Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crenshaw Nursing Home during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and no capacity to make medical decisions was transferred to the hospital for further evaluation, but the facility did not notify the resident's Public Guardian, who was listed as the first emergency contact and responsible party. Staff interviews and record review showed the facility notified the conservator instead, despite the P&P requiring prompt notification of the resident representative when a transfer to a hospital or treatment center is needed.
Medication Refrigerator Stored Above Acceptable Temperature: During an observation and interview, the Annex med storage refrigerator was found at 49 degrees Fahrenheit while containing 7 insulin pens and vials. An LVN stated the refrigerator was warm and confirmed refrigerated meds should be kept below 40 degrees Fahrenheit. The facility P&P required drugs and biologicals to be stored under proper temperature controls.
Failure to obtain valid informed consent and IDT review before psychotropic meds: A resident with dementia, mood disorder, and major depressive disorder was started on Depakote for mood swings and Trazodone for depressive symptoms despite documentation that the resident lacked capacity to make decisions. RN and SSD interviews confirmed the consent was not signed by the IDT, no IDT or bioethics meeting occurred before the meds were initiated, and the resident’s consent was not valid.
The facility failed to accurately complete the MDS for two residents. One resident’s Gabapentin was not coded in the high-risk drug class section as an anticonvulsant, and another resident’s dialysis treatment was not entered in the dialysis section. The MDSN confirmed one assessment was completed inaccurately, and the report states the incorrect data was transmitted to CMS.
PASARR Level 1 Screening Not Updated for a Resident With Mental Illness: The facility failed to complete and resubmit a new PASARR Level 1 screening for a resident with schizoaffective disorder, depression, and anxiety who was later prescribed psychotropic meds including Olanzapine and Trazodone. During review, an LVN stated the prior PASARR did not reflect the resident’s current mental health diagnoses or medications, and the facility policy required a new Level 1 when the MDS did not match the prior screening.
PASRR screening for mental disorders or ID was not completed for a resident with bipolar disorder, schizoaffective disorder, major depressive disorder, and psychosis. The resident’s Level 1 PASRR indicated a Level 2 screening was required, but no Level 2 PASRR was found in the chart. An LVN confirmed the screening was not performed or followed up on, despite the facility policy addressing assistance with the Level 2 evaluation process.
Missing Oxygen Care Plans for Two Residents: Two residents receiving O2 via nasal cannula had no documented oxygen care plan in their charts. One resident had COPD, acute respiratory failure, pneumonia, and bronchitis with moderately impaired cognition and needed maximal ADL assistance; the other had COPD, emphysema, psychosis, and bipolar disorder with severely impaired cognition and total ADL dependence. RN confirmed both residents should have had oxygen care plans, and the facility’s Oxygen Administration policy required review of the care plan for special needs.
A resident with HTN, cerebral infarction with hemiplegia, and DM was scheduled to receive hydrochlorothiazide 12.5 mg daily with instructions to hold if SBP was below 110. During observation, an LVN was about to administer the medication without first checking the resident’s BP, despite the prescriber’s parameter. The LVN stated the BP check was important before giving the medication and acknowledged the order should be followed.
Failure to act on a Consultant Pharmacist MRR recommendation for a resident receiving Depakote. The resident had dementia, mood disorder, and major depressive disorder, with severely impaired decision-making ability. The pharmacist recommended considering a Depakote level for routine monitoring, but RN stated the report was not communicated to the physician and there was no documentation that it was completed. The DON stated the physician should have addressed the MRR within a week, and the facility policy required the attending physician to document review of the irregularity and the action taken.
Expired chlorine test strips were used to test a commercial dishwasher’s sanitation level. An aide tested the dishwasher water without checking the strip expiration date, and the DSS stated that expired strips could produce false or inaccurate readings and lead to improperly sanitized water.
Room size requirements were not met in multiple rooms after record review showed several House Station and Annex Station rooms with multiple resident beds in spaces below the required square footage per resident. An AA acknowledged that some rooms were smaller than required and stated a waiver form had been submitted; the AA also stated the issue could limit residents' ability to move around freely, while noting no harm was caused and observations did not show an adverse effect on resident health or safety.
A CNA failed to provide respectful and dignified care to a resident requiring assistance with toileting and hygiene, instead speaking rudely and refusing to help, which left the resident feeling upset. Another resident and facility leadership confirmed the inappropriate behavior, which was not in line with facility policy requiring respectful and prompt care.
A resident with significant physical impairments reported being physically and verbally mistreated by a CNA, and the incident was not reported to authorities within the required two-hour timeframe as mandated by facility policy. Another resident confirmed the rude behavior, and the delay in reporting resulted in a postponed investigation by the state health department.
A resident with severe cognitive impairment and multiple care needs was discharged without proper IDT planning, to a private home that was not equipped to meet their needs. The discharge was arranged by a marketer, with no verification of the location, no involvement of the family in the decision, and no notification to the Ombudsman or Local Contact Agency. The resident was sent without proper documentation, medication management, or follow-up, and was later found unconscious and hospitalized for altered mental status and infection.
The facility failed to obtain informed consent before administering lorazepam to two residents with severe cognitive impairments, violating their rights to make informed decisions. The Minimum Data Set Nurse confirmed the absence of documentation for informed consent, which is required by the facility's policy.
The facility did not ensure that the most recent survey results were posted in a location readily accessible to residents. A sign at the Annex Station indicated survey information was available upon request, but the survey binder was not near the signage or the nurse's station. The DON confirmed that survey results should have been freely accessible to all residents. The facility's policy stated that residents have the right to examine survey results and any plan of correction, which should be available in a readily accessible place.
The facility failed to correctly set low air loss mattresses (LALM) for two residents, risking skin breakdown due to incorrect weight settings. Additionally, a resident with an unstageable pressure ulcer did not receive a prescribed LALM, potentially worsening their condition. These actions violated facility protocols for pressure ulcer prevention and management.
The facility failed to maintain the medication room storage refrigerator at the required temperature, as outlined in their policy. The refrigerator contained unopened insulin vials, insulin pens, and multidose tuberculin injection vials, with the temperature recorded at 48 degrees Fahrenheit, exceeding the policy requirement of 36-46 degrees Fahrenheit. An LVN confirmed the temperature discrepancy and acknowledged the risk of medications expiring.
A resident with a urinary catheter did not have a privacy bag covering the collection bag, violating their right to dignity and privacy. The resident, who had anxiety disorder and other medical conditions, was capable of understanding and decision-making. An LVN confirmed the importance of covering the catheter bag, as per the facility's dignity policy.
A resident with chronic conditions and right-sided weakness had their call light placed on the floor behind their bed, making it inaccessible. The resident's care plan required the call light to be within reach, but this was not followed, as confirmed by an LVN. The facility's policy also emphasized the importance of call light accessibility for prompt assistance.
A facility failed to develop a baseline care plan for a resident on dialysis within 48 hours of admission, as required by their policy. The resident, who had ESRD, hypertension, and anemia, required dialysis treatment three times a week. Despite having the mental capacity to make medical decisions, the resident's care plan was not established, which was confirmed by the MDS Nurse. This omission could affect the resident's dialysis care and treatment.
A facility failed to develop a care plan for a resident receiving oxygen therapy, as identified during a review of records and an interview with an LVN. The resident, with diagnoses including ESRD, DM, and dementia, required respiratory treatment with O2. The LVN confirmed the absence of a care plan, which was necessary to outline services, track interventions, and monitor outcomes. The facility's policy required care plans to include measurable objectives and reflect current standards of practice.
