Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dept Of State Hospitals - Metropolitan Snf during CMS and state inspections, most recent first.
Failure to Timely Report Suspected Neglect During LOS Observation: An RN observed a registry RN asleep while assigned to LOS for a resident with schizophrenia, epilepsy, and self-injurious behaviors. The incident was treated as suspected neglect, but the SOC 341 was not completed promptly and the report was not made within the required timeframe. Staff interviews confirmed the event was known during the NOC shift, yet the mandated abuse/neglect reporting process was delayed.
The facility failed to define resident‑to‑resident acts as abuse in its P&P and training, causing multiple resident‑to‑resident physical and alleged sexual assaults to be treated only as "altercations" rather than abuse. In one case, a highly dependent resident with a trach, G‑tube, and vision loss was punched in the face while sleeping by a resident with schizophrenia and a violent history, who alleged the other resident tried to have sex with him; staff did not classify this as physical or sexual abuse, did not initiate an abuse investigation, and delayed reporting to the state. In another case, a non‑ambulatory resident at high risk for violence kicked a resident with gait instability and a healing femur fracture, who then punched him three times in the face; this was not recognized as abuse, was reported late, and no enhanced monitoring or medication changes were implemented despite subsequent aggression. A third incident involved two residents with known DTO histories and moderate violence risk, where one struck the other in the chin during a verbal altercation; again, the event was not treated as abuse, reporting and SOC 341 completion were delayed, and behavioral care plans were missing or outdated despite ongoing aggressive behaviors. These failures, rooted in P&P and training that explicitly excluded resident‑to‑resident acts from abuse definitions, led to missed screening, protection, investigation, and timely reporting, and resulted in an Immediate Jeopardy finding under F607.
A resident with significant medical fragility, including a trach and G-tube, was punched in the face while sleeping by another resident with schizophrenia and a documented history of assault and moderate risk for violence. Staff and medical records showed the aggressive resident had previously attempted to hit staff, reported hearing voices to hurt others, and stated he would continue attacking people to secure discharge. Despite these known risks and facility policies requiring individualized treatment plans and monitoring for danger to others, the aggressive resident was not adequately supervised or managed, allowing him to enter the vulnerable resident’s room and inflict a facial laceration requiring wound care.
Surveyors found that staff were inadequately trained to recognize and report abuse when one resident punched another, causing a facial laceration requiring medical attention, and stated he did so because the other resident tried to have sex with him. Multiple RNs and supervisory staff reported that their annual abuse training addressed only staff-to-resident abuse and that they did not consider resident-to-resident physical or sexual incidents to be abuse. Review of the facility’s policies and training materials confirmed that definitions of physical, psychological, verbal, and sexual abuse were limited to actions by someone other than another patient, resulting in resident-to-resident abuse not being identified or reported as required.
The facility failed to timely report multiple resident-to-resident abuse allegations as required by its own policy and regulatory standards. In three separate incidents, one resident punched another in the face causing a laceration after an alleged unwanted sexual advance, two residents engaged in a physical altercation involving kicking and repeated punching, and another resident allegedly punched a peer in the chin following a verbal dispute. These events were reported to the state survey agency days after they occurred instead of within the mandated 2-hour window, and the PRA was not notified of any of the physical or sexual abuse allegations.
Two residents were involved in an incident where one resident with schizophrenia punched another medically complex, wheelchair-dependent resident in the face while he was sleeping, causing a laceration requiring medical attention, and stated he did so because the other resident tried to have sex with him. Nursing and clinical staff documented the injury and allegation but did not conduct further questioning, did not treat the physical or alleged sexual assault as abuse, and did not complete required SOC 341 abuse reports or notify the Patients’ Rights Advocate. Psychiatrists did not promptly evaluate the residents in relation to the allegation, and the facility reported the events to the state agency several days later instead of within the required 2-hour window, and did not submit investigation results within 5 working days as required by facility policy and regulations.
Failure to assess and monitor an AV fistula for a resident on dialysis. A resident with ESRD, DM2, HTN, and HF had a left upper arm AV fistula with marked swelling, pain, and limited movement, and staff observed that the fistula was no longer being used after a blood clot was found. Licensed nursing staff stated they did not know how to assess bruits and thrills or monitor the access site, and the MD reported there had been no new interventions or monitoring after the clot was identified.
Two residents with impaired skin integrity did not receive consistent pressure-injury monitoring or treatment. One resident with DM, limited mobility, and a wheelchair dependence was found with multiple untreated buttock wounds, including Stage II pressure injuries and a DTI, while staff had not documented ongoing wound assessments and the LAL mattress was set to the wrong weight. Another resident with brain dysfunction and wheelchair dependence had a previously identified ischial area that was not monitored, later developing a new Stage II pressure injury, and the LAL mattress was also programmed incorrectly.
Kitchen sanitation and food storage deficiencies were identified when two worn cutting boards with deep gouges were observed in use for meal prep, five dirty resident trays were found stacked in the clean tray area, and an opened box of previously frozen french toast was left uncovered in the refrigerator with an expired date label. The FSS and DD acknowledged the conditions, including that the cutting boards were worn out, the trays needed to be re-cleaned, and the food was expired and should have been covered.
Facility Assessment Not Updated or Fully Developed: The facility failed to update its Facility Assessment annually and did not include the specific competencies of licensed nursing staff or how often competency evaluations were to be completed. Review of the assessment showed the required skills and competencies for licensed staff based on resident population and needs were not included, and the PD confirmed the assessment had last been updated in 2021. The SCD stated the facility did not have a policy on Facility Assessment requirements, and the facility could not provide a P&P for the assessment.
QAPI Plan Not Implemented for Pressure Ulcer Monitoring: The facility failed to implement its QAPI plan to identify areas for improvement for residents at risk for pressure ulcers. The NC stated PIPs were based on prior survey results and covered call light accessibility, dining dignity, and enhanced barrier precautions, but none addressed pressure ulcers or AV fistula assessments for residents on dialysis. The PD stated the QAPI team had no data to monitor and no baseline assessments for residents returning from outside facilities, so they could not compare before and after status.
Infection control practices were not followed when clean laundry in a linen room was left uncovered and mixed with a water bottle and items on the floor, a resident with a Foley catheter had the drainage bag resting across the lap instead of below the bladder, and an LPT performed a blood glucose check on a resident with DM and HIV without wearing gloves. The resident care plans and facility policy directed proper linen handling, keeping the catheter bag below the bladder, and using PPE during invasive procedures involving blood or body fluids.
Licensed nursing staff were unable to demonstrate competency in assessing and monitoring an AV fistula for a resident with ESRD on dialysis. An RN shift lead, an RN unit supervisor, and two LPTs stated they did not know how to check for bruit and thrill, and several staff said they had not received training on dialysis resident care or AV fistula assessment. Facility leaders confirmed dialysis-specific training and competency checks were not provided, despite orders and care plan directions to assess the access every shift.
The facility failed to ensure four of five outside dumpsters were covered. During observation with the DD in the loading dock area, the dumpsters were overflowing with garbage, uncovered, and associated with many flies and a foul odor. The DD stated the dumpsters should have been covered and the area kept clean.
Failure to complete annual abuse training for 13 licensed nursing staff. Record review showed multiple LPTs and RNs had gone beyond the annual training interval, and the SRN confirmed they were past due and actively assigned to skilled nursing units. The NC stated training was scheduled by birth month, which could allow staff to go longer than a year between trainings, despite the facility policy requiring annual abuse prevention training.
A resident with cognitive impairment and seizure history, identified as high risk for falls, was able to manipulate and open the zipper of an enclosure bed due to staff not properly securing it or a zipper malfunction. The resident subsequently fell from the bed despite being on 15-minute safety checks, as staff failed to ensure the bed was properly secured in accordance with facility policy.
A resident with type 2 DM was given insulin in the Day Hall while seated with other residents nearby, despite stating he did not want to be undressed there. An LPT pulled up the resident's shirt and administered the insulin in view of others, and later confirmed the resident had requested privacy. The RNSL stated privacy should always be provided during med administration, and the facility policy required residents to be sufficiently covered.
