Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Courtyard Health Care Center during CMS and state inspections, most recent first.
Failure to obtain and implement physician orders for ostomy care. A resident with ulcerative colitis and a new ileostomy had no documented MD orders or treatment care on the TAR, while an ER note described reddened, moist, friable tissue around the ostomy with stool leaking onto the skin. An LN said she only gathered supplies and had not seen the stoma because the resident did her own care, and the ADON confirmed no documented ostomy orders were in place.
Food service practices were not followed when kitchen ovens were found with burnt debris, opened frozen items were left undated, cereal bowls in dry storage were unlabeled and undated, and meal trays were delivered with uncovered food. The DM and RD confirmed the findings, and facility policies required ovens to be cleaned, food items to be labeled and dated, and trays to be covered during transport when not in an enclosed cart.
Psychotropic medications were administered to five residents without documented nonpharmacological interventions. The residents had orders for medications including antipsychotics, antidepressants, and Ativan for conditions such as depression, anxiety, schizoaffective disorder, agitation, hallucinations, social isolation, and insomnia. The DON confirmed the records did not show behavioral interventions were implemented or documented for these residents.
Medication administration and pain management orders were not followed for several residents. A resident with chronic pain and pressure wounds was observed in severe pain during wound care, with missed PRN pain medication opportunities and no pain assessment or pre-medication before treatment. Another resident's melatonin order was not discontinued despite a psychiatry recommendation, an opioid was given outside the ordered pain-score parameters for a resident with a PEG tube, and a diabetic resident's semaglutide was administered without routine pre-dose BS checks to confirm the hold parameter.
Emergency kit management deficiencies were identified when an opened E-kit in the Station 1 med storage room had a log dated 20 days earlier, showing it had not been replaced timely after medication removal, and another E-kit in the Station 2 med storage room did not have a contents list affixed to the outside. The DON confirmed both findings and stated the log was used to notify the supplier pharmacy and that the contents list was needed so staff would know what was available and when the kit expired.
Medication administration errors exceeded the allowed rate after four errors were found in 37 observed opportunities. An LPN gave levothyroxine in a way that did not match standard administration instructions, administered a calcium/vitamin D supplement that did not match the ordered vitamin D strength, and gave two different eye drops too close together instead of waiting the required interval. The DON stated levothyroxine should be given on an empty stomach, eye drops should be separated by five minutes, and supplements should match the physician’s order.
Infection prevention and control practices were not followed during resident care. Nurses were observed with artificial nails and one with ungloved hands, oxygen tubing for multiple residents was left on the floor, a nurse used the same gloves for two different wound sites on a resident with osteomyelitis and cellulitis, a resident’s PICC dressing was not intact, and CNAs provided care to residents on EBP without wearing the required gown and gloves.
Failure to preserve resident dignity during feeding and wound care: one resident with MS and dysphagia was fed lunch by a CNA who remained standing over him instead of sitting, and another resident with DM, diabetic neuropathy, and a wound treatment order received wound care while the privacy curtain between roommates stayed open. The DSD and LN both acknowledged that sitting during feeding and closing the curtain during treatment were expected to protect dignity and privacy.
Failure to accommodate a resident's communication needs occurred when staff did not use the resident's communication board during GT dressing care. The resident, who speaks mainly Hmong and has limited ability to communicate after a stroke, began crying during the procedure, but the LPN continued without asking why and no communication board was at the bedside. A later LN confirmed the board was not within reach, and the DON stated it should always be kept within reach like a call light.
Failure to provide adequate ADL assistance and nail care for three residents was identified. One resident with sepsis and weakness, one resident with CVA, hemiplegia, and aphasia, and one resident with intracerebral hemorrhage and hemiparesis were all dependent on staff for hygiene-related care, yet were observed with long nails, debris under nails, dry cracked heels, and other signs of poor grooming. Staff confirmed the conditions, and records showed missing or incomplete person-centered care planning for ADLs and nail care for two of the residents.
The facility failed to keep the resident environment free of accident hazards for two residents. A portable O2 cylinder in one resident’s room was observed unsecured and not placed in a stand or carrier, despite the DON stating cylinders should be secured to prevent falling. In another room, a resident with dementia, Alzheimer’s disease, osteoporosis, and fall risk had a bedside fall mat placed underneath the bed instead of beside it, and the CNA confirmed it should have been positioned next to the bed as part of fall precautions.
A resident with chronic pain and multiple pressure injuries was observed moaning, yelling, and reporting severe pain during wound care and ADL care, yet staff did not assess pain promptly or pre-medicate before treatment. MAR review showed repeated missed opportunities to give PRN acetaminophen, with no documentation that it was offered, refused, or administered, and oxycodone was given only after wound care had already been completed. The DON stated staff were expected to pre-medicate before care and use a pain scale assessment.
Unlabeled and undated resident food was found in a memory care unit refrigerator, including an opened package of cheese and two bags of take-out food. The DSD stated she could not tell who the items belonged to and noted take-out food should be discarded after 72 hours. The RD stated food in a resident refrigerator should be dated so staff can determine how long it has been there and when it should be discarded.
A resident with encephalitis, encephalomyelitis, and hepatic encephalopathy did not receive ordered itraconazole via G-tube on time. The MAR showed three missed doses, and notes documented that the antifungal had not been received from the pharmacy, then could not be located in the med carts after it reportedly arrived. The resident was later transferred to the ER because anti-fungal medication was needed.
Failure to Protect Resident from Abuse: A resident with severe cognitive impairment struck another resident in the back with a closed hand, and staff witnessed the altercation. The resident who was hit confirmed the incident and said he felt angry. Both residents had significant cognitive and psychiatric diagnoses, and the DON stated the facility’s expectation is to keep residents safe.
The facility failed to report the results of an abuse allegation investigation within the required five working days. An SBAR note documented that two residents in the lobby began cussing at each other while one was preparing to leave for dialysis, and that one resident punched the other on the body as she was on the gurney leaving. The Administrator confirmed that while the initial SOC 341 was sent on the date of the incident, the 5-day summary of the investigation was not sent to the state agency until several days later, exceeding the timeframe required by the facility’s abuse reporting policy.
Two residents with multiple medical diagnoses, including surgical aftercare and respiratory failure, reported physical abuse by a CNA. The facility submitted initial incident reports to CDPH but did not provide the required 5‑day investigation results within the mandated timeframe. In addition, after one resident’s abuse allegation, nursing staff did not complete or document the immediate assessment required by facility policy, as confirmed by the DON.
A resident with CKD, schizophrenia, and bipolar disorder, who was cognitively intact, was found with bruising on the face and reported that a CNA had hit her and pulled her hair during care. Another CNA had been told of this allegation the prior day when the resident pointed out the facial bruise and described being hit and having her hair pulled at night, but the CNA did not report the allegation immediately, stating she did not know what to do and did not believe the resident. The facility’s abuse policy required staff to immediately report any actual or potential abuse to a supervisor or the administrator, and leadership confirmed this incident was reportable and should have been reported without delay.
Improper Storage of Clean Dishes: A dirty cup with half-eaten food was found on a clean dish shelf, and a hot water jug stored with clean dishes had dark brown residue in its crevices. The DM confirmed both items should not have been in the clean dish area. A resident with intact cognition also reported a breakfast fork with dried crusty residue on it.
Therapeutic Diet Not Followed for Easy-to-Chew Meal: A resident with PMH of malnutrition, dysphagia, and adult failure to thrive was served a chicken burger that was hard to chew instead of the ordered easy-to-chew texture. The resident reported broken upper teeth and said the chicken was hard and chewy, and the facility policy for Level 7 regular easy-to-chew diets prohibited hard, tough, chewy, and fibrous foods and required tender meat or minced and moist meat if needed.
Surveyors observed that clean utensils had food particles and water residuals, and utensil holders contained black particles. A dietary aide handled clean kitchenware without washing hands after working with dirty dishes. The dietary manager and registered dietician confirmed these practices did not meet sanitation standards, and facility policy requiring proper dishwashing and hand hygiene was not followed.
A resident was not adequately prepared for a safe transfer or discharge, as the facility did not ensure the process met the individual's needs and preferences.
A resident with severe cognitive impairment and recent brain surgery was discharged to a hotel without home health services in place, contrary to physician orders. The required 30-day discharge notice was not provided in advance, and necessary post-discharge follow-up and documentation, including a physician discharge summary and MDS assessment, were missing. The resident was later found confused and hospitalized, and facility staff confirmed these failures.
A resident with severe cognitive impairment and a history of wandering exited the facility without staff authorization and was found offsite. Facility staff did not complete an elopement risk assessment, care plan, or document the incident as required by policy.
Three residents with specific dietary preferences and medical conditions did not receive their requested meal items, including double protein portions, green salad, and fresh fruit, as documented on their meal tickets. These omissions were confirmed by both the residents and dietary staff, indicating a failure to honor resident food preferences during meal service.
Surveyors found that refrigerated food items, including yogurt, were left at room temperature for several hours after delivery and not promptly stored as required. Additionally, staff failed to document freezer temperatures during one shift, contrary to facility policy. These actions did not meet professional standards for food safety.
