report indicated the vaccine was refused without a documented date. Resident 23, with heart failure and diabetes mellitus type 2, had a signed consent, but the immunization report showed the vaccine was pending consent. Resident 32, with diabetes mellitus type 2 and chronic kidney disease, had a signed consent, but the immunization report stated the resident was not eligible, with no date provided. The Infection Prevention Nurse (IPN) mentioned plans to contact the local health department to arrange a vaccination clinic but did not provide evidence of such communication. The facility's policy on influenza prevention and control mandates offering immunizations annually during flu season unless contraindicated or already administered, with consent required. The lack of proper documentation and follow-through on vaccination plans led to the deficiency, potentially putting the residents at risk for influenza infection.
Failure to Educate and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide and document pertinent information regarding COVID-19 immunizations for 9 out of 21 residents upon admission. These residents were not educated about the benefits and potential side effects of the COVID-19 vaccine, nor were they given the opportunity to agree to or decline the vaccination. The residents involved had various medical conditions, including end-stage renal disease, chronic respiratory failure, HIV, acute pulmonary edema, and type 2 diabetes mellitus, which could potentially increase their risk of complications from COVID-19. The Infection Prevention Nurse (IPN) admitted to not having access to the California Immunization Registry, which hindered the collection of immunization data. The IPN was responsible for providing education on COVID-19 vaccines to residents and their representatives but failed to maintain a log for COVID-19 vaccinations for both staff and residents. The facility's policy indicated that they would offer COVID-19 vaccinations to all residents and maintain separate logs for tracking vaccination status, but this was not adhered to, as evidenced by the lack of documentation and education provided to the residents.
Failure to Notify Physician of Resident's AMA Discharge
Penalty
Summary
The facility failed to inform the physician of a resident's decision to leave the facility Against Medical Advice (AMA), as required by the facility's policy and procedure. The resident, who was admitted with diagnoses including hypertension, difficulty walking, and lack of coordination, was cognitively intact and required supervision for certain activities of daily living. Despite these needs, the resident left the facility without a discharge order, and the physician was not notified of this action, which was contrary to the facility's policy. During an interview and record review, a registered nurse confirmed that there were no discharge orders for the resident and acknowledged that the physician should have been informed of the resident's departure to ensure appropriate post-care recommendations and medication adjustments. The facility's policy on Discharge Against Medical Advice mandates that a licensed nurse notify the attending physician or medical director when a resident decides to leave AMA, and document all pertinent information in the progress notes. This failure to follow protocol had the potential to impact the resident's transition back home.
Failure to Maintain Homelike Environment During Dining
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for Resident 67 during lunch in the dining room area. On January 6, 2025, Resident 72 repeatedly regurgitated and spit into a trashcan located inside the dining room without staff intervention. This incident was witnessed by Resident 67, who felt uncomfortable, nauseated, and lost her appetite as a result. Resident 67 had been admitted to the facility with diagnoses including hemiplegia, hemiparesis, and anxiety disorder, and her cognition was severely impaired, requiring substantial assistance with activities of daily living and mobility. Resident 72, who was admitted with diagnoses including syncope, esophageal obstruction, and gastro-esophageal reflux disease, also had severely impaired cognition and required moderate assistance with activities of daily living and mobility. During the incident, staff, including a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), observed Resident 72's actions but did not provide immediate assistance to maintain privacy or address the situation. The facility's policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment, emphasizing comfort, independence, and personal needs, which was not upheld in this instance.
Failure to Develop Baseline Care Plan for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented for a resident who was readmitted with a gastrostomy tube and on oxygen therapy. This deficiency was identified during a review of the resident's records, which revealed that the resident was readmitted with multiple diagnoses, including chronic respiratory failure and dependence on supplemental oxygen. Despite these conditions, the resident's Minimum Data Set did not reflect the presence of a feeding tube or oxygen therapy, and there was no specific care plan addressing the resident's needs for gastrostomy tube management and oxygen administration. During an interview with the Registered Nurse Supervisor, it was confirmed that a care plan should have been created upon the resident's readmission to address the new needs related to the gastrostomy tube and oxygen therapy. The facility's policy and procedure on Comprehensive Person-Centered Care Planning, revised in November 2018, mandates that a baseline care plan be developed and implemented within 48 hours of a resident's admission. The absence of such a care plan for the resident had the potential to compromise the resident's health and safety due to a lack of communication among staff on how to manage the resident's care effectively.