Inaccurate MDS Coding of Active Viral Hepatitis: Two residents’ MDS assessments listed viral hepatitis as an active infection even though neither resident had treatment for hepatitis C while in the facility. During record review with the MDSC, the MDS entries and active orders were compared, and the MDSC confirmed the diagnoses should not have been coded as active infections.
Three LPNs inaccurately documented a resident’s weekly skin checks as showing no skin impairment despite ongoing boils and a Stage III sacral pressure injury. In a separate event, an LVN crushed Trazadone for a resident with dysphagia and G-tube status but gave it by mouth instead of via the ordered G-tube route.
A resident on continuous O2 had an order that did not specify the amount of oxygen to be given, and staff observed the nasal cannula prongs outside the resident's nose. Another resident with OSA had a CPAP order, but staff had not cleaned or documented cleaning of the CPAP components since admission, and the RT was unaware the resident had CPAP. The resident's O2 concentrator humidifier was also overdue for replacement despite staff stating it should be changed daily.
Incomplete documentation was found for two residents’ repositioning schedules and one resident’s MTAR. Two residents had bedside repositioning forms with missing staff initials despite orders to reposition at least every 2 hours, and an RN confirmed one resident was repositioned but not documented. Another resident with ESRD and a LUE AV fistula had missing PM-shift RN assessment entries on the MTAR for required every-shift checks of the fistula and related complications.
A resident with a mental health diagnosis disclosed past physical and sexual abuse to a psychologist, but the psychologist did not report the allegation or complete required documentation as mandated by facility policy. Multiple staff confirmed that no incident report or notifications to authorities were made, resulting in a delay in the investigation process.
A psychiatric technician employed since 2017 did not receive any annual performance evaluations, as required by facility policy. The HR manager and unit supervisor confirmed the absence of these evaluations, citing oversight as the reason for non-compliance.
A facility failed to document a resident's leaking G-Tube, as observed by a Psychiatric Technician after the resident returned from dialysis. Despite notifying a registered nurse, the incident was not recorded in the medical records, violating the facility's policy for documenting abnormalities in G-Tube care.
The facility failed to maintain an effective infection prevention and control program, with deficiencies involving six residents. Trash and linen carts were improperly placed outside an isolation room, and staff did not use appropriate PPE during wound care and personal hygiene activities, contrary to Enhanced Barrier Precautions guidelines. This lack of adherence to infection control policies placed residents at risk of cross-contamination and infection spread.
The facility lacked a written QAPI plan for its Skilled Nursing units, failing to identify systemic issues related to infection prevention and enhanced barrier precautions (EBP). Interviews with a Supervising RN revealed the absence of data tracking and trending, and the facility's policy on quality assurance was not followed, leading to ineffective monitoring and evaluation of patient care quality.
The facility's QAA committee failed to include the Infection Preventionist/Public Health Nurse II in its meetings, as noted in the Quality Council Minutes from two separate dates. The facility's policy did not list the Infection Preventionist as a required member, contributing to this oversight.
The facility failed to implement an effective infection control training program for all staff by not developing a written policy and training on Enhanced Barrier Precautions (EBP). Staff interviews revealed a lack of awareness and training on EBP, with admissions of not using gowns during wound care. The facility was unable to provide a policy for EBP, potentially affecting the safety and infection control among residents.
Two residents were not treated with dignity during meal times as staff stood while feeding them, contrary to facility policy requiring seated interaction. One resident was nonverbal and the other was at risk for choking, highlighting the importance of following procedures for a respectful dining experience.
The facility failed to ensure that two residents had their call lights within reach, potentially resulting in unmet needs. One resident with a history of mental health and neurocognitive disorders was observed with the call light out of reach in an enclosure bed. Another resident was repeatedly observed with the call light hanging from the wall and out of reach, despite staff acknowledging the requirement for accessibility as per facility policy.
A resident with a gastrostomy tube did not receive the prescribed amount of tube feeding due to the feeding pump being left on hold. The pump was set to deliver 60 ml per hour, but the resident only received 470 ml instead of the 660 ml ordered by the physician. This deficiency was confirmed by nursing staff and the registered dietitian.
The facility failed to ensure food safety and sanitation by having unclean, chipped, and stained food trays, expired food items in storage, a dented can improperly stored, and a marred cutting board in use. These issues were contrary to the facility's policies, which require proper cleaning, sanitization, and monitoring of food items and equipment.
The facility failed to maintain cleanliness in food storage areas, with grape juice cups, chipped wood debris, and plastic wrappers found on the floors of the warehouse and walk-in freezer. The Dietetics Director and Assistant Dietetics Director acknowledged that these areas should have been cleaned, as per the facility's policy, which requires daily sweeping and proper disposal of garbage.
A facility failed to provide a qualified interpreter for a Spanish-speaking resident, leading to communication barriers. Staff used unapproved interpreters, including other residents, to communicate with the resident, raising concerns about translation accuracy. The resident's care plans indicated the need for an interpreter, but the facility lacked a process to ensure availability each shift, despite policy requirements.
A resident, who is blind and requires moderate assistance for ambulation, fell and sustained a scalp contusion due to the facility's failure to implement fall prevention interventions. A nurse observed the resident standing unassisted but did not intervene, contrary to the resident's care plan and the facility's fall prevention policy.
A resident experienced a fall resulting in a fractured finger due to the facility's failure to implement fall prevention measures. Despite the resident's documented need for supervision and a walker, a nurse observed her walking without assistance and did not intervene. The facility's policy required registered nurses to oversee fall prevention strategies, which were not adhered to in this case.
A resident with severe cognitive impairment was assaulted by another resident with a history of behavioral disturbances, resulting in significant injuries. Despite previous incidents of aggression, no interventions were implemented for the aggressive resident, who was roomed with the vulnerable resident due to a COVID quarantine. The facility's failure to monitor and manage the aggressive resident's behavior led to the assault.
Failure to Timely Report Suspected Neglect During LOS Observation
Penalty
Summary
The facility failed to ensure that an alleged violation of neglect was reported within 24 hours to the administrator and that a SOC 341 report of suspected dependent adult/elder abuse was initiated timely when a registry RN was observed asleep while assigned to provide line-of-sight (LOS) observation to a resident. The resident had diagnoses including schizophrenia, epilepsy, and a benign neoplasm of the cerebral meninges, and was on LOS for danger to self behaviors, including throwing herself to the ground and injuring herself. According to staff interviews, an RN working the night shift observed the registry RN with eyes closed and appearing asleep during the LOS assignment, and the RN notified the acting after-hours supervisor. The acting supervisor confirmed he was informed early in the morning that the registry RN had fallen asleep while responsible for LOS observation and stated this would be considered neglect because the resident was not being watched for safety. He also confirmed that he did not initiate a SOC 341 at the time of the incident, and the RN stated she did not know the form needed to be completed. The record showed the incident was not documented as an alleged neglect event until several days later, when an interdisciplinary note stated that information had been obtained that an employee assigned to monitor a patient on LOS had been sleeping during the assignment. The facility’s SOC 341 was dated later and indicated neglect occurred during the overnight hours, with the report not submitted to law enforcement until that later date. The facility policy required LOS patients to always remain in the field of vision of assigned staff and required suspected abuse or neglect to be reported immediately or as soon as practicably possible, with the SOC 341 completed by end of shift.
