Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Del Rosa Villa during CMS and state inspections, most recent first.
A resident with intact cognition reported an uncomfortable mattress after returning from the hospital and said he had been sleeping in a chair in the lobby because staff did not resolve the issue. Another resident with Parkinson's disease requested a powered wheelchair because she could not self-propel a manual wheelchair, but nursing, rehab, and SS staff were not informed of the request and no follow-up was documented.
A resident with dementia was repeatedly observed with long, dirty fingernails, and staff did not notice the condition; the ADL care plan identified risk for decline in self-care and mobility but did not include nail care or other hygiene interventions. Another resident with hemiplegia and severe cognitive impairment remained in bed without activities for two days, and although staff identified 1:1 Spanish music and Spanish books as appropriate, the activity care plan did not include those individualized interventions.
Failure to provide ADL assistance with nail care and personal hygiene for a resident with dementia. The resident was assessed as needing help with personal hygiene, but staff observed long, visibly dirty fingernails during multiple observations, including while eating and touching food. CNAs stated they did not notice the condition, while the LVN and DON stated CNAs were responsible for residents' nail care and ADL assistance.
A resident with encephalopathy and MS was identified as a fall risk, but staff observed the bed raised in a high position and the call light out of reach under the bed. A CNA confirmed the resident was high risk for falls and the bed should have been lowered, and an LVN stated fall precautions should include a low bed and call light within reach. The resident’s care plan included those same interventions.
Failure to provide ordered respiratory care: one resident had oxygen cannula tubing left in place beyond the required change interval, and another resident did not receive prescribed nebulizer treatments or an Incentive Spirometer after returning from the hospital. Staff observations and interviews confirmed the tubing was overdue, the nebulizer was not set up, the IS was not at bedside, and the MAR lacked documentation that the respiratory medication was administered, offered, attempted, or refused.
Hot food was served below acceptable temperature for two residents. One resident said meals were delivered cold and often not finished because they were not appetizing, and another said the tray was cold by the time it reached her room. During a tray check, the DS found the entree and rice on a regular diet tray were both below the expected hot-holding temperature, and acknowledged the food should have been served warmer.
Infection Control Program Failure With Urinary Bag Self-Emptying: A resident with intact cognition and diagnoses including fluid overload and hypoxemia was observed emptying his own urinary drainage bag without gloves or hand hygiene. He stated staff were not coming in to empty the bag, while a CNA was unaware of the bag and an LVN could not confirm whether the resident had been screened for self-care. The IP could not confirm documentation of assessment, education, supervision, or competency for catheter-bag emptying.
A resident reported a large number of bugs in a shared bathroom and said staff had been told the prior week, but no action was taken. Surveyors observed many small flying insects in the bathroom and around the toilet seat, while the Administrator and ESD said they were unaware of the issue. Record review showed no documented staff report of the problem, despite the facility pest control policy requiring an effective pest control program.
A resident with quadriplegia, schizoaffective disorder, and cannabis dependence was sent to acute care for behavioral concerns and, after being cleared for discharge, was declined readmission by the facility without a documented assessment of current condition, contrary to facility policy.
A CNA verbally abused a resident with a history of stroke and paralysis during perineal care, dismissing the resident's complaints of pain and ultimately using a derogatory term. The incident was witnessed by another CNA and confirmed by the DON's investigation, violating facility policy requiring respectful and abuse-free treatment.
A CNA in an LTC facility used profanity in the presence of two residents, violating their right to dignity and respect. Both residents, with intact cognition, felt disrespected by the CNA's language, which was perceived as directed towards them. The incident occurred when one resident requested assistance, and the CNA expressed frustration using inappropriate language. The facility's policy on treating residents with respect was not followed, resulting in emotional distress for one resident.
A resident with a complex medical history experienced a change in condition, including altered consciousness and confusion. The facility notified the doctor and executed orders but failed to successfully notify the responsible party on the day of the incident. The responsible party was informed the following day, but this was not documented, violating the facility's policies on notification and documentation.