Failure to Implement Care Plan for Resident's Impaired Vision
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with impaired vision. The resident, who was admitted with diagnoses including amputation, End Stage Renal Disease, and Diabetes Mellitus with diabetic neuropathy, was observed to have intact cognition and normally used a wheelchair. Despite having a history of worsening eye health, including conditions such as nystagmus, diabetic retinopathy, cataracts, and being legally blind, there was no documented evidence of a care plan addressing the resident's visual impairment. Interviews with nursing staff revealed that the resident received regular eye injections and had a rescheduled eye appointment, yet no care plan was in place to monitor and address the resident's impaired vision. The facility's policy on comprehensive person-centered care planning emphasized the need for care plans to reflect best practice standards and be updated based on assessed needs. However, the lack of a care plan for the resident's visual impairment indicated a failure to adhere to this policy, potentially affecting the resident's physical and psychosocial well-being.
Failure to Provide Adequate Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene care for Resident 285, who was dependent on assistance for activities of daily living. The resident, who had been admitted with conditions including rhabdomyolysis, diabetes mellitus with a foot ulcer, and pneumonia, was observed to have black residue under the fingernails on both hands. This observation was made during a visit by the Infection Preventionist Nurse, who confirmed that the resident's nails were soiled and should have been kept well-groomed as part of basic personal care and infection control. The facility's policy on grooming care indicated that Certified Nursing Assistants are responsible for trimming fingernails, except for residents with diabetes or circulatory impairments, who should be referred to a podiatrist. Despite this policy, the resident's nails were not properly maintained, and a referral to podiatry services was not made as required. The Registered Nurse acknowledged that dirty nails could harbor bacteria and other pathogens, posing an infection risk, especially for a diabetic resident like Resident 285, whose condition could impair the body's ability to fight infections. This oversight in nail care had the potential to negatively impact the resident's health by increasing the risk of infection and complications due to their existing medical conditions.
Incorrect LAL Mattress Settings for At-Risk Resident
Penalty
Summary
The facility failed to ensure the low air loss (LAL) mattress was set correctly for a resident at risk for developing pressure ulcers. The resident, who was readmitted with conditions including dysphagia, muscle weakness, and quadriplegia, required a pressure-reducing device for their bed as part of their care plan. However, during an observation, it was found that the LAL mattress was set to static mode and the pressure-adjust knob was incorrectly set at 350 pounds, which was too firm for the resident who weighed 137 pounds. This setting was confirmed by the Director of Staff Development and Treatment Nurse 1, who acknowledged the incorrect settings and adjusted the pressure to 100 pounds. The resident's care plan indicated the need for a LAL mattress for wound management due to their risk factors, including diabetes, incontinence, and impaired mobility and cognition. The facility's policy and procedure for pressure injury prevention and mattress use emphasized the importance of using pressure redistributing devices and ensuring they are properly working. The incorrect settings on the LAL mattress had the potential to result in the development of a pressure injury for the resident, as confirmed by Registered Nurse 1, who stated that incorrect settings could cause pressure injuries rather than prevent them.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,170 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Claremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Claremont Manor Care Center | 1 mi | ★★★★★ | 18 | 0 |
| Pilgrim Place Health Services Center | 1.1 mi | ★★★★★ | 20 | 0 |
| Mount San Antonio Gardens | 1.5 mi | ★★★★★ | 1 | 0 |
| Landmark Medical Center | 1.7 mi | ★★★★★ | 26 | 0 |
| Community Extended Care Hospital Of Montclair | 1.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Claremont Heights Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.