Failure to Define and Manage Resident‑to‑Resident Abuse, Leading to Unrecognized and Unreported Assaults
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement abuse policies and procedures that clearly define all forms of abuse, including resident‑to‑resident abuse, which led to multiple resident‑to‑resident physical and alleged sexual assaults not being recognized, reported, or investigated as abuse. The facility’s written abuse P&P, incident management P&P, and related training materials explicitly limited abuse definitions to acts committed by someone other than another patient, and sexual abuse to employee‑patient contact or employee‑facilitated patient contact. As a result, staff, including the Standards Compliance Director, Standards Compliance Supervising RN, Program Director, RN Shift Lead, and other nursing staff, consistently stated that resident‑to‑resident physical or sexual assaults were not considered abuse and therefore did not trigger abuse investigations, SOC 341 completion, or 2‑hour reporting to CDPH. One incident involved a resident with significant physical impairments, including absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating, and wheelchair dependence, who sustained a 1.2 cm laceration above the right eyebrow with bruising after being punched in the face while sleeping by another resident. The aggressor resident had schizophrenia, a criminal history of assault with force likely to produce great bodily injury, and was assessed as a moderate risk for violence against others. Staff documented that the aggressor stated he punched the other resident because the resident “tried to have sex with me,” and the injured resident reported the attack was unprovoked. Despite this, the incident was treated as a physical altercation rather than abuse, the alleged sexual component was not treated as sexual assault or abuse, no abuse investigation was conducted, and the report to CDPH was delayed until three days later because the facility did not consider resident‑to‑resident events to meet its definition of abuse. The covering psychiatrist did not evaluate either resident at the time and was unaware of the sexual abuse allegation, and there was no treatment plan or interventions in place to address the aggressor’s known aggressive behaviors or to protect other residents. A second incident involved a resident with gastrostomy status, pulmonary fibrosis, nonfunctional ambulation, and a high risk for violence against others, who kicked another resident using a front‑wheel walker in the buttocks, prompting the second resident, who had unsteadiness on feet, blindness in one eye, and a healing femur fracture with a past history of danger‑to‑others behaviors, to turn and punch the first resident in the face three times. This event was documented in the interdisciplinary notes as a physical altercation in the day hall. The facility’s leadership confirmed that resident‑to‑resident abuse was not included in the abuse P&P and that there was no separate P&P addressing protection and prevention of resident‑to‑resident abuse. The altercation was not reported to CDPH within 2 hours but instead two days later, and the resident who retaliated did not receive medication changes or enhanced monitoring after the incident, despite later having another aggressive outburst toward staff. A third incident involved two residents both assessed as moderate risk for violence against others, one with a back fracture, epilepsy, and a significant history of danger‑to‑others behaviors, and the other with a history of verbalizing thoughts of harming another resident. Staff heard yelling in the day hall and found the two residents in a verbal altercation when one resident struck the other, who reported being hit in the chin. The striking resident later stated he used a closed fist to touch the other resident’s chin to make him stop cursing and yelling. This event was also treated as a resident‑to‑resident altercation rather than abuse, resulting in delayed reporting to CDPH by two days and delayed completion of the SOC 341 until several days after the incident, instead of by the end of the shift. The psychologist later confirmed that one resident had an extensive history of verbal aggression with prior alleged physical altercations and no behavioral care plan, and that another resident’s behavioral care plan had not been updated in over a year despite aggressive incidents and stated intent to harm another resident. Across these incidents, the facility’s P&P, definitions, and staff training excluded resident‑to‑resident acts from the abuse framework, leading to failures in recognizing, preventing, investigating, protecting, and timely reporting abuse, and placing all residents at risk of unreported and unmitigated abuse. On 3/5/2026, surveyors declared an Immediate Jeopardy related to the lack of written policies and procedures prohibiting and preventing abuse that included resident‑to‑resident abuse, and to staff competency in identifying, preventing, screening, investigating, protecting, and reporting abuse under F607.
Removal Plan
- Treat physical altercations, sexual allegations, possible mental or psychological abuse, and exploitation in the SNF area as potential abuse allegations.
- Complete an SOC 341 form for each allegation of an abuse incident.
- Verify completion of SOC 341 by the RN Health Services Specialist/Supervising Registered Nurse prior to the end of the shift.
- Update reporting of unusual occurrences related to possible abuse incidents to ensure compliance with the reporting requirement.
- Program VI management/Unit Shift Lead will notify Standards immediately upon identification of a possible abuse incident to ensure reporting requirements are completed within the required timeframe.
- Program VI manager on call/unit shift lead will notify CNS for HSS to complete reporting within the required timeframe.
- Issue a written memorandum for all SNF nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting, clarifying resident-to-resident incidents must be treated as potential abuse, and including CMS SOM reference, recognition/identification, screening, prevention/protection measures, early intervention/behavioral monitoring expectations, investigation/documentation requirements, reporting requirements, and SOC 341 completion.
- Require SRN attestation that staff can verbalize understanding of the memo/education, track training via a tracking log, and provide clarification as needed to ensure staff understand the abuse screening and reporting process.
- Issue a written memorandum for all registry nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide training via memorandum to non-nursing clinical staff and ancillary staff on federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide additional staff training regarding intervention protocols to enhance behavioral monitoring and intervention strategies for residents identified as high risk for behavioral escalation or aggression, including identification of high-risk residents, enhanced monitoring/supervision strategies, early interventions/de-escalation techniques, implementation of individualized behavioral interventions, documentation, and communication to the interdisciplinary team.
- Conduct an analysis of the physical environment, staffing, supervision, and resident assessment/care planning/monitoring to identify, correct, and intervene in situations where possible abuse, neglect, or misappropriation of resident property is more likely to occur.
- Update Administrative Directive 3308 to include resident-to-resident physical and verbal assaults, possible mental or psychological abuse, sexual allegations, and exploitation as potential abuse, including expectations for abuse screening, investigations, and reporting requirements.
- Conduct an ongoing review of all incident reports involving resident-to-resident altercations or allegations to ensure SOC 341 reports are completed and reporting timelines are met.
Failure to Protect Resident From Assault by Known Violent Peer
Penalty
Summary
The deficiency involves the facility’s failure to protect a medically fragile resident from physical abuse by another resident who had been previously identified as a moderate risk for violence against others. Resident 1’s MDS showed he had an absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating needs, and required a wheelchair for ambulation. On observation, Resident 1 was seen in bed with a noticeable laceration and bruising above the right eyebrow, and he reported that another resident attacked him in his sleep without provocation. A nurse later observed dried blood above Resident 1’s eyebrow, and Resident 1 again reported that he had been punched in the face while sleeping. Resident 2’s treatment plan documented diagnoses including schizophrenia and a criminal history of assault by means of force likely to produce great bodily injury, and an evaluation on 1/22/2026 identified Resident 2 as a moderate risk for violence against others. Staff interviews indicated that Resident 2’s medical condition had improved to the point that he was highly ambulatory and no longer medically fragile. The Registered Nurse Shift Lead stated she was not surprised by the incident because Resident 2 had attempted to punch a staff member in October 2025, and a prior recommendation from the state hospital indicated Resident 2 should be carefully monitored due to a demonstrated history of violent behaviors. Despite these known risks, Resident 2 was able to access Resident 1’s room and punch him in the face while he slept. Subsequent documentation and interviews confirmed Resident 2’s aggressive behavior and intent. During an interview, Resident 2 admitted punching Resident 1 and stated he did so because he believed Resident 1 wanted to have sex with him. Physician progress notes recorded that Resident 2 told staff he was hearing voices to hurt others, that he had attacked a peer and caused injury, and that he would continue hitting people until he was discharged. The facility’s policies on reporting abuse and on treatment planning required that abuse not be tolerated and that treatment plans address individualized risks, including danger to others, and that mini-team conferences be held after episodes of aggression. The failure to implement adequate supervision, environmental interventions, and behavioral interventions for Resident 2, despite documented risk factors and prior aggressive behavior, led to Resident 1 being physically assaulted and injured while asleep.
