Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Devonshire Care Center during CMS and state inspections, most recent first.
Surveyors found that a sit-to-stand lift and its sling were visibly soiled with debris, dust, hair, and a whitish substance, and the DON acknowledged the equipment was dirty despite facility policy requiring an effective IPCP. Shower rooms contained linen and trash bins full of used linens with strong urine and stool odors, and CNAs and the IP reported that these bins should be emptied and removed after morning rounds, and that shared equipment and slings should be disinfected or washed between uses. These observations demonstrated that infection prevention and control practices, including cleaning of shared equipment and timely removal of soiled linens and trash, were not being consistently implemented.
Surveyors found that shower rooms were not maintained in a safe and sanitary condition, including missing floor tiles and damaged baseboards, dirty shower tiles and grout with brown/black buildup, used razors discarded in a regular trash bin, and an overflowing sharps container that would not close. During interviews, the DON, CNAs, and IP all acknowledged that razors should be placed in sharps containers and that sharps containers should not be overfilled. The Director of Maintenance reported that staff had notified him of shower room issues and that he had removed additional tiles and ordered replacements, but he had not entered a work order or maintained documentation as required by facility maintenance and bathing policies.
A resident with a right arm fracture and chronic pain conditions reported constant, uncontrolled pain despite having PRN orders for acetaminophen for mild pain (1–4) and oxycodone for moderate to severe pain (5–10). Record review showed staff administered oxycodone without following the ordered pain scale parameters, including one dose with the pain level documented as "NA" and two doses given when the recorded pain level was 4, for which acetaminophen was ordered. The care plan required assessment of pain characteristics and medication as ordered, and the facility’s pain policy required documenting pain presence on the MAR; the DON confirmed that acetaminophen should have been used for pain level 4 and that "NA" did not represent an accurate pain assessment.
A resident with oropharyngeal dysphagia and Alzheimer’s disease, who had orders for a regular diet with mildly thick (IDDSI Level 2) liquids and care plans addressing altered texture and consistency, was observed receiving water that had been inadequately thickened by nursing staff. The thickener had settled at the bottom of the glass, leaving the liquid on top thinner than ordered, and when the resident drank it, the resident began coughing and choking and required repositioning and nursing assistance. In interviews, the DON explained that liquids require several minutes to reach the proper consistency, and an LN admitted not allowing enough time for the water to thicken, contrary to the facility’s guidelines for serving thickened liquids.
Two residents were found occupying a room with a damaged ceiling above one bed, showing a warped protrusion, peeling paint, and a crack exposing the board underneath. Additionally, a television cable outlet near the beds was missing a plate cover, leaving the cable wire exposed. The Maintenance Director confirmed the ceiling damage was likely from a past water leak and acknowledged both issues should have been addressed.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for supporting residents' physical, mental, and psychosocial health.
A resident did not receive a physician-ordered IV antibiotic for 35 days following a surgical procedure due to the facility's failure to identify and address the missed order through its QAPI program. The issue was not discussed in QAPI meetings, and the Administrator was unaware of the problem until a complaint investigation, resulting in Immediate Jeopardy and substandard quality of care.
The facility did not have a program in place to monitor antibiotic use, resulting in a lack of systematic tracking or evaluation of antibiotic prescribing and administration for residents.
The facility did not ensure adequate CNA staffing coverage during lunch breaks, resulting in periods where large areas of the facility were left without CNA presence. Multiple CNAs took extended or simultaneous breaks, leaving only a few staff to care for a high census of residents, which did not meet the facility's own standards for safe and responsive care.
Two nursing staff members were observed using personal cell phones in patient care areas, in violation of facility policy. One LVN was seen with a cell phone and earbud at a nurse's station, and a CNA was observed texting at another nurse's station. Both staff acknowledged that cell phone use was not permitted while working on the floor, and the Director of Staff Development confirmed the policy restricting such use to breaks or off-duty times.
A resident with COPD, heart disease, and recent hernia surgery did not receive required weekly CBC labs or follow-up appointments with a surgeon, cardiologist, and pulmonologist as ordered in hospital discharge instructions. Facility staff interviews and record review confirmed that these orders were missed during admission and not entered into the system, resulting in a delay in care.
A resident with end stage renal disease and diabetes, who was cognitively intact, reported that a CNA repeatedly placed her cell phone in his pocket without permission. The allegation was communicated to staff by the resident's family, but the required report to CDPH was not made within the facility's two-hour policy timeframe, as confirmed by staff interviews and record review.
The facility did not ensure accurate documentation and regular review of Advance Directives and POLST forms for multiple residents, with missing physician signatures, incomplete forms, and lack of evidence that residents or their representatives were offered information about advance directives or that these were reviewed as required by policy.
Multiple residents reported that meals were unpalatable, unattractive, and often served at improper temperatures, with some not receiving preferred diets or supplements. Delays in meal service, lack of communication about menu changes, and inconsistent snack availability were observed. Dietary staff confirmed that resident preferences were not consistently entered or followed, leading to dissatisfaction and unmet nutritional needs.
Surveyors found that an open box of breakfast patties was left exposed to air in the walk-in freezer, and black wet debris was present where the metal walls met the flooring on all sides of the walk-in refrigerator. The Dietary Manager confirmed these conditions could lead to cross-contamination, and both issues were not in compliance with facility policies requiring proper food storage and kitchen sanitation.
Staff did not follow infection prevention protocols when a CNA placed an ice scoop on a transport cart instead of in its designated container, a resident's IV site was left unlabeled without a date or nurse's initials, and an LVN failed to disinfect a blood pressure machine between uses and did not use PPE correctly during medication administration to a resident on enhanced barrier precautions.