A resident with hemiplegia and no memory impairment was physically struck multiple times by another resident with severe memory impairment and bipolar disorder, as witnessed by staff. The incident caused physical pain, facial redness, and emotional distress, with the affected resident becoming tearful and upset. Staff acknowledged the event as physical abuse, and facility records confirmed the altercation and its impact.
Sixteen meal tickets containing residents' names, allergies, and therapeutic diets were left unattended in the memory unit dining area. Both the RD and DON confirmed this was a HIPAA violation, as facility policy requires safeguarding and proper disposal of PHI.
Licensed nurses did not administer medications on time, failed to verify resident identity or explain medications before administration, and did not follow physician orders for continuous gastrostomy feeding. These deficiencies were observed in multiple residents with complex medical needs, and staff acknowledged not following required procedures.
During an EHR system outage, nursing staff were not provided with timely instructions and were unaware of the contingency procedures, resulting in delays in medication administration. The DON and ADM confirmed that no mock drills for EHR outages had been conducted, and staff had not been trained on the emergency plan, despite facility policies requiring such preparation.
The facility did not maintain documentation or evidence of QAPI meetings for three consecutive quarters, and multiple staff members were unaware of the required QAPI activities. The Administrator confirmed the absence of records and meetings, and the facility's policy requiring ongoing documentation was not followed.
Surveyors found that infection control practices were not followed, including improper storage of a CPAP mask, lack of Enhanced Barrier Precautions for multiple residents with invasive devices or wounds, and failure to label and date medical equipment such as oxygen tubing, feeding tubes, and IV bags. Staff were also observed not performing hand hygiene between resident contacts and during medication administration, with both a CNA and an LPN confirming they forgot to do so.
Several residents with complex medical needs reported and were observed experiencing late meal service, with some waiting up to 1 to 2 hours for meals. Staff confirmed the delays, and the posted dining schedule lacked specific meal times. The facility's policy required timely meal delivery in line with resident preferences and community norms, but this was not followed, resulting in resident dissatisfaction and potential impacts on care.
Surveyors found that food service staff failed to label, date, and monitor refrigerated and frozen foods, with expired and improperly stored items present. Temperature logs for all cold storage units were incomplete. In the dry storage area, fruit flies and improperly sealed food items were observed. Additionally, a dietary aide was seen assembling trays without a beard net, exposing facial hair near uncovered food. These failures were confirmed by the Dietary Manager and Registered Dietician.
Surveyors observed a brownish frozen residue in a freezer, ovens and stove burners with food and burnt residue, and a boilerless steamer leaking liquid onto the floor. The Dietary Manager and Registered Dietician confirmed these unsanitary conditions, and the Maintenance Assistant stated the steamer was broken and not repaired. Facility policies required regular cleaning and maintenance, which was not followed.
Three non-English speaking residents with documented language barriers and care plans requiring communication boards did not have these aids available at their bedside. Staff confirmed that communication boards in the residents' primary languages should have been present, but observations showed they were missing, with only English-language materials available in one case. This was not in accordance with facility policy or the residents' care plans.
A resident reported and staff confirmed unsanitary conditions in a shower room, including a dark brown substance on the floor, and four rooms in the memory care unit had dirty, worn curtains with brown discolorations. Facility policy required clean, intact linens and prompt reporting of areas needing cleaning, but these standards were not met.
A resident who was bedbound and dependent on staff for mobility did not receive regular turning and repositioning as required for pressure ulcer prevention. Despite being at risk for skin breakdown and unable to reposition independently, the care plan lacked specific interventions for two-hourly turning, and staff interviews confirmed the resident was not consistently turned. This failure to follow professional standards and facility policy placed the resident at risk for pressure injuries.
A resident with multiple complex medical conditions, including dementia and dysphagia, experienced significant unaddressed weight loss after admission. Despite care plans and facility policies requiring weekly weight monitoring and prompt intervention for significant changes, a weight entry was missed, and the resident was not included in weight review meetings. This failure to monitor and address the resident's weight loss resulted in further decline.
Two residents with significant pain-related diagnoses did not receive timely pain assessments or administration of prescribed pain medications. One resident was left in severe pain and unable to participate in therapy, while another experienced prolonged discomfort due to delayed medication administration. Staff did not follow care plans or facility policies regarding pain management and medication timing.
The facility did not maintain proper destruction logs for discontinued controlled medications and failed to reconcile controlled drug records when original narcotic sheets went missing for 11 residents. The DON confirmed that medications were not properly documented or scanned into the pharmacy system, and no reconciliation was performed when the original records were recovered, contrary to facility policy.
Surveyors found expired tube feeding formulas, unlabeled medical supplies, and improper storage of medications in medication rooms and carts. Non-narcotic medications were kept in narcotic cabinets, expired and unsealed medications were not discarded, and medications for discharged residents remained in carts. Opened over-the-counter medications lacked open dates, and narcotic count sheets were missing required nurse signatures, all contrary to facility policy as confirmed by the DON and pharmacy consultant.
A resident with diabetes and a recent amputation did not receive prescribed Novolin insulin on several occasions, with medication administration records left blank or marked as held without a physician's order. The DON confirmed there was no documentation or order to justify withholding the insulin, in violation of facility policy requiring proper medication administration and documentation.
The facility failed to maintain sanitary practices in the kitchen, with freezer temperatures out of range and incomplete cleaning schedules. Mold was found near the kitchen exit, and infection control practices were inadequate, as confirmed by the RD and Environmental Services staff.
A resident with anemia, depression, and diabetes did not receive their prescribed Vitamin D3 1000 IU due to the facility's failure to stock the medication. A nurse resorted to cutting unscored 2000 IU tablets, contrary to policy. The DON expected OTC medications to be stocked, but a refill request was pending.
The facility failed to follow food safety standards by improperly thawing frozen fish filets on a countertop and not labeling opened food items, including spices and beef base. The Dietary Supervisor confirmed these practices, which contradict the facility's policies on safe food handling and labeling.
A kitchen freezer in the facility was found with a broken seal gasket and ice buildup, potentially compromising food safety. The Dietary Supervisor confirmed the issue, noting that some food items were not properly frozen and had freezer burn. The facility's guidelines and FDA Food Code require equipment seals to be intact and free of ice buildup, which was not maintained.
A resident with dementia and other mental health conditions was punched by another resident while attempting to enter their room, as witnessed by staff. The incident occurred due to inadequate supervision, allowing the resident to access the courtyard. Both residents had care plans indicating the need for monitoring, which were not effectively implemented, leading to the altercation.
A resident with a history of disruptive behavior and cognitive impairments was unsupervised in the courtyard, leading to an altercation with another resident. Despite protocols requiring supervision and locked doors, the resident accessed the courtyard and was punched by another resident, resulting in a fall.
A resident with Type 2 diabetes was struck multiple times by another resident with moderate memory impairment and hemiplegia after a minor collision in the hallway. The incident, witnessed by staff and other residents, resulted in no physical injury but impacted the victim's self-esteem. Facility staff acknowledged the incident as abuse, as it affected the resident's mental well-being.
Failure to Obtain and Implement Ostomy Care Orders
Penalty
Summary
The facility failed to ensure physician orders were obtained and implemented for the assessment, monitoring, and care of a newly created ileostomy for one resident. The resident was admitted in 7/2026 with diagnoses including ulcerative colitis and rectal bleeding, and the MDS indicated intact cognition. Review of the TAR for July 2026 showed no physician order obtained and no provision of treatment care for the ileostomy. An outside hospital ER note dated 7/19/26 documented abdominal pain and rash, with erythematous, moist, friable tissue in the right lower quadrant surrounding the ostomy. The note stated the ostomy did not have normal output but was draining on the skin, and the tissue appeared excoriated and related to stool contents leaking on the skin. During interview, an LN stated she had not seen the stoma because the resident did her own ostomy care and that she only gathered supplies and gave them to the resident. The resident stated she changed her ileostomy bag herself after showering and had to call the ostomy representative to do her ostomy self-care because she could not get the help she needed in the facility. The ADON reviewed the physician orders and confirmed there were no documented physician orders for ostomy care.
Food Storage and Tray Transport Deficiencies
Penalty
Summary
Food was not stored, prepared, and distributed in accordance with professional standards for a census of 104 residents. During observation with the Dietary Manager and Registered Dietician, two kitchen ovens were found with blackened, burnt debris on the bottom and oven doors, and the Dietary Manager confirmed the ovens were not as clean as expected. The Registered Dietician stated that if the oven is not kept clean, it could affect the cooking temperature of the food. The facility policy for ranges and ovens indicated ovens should be cleaned weekly or as often as necessary, and the oven manual directed daily wiping of the inside of the oven. In freezer #1, opened gallon containers of mayonnaise, sesame dressing, and pickle relish were observed without dates, and the Dietary Manager confirmed the items should have been dated when opened. In the dry storage area, eight covered serving bowls of cereal were observed unlabeled and undated, and the Dietary Manager stated the cereal bowls should have had a date they were prepared. During meal delivery observations, multiple trays were transported and delivered with uncovered food, including brownies, salad, fruit cups, and bean salad, while being moved from food carts or left on top of carts in hallways. Staff members confirmed the food was uncovered, and the Registered Dietician stated that food on trays delivered from hallway carts should be covered because of risk of contamination. The facility policy on covering food during transport stated that meal trays should be covered when not in an enclosed or covered cart and that food on trays delivered to patient rooms needs to be covered.