Failure to Train Staff on Recognition and Reporting of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure all staff received adequate training on the recognition, prevention, and reporting of all forms of abuse, including resident-to-resident abuse, as required by Federal regulations. Surveyors reviewed an interdisciplinary note for one resident dated 2/7/2026, which documented that this resident was punched in the face by another resident, resulting in a 1.2 cm laceration to the right upper eyebrow that required medical attention. The note further documented that the resident who did the punching told staff, “I punched him early in the morning because he tried to have sex with me,” indicating an alleged attempted sexual contact and a physical assault between residents. During interviews, multiple staff members demonstrated that they did not recognize resident-to-resident physical or sexual incidents as abuse. One RN stated he received annual abuse training that covered only staff-to-resident abuse, reporting, and prevention. Another RN described finding dried blood above a resident’s right eyebrow, being told by that resident that another resident had punched him while he was sleeping, and then being told by the alleged aggressor that he hit the resident because the resident wanted to have sex with him. This RN characterized the incident as a physical altercation rather than abuse and did not consider the allegation of attempted sexual contact to be sexual assault or abuse, despite confirming he had received annual abuse training. Additional interviews with the Registered Nurse Shift Lead, the Program Director, and the Nursing Coordinator showed a consistent belief that only staff-to-resident physical or sexual assault constituted abuse and that residents could not be perpetrators of abuse. Review of the facility’s abuse training materials and policies showed that the definitions of physical, psychological, verbal, and sexual abuse were limited to actions by “someone other than another patient,” and sexual abuse was defined in terms of employee conduct or employee allowance of sexual contact between patients. These policy definitions and training content excluded resident-to-resident abuse, contributing directly to staff’s inability to recognize and report the resident-to-resident physical and alleged sexual assault as abuse for two sampled residents.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to identify and report resident-to-resident physical and sexual abuse allegations within the required timeframe for three separate incidents. In the first incident, one resident punched another in the face, causing a laceration above the right eyebrow, after alleging that the other resident attempted to engage in unwanted sexual activity. The Standards Compliance Supervising RN confirmed the incident and the sexual assault allegation but stated that the department of standards and compliance was not open over the weekend and that she did not consider resident-on-resident physical and/or sexual assault as abuse, so it was not reported within 2 hours. The facility’s own policy, however, defined abuse of a dependent adult/elder to include physical abuse and sexual assault and required all alleged violations involving abuse in skilled nursing units to be reported to CDPH immediately, but not later than 2 hours after the allegation. The Patients’ Rights Advocate (PRA) also reported not receiving any notification of physical and/or sexual assault or abuse related to this incident. In the second incident, one resident kicked another in the buttocks without provocation, and the second resident retaliated by punching the first resident in the face three times. The Standards Compliance Director confirmed that this physical altercation was not reported to CDPH until two days after it occurred, despite the policy requiring reporting within 2 hours, and the PRA stated he had not received any notification of physical abuse for either resident. In the third incident, a resident allegedly punched another resident in the chin following a verbal altercation; the Standards Compliance Director again confirmed that this allegation was not reported to CDPH until two days after the incident, and the PRA reported no notification of this physical abuse allegation. Across all three events, the facility did not follow its policy requiring immediate, but no later than 2-hour, reporting of all alleged abuse to CDPH and failed to notify the PRA of the allegations.
Failure to Investigate and Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to treat resident-to-resident physical and sexual assault allegations as abuse, to conduct thorough investigations, and to report results to the State Survey Agency within required timeframes. One resident with schizophrenia (Resident 2) alleged that another resident (Resident 1) tried to have sex with him, and also admitted to punching that resident in the face. Interdisciplinary notes dated 2/7/2026 documented that Resident 1 sustained a 1.2 cm laceration to the right upper eyebrow requiring medical attention after being punched by Resident 2. Standards Compliance Supervising RN confirmed that these incidents were not considered abuse by the facility because they involved resident-to-resident physical and sexual assault, and therefore were not reported to the California Department of Public Health (CDPH) within 2 hours; instead, they were reported three days later. The facility did not conduct a thorough investigation into the alleged sexual assault. RN 2 stated he interviewed Resident 2, who reported he hit Resident 1 because he was trying to have sex with me, but RN 2 did not ask any further questions. The Program Director reported that after speaking with nursing staff and the treatment team, they concluded there was no validity to the sexual assault allegation and determined it was a delusion, and therefore did not investigate it as abuse or complete a SOC 341 suspected abuse report. Resident 2’s medical record did not contain a physician report following the sexual assault allegation, and the temporarily assigned psychiatrist did not see or evaluate Resident 2 until three days after the incident and did not address the allegation. The on-call psychiatrist on the date of the incident did not go to the unit to evaluate Resident 2 after the allegation, and the Patients’ Rights Advocate was not notified of the allegation. The facility also failed to investigate the physical assault on Resident 1 as abuse and to follow its own abuse reporting policies. Resident 1, who had multiple complex medical conditions including absence of the left eye, a tracheostomy, a gastrostomy tube, need for assistance, difficulty communicating needs, and use of a wheelchair for ambulation, was punched in the face by Resident 2 while sleeping, resulting in a laceration requiring medical attention. The Program Director stated that resident-on-resident physical assault was not considered abuse and that only staff could be perpetrators, so the incident was not investigated as abuse and a SOC 341 was not completed. The psychiatrist who saw Resident 1 four days after the incident focused only on medical issues related to the tracheostomy and did not address the physical assault. The Patients’ Rights Advocate was not notified of the physical assault, and the on-call psychiatrist did not evaluate either resident after being informed of the incident. These actions and inactions occurred despite facility policies defining physical abuse as including assault and requiring immediate completion of SOC 341, protection and counseling for the resident, notification of the Patients’ Rights Advocate, immediate reporting of alleged abuse to CDPH within 2 hours, and submission of investigation results to CDPH within 5 working days. The facility’s written policies on rape or sexual assault of elder/dependent adults and on reporting patient abuse and neglect required immediate medical attention, supportive counseling, evidence gathering, completion of SOC 341, physician reporting, and prompt reporting to CDPH for all alleged abuse, including in skilled nursing units. The policies also required that all alleged violations involving abuse be reported immediately but not later than 2 hours if the events involved abuse, and that results of investigations or follow-up reports be submitted to CDPH within 5 working days. In the incidents involving Residents 1 and 2, the facility did not follow these policies: alleged sexual assault and physical assault were not treated as abuse, SOC 341 forms were not completed, the Patients’ Rights Advocate was not notified, physician evaluations and reports were delayed or omitted, and the results of investigations were not submitted to the State Survey Agency within 5 working days because investigations were not conducted.
Failure to Assess and Monitor AV Fistula in Dialysis Resident
Penalty
Summary
The facility failed to provide ongoing assessment, monitoring, and implementation of interventions for a resident with ESRD who was dependent on renal dialysis and had an AV fistula in the left upper arm. The resident’s record showed diagnoses of ESRD, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, and heart failure. The physician had ordered the AV shunt on the left upper arm to be checked every shift for bruit and thrill, and the resident’s ESRD care plan directed staff to assess the non-functional AV fistula every shift for bleeding, thrombosis, stenosis, pain, and increased swelling. During observation, the resident was found sitting on the edge of the bed with a visibly swollen left hand and significant swelling of the entire left arm. The resident removed his jacket and showed the AV fistula site on the left upper arm. The resident had facial grimacing when attempting to make a fist with the left hand and stated he had been told about a month earlier that he had a blood clot near the AV fistula. The resident stated the fistula was no longer being used for dialysis because of the clot and that he had undergone a procedure for a new access site on the right side of the chest. He also stated the swelling made it very difficult to move his wrist and hand and that he experienced constant pain. Staff interviews showed that licensed nursing staff did not know how to properly assess or monitor an AV fistula. One LPT stated he was unsure how to monitor an AV fistula site and had not received training for dialysis patients. An RN shift lead stated she had not received training for dialysis care and did not know how to assess for bruits and thrills. Another RN unit supervisor stated she was not familiar with how to assess bruits and thrills on an AV fistula and that the facility did not provide training for dialysis patients. The medical doctor stated the resident had swelling in the left arm since May 2025 but was not evaluated by a vascular surgeon until the blood clot was found on 10/23/2025, and that there had been no new interventions or monitoring since that diagnosis. The RN shift lead confirmed that no interventions had been implemented after the blood clot was identified.
