Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coral Cove Post Acute during CMS and state inspections, most recent first.
The facility did not follow its abuse prevention policy requiring immediate reporting of suspected abuse when an allegation arose that one resident used a cane to strike another resident who required substantial assistance with care. A nurse was informed of the allegation by a COTA, assessed both residents, and notified an RN supervisor, who then separated the residents and removed the cane. The administrator later confirmed that, instead of reporting to CDPH, law enforcement, and the Ombudsman within two hours as required, facility administration first conducted its own investigation and submitted the SOC341 report approximately seven hours after the alleged incident.
Dietary staff did not consistently wear proper hair and beard nets while preparing food, with some staff having uncovered hair or beards and beard nets unavailable for several days. This resulted in food being prepared for a large number of residents without adherence to infection control policies requiring hair restraints.
A nurse failed to follow Enhanced Barrier Precautions (EBP) by not wearing a gown or performing hand hygiene while providing high-contact care, including a dressing change and feeding tube disconnection, for a resident with a tracheostomy and G-tube. The resident was severely cognitively impaired and dependent on staff, and EBP orders were in place requiring PPE and hand hygiene for such tasks.
Two residents with mental health diagnoses engaged in a verbally aggressive altercation on the patio, which was witnessed by staff. Despite facility policy requiring immediate reporting of all abuse allegations, including verbal aggression, the incident was not reported to the state agency or investigated as abuse. This failure delayed state inspection and potentially placed other residents at risk.
Two residents with intact cognition and psychiatric diagnoses engaged in a verbally aggressive altercation on the smoking patio, including the use of derogatory language. An LPN witnessed and reported the incident as verbal aggression, but it was not investigated as verbal abuse by facility administration, contrary to facility policy requiring immediate investigation of all abuse allegations.
A resident with severe cognitive impairment and multiple medical conditions was not re-admitted to the facility after being cleared for return by an LTAC hospital. Although the facility initially cited no available beds, census records confirmed that open female beds were present on several dates. Facility staff could not explain why the resident was not re-admitted, despite policy requiring the first available bed to be offered.
Failure to provide timely pressure injury care and repositioning: Three residents with severe cognitive impairment and significant ADL dependence developed pressure injuries that progressed after redness was first noted. Staff did not document q2h repositioning, wound treatment was delayed, low air loss mattress support was not provided promptly, and RD/IDT involvement was not timely for two residents. One resident’s buttock redness progressed to a Stage III PI, another’s coccyx redness progressed from unstageable to Stage III, and a third resident’s buttock redness progressed to a Stage II PI.
The facility failed to maintain infection control in the clean linen area when staff personal items and food were found stored there, contrary to the laundry policy requiring a clean and sanitary environment. The facility also did not follow its Water Management Plan by failing to monitor pH, chlorine residual, and cold-water temperature monthly, and a resident with chronic respiratory failure, ventilator dependence, severe cognitive impairment, and HAI pneumonia was not tested for Legionella as required by the plan.
A resident with a G-tube, malnutrition, and severe cognitive impairment did not receive the RD evaluation called for in the care plan, with the last RD note documented months earlier than the quarterly schedule. Two other residents with severe cognitive impairment and pressure injury risk or an active pressure injury had care plans directing repositioning every 2 hours, but staff could not show documentation that the repositioning occurred, and CNA/LVN interviews confirmed gaps in the record.
Failure to Provide Ordered RNA ROM and Splinting Services: The facility did not ensure ordered RNA services were provided for multiple residents with significant neurologic impairment, contractures, and dependence for ADLs. Records and staff interviews showed missed PROM, AAROM, splint applications, and mobility exercises for residents with orders for bilateral and unilateral splints, ROM, and sit-to-stand activities. Staff confirmed several residents did not receive the ordered frequency of restorative care, including one resident whose splints and ROM services were provided fewer than the ordered five times per week.
Failure to Notify MD and Implement Nutrition Orders for a Resident With Significant Weight Loss: A resident with chronic respiratory failure, trach status, DM, malnutrition, and severe cognitive impairment had >10% wt loss in 6 months. The RD recommended Ensure Enlive TID and consideration of an appetite stimulant, but the MD was not notified and the orders were not implemented promptly. Meal intake was also not documented for 29 of 87 meals, and the resident’s wt dropped from 171 lbs to 149 lbs.
Respiratory care was not provided as ordered for multiple residents. One resident with a trach and severe cognitive impairment missed ordered trach care and chlorhexidine oral hygiene on several occasions, another resident with COPD was observed receiving O2 at 5 L/min NC instead of the ordered 2 L/min, and a third resident’s humidifier was observed without a date despite orders and care plan directions to change it weekly and label it with the date.
Food Storage, Labeling, and Temperature Monitoring Deficiencies: Surveyors observed expired dressings and chili oil in storage, unlabeled popsicles in the hydration freezer, and a hydration freezer without a thermometer or temperature log. In the resident refrigerator/freezer, a box of chicken wings lacked a date label and ice cream sandwiches were coming out of their packaging. The DS and DON stated that improper storage, monitoring, and discarding of food could lead to cross contamination and food borne illness.
Failure to Offer and Document COVID-19 Vaccination Status: The facility did not document that a resident with a history of COVID-19 and severely impaired cognition was offered or educated on the 2024 to 2025 COVID-19 vaccine. The facility also lacked documented evidence that all employees, including consultants and physicians, had COVID-19 vaccination status recorded and had been educated on the vaccine’s benefits and side effects, or that the vaccine had been offered to them.
A resident with anoxic brain damage and dementia had an EEG ordered by the MD for subclinical seizure activity, but staff did not follow through with the test and did not notify the physician that it was incomplete. An LVN stated nurses could track orders in PCC and confirmed the EEG order was missed, despite the facility policy requiring outside services as ordered by the physician or care plan.
Failure to Provide Timely Transfer and Discharge Notice: A resident with chronic respiratory failure, ventilator dependence, hemiplegia, and severely impaired cognition was transferred to an acute care hospital after severe respiratory distress. RN stated the Notice of Proposed Transfer and Discharge Form was not completed or given to the RP or ombudsman, and the DON confirmed the notice needed to be faxed to the ombudsman.
Inaccurate MDS Documentation of RNA Splint Services: A resident with severe cognitive impairment, dependence for ADLs, and contractures had physician orders for RNA-applied splints to the elbow and hand. Review of the RNA flowsheet showed splint application services were provided on two days during the look-back period, but the MDS did not reflect those services. The MDSC stated the MDS was inaccurate, and the DON stated the MDS should reflect the resident’s whole care.
Failure to Update Nutrition Care Plan After Weight Loss: A resident with chronic respiratory failure, tracheostomy status, malnutrition, diabetes, and left-sided hemiplegia had significant weight loss and severe cognitive impairment. The RD documented a lower weight and recommended Ensure Enlive TID and consideration of an appetite stimulant, but the care plan was not updated to reflect the new nutrition recommendations.
Failure to Follow Specialty Referrals and Communicate Results: A resident with quadriplegia, shoulder rotator cuff injury, and multiple contractures had an orthopedic consult that recommended MRI, neurology, rheumatology, and a 6-week follow-up. The MRI showed chronic rotator cuff tendinosis and muscle deterioration, but the rheumatology referral and neurology follow-up were not completed, and the resident was not informed of the shoulder X-ray results showing mild DJD in both shoulders until much later. RN and DON interviews confirmed the specialty appointments were not followed up and that residents should be informed of test results.
Dirty and thickened toenails were observed on a dependent resident with severe cognitive impairment, diabetes, ventilator dependence, hemiplegia, and hemiparesis. An RN acknowledged the toenails were dirty and thickened, and record review showed an order for podiatry services as indicated, but no recent documentation of podiatry follow-up was found. The DON stated grooming is an important part of resident care and toenails need to be clean.
A facility failed to provide appropriate GT care for two residents receiving enteral nutrition. One resident’s tube feeding was left connected even after it was turned off, and staff stated this was standard practice despite acknowledging it could lead to dislodgement and entanglement. For another resident with a GT, the feeding was running while the resident was lying flat during treatment, even though the care plan and physician orders required head-of-bed elevation during feedings; the LVN and DON stated the feeding should have been held while the resident was flat.
A resident with dialysis, Type 2 DM, and CHF missed a scheduled dialysis appointment when transportation never arrived because the resident’s transport eligibility had expired. RN and DON interviews confirmed the resident could have been taken to dialysis, but the chart lacked documentation showing the treatment was received that day. The facility policy required dialysis services, transportation, and documentation to be maintained.
An LVN did not have his medication administration competency re-evaluated after a resident questioned receiving four gabapentin tablets instead of her usual dose. The resident had HTN and neuropathy, was cognitively intact, and had decision-making capacity. The LVN said the order was confusing and he did not clarify it because he was working alone. The RN found no incident report, in-service, or skills re-evaluation in the employee file, and the DON stated competency should be maintained through skill evaluation and validation.
A resident with quadriplegia and contractures had orders for baclofen and methocarbamol every 6 hours for muscle spasms, but the MAR audit showed multiple late doses and one instance where the medications were given too close together. The resident said late doses made his spasms uncomfortable, and RN and DON interviews confirmed that doses given more than 1 hour late required physician notification and that giving the medications too close together created a risk for an adverse reaction.
A facility failed to maintain accurate medical records for two residents. One CNA documented meal intake for a resident she was not assigned to and did not observe, while a restorative nurse assistant documented services for another resident without recording the time spent, the resident's tolerance, or her initials on each occurrence, and also marked services on dates she did not work. The residents had significant medical needs, including impaired cognition, ADL dependence, respiratory failure with ventilator dependence, and restorative nursing orders for AAROM and orthotic use.
An IPN incorrectly determined that two residents met McGeer criteria for antibiotic use, despite the surveillance log showing they did not. One resident with a G-tube site abscess and another resident with a furuncle were both placed on antibiotics, and the IPN gave conflicting statements during record review about whether the documented findings supported the orders. The DON stated McGeer criteria must be applied correctly for infection surveillance and antibiotic stewardship.