Psychotropic Medications Given Without Documented Nonpharmacological Interventions
Penalty
Summary
The facility failed to ensure five sampled residents were free from unnecessary psychotropic medications when nursing staff did not implement nonpharmacological interventions. The deficiency involved Residents 1, 3, 4, 12, and 91, all of whom had orders for psychotropic medications related to diagnoses such as major depressive disorder, anxiety disorder, schizoaffective disorder, and behavioral symptoms including hallucinations, agitation, compulsive skin picking, social isolation, tearfulness, and inability to sleep. For Resident 12, the record showed orders for risperidone, sertraline, and trazodone for schizoaffective disorder, depression, suicidal ideation, tearfulness, and insomnia. During interview and record review, the DON stated behavioral interventions were expected to be used and documented, but he did not see non-drug interventions in the record. For Resident 4, the record showed orders for aripiprazole and escitalopram for major depressive disorder manifested by self-isolation and sadness, and the DON confirmed there was no documentation that behavioral interventions were implemented. For Resident 91, the record showed fluoxetine for anxiety manifested by compulsive skin picking and Seroquel for behavioral disturbance manifested by agitation, and the DON confirmed the record did not indicate nonpharmacological interventions because the psychotropic medications were administered routinely rather than as needed. For Resident 3, the record showed Ativan as needed for anxiety/inability to relax and sertraline for depression manifested by social isolation, and the DON stated the record did not indicate nursing staff implemented behavioral interventions. For Resident 1, the record showed venlafaxine for anxiety disorder manifested by worrying about dying and feeling fatigue, and the DON confirmed no non-drug interventions were documented in an effort to use the lowest effective dose.
Medication Orders and Pain Management Not Followed
Penalty
Summary
Professional standards of quality were not followed for four residents when nursing staff failed to carry out ordered medication and pain-management practices as documented in the record and observed by surveyors. Resident 3, who was admitted with chronic pain syndrome and pain in the thoracic spine and who had multiple pressure-related wounds, was observed during wound care moaning, yelling, and stating severe pain. The record showed orders for scheduled morphine, PRN acetaminophen, and documentation of pain each shift, yet surveyors found repeated missed opportunities to administer acetaminophen, no documented evidence that it was offered, refused, or given, and no pain assessment or pain medication provided before wound treatment. The DON confirmed that pain should be assessed and medication given before care when possible, but during the observed wound treatment the resident continued to yell in pain and oxycodone was not administered until after the treatment had ended. Resident 12, who had diagnoses including seizures, depression, and schizoaffective disorder, had a physician order for melatonin at bedtime for inability to sleep. The record review with the DON showed that psychiatry documented concern for altered mental status and sedation and recommended discontinuing melatonin, and the physician note reflected that the order should have been discontinued. However, the medication remained on the physician's orders and had not been discontinued. Resident 4, who had type 1 diabetes, muscle weakness, and dysarthria following cerebral infarct, had an order for oxycodone 5 mg via PEG tube every 8 hours as needed for severe pain with a pain score of 7 to 10. Review of the June and July MARs showed nursing staff administered oxycodone for pain scores outside the ordered parameters, including pain levels of 5, 6, and 0. Resident 1, who had type 2 diabetes, had an order for semaglutide 14 mg daily 30 minutes before breakfast with instructions to hold the medication if blood sugar was less than 100 mg/dl. The DON confirmed the medication was given daily at 5:45 a.m., but blood sugar was not routinely checked before administration to verify the hold parameter was met.
Emergency Kit Management Deficiencies
Penalty
Summary
The facility failed to ensure that one of four emergency kits was replaced timely after medication had been removed. During a concurrent inspection and interview in the Station 1 Medication Storage Room, the Director of Nursing identified a refrigerated E-kit with a red plastic tie indicating it had been opened by nursing staff. The emergency kit log for that kit was dated 20 days earlier. The DON stated that when nursing staff opened an E-kit and removed medication, the log was to be completed and faxed to the supplier pharmacy to notify them, and that timely replacement was important so medications would be available for administration in an emergency or while waiting for a new resident's medications to be delivered from the pharmacy. The facility also failed to ensure that one of four E-kits had its contents clearly listed on the exterior. During inspection of the Station 2 Medication Storage Room, the DON identified a large white opaque E-kit that did not have a list of contents affixed to it. The DON confirmed the finding and stated the list should have been on the outside so staff would know what was available for use and when the E-kit expired. Review of the facility's undated policy and procedure titled Emergency Medications stated that the facility shall maintain a supply of medications typically used in emergencies, that the contents of each emergency medication kit will be clearly listed, and that medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep medication error rates below 5 percent after four medication errors were identified in 37 observed medication administration opportunities, resulting in a 10.81% error rate. During a medication pass observation, a nurse prepared levothyroxine 25 mcg for a resident with hypothyroidism, and the resident’s record showed the order was for one tablet by mouth daily. The nurse stated the medication was scheduled for 9 a.m. and was to be given with food, while the DON stated levothyroxine should be given on an empty stomach 30 minutes to one hour before breakfast. The manufacturer’s labeling also stated levothyroxine should be administered as a single daily dose on an empty stomach, one-half to one hour before breakfast. During another medication pass, a nurse prepared calcium 600 mg with vitamin D 10 mcg for a resident whose order was for calcium 600 mg with vitamin D 5 mcg twice daily. The nurse later confirmed the vitamin D strength did not match the physician’s order. The same nurse administered timolol eye drops and then brimonidine eye drops to the resident’s right eye with only about 30 seconds between them, even though the eye drop labeling indicated to wait five minutes between drops. The resident refused brimonidine in the left eye. The DON stated staff were expected to wait five minutes between different eye drops and that supplements administered to residents should match the physician’s order.
Infection Prevention and Control Failures During Resident Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices during multiple observed resident care activities. During medication preparation, three nurses were observed with polished artificial nails of approximately one quarter inch in length, and one nurse was also observed with ungloved hands. The nurses stated they were responsible for medication administration and direct resident care. The Infection Preventionist, Director of Staff Development, and Director of Nursing stated that nursing staff were expected to keep nails natural and short, and the facility policy stated that artificial fingernails were strongly discouraged for staff with direct resident-care responsibilities and that fingernails must be kept clean, neatly trimmed, and well-groomed. Oxygen tubing was observed on the floor for three residents who had orders for continuous oxygen therapy. Resident 18 had diagnoses including chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and obstructive sleep apnea, and had an order for oxygen via nasal cannula. Resident 65 had chronic respiratory failure with hypercapnia and obstructive sleep apnea and also had an order for oxygen via nasal cannula. Resident 104 had acute and chronic respiratory failure and was receiving oxygen via nasal cannula when a portion of the tubing was observed on the floor. Nursing staff and the CNA confirmed the tubing was on the floor, and the Infection Preventionist stated that oxygen tubing should not touch the floor for infection control purposes. During wound care for Resident 106, who had diagnoses including osteomyelitis, cellulitis of the left lower limb, type 2 diabetes mellitus with diabetic neuropathy, and absence of left toes, a nurse used the same gloves to clean and dry two different wound sites without changing gloves between sites. The nurse confirmed this during interview and stated different gloves should be used for each wound site. Resident 106 also had a PICC line with a dressing that had dried blood underneath and was not intact at the right corner and left side. Staff confirmed the dressing was not intact, and the Infection Preventionist stated the dressing should be checked every shift and that any non-intact dressing increased the risk of infection. The facility also failed to ensure staff wore required PPE for residents on Enhanced Barrier Precaution. Resident 28, who had diagnoses including cerebral infarction, aphasia, and a gastrostomy tube, was observed receiving incontinence care from a CNA who entered the room without a gown and later confirmed she had forgotten to wear the required PPE. Resident 59, who had endocarditis and a PICC line, was observed being assisted to the bathroom and having bed linens handled by a CNA who did not wear a gown. The CNA confirmed gown use was required for this resident, and the Infection Preventionist stated staff were expected to wear gloves and gowns for residents on EBP, including during close contact care.
Failure to Preserve Resident Dignity During Feeding and Wound Care
Penalty
Summary
The facility failed to promote dignity and respect for two residents when CNA 5 remained standing while assisting and feeding one resident lunch. Resident 48 was admitted with diagnoses including MS and dysphagia, and the care plan stated that the resident required assistance to eat. During an observation in the dining room, the resident was seated in a wheelchair while CNA 5 stood over him and fed him with a spoon. The DSD stated that staff were expected to sit while assisting residents with eating to promote dignity, and the facility’s Dignity policy stated that residents are to be treated with dignity and respect at all times and provided with a dignified dining experience. The facility also failed to maintain privacy during wound treatment for another resident. Resident 106 was admitted with diagnoses including type 2 DM, diabetic neuropathy, and acquired absence of left toe(s), and had orders for treatment of a left shin trauma wound and a TMA site venous ulcer. During wound treatment in the resident’s room, the privacy curtain between Resident 106 and the roommate remained open throughout the procedure. The LN stated that privacy during wound treatment included closing the curtain between roommates and confirmed that the curtain was not closed. The facility’s Dignity policy stated that staff promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Use Communication Board for Resident with Limited Communication
Penalty
Summary
The facility failed to ensure communication needs were accommodated for Resident 28, who speaks mainly Hmong and has limited ability to communicate. Resident 28 was admitted in 2/2026 with diagnoses including cerebral infarction and hemiplegia. The MDS dated 5/27/26 indicated the resident was unable to complete the BIMs due to the stroke, and the staff assessment noted moderately impaired cognitive skills for daily decision making. The communication care plan revised 5/22/26 directed staff to use alternative communication tools such as a communication board, pictures, and signs. During an observation on 7/9/26, an LN was preparing to change the dressing around Resident 28's GT when the resident began crying, but the LN continued the dressing change without asking why the resident was crying. The LN did not use a communication board, and none was observed at the bedside. During a later observation and interview, another LN confirmed the communication board was not within reach and was tucked underneath the bedside drawer. The DON stated the communication board must always be within reach and should be treated like a call light. The facility policy on Resident's Rights states residents have the right to be treated with respect, kindness, and dignity and to communicate with and access people and services.