Missed pressure-injury monitoring and treatment
Penalty
Summary
The facility failed to provide consistent pressure-injury prevention, monitoring, and treatment for two residents with impaired skin integrity. Resident 30 had a history of Type 2 diabetes, required maximum assistance for mobility, was dependent on a wheelchair, and was at risk for pressure injuries. The resident’s buttocks had previously been identified as areas of impaired skin integrity, but the record showed no wound treatment entries or weekly wound assessments after the initial photographic documentation. During observation, Resident 30 was found with multiple untreated wounds on the buttocks, including a Stage II pressure injury on the left buttock, a Stage II pressure injury on the right buttock, and a deep tissue injury on the right buttock. The resident stated he had a painful wound on his bottom and said he was not receiving wound care. Resident 30 was also observed lying on an inflated low air loss mattress that was programmed for 400 lbs., despite the resident weighing far less than that. Staff confirmed the mattress had to be programmed to the resident’s actual weight to function correctly. Interviews and record review showed staff were unaware of the resident’s buttock wounds, and the medical doctor stated he had not physically seen the wounds until they were discovered. The facility’s wound documentation showed multiple open sores and deep red areas on the buttocks that were not included in assessments, treatments, or interventions, and staff confirmed each wound should have had an individual assessment, treatment, and intervention. Resident 4 had a history of non-traumatic brain dysfunction, required maximum assistance for mobility, was dependent on a wheelchair, and was at risk for pressure injuries. The resident’s left ischial tuberosity had previously been identified as an area of impaired skin integrity, but the record showed no weekly monitoring after the wound was documented as closed. During later review, a new open sore with a red wound bed was found on the left buttock and was identified by staff as a Stage II pressure injury. Resident 4 was also observed lying on an inflated low air loss mattress programmed for 300 lbs., despite weighing less than that amount. Staff and the medical doctor stated they were not aware of any new or current wounds, and the supervising nurse confirmed there was no documentation of skin assessments or monitoring after the prior wound had been noted as closed.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
Food safety and sanitation measures were not maintained in the kitchen when two cutting boards used for resident meal preparation were observed with discoloration and deep gouges on the surface. During the observation, the Food Service Supervisor stated that both cutting boards were worn out and needed to be thrown away. The report also cited the FDA Food Code section on cutting surfaces, which states that scratched and scored cutting boards may be difficult to clean and sanitize and can allow pathogenic microorganisms to build up and transfer to foods prepared on those surfaces. In addition, five resident food trays were observed dirty with built-up chocolate pudding and rice and unknown black marks while stored in the clean tray area. The Food Service Supervisor confirmed the trays needed to be re-cleaned. An opened box of previously frozen french toast was also found uncovered in a refrigerator and labeled with a date of 3/25/25. The Director of Dietetics stated the food had been moved from the freezer to the refrigerator to thaw, that it should have been completely closed and covered, and that it was expired with no known time of transfer to the refrigerator. The report cited the FDA Food Code requirement that refrigerated time/temperature control for safety foods be consumed, sold, or discarded by the expiration date.
Facility Assessment Not Updated or Fully Developed
Penalty
Summary
The facility failed to update its Facility Assessment annually and failed to include the specific competencies of licensed nursing staff and how often competency evaluations needed to be completed to care for residents competently during day-to-day operations and emergencies. During review of the facility assessment titled, Program 6: Skilled Nursing Facility Program Description, the required skills and competencies for licensed staff based on resident population and needs were not found. The assessment was last updated in 2021, and the Program Director confirmed it had been completed by herself and one Supervising RN. During interview, the Program Director stated she was unaware of how frequently the assessment was required to be updated and said the assessment did not break down the required skills and competencies for licensed nursing staff because those skills and competencies were dependent upon staff license. She also confirmed the facility assessment did not contain the required education, training, and staff competencies related to ongoing resident needs. The Standards Compliance Director stated the facility did not have a policy on the requirements of the facility assessment, and the facility was unable to provide a policy and procedure for Facility Assessment.
QAPI Plan Not Implemented for Pressure Ulcer Monitoring
Penalty
Summary
The facility failed to ensure its QAPI program implemented the plan to identify areas for improvement for residents at risk for developing pressure ulcers. During interview, the Nursing Coordinator stated that performance improvement plans were based on the previous year's survey results and included monitoring resident call light accessibility, resident dignity while dining, and the use of enhanced barrier precautions for identified residents. The Nursing Coordinator also stated there were no performance improvement plans that included monitoring pressure ulcers and no plans for assessing AV fistulas for residents requiring dialysis, and that there was no formal mechanism for prioritizing issues. The Program Director stated the QAPI team did not have any data to monitor and were not aware of any issues in the incidences of pressure ulcers or assessments of AV fistulas because there was not a baseline assessment for residents returning from outside facilities, so a comparison of before and after could not be made. A review of the facility's December 2024 QAPI plan showed it included identifying and using data to monitor performance, establishing goals and thresholds, utilizing resident and staff input, identifying and prioritizing problems and opportunities for improvement, systematically analyzing underlying causes of systemic problems and adverse events, and developing corrective action or performance improvement activities.
Infection Control Failures in Clean Linen Storage, Foley Care, and Glucose Monitoring
Penalty
Summary
The facility failed to implement infection prevention and control practices in Unit 404's clean linen room when multiple pieces of laundry were observed piled on a chair, on the floor in a corner, and on the floor in front of the storage shelving. Three linen covers were not covering clean laundry, and an opened water bottle was found on the floor mixed in with the laundry. The Unit Supervisor confirmed the water bottle should not have been in the clean laundry room, stated the laundry on the floor and chair should have been picked up, and stated clean laundry should be covered to prevent dust and contamination. The facility policy for transportation and management of clean linen stated clean linen should be handled and stored to maintain standard precautions and avoid contamination, with clean linen placed on shelves with protective covering and no other items stored in the clean linen room. The facility also failed to maintain infection control during care for a resident with an indwelling Foley catheter and during blood glucose monitoring for a resident with diabetes and HIV. Resident 4, who had urine retention and required a long-term Foley catheter, was observed sitting in a geriatric chair with the Foley collection bag lying across the resident's lap rather than below the bladder; the RN stated the bag needed to be placed below the bladder to drain properly, and the care plan directed staff to keep the drainage bag below the bladder. In a separate observation, LPT 2 checked Resident 10's blood sugar without wearing gloves, used an ungloved hand to apply pressure to the finger after the lancet stick, and then completed the glucose test. LPT 2 confirmed gloves were not worn, and the resident's care plan directed nursing staff to wear PPE, including gloves, gowns, and eyewear, during invasive procedures involving blood or body fluids as clinically indicated.
Staff Unable to Assess AV Fistula in Dialysis Resident
Penalty
Summary
Licensed nursing staff were found to be incompetent in assessing and monitoring dialysis residents for bruits and thrills. For Resident 10, who was admitted with ESRD, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, and heart failure, the physician’s orders directed staff to check the AV shunt in the left upper arm for bruit and thrill every shift. The resident’s ESRD care plan also directed assessment of the left upper arm AV fistula every shift for bleeding, thrombosis, and stenosis, with monitoring for pain and swelling. During interviews, multiple licensed nursing staff stated they did not know how to assess or monitor an AV fistula. LPT 1 stated he was unsure how to monitor an AV fistula site and had not received training for caring for dialysis residents. RNSL 2 stated, “I don't know” when asked how to assess for bruits and thrills. RNUS 1 stated she was not familiar with how to assess bruits and thrills on an AV fistula and said the facility did not provide training for caring for dialysis residents. LPT 2 also stated she did not know how to monitor an AV fistula and had not received training. Facility leadership confirmed the lack of training and competency checks. The SCD stated the facility does not provide specific training for caring for dialysis patients/residents or how to assess AV fistulas. The PD stated the facility does not provide training to staff for caring for residents that have dialysis and assessing AV fistulas. The NC stated the facility does not provide training or check staff competency with assessing AV fistulas and said the facility should have provided AV fistula training and checked staff competency. The DNE confirmed the facility’s training did not cover caring for dialysis residents or assessing AV fistulas. The facility policy required RN assessment of the vascular access site every shift and licensed nursing staff to monitor and report signs and symptoms, including changes in pulse, thrill, or bruit.