Failure to Offer Pneumococcal Vaccine: A resident with severely impaired cognition and a history of COVID-19 and stroke was not documented as being offered or educated on the pneumococcal vaccine. The IPN found no evidence of an offer or education, and the DON stated residents need to be educated and offered the vaccine. The facility policy required all residents to be given the opportunity to receive pneumococcal vaccination unless contraindicated or already immunized.
A resident with paraplegia and hydronephrosis was not readmitted to the facility after a hospital transfer, despite being medically ready and having at least one available male bed for several days. The resident remained in the hospital due to the facility's claim of no available beds, contrary to census records and facility policy.
A resident with a history of encephalopathy, schizophrenia, and bipolar disorder was readmitted after a hospital transfer for aggressive behavior, but the care plan was not reviewed or revised upon return. This omission led to the resident exhibiting further behavioral issues, including throwing a book at another resident, despite staff and documentation noting ongoing emotional instability and poor impulse control.
Two CNAs were assigned to the Subacute Unit without receiving the necessary training or orientation, as confirmed by their own statements and facility leadership interviews. Staffing records showed at least one CNA was assigned to the unit without prior preparation, and there was no documentation of required training. Facility leaders acknowledged that additional training is needed for staff working with residents requiring more intensive care, including those with ventilators.
A CNA was permitted to work without an active certificate after presenting exam results, but their certification was not yet listed on the state registry. The ADON allowed the CNA to begin work without verifying active status, and both the DSD and DON later confirmed the lack of proper certification verification.
A CNA worked ten shifts with an expired certification, as confirmed by state certification records and facility assignment sheets. The CNA was aware of the expiration but continued to perform CNA duties. Facility leadership acknowledged that certification tracking is the responsibility of the DSD and that a valid certification is required for CNA duties.
A resident with schizoaffective disorder and a history of aggressive behavior repeatedly refused prescribed psychotropic medications, but staff did not consistently document behavioral episodes or notify the psychiatrist as required. Nursing staff confirmed that behavioral monitoring was sometimes incomplete and that the psychiatrist was not informed of the refusals, despite facility policy mandating timely documentation and notification for such changes in condition.
Two residents with significant mobility impairments were found to have nonfunctional or inaccessible call lights, resulting in prolonged waits for assistance and increased frustration. Staff confirmed the issues, and observations showed call lights either did not work or were placed out of reach, contrary to facility policy.
A resident with a history of wandering and multiple mental health conditions eloped from a facility due to an inactive front door alarm and incorrect elopement assessment. The resident was found miles away, confused, after the facility failed to develop a care plan or interventions for her elopement risk. Staff interviews revealed non-functional cameras and unmonitored alarms, contributing to the incident.
The facility failed to address concerns raised by the resident council about delayed call light response times during the 11pm-7am shift. A resident with intact cognition and significant medical history reported these delays, which were documented in council meetings without any action plan developed. The Director of Staff Development did not provide necessary oversight during this shift, focusing instead on paperwork, and the facility's policies requiring response to council concerns were not followed.
A resident with intact cognition was involved in an altercation with another resident who has severe cognitive impairment. The incident, witnessed by an MDS nurse, was not reported to the resident's physician by RN 1, leading to a delay in necessary assessments and services. The facility's policy requires notifying the physician of significant changes in condition, which was not followed in this case.
A facility failed to report a physical altercation between two residents to CDPH within the required two-hour timeframe. The incident involved a resident with intact cognition protecting himself from another resident with severely impaired cognition. The MDS nurse witnessed the event and informed an RN, who did not report it, believing it was not abuse due to the lack of injuries. This oversight delayed necessary assessments and services, violating federal regulations and facility policy.
A facility failed to create a comprehensive care plan for a resident after an altercation with another resident. The incident involved one resident trying to protect himself from being hit by another resident with severe cognitive impairment. Despite the incident, no care plan was developed, and no interdisciplinary team meeting was held to address the concerns, resulting in a delay in care and services for the resident.
The facility did not post accurate daily staffing information, as required, at the entrance. Observations and interviews revealed that only projected hours were posted, not the actual number of staff or hours worked. This failure was contrary to the facility's policy, which mandates posting the total number and actual hours worked by nursing staff per shift.
A resident with respiratory failure and intact cognition, dependent on staff for ADLs, was not provided incontinence care due to insufficient staffing. On a night shift, only two CNAs were present instead of the scheduled four, with one CNA responsible for 82 residents. This led to the resident calling the police for assistance, highlighting a failure to treat the resident with dignity and respect.
The facility failed to implement its water management plan effectively, leading to potential risks of Legionella bacteria growth. The water management team did not meet regularly, and there was no documentation of control measures being monitored. The resignation of the full-time IPN led to confusion in infection control duties, further exacerbating the issue. The Maintenance Supervisor did not maintain logs, and there was no communication regarding a Legionella concern from the Department of Health.
The facility failed to appoint a full-time IPN, leading to inadequate oversight of the infection prevention and control program. The RNC assumed IPN duties without clear documentation or role delineation, sharing responsibilities with the DSD. This resulted in missed water management meetings and unaddressed infection control risks, increasing the potential for waterborne pathogen outbreaks.
A resident experienced an unwitnessed fall, and the facility failed to notify the physician or responsible party, assess the resident's condition, or document the incident. The resident, with a history of serious health conditions and on medications increasing bleeding risk, was found on the floor by a CNA. The LVN did not perform a full assessment or communicate the incident to the oncoming shift, leading to a delay in care. The resident was later transferred to a hospital with multiple injuries.
A resident with multiple medical conditions was found with skin tears, which were not reported to the CDPH in a timely manner. The injuries were attributed to a rough towel used by a CNA, but the LVN and DON failed to report them as required. The facility's policy mandates prompt reporting of such incidents to prevent potential mistreatment.
A resident with a history of falls and high fall risk was not provided a one-on-one sitter as ordered by the physician. Despite the resident's need for constant supervision due to conditions like metabolic encephalopathy and Parkinsonism, staff failed to consistently assign a sitter, leaving the resident unsupervised and at risk for further falls. The facility's fall management policy was not effectively implemented, resulting in this deficiency.
A resident's bed was cluttered with dirty blankets, limiting comfort and mobility. Despite the resident's cognitive ability and need for assistance, CNA 1, who had a poor relationship with the resident, was repeatedly assigned to them. The DON confirmed the lack of bed space, and the DSD admitted to ineffective communication of staff assignments, contributing to the issue.
The facility did not follow LBDHHS guidelines during a CPO outbreak by posting incorrect isolation signs on 8 out of 12 rooms in the SAU. Instead of contact isolation precautions, Enhanced Barrier Precautions were used, which do not align with the guidelines for residents who tested positive for CPO. The error was acknowledged by the DSD and IPN, and the DON confirmed receipt of the guidelines but could not explain the oversight.
A resident with a history of anxiety and depression was verbally and physically abused by a CNA who entered the bathroom without waiting, despite the resident's request for privacy. The CNA yelled and threw a urinal and water bottle at the resident, causing emotional distress. The facility's abuse prevention policy was not followed, as confirmed by staff interviews and documentation.
A resident in an LTC facility experienced an alleged abuse incident when another resident pulled her beanie and hair. The incident was reported to a CNA, who informed an LVN. However, the LVN failed to report it to the Administrator due to workload, resulting in a delay in notifying the CDPH within the required two-hour timeframe. The facility's policy requires immediate reporting of abuse allegations to ensure resident safety.
Failure to Timely Report Alleged Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an allegation of physical abuse between two residents to the California Department of Public Health (CDPH) within two hours of the occurrence. One resident, admitted with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, osteoarthritis, and schizophrenia, required substantial/maximal assistance with care per the Minimum Data Set (MDS). The other resident, admitted with chronic kidney disease, type 2 diabetes mellitus, heart disease, and gout, had documented capacity to understand and make decisions and required moderate assistance for bed mobility and transfers. An occupational therapy assistant reported that the second resident allegedly hit the first resident on the head with a cane while the first resident was lying on his side and coughing. Following the allegation, the LVN assessed both residents and informed the registered nurse supervisor (RNS), who then took steps such as relocating the first resident and removing the second resident’s cane and notifying the physician. The administrator stated that, per facility policy and the abuse prevention and management procedure dated 1/1/2026, law enforcement must be notified immediately or as soon as practicably possible, and a written SOC341 report must be sent to the Ombudsman, law enforcement, and CDPH immediately, but not later than two hours after forming the suspicion if the events result in serious bodily injury. However, the administrator acknowledged that administration conducted its own investigation first, and the SOC341 was faxed to CDPH and the Ombudsman approximately seven hours after the allegation, exceeding the required two-hour reporting timeframe.
Failure to Ensure Dietary Staff Wore Required Hair and Beard Nets During Food Preparation
Penalty
Summary
Dietary staff in the facility failed to consistently wear appropriate hair and beard nets while preparing or handling food in the kitchen. During observations, one cook was seen with a hair net that did not fully cover the back and sides of her head, and another staff member with a beard was not wearing a beard net in the food preparation area. The Dietary Supervisor confirmed these lapses and stated that the requirement is for all hair, including beards, to be covered while in the kitchen to prevent hair from contaminating food. Additionally, it was noted that beard nets had not been available for three days prior to the observation, resulting in multiple dietary staff with beards not wearing the required protective equipment during food preparation for a significant portion of the resident population. The Director of Nursing confirmed that the facility's infection control practices require dietary staff to wear hair and beard nets in the kitchen to prevent hair shedding and potential food-borne illness. Review of the facility's policy indicated that personal cleanliness and effective hair restraints are mandatory in all kitchen and food storage areas. At the time of the deficiency, 104 residents were in the facility, with 73 receiving meals prepared in the kitchen where these lapses occurred.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during care of a resident who was on EBP due to a tracheostomy and gastrostomy tube. The LVN performed a dressing change at the tracheostomy site and disconnected a feeding tube without donning a gown or performing hand hygiene prior to these high-contact tasks. The LVN acknowledged not following the required infection control practices, despite the presence of signage indicating EBP requirements and her awareness of the necessity for gown use and hand hygiene. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene and device care. Facility records confirmed that EBP precautions were ordered for the resident, and the infection prevention nurse and director of nursing both stated that staff are required to use gowns and perform hand hygiene for high-contact care tasks under EBP. The facility's policy specified that PPE, including gowns and gloves, must be donned before each high-contact task and that adherence to infection prevention practices should be periodically monitored.