Failure to Provide ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with ADLs, including hygiene and nail care, for three sampled residents who were unable to complete these tasks independently. Resident 9 was admitted with sepsis, bacteremia, and generalized muscle weakness, had intact cognition, and required maximal assistance with showering, bed baths, and personal hygiene. The care plan did not include a person-centered focus for self-care deficit or ADLs, including nail care. During observation, Resident 9 was found in bed with long toenails, dry thickened heels, and dry scaly skin on both lower extremities, with flakes of dry skin on the bed. The resident stated she would agree to have her nails trimmed when staff had time, and an LN confirmed the toenails were long and the heels were cracked and dry. Resident 28 was admitted with cerebral infarction, hemiplegia, and aphasia, and the MDS indicated he could not complete the BIMs and had moderately impaired daily decision-making skills. He required dependent assistance with showering, bed baths, and personal hygiene, but his care plan did not include a person-centered focus for self-care deficit or ADLs, including nail care. During observation, Resident 28 was lying in bed with greasy hair and face, dried crusted nasal mucus in both nostrils, long fingernails with brown debris underneath, long toenails, dry thickened skin around the toenails, and thick dry cracked heels. CNA and LN staff both confirmed the condition of his nails and feet, and the resident nodded when asked if he wanted his nails trimmed. Resident 102 was admitted with nontraumatic intercerebral hemorrhage, hemiplegia and hemiparesis affecting the left dominant side, muscle weakness, and need for assistance with personal care. The MDS indicated intact cognition, and the care plan identified risk for self-care deficit with an intervention to provide assistance with ADLs. During observation, Resident 102 was lying in bed with long fingernails and a dark brown substance under the fingernails on the right hand. The resident stated the long nails bothered him because he could not use his phone and could not use his left arm due to the stroke. CNA staff confirmed the fingernails had brown substance underneath and needed to be trimmed, and the IP stated unclean fingernails could spread germs and were an infection control problem.
Unsecured oxygen cylinder and misplaced fall mat
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for two residents. In one instance, a portable oxygen cylinder in Resident 18’s room was observed positioned on the right side of the bed in front of the oxygen concentrator and was not secured in an oxygen stand or carrier. During interview, the DON stated that portable oxygen cylinders should be secured in an oxygen carrier to prevent them from falling and causing injury or accident. The facility policy titled Oxygen Safety stated that oxygen cylinders must be properly chained or supported in racks or other fastenings, such as sturdy portable carts or approved stands, to secure all cylinders from falling whether connected, unconnected, full, or empty. In another instance, Resident 91, who was admitted with vascular dementia, Alzheimer’s disease, and age-related osteoporosis without current pathological fracture, had a care plan identifying a fall risk and a progress note listing safety interventions including half side rails, a low bed, and a bedside fall mat. During observation, the resident was lying in bed and the floormat was located underneath the bed rather than beside it. The CNA confirmed the mat was under the bed and stated it should have been placed beside the bed as part of the resident’s fall precaution. The facility’s policy on Fall and Fall Risk, Managing, stated that staff would implement a resident-centered fall prevention plan and listed fall mats among example approaches.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident with chronic pain syndrome and pain in the thoracic spine who was receiving multiple daily wound treatments for a stage 3 pressure injury to the right lower buttock and deep tissue injuries to both heels. The resident’s orders included morphine 15 mg every 8 hours for pain, acetaminophen 650 mg every 6 hours as needed for mild pain, and documentation of the highest pain level every shift. During wound care, the resident was observed moaning, yelling, and stating that it hurt, while staff were providing treatment inside the room. On one observation, the resident was heard crying out in pain while the wound doctor and an LN were providing treatment. An LN stated the resident was always complaining of pain and acknowledged that pain medication was important to keep the resident comfortable during wound treatment. Review of the MARs showed 21 episodes of pain greater than 2 in June 2026 and 5 episodes in July 2026, with 21 and 5 missed opportunities, respectively, to administer acetaminophen. The record contained no documented evidence that acetaminophen was offered, refused, or given. On another observation, the resident was continuously grimacing, groaning, moaning, and yelling during ADL care and wound treatment. The LN did not initially ask the resident to rate pain, and when prompted, the resident stated pain was 10/10. Staff continued wound treatment without administering pain medication before care, and oxycodone was later given after the treatment had already occurred. The DON stated the expectation was to pre-medicate residents before care and to use a pain scale assessment. The facility’s pain management, wound care, and resident rights policies also addressed anticipating pain, administering pain medication as needed, and treating residents with dignity.
Unlabeled and Undated Resident Food in Refrigerator
Penalty
Summary
The facility failed to store resident food in a sanitary manner in the resident refrigerator for a census of 104 when an 8 oz. package of cheese and two plastic bags with take-out food were found without residents' names and without dates. During a concurrent observation and interview in the memory care unit, the Director of Staff Development observed the opened package of cheese and the two bags of take-out food in the resident refrigerator and confirmed she could not tell who the items belonged to and that they should be dated. She also stated that takeout food should be thrown out after seventy-two hours. During interview, the Registered Dietician stated that food in a resident's refrigerator should be dated because, if it is not dated, staff cannot determine how long it has been there or when it should be discarded. Review of the policy titled, Foods Brought by Family or Visitor, indicated that resident food will be stored at the facility, all foods shall be labeled with the resident's name, location and date, and perishable food will be checked by activities staff and discarded after 72 hours.
Delayed Administration of Ordered Antifungal Medication
Penalty
Summary
The facility failed to meet professional standards of care when Resident 1 did not receive the physician-ordered itraconazole oral solution in a timely manner. Resident 1 was admitted in June 2026 with diagnoses including encephalitis, encephalomyelitis, and hepatic encephalopathy, and the physician determined the resident did not have the mental capacity to make healthcare decisions. The order summary showed itraconazole oral solution 10 mg/mL, 30 mL via G-tube every 12 hours for systemic fungal infection, and the after visit summary identified itraconazole as the resident’s most important medication. The medication administration record showed the itraconazole was not administered on 6/17 at 9:00 p.m. or on 6/18 at 9:00 a.m. and 9:00 p.m. Progress notes documented that the medication had not been received from the pharmacy, that the nurse called the pharmacy and was told the medication had arrived at the facility at 6:04 p.m., and that the nurse could not find it in the med carts. The resident was transferred to the hospital emergency room on 6/19/26 at 12:22 a.m. for the reason that anti-fungal medication was needed. During interview, LN 1 confirmed the missed doses, and the DON stated there had been a delay in the medication and it was not administered on time.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from abuse when staff witnessed one resident hit another resident in the back with a closed hand. The incident was documented in a progress note describing an altercation between the two residents. The resident who was hit confirmed during interview that another resident struck him in the back and stated that he felt angry about being hit. The resident who struck the other resident had diagnoses including dementia, anxiety, and psychosis, and had a BIMS score of 0 out of 15, indicating severely impaired cognition. The resident who was hit also had diagnoses including dementia, anxiety, bipolar disorder, Alzheimer’s disease, and Parkinson’s disease, and had a BIMS score of 0 out of 15, indicating severely impaired cognition. The RNA stated she witnessed the resident hit the other resident on the back with a closed hand, and the DON stated the expectation is to keep residents safe and that the facility has a duty to keep the resident safe.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to ensure the results of an abuse allegation investigation were reported to the state agency within the required five working days. Resident 1, who had diagnoses including a right shoulder fracture and end-stage renal failure, was involved in an altercation documented in an SBAR note dated 4/13/26, which stated that the resident and her roommate were in the lobby, began cussing at each other while the roommate was preparing to leave for dialysis, and that when Resident 1 was on the gurney leaving, the roommate punched Resident 1 on the body. The Administrator confirmed that the initial SOC 341 report was sent on 4/13/26, but the 5-day summary of the abuse allegation investigation was not sent to CDPH until 4/21/26. This reporting timeframe did not comply with the facility’s policy titled “Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment,” which requires that results of all investigations of alleged violations be reported within five working days of the incident. The deficiency centers on the delay between the incident date and the submission of the 5-day investigation summary, as verified through interview with the Administrator and review of the email to CDPH, demonstrating that the facility did not adhere to its own policy and the expected reporting timeframe for abuse investigation results.