Uncovered Outside Dumpsters With Overflowing Garbage
Penalty
Summary
The facility failed to ensure four of five outside dumpsters were covered. During a concurrent observation and interview on 12/1/25 at 12:53 p.m. with the Dietetics Director in the outside loading dock area of Program VI building, four dumpsters were observed with overflowing garbage and no covers. There were many flies and a foul odor coming from the dumpsters. The Dietetics Director stated the dumpsters should have been covered and the area should have been kept clean. A review of the 2022 FDA Food Code, Section 5-501.15, indicated that outside receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue should be designed and constructed to have tight-fitting lids, doors, or covers.
Failure to Complete Annual Abuse Training for Licensed Nursing Staff
Penalty
Summary
The facility failed to maintain an effective abuse and neglect training program for 13 of 116 skilled nursing employees when annual abuse training was not completed for 13 licensed nursing staff members. During interview and record review, the employee Recognizing and Reporting Abuse Neglect training records showed that LPT 1, LPT 2, LPT 3, LPT 4, LPT 5, LPT 6, LPT 7, LPT 8, LPT 9, RN 4, RN 5, RN 6, and RN 7 had last completed abuse training on dates ranging from 10/12/21 to 11/26/24, and all were confirmed to be currently employed and assigned to the skilled nursing units. The Supervising RN confirmed the training dates and stated the staff were past due for annual abuse training and were not on long-term leave. During interview, the Nursing Coordinator stated Nursing Education provides a monthly list of staff due for training and that staff are scheduled during their birth month, which could result in staff going longer than a year between trainings because the schedule is based on birth month rather than the last completion date. The Nursing Coordinator confirmed that not receiving abuse training annually would cause staff to not receive the most current updates and might cause them to miss information. The facility policy titled Reporting Patient Abuse and Neglect stated that all employees are required to complete annual patient abuse prevention training.
Failure to Ensure Enclosure Bed Safety Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of neurocognitive disorder, epileptic seizures, and traumatic brain injury, who was identified as high risk for falls, experienced a fall from an enclosure bed. The enclosure bed, designed with mesh walls and a zipper to prevent falls, failed to provide adequate protection when the net zipper malfunctioned or was not properly secured. Staff had previously observed the resident inspecting and attempting to manipulate the zipper while inside the bed. On the day of the incident, the resident was found on the floor after managing to open the zipper, either due to a malfunction or because it was not properly secured by staff. Record reviews and staff interviews revealed that the resident was on 15-minute supervision for safety at the time of the unwitnessed fall. Facility policy required nursing staff to ensure all zippers were secure and clipped during rounds, whether the bed was occupied or unoccupied. However, staff did not ensure the enclosure bed was properly secured or in good working condition, which contributed to the resident's ability to open the bed and fall.
Failure to Provide Privacy During Insulin Administration
Penalty
Summary
The facility failed to honor a resident's expressed desire for privacy and dignity during insulin administration. Resident 10, who had a diagnosis of type 2 diabetes mellitus, was observed sitting in a wheelchair in the Unit 404 Day Hall with a food tray in front of him and six other residents present when LPT 2 brought the medication cart to him and informed him he needed insulin for an elevated blood sugar level. LPT 2 pulled up the resident's shirt to expose his abdomen, and the resident pulled his shirt back down and stated he did not want to get undressed in the Day Hall while eating with other residents. Despite the resident's request, LPT 2 told him it was okay and lifted his shirt again to administer insulin in the lower quadrants of the abdomen while he remained in view of others. During interview, LPT 2 confirmed the resident requested privacy and stated he should have taken the resident to his room or the treatment room to administer insulin. The RNSL stated staff should always provide privacy during medication administration and that LPT 2 should have brought the resident to his room. The facility policy titled Dignity and Respect of Individuality stated residents' privacy of body should be maintained and residents should be sufficiently covered.
Inaccurate MDS Coding of Active Viral Hepatitis
Penalty
Summary
The facility failed to assess and submit accurate MDS data for two sampled residents when Section I, Active Diagnoses, identified viral hepatitis as an active infection even though there was no treatment for hepatitis C for either resident. During a concurrent interview and record review with the MDS Coordinator, Resident 21’s MDS dated 10/4/25 and active orders dated 11/26/25 were reviewed. The MDS showed viral hepatitis as an active infection, while the active orders showed no treatment for viral hepatitis. The MDS Coordinator stated the resident was diagnosed with hepatitis C in 2015 and had not received treatment while at the facility, and confirmed the MDS should not have indicated viral hepatitis as an active infection. A similar finding was identified for Resident 1 during a concurrent interview and record review with the MDS Coordinator. Resident 1’s MDS dated 8/23/25 and active orders dated 11/26/25 were reviewed, and the MDS also indicated viral hepatitis as an active infection despite no treatment being ordered for hepatitis C. The MDS Coordinator stated Resident 1 was diagnosed with hepatitis C in 2022 and had not received treatment while residing at the facility, and confirmed the MDS should not have indicated viral hepatitis as an active infection. The CMS LTCF RAI 3.0 User’s Manual was reviewed and stated that diagnoses should be coded when documented in the last 60 days and directly related to the resident’s current functional status, cognitive status, mood or behavior status, or medical treatments, and gave inactive diagnoses as examples when the resident has recovered with no residual effects and no continued treatment.
Inaccurate skin assessments and incorrect medication route
Penalty
Summary
Three licensed nurses inaccurately completed weekly skin assessments for a resident with multiple ongoing skin problems. The resident had a diagnosis of type 2 diabetes mellitus, required maximum assistance for mobility, was dependent on a wheelchair, and was at risk for pressure injuries. The record showed active care plans for five boils to the buttocks, one boil to the left abdomen, and two boils on the gluteal area, along with photographic wound documentation showing ongoing treatment for a Stage III pressure injury to the sacral area. Weekly Body Check reports dated 10/1/25, 10/8/25, 11/12/25, and 12/3/25 were signed by LPT 12, LPT 11, and LPT 10 and indicated there was no skin impairment. During interview, the Registered Nurse Shift Lead stated these reports should have included all ongoing wounds being treated on the resident. The Unit Supervisor reviewed the same reports and confirmed the nurses did not accurately document the resident’s current skin status, stating the expectation was to complete the weekly body checks to accurately reflect the resident’s skin. A second deficiency involved a resident with schizoaffective disorder-bipolar type, dysphagia, and gastrostomy status. During medication administration, an LVN crushed Trazadone 100 mg in pudding and gave it to the resident by mouth, even though the physician’s order directed that the medication be crushed and given via G-tube. The medication administration record and physician orders both reflected the G-tube route, and the LVN stated she gave it by mouth because she saw the resident eating. The RN confirmed the order required administration via G-tube and stated there would be concern for aspiration if the medication were given by mouth instead of as ordered.
Respiratory Equipment and Oxygen Orders Not Properly Managed
Penalty
Summary
Resident 9 had a physician order dated 11/26/25 that stated, "May apply Oxygen to keep Oxygen Saturation 92% or above," but the order did not specify the amount of oxygen to be administered. During observation on 12/1/25, oxygen was running at 2 L per minute via nasal cannula, and the cannula prongs were observed outside the resident's nose. The RN confirmed the prongs should have been in the resident's nose and stated the resident was on 2 L of oxygen continuously. The HSS later confirmed there was no amount listed in the order and stated the order should specify the amount of oxygen. The MD stated he did not put the specific liters into the order and that 2 liters are administered instinctively. Resident 9's care plan indicated the resident was on continuous nasal cannula oxygen per order and had a risk for activity intolerance related to COPD. The RN Shift Lead stated oxygen is considered a medication and that oxygen orders should include parameters for how much oxygen to deliver as well as titration parameters. The facility's Oxygen Administration and Storage policy stated licensed nursing staff may administer oxygen per physician or nurse practitioner order. Resident 10 had a diagnosis of obstructive sleep apnea and an order for CPAP to be on at night and off when awake in the morning. During observation, the resident stated he cleaned his CPAP tubing and mask in the public bathroom sink and had never received training on cleaning the CPAP components. He also stated staff had not cleaned or changed any CPAP components since admission in May 2025. The RN Shift Lead confirmed staff had not cleaned the CPAP machine because there was no documentation on the CPAP/BiPAP Parts Cleaning Log. The RT stated she was unaware the resident had a CPAP machine and said the mask, tubing, and water chamber needed to be dumped out and cleaned daily to prevent mold buildup. In addition, the humidifier on Resident 10's oxygen concentrator was labeled to be changed on 11/28/25, and the RN confirmed it should have been changed and was supposed to be changed daily.