The facility did not follow the approved menu for residents on pureed and carbohydrate-controlled diets, serving incorrect portion sizes. Six residents on a pureed diet received 2/3 cup of Jambalaya instead of one cup, and 33 residents on a carbohydrate-controlled diet were given a whole slice of garlic bread instead of half. The cook was unaware of the correct portions, and the Registered Dietician Nutritionist confirmed the need to adhere to the menu.
A facility failed to send a notice of transfer or discharge to the Ombudsman for a resident hospitalized twice. The resident, with hemiplegia and dysphagia, was sent to the hospital without the required notification. Interviews confirmed the facility's policy was not followed, risking inappropriate transfer or discharge.
A resident's medications were found unattended in a medication cup on their bedside table, contrary to the facility's policy. The resident had not taken their morning medications, and the LVN responsible was unsure if the medications were administered correctly. The DON confirmed the policy was not followed, highlighting the importance of proper medication administration.
A facility failed to maintain cleanliness in a residents' refrigerator, as a dark brownish-reddish frozen spill was found in the freezer. The RN and DS were unaware of the spill, and the DON acknowledged that the facility's policy on refrigerator maintenance was not followed. The FDA Federal Food Code highlights the need to keep surfaces free of debris to prevent microorganism accumulation.
A facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for a resident with a wound on the right leg. A CNA was observed providing incontinence care without wearing a gown, despite the requirement for EBP. The CNA admitted to forgetting due to being in a rush. The facility's policy mandates gowns and gloves for high-contact tasks, which was not adhered to, posing a risk to resident safety.
A resident with cognitive impairments and mental health disorders eloped from a facility due to inadequate monitoring and a malfunctioning wander guard system. Despite being assessed as an elopement risk and wearing a wander guard bracelet, the resident left through a parking lot gate without triggering an alarm. The resident was last seen in an area accessible to the parking lot, and staff did not hear any alarm during the time the resident went missing.
A resident with a history of stroke and paralysis experienced verbal abuse when a Physical Therapy Assistant (PTA) yelled an expletive during a transfer. The incident was witnessed by multiple staff members, and the Director of Nursing confirmed the use of profanity. This violated the facility's policy on Residents' Rights, which requires treating residents with respect and dignity.
A resident with dementia and unsteadiness on feet fell in their room, and although neurological checks were initiated, the LVN failed to notify the physician about the resident's deteriorating level of consciousness. The resident's condition worsened, leading to their transfer to a hospital. The ADON confirmed that the physician should have been notified, as per the facility's policy on falls.
Failure to Accommodate Mattress and Mobility Equipment Needs
Penalty
Summary
Reasonably accommodating resident needs and preferences was not met for a resident who returned from the hospital with diagnoses including fluid overload and hypoxemia and had intact cognition on the admission MDS. The resident stated that his bed mattress was uncomfortable after readmission, that he had told different staff about the problem, and that because of the discomfort he had been sleeping in a chair in the lobby every night and had not slept in his bed since hospital discharge. During interviews, an LVN stated she was not aware of the mattress issue, and the Environmental Services Director stated no request for a bed mattress was documented in the work order logbook and he had not been informed of the concern. The facility policy referenced providing an environment and staff behaviors directed toward assisting residents in maintaining safe independent functioning, dignity, and well-being. A second resident with Parkinson's disease stated she requested a powered wheelchair from multiple staff because she could not use a manual wheelchair by herself and wanted to be more independent, but she received no follow-up information about the request. The Director of Rehab stated the rehab department screens residents and provides physician recommendations for powered wheelchairs, but she had not been informed of the resident's request. An LVN stated nursing staff are responsible for communicating resident concerns or requests to the appropriate departments, and the Social Services Director stated she coordinates and orders specialized equipment but had not been informed of the request. A psychotherapy progress note also documented encouragement to communicate with staff regarding mobility options and equipment needs and to coordinate with nursing and rehab staff regarding wheelchair evaluation and mobility planning.