A resident with End Stage Renal Disease and a physician's order for Midodrine was not monitored for blood pressure every 8 hours as required. This failure was confirmed by an LVN and the DON, who acknowledged the importance of monitoring to adjust medication and ensure safety. The facility's policies on medication administration and care for residents with ESRD were not followed.
The facility failed to provide adequate respiratory care for two residents, leading to potential infection risks. A resident with a tracheostomy had dried secretions on the site and tube due to inconsistent care, while another resident's nebulizer tubing was not dated, making it unclear when it was last changed. These lapses in care violated the facility's policies for respiratory care and equipment maintenance.
A facility failed to monitor and record a resident's blood pressure every 8 hours as required for a resident receiving hemodialysis and prescribed midodrine for low blood pressure. The resident's blood pressure was not monitored according to the physician's order, which is essential for medication administration and resident safety. Both the LVN and DON acknowledged the importance of this practice, yet it was not followed, resulting in a deficiency.
The facility failed to act on pharmacist consultant recommendations for two residents, risking unnecessary medication administration. One resident's lorazepam order could exceed the recommended dose, while another's lacked a stop date, violating CMS rules. The DON confirmed no follow-up documentation with physicians, contrary to facility policy.
Two residents receiving PRN lorazepam for anxiety were not reevaluated after 14 days, contrary to facility policy. Both residents had severely impaired cognitive skills and required significant assistance from staff. The DON confirmed the absence of a stop date and reevaluation, which could lead to unnecessary medication use.
The facility failed to maintain proper food safety standards, with a malfunctioning thermometer in Kitchen Refrigerator 1 and an unlabeled pasta bin in dry storage. Additionally, Kitchen Refrigerator 2 was found to have an internal temperature above the recommended level, posing a risk of expired food. These issues were observed during a survey, highlighting deficiencies in the facility's adherence to its own policies.
A facility failed to change and label the humidifier for a resident's oxygen therapy, as required by policy. The resident, with a history of ESRD, DM, and dementia, required respiratory treatment. An LVN confirmed the humidifier was undated, risking respiratory infection.
The facility did not meet the required 80 square feet per resident in several rooms, as confirmed by a waiver request and room measurements. The DON acknowledged the issue, noting potential movement restrictions for residents, though no harm was reported. Observations indicated no adverse effects on residents' health or safety, and a waiver was recommended.
A deficiency occurred when a resident-to-resident physical altercation was not timely reported to the CDPH, delaying the investigation and placing a resident at risk for further abuse. The incident involved two residents with intact cognitive skills and various medical conditions. A CNA observed one resident slap the other, but the LVN and DON lacked evidence of reporting the incident as required by facility policy.
A resident with schizophrenia and major depressive disorder, under 24/7 one-on-one care, sustained multiple unexplained injuries that were not reported to CDPH within the required timeframe. Despite being monitored, the resident experienced a swollen tibia and fibula, a swollen left wrist, and skin discolorations, which were not reported as per the facility's policy.
A resident with cognitive impairment and on one-on-one care sustained multiple injuries of unknown origin, which the facility failed to investigate on three occasions. Despite constant supervision, the facility did not document or investigate the causes of the injuries, contrary to their policy requiring thorough investigation and reporting of such incidents.
A facility failed to create an individualized care plan for a resident with schizophrenia and major depressive disorder, who required constant supervision due to a high risk of falls. The care plan lacked specific monitoring details and did not address the resident's unsteady gait, lack of shoes, or abrupt behavior. An incident occurred where the resident fell and was injured, revealing the care plan's inadequacy.
A resident with schizophrenia and major depressive disorder experienced multiple incidents of bruising and swelling due to the facility's failure to provide an environment free from accident hazards and adequate supervision. The resident's fall risk assessment was inaccurate, leading to insufficient interventions for their high fall risk. The facility also did not implement its policy for safety and supervision, resulting in unaddressed safety risks and environmental hazards.
A resident with dysphagia was served the wrong diet, contrary to physician orders, placing them at risk for aspiration. Despite reporting the error to the administration and DON, no follow-up actions were communicated. Interviews confirmed the dietary mistake and the associated risks, highlighting a failure in adhering to the facility's policy for resident-centered diet planning.
A resident with unstageable pressure ulcers was not provided with a low air loss mattress, essential for wound management, despite being at high risk for skin breakdown. The facility failed to order the mattress, citing insurance approval delays, and did not adhere to its policy of providing appropriate support surfaces for high-risk residents.
A resident with cognitive impairments and fall risk was left unsupervised during the night shift while a CNA was asleep at the nurse's station. The resident's care plan required frequent observation and assistance with ADLs, which was not provided, leading to a deficiency in supervision and safety.
The facility failed to maintain a sanitary environment, with observations of dirty stains, mouse droppings, and clutter in resident rooms, laundry, and shower areas. Housekeeping staff admitted to inconsistent deep cleaning practices, and documentation was lacking. The Infection Control Nurse and DON stressed the importance of cleanliness to prevent infections, but facility standards were not consistently met.
A resident with schizoaffective disorder and other conditions reported pain and discoloration in the right index finger, but the complaint was not documented by the LVN as required by facility protocol. This lack of documentation was identified during interviews with staff, highlighting a failure to follow procedures for recording changes in a resident's condition.
A resident in an LTC facility was subjected to repeated physical abuse by another resident, resulting in injuries. Despite reports of the abuse, the facility failed to separate the residents or update their care plans, leading to further harm. The facility's staff did not follow protocols for documenting incidents or ensuring resident safety, contributing to the deficiency.
A facility failed to implement its abuse prevention policy, resulting in a resident being repeatedly hit by a roommate. Despite known issues with the aggressor's behavior, staff did not separate the residents or update care plans. The DON was unaware of the initial incident, and the facility's inaction placed residents at risk for further abuse.
The facility failed to report alleged abuse incidents involving two residents to the CDPH within the required two-hour timeframe. One resident reported being physically assaulted by their roommate, resulting in visible injuries. Despite staff observations and reports, the residents were not separated, and the DON misunderstood the reporting requirements, delaying the investigation process.
A facility failed to investigate a resident-to-resident altercation, leading to a subsequent incident where a resident was hit, resulting in a bruise and swelling. Despite reports of feeling unsafe, the facility did not separate the residents. The resident with a history of aggression was not adequately monitored, and staff failed to follow abuse reporting protocols, leaving the affected resident at risk.
A facility failed to develop a comprehensive abuse care plan after two incidents where a resident with schizophrenia physically abused another resident, resulting in injuries. Despite staff awareness and policy requirements, no care plans were initiated, and the residents were not separated, leading to repeated abuse.
Failure to Notify Public Guardian of Hospital Transfer
Penalty
Summary
The facility failed to follow its Policy and Procedure titled, Change In a Resident's Condition, when it did not notify a resident's Public Guardian of the resident's transfer to a General Acute Care Hospital. The resident's admission record identified a Public Guardian as the first emergency contact, and the History and Physical dated 1/8/2026 stated the resident lacked capacity to make medical decisions. The Minimum Data Set dated 4/4/2026 indicated severe cognitive impairment and dependence for activities of daily living including toileting, personal hygiene, and transfer from bed to chair. Progress notes dated 4/4/2026 documented that the resident was transferred to the hospital for further evaluation, but did not indicate that the Public Guardian was notified. During interviews, an LVN stated staff should inform the first listed contact of changes in condition or transfers and that a Public Guardian must be notified if listed. Another LVN stated the facility notified the resident's conservator and did not attempt to notify the Public Guardian. The DON reviewed the record and stated the Public Guardian, as the first emergency contact and responsible party, should have been notified first rather than the conservator.