Incomplete Repositioning and Treatment Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete for three sampled residents. For one resident, a Repositioning Schedule posted at the bedside showed no repositioning entries from 12 a.m. to 5 a.m., even though the form directed staff to change the resident’s position at least every 2 hours while in bed and to place initials in the appropriate column. During interview, the Nursing Coordinator stated a staff initial should have been entered on the repositioning form. For another resident, a Repositioning Schedule posted at the bedside showed no repositioning entries from 12 a.m. to 12 p.m. on the day reviewed, despite the same instruction to document position changes every 2 hours while in bed. During interview, RN 1 stated the resident was repositioned, but it was not documented on the form, and that a staff initial should have been entered. For a third resident with End Stage Renal Disease and a left upper extremity AV fistula for dialysis, the Medication and Treatment Record had missing entries for RN assessments on the PM shift on 1/7/2026 and 1/13/2026. The physician orders required every-shift RN assessments of the AV fistula for bleeding, infection, aneurysm, vascular insufficiency, stenosis, thrombosis, pulse, thrill, and bruit. RN 2 confirmed the missing entries, and the facility policy stated that the assessment and care provided must be documented every shift in the Medication and Treatment Record.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for reporting allegations of abuse when a resident with schizoaffective disorder, bipolar type, disclosed to a psychologist that they had been beaten and raped. The psychologist documented the disclosure in a progress note but did not report the allegation to her supervisor, program management, or standards and compliance, nor did she complete the required incident report or SOC 341 form. The psychologist believed that abuse occurring in a different facility did not require reporting, despite facility policy stating that all allegations, regardless of when or where they occurred, must be reported if not previously documented. Interviews with facility staff, including the Standards and Compliance officer, Psychologist Director, Unit Supervisor, and Program Director, confirmed that no incident report was filed, and the required notifications to the state survey agency and other authorities were not made. The facility's policies clearly require immediate reporting and documentation of all abuse allegations, including those reported to have occurred prior to admission or in other facilities, but these procedures were not followed in this case.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for a psychiatric technician who had been employed since November 2017, resulting in eight missed evaluations. During a review of the employee's file, it was confirmed by the Staff Services Manager HR that no performance evaluations had been conducted, despite facility policy requiring annual appraisals. The Unit Supervisor acknowledged that she had not completed any evaluations for the employee, attributing the omission to oversight. The facility's policy and procedure document specified that supervisors and managers are responsible for preparing annual performance appraisal summaries for their assigned employees.
Failure to Document G-Tube Leakage
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident with a leaking Gastrostomy-tube (G-Tube). The resident, who had a history of schizophrenia, end-stage renal disease, essential hypertension, heart failure, and type 2 diabetes mellitus, was admitted to the facility and required a G-Tube for nutrition. On a specific date, a Psychiatric Technician (PT) observed that the resident's G-Tube dressing was saturated with clear liquid, and the abdominal binder was wet after the resident returned from dialysis. The PT notified the registered nurse about the situation but did not document the assessment in the treatment record. During a review of the resident's medical records, it was confirmed that there was no documentation of the leaking G-Tube in the Interdisciplinary Note (IDN) or the Medication and Treatment Record. The facility's policy and procedure for enteral tubes required that any abnormalities or refusals discovered during G-Tube care should be documented in an IDN. However, the Registered Nurse Mentor (RNM) confirmed that no such documentation was present in the resident's medical record, indicating a failure to adhere to the facility's documentation policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies involving six residents. For Resident 7, trash and linen carts were improperly placed outside the isolation room, contrary to the facility's policy that requires these carts to be inside the room to contain infection. Additionally, a psychiatric technician accepted a water pitcher from Resident 7, who was on isolation precautions, without wearing gloves, risking the transmission of influenza. In the case of Resident 36, a registered nurse and a psychiatric technician performed wound care using only gloves and masks, without the required gowns, despite the resident having unstageable pressure injuries. This was a breach of the Enhanced Barrier Precautions (EBP) guidelines, which mandate gown and glove use during high-contact care activities for residents with wounds. Similarly, Resident 1 received wound care without the use of a gown, and the staff involved were unaware of the EBP guidelines, indicating a lack of training and policy implementation. Further deficiencies were noted with Residents 35, 11, and 54, where staff failed to wear gowns during personal hygiene and dressing changes, despite the presence of conditions such as MRSA colonization and pressure injuries. The facility's policies and procedures were not followed, and there was a lack of awareness and training regarding EBP among the staff, contributing to the risk of cross-contamination and the spread of infections.
Lack of QAPI Plan in Skilled Nursing Units
Penalty
Summary
The facility failed to have a written Quality Assurance Performance Improvement (QAPI) plan in place for the Skilled Nursing units, which is essential for evaluating and improving the quality of resident care and services. During interviews with the Supervising Registered Nurse (SRN) 3, it was revealed that there was no existing QAPI plan, and the facility was not actively tracking or trending data related to the program and residents. This lack of a structured QAPI plan resulted in the facility's inability to identify systemic problems, particularly concerning infection prevention and enhanced barrier precautions (EBP). The facility's policy and procedure document, titled 'Quality Assurance' and dated 5/3/24, outlined the purpose of the Quality Assurance Program as establishing a systemic process to monitor and evaluate patient care quality. However, the facility did not adhere to this policy, as evidenced by the absence of a QAPI plan and the failure to discuss EBP during QAPI activities. This deficiency highlights the facility's inability to implement and report on activities and mechanisms for monitoring and evaluating the quality of patient care, as required by the governing body.
QAA Committee Lacks Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee had the required members in attendance, specifically the Infection Preventionist/Public Health Nurse II for the Skilled Nursing unit. This was identified during a concurrent interview and record review with the Standards Compliance Director (SCD) on November 8, 2024, where the SCD acknowledged the absence of the Infection Preventionist in the Quality Council Minutes from the September 5, 2024 meeting. Additionally, a review of the Quality Council Minutes from April 23, 2024, also indicated the absence of the Infection Preventionist. The facility's Policy and Procedure titled 'Risk Management,' dated July 8, 2024, did not list the Infection Preventionist as a required member of the Quality Council under section 4.3.1, which contributed to this oversight.