Failure to Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency for two residents who were involved in a verbally aggressive incident. Both residents had intact cognition and were diagnosed with mental health conditions such as bipolar disorder, depression, and schizophrenia. The incident occurred on the facility's patio, where one resident made inappropriate and aggressive comments towards the other, resulting in a verbal altercation that included cursing and shouting. Staff members, including a Licensed Vocational Nurse and a Social Service Assistant, witnessed or were made aware of the incident and acknowledged that all abuse allegations, including verbal aggression, should be reported immediately to supervisors and the administrator. Despite the facility's policy requiring immediate reporting of all abuse allegations, including verbal abuse, to the administrator and appropriate authorities, the incident was not reported to the state agency. The Director of Nurses confirmed that the incident was not reported, and the administrator stated that the event was not investigated as abuse because it was perceived as only verbal aggression. Multiple staff interviews indicated awareness of the incident, but no formal report or investigation was initiated as required by facility policy and state regulations. The failure to report the incident resulted in a delay in an onsite inspection by the state agency and had the potential to place other residents at risk for unaddressed abuse and unsafe interactions. The facility's own policy defined abuse to include verbal aggression and mandated reporting to law enforcement and the state agency within two hours of an initial report, which was not followed in this case.
Failure to Investigate Alleged Verbal Abuse Between Residents
Penalty
Summary
The facility failed to investigate an incident of verbal abuse involving two residents. Resident 1, who had diagnoses including bipolar disorder, depression, schizoaffective disorder, and diabetes, was observed on the smoking patio when Resident 2, diagnosed with schizophrenia and bipolar disorder, spoke to her in a loud tone. Resident 1 responded by standing up, but there was no physical contact. Documentation indicated that Resident 1 exhibited verbal aggression, including cursing and screaming, while Resident 2 was noted to have made inappropriate comments and shown increased aggression toward another resident. Both residents were assessed as having intact cognition and required minimal assistance with daily activities. During interviews, Resident 1 reported being called a derogatory name by Resident 2 after refusing to give him cigarettes. An LVN confirmed witnessing verbal aggression between the two residents and reported the incident to a supervisor, but did not consider it verbal abuse. The administrator acknowledged being notified of the incident but did not initiate an investigation, as he was only aware of verbal aggression and not abuse. The facility's policy required immediate investigation of all abuse allegations, but this was not followed in this case.
Failure to Re-Admit Resident Despite Bed Availability
Penalty
Summary
The facility failed to re-admit a resident after the resident was cleared for return by a Long-Term Acute Care (LTAC) hospital. The resident, who had been living at the facility for two years and had diagnoses including anoxic brain injury, chronic respiratory failure, and atrial fibrillation, was transferred to a General Acute Care Hospital for generalized body swelling. After treatment, the LTAC facility issued a discharge order for the resident to return. Despite communication from the LTAC case manager to the facility's admission coordinator, the resident was not re-admitted, with the initial explanation being a lack of available beds. However, facility census records reviewed with the Director of Nursing and Administrator showed that there were open female beds available on multiple dates following the discharge order. Interviews with facility staff, including the Director of Business Development and the Administrator, revealed uncertainty and lack of clear communication regarding why the resident was not re-admitted despite bed availability. The facility's own bed hold policy indicated that the resident should have been offered the first available bed upon return, but this did not occur, and staff could not provide a reason for the failure to re-admit.
Failure to Provide Timely Pressure Injury Care and Repositioning
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new pressure injuries for three residents. Resident 62, who had severe cognitive impairment, diabetes, dementia, and dependence on staff for most care, developed redness on the right buttock that was later reclassified as a Stage III pressure injury. The change of condition was identified on 6/25/2025, and the wound was documented as Stage III on 6/26/2025 with measurements of 2 cm by 2 cm by 0.2 cm. The record showed the treatment order was not started until 6/28/2025, and the care plan addressing the Stage III pressure injury was not entered until 6/30/2025. For Resident 62, the record and staff interviews showed repositioning every 2 hours was part of the plan, but CNA documentation of repositioning could not be located in the electronic record. Staff also stated the resident should have been placed on a low air loss mattress when the Stage III pressure injury was identified, but it was not implemented until 23 days later. The Registered Dietitian did not reassess the resident until 7/22/2025, nearly a month after the pressure injury was identified, and the interdisciplinary team did not evaluate the wound until 7/20/2025. During observation on 8/14/2025, Resident 62 was lying on a low air loss mattress with three linen sheets under the buttocks, and staff stated multiple sheets interfered with air circulation. Resident 101, who had severe cognitive impairment, hemiplegia/hemiparesis, diabetes, and dependence for all ADLs, had redness on the coccyx noted on 6/25/2025 that was later reclassified as an unstageable pressure injury on 6/26/2025 and then as a Stage III pressure injury with granulation tissue. The care plan indicated repositioning every 2 hours, but staff stated there were no CNA notes showing repositioning. The treatment started on 6/28/2025, the low air loss mattress was ordered 22 days after the pressure injury was first identified, and the RD did not evaluate the resident until 7/30/2025. Staff also stated labs should have been ordered when the wound was identified, and the IDT notes did not show RD consultation during the IDT meetings. Resident 80, who had severe cognitive impairment, dementia, contractures, and dependence for eating, toileting, bathing, and dressing, developed right buttock redness that progressed to a Stage II pressure injury. Staff stated the care plan was not revised until 6/27/2025, after the redness had already been identified, and the plan included repositioning every 2 hours. The treatment nurse stated there was no documentation showing the resident was repositioned every 2 hours. The facility policies reviewed stated skin integrity conditions were to be identified, evaluated, and intervened on, and care plans were to be reviewed and updated as necessary.
Infection Control Failures in Laundry Area and Water Management
Penalty
Summary
The facility failed to implement its infection prevention and control program when the laundry's designated clean linen area was observed with staff personal items and food stored on the shelves. During the 8/14/2025 observation, the Housekeeping Laundry Supervisor identified two black bags, two leftover water bottles, one toaster plugged into an outlet, one bottle of sauce, multiple crackers, and two plastic bags of staff food in the clean laundry area. The supervisor stated those items should not have been there and that the area was not clean. The facility's Laundry Services policy stated on-site laundry services are to be maintained in a clean and sanitary condition, and the DON stated the clean linen room should be kept free of food and staff personal items for infection control. The facility also failed to implement its Water Management Plan and Legionella Prevention Program. The plan required monthly measurement of cold water temperatures, disinfectant residual, and pH, but the Director of Maintenance stated the facility did not check pH, chlorine levels, or cold-water temperature monthly. In addition, Resident 9, who had chronic respiratory failure, was ventilator-dependent, severely cognitively impaired, and dependent on staff for all ADLs, was sent to the hospital for altered mental status and returned with pneumonia. The Infection Prevention Nurse stated Resident 9 had HAI pneumonia on 7/15/2025 and was not tested for Legionella even though the Water Management Plan stated that upon detection of HAI pneumonia, the IPN would notify the medical director to obtain Legionella testing for affected residents.
Failure to Implement RD Evaluation and Repositioning Care Plans
Penalty
Summary
The facility failed to implement Resident 8’s care plan when the Registered Dietician did not evaluate the resident as scheduled. Resident 8 was admitted with protein calorie malnutrition, type 2 DM, and a G-tube, and the MDS dated 8/6/2025 indicated severely impaired cognition and dependence for all ADLs. The care plan, revised 8/11/2025, stated the RD would evaluate quarterly and as needed to monitor caloric intake and make recommendations for tube feeding changes, but the RD notes showed the last evaluation was on 3/12/2025. RN 1 stated the RD should have evaluated Resident 8 in June 2025 to assess nutritional status. The facility also failed to implement repositioning interventions for Resident 62. Resident 62 was admitted and readmitted with diagnoses including G-tube, type II DM, and dementia, and the MDS showed severe cognitive impairment, dependence for transfers, bathing, dressing, toileting hygiene, and supervision for eating. The MDS also identified risk for pressure injuries and noted MASD with skin and ulcer/injury treatments. The care plan dated 6/30/2025 for a stage III right buttocks pressure injury directed staff to keep skin clean and dry, moisturized, turn and reposition every 2 hours, and provide treatment per MD order. The facility likewise failed to document or demonstrate that Resident 101 was repositioned every 2 hours. Resident 101 was admitted and readmitted with hemiplegia/hemiparesis following cerebral infection, G-tube, and type II DM, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS showed severely impaired cognition, dependence for all ADLs, impairment of both upper and lower extremities, and a Stage III pressure injury with pressure-reducing devices, nutrition or hydration intervention, and pressure ulcer/injury care. The care plan dated 6/29/2025 directed repositioning every 2 hours, but CNA 4 stated there was no documentation of repositioning on paper or in the POC, and the ADL record for Resident 62 showed no records of repositioning every 2 hours as stated in the care plan.