Individualized Care Plans Not Developed for Hygiene and Activity Needs
Penalty
Summary
The facility failed to develop and implement individualized care plan interventions for Resident 6 related to hygiene needs. Resident 6 had diagnoses including dementia, and during multiple observations on 2/8/26, 2/9/26, and 2/10/26, the resident was seen with long, visibly dirty fingernails. During a meal observation, Resident 6 was eating and touching food with both hands, and when asked about the fingernails, the resident stated, "I know." On 2/9/26, CNA 1 stated she did not notice the condition of the resident's fingernails, and LVN 1 stated CNAs were responsible for cutting and cleaning residents' fingernails. Review of the ADL care plan dated 2/14/24 and last reviewed 1/13/26 showed the resident was at risk for decline in self-care and mobility skills, but it did not include individualized goals or interventions addressing hygiene needs, including nail care. The facility also failed to develop and implement individualized activity care plan interventions for Resident 73. Resident 73 had diagnoses including hemiplegia and severe cognitive impairment. During observations on 2/8/26 and 2/9/26, the resident remained in bed without participation in activities or being offered activities for two consecutive days. CNA 1 stated she did not ask or offer the resident to be up in a Geri-chair, while LVN 1 stated the resident did not have a physician's order to be up in a Geri-chair but CNAs could still get her up. The Activity Director stated staff should provide 1:1 activities such as Spanish music and reading Spanish books while in the room and up in the dining room. However, the resident's activity care plan dated 5/5/21 only stated the resident needed one-on-one activity visits for social interaction and mental/sensory stimulation and did not address music or books as part of the plan.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for one sampled resident, specifically nail care and personal hygiene. Resident 6 had diagnoses including dementia and, on the quarterly MDS dated 1/14/26, was assessed as requiring assistance with personal hygiene. During observation on 2/8/26, Resident 6 was seen in the dining room with long, visibly dirty fingernails, and later that day was observed eating and touching food with both hands while her fingernails remained unclean. When asked about the condition of her fingernails, Resident 6 stated, "I know." On 2/9/26 and 2/10/26, Resident 6 was again observed with long, dirty fingernails during concurrent observations with CNA staff, and both CNAs stated they did not notice the condition of her fingernails. During interview, LVN 1 stated CNAs were responsible for cutting and cleaning residents' fingernails, and the DON stated CNAs were responsible for maintaining and providing ADL assistance to residents. The facility policy on ADL support stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, including assistance with hygiene such as bathing, dressing, grooming, and oral care.
Fall precautions not maintained for a resident at high risk for falls
Penalty
Summary
The facility failed to keep the environment safe and free from hazards for one sampled resident when fall-prevention interventions were not in place. Resident 28 was readmitted with diagnoses including encephalopathy and multiple sclerosis and was identified as a fall risk by a wristband. During an observation in the resident’s room, the bed was elevated in a high position from the floor. On a later observation, Resident 28 was again found resting in bed with the bed raised high, and the call light was located underneath the bed on the floor. A CNA confirmed the bed was in a high position and stated the resident was considered a high fall risk and the bed should be lowered to prevent injury. The CNA also stated the call light should have been within the resident’s reach. An LVN later stated the resident was a fall risk and that safety interventions should be in place, including keeping the bed in a low position and the call light within reach. The resident’s care plan for falls included keeping the bed in low position and keeping the call light within reach, and the facility’s Falls/Fall Risk Management policy stated staff and the physician would identify interventions to try to prevent subsequent falls and address risks of serious consequences of falling.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents. One resident, admitted with pneumonia, had oxygen cannula tubing at the bedside with a date label of 1/27/26 during an observation on 2/8/26, and the resident stated the oxygen had been used two days earlier. An LVN stated that oxygen tubing should be replaced every three days and that charge nurses were responsible for changing it, while the DON stated charge nurses were responsible for changing the tubing and the IP was responsible for overseeing the task. The facility policy titled Prevention of Infection Respiratory Equipment stated to change the oxygen cannula and tubing every seven days or as needed. A second resident, readmitted with diagnoses including fluid overload and hypoxemia, had physician orders for nebulizer treatments every 6 hours as needed for shortness of breath or hypoxia and for an Incentive Spirometer three times a day for 10 days. During observations, the nebulizer machine was not set up and no Incentive Spirometer was found at bedside, and the resident stated he had not received any breathing treatments since returning from the acute hospital. The resident also stated the Incentive Spirometer had not been provided. An LVN confirmed the respiratory treatments were not administered during her shift and that the nebulizer had no set-up and no Incentive Spirometer was at bedside. The MAR for February 2026 did not document that the prescribed nebulizer medication was administered, offered, attempted, or refused. The DON stated respiratory medications should have been administered according to the physician's order, and the facility policy stated residents receive respiratory treatments and monitoring per physician's orders, standards of practice, and plan of care.