Medication Refrigerator Stored Above Acceptable Temperature
Penalty
Summary
The facility failed to ensure the Annex medication storage refrigerator temperature was below 40 degrees Fahrenheit. During a concurrent observation and interview on [DATE] at 8:45 a.m. with LVN 3, the Annex station medication storage refrigerator, which contained 7 insulin pens and vials, was observed with an internal temperature of 49 degrees Fahrenheit. LVN 3 stated the refrigerator was warm and confirmed that refrigerated medications should be stored below 40 degrees Fahrenheit. LVN 3 also stated that when the refrigerator is not within the acceptable temperature range, the medications could lose potency. A review of the facility's policy and procedures titled Storage of Medications, dated 3/2023, indicated that drugs and biologicals are to be stored in locked compartments under proper temperature, light, and humidity controls.
Failure to Obtain Valid Informed Consent and IDT Review Before Psychotropic Medications
Penalty
Summary
The facility failed to ensure a written informed consent was obtained and an interdisciplinary team (IDT) meeting was conducted before initiating psychotropic medications for one resident with dementia. The resident was initially admitted and later readmitted to the facility, and diagnoses included dementia, mood disorder, and major depressive disorder. A history and physical dated 1/11/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 2/9/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired. The order summary showed telephone orders on 1/11/2026 for Depakote 250 mg twice daily for mood swings and Trazodone 25 mg at bedtime for major depressive disorder. During interview and record review, RN 2 stated the informed consent for Depakote and Trazodone was not signed by the IDT and that the resident lacked capacity to give informed consent because of dementia. The Social Service Director stated there was no IDT or bioethics committee meeting before the psychotropic medications were started, and that the resident’s informed consent was not valid. The facility policy required an IDT review before administration of medical interventions and a bioethics meeting when a resident lacks capacity and a psychoactive medication is ordered.
Inaccurate MDS Coding for Medication and Dialysis
Penalty
Summary
The facility failed to ensure the MDS accurately reflected Resident 2’s medication use. Resident 2 was admitted and readmitted to the facility with diagnoses including ESRD, dependence on renal dialysis, and DM. The record showed Resident 2 had the mental capacity to understand and make decisions, and the MAR documented Gabapentin 100 mg at bedtime for nerve pain. However, the MDS dated 3/10/2026 did not code Gabapentin in Section N0415 (K1) as an anticonvulsant medication. During interview, the MDSN stated the MDS was completed inaccurately and confirmed Gabapentin should have been checked in that section because it is classified as an anticonvulsant. The facility also failed to accurately code Resident 32’s dialysis treatment in the MDS. Resident 32’s face sheet listed diagnoses including ESRD, dependence on renal dialysis, and HTN. The report states that during review of Resident 32’s physician order, the dialysis treatment was not encoded in MDS Section O0110 (J1 - Dialysis). The deficiency was identified through record review and interview, and the report states the inaccurate MDS data was transmitted to CMS.
PASARR Level 1 Screening Not Updated for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure a PASARR Level 1 screening was completed and resubmitted for a resident with diagnoses of schizoaffective disorder, major depressive disorder, and anxiety disorder. The resident was initially admitted and later readmitted to the facility, and the chart showed the resident had the capacity to understand and make decisions, was independent in cognitive skills for daily decision making, and required moderate assistance with eating, oral hygiene, and upper body dressing. The resident’s order summary showed a telephone order for Olanzapine 10 mg at bedtime for schizoaffective disorder and a later telephone order for Trazodone 150 mg at bedtime for depression. During interview and record review, the LVN reviewed the resident’s PASARR Level 1 completed by GACH and stated it indicated no serious mental illness diagnoses and no prescribed psychotropic medications. The LVN stated a new PASARR Level 1 under Resident Review should have been completed and resubmitted because the resident had a new mental illness diagnosis and was prescribed psychotropic medications; the facility policy also stated a new Level 1 PASARR would be submitted if the MDS did not match the prior screening or if there was an error or discrepancy in the previous PASARR screening.
PASRR Level 2 Screening Not Completed
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed for one resident with a history of bipolar disorder, schizoaffective disorder, major depressive disorder, and psychosis. The resident’s face sheet showed an original admission and a readmission, and the MDS dated 2/23/2026 indicated severely impaired cognitive skills and partial assistance needed with ADLs. During record review on 4/22/2026, the resident’s positive Level 1 PASRR dated 4/18/2021 showed that a Level 2 PASRR screening was required, but no Level 2 PASRR screening was found in the medical chart. In a concurrent interview, an LVN stated that she and other staff were responsible for PASRR screenings, confirmed that the resident required a Level 2 PASRR, and stated that the facility did not perform it or follow up for it. The facility policy stated that if the contractor deems a Level 2 evaluation necessary, the facility will assist with additional information and a face-to-face visit for further evaluation as indicated.
Missing Oxygen Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans for oxygen use were initiated for two sampled residents, Resident 22 and Resident 6. Resident 22’s face sheet showed diagnoses including COPD, acute respiratory failure, pneumonia, and bronchitis. The MDS dated 10/17/2025 indicated Resident 22 had moderately impaired cognitive skills and required maximal assistance with ADLs. During observation on 4/21/2026 at 10:37 a.m., Resident 22 was receiving oxygen via nasal cannula at 5 liters per minute, but a review of the medical chart on 4/23/2026 at 9:59 a.m. found no oxygen care plan. RN 2 stated care plans were initiated on admission and with a change in condition, and confirmed Resident 22 did not have an oxygen care plan, which should have been initiated. Resident 6’s face sheet showed diagnoses including COPD, emphysema, psychosis, and bipolar disorder. The MDS indicated Resident 6 had severely impaired cognitive skills and was dependent on staff members with ADLs. During observation on 4/21/2026 at 12:07 p.m., Resident 6 was receiving oxygen via nasal cannula at 4 liters per minute, but a review of the medical chart on 4/23/2026 at 10:01 a.m. found no oxygen care plan. RN 2 confirmed there was no oxygen care plan for Resident 6 and stated the resident should have had one. The facility policy titled Oxygen Administration stated to review the resident's care plan to assess for any special needs of the resident.
Medication Given Without Required Blood Pressure Check
Penalty
Summary
The facility failed to ensure that Resident 11’s blood pressure was checked before hydrochlorothiazide was administered. Resident 11 was admitted with diagnoses including HTN, cerebral infarction with hemiplegia, and DM. The resident’s H&P stated that Resident 11 could understand and make own medical decisions, and the MDS indicated the resident was independent in cognitive skills for daily decision making and required moderate assistance with some activities of daily living. The order summary showed a physician’s telephone order for hydrochlorothiazide 12.5 mg by mouth daily for HTN, with instructions to hold the medication if systolic blood pressure was less than 110. During observation, LVN 1 was about to administer the hydrochlorothiazide without first checking Resident 11’s blood pressure. In interview, LVN 1 stated it was important to follow the physician’s order to check blood pressure before giving the medication and acknowledged that administering it without first checking blood pressure could cause hypotension, dizziness, and fatigability. The facility policy stated medications are to be administered in a safe and timely manner and in accordance with prescriber orders.