Failure to Provide Ordered RNA ROM and Splinting Services
Penalty
Summary
The facility failed to ensure residents with physician-ordered restorative nursing assistant (RNA) services received the ordered range of motion (ROM) treatment, splinting, and mobility interventions. The deficiency involved four residents who had orders for RNA exercises and splint applications intended to maintain or improve ROM and mobility. Facility staff and records showed that the ordered services were not consistently provided as prescribed. Resident 7 had diagnoses including quadriplegia, a right shoulder rotator cuff tear or rupture, and contractures of both knees, both hands, and the left elbow. The resident was documented as cognitively intact and dependent for all ADLs. Orders included passive ROM to both lower extremities, bilateral upper extremity PROM, bilateral wrist-hand-finger orthosis resting hand splints, a left elbow extension splint, and bilateral knee splinting. During interview, the DOR stated splints are used for contracture management and prevention and that residents cannot miss a day without splints. RNA staff stated the resident did not receive RNA services as ordered, and the restorative records reviewed showed blank sections that the RNA said may have been her day off. Resident 8 had diagnoses including chronic respiratory failure, ventilator dependence, quadriplegia, and unspecified joint contracture, and was severely cognitively impaired and dependent for all ADLs. Orders included bilateral elbow extension splints, bilateral WHFO splints, bilateral PRAFOs, and PROM to both upper and lower extremities. Review of the restorative records showed the resident did not receive RNA services five times a week or as tolerated. RN staff stated the resident did not use the elbow splints from 7/2025 to 8/2025, did not receive PROM to the lower extremities as ordered, did not wear the WHFO and PRAFO devices five times a week, and did not receive PROM to the upper extremities five times a week. Resident 90 had chronic respiratory failure, ventilator dependence, hemiplegia, and hemiparesis, was severely cognitively impaired, and dependent for all ADLs. The order required PROM to both upper and lower extremities five times a week, but the restorative record showed the resident did not receive RNA services five times a week or as tolerated for all RNA orders, and RN staff confirmed the PROM was not provided as ordered. Resident 54 had obstructive hydrocephalus, anoxic brain damage, and contractures of the right elbow and hand, and was severely cognitively impaired and dependent for eating, toileting hygiene, bathing, and dressing. Orders included a right elbow extension splint, a right WHFO splint, AAROM to both lower extremities, PROM to both upper extremities, and sit-to-stand exercises in parallel bars, each five times a week. Review of July 2025 RNA flowsheets showed the resident received each intervention on fewer than 20 days in the month, including 18 days for the elbow splint, 17 days for the WHFO splint, 18 days for AAROM, 18 days for PROM, and 16 days for sit-to-stand exercises. RNA staff stated that five-times-a-week orders should have resulted in at least 20 treatments in a month, and confirmed the resident did not receive any of the ordered RNA services at least 20 times in July 2025.
Failure to Notify MD and Implement Nutrition Orders for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician on 7/29/2025 after Resident 77 had a significant weight loss greater than 10% in 6 months. Resident 77 was admitted with chronic respiratory failure, acquired absence of stomach, tracheostomy status, mild calorie protein-calorie malnutrition, diabetes mellitus, and left-sided hemiplegia/hemiparesis. The MDS dated 7/28/2025 indicated severe impairment in cognitive skills for daily decision making, dependence with all ADLs, and weight loss of 5% or more in the last month or 10% or more in the last 6 months. On 7/29/2025, the Nutrition/Dietary Note documented a most recent weight of 149 lbs. and a goal weight of 160 to 170 lbs., and RD 1 stated RD 2 recommended Ensure Enlive three times a day and for the physician to consider an appetite stimulant. The facility also failed to ensure the RD recommendations were implemented in a timely manner. The order summary showed Ensure Enlive one carton three times a day was not ordered until 8/5/2025, and Megestrol Acetate Suspension 400 mg/10 ml, 10 ml by mouth daily for appetite stimulant, was not ordered until 8/6/2025. RN 2 stated that on 7/29/2025 the physician was not notified, no change of condition assessment was completed, and the RD recommendations were not implemented. In addition, the facility failed to ensure Resident 77's meal intake was recorded for every meal from 7/15/2025 to 8/12/2025; 29 of 87 meals were not monitored and the amount eaten was not recorded. Resident 77's weight summary showed a weight of 171 lbs. on 2/4/2025, 149 lbs. on 7/29/2025, and 150 lbs. on 8/4/2025, and RN 2 stated Resident 77 had a 12.9% weight loss in approximately 6 months.
Respiratory Care Not Provided as Ordered
Penalty
Summary
Respiratory care was not provided as ordered for a resident with chronic respiratory failure, ventilator dependence, quadriplegia, and a tracheostomy. The resident’s MDS indicated severely impaired cognition and total dependence on staff for all ADLs. The order summary required tracheostomy care every shift, including cleaning with normal saline, patting dry with gauze, and applying a T-sponge and foam dressing if needed, as well as chlorhexidine gluconate mouth and throat solution 0.12% every 12 hours for oral hygiene. A review of the resident’s RMAR showed the chlorhexidine oral hygiene was not administered on multiple dates, and tracheostomy care was not administered on two dates. During the record review, the DORT stated that if it was not documented, it was not completed. The DON stated oral hygiene and tracheostomy care should be administered as ordered. The facility’s tracheostomy care policy stated care would be provided every shift and as needed, and the medication-administration policy stated medications and treatments would be administered as prescribed. Respiratory care was also not provided as ordered for another resident who had COPD and cognitive communication deficit. The resident’s order summary directed oxygen at 2 L/min via nasal cannula continuously to keep oxygen saturation at or above 90%, but the resident was observed receiving oxygen at 5 L/min via nasal cannula. An LVN stated the resident should have been receiving 2 L/min and that 5 L/min was too much oxygen and could be unsafe and harmful. In a separate finding, a resident with COPD, emphysema, chronic pulmonary edema, and pneumonia had a humidifier observed without a date marked on the bottle or tubing, despite an order to change the humidifier weekly and the care plan directing weekly or as-needed changes; the DON stated staff are required to date the humidifier upon application and change it weekly or as needed for infection control.
Food Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
Food storage and handling deficiencies were identified in the kitchen, hydration freezer, and resident refrigerator/freezer areas. During a concurrent observation and interview with the Dietary Supervisor (DS) on 8/12/2025 at 8:14 a.m., surveyors observed two Italian dressings with a use by date of 6/30/2025 in dry storage, one container of chili oil with a use by date of 8/8/2025 in the refrigerator, and one shelf of unlabeled popsicles in individual clear packaging plus two shelves of unlabeled popsicles in opaque packaging without expiration dates in the hydration freezer. The DS stated the hydration freezer did not have a thermometer and was not monitored with a thermometer or temperature log. The DS also stated that because the popsicles were out of their original packaging, the flavors, ingredients, and expiration dates were unknown. During a concurrent observation and interview with the DS in the activity room on 8/14/2025 at 10:55 a.m., surveyors inspected the resident refrigerator and freezer and observed one box of chicken wings in a to-go container that was not labeled with a date in the refrigerator and two ice cream sandwiches coming out of the paper packaging in the freezer. The DS stated that not having labels and properly stored food would place residents at risk for cross contamination and food borne illness. During an interview with the DON on 8/15/2025 at 4:10 p.m., the DON stated that if food is not properly stored, monitored, or discarded, there is a risk of infection control and discomfort for residents. Facility policy titled Food Storage and handling required frozen foods to be labeled and dated and dry storage products to be labeled and dated, and the Refrigerator/Freezer Temperature Records policy required daily temperature records for refrigerated and frozen storage areas.
Failure to Offer and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure that Resident 95 was offered the 2024 to 2025 COVID-19 vaccine and failed to document that the resident was educated on the benefits and risks of the vaccine. Resident 95’s admission record showed a history of COVID-19 and cerebral infarction. The MDS dated 8/6/2025 indicated the resident had severely impaired cognition and required set-up assistance with eating, oral care, and personal hygiene, as well as substantial assistance with showering. During a concurrent interview and record review on 8/13/2025, the Infection Prevention Nurse stated there was no documented evidence that Resident 95 was offered or educated on the benefits and risks of the 2024 to 2025 COVID-19 vaccine. The facility also failed to provide documented evidence that all employees, including consultants and physicians, had COVID-19 vaccination status documented and had received education on the benefits and side effects of the 2024 to 2025 COVID-19 vaccine, along with documentation that the vaccine was offered. During a record review on 8/14/2025, the Infection Prevention Nurse stated the facility’s COVID staff vaccination status roster did not include physicians or consultants and did not show documented evidence that education on benefits and side effects or the offering of the 2024 to 2025 COVID-19 booster vaccine had been provided for all staff. During an interview on 8/15/2025, the DON stated staff and residents need to be educated and offered the 2024 to 2025 COVID-19 booster, and that employee COVID vaccination status needed to be updated to include physicians and consultants. The facility policy stated employees are required to have a COVID-19 booster dose when eligible unless waived, residents are encouraged to receive COVID-19 vaccination and boosters, vaccination status is to be documented, and vaccines will be provided to residents and staff.
Failure to Notify Physician of Incomplete EEG
Penalty
Summary
The facility failed to notify the physician that Resident 62's EEG test was incomplete. Resident 62 was initially admitted and later readmitted with diagnoses of anoxic brain damage and dementia. The MDS dated 6/25/2025 indicated the resident was cognitively severely impaired. During a concurrent interview and record review on 08/14/2025 at 3:49 pm, LVN 4 stated the EEG had been ordered because of the resident's dementia and age, and confirmed that the EEG order was not followed through by staff. The neurology note dated 5/9/2025 indicated the MD ordered an EEG for Resident 62 for subclinical seizure activities. LVN 4 stated that any nurse could follow orders through the facility's 24-hour Communication in the PCC system to ensure orders would not be missed, and stated it was important to communicate to prevent complications. The facility policy titled Referrals to outside services dated 12/2013 indicated the facility provides residents with outside services as required by physician orders or the care plan.
Failure to Provide Timely Transfer and Discharge Notice
Penalty
Summary
The facility failed to ensure the Notice of Proposed Transfer and Discharge Form was provided timely to Resident 90's responsible party. Resident 90 was originally admitted with chronic respiratory failure, dependence on a ventilator, hemiplegia, and hemiparesis affecting the left non-dominant side. The Minimum Data Set dated 6/7/2025 indicated Resident 90 had severely impaired cognition and was dependent on staff for all ADLs. On 6/7/2025, a Change of Condition Evaluation documented that Resident 90 was observed in severe respiratory distress at approximately 6:44 a.m., EMS was called at 6:47 a.m., and the resident was transferred to GACH 1 at 7:08 a.m. During interview and record review, RN 2 stated the Notice of Proposed Transfer and Discharge Form was not completed and given to the responsible party or the ombudsman. The DON stated transferred residents need the written notice to be faxed to the ombudsman. The facility policy stated a copy of the notice is to be placed in the medical record and faxed to the ombudsman, and that within 48 hours of giving written notice, the facility shall provide the resident and, if applicable, the resident representative with the required discharge evaluation and related information.