Hot Food Served Below Acceptable Temperature
Penalty
Summary
The facility failed to ensure hot food was served at an acceptable temperature for two sampled residents, Resident 67 and Resident 116. During interviews, Resident 67 stated the food was not good, was delivered cold, and was often not finished because it was not appetizing. Resident 116 stated she did not like the food because the tray was cold by the time it was delivered to her room. On 2/9/26, during a test tray observation and interview with the Dietary Supervisor, a regular diet tray was removed from the last meal cart for delivery to residents' rooms and the temperatures were checked. The entree of Fish with Tarragon measured 126.8 degrees F and the Cajun Country Rice measured 127.8 degrees F. The Dietary Supervisor acknowledged the low temperatures and stated the food should be served warmer. The facility menu for that meal included Fish with Tarragon, Cajun Country Rice, Creamed Spinach, Sweet Corn Salad, and Fruit Bavarian Cream. The facility policy stated proper hot and cold temperatures are maintained during food distribution and service.
Infection Control Program Failure With Urinary Bag Self-Emptying
Penalty
Summary
Provide and implement an infection prevention and control program was cited after Resident 107 was observed emptying his own urinary drainage bag without gloves or hand hygiene. During a concurrent observation and interview on 2/8/26 at 10:10 a.m., Resident 107, who had been readmitted with diagnoses including fluid overload and hypoxemia and whose MDS indicated intact cognition, stated that staff were not coming in to empty the urinary bag and that he had been emptying the urine by himself. He was observed removing the drainage port, showing how to empty it, and replacing the port without gloves or performing hand hygiene before and after the task. During follow-up interviews, CNA 4 stated he was not the resident’s regular assigned CNA and was not aware of the urinary bag. LVN 1 stated CNAs were responsible for emptying urinary bags but could not state whether Resident 107 had been screened to perform self-emptying of the urinary bag. The Infection Preventionist could not confirm documentation showing that Resident 107 had been assessed as capable of managing his own catheter care, or that there was documentation of resident education, supervision, or competency evaluation related to catheter-bag emptying. The facility policy stated that an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection.
Failure to Report and Address Flying Insects in Shared Bathroom
Penalty
Summary
The facility failed to maintain an effective pest control program when staff did not report the presence of flying insects in a shared bathroom in room [ROOM NUMBER]. Resident 14 stated he had seen a lot of bugs in the bathroom and said he had told staff about them the prior week, but nothing was done. During observation, surveyors found a large amount of small dark colored flying insects inside the bathroom and many resting around the toilet seat. The Administrator and Environmental Service Director stated they were unaware of the bug issue and confirmed the insects were present. The Environmental Service Director later stated he had not been notified by staff, and review of the communication folder showed no documented evidence that the issue had been reported. The facility policy stated that the facility shall maintain an effective pest control program.
Failure to Assess Resident for Return Following Hospitalization
Penalty
Summary
The facility failed to conduct an assessment to evaluate a resident's status and needs at the time of a proposed return from the hospital. The resident, who had a history of quadriplegia, schizoaffective disorder, and cannabis dependence, was sent to the hospital for behavioral evaluation due to being a danger to others. After being cleared for discharge by a psychiatrist, attempts were made by the hospital to return the resident to the facility. However, the facility declined to accept the resident back, citing her history of attempting to harm others, without performing a documented assessment of her current condition as required by facility policy. Record reviews and staff interviews confirmed that there was no documentation of an evaluation to determine if the resident was appropriate for transfer back to the facility. The facility's own policies require that residents returning from hospitalization be evaluated based on their current condition at the time of return, not their condition at the time of transfer. Despite this, the Director of Community Relations and the DON acknowledged that no such assessment was completed, and the facility's policies and procedures were not followed in this instance.