Failure to Act on Consultant Pharmacist MRR Recommendation
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist’s medication regimen review recommendation for Resident 26 was acted upon. Resident 26 was admitted and later readmitted to the facility and had diagnoses including dementia, mood disorder, and major depressive disorder. The resident’s H&P stated that the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decision making. The resident also required setup assistance from staff with oral hygiene, lower body dressing, and personal hygiene. Resident 26 had an active order for Depakote 250 mg by mouth twice daily for mood swings. The Consultant Pharmacist’s MRR, dated 2/10/2026, recommended considering a Depakote level for routine monitoring because the resident was receiving Depakote for mood disorder. During interview and record review, RN 2 stated the MRR was not communicated to the physician and there was no documentation in the progress notes that the MRR was completed. RN 2 stated the timeframe to follow up the Consultant Pharmacist MRR report to the physician was 5-7 days. The DON stated the physician should have addressed the MRR within a week and that checking the Depakote level was important to better regulate the medication and manage the resident’s mood condition. The facility policy stated the attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it.
Expired Chlorine Test Strips Used for Dishwasher Sanitation Testing
Penalty
Summary
The facility failed to ensure that the dishwasher chlorine test paper strips used to test the commercial dishwasher for proper sanitation levels were not expired. During a concurrent observation and interview in the kitchen dishwashing machine area, Dietary Aide 2 tested the dishwashing machine sanitation running water after it had been sanitized with a chlorine test paper strip, and stated that the bottle of test strips showed an expiration date of 3/2026. Dietary Aide 2 stated he did not check the expiration date before testing. During an interview, the Dietary Service Supervisor stated that using an expired chlorine test paper strip would give a false or inaccurate reading and could lead to improperly sanitized water. A review of the 2022 U.S. Food and Drug Administration Food Code, Equipment Code #4-501.114, noted that verifying the adequacy of chlorine-based solutions can be done on an ongoing basis by confirming that concentration, temperature, and pH comply with paragraph 4-501.114(A) using acceptable test methods and equipment.
Room Size Requirements Not Met in Multiple Resident Rooms
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. During review of the facility's Client Analysis form on 4/22/2026, several House Station rooms were documented as having multiple resident beds in spaces measuring 216 square feet for three beds, 144 square feet for two beds, 252 square feet for four beds, 198 square feet for three beds, 208 square feet for three beds, 208 square feet for three beds, and 260 square feet for four beds. Two single resident rooms in the House Station were each documented as measuring 99 square feet, and Annex Station rooms were documented as measuring 168 square feet for three beds and 312 square feet for four beds. During an interview on 4/24/2026, the Assistant Administrator stated the Administrator submitted a room waiver form on 4/20/2026 and acknowledged that some rooms were smaller than the required square footage of 80 square feet per resident. The AA stated the risk of not meeting the required square footage for each resident could result in residents not being able to move around freely, and stated there was no harm caused to the residents in the affected rooms. Observations made from 4/21/2026 to 4/24/2026 confirmed the room sizes of the affected House Station and Annex Station rooms did not adversely affect the residents' health or safety.
Failure to Treat Resident with Dignity During Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during care. The resident, who had hemiplegia, hemiparesis, osteoarthritis, and was always incontinent of urine, required partial to moderate assistance for activities of daily living, including toileting hygiene. The resident reported that the CNA on the night shift pushed on his leg, hit him with a pillow, and spoke to him in a rude and dismissive manner, telling him to clean himself. This interaction left the resident feeling frustrated, upset, and reluctant to request further assistance. Another resident, who also required partial to moderate assistance for daily care, confirmed that the CNA spoke rudely to the first resident, instructing him to change himself if he did not want to wait. The Director of Staff Development and the Director of Nursing both acknowledged that the CNA's behavior was inappropriate and not in accordance with facility policy, which requires staff to treat residents with dignity and respond promptly and respectfully to care requests. The facility's policy prohibits demeaning practices and mandates respectful communication at all times.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to implement its policies and procedures regarding the timely reporting of an abuse allegation for one of three sampled residents. Specifically, a resident with hemiplegia, hemiparesis, and osteoarthritis reported to the Director of Staff Development (DSD) that a Certified Nursing Assistant (CNA) had pushed on his leg, hit him with a pillow, and spoken to him in a rude and disrespectful manner during care. The DSD acknowledged that these actions constituted abuse and that, according to facility policy, such allegations must be reported to the California Department of Public Health (CDPH) and other agencies within two hours. However, the report was not made within the required timeframe, resulting in a delay in the investigation by CDPH. Interviews and record reviews confirmed that the resident was able to make decisions for activities of daily living and required moderate assistance for personal care. Another resident corroborated that the CNA had spoken rudely to the affected resident. The facility's policy clearly stated that abuse allegations must be reported immediately, defined as within two hours, and that employees involved would be placed on leave pending investigation. Despite these policies, the required timely reporting did not occur in this instance.
Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, dementia, schizophrenia, and a history of falls was discharged from the facility without proper discharge planning or interdisciplinary team (IDT) involvement. The resident required significant assistance with activities of daily living, was on antipsychotic and nerve pain medications, and had a care plan indicating the need for one-on-one supervision due to poor safety awareness. Despite these needs, there was no evidence of an IDT meeting or discharge care plan prior to the resident's discharge, and the resident's physician was not notified or involved in the discharge decision. The discharge location was a private home, not an assisted living or dementia care unit, and was arranged by a facility marketer without verification that the location could meet the resident's needs. The address provided to the family could not be verified, and the landlord of the home was not a healthcare professional and was unaware of the resident's medical requirements. The resident's family was not involved in selecting the discharge location, and the facility failed to notify the Local Contact Agency or the Ombudsman of the discharge. No discharge documents or information were provided to the receiving location, and there was no follow-up to ensure the resident was safely settled. Upon arrival at the home, the resident was found to be in poor condition, non-verbal, and later became unconscious, requiring emergency transfer to a hospital where a urinary tract infection and altered mental status were identified. The facility did not document the medications sent with the resident, did not ensure a responsible party was available to administer medications, and failed to provide necessary education or instructions regarding medication administration. The facility's actions were not in accordance with its own policies and procedures for safe discharge, notification, and documentation.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medication to two residents, violating their right to make informed decisions about their treatment. Resident 16, who was diagnosed with anxiety disorder, COPD, and dementia, was given lorazepam without documented informed consent. The resident's cognitive skills were severely impaired, and they were dependent on staff for daily activities. Similarly, Resident 41, with diagnoses including anxiety disorder, anemia, and protein calorie malnutrition, also received lorazepam without informed consent. This resident also had severely impaired cognitive skills and required maximal assistance for daily activities. During a review of the clinical records, it was found that there was no documentation indicating that the physician had obtained informed consent or discussed the side effects of lorazepam with the residents or their representatives. The facility's policy requires that residents or their representatives be informed of their health status and treatment options, including the right to decline psychotropic medications. The Minimum Data Set Nurse confirmed the lack of informed consent documentation and acknowledged that administering the medication without it was a violation of resident rights.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were posted in a location readily accessible to residents. During an observation at the Annex Station, a sign was noted indicating that CDPH survey information was available upon request, but the survey binder was not placed near the signage or around the nurse's station. The Director of Nursing (DON) confirmed that all recertification survey results should have been in a folder at the nursing station, freely accessible to all residents. The absence of the survey binder could result in residents not being informed of the facility's previous survey information and any corrections made. The facility's policy and procedures indicated that residents have the right to examine the results of the most recent survey and any plan of correction, and these should be made available in a place readily accessible to residents.