Inaccurate MDS Documentation of RNA Splint Services
Penalty
Summary
The facility failed to accurately document Restorative Nurse Assistant (RNA) services on the MDS for one sampled resident. The resident was admitted with diagnoses including obstructive hydrocephalus, anoxic brain damage, and contractures of the right elbow and hand. The resident’s MDS dated 7/17/2025 indicated severe cognition and dependence for eating, toileting hygiene, bathing, and dressing. The physician order summary dated 8/15/2025 included orders for RNA to apply a right elbow extension splint up to four hours, five times a week, and to apply a right wrist-hand-finger orthosis splint with hand grasp up to four hours, five times a week. During interview and record review, the MDS Coordinator reviewed the resident’s RNA flowsheet for July 2025 and stated the resident received splint application services on 7/12/2025 and 7/14/2025 for greater than 15 minutes during the look-back period of 7/11/2025 through 7/17/2025. The MDS Coordinator stated the resident’s MDS did not reflect that the resident received two days of splint application and was inaccurate. The DON stated it is important for the MDS to reflect the whole care of the resident. The facility policy titled RAI Process stated the facility will utilize the RAI process as the basis for the accurate assessment of each resident’s functional capacity and health status, and the Completion & Correction policy stated medical records are complete and accurate and documentation will reflect medically relevant information concerning the resident.
Failure to Update Nutrition Care Plan After Weight Loss
Penalty
Summary
The facility failed to update the care plan for Nutrition after significant weight loss was identified for one resident. The resident was admitted with chronic respiratory failure, acquired absence of stomach, tracheostomy status, mild calorie protein-calorie malnutrition, diabetes mellitus, and left-sided hemiplegia and hemiparesis. The resident’s MDS dated 7/28/2025 showed severe impairment in cognitive skills for daily decision making and dependence with all ADLs. During record review and interview, the RD noted that the resident’s most recent weight was 149 lbs., reflecting a 3.8% weight change from 155 lbs., and the goal weight was 160 lbs. to 170 lbs. The RD stated that another RD recommended Ensure Enlive three times a day and that the physician consider an appetite stimulant. RN 2 stated the care plan, initiated on 7/3/2025, reflected a 4 lb. weight loss in one month and 7.5% weight loss in 90 days, but it was not updated with the new RD recommendations after the 7/29/2025 nutrition note. The DON stated staff should update the care plan when there are changes, and the facility policy required the interdisciplinary team to update and revise the care plan as appropriate.
Failure to Follow Specialty Referrals and Communicate Test Results
Penalty
Summary
The facility failed to ensure Resident 7 received treatment and care in accordance with professional standards of practice when ordered specialty follow-up was not completed and test results were not communicated to the resident. Resident 7 was admitted and later readmitted with diagnoses including quadriplegia, a right shoulder rotator cuff tear or rupture, and multiple contractures affecting both knees, both hands, and the left elbow. The resident’s history and physical indicated he had the capacity to understand and make decisions, and the MDS indicated intact cognition, dependence on staff for all ADLs, and impairments in both upper and lower extremities. An orthopedic surgery evaluation on 10/1/2024 recommended an MRI, referral to neurology, referral to rheumatology, and a follow-up appointment in six weeks to review MRI results. The order summary showed an order for rheumatology and an MRI for right shoulder pain, but the rheumatology order was discontinued on 12/8/2024. The MRI of the right shoulder was completed on 12/16/2024 and showed thinning of the rotator cuff tendon, suggesting chronic tendinosis, and deterioration of the rotator cuff muscle. During the survey, Resident 7 stated he was still waiting for the rheumatology consult and reported ongoing shoulder pain and worsening arm condition. The record also showed a shoulder X-ray on 5/22/2025 that indicated mild degenerative joint disease in both shoulders. Resident 7 stated he was not informed of the MRI results until 8/11/2025 and was only told on 8/14/2025 that the X-ray showed bone degeneration in both shoulders. RN 4 stated the neurology and rheumatology appointments were not followed up with, and that the X-ray results were relayed to the doctor on 5/23/2025 with no new orders. The DON stated residents who are alert should be informed of results and that referrals are important and should be followed up with. Facility policies addressed resident rights, quality of life, referrals to outside services, and documentation of physician orders.
Dirty and Thickened Toenails Not Addressed
Penalty
Summary
Provide appropriate foot care was not ensured for one dependent resident with severely impaired cognition and total dependence for all ADLs. During a concurrent observation and interview, the resident was noted to have dirty, discolored, and thickened toenails. An RN stated the toenails were dirty and thickened and that the treatment nurse should be looking at them and the wound doctor should be following them up. Record review showed the resident was admitted with chronic respiratory failure, type 2 diabetes, ventilator dependence, hemiplegia, and hemiparesis affecting the left non-dominant side. The resident’s MDS indicated severe cognitive impairment and dependence on staff for all ADLs. An order dated 7/26/2025 indicated podiatry services as indicated, but RN 3 stated the records did not show recent documentation that the resident had been seen or referred to a podiatrist. The DON stated grooming was an important aspect of resident care and toenails need to be clean, and also stated the resident was last seen by the podiatrist in 2/2025.
Feeding Tube Care Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure appropriate care for two residents who were receiving nutrition through gastrostomy tubes. One resident had diagnoses including GT, dysphagia, and dementia, and was documented as severely cognitively impaired and dependent for all ADLs. During observation, the resident’s tube feeding was turned off but remained connected to the resident. The LVN stated that leaving the tube feeding attached after it was turned off was standard practice, although the LVN also stated it could lead to dislodgement and entanglement. The DON stated that after a tube feeding is completed, it should ideally be detached from the resident so the resident can be free for repositioning or ADLs, and that keeping it attached can lead to discomfort and possible dislodgement. A second resident had diagnoses including hemiplegia, hemiparesis following cerebral infection, gastrostomy, and Type II DM, and was documented as lacking capacity to understand and make decisions, with severely impaired cognition and dependence for all ADLs. The resident’s orders required head-of-bed elevation of 30 to 45 degrees during feedings, and the care plan for swallowing problems included enteral nutrition through a GT with interventions to keep the head of bed elevated 30 to 45 degrees and monitor for signs of aspiration. During observation, the resident’s tube feeding was running at 50 mL/hr while the resident was lying flat on the left side during treatment. During the same observation, the LVN stated the tube feeding was running while the resident was lying flat, but it should have been turned off prior to the treatment to prevent aspiration. The DON stated staff need to hold tube feeding during treatment to prevent aspiration or discomfort, and also stated that even without specific policy language, holding tube feeding while residents are flat is required based on nursing judgment and professional standards of care. The facility policy reviewed stated to elevate the head of the bed at least 30 degrees.
Missed Dialysis Treatment Due to Transportation Failure
Penalty
Summary
The facility failed to ensure that a resident who required dialysis received treatment as ordered. Resident 10 was admitted and readmitted with diagnoses including dialysis, Type 2 DM, and CHF. The resident’s H&P indicated he had the capacity to understand and make decisions, and the MDS described him as cognitively intact. The resident’s pre- and post-dialysis documentation showed the last dialysis treatment was on one date and the next treatment was not received until a later date. A COC note dated at 10:12 a.m. indicated Resident 10 missed a dialysis appointment and recommended calling the dialysis center to reschedule a makeup dialysis. During interview and record review, RN 5 stated the resident was waiting for transportation to dialysis, but transportation never came because the resident’s eligibility to be transported had expired and he would need to reapply. RN 5 stated the dialysis center said the resident could reschedule for the same day or the following day, and the DON stated the resident could have gone to dialysis on the missed day, but there was no documentation showing he received dialysis then. The facility policy stated it must ensure residents who require dialysis receive such services and that transportation and documentation are to be maintained.
Medication Administration Competency Not Re-Evaluated After Confusing Gabapentin Pass
Penalty
Summary
The facility failed to ensure an LVN remained competent in medication administration for one resident when the nurse did not re-evaluate competency after the resident questioned receiving more pills than her usual medication pass. Resident 119 had diagnoses including hypertension and neuropathy, had decision-making capacity, and was cognitively intact. Her order summary showed a standing order for gabapentin 300 mg by mouth every six hours for neuropathy, totaling 1200 mg daily. On the medication administration audit report, the gabapentin dose was documented as scheduled for administration, and the actual administration time and the LVN's documentation time were recorded. During interview, the LVN stated he brought four 300 mg gabapentin tablets to the resident, who told him that was not her usual medication, and she took one tablet instead of four. The LVN stated the order was confusing and he did not clarify it because he was the only one working and no one was available to help him. The RN reviewing the employee file stated there was no documentation of an incident report, in-service, or skills re-evaluation, and the DON stated the facility should maintain staff competency through skill evaluation, competency validation, in-service, or disciplinary action when concerns arise. The facility policy stated that re-education is to be provided when an employee is unable to satisfactorily perform the skill, followed by re-evaluation of competency.
Late and Too-Close Administration of Muscle Relaxants
Penalty
Summary
The facility failed to ensure medications were administered on time for one sampled resident with quadriplegia, right shoulder rotator cuff tear or rupture, and contractures of the knees, hands, and left elbow. The resident’s admission record showed he was originally admitted and later readmitted to the facility, and his H&P indicated he had the capacity to understand and make decisions. His MDS indicated his cognition was intact and that he was dependent for eating, toileting, bathing, and dressing. He had physician orders for baclofen 20 mg every 6 hours for muscle spasms and methocarbamol 1000 mg every 6 hours for muscle spasms. A review of the medication administration audit report showed multiple late administrations of both baclofen and methocarbamol, including doses given more than one hour after the scheduled time and one instance where the medication was given only two and a half hours before the next scheduled dose. The resident stated he had received baclofen and methocarbamol late at least three times in the last month and that when they were late his muscle spasms were uncomfortable. RN 4 reviewed the record and stated medications may be given one hour before or after the scheduled time, that doses given later than one hour after the scheduled time require physician notification and clarification, and that the 7/20/2025 administrations were too close together. The DON stated that when these medications are administered late, the resident can experience muscle spasms and discomfort, and that giving medications too close together creates a risk for an adverse reaction.