Verbal Abuse of Resident During Perineal Care
Penalty
Summary
A Certified Nursing Assistant (CNA 1) verbally abused a resident with a history of stroke and left-sided paralysis during perineal care. The resident expressed pain and concern about rough handling, which CNA 1 did not acknowledge. Another CNA (CNA 2) present during the care asked CNA 1 to be more careful, but CNA 1 responded dismissively. After care was completed, the resident told CNA 1 she did not want her to provide care anymore, at which point CNA 1 called the resident a derogatory name. CNA 2, who was leaving the room, overheard the verbal abuse. The incident was confirmed through statements from the resident, CNA 2, and CNA 1, as well as an investigation by the Director of Nursing (DON). The facility's policy requires all employees to treat residents with kindness, respect, and dignity, and prohibits abuse of any kind. The failure to adhere to these standards resulted in the resident experiencing pain, fear, and anxiety.
CNA's Use of Profanity Violates Resident Dignity
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect when a Certified Nursing Assistant (CNA) used profanity in their presence. This incident involved two residents, both of whom had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. Resident 1, who had diagnoses including major depressive disorder, bipolar disorder, chronic pain, and alcoholic polyneuropathy, felt disrespected when the CNA used derogatory language while addressing her need for assistance. Resident 2, who had diagnoses including morbid obesity, muscle weakness, major depressive disorder, bipolar disorder, anxiety disorder, and kidney failure, witnessed the incident and corroborated the use of profanity by the CNA. The incident occurred when Resident 1 had activated her call light for assistance with changing her diaper. The CNA, identified as CNA 1, entered the room and expressed frustration using profanity, which both residents perceived as directed towards them. The Director of Nursing (DON) confirmed that CNA 1 admitted to using inappropriate language due to feeling overwhelmed by the workload. The facility's policy on resident rights, which mandates treating residents with kindness, respect, and dignity, was not adhered to in this instance, leading to emotional distress for Resident 1 as documented in her medical record.
Failure to Notify and Document Change of Condition
Penalty
Summary
The facility failed to adhere to its Change of Condition (COC) and Documentation Policies for a resident who experienced a significant change in condition. The resident, who had a medical history including rhabdomyolysis, cirrhosis, hepatic encephalopathy, type 2 diabetes mellitus, and Hepatitis C, exhibited altered levels of consciousness and confusion. Although the medical doctor was notified and orders were received and executed, the responsible party was not successfully contacted on the day of the incident. The facility attempted to reach the responsible party but marked them as unreachable, and there was no documentation of any follow-up notification. The deficiency was further compounded by the lack of documentation regarding the notification of the responsible party about the resident's change in condition. An LVN later communicated with the responsible party the following day, informing them of the previous day's events, but failed to document this conversation. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the lapse in documentation, which was contrary to the facility's policy that mandates prompt notification and documentation of any significant changes in a resident's condition.