Failure to Properly Set and Provide Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALM) for two residents, Resident 16 and Resident 41, were set and maintained at the correct settings according to the manufacturer's guidelines. Both residents were at high risk for developing pressure ulcers due to their medical conditions and required the LALM for skin maintenance. During an observation, it was found that the LALM settings for Resident 16 and Resident 41 were incorrectly set at 300 lbs. and 350 lbs., respectively, despite their actual weights being 106 lbs. and 87 lbs. The Licensed Vocational Nurse (LVN) acknowledged the incorrect settings and stated that the settings should be based on the residents' current weights to prevent skin breakdown. Additionally, the facility failed to provide a LALM for Resident 105, who had an unstageable pressure ulcer and was at high risk for further skin breakdown. Despite having a physician's order for a LALM to maintain skin integrity, the mattress was not provided. The Director of Nursing (DON) confirmed the absence of the LALM and acknowledged the potential for the resident's wound to worsen due to the delay in providing the necessary equipment. The facility's policies and procedures for pressure-reducing mattresses and pressure ulcer management were not followed, as evidenced by the incorrect settings of the LALM for Residents 16 and 41 and the lack of a LALM for Resident 105. The facility's failure to adhere to these protocols placed the residents at risk for discomfort, skin breakdown, and potential worsening of existing pressure ulcers.
Medication Storage Temperature Deficiency
Penalty
Summary
The facility failed to maintain the medication room storage refrigerator at the required temperature, as outlined in their policy and procedure titled 'Medication Storage in the Facility.' During an observation, the refrigerator was found to contain unopened insulin vials, insulin pens, and unopened multidose tuberculin injection vials, with the temperature recorded at 48 degrees Fahrenheit. This temperature exceeded the facility's policy requirement of maintaining between 36-46 degrees Fahrenheit. During an interview, a Licensed Vocational Nurse confirmed the temperature discrepancy and acknowledged that an out-of-range temperature could result in medications expiring.
Failure to Provide Privacy for Urinary Catheter
Penalty
Summary
The facility failed to provide a privacy bag for a resident with a urinary catheter, which is a violation of the resident's right to dignity and privacy. The deficiency was identified during an observation where the resident's urinary catheter collection bag was visible and uncovered, hanging on the side of the bed. This oversight was confirmed during an interview with an LVN, who acknowledged the importance of covering the catheter bag to prevent discomfort and maintain the resident's dignity. The resident involved had been admitted with diagnoses including anxiety disorder, kidney calculus, and cerebral infarction. The resident was capable of understanding and making decisions, as indicated in their medical records. The facility's policy on dignity, which mandates that urinary catheter bags be covered to enhance residents' well-being and self-esteem, was not adhered to in this instance, leading to the identified deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident, identified as Resident 44, was observed to have their call light on the floor behind their bed, making it inaccessible. This observation was made during a room visit, and it was noted that the resident had right-sided weakness, making it essential for the call light to be placed on their functional left side. The resident's care plan specifically indicated that the call light should be within reach to attend to their needs promptly. Resident 44 had a medical history that included chronic obstructive pulmonary disease, epilepsy, and diabetes mellitus, and was dependent on staff for activities of daily living such as showering, dressing, and personal hygiene. The facility's policy and procedure on call lights emphasized the importance of ensuring that call lights are within reach to provide prompt assistance. However, this policy was not adhered to in the case of Resident 44, as confirmed by an interview with an LVN who acknowledged the necessity of having the call light accessible to the resident.
Failure to Develop Baseline Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was on dialysis, which is a critical treatment for individuals with End Stage Renal Disease (ESRD). The resident, identified as having the mental capacity to make medical decisions, was admitted with diagnoses including ESRD, hypertension, and anemia. Despite the resident's need for dialysis treatment every Tuesday, Thursday, and Saturday, as indicated in the physician's order, the facility did not create a baseline care plan within 48 hours of admission. This omission was confirmed during a review of the resident's clinical records and an interview with the Minimum Data Set Nurse (MDSN). The facility's policy and procedure on baseline care plans, dated March 2022, mandates that a baseline plan of care should be developed within 48 hours of a resident's admission to address immediate health and safety needs. The MDSN acknowledged that the absence of a baseline care plan meant that the facility staff would not be able to properly assess and manage the resident's dialysis needs. This deficiency had the potential to impact the resident's care and treatment specific to their dialysis requirements.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 105, who was receiving oxygen therapy. This deficiency was identified during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN). The resident, who had been initially admitted and later readmitted to the facility, had diagnoses including end-stage renal disease, diabetes mellitus, and dementia. The Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and was dependent on staff for activities such as showering and dressing. The MDS also noted the resident's requirement for respiratory treatment with oxygen therapy. During an interview, LVN 2 confirmed that there was no care plan in place to address the resident's use of oxygen. The LVN emphasized the importance of having a care plan to outline the necessary services, track interventions, and monitor outcomes related to the resident's oxygen use. The facility's policy and procedure on care plans, dated March 2022, required that care plans include measurable objectives, timeframes, and reflect current standards of practice. The absence of a care plan for Resident 105's oxygen therapy meant that there were no documented goals or interventions to guide the staff in providing appropriate care.
Failure to Monitor Blood Pressure for Resident on Midodrine
Penalty
Summary
The facility failed to monitor and record the blood pressure of Resident 202, who had a physician's order for Midodrine to be administered every 8 hours as needed for systolic blood pressure (SBP) less than 120. This oversight was identified during a review of Resident 202's Medication Administration Record (MAR) and confirmed by Licensed Vocational Nurse (LVN) 3, who acknowledged that the standard of practice was not followed. The LVN stated that monitoring blood pressure every 8 hours was crucial for adjusting medication and ensuring the resident's safety. Resident 202 was admitted with diagnoses including End Stage Renal Disease, hypertension, and anemia, and had the mental capacity to make medical decisions. The Director of Nursing (DON) confirmed that the order for Midodrine was intended to maintain stable blood pressure, especially during dialysis treatment. The facility's policies on care for residents with End Stage Renal Disease and medication administration were not adhered to, as they require medications to be administered according to physician orders and emphasize the importance of timing and administration of medications, particularly around dialysis sessions.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to potential risks of respiratory infection. Resident 12, who has a tracheostomy due to chronic obstructive pulmonary disease and neck cancer, was found with dried secretions on the tracheostomy site and tube. Despite a physician's order to cleanse the tracheostomy site daily, the care was not performed consistently, as confirmed by the Director of Nursing. The facility's policy requires tracheostomy care every shift to ensure airway patency and minimize infection risk, but this was not adhered to, as evidenced by the presence of dried secretions and missed care on specific dates. Resident 16, diagnosed with COPD, anxiety disorder, and dementia, had a face mask nebulizer tubing that was not labeled with the date of change. The Licensed Vocational Nurse was unable to determine when the tubing was last changed, which is required weekly for safety and infection control. The facility's policy mandates weekly changes of respiratory equipment, including nebulizer tubing, but this was not followed, creating a potential risk for respiratory infection. These deficiencies highlight lapses in the facility's adherence to respiratory care protocols for residents with significant respiratory needs.