Inaccurate resident charting and incomplete restorative documentation
Penalty
Summary
The facility failed to ensure accurate medical record documentation for two residents. For one resident with cerebral ischemia and benign prostatic hyperplasia, the admission record, MDS, and care plan showed intact cognition, supervision needs for eating and oral hygiene, and maximal assistance for toileting, bathing, and dressing, with a noted risk for malnutrition. During a meal observation review, a CNA documented that the resident ate 75% to 100% of lunch even though that CNA stated she was not assigned to the resident, did not observe the lunch tray, and documented for another CNA who had trouble logging in to the charting system. For another resident with chronic respiratory failure, ventilator dependence, hemiplegia, hemiparesis, and severely impaired cognition, the MDS showed dependence on staff for all ADLs. The resident had restorative nursing orders for AAROM to both upper and lower extremities and for application of WHFO and PRAFO devices. The restorative administration record for 1/2025 to 3/2025 only showed check marks or X marks for services provided and did not document the amount of time spent, the resident's tolerance to the services, or the initial of the nurse providing the services on each occurrence. During review of staffing sheets, the DSD stated the restorative nurse assistant did not work on several dates that were nevertheless marked as having restorative services provided. In interview, the restorative nurse assistant stated she only marked days services were provided and did not document time spent or tolerance, and she acknowledged documenting services on dates she did not work by mistake. The DON stated documentation needed to be complete and accurate, and facility policies stated staff may not sign for another person and that restorative documentation must include the time spent and the resident's tolerance.
Incorrect McGeer Criteria Use for Antibiotic Surveillance
Penalty
Summary
The Infection Prevention Nurse (IPN), who was responsible for the facility’s infection prevention and control program and antibiotic stewardship oversight, incorrectly identified two residents as meeting McGeer criteria for antibiotic use when the surveillance log later showed they did not. Resident 11 was admitted with a G-tube and had intact cognition on the MDS, with assistance needs for eating, hygiene, toileting hygiene, and showering. An order was written for Bactrim DS for a G-tube site abscess, and the wound assessment noted pain at the G-tube peristomal area, a visible abscess, and moderate serous drainage. During interview, the IPN stated Resident 11 did not meet McGeer criteria and only had an abscess with no other symptoms, but also stated the wound assessment supported that the antibiotic order met McGeer criteria. Resident 47 was admitted and later readmitted with diagnoses including type 2 DM with foot ulcer and muscle weakness, and the MDS indicated intact cognition and supervision needed with all ADLs. An order was written for cephalexin for a furuncle on the right armpit. The surveillance log showed Resident 47 did not meet McGeer criteria, and the IPN stated the resident only had a furuncle and no other symptoms. However, during review of the change-of-condition evaluation, the IPN stated the furuncle was raised, erythematous, warm, and painful, and based on that data the antibiotic order met McGeer criteria. The DON stated McGeer criteria need to be done correctly to ascertain appropriate infection surveillance and antibiotic stewardship.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a pneumococcal vaccination for one of five sampled residents, Resident 95. Resident 95’s admission record showed admission to the facility with diagnoses including a history of COVID-19 and cerebral infarction. The Minimum Data Set dated 8/6/2025 indicated Resident 95 had severely impaired cognition and required set-up assistance with eating, oral hygiene, and personal hygiene, as well as substantial assistance with showering. During a concurrent interview and record review on 8/13/2025, the Infection Prevention Nurse stated there was no documented evidence that Resident 95 was offered or educated on the benefits and risks of the pneumococcal vaccine. During an interview on 8/15/2025, the DON stated residents need to be educated and offered the pneumococcal vaccine. The facility policy titled, Pneumococcal Vaccination - Pneumovax (PPSV23) or Pneumococcal conjugate vaccines (PCV13, PCV15 or PCV20), effective 5/4/2023, stated the facility will provide all residents the opportunity to receive the pneumococcal vaccine unless medically contraindicated or already immunized according to CDC recommendations or state/local public health guidelines.
Failure to Readmit Resident Despite Available Bed
Penalty
Summary
The facility failed to readmit a resident after transfer to a General Acute Care Hospital (GACH) for evaluation of a distended abdomen with pain. The resident, who had diagnoses including paraplegia and hydronephrosis and was cognitively intact, was initially admitted and later readmitted to the facility. After the hospital transfer, the resident was determined to be ready for discharge back to a skilled nursing facility, and the discharge order remained active for several days. Despite this, the facility informed the hospital case manager that there were no available male beds, and the resident remained at the hospital awaiting placement. A review of the facility's census and bed assignments revealed that there was at least one available male bed for 11 consecutive days during the period the resident was waiting for readmission. The Director of Nursing confirmed that a bed was available and stated that the resident should have been readmitted. The facility's policy indicated that residents eligible for Medi-Cal/Medicaid should be readmitted to their previous room or the first available bed. The failure to readmit the resident resulted in a prolonged hospital stay and frustration for the resident, who considered the facility his home.
Failure to Revise Care Plan After Readmission Leads to Resident-to-Resident Altercation
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was readmitted after a transfer to a General Acute Care Hospital (GACH) due to aggressive behavior. Upon readmission, the resident, who had diagnoses including encephalopathy, schizophrenia, and bipolar disorder, did not require 1:1 supervision according to staff, and the behavior care plans were not updated. The Minimum Data Set Coordinator (MDSC) acknowledged that the care plan should have been reviewed and revised upon the resident's return, but this was not done. As a result of the lack of care plan revision, the resident exhibited further behavioral issues, including throwing a book at another resident. Documentation indicated the resident was anxious, irritable, emotionally labile, and demonstrated poor impulse control and unpredictable behavior. The Director of Nursing (DON) confirmed that care plans need to be updated upon readmission to prevent gaps or delays in care, and the facility's policy required comprehensive care planning to be reviewed and revised as needed.
CNAs Assigned to Subacute Unit Without Required Training or Orientation
Penalty
Summary
Two Certified Nursing Assistants (CNAs) were assigned to work in the Subacute Unit without receiving the necessary training or orientation specific to that unit. Both CNAs reported in interviews that they had not been trained prior to floating to the Subacute Unit and expressed feeling unsafe and unprepared to care for residents requiring more intensive care, including those with ventilators. Review of staffing records confirmed that at least one CNA was assigned to the Subacute Unit on a specific date without prior training. Interviews with facility leadership, including the Registered Nurse Supervisor, Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that CNAs should receive additional training and orientation before working in the Subacute Unit due to the specialized needs of the residents. The DSD and DON acknowledged there was no documentation of training or orientation for the CNAs in question, and the DSD's job description indicated responsibility for coordinating ongoing in-service training for all employees. The lack of training and documentation had the potential to result in inadequate care for residents in the Subacute Unit.
Plan Of Correction
Competent Nursing Staff How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 05/22/2025, CNA 1 was provided training and orientation to work in the Subacute Unit. Competencies were completed and filed on the employee's file. On 05/22/2025, CNA 2 was provided training and orientation to work in the Subacute Unit. Competencies were completed and filed on the employee's file. On 05/22/2025, The Administrator/ DON provided a 1 on 1 education to the new DSD and DSD Assistant on ensuring that all licensed and certified staff assigned to the Subacute Unit shall receive orientation, training and competencies prior to any assignment on the floor and a retraining shall be provided as needed. On 05/22/2025, residents identified to be under the care of CNA 1 in the Subacute Unit on 05/09/2025 were assessed and no negative findings were noted. On 05/22/2025, residents identified to be under the care of CNA 2 in the Subacute Unit on 05/09/2025 were assessed and no negative findings were noted. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 05/22/2025 and 05/23/2025, DON/DSD/Designee reviewed the employee files of licensed and certified staff assigned to work for the Subacute Unit in the past 30 days and found no other licensed or certified staff were scheduled without orientation, training and competencies for the unit; hence, no other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 05/22/2025, The Administrator/ DON provided a 1 on 1 education to the new DSD and DSD Assistant on ensuring that all licensed and certified staff assigned to the Subacute Unit shall receive orientation, training and competencies prior to any assignment on the floor and retraining shall be provided as needed. On 05/22/2025 and 05/23/2025, Administrator, DON/Designee initiated an in-service education to Licensed Nurses, Certified Nursing Assistants, and Restorative Nursing Assistants on assuring that they receive the necessary orientation, training and competency to ensure that residents under their care will receive the appropriate care. A tracking log was created to ensure that all staff orientation, training, re- training and competencies are documented and filed in each respective employee file. This file will be kept by the DSD and will be updated accordingly. All licensed and certified staff members who do not have any documented Subacute orientation, training, retraining or competencies will not be scheduled in the Subacute Unit. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/Designee will conduct an audit of the DSD's tracking log for 4 weeks then bi- weekly for 3 months, to ensure that staff assigned to the Subacute Unit have the proper orientation, training, retraining and competencies needed prior to being assigned in the unit. Any issues identified will be addressed immediately. The Administrator will present the results of the above reviews to the Quality Assurance and Performance Improvement Committee for review and recommendations monthly for 3 months then quarterly thereafter. The plan will be reevaluated monthly by the QA Committee and make necessary changes as warranted to ensure that safety of the residents. Completion Date: 05/30/2025 F 726
CNA Worked Without Active Certification
Penalty
Summary
A Certified Nursing Assistant (CNA 1) was allowed to work without an active certification. Review of the California Department of Public Health (CDPH) License and Certification Verification Detail Page showed that CNA 1 did not have an active certificate. Although CNA 1 had passed both the skills and knowledge portions of the California Nurse Aide Assessment Program (NNAAP) examination, the results indicated that certification would only be granted and appear on the registry up to 60 days after submission. At the time CNA 1 began working, their certification was not yet active or verifiable on the registry. The Assistant Director of Nursing (ADON) permitted CNA 1 to work after being shown the exam results, relying on personal experience rather than verifying active certification status on the registry. The Director of Staff Development (DSD) and Director of Nursing (DON) both confirmed that CNA 1's certification was not active and that proper verification procedures were not followed prior to CNA 1 starting work. The facility's job description for CNAs also required an active license, which was not met in this instance.