Failure to Follow Menu Portion Sizes for Special Diets
Penalty
Summary
The facility failed to adhere to the approved menu for residents on specific diets, which could potentially compromise their nutritional status. During a tray line observation, it was noted that six residents on a pureed diet were served 2/3 cup of pureed Jambalaya instead of the one cup specified in the menu. The cook admitted to being unaware of the correct portion size and acknowledged the discrepancy. The facility's winter menu clearly indicated that one cup of pureed Chicken Jambalaya should be served to residents on a pureed diet. Additionally, 33 residents on a regular carbohydrate-controlled diet were served a whole slice of garlic bread instead of the half slice specified in the menu. The cook again admitted to not following the portion sizes listed on the menu. The Registered Dietician Nutritionist confirmed that the recipes and menu should be strictly followed. The facility's policy on menu planning, dated 2023, states that menus are designed to meet the nutritional needs of residents according to established national guidelines.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the notice of transfer or discharge was sent to the Ombudsman for a resident who was hospitalized on two separate occasions. The resident, who was admitted with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, was sent to the hospital on two occasions. On both February 16, 2024, and July 6, 2024, there was no record of the notice of transfer or discharge being sent to the Ombudsman, as required by the facility's policy. Interviews with the Social Worker and the Director of Nursing confirmed that the notices were not sent, and the facility's policy and procedure for transfer or discharge notices were not followed. The policy stated that for facility-initiated discharges, a copy of the notice should be sent to the Office of the State Long-Term Care Ombudsman at the same time it is provided to the resident and their representative. This oversight had the potential for the resident to be inappropriately transferred or discharged.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to its policy and procedure for one resident. During an observation and interview, five medication tablets were found unattended in a medication cup on the bedside table of a resident. The resident indicated that these were their morning medications, which they had not yet taken. The resident then proceeded to take the medications. This incident occurred despite the facility's policy requiring medications to be administered safely, timely, and as prescribed. Further investigation revealed that the Licensed Vocational Nurse (LVN) responsible for administering the morning medications to the resident was unsure if the tablets found were indeed the resident's morning medications. The LVN admitted to not remembering if the resident took their medication at the prescribed time. The Director of Nursing confirmed that the facility's policy was not followed, emphasizing the importance of ensuring medications are not left unattended and are administered as prescribed by the physician.
Failure to Maintain Cleanliness in Residents' Refrigerator
Penalty
Summary
The facility failed to store residents' food according to professional standards for food service safety when a dark brownish-reddish frozen spill was found on the bottom part of the freezer of the residents' refrigerator. This observation was made on January 21, 2025, at 10:55 AM. During an interview with a Registered Nurse (RN 1) shortly after the observation, it was revealed that the responsibility for cleaning the residents' refrigerator typically falls to the Licensed Vocational Nurse on duty or the housekeeping staff. However, RN 1 was unaware of why the freezer was dirty. Further interviews with the Dietary Supervisor (DS) and the Director of Nursing (DON) revealed a lack of awareness and adherence to the facility's policy and procedures (P&P) regarding refrigerator maintenance. The DS expressed an expectation for the refrigerator to be clean and admitted to not being aware of the spill. The DON, during a review of the facility's P&P, acknowledged that the policy was not followed, as housekeeping was not informed about the spill. The FDA Federal Food Code was also reviewed, which emphasizes the importance of keeping non-food-contact surfaces free of debris to prevent the accumulation of pathogenic microorganisms.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure compliance with Enhanced Barrier Precautions (EBP) for one of the sampled residents, Resident 97, who was on EBP due to a wound on the right leg. During an observation, a Certified Nurse Assistant (CNA 1) was seen providing incontinence care to Resident 97 without wearing a gown, despite a sign outside the room indicating the need for EBP. CNA 1 admitted to forgetting to wear a gown, citing being in a rush as the reason for the oversight. Resident 97 was admitted with diagnoses including Leukocytoclastic Vasculitis, Cellulitis of the lower limbs, and a non-pressure chronic ulcer on the left lower leg. The facility's policy, reviewed with the Director of Nursing, clearly stated the requirement for gowns and gloves during high-contact tasks such as changing incontinence briefs. The Director of Nursing acknowledged that CNA 1 did not comply with the policy, which posed a risk to resident safety throughout the facility.