Failure to Timely Report Abuse Investigation Results and Assess Resident After Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of abuse investigation results to the California Department of Public Health (CDPH) and failed to complete a required nursing assessment following an abuse allegation. One resident, admitted in September 2025 with multiple diagnoses including surgical aftercare, and another resident, admitted in December 2024 with multiple diagnoses including respiratory failure, each reported physical abuse by a CNA. Incident reports for these allegations were submitted to CDPH on 1/26/26 and 1/28/26. However, the facility’s 5‑day investigation results for both incidents were not submitted to CDPH until 2/10/26, which exceeded the required five working days. The Administrator confirmed that the results of the investigations were not provided within the regulatory timeframe, despite facility policy stating that allegations of abuse will be reported to state or federal agencies within applicable regulatory timeframes. The facility also failed to perform and document a nursing assessment for the resident with respiratory failure after the abuse allegation on 1/28/26. Review of this resident’s medical record showed no documentation that a nurse assessed the resident following the reported abuse. In an interview, the DON confirmed that an assessment was not completed after the allegation and stated that the expectation was for an assessment to be done. The facility’s abuse prevention policy specified that a licensed nurse will immediately examine a resident upon receiving reports of alleged physical abuse and that the findings of the examination shall be recorded in the resident’s medical record, which did not occur in this case.
Failure to Timely Report Resident’s Allegation of Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported within the required timeframe after a cognitively intact resident reported being injured by staff during care. The resident, admitted with chronic kidney disease, schizophrenia, and bipolar disorder, was observed by a charge nurse late in the evening with purple and yellow discoloration on the right cheek. When questioned, the resident stated that a CNA assigned to her had hit her in the face and pulled her hair after she touched the CNA without notice, though she could not recall the exact date, time, or identity of the staff member involved. The resident later described that the CNA thought she was acting out in aggression, grabbed her hands, hit her in the face, and pulled her hair, which made her feel scared and hurt. Investigation documents showed that another CNA (CNA 2) became aware of the resident’s allegation the day before the charge nurse noted the bruising, when the resident asked if she saw the bruise and reported that a CNA had hit her and pulled her hair in the middle of the night. CNA 2 did not report this allegation at that time, stating she did not know what to do with the information and did not believe the resident because of things the resident says, and instead waited until the next day to ask the resident again, who repeated the same story. The facility’s abuse policy required staff with knowledge of an actual or potential violation to report it to a supervisor or the administrator immediately, and stated that all allegations of abuse, neglect, misappropriation, or exploitation should be reported immediately to the administrator. The Executive Director confirmed this was a reportable incident and that his expectation was that staff report such allegations to the charge nurse within the required timeframe.
Improper Storage of Clean Dishes
Penalty
Summary
The facility failed to store clean dishes in a sanitary manner for a census of 109 residents. During a kitchen observation with the Dietary Manager, a dirty cup containing half-eaten food was found on a shelf with clean dishes used by residents. The Dietary Manager confirmed the cup was not supposed to be left in the clean dish storage area and stated that cross contamination could have been an issue as well as pest control. During another kitchen observation, a hot water jug stored with clean dishes was found with dark brown residue in its crevices. The Dietary Manager confirmed the jug should not have been stored with the clean dishes and stated he did not know what the residue was, adding that crevices such as where the residue was seen could have had the potential to harbor bacteria. Resident 1, admitted in June 2023, had an MDS dated 2/26/25 showing a BIMS score of 15 out of 15 with intact cognition, and later stated her breakfast fork had a dried crusty residue on it.
Therapeutic Diet Not Followed for Easy-to-Chew Meal
Penalty
Summary
The facility failed to follow Resident 2’s therapeutic diet plan when the resident was served a hard-to-chew chicken burger at lunch. Resident 2 was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, and adult failure to thrive, and the MDS dated 7/23/25 showed intact cognition with a Brief Interview of Mental Status score of 15 out of 15. During the lunch tray observation, Resident 2’s tray included a burger bun with a large breaded piece of chicken, tomato slice, lettuce, macaroni salad, juice, and pudding. During interview, Resident 2 stated she did not eat the lunch because she could not chew it and reported that her upper teeth were broken, making it hard to eat the chicken burger. Resident 2 also stated the chicken was not tender enough to bite and was hard and chewy. The therapeutic diet plan dated 9/3/25 directed that Resident 2 receive a regular diet easy to chew level 7 texture, and the care plan dated 9/23/25 identified swallowing problems and nutritional risk related to underweight, protein calorie malnutrition, dysphagia, and adult failure to thrive. The facility’s policy for Level 7 Regular Easy to Chew for Adults stated not to use hard, tough, chewy, or fibrous foods and indicated meat should be cooked until tender or served minced and moist if it cannot be served soft and tender.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in food service, as evidenced by observations of unclean utensils and improper hand hygiene practices among dietary staff. During an inspection, multiple small black particles were found on utensil holders, and several forks and spoons had visible food particles and water residuals. Both the Dietary Manager and Registered Dietician confirmed that these utensils were not properly cleaned and acknowledged that utensils used for residents should be free of food particles. The facility's policy requires all dishes to be properly sanitized and gross food particles to be removed before washing, which was not followed in this instance. Additionally, a Dietary Aide was observed manually washing kitchenware and then handling clean kitchen containers without performing hand hygiene in between tasks. The aide confirmed that he did not wash his hands before touching the clean side of the dishwashing area, despite being the only person assigned to dishwashing at the time. The Registered Dietician stated that two people should be involved in dishwashing to prevent cross-contamination and that handwashing is required before handling clean items. The facility's policy also specifies the need to wash hands and change gloves to prevent cross-contamination, which was not adhered to during the observed events.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Ensure Safe and Appropriate Discharge for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge for a resident with severe cognitive impairment and a history of brain tumor and craniotomy. The facility did not follow physician discharge orders, as the resident was discharged to a hotel without home health services being established, despite orders for home health RN, PT, and OT. The required 30-day discharge notice was not provided in advance but was instead given at the time of discharge, depriving the resident of the opportunity to appeal. Additionally, the facility did not develop or document post-discharge follow-up for a neurology referral, and there was no physician discharge summary in the resident's medical record. Further review revealed that the MDS discharge assessment was incomplete and not submitted, and cognition and mood assessments were not performed. The resident, who had documented severe cognitive deficits and required maximum cues for memory and following directions, was found confused and non-verbal after discharge, leading to hospitalization. Facility staff, including the Social Services Director, MDS Coordinator, DON, and Administrator, confirmed these deficiencies and acknowledged that the discharge was not conducted safely or in accordance with facility policy and federal requirements.
Failure to Assess and Intervene After Resident Elopement
Penalty
Summary
A resident with a history of severe cognitive impairment, including a brain tumor, cognitive communication deficit, and memory impairment, was admitted to the facility. The resident's records indicated difficulty following directions and a need for maximum cues. Despite these documented cognitive deficits and a known tendency to wander, the resident was able to exit the building without staff authorization and was later found at a liquor store by facility staff. Review of the resident's medical records revealed there was no documented evidence of an elopement care plan, elopement risk assessment, or change of condition assessment following the incident. Interviews with facility staff, including a licensed nurse, the Social Services Director, and the Administrator, confirmed that the facility did not assess or implement interventions for the resident's elopement risk as required by facility policy. Additionally, there was no documentation of the incident or follow-up actions in the resident's record, contrary to the facility's elopement and missing resident policy.
Failure to Accommodate Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to accommodate the documented food preferences of three residents during a lunch meal service. One resident, with a history of anemia and vitamin D deficiency, did not receive the double portion of protein as specified on her meal ticket and confirmed this during an interview. The Dietary Manager also verified that the lunch tray did not include the required double protein portion. Another resident, also diagnosed with anemia, had a preference for a green vegetable with every meal, specifically requesting a green salad, but did not receive any salad with her lunch. This was confirmed by both the resident and the Dietary Manager upon review of the meal tray. A third resident, with a diagnosis of vitamin D deficiency, had a preference for fresh fruit for dessert, as indicated on her meal ticket. During observation and interview, it was noted that no fresh fruit was provided on her lunch tray, and the resident expressed concern about its absence. The Registered Dietician confirmed that the fresh fruit was not included and acknowledged that residents' food preferences should have been honored according to their choices. The facility's policy requires staff to determine and provide for residents' food preferences at meals, but this was not followed for these three residents.
Plan Of Correction
This plan of correction constitutes the facility's written credible allegation of compliance. Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusion set forth on the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because required by the provisions of the health and safety code section 1280 and 42 CFR 483. Immediate corrective action(s) for those Residents affected by the deficient practice: Dietary Manager (DM) and Resident 1 communicated to clarify this resident's preference as it was stated small portions and double protein. Residents requested to maintain small portions and remove double protein. Dietary Manager updated resident's preferences. Registered Dietitian (RD) clarified with Resident 2 that she wants green vegetables with lunch and a spinach salad during dinner, no green vegetable with breakfast. Resident's meal ticket updated with these preferences. In addition to a preference on her meal ticket, RD added Resident's request to the standing daily meal request list to ensure our staff prepare and serve this each meal. RD clarified with Resident 3 who confirmed she wants fresh fruit with all meals, and this Resident's meal ticket updated reflecting this. Plan / Process to identify other residents potentially affected by the same deficient practice and corrective action(s) to be taken; All residents have the potential to be negatively affected if Resident's preferences aren't followed. Facility measures and systemic changes to ensure the deficient practice does not recur; Systemic changes to address the deficient practice include, but are not limited to auditing all current residents' preferences regarding double protein, green vegetables with every meal, and fresh fruit for dessert. RD to clarify that double protein requests are nutritionally appropriate. Dietary Manager will create a list of residents who request green vegetables with every meal and fresh fruit for dessert and assign a Dietary Aide to prepare an adequate number of items prior to meal service. Each of the following team members will audit 2 meal services per week by pulling 4 random trays prior to each meal cart exiting the kitchen. The attached audit form will be utilized for this audit.