CNA Worked Shifts with Expired Certification
Penalty
Summary
A Certified Nursing Assistant (CNA) worked ten shifts with an expired certification, as confirmed by a review of the California Department of Public Health License and Certification Verification Detail Page and the facility's Nursing Staff Assignment Sheets. The CNA was aware that her certification had expired but continued to perform CNA duties during this period. The facility's Director of Staff Development (DSD) acknowledged that the CNA functioned in her role with an expired certification and was only reassigned to non-clinical duties after the expiration was discovered. Interviews with facility leadership revealed that the DSD is responsible for tracking CNA certifications, and the Director of Nursing (DON) stated that employees should notify the DSD if they encounter issues with renewal. The facility's job description for CNAs requires a valid certification, and both the DSD and DON confirmed that working with an expired certification is not permitted. The deficiency was identified through interviews and record reviews, with no mention of corrective actions taken at the time of the incident.
Failure to Monitor and Report Psychotropic Medication Refusals and Behaviors
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of targeted behaviors for a resident prescribed psychotropic medications, and did not notify psychiatry when the resident refused these medications. The resident in question had diagnoses including schizoaffective disorder, violent behavior, and delusional disorder, and was prescribed Depakote and Invega Sustenna to manage symptoms such as sudden mood changes and aggressive behavior. Physician orders required staff to monitor and document behavioral episodes and to indicate the use and effectiveness of nonpharmacological interventions. Record reviews revealed that the resident refused the prescribed medications multiple times over the course of two months, with documentation showing frequent refusals and several episodes of behavioral disturbances. Despite these refusals and behavioral episodes, there was inconsistent documentation of the behaviors, and staff did not consistently notify the attending physician or psychiatrist as required by facility policy. Interviews with nursing staff confirmed that the psychiatrist was not informed of the medication refusals, and that documentation of behavioral monitoring was sometimes inaccurate or incomplete. Facility policies required that occurrences of behaviors for which psychoactive medications are used be documented on the medication administration record every shift, and that significant changes in a resident's condition, including medication refusals, be promptly reported to the physician and family. However, the report found that these procedures were not consistently followed, resulting in a lack of timely notification to the medical team and incomplete behavioral monitoring for the resident.
Failure to Provide Functioning and Accessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were functioning and accessible for two of six sampled residents. For one resident with hemiplegia, hemiparesis, contractures, and cognitive communication deficits, the call light was observed to be nonfunctional, with no response when pressed. The resident reported waiting for two hours for assistance and expressed frustration. Staff confirmed the call light was not working and acknowledged that the resident had to call out for help. Additionally, the call light was placed on the side of the bed that the resident could not reach due to a dislocated shoulder, further limiting access to assistance. Another resident with contractures, hemiplegia, hemiparesis, and generalized muscle weakness also experienced issues with the call light system. The resident reported that pressing the call light did not result in staff response and was unaware of the call light's location, which was observed to be on the floor and out of reach. Staff interviews confirmed the importance of accessible and functioning call lights for resident safety and indicated that nonfunctional call lights would be reported to maintenance. Facility policy requires call lights to be within reach and operational to allow residents to request assistance.
Resident Elopement Due to Inactive Door Alarm and Inadequate Assessment
Penalty
Summary
The facility failed to ensure the front door was alarmed, which led to a resident under conservatorship eloping from the facility. The resident, who had a history of wandering and was assessed incorrectly during an elopement evaluation, was not provided with a care plan or interventions to address her elopement risk. This oversight resulted in the resident leaving the facility unsupervised and being found approximately four miles away, confused and incoherent. The resident's medical history included schizophrenia, brief psychotic disorder, generalized anxiety disorder, dementia, and aphasia, with moderately impaired cognition requiring supervision for walking. Despite these conditions, the resident's elopement evaluation was inaccurately completed, indicating no history of elopement or wandering, which contradicted previous assessments. The facility's staff, including the Registered Nurse Supervisor and Certified Nursing Assistant, acknowledged the resident's frequent hallway walking but did not perceive it as wandering or a risk for elopement. Interviews revealed that the facility's cameras were non-functional, and the front door alarm was not activated at the time of the incident. The Administrator admitted that the alarm should have been on, and the Maintenance Supervisor confirmed that alarm checks were not conducted on weekends or after hours. The Director of Nursing acknowledged the resident's elopement risk and the need for a care plan, which was not developed, leading to the resident's unsupervised departure from the facility.
Failure to Address Resident Council Concerns and Provide Adequate Staff Oversight
Penalty
Summary
The facility failed to uphold residents' rights by not addressing concerns raised by the resident council regarding delayed call light response times during the 11pm-7am shift. Resident 1, who has intact cognition and a medical history including type 2 diabetes and a traumatic partial amputation, reported that the staffing during this shift is very short, leading to significant delays in response times when residents call for assistance. These concerns were documented in resident council meetings held on two occasions, but no action plan was developed or implemented to address these issues. The Director of Staff Development (DSD) did not provide appropriate oversight during the 11pm-7am shift, as required by the facility's job description. The DSD was aware of the residents' concerns but did not conduct rounds or check in with the staff during her presence at the facility. Instead, she focused on paperwork in her office, missing the opportunity to address the staffing issues and delayed response times. The Assistant Director of Nursing (ADON) emphasized that it is the responsibility of department heads, including the DSD, to ensure that residents' call lights are answered promptly and that residents' rights are upheld. The facility's policies and procedures require that concerns raised by the resident council be addressed by the responsible department, with a response form used to track issues and resolutions. However, the minutes from the resident council meetings did not indicate any actions taken to resolve the identified issues. The Administrator acknowledged the staffing shortage and the need for department heads to conduct rounds and provide oversight, but the lack of documented action plans in response to the resident council's concerns highlights a failure to uphold residents' rights and dignity.
Failure to Notify Physician of Resident Altercation
Penalty
Summary
The facility failed to maintain resident rights by not notifying a resident's physician about a change in condition following an altercation. Resident 1, who has intact cognition and a history of type 2 diabetes, muscle weakness, and traumatic partial amputation, was involved in an incident where Resident 2 attempted to hit him. Resident 2, who has severe cognitive impairment and a history of type 2 diabetes and metabolic encephalopathy, was noted to have behavioral symptoms and attempted to strike peers, including Resident 1. The incident was witnessed by the MDS nurse, who reported it to RN 1. However, RN 1 did not notify the administrator or Resident 1's physician, as she did not consider the incident to be abuse since no physical harm occurred. This oversight resulted in a delay in necessary assessments and services for Resident 1, as the physician was unaware of the altercation and its potential impact on Resident 1's health. The facility's policy requires prompt notification of the resident's physician and legal representative in the event of a significant change in condition. The failure to adhere to this policy led to a delay in addressing Resident 1's needs, as the physician was not informed of the incident, which could have warranted further medical assessment and intervention.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report a physical altercation between two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved Resident 1, who was attempting to protect himself from being hit by Resident 2. The altercation was witnessed by the Minimum Data Set (MDS) nurse, who reported it to Registered Nurse (RN) 1. However, RN 1 did not report the incident to the Administrator or the appropriate authorities, as she did not consider it abuse since no injuries were observed. Resident 1, who has intact cognition, reported feeling threatened by Resident 2, who has severely impaired cognition and a history of behavioral symptoms. The MDS nurse witnessed the incident and redirected Resident 2 but assumed RN 1 would report it. RN 1 acknowledged her mistake in not reporting the incident, which placed Resident 1 at risk for further harm and delayed necessary assessments and services. The facility's policy requires all allegations and suspected abuse incidents to be reported immediately to the Administrator, police, ombudsman, and CDPH. The Administrator was unaware of the incident until informed by the ombudsman over two months later, at which point the incident was reported to CDPH. This delay violated federal regulations and the facility's policy, potentially delaying CDPH's investigation and leaving other abuse allegations unreported.
Failure to Develop Comprehensive Care Plan After Resident Altercation
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for Resident 1 after an incident involving Resident 2. On December 3, 2024, the MDS nurse witnessed Resident 1 holding Resident 2's hands and was informed by Resident 1 that he was trying to protect himself from being hit by Resident 2. Despite this incident, no care plan was created for Resident 1, and there was no interdisciplinary team meeting to address Resident 1's concerns or to develop a plan of care. This oversight resulted in a delay in care and services for Resident 1, placing him at risk for a decline in mental and psychosocial well-being. Resident 1 was initially admitted to the facility with diagnoses including type 2 diabetes, muscle weakness, and traumatic partial amputation of the right foot. His cognition was intact, and he was able to understand and be understood by others. In contrast, Resident 2, who was involved in the incident, had severe cognitive impairment and was sometimes understood by others. The facility's policy required a comprehensive care plan to be reviewed and revised at the onset of new problems or changes in condition, but this was not done for Resident 1 following the altercation with Resident 2.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to ensure that accurate daily staffing information was posted and readily available to residents and visitors. During an observation at the facility entrance, it was noted that there was no visible daily staffing information, including the total number of staff and actual hours worked, at the receptionist desk. Interviews with the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD) revealed that the hours posted were only projected hours and did not reflect the actual number of staff hours or the number of staff working. The ADON and the Administrator (ADM) acknowledged that the purpose of posting staffing hours was to ensure compliance with staffing requirements and to demonstrate that the facility was staffed at or above the required number. The facility's policy and procedure, dated July 2018, indicated that the facility should post the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. However, this was not being adhered to, resulting in residents and visitors not having access to accurate daily staffing numbers.