Failure to Monitor Blood Pressure for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving hemodialysis by not monitoring and recording the resident's blood pressure every 8 hours as required. The resident, who was diagnosed with End Stage Renal Disease, hypertension, and anemia, was prescribed midodrine to manage low blood pressure, with specific instructions to administer the medication if the systolic blood pressure was less than 120. However, the facility did not adhere to the physician's order to monitor the resident's blood pressure every 8 hours, which is crucial for determining when to administer the medication. Licensed Vocational Nurse 3 confirmed that the resident's blood pressure was not monitored as required, acknowledging the importance of this practice for medication adjustment and resident safety. The Director of Nursing also recognized the necessity of monitoring the resident's blood pressure to prevent hypotension, especially during dialysis treatment. The facility's policies on care for residents with End Stage Renal Disease and medication administration emphasize adherence to physician orders, yet these were not followed, leading to the deficiency.
Failure to Act on Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to act on the pharmacist consultant's recommendations in a timely manner for two residents, placing them at risk for unnecessary medication administration. Resident 16, who was diagnosed with anxiety disorder, COPD, and dementia, had a physician's order for lorazepam that could potentially exceed the recommended maximum daily dose for the elderly. The pharmacist consultant recommended that the physician re-evaluate the order or document the risk and benefit if the current order was indicated. However, there was no documentation indicating that the licensed nursing staff followed up with the physician regarding this recommendation. Similarly, Resident 41, who had diagnoses including anxiety disorder, anemia, and protein calorie malnutrition, was prescribed lorazepam without a stop date, contrary to CMS Mega Rules requiring documentation of rationale and duration for psychotropic drug orders beyond 14 days. The pharmacist consultant noted this issue, but again, there was no documentation of follow-up with the physician. The Director of Nursing confirmed that the clinical records for both residents lacked documentation of follow-up actions, which was against the facility's policy requiring timely action on pharmacist recommendations.
Failure to Reevaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents, who were receiving PRN psychotropic medication, were reevaluated after 14 days as required. Resident 16, who had diagnoses including anxiety disorder, COPD, and dementia, was prescribed lorazepam to be taken as needed for anxiety. The resident's cognitive skills were severely impaired, and they were dependent on staff for daily activities. Similarly, Resident 41, with diagnoses of anxiety disorder, anemia, and protein calorie malnutrition, was also prescribed lorazepam PRN for anxiety. This resident also had severely impaired cognitive skills and required maximal assistance from staff. The Director of Nursing acknowledged that both residents were on lorazepam PRN without a specified duration of therapy, which is against the facility's policy. The facility's policy requires that PRN psychotropic medications have a stop date and that the physician should document the rationale for extending the use beyond 14 days. The lack of a stop date and reevaluation placed the residents at risk of receiving unnecessary medication, as there was no documented justification for the continued use of lorazepam beyond the initial 14-day period.
Deficiencies in Kitchen Food Safety Standards
Penalty
Summary
The facility failed to maintain proper food safety standards in their kitchen, as observed during a survey. The external thermometer of Kitchen Refrigerator 1 was malfunctioning, as it was observed counting upwards in seconds and minutes starting from zero, which was confirmed by a Dietary Aide who was unaware of the malfunction. This malfunction posed a risk of spoiled food due to the inability to monitor the refrigerator's temperature accurately. Additionally, the large clear egg noodle pasta bin in the dry storage area was not labeled with a name and date, which could lead to uncertainty about the contents and their expiration. Furthermore, Kitchen Refrigerator 2 was found to have an internal temperature of 42 degrees Fahrenheit, which is above the recommended 40 degrees Fahrenheit or lower, as stated in the facility's policy. The Dietary Supervisor acknowledged this discrepancy and the potential risk of expired food due to improper temperature maintenance. The facility's policies on refrigerator and dry goods storage were reviewed, indicating that temperatures should be monitored and food items should be labeled and dated, but these procedures were not followed, leading to the deficiencies noted.
Failure to Change and Label Humidifier for Resident's Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the humidifier used for a resident's oxygen therapy was changed and labeled with the date, as required by the facility's policy. This oversight was identified during an observation in the resident's room, where the humidifier attached to the oxygen concentrator was found to be undated and unlabeled. The facility's policy mandates that the oxygen humidifier should be changed weekly and as needed, but this was not adhered to in this instance. The resident involved, who was dependent on staff for various activities of daily living, had a medical history that included end-stage renal disease, diabetes mellitus, and dementia. The resident required respiratory treatment with oxygen therapy, making the proper maintenance of the humidifier crucial. During an interview, a Licensed Vocational Nurse confirmed that the lack of a date label on the humidifier made it impossible to verify if it had been changed as required, thereby placing the resident at risk for developing a respiratory infection.
Facility Fails to Meet Required Room Size Standards
Penalty
Summary
The facility failed to meet the required 80 square feet per resident in several rooms, specifically in House Station Rooms 1, 2, 3, 4, 6, 8, 9, and 10, as well as Annex Station room. This deficiency was identified through observation, interviews, and record reviews. The facility's document titled 'Request for Waiver Variation Letter' dated 3/18/2025, confirmed that these rooms did not meet the required square footage per resident. The Client Analysis form further detailed the measurements of these rooms, showing that the space allocated per resident was below the required standard. During an interview, the DON acknowledged that the Administrator had submitted a room waiver form and confirmed that some rooms were smaller than the required size. The DON noted that the lack of adequate space could potentially restrict residents' movement, although no harm was reported to have occurred to the residents in the affected rooms. Observations made during the survey period indicated that the room sizes did not adversely affect the residents' health or safety. The Department recommended a waiver for the facility.
Failure to Timely Report Resident Altercation
Penalty
Summary
The deficiency involves a failure to timely report a resident-to-resident physical altercation to the California Department of Public Health (CDPH), which delayed the investigation and placed one resident at risk for further abuse. The incident involved two residents, one with a history of schizophrenia, bipolar disorder, epilepsy, and insomnia, and the other with osteoarthritis, hypertension, muscle weakness, and cellulitis. Both residents had intact cognitive skills and required supervision with activities of daily living. The altercation occurred when one resident attempted to enter through a door where the other was sitting, leading to a verbal exchange and an alleged physical slap by one resident, as observed by a Certified Nursing Assistant (CNA). The report indicates that the Licensed Vocational Nurse (LVN) claimed to have reported the incident to CDPH but lacked evidence of a fax confirmation or a written Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. The Director of Nursing (DON) also stated that there was no confirmation of the report being made. The facility's policy requires immediate reporting of such incidents within two hours, but the lack of documentation and confirmation suggests a failure to comply with this policy, resulting in a delay in the investigation by CDPH and potential risk for further abuse to the resident involved.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report incidents of suspected abuse, neglect, or injury of unknown origin to the California Department of Public Health (CDPH) within the required timeframe for a resident who sustained multiple bruises and swellings. The resident, who had diagnoses of schizophrenia and major depressive disorder, was under one-on-one care due to impaired cognitive function and a high risk of falls. Despite being monitored 24/7, the resident experienced unexplained injuries on three separate occasions, which were not reported to CDPH as required by the facility's policy. The incidents involved the resident having a swollen tibia and fibula, a swollen left wrist, and skin discolorations on the left lower extremities. These injuries were documented in the resident's records, but there was no indication that they were reported to CDPH. Interviews with facility staff, including a Certified Nurse Assistant and the Administrator, revealed that the injuries were suspicious and should have been reported immediately. The facility's policy mandates that any injury of unknown source be reported to the administrator and state licensing agency within two hours if it results in serious bodily injury, or within 24 hours if it does not, which was not adhered to in these cases.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate multiple instances of swelling and bruises of unknown origin for a resident, identified as Resident 3, on three separate occasions: 6/18/2024, 11/5/2024, and 12/24/2024. Resident 3, who was admitted with schizophrenia and major depressive disorder, had impaired cognitive function and required assistance with daily activities. Despite being on one-on-one care due to poor balance and risk of falls, the facility did not conduct investigations into the causes of the injuries noted on these dates. Progress notes from the days following each incident did not document any investigation into the causes of the injuries. Interviews with staff, including a Certified Nurse Assistant and a Treatment Nurse, revealed that the facility was unaware of how the injuries occurred, despite the resident being under constant supervision. The Treatment Nurse expressed suspicion about the unexplained nature of the injuries, indicating that they should have been investigated. The facility's policy on abuse, neglect, and injuries of unknown source required thorough investigation and reporting, which was not adhered to in these instances. The facility administrator acknowledged the lack of investigation and the suspicious nature of the injuries, which should have prompted immediate action.