Resident Elopement Due to Inadequate Monitoring and System Failure
Penalty
Summary
The facility failed to prevent the elopement of a resident who was at risk due to cognitive impairments and mental health disorders. The resident, who had been assessed as an elopement risk with a high score of 18 on the Elopement and Wandering Risk Observation/Assessment, was wearing a wander guard bracelet. Despite this, the resident managed to leave the facility through a parking lot gate that automatically opened for vehicles, without triggering an alarm or being noticed by staff. Interviews and record reviews revealed that the resident was last seen in the facility's smoking area, which was accessible to the parking lot, and was not closely monitored. The Assistant Director of Nursing (ADON) confirmed that the wander guard system was supposed to alarm when a resident with a bracelet approached an exit, but no alarm was heard during the time the resident went missing. A test of the system showed that a facility exit door did not alarm, indicating a malfunction. The Certified Nursing Assistant (CNA) who last saw the resident reported that the resident was known to walk quickly around the parking lot area, which was near the automatic gate. The resident later stated that he left because he believed he was going to be sent to a mental health facility. The facility's policy on wandering and elopements was not effectively implemented, as the resident's care plan included strategies to prevent elopement, but these were not adequately followed, leading to the resident's unsupervised departure.
Removal Plan
- The administrator assigned a staff member to monitor the entrance gate of the facility by the parking lot to ensure no other residents could exit from parking lot main gate. The area will be monitored every shift. The assigned staff member will redirect residents to safety. The staff member will contact another staff member to assist as needed, so the area is not left unmonitored.
- There are 7 residents identified as high risk for elopement risks and these residents are still using a wander guard alarm system.
- Assigned Staff checks for the presence of the wander guard as well as the functionality of the wander guard daily.
- IPN, Case Manager and MDS staff conducted reassessment on the 7 residents for elopement risks and clarified the orders to reflect Licensed Nurses monitoring of the presence of the wander guard device every shift and notified the responsible party and attending physicians accordingly.
- Assigned Staff to monitor and log the expiration date of the wander guard device weekly.
- The Administrator initially in-serviced staff regarding Monitoring of Residents on wander guard. In-servicing of staff will continue.
- The facility created elopement binders for each nursing station and one by the receptionist with the resident's photo, face sheet and redirect residents who are wandering in the unit.
- Maintenance Staff removed the air curtain on door 3 so it doesn't interfere with the functionality of the wander guard system.
Verbal Abuse Incident by Physical Therapy Assistant
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a Physical Therapy Assistant (PTA) yelled an expletive at the resident during a transfer. The incident occurred when the resident, who had a history of stroke and left-sided paralysis, was found on the floor by a Certified Nursing Assistant (CNA). The CNA sought assistance from the PTA, who became frustrated when the resident did not respond to instructions to get on her knees. The PTA then yelled, "Get the f**k up!" at the resident, causing fear, confusion, and anxiety. Multiple staff members, including two CNAs and a Licensed Vocational Nurse (LVN), witnessed the incident. The Director of Nursing (DON) confirmed through interviews with the witnesses that the PTA used profanity directed at the resident. The facility's policy on Residents' Rights, which mandates treating residents with kindness, respect, and dignity, was violated. The incident highlights a failure to protect the resident from verbal abuse, as required by federal and state laws.
Failure to Notify Physician of Resident's Deteriorating Condition After Fall
Penalty
Summary
The facility failed to implement its policy regarding falls when a resident experienced a change in cognition or level of consciousness following an unwitnessed fall. The resident, who had a diagnosis of unsteadiness on feet and unspecified dementia, fell in their room. Although neurological checks were initiated and an X-ray was ordered, the Licensed Vocational Nurse (LVN) did not notify the physician about the resident's deteriorating level of consciousness. The resident's condition worsened from being very drowsy but responsive to touch stimuli to only responding to painful stimuli, yet the physician was not informed. The resident was later found unresponsive during routine checks and was transferred to an acute general hospital. The Assistant Director of Nursing (ADON) confirmed that the physician should have been notified of the changes in the resident's condition, as per the facility's policy and procedure on falls. The policy required nurses to assess and report any change in cognition or level of consciousness, which was not adhered to in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Bernardino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Post Acute | 0.8 mi | ★★★★★ | 1 | 0 |
| Sierra Vista | 1.1 mi | ★★★★★ | 18 | 0 |
| Waterman Canyon Post Acute | 1.7 mi | ★★★★★ | 2 | 0 |
| Valley Healthcare Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Medical Center Convalescent Hospital | 1.8 mi | ★★★★★ | 13 | 0 |
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