Failure to Store and Monitor Food Safely
Penalty
Summary
The facility failed to store food in a sanitary manner for its residents. On the day of the survey, two boxes containing 48 cups each of yogurt were observed left on the kitchen floor at room temperature for over three hours after delivery. The Dietary Manager confirmed that the yogurt, along with other refrigerated items such as milk and eggs, should have been placed in the refrigerator immediately upon arrival but were not. Both the Dietary Manager and the Registered Dietician acknowledged that the yogurt should have been discarded due to the risk of foodborne illness. Facility policy requires that potentially hazardous foods be put away quickly to minimize contamination and bacterial growth. Additionally, the facility did not monitor and document the temperature of a freezer during an evening shift, as required by their policy. The Dietary Manager confirmed that the freezer temperature log was missing an entry for the specified shift, and stated that accurate documentation is necessary to ensure food is held at safe temperatures. The facility's policy mandates that cooler and freezer temperatures be checked and recorded daily using internal thermometers.
Plan Of Correction
Facility plan to monitor corrective actions & sustain compliance; Integrate QA Process; RD will compile data from these audits and present to monthly QAPI meetings for 3 months to ensure substantial compliance. F0812 - Immediate corrective action(s) for those residents affected by the deficient practice; Dietary staff threw the yogurt out that wasn't properly stored within two hours of delivery. Plan / Process to identify other residents potentially affected by the same deficient practice and corrective action(s) to be taken; All residents have the potential to be affected if time sensitive foods aren't properly stored after delivery within 2 hours. Facility measures and systemic changes to ensure the deficient practice does not recur; Dietary Manager (DM) completed an in-service focusing on the urgency of prioritizing time sensitive foods on 7/29/25 for dietary staff that manage food delivery. In-service conducted on 8/7/25 covering proper procedure for logging fridge and freezer temperatures. The DM or designee will audit to ensure that all time sensitive items have been properly stored one hour after food delivery (Tuesdays and Fridays). If any item is found to still be out, DM or designee will assist Dietary Aide to ensure time sensitive items are stored properly within 2 hours of delivery. Freezer temperature logs will be audited daily by the DM and Assistant Dietary Manager daily. Facility plan to monitor corrective actions & sustain compliance; Integrate QA Process; Audit results will be presented at monthly meetings for a minimum of three months to the QAPI committee to ensure compliance.
Resident-to-Resident Physical Abuse Resulting in Pain and Emotional Distress
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and no memory impairment was physically abused by another resident with severe memory impairment and a diagnosis of bipolar disorder. Staff, including a CNA, witnessed the second resident striking the first resident multiple times on the hand and face. The incident resulted in the first resident experiencing physical pain, redness on the face, and emotional distress, as documented in progress notes and interviews. The affected resident was observed to be tearful, upset, and uncomfortable following the altercation. The facility's own policy states that each resident has the right to be free from abuse, including physical abuse such as hitting. Multiple staff members, including the CNA, Social Services Director, and DON, acknowledged that the first resident was a victim of physical abuse by another resident. The incident was documented in the SBAR form and progress notes, and the emotional impact on the resident was significant enough to warrant a referral to psychiatry.
Resident Meal Tickets with PHI Left Unattended in Memory Unit
Penalty
Summary
Sixteen resident meal tickets containing sensitive information, including residents' names, allergies, and therapeutic diets, were left unattended on a table in the facility's memory unit dining area. This was observed during a visit with the Registered Dietician, who acknowledged that the meal tickets should not have been left out and should have been taken to the shredder, identifying the situation as a HIPAA violation. The Director of Nursing also confirmed that leaving meal tickets unattended constitutes a HIPAA violation and that such documents need to be shredded. Review of the facility's policy indicated that employees are required to safeguard protected health information (PHI) and ensure proper disposal to prevent unauthorized access.
Failure to Adhere to Medication Administration and Feeding Protocols
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted professional standards of clinical practice in several key areas. Licensed nurses did not administer medications in a timely manner to multiple residents, with medication administration times significantly delayed beyond the facility's policy of one hour before or after the scheduled time. For example, medications scheduled for early morning were not given until late morning or early afternoon for several residents with complex medical conditions, including Parkinson's disease, diabetes, heart failure, stroke, and hypertension. These delays were confirmed through review of medication administration records and direct interviews with staff, who acknowledged the late administration. Additionally, licensed nurses did not follow proper procedures for verifying resident identity or explaining medications prior to administration. Observations showed that nurses prepared and administered medications to several residents without checking identification or informing them about the medications being given. When questioned, the nurses admitted to omitting these steps. Facility policy requires verification of resident identity and explanation of medications, but these procedures were not followed during the observed medication passes. The facility also failed to follow physician orders for continuous gastrostomy feeding for a resident dependent on tube feeding. Observations revealed that the resident's feeding pump was repeatedly beeping with a hold error, and the feeding formula volume remained unchanged over several hours, indicating that the prescribed nutrition was not being delivered. The nurse responsible confirmed that the pump should have been running continuously, and the DON stated that staff are expected to monitor and respond to feeding pump alarms. The facility's policy requires medications and treatments to be administered in accordance with prescriber orders, but this was not done in this case.
Failure to Implement EHR Downtime Contingency Plan and Staff Training
Penalty
Summary
The facility failed to implement its facility assessment and ensure staff adherence to the established contingency plan during an electronic health record (EHR) system downtime. When the EHR became inaccessible due to an internet outage, nursing staff were not provided with timely direction and were unaware of the procedures to follow. The Director of Nursing (DON) stated that nurses were expected to print medication administration records (MARs) from a backup computer, but the backup computer was also not functioning, requiring staff to use a different computer. Multiple licensed nurses reported that upon arrival, they were informed of the system outage by the night nurse, but had not received any guidance from management and were not aware of the contingency plan for EHR outages. There was no prior notification from management regarding the outage, and staff were left waiting for instructions. Interviews with the DON and Administrator (ADM) confirmed that no mock drills had been conducted for an EHR outage, despite facility policies indicating that such drills should be performed. Review of the facility's assessment and policies showed that procedures and drills for EHR outages were outlined, but these were not followed or communicated to staff during the incident. As a result, there were delays in medication administration, with the potential to affect the health and safety of the facility's 104 residents.
Failure to Maintain and Document QAPI Program Activities
Penalty
Summary
The facility failed to ensure an effective and comprehensive Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) program was performed for a census of 104 residents. During interviews, multiple staff members, including the Director of Staff Development, Social Services Director, Infection Preventionist, and Minimum Data Set Manager, were either unaware of or unable to provide documentation for the previous three quarterly QAPI meetings. The Administrator confirmed that there were no records of QAPI meetings for the last three quarters and acknowledged that QAPI meetings had not been conducted prior to their arrival. The facility's policy requires maintaining documentation and evidence of ongoing QAPI activities, but this was not followed. Record review and staff interviews revealed that the facility did not maintain documentation or present evidence of QAPI meetings as required. The lack of documentation and awareness among staff indicated that QAPI activities were not being consistently performed or tracked. The Minimum Data Set Manager noted ongoing issues with resident rehospitalization rates, suggesting that performance improvement activities were not being effectively evaluated or revised. The absence of QAPI meeting records and lack of staff knowledge about the process contributed directly to the deficiency.
Infection Control Lapses in Device Management, EBP Implementation, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. One deficiency involved a resident's CPAP mask, which was not stored in a microbial bag as required by facility policy. Instead, the mask was left on top of the CPAP machine, exposing it to potential contamination. The Director of Nursing and Infection Preventionist confirmed that the mask should have been stored in a microbial bag to prevent infection, as per standard practice. Another deficiency was observed regarding the lack of Enhanced Barrier Precautions (EBP) for several residents with invasive medical devices or wounds. Residents with urinary catheters, gastrostomy tubes, suprapubic catheters, and pressure ulcers did not have EBP signage posted, nor was personal protective equipment (PPE) available inside or outside their rooms. Medical records for these residents did not document EBP implementation, despite facility policy requiring EBP for residents with such conditions. The Infection Preventionist confirmed that EBP, including gown and glove use during high-contact care, should have been in place for these residents. Additional deficiencies included the failure to label and date medical equipment such as oxygen tubing, feeding tubes, and IV bags and tubing for several residents. Staff were observed not performing hand hygiene between resident contacts in the dining room and during medication administration. Both a CNA and a licensed nurse admitted to forgetting to perform hand hygiene, which was confirmed as a requirement by the facility's policies. These lapses in infection control practices were directly observed and verified by staff interviews.