Lack of EBP Training and Policy in Facility
Penalty
Summary
The facility failed to maintain an effective infection control training program for all 94 staff members by not developing a written policy and training regarding Enhanced Barrier Precautions (EBP). EBP involves the use of gowns and gloves during high-contact resident care activities to reduce the spread of infections. During an observation, it was noted that there was no personal protective equipment (PPE) cart or EBP signage by the door of a resident's room who had unstageable pressure injuries. Interviews with various staff members, including the Interim Infection Preventionist, Registered Nurse, Psychiatric Technician, RN Shift Lead, Supervising RN, and Nursing Coordinator, revealed a lack of awareness and training on EBP. The staff admitted to not using gowns during wound care and were unaware of the EBP guidelines. The facility was unable to provide a policy for EBP upon review, and staff interviews confirmed that no training had been conducted. The Interim Infection Preventionist and other staff members acknowledged that they were not up to date with EBP and that the facility's policy did not address it. The lack of training and policy on EBP had the potential to negatively affect the facility's ability to maintain a safe environment and prevent the spread of infectious diseases among the 54 residents in the facility.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during meal times for two residents. In the first instance, a registered nurse (RN) was observed standing while feeding a nonverbal resident in bed, which did not allow for eye-level interaction. The RN acknowledged that standing over the resident could be intimidating and affect the resident's dignity. The facility's policy required staff to be seated and attentive when feeding residents, which was not followed in this case. In the second instance, another RN was observed standing while assisting a resident with drinking in the dining room. This resident was at risk for choking, and the RN admitted that he should have been seated while assisting the resident. The facility's policy also required staff to remain seated and attentive when feeding residents, which was not adhered to. Both instances highlight a failure to provide a respectful and dignified dining experience as per the facility's established procedures.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which could potentially result in unmet needs. Resident 357, who has a history of schizoaffective disorder, bipolar type, and major neurocognitive disorder due to traumatic brain injury, was observed in an enclosure bed with the call light dangling outside and out of reach. During interviews, both a Psychiatric Technician and a Registered Nurse acknowledged that the call light should have been accessible to the resident, as per the resident's care plan and the facility's policy and procedure on call light use. Similarly, Resident 26 was observed multiple times with the call light hanging from the wall and out of reach. A Registered Nurse confirmed that the call light should have been within reach, and a Supervising Registered Nurse stated that rounds were conducted every 30 minutes to ensure resident safety, including the accessibility of call lights. Despite these procedures, the call light was repeatedly found out of reach during observations, indicating a failure to adhere to the facility's policy and procedure on call light use.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to provide tube feeding according to the doctor's order for a resident with a gastrostomy tube (GT). During an observation, the resident's tube feeding pump was found alarming and not delivering the prescribed nutrition. The feeding pump was set to deliver 60 milliliters of liquid nutrition per hour, but the pump was left on hold after patient care, resulting in the resident not receiving the correct amount of tube feeding. The registered nurse shift lead confirmed the pump was not infusing and was unaware of the duration or the amount of feeding missed. Further interviews revealed that the resident received only 470 milliliters of tube feeding instead of the 660 milliliters ordered by the physician. The registered dietitian confirmed that not receiving the ordered tube feeding could lead to weight loss for the resident. The physician's orders indicated the resident should receive tube feeding at a rate of 60 milliliters per hour for 22 hours via the GT, but this was not adhered to, leading to a deficiency in care.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to meet food service safety and sanitation requirements, as observed during a survey. In the clean tray area, 15 food trays were found to be unclean, chipped, and stained with brown and yellowish marks, with one tray still having an old meal ticket attached. This was contrary to the facility's policy, which mandates that all kitchen and dining room utensils, along with food contact surfaces, be cleaned and sanitized before use, after use, and after each meal. Additionally, expired food items, including a pack of sugar and 16 boxes of coleslaw, were found in the dry warehouse and food storage area, respectively. The facility's policy requires staff to observe all food item expiration dates to ensure no expired products are used or stored. Further deficiencies were noted in the dry warehouse, where a dented can of vanilla pudding was improperly stored on a rack labeled 'use it first' instead of being placed in the designated Dented Cans Area. The facility's policy states that any damaged or dented cans should be rejected at the point of delivery. In the cold prep area, a yellow cutting board was found to be heavily marred with deep cut marks, which could harbor bacterial growth. This was inconsistent with the facility's policy that requires all food contact surfaces to be cleaned and sanitized before and after use.
Improper Disposal of Garbage and Debris in Food Storage Areas
Penalty
Summary
The facility failed to maintain cleanliness in food storage areas, specifically in the warehouse and main kitchen, which could potentially lead to foodborne illness among residents. During an observation and interview with the Dietetics Director (DD), two cups of grape juice and chipped wood debris were found on the warehouse floor. The DD disposed of the grape juice cups and acknowledged that the trash and debris should have been cleaned. Similarly, during an observation with the Assistant Dietetics Director (ADD) in the walk-in freezer, chipped wood and plastic wrappers were observed on the floor, and the ADD confirmed that these should have been cleaned. The facility's Policy and Procedure, titled Nutrition Policy Manual Policy Number: 3401, dated July 2018, states that garbage should always be placed in designated disposal units with lids, and storerooms should be swept daily to remove debris from deliveries or daily activities. The failure to adhere to these procedures was noted during the survey.
Failure to Provide Qualified Interpreter for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide a qualified, facility-approved interpreter for a Spanish-speaking resident, resulting in communication barriers. During an observation and interview, it was noted that the resident was unable to communicate effectively with staff due to the lack of a Spanish-speaking interpreter. The Lead Registered Nurse admitted to using non-approved interpreters, including other residents, to communicate with the resident. This issue was further highlighted when a medical evaluation was conducted using an unapproved interpreter, raising concerns about the accuracy of the translation and the resident's ability to convey his needs and concerns. The resident's care plans and assessments clearly indicated the need for a Spanish-speaking interpreter, yet the facility did not have a process to ensure interpreters were available each shift. Interviews with staff, including a Supervising Registered Nurse and a Social Worker, confirmed the absence of a reliable system for providing interpreters, leading to reliance on unapproved staff for translation. This deficiency was compounded by the facility's policy, which stated that accommodations should be made for non-English speaking patients, yet failed to implement a practical solution to meet this requirement.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident, resulting in a fall and a scalp contusion. During an observation and interview, the resident was found with discoloration on the left side of his forehead and reported not using his wheelchair when standing, which led to a fall. The resident, who is blind and requires moderate assistance for ambulation and transfers, experienced pain and nausea following the incident. A registered nurse observed the resident standing unassisted from his wheelchair and falling forward but did not intervene or educate the resident to sit down. The resident's care plan indicated the need for moderate assistance and education to prevent unassisted transfers. The facility's policy on fall prevention requires registered nurses to implement and oversee fall prevention strategies, which were not followed in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident, resulting in a fracture to the resident's left fifth finger. During an observation and interview, the resident revealed that she did not use her walker while ambulating, which led to her fall and subsequent injury. The resident's Minimum Data Set indicated that she required supervision or assistance when ambulating, and her treatment plan highlighted her unsteadiness and risk for falls, specifying the need for a walker and staff assistance. Despite these documented needs, a registered nurse observed the resident walking without her walker and did not intervene or educate her to use it. The supervising registered nurse confirmed that the resident should have been stopped and reminded to use her walker. The facility's policy on fall prevention emphasized the responsibility of registered nurses to implement fall prevention strategies, which were not followed in this instance, leading to the resident's fall and injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in significant injuries. Resident 1, who was non-verbal, medically compromised, and bedridden, was assaulted by Resident 2, who had a history of major neurocognitive disorder with behavioral disturbances. Resident 1 sustained multiple facial lacerations, contusions, and a nasal bone fracture due to the assault. The incident was unwitnessed, but Resident 2 was found with bloodied hands and blanket, and Resident 1 was transferred to the hospital for evaluation. Resident 2 had a documented history of impulsivity, low frustration tolerance, and dangerousness to others, with previous incidents of aggression towards peers. Despite this, no interventions were implemented following a prior altercation with another resident, and Resident 2 was roomed with Resident 1 due to a COVID quarantine on the unit. The facility's treatment plan for Resident 2 noted a moderate violence risk factor, but lacked documented interventions related to dangerousness and impulsivity. Interviews with facility staff revealed that Resident 2's behaviors were unpredictable, and no PRN medication or increased observation was ordered after the incident. The facility's policy on reporting patient abuse and neglect clearly stated that abuse is not tolerated, yet the lack of appropriate interventions and monitoring for Resident 2 contributed to the failure to protect Resident 1 from harm.
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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 Norwalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottage Crest Post Acute | 1.8 mi | ★★★★★ | 21 | 0 |
| Norwalk Skilled Nursing & Wellness Centre, Llc | 1.9 mi | ★★★★★ | 4 | 0 |
| Southland | 2.3 mi | ★★★★★ | 33 | 0 |
| Intercommunity Healthcare & Rehabilitation Center | 2.4 mi | ★★★★★ | 3 | 0 |
| Studebaker Healthcare Center | 2.5 mi | ★★★★★ | 46 | 0 |
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