Inadequate Staffing Leads to Resident's Call to Police for Incontinence Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect due to insufficient staffing, resulting in inadequate incontinence care. A resident, who was admitted with respiratory failure and had intact cognition, was dependent on staff for activities of daily living, including toileting. On a specific night, the facility had only two CNAs working the night shift instead of the scheduled four, with one CNA assigned to care for 82 residents. This staffing shortage led to the resident not receiving necessary incontinence care, prompting the resident to call the police for assistance. The facility's records indicated discrepancies in staffing, with timecards showing only two CNAs clocked in and out, despite the schedule indicating four were assigned. Interviews with staff confirmed the shortage, with one CNA assigned as a sitter for two residents, leaving the other CNA responsible for the remaining 82 residents. The facility's policy on resident rights emphasized treating residents with kindness, respect, and dignity, which was not upheld in this instance due to the staffing issue.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement its water management plan effectively, which is crucial for preventing the growth and spread of Legionella bacteria. The water management plan team, responsible for overseeing and implementing the plan, did not meet regularly to discuss issues related to water management. This lack of regular meetings and discussions led to a failure in recognizing and addressing potential issues within the facility's water system. The facility's water management policy and procedure required regular meetings and documentation, but there was no evidence of such meetings or documentation being maintained. The deficiency was further compounded by the resignation of the full-time Infection Prevention Nurse (IPN) in November 2024, which left the infection prevention duties to be shared between the Regional Management Quality Nurse Consultant (RNC) and the Director of Staff Development (DSD). This arrangement led to confusion and delays in implementing infection control measures, including the water management plan. The Maintenance Supervisor (MS) was aware of the water management plan but did not maintain logs to demonstrate how control measures were monitored and implemented. Additionally, there was no communication or team meetings to discuss a Legionella concern raised by the Department of Health. The facility's Water Management Plan for Legionella Control was not updated to reflect current team members, and the team had not reviewed the facility's water infection control risk assessments. The plan required maintaining logs and documentation for various water-related equipment and systems, but these were not reviewed by the team. The lack of regular meetings and documentation review could lead to undetected water contamination and potential outbreaks, posing a risk to the health of the residents.
Failure to Designate Full-Time Infection Preventionist
Penalty
Summary
The facility failed to designate a full-time infection preventionist nurse (IPN) to oversee the infection prevention and control program, as required by the facility's job description. This deficiency resulted in inadequate oversight of the facility's water management plan team, which is responsible for addressing hazardous conditions in the water system to prevent legionella growth. The absence of a dedicated IPN led to a lack of regular meetings and discussions about water management issues, increasing the risk of infection for residents. The Regional Management Quality Nurse Consultant (RNC) assumed the IPN duties after the previous IPN resigned in November 2024. However, the RNC was unable to provide documentation of the hours spent performing IPN responsibilities and shared these duties with the Director of Staff Development (DSD), who also had other responsibilities. This lack of clear role delineation caused confusion and delays in implementing the infection prevention and control program. Additionally, the RNC was also acting as the Director of Nursing (DON) after the DON resigned, further complicating the situation. The facility's water management policy and procedure required regular meetings of the water management plan team, which included the IPN, DON, Administrator, and Maintenance Director/Supervisor. However, the RNC could not locate any documentation of such meetings, and the team members listed in the plan had resigned or left their roles. Consequently, the team had not reviewed the facility's water infection control risk assessments, potentially leading to the proliferation of waterborne pathogens and an outbreak. The facility's job description for the IPN emphasized the need for a full-time role to oversee infection prevention and control activities, but this requirement was not met.
Failure to Notify and Assess After Resident Fall
Penalty
Summary
The facility failed to provide appropriate care for a resident who experienced an unwitnessed fall, resulting in injuries. The nursing staff did not notify the resident's physician or responsible party following the incident, which occurred during the night shift. The resident, who had a history of atrial fibrillation, cirrhosis of the liver, and other serious health conditions, was on medications that increased the risk of bleeding. Despite these factors, the nursing staff did not assess or monitor the resident's condition adequately after the fall. The resident was found on the floor by a CNA, who informed an LVN of the situation. However, the LVN did not perform a full assessment, check vital signs, or document the incident in the resident's medical record. The LVN also failed to communicate the incident to the oncoming shift, leaving the resident's condition unmonitored and unreported. This lack of communication and documentation resulted in a delay in the resident's care, as the physician and responsible party were not informed until two days later. The resident was eventually transferred to a general acute care hospital, where multiple bruises and skin abrasions were noted. The facility's policy requires that any change in a resident's condition be reported to the physician and family, but this protocol was not followed. The Director of Nursing acknowledged the oversight, emphasizing the importance of timely assessment and communication to prevent delays in treatment and potential complications.
Failure to Report Resident's Injuries of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH) in a timely manner. The resident, who had multiple medical conditions including atrial fibrillation, cirrhosis of the liver, and cancer, was found with multiple skin tears on his body. These injuries were discovered during a review of the resident's records and interviews with staff and the resident's responsible party. The resident reported that the skin tears were caused by a rough towel used by a certified nursing assistant during the night shift. The licensed vocational nurse (LVN) who observed the injuries was not informed about them by the previous shift and found no documentation regarding the change of condition in the resident's medical record. The LVN acknowledged that she should have reported the injuries to the Director of Nursing Services (DON) or the Administrator. The Registered Nurse Supervisor stated that such injuries should be reported to the CDPH within 24 hours to prevent potential mistreatment. The Director of Nursing was not aware of the injuries until two days later and did not report them to the CDPH, believing the explanation of the rough towel was sufficient. The Administrator confirmed that injuries of unknown origin should have been reported, especially given the questionable nature of the injuries. The facility's policy on abuse prevention and management requires prompt reporting of such incidents to the appropriate authorities.
Failure to Provide One-on-One Sitter for High-Risk Resident
Penalty
Summary
The facility failed to provide a one-on-one sitter for a resident with a history of falls, as per the physician's order. The resident, who was admitted with diagnoses including metabolic encephalopathy, Parkinsonism, and epilepsy, was assessed as having a high risk for falls. Despite the physician's order for a one-on-one sitter following an unwitnessed fall, the resident was observed without a sitter on multiple occasions, attempting tasks beyond her capacity due to her condition. The resident's care plan and physician's order both indicated the need for a one-on-one sitter to ensure safety, especially after a recent fall that resulted in pain and injury. However, during observations and interviews, it was noted that the resident was left unsupervised, attempting to reposition herself and reach for items, which posed a risk of further falls. Staff interviews confirmed that the resident was forgetful, unsteady, and required constant supervision, yet no sitter was consistently assigned. The facility's Director of Nursing and other staff members acknowledged the lack of consistent assignment of a sitter for the resident, despite being aware of the physician's order and the resident's high fall risk. The facility's policy on fall management was not effectively implemented, as the interdisciplinary team failed to ensure the resident's care plan was followed, leading to the deficiency in providing appropriate care and supervision.
Deficiency in Bed Maintenance and Staff Assignment
Penalty
Summary
The facility failed to ensure a clean and comfortable bed for a resident, resulting in a deficiency. The resident, who was cognitively intact and required assistance with activities of daily living, was observed with a bed cluttered with dirty blankets, limiting their ability to sit up properly and rest comfortably. The resident expressed dissatisfaction with the care provided by CNA 1, who was repeatedly assigned to them despite the resident's requests for reassignment. CNA 1 believed the resident could make their own bed and acknowledged a poor relationship with the resident. The Director of Nursing confirmed the lack of space in the resident's bed for comfortable rest. The Director of Staff Development admitted to failing to communicate changes in staff assignments effectively, which contributed to the ongoing issue. The facility's policies on resident rights and activities of daily living emphasize the need for accommodating individual needs and providing appropriate support, which was not adhered to in this case.
Failure to Implement Correct Isolation Precautions During CPO Outbreak
Penalty
Summary
The facility failed to adhere to the Long Beach Department of Health and Human Services (LBDHHS) guidelines during an outbreak of Carbapenemase-producing organisms (CPO) by not posting the correct isolation precaution signs on 8 out of 12 rooms in the sub-acute unit (SAU). Instead of using contact isolation precautions, which require staff to don personal protective equipment (PPE) before entering a resident's room, the facility posted Enhanced Barrier Precautions (EBP) signs. EBP requires PPE only during high-contact activities, which is not in line with the LBDHHS guidelines for residents who tested positive for CPO. The issue was identified during observations and interviews conducted on the SAU. The Director of Staffing (DSD) and the Infection Preventionist Nurse (IPN) both acknowledged the error, noting that the correct contact isolation signs were not posted despite the guidelines being communicated to staff. The Director of Nurses (DON) also confirmed that the LBDHHS guidelines were received but could not explain why the incorrect signs were used. The facility's policy and procedure for infectious disease management indicated adherence to CDC and local health department recommendations, which were not followed in this instance.
Resident Abused by CNA During Bathroom Incident
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA 1). The incident involved CNA 1 yelling at the resident and throwing a urinal and a bottle of water towards the resident. This occurred when CNA 1 entered the bathroom while the resident was using it, despite the resident's request for privacy. The resident reported feeling emotionally distressed and disrespected due to this interaction. The resident, who was admitted with diagnoses including muscle weakness, anxiety, major depressive disorder, and schizophrenia, had intact cognitive abilities and required supervision for various activities of daily living. The resident's care plan highlighted a risk for psychosocial well-being problems related to disagreements with CNA 1. On the day of the incident, the resident reported the altercation to the nursing staff, stating that CNA 1 had entered the bathroom without waiting and had thrown a drinking cup towards him. Interviews with staff and the resident confirmed the events, with CNA 1 admitting to entering the bathroom without waiting and responding with attitude when the resident requested privacy. The facility's policy on abuse prevention and reporting was not adhered to, as CNA 1's actions constituted verbal abuse and a violation of the resident's dignity and respect. The incident was documented in various notes, including the resident's care plan, nurse's progress notes, and interdisciplinary team discussions.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. This incident involved two residents, where one resident pulled the beanie off another resident's head and pulled her hair. The affected resident, who was independent in decision-making, reported the incident to the Administrator the following day. However, the Certified Nursing Assistant (CNA) who witnessed the event reported it to the Licensed Vocational Nurse (LVN), who then failed to report it to the Administrator due to being overwhelmed with work. The LVN acknowledged the oversight, recognizing the obligation to report any allegations of abuse to ensure safety and prevent further incidents. The facility's policy mandates that any abuse allegations be reported to law enforcement and CDPH within two hours. The Administrator confirmed that the incident was not reported to him and emphasized the importance of reporting and investigating all abuse allegations to maintain a safe environment for residents.
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What surveyors actually found near you
We read the 5,673 citations issued within 25 miles in the last 12 months — including the 23 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.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ocean Ridge Post Acute | 0 mi | ★★★★★ | 23 | 0 |
| Marlora Post Acute Rehab Hosp | 0.4 mi | ★★★★★ | 31 | 1 |
| Pacific Palms Healthcare | 0.5 mi | ★★★★★ | 41 | 0 |
| Shoreline Healthcare Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Bel Vista Healthcare Center | 0.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.