Failure to Develop Individualized Care Plan for Resident at Risk of Falls
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who required constant supervision due to a high risk of falls and injuries. The resident, diagnosed with schizophrenia and major depressive disorder, was admitted with a care plan that aimed to prevent falls and injuries but lacked specific details on the frequency of monitoring. The resident's Minimum Data Set (MDS) indicated a need for supervision and assistance with activities of daily living, yet the care plan did not address the resident's unsteady gait, lack of shoes, or abrupt behavior. An incident occurred where the resident fell and sustained an injury, highlighting the inadequacy of the care plan. Interviews with staff revealed that the resident was on one-on-one supervision due to poor balance and self-awareness, but this was not reflected in the care plan. The Director of Nursing acknowledged the care plan's shortcomings, noting that it failed to include necessary interventions such as non-skid socks, psychological consultation, and constant supervision. The facility's policy required comprehensive, person-centered care plans with measurable objectives, which was not met in this case.
Failure to Prevent Accidents and Conduct Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not offer adequate supervision and assistance to prevent accidents for a resident with a history of falls. The resident, who had diagnoses including schizophrenia and major depressive disorder, experienced multiple incidents of bruising and swelling, including a swollen tibia and fibula, a swollen left wrist, and a bluish discoloration and swelling on the left eye. These incidents occurred despite the resident being on a care plan that aimed to keep them free from falls and injury, which included interventions such as frequent visible observation and safety instructions. The facility also failed to conduct an accurate fall risk assessment for the resident. The fall risk assessment did not account for the resident's history of falls, resulting in an incorrect classification of the resident as a low fall risk. This misclassification meant that the resident did not receive the necessary interventions for high fall risk individuals, such as increased supervision and safety measures. Interviews with facility staff revealed that the fall risk assessment should have included the resident's history of falls, which would have resulted in a high fall risk classification. Additionally, the facility did not implement its policy and procedure for safety and supervision of residents. The policy indicated that safety risks and environmental hazards should be identified on an ongoing basis, and the Quality Assurance and Performance Improvement (QAPI) team should review safety and incident/accident data. However, the facility did not know what caused the resident's injuries and could not address the specific problems that led to the bruises and swelling. The Director of Nursing acknowledged that the facility should have provided constant supervision to assist the resident in ambulation and prevent the incidents that occurred.
Dietary Error Puts Resident at Risk for Aspiration
Penalty
Summary
The facility's dietary staff failed to serve the correct food consistency to a resident as per the physician's order, which placed the resident at risk for potential aspiration. The resident, who had a diagnosis of dysphagia and muscle weakness, was supposed to receive a NAS diet with minced and moist texture and nectar/mildly thick consistency. However, on June 1, 2024, the resident was served a regular diet instead of the prescribed chopped diet. This error was reported by the resident and their family member to the administration and the director of nursing (DON), but no follow-up actions were communicated back to them. Interviews with various staff members, including the Registered Nurse and Dietary Supervisor, confirmed the incident and acknowledged the risk of aspiration due to the dietary error. The facility's policy indicated that a multidisciplinary team should assess and plan each resident's diet based on their nutritional needs and preferences. Despite this policy, the resident received the wrong diet, and the staff failed to communicate any interventions to prevent further errors. The DON, who was supposed to address the issue, was no longer with the facility, and it was unclear if any corrective actions were taken.
Failure to Provide Low Air Loss Mattress for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident who was admitted with unstageable pressure ulcers. The resident, who was at high risk for skin breakdown, was not provided with a low air loss mattress, which is essential for wound management and healing. Despite the resident's requests for a special mattress due to discomfort and pain, the facility did not take timely action to address this need. Interviews with staff revealed that there was no documented evidence of an order for the low air loss mattress, and the facility was waiting for insurance approval. The Treatment Nurse confirmed that all residents with pressure ulcers should have a low air loss mattress as part of their care plan. The Quality Assurance Nurse also emphasized the importance of the mattress in preventing further skin damage and stated that it was part of the facility's policy for residents at high risk of skin breakdown. The facility's policies and procedures indicated that appropriate support surfaces should be selected based on the resident's risk factors. However, the failure to provide the necessary mattress for the resident with pressure ulcers was a clear deviation from these guidelines. This oversight had the potential to worsen the resident's condition and contribute to further skin breakdown.
Inadequate Night Shift Supervision Leads to Resident Safety Risk
Penalty
Summary
The facility failed to provide adequate supervision during the night shift for a resident, identified as Resident 4, who was observed going to the bathroom unsupervised on multiple occasions. This occurred while a Certified Nurses Assistant (CNA) was asleep at the nurse's station. Resident 4 had a history of anxiety, Major Depressive Disorder, and dementia, and was assessed to be at risk for falls due to general weakness, poor balance, and cognitive deficits. The care plan for Resident 4 indicated that nursing staff should frequently observe the resident and assist with Activities of Daily Living (ADLs) as needed. Observations from facility camera footage confirmed that the CNA was asleep at the nurse's station during the times Resident 4 was unsupervised. Interviews with the CNA, the Director of Nursing (DON), and the Assistant Administrator (AADM) revealed that it was unacceptable for staff to sleep during working hours, as it compromised resident safety and care. The facility's policy emphasized the importance of resident supervision to prevent accidents, but this was not adhered to, leading to the deficiency.
Sanitation Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain a sanitary environment for residents, as observed in multiple areas including resident rooms, the laundry area, and shower rooms. Observations revealed brown, dry, dirty stains on walls next to beds, old mouse droppings on the floor, and brown spots on walls near bathrooms. The laundry area was cluttered with dirty plastic bags and clothes on the floor, while the shower room had dry pieces of paper, hair, and black spots on the walls. Interviews with housekeeping staff indicated a lack of consistent deep cleaning practices, with one housekeeper unaware of who was responsible for checking and documenting deep cleaning, and another admitting that deep cleaning was not performed as scheduled. The Housekeeping Supervisor confirmed that deep cleaning should occur daily in one resident's room, but documentation was missing for several dates. The Infection Control Nurse and Director of Nursing emphasized the importance of maintaining a clean environment to prevent infections and ensure resident safety. The facility's policies outlined the need for clean and orderly conditions, but observations and interviews indicated these standards were not consistently met, leading to potential cross-contamination and pest activity.