Failure to Serve Meals Timely According to Resident Needs and Preferences
Penalty
Summary
The facility failed to serve meals and snacks at times consistent with resident needs, preferences, and requests, as well as with community norms, for five sampled residents. Multiple residents reported that meals were consistently late, with some waiting up to 1 to 2 hours for their food. Observations confirmed that meal trays were not served at the scheduled times, and staff interviews acknowledged the delays. The posted dining schedule did not indicate specific meal times, and on several occasions, meal trays had not arrived or been served at the expected times. Residents expressed dissatisfaction, noting that meals were sometimes cold and that the lack of a consistent schedule made it difficult to plan their day. The affected residents had various medical conditions, including type 2 diabetes with hypoglycemia, hypomagnesia, hypokalemia, acute kidney failure, myopathy, paraplegia, anemia, and hyperlipidemia. Some residents had impaired cognition, while others were cognitively intact. Staff, including a registered dietician, CNA, dietary consultant, and the DON, confirmed awareness of the late meal service and acknowledged that it could impact medication administration and resident satisfaction. Review of facility policy indicated that meals should be served according to routine schedules and resident preferences, but these procedures were not followed.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure food service staff adhered to current standards of practice for food safety in several key areas. Surveyors observed that staff did not consistently label, date, or monitor refrigerated and frozen foods, with expired items and items lacking expiration dates found in multiple refrigerators and freezers. Additionally, temperature logs for all refrigerators and freezers were incomplete, with missing entries for several days. The Dietary Manager confirmed these findings and acknowledged that expired food should be discarded and that failure to do so could result in residents becoming ill. In the dry storage area, surveyors observed the presence of fruit flies and flies, as well as improperly stored food items such as an uncovered container of sugar, unsealed boxes of instant hot cereal mix, and bags of oats and cereal with ripped openings. The Registered Dietician confirmed that these conditions could lead to food contamination and stated that expired food should be thrown out and food should be stored in sealed containers. Both the DM and RD confirmed the missing temperature log entries and agreed that temperatures should be checked and logged regularly. Additionally, staff failed to adhere to standards of practice regarding personal hygiene, as a dietary aide was observed assembling resident trays without wearing a beard net, with facial hair protruding from a face mask and later exposed while calling out tray orders over uncovered food. The RD confirmed that beard nets are required and that the facility had run out of them. Review of facility policy and the FDA Food Code indicated that all perishable food items must be properly stored, labeled, and dated, and that staff must wear appropriate hair restraints to prevent contamination.
Failure to Maintain Kitchen Equipment in Safe and Sanitary Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe and sanitary operating condition. Observations revealed a brownish frozen residue on the bottom shelf of a freezer, which was confirmed by the Dietary Manager, who stated that there should not be any residue or crumbs present. Additionally, two ovens were found with brownish-black residue, and all four stove burners had food and black burnt residue. Three of the burners were in use at the time, with a pot containing a clear golden liquid with sediment. The Registered Dietician confirmed these findings and noted that the boilerless steamer was leaking clear liquid onto the floor, pooling at the base of a metal panel, and described the equipment as unstable and in disrepair, an issue that had been ongoing for weeks. The Maintenance Assistant confirmed the drainage and leaking from the boilerless steamer, stating that it was broken and not fixed. The Dietary Manager reiterated that the expectation is for equipment to be in clean working order and not leaking. Review of facility policies indicated that equipment should be cleaned and sanitized regularly to prevent foodborne illness, with specific cleaning schedules for freezers and stoves, and that maintenance tasks should ensure all equipment is safe and functional. These observations and staff interviews demonstrate a failure to adhere to the facility's own sanitation and maintenance policies.
Failure to Provide Communication Boards for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide communication boards at the bedside for three residents who did not speak English, despite care plans indicating the need for such aids due to language barriers. Resident 19, whose primary language was Russian and who had chronic kidney disease and hemiplegia, was observed without a communication board in the room. Resident 24, with congestive heart failure and a primary language of Cantonese, also did not have a communication board available. Resident 58, diagnosed with Alzheimer's disease and dementia and whose primary language was Mandarin, had only an English-language poster in the room, with no communication board in Mandarin present. Interviews with staff confirmed that communication boards in the residents' primary languages should have been available in their rooms. The facility's policies emphasized the importance of dignity, respect, and non-discrimination, including the provision of free language services and information in other languages. However, during observations and interviews, it was evident that these communication supports were not in place for the identified residents, contrary to both care plan interventions and facility policy.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a homelike environment as evidenced by unclean and worn conditions in resident areas. In one instance, a resident with myopathy and paraplegia, who was cognitively intact, reported that the shower rooms were dirty and unsanitary, specifically noting the presence of mold and dirt in the grout. Direct observation confirmed a dark brown substance on the floor of a shower room, which was acknowledged by a licensed nurse, who stated that staff should have notified housekeeping. The Infection Preventionist confirmed that shower rooms should always be clean to prevent infection and support residents' psychosocial wellbeing. Additionally, four rooms in the memory care unit were found to have curtains by the sliding doors that were worn and had visible brown discolorations. The Director of Staff Development described the curtains as dirty, old, and stained, and the Director of Nursing stated that curtains should be clean and intact to maintain a homelike environment. Review of facility policy indicated that stained or worn linens should be removed upon discovery and that areas needing cleaning should be reported to housekeeping, but these practices were not followed.
Failure to Provide Timely Turning and Repositioning for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when staff failed to implement regular and timely turning and repositioning for a resident who was dependent on assistance for bed mobility and at risk for pressure ulcers. The resident, admitted with multiple diagnoses including hematoma of the skin, chronic kidney disease, muscle weakness, and limited mobility, was assessed as being at risk for skin breakdown and unable to turn or reposition independently. The care plan identified the need for assistance with activities of daily living and bed mobility, but did not include specific interventions for turning and repositioning every two hours. Multiple observations and interviews revealed that the resident remained in the same position for extended periods and was not aware of the need for regular repositioning. Staff interviews confirmed that the resident had not been turned as required, despite facility policy and professional standards indicating the necessity of such care for immobile residents. The lack of consistent implementation of pressure injury prevention measures placed the resident at risk for skin breakdown.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to address and monitor significant weight loss for one resident. The resident, who had multiple diagnoses including metabolic encephalopathy, Alzheimer's disease, dementia, hypothyroidism, hyperosmolality, hypernatremia, and dysphagia, was dependent on staff for feeding. Upon admission, the resident's usual body weight was around 125 lbs, and care plans were in place to monitor for malnutrition and significant weight changes, including weekly weight checks for the first month and notification of the physician if significant changes occurred. However, a weight entry was missing for the week following admission, and the resident experienced a 13.5% weight loss over a week and a half, dropping from 124 lbs to 107.2 lbs, which was not promptly identified or addressed. Further review revealed that the resident continued to lose weight, reaching 102.6 lbs, and was not included in the most recent weekly weight meeting. The facility's policies required weekly weight monitoring for new admissions and for residents with significant unplanned weight loss, but these procedures were not followed. The registered dietician confirmed the lack of timely monitoring and intervention, which resulted in continued weight loss for the resident.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to pain assessment and timely administration of pain medication. One resident, admitted with multiple fractures and osteoarthritis, had a care plan indicating the need for pain medication before therapy and as needed for pain. Despite this, the resident reported severe pain in the morning, rated as 10 out of 10, and stated that they had been requesting pain medication since waking. The resident was observed in discomfort and unable to participate in therapy exercises due to pain. The nurse confirmed that the resident had not been assessed or given pain medication, and the occupational therapist had not communicated the resident's pain to nursing staff. Another resident with chronic pain conditions, including intervertebral disc degeneration, rheumatoid arthritis, and osteoarthritis, was observed in visible distress, moaning and expressing pain. The resident's scheduled pain medications, including opioids and other analgesics, were not administered at the prescribed times. Staff interviews revealed that the nurse had not been able to administer any scheduled morning medications, and the resident continued to experience pain for an extended period. The delay in medication administration was confirmed by both the resident's family and staff, and the facility's medication administration audit showed that medications were given significantly later than scheduled. Both cases demonstrated a lack of timely pain assessment and intervention consistent with the residents' care plans and professional standards of practice. The facility's own policies required pain management and medication administration within specific timeframes, but these were not followed, resulting in unmanaged pain and discomfort for the affected residents.
Failure to Maintain Controlled Substance Accountability and Documentation
Penalty
Summary
The facility failed to maintain proper pharmacy services for 11 residents by not documenting destruction logs for discontinued controlled medications and not reconciling controlled drug records when original narcotic sheets went missing. During an observation and record review, it was found that 11 controlled medications stored in the DON's office lacked destruction logs, and the medications were not scanned or recorded into the pharmacy website upon receipt from the nurses. The DON confirmed these omissions and acknowledged that the controlled drugs in the locked cabinet were not properly accounted for at the time of transfer from nursing staff. Additionally, the original controlled drug sheets for medication cart A2 went missing and were replaced with photocopied handwritten narcotic sheets. When the original sheets were later found, no reconciliation was performed to check for discrepancies. The DON verified that the reconciliation process was not completed, and the facility's consultant pharmacist confirmed that both a destruction log and reconciliation between two nurses were required by facility policy. The facility's policy also stated that all controlled substances must be fully accounted for and any discrepancies resolved by the end of the shift.