Failure to Document Resident's Finger Injury
Penalty
Summary
The facility failed to ensure that a resident had a documented assessment for an injured right index finger after a notification of a change in condition. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and metabolic encephalopathy, reported pain and discoloration in the right index finger to the Activities Director. The Activities Director then reported this to a Licensed Vocational Nurse (LVN), but there was no documentation of the complaint or the condition of the finger in the Progress Nurses Notes. Interviews with the LVNs and the Director of Nursing (DON) revealed that the lack of documentation was a breach of protocol, which requires that any changes in a resident's condition be recorded. The LVNs acknowledged the importance of documenting such complaints to communicate effectively with other staff and to ensure proper follow-up. The facility's policy and procedure on charting and documentation, as well as the job description for LVNs, emphasize the necessity of accurate and complete documentation of changes in a resident's condition.
Failure to Protect Resident from Repeated Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in multiple incidents of harm. Resident 1, who had intact cognition and required supervision with certain activities, reported being hit by Resident 2 on two separate occasions. Despite these reports, the facility did not take immediate action to separate the residents or update their care plans to prevent further abuse. Resident 1 sustained a red bruise and swelling around the right eyelid as a result of the abuse. Resident 2, diagnosed with schizophrenia and known for striking out behavior, was on antipsychotic medication. The facility's records indicated multiple episodes of striking out behavior by Resident 2, yet staff interventions were inadequate. The facility's policy required separating residents involved in abuse incidents, but this was not followed. Staff, including an LVN, failed to document the incidents properly, assess the residents, or implement a care plan to prevent recurrence. Interviews with staff and residents revealed that the facility was aware of the abuse incidents but did not take appropriate measures to ensure the safety of Resident 1. The DON admitted that the residents should have been separated after the first incident to prevent further abuse. The facility's failure to act according to its policy and procedures resulted in continued risk and harm to Resident 1.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure titled, Abuse & Mistreatment of Residents, which led to a situation where Resident 1 was hit by Resident 2, resulting in a swollen and red discoloration to the right eyelid of Resident 1. The policy required that when incidents involving the health, welfare, or safety of residents are reported, the involved resident(s) should be removed from the environment that threatened their health, welfare, or safety. However, this was not done, and both residents continued to share the same room despite the reported incidents. Resident 1, who had an intact cognition and was independent with personal hygiene and mobility, reported being hit by Resident 2 on multiple occasions. Resident 2, diagnosed with schizophrenia and on antipsychotic medication, had a care plan indicating episodes of striking out behavior. Despite these known issues, the facility did not separate the residents or update the care plan to prevent further incidents. Staff, including LVN 1 and CNA 1, were aware of the incidents but did not take appropriate actions such as documenting the incidents, notifying the physician and family, or creating a care plan with interventions to prevent further abuse. The Director of Nursing (DON) acknowledged that the residents should have been separated after the first incident to prevent further abuse. However, the DON was not informed of the initial incident and did not investigate it. The facility's failure to follow its own policies and procedures placed Resident 1 and potentially other residents at risk for further abuse, which could result in serious physical harm or injuries.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to report alleged abuse incidents involving two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. On two separate occasions, one resident reported being physically assaulted by their roommate, resulting in visible injuries such as a red bruise and swollen eyelid. Despite these reports, the facility did not promptly notify the CDPH, delaying the investigation process. Resident 1, who was cognitively intact and capable of making decisions, reported being hit by Resident 2 on multiple occasions. The incidents were observed by staff, including a Certified Nurse Assistant (CNA) and a former Housekeeping Supervisor, who witnessed the altercations. Despite these observations and reports, the residents were not separated, and the facility's Director of Nursing (DON) was not informed in a timely manner. The facility's policy required that all allegations of abuse be reported to the CDPH within two hours. However, the DON misunderstood the reporting requirements, believing that a 24-hour window was permissible if there were no significant injuries. This misunderstanding, along with the failure to act on staff reports, resulted in a delay in addressing the abuse allegations and ensuring the safety of the residents involved.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to investigate a resident-to-resident altercation that occurred on 4/1/2024 between two residents, leading to a subsequent incident on 4/23/2024 where Resident 2 hit Resident 1 in the face, resulting in a red bruise and swelling on the right eyelid. Resident 1, who was cognitively intact and capable of making decisions, reported feeling unsafe sharing a room with Resident 2, who had a history of striking out behavior and was on antipsychotic medication for schizophrenia. Despite Resident 1's reports of being hit and feeling unsafe, the facility did not offer a room change or take adequate measures to separate the residents. Resident 2's care plan included monitoring and recording episodes of striking out behavior, yet there were six recorded episodes from 3/31/2024 to 4/2/2024, indicating a pattern of aggression that was not adequately addressed. The facility's staff, including a Licensed Vocational Nurse (LVN 1) and a Certified Nurse Assistant (CNA 1), were aware of the incidents but did not take appropriate action to separate the residents or ensure Resident 1's safety. The facility's Secretary confirmed that the incidents were reported to the Administrator and Director of Nurses, but no action was taken to move the residents to separate rooms. The Director of Nursing (DON) stated that the initial incident on 4/1/2024 was not reported to him, highlighting a breakdown in communication and reporting procedures within the facility. The facility's policy on abuse and mistreatment of residents required immediate investigation and reporting of all allegations, but this protocol was not followed. The Director of Staff Development emphasized the importance of reporting alleged abuse within two hours to ensure resident safety, yet this standard was not met, resulting in continued risk to Resident 1.
Failure to Implement Abuse Care Plan Leads to Repeated Incidents
Penalty
Summary
The facility failed to develop a comprehensive and resident-centered abuse care plan following two alleged physical abuse incidents involving two residents. On two separate occasions, one resident physically abused another, resulting in a red bruise and swelling on the victim's right eyelid. Despite the incidents being reported to the Director of Nursing (DON) and Administrator (ADM), no care plans were initiated to prevent further occurrences, and the residents were not separated to avoid further contact. Resident 1, who was cognitively intact and required supervision for certain activities, was repeatedly hit by Resident 2, who had a diagnosis of schizophrenia and was on antipsychotic medication. The facility's staff, including a Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA), were aware of the incidents but did not take adequate steps to address the situation. The LVN failed to document a change of condition, implement interventions, or conduct a 72-hour monitoring period after the incidents, despite recognizing the importance of these actions. The facility's policy and procedure on abuse and mistreatment of residents required the initiation of a care plan to reflect current conditions and measures to prevent recurrence. However, this was not done, and the residents continued to share a room, increasing the risk of further abuse. The lack of a comprehensive care plan and failure to separate the residents contributed to the repeated abuse incidents.
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 7,233 citations issued within 25 miles in the last 12 months — including the 34 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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Longwood Manor Conv.hospital | 0 mi | ★★★★★ | 4 | 0 |
| Miracle Mile Healthcare Center, Llc | 1.4 mi | ★★★★★ | 46 | 0 |
| Pavilion On Pico Healthcare & Wellness Centre, Lp | 1.4 mi | ★★★★★ | 27 | 0 |
| West Pico Terrace Healthcare & Wellness Centre Lp | 1.4 mi | ★★★★★ | 15 | 0 |
| Western Convalescent Hospital | 1.8 mi | ★★★★★ | 38 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Crenshaw Nursing Home.
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 August 2026) and official state health department websites.