Deficient Medication Storage, Labeling, and Accountability Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management and storage practices. In the medication room, expired tube feeding formulas and unlabeled medical supplies, such as anti-embolic stockings, suction catheter trays, and tracheostomy care kits, were found. These items lacked use-by dates or were past their expiration, and the DON confirmed that such items should have been disposed of according to facility policy. The facility's policy requires routine checks and removal of expired or opened items, which was not followed. Further observations in medication carts revealed additional deficiencies. In medication cart A1, non-narcotic medications were stored in the narcotic cabinet, expired and unsealed medications were present, and medications belonging to discharged residents were not removed. Some medications, such as Doxycycline and Famotidine, were found in cups without resident labels or original packaging. Treatment supplies were also stored in the medication cart instead of the designated treatment cart. The pharmacy consultant and DON confirmed these practices were not in line with facility policy and could lead to medication errors. In medication cart A2, opened over-the-counter medications lacked open and discard dates, and the narcotic count sheet was missing required signatures from both incoming and outgoing licensed nurses. Facility policy mandates that all opened medications be labeled with the date opened and that narcotic count sheets be signed by both shifts to ensure accountability. These lapses in documentation and storage practices were confirmed by interviews with nursing staff and the DON.
Failure to Administer Insulin as Prescribed and Inadequate Documentation
Penalty
Summary
The facility failed to administer insulin as prescribed for one resident with diabetes and a recent surgical amputation. The resident had a physician's order for Novolin Insulin 90 units subcutaneously twice daily. Review of the Medication Administration Record (MAR) for March showed that on two occasions, the initial boxes for insulin administration were left blank with no documentation explaining the omission. Additionally, on two other occasions, the licensed nurse documented codes indicating the insulin was not given due to blood sugar being outside parameters or being held, but there was no physician's order allowing the insulin to be withheld for any parameters. The Director of Nursing (DON) confirmed these findings during interviews and record reviews, acknowledging the lack of documentation and absence of physician orders to hold the insulin. The facility's policy required staff to follow the MAR and document medication administration according to regulations, which was not done in these instances. The failure to administer insulin as ordered and to properly document or obtain appropriate physician orders for withholding medication constituted a deficiency in pharmaceutical services.
Sanitary Practices Lapse in Kitchen
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, which could potentially lead to foodborne illness. During an observation, the freezer temperatures were found to be out of the acceptable range, with one freezer at the entrance of the kitchen observed at 10 degrees Fahrenheit and another next to the dishwashing area at 38 degrees Fahrenheit. The Registered Dietician (RD) confirmed these temperatures were out of range and should have been reported to environmental services immediately. The facility's policy indicated that freezer temperatures should be maintained at 0 degrees Fahrenheit or below. Additionally, the Registered Dietician Consultant (RDC) noted that the freezer door was left open, contributing to the temperature issue, and reported that two freezers and two refrigerators needed replacement. Unsafe infection control practices were also observed in the kitchen. The cleaning schedule was incomplete, with only three signatures and blank sheets, and the RD could not provide documentation of staff sanitizing kitchen areas. A sanitizer bucket and log were observed, but it was unclear if the sanitizer was replaced throughout the day as required. Mold was found near the kitchen exit door, confirmed by the Environmental Services Director and Manager, who stated it was not sanitary for a food preparation area. The Infection Preventionist noted issues with freezer temperature checks and other infection control practices during audits. The Executive Director stated that the dietary supervisor manages kitchen cleaning and staffing, but no documentation was provided to confirm daily cleaning activities.
Deficiency in Medication Availability for Resident
Penalty
Summary
The facility failed to ensure the availability of routine medications for a resident, leading to a deficiency in pharmaceutical services. The resident, admitted in November 2024 with conditions including anemia, depression, and diabetes, had a prescribed order for Vitamin D3 1000 IU to be administered daily. However, the facility did not have the Vitamin D3 tablets in the required dosage in stock. This lack of availability was confirmed during an interview with a licensed nurse, who indicated that due to the absence of the correct dosage, she resorted to cutting unscored 2000 IU tablets to meet the resident's medication order. Further investigation revealed that a refill request for the Vitamin D3 1000 IU was placed, but the medication was still not available at the time of the survey. The Director of Nursing expressed an expectation that over-the-counter medications should be stocked adequately. A review of the facility's policy indicated that unscored tablets should not be split, highlighting a deviation from the established medication administration procedures. This deficiency had the potential to impact the resident's therapeutic needs or exacerbate their medical conditions.
Improper Food Thawing and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as observed during a survey. Two packages of frozen salmon filets and two packages of frozen cod filets were found thawing on a kitchen table countertop, which is not in accordance with the facility's policy and procedure for safe food handling. The policy specifies that frozen foods should be thawed during the cooking process, under refrigeration, or by immersion under running potable water at a temperature of 70 degrees Fahrenheit or lower. This improper thawing method was confirmed by the Dietary Supervisor during an observation and interview. Additionally, the facility did not comply with its policy on labeling and dating food items. Nine opened bottles of dry spices, one opened bottle of beef base, and one bag of opened pink lemonade powder were found unlabeled. The Registered Dietitian indicated that proper labeling is crucial for kitchen staff to know when food was prepared and when it expires. The facility's policy requires that all opened food products be labeled with the date they were opened, which was not followed in this instance.
Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically a kitchen freezer, which was found to have a broken seal gasket and ice buildup on its ceiling. This issue was observed during a survey with the Dietary Supervisor, who confirmed the freezer's poor condition. The broken gasket seal and ice buildup were noted to potentially affect the quality of food stored within, as evidenced by five bags of hash browns that were not frozen solid and one bag of vegetables that had freezer burn. The facility's document on kitchen sanitation and food storage required that freezer seals be tight and free of ice buildup, which was not adhered to in this instance. The Registered Dietitian confirmed that a poor seal could lead to ice buildup and affect the freezer's ability to maintain consistent temperatures, potentially compromising food safety. The 2022 Federal Food and Drug Administration Food Code also mandates that equipment components such as seals be kept intact and tight to ensure proper operation, which was not the case here.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when Resident 4 punched Resident 5. This incident was witnessed by two staff members as Resident 5 attempted to enter Resident 4's room from the courtyard. Resident 5, who has multiple diagnoses including dementia, major depressive disorder, bipolar disorder, and undifferentiated schizophrenia, fell to the ground and began yelling at the nurse during an assessment. Resident 4, who also has dementia, bipolar disorder, and Alzheimer's disease, confirmed the altercation, stating that he knocked Resident 5 down. The facility's policy and procedure on abuse prevention and reporting were not effectively implemented, as evidenced by the lack of supervision in the Activity Room, which allowed Resident 5 to access the courtyard. Resident 5's care plan included monitoring for behaviors such as intrusiveness and wandering, as well as regular checks for safety, but these measures were not adequately followed. Resident 4's care plan, initiated after the incident, noted a risk for psychosocial decline related to resident-to-resident altercations. The facility's failure to monitor and intervene in situations likely to lead to conflict contributed to the occurrence of this incident.
Failure to Supervise Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for Resident 5, who has a history of disruptive behavior and cognitive impairments, resulting in an altercation with Resident 4. Resident 5, admitted in 2016 with diagnoses including dementia, major depressive disorder, bipolar disorder, and undifferentiated schizophrenia, was found unsupervised in the courtyard, an area where residents from the locked memory care unit are not allowed without supervision. Resident 5 attempted to enter Resident 4's room from the courtyard, leading to Resident 4, who also has severe cognitive impairments and a history of aggressive behavior, punching Resident 5, causing him to fall to the ground. Interviews with facility staff, including the Administrator, CNA, Activity Assistant, and Sr Regional Director Clinical, confirmed that residents from the locked memory care unit should not be in the courtyard unsupervised and that the sliding glass doors should always be locked. Despite these protocols, Resident 5 accessed the courtyard through the sliding glass doors in the Activity Room, which were supposed to be locked. The facility's policy on abuse prevention emphasizes the need for a safe environment and monitoring residents with behaviors that may lead to conflict, which was not adhered to in this instance.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident struck him multiple times in the chest and face. Resident 1, who has Type 2 diabetes and no memory impairment, was involved in an incident where he accidentally bumped into Resident 2's wheelchair in the hallway. In response, Resident 2, who has moderate memory impairment and hemiplegia following a stroke, struck Resident 1 in the face and chest three times. Although Resident 1 was not physically injured, the incident negatively impacted his self-esteem. Interviews conducted with staff and residents revealed that the incident was witnessed by others, including a licensed nurse who heard the altercation and a resident who saw the physical confrontation. The Social Services Director and the Assistant Director of Nursing acknowledged that the incident constituted abuse, as it affected Resident 1's mental well-being. The facility's policy on abuse emphasizes the right of each resident to be free from abuse, including resident-to-resident abuse that results in physical injury, pain, or mental anguish.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 627 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Davis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Retirement Community At Davis | 2.2 mi | ★★★★★ | 0 | 0 |
| Woodland Post-acute | 8.5 mi | ★★★★★ | 24 | 0 |
| Cottonwood Healthcare Center | 8.9 mi | ★★★★★ | 13 | 0 |
| The Grove Post-acute | 9.2 mi | ★★★★★ | 14 | 0 |
| River Bend Nursing Center | 10.4 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Courtyard Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.