Several residents did not have comprehensive or updated care plans for discharge, indwelling catheter use, or changes in condition such as UTIs. Despite ongoing discharge planning, physician orders, and new diagnoses, the interdisciplinary team did not consistently initiate or revise care plans as required, as confirmed by staff interviews and record reviews.
Several residents who were dependent on staff for ADLs, including toileting and hygiene, were left soiled and unchanged for extended periods. Residents and their roommates reported that call lights were not answered and requests for assistance were ignored, resulting in residents remaining in urine and feces. Staff interviews confirmed that residents were not cleaned in a timely manner, and facility policies requiring prompt response and maintenance of dignity were not followed.
Multiple residents with significant medical needs reported that call lights were not answered promptly and that they were left soiled for extended periods due to insufficient CNA staffing. Staff and management confirmed that required direct care service hours were not met on several days, and CNAs were assigned more residents than facility guidelines allowed, resulting in delays in assistance with activities of daily living (ADLs) and negatively affecting resident care.
A resident with significant ADL assistance needs and cognitive intactness was found with their call light placed out of reach, tucked in a bedside drawer. The resident reported previous concerns about not being able to access the call light when needed. Staff interviews confirmed the expectation that call lights should always be within reach, in accordance with facility policy and CNA job descriptions.
A resident with dementia and depression lost her lower dentures, which were not promptly reported or investigated according to facility policy. The DON was unaware of the loss for several days, and staff did not immediately search for or attempt to replace the dentures, resulting in resident distress.
A resident with congestive heart failure, chronic kidney disease, and an automatic cardiac defibrillator was incorrectly coded as receiving dialysis on an MDS assessment, despite only being on hospice care. The MDS Nurse and DON confirmed the resident was never on dialysis and that the assessment should have reflected hospice status, in accordance with facility policy.
A resident with diabetes and chronic kidney disease experienced symptoms of a UTI and underwent urinalysis and urine culture, which confirmed infection. Despite these results, there was no documented physician notification, no antibiotic order, and no care plan initiated. Staff interviews confirmed the resident was not informed of the results or treated, and the DON acknowledged that required protocols for change in condition and physician notification were not followed.
A resident with a history of major depressive disorder and diabetes cellulitis was admitted with broken eyeglasses and waited months for optometry services despite a physician's order and repeated requests. The facility failed to arrange for the resident to be seen by the optometrist during scheduled visits, and staff interviews confirmed that the need for ancillary care was communicated but not acted upon in a timely manner.
Two residents with indwelling urinary catheters experienced excessive sediment buildup and missed or delayed urology follow-up appointments. Staff failed to assess, document, and report changes in catheter condition to the physician, despite care plan requirements and repeated observations of catheter complications. Facility policy for daily catheter care and timely follow-up was not followed.
A resident with limited jaw movement was kept on a pureed diet despite a speech therapy evaluation and physician order for a regular texture, thin liquid consistency diet. The resident consumed only a quarter of meals and expressed dissatisfaction until the diet was corrected, indicating the facility did not promptly update the dietary plan as required.
A direct care staff member did not have documentation of an annual performance evaluation as required by facility policy. The Director of Staff Development confirmed the absence of this documentation during a review of the staff member's personnel file.
Surveyors found expired Biopatch IV dressings and an outdated bottle of Fluocinonide 0.05% topical solution with a damaged label stored in medication and treatment carts. Both a nurse and the DON confirmed these items should have been discarded according to facility policy, but were instead readily available for use.
Loose, unsecured wires were found hanging in a resident's room, despite facility policies and staff training requiring such hazards to be reported and addressed. The resident, who used mobility aids and required assistance with care, expressed concern about the exposed wires, and the Maintenance Director confirmed the wires should not have been left open or unreported.
A resident with end stage renal disease missed multiple scheduled hemodialysis treatments because transportation to the dialysis center was not arranged or verified by staff, despite physician orders and facility policy requiring such arrangements. Documentation and staff interviews confirmed that the lack of follow-up led to the missed treatments.
The facility failed to monitor three residents after falls, as per policy. A resident with Parkinson's and subdural hemorrhage fell and complained of neck pain but was not immediately sent to the ER. Another resident with encephalopathy and cerebral infarct had two falls without documented monitoring. A third resident with dementia had two falls, with inconsistent neuro checks. The administrator confirmed the need for monitoring per policy.
The facility failed to manage pain for two residents according to physician's orders. One resident, with encephalopathy and cerebral infarct, did not receive acetaminophen after a fall despite showing pain. Another resident, with congestive heart failure, received tramadol for severe pain without proper orders for such pain levels. The facility's pain management policy was not followed.
A resident with severe cognitive impairment and multiple health issues was found with unexplained discolorations on their body. Despite facility policy requiring immediate reporting of such injuries to CDPH, the incident was not reported. The DON and Administrator later acknowledged the oversight, recognizing the need for compliance with reporting regulations.
A facility failed to develop care plans for five residents with rashes, despite their identification through body checks. The residents had various medical conditions and cognitive impairments, requiring different levels of assistance with ADLs. Interviews with staff highlighted the importance of immediate care plan creation following changes in residents' conditions, as per facility policy. However, the absence of care plans for the rashes indicated non-compliance with these guidelines.
A resident's cash amounting to $1,176 went missing after admission to the facility, with discrepancies in documentation and handling by staff. The facility's policy on preventing misappropriation of resident property was not followed, leading to the unaccounted funds. Staff interviews revealed inconsistencies, with a CNA claiming to have given the money to an LVN, who denied receiving it.
During a COVID-19 outbreak, the facility failed to implement proper infection control practices. The DON wore an improperly fit-tested N95 mask, and 46 out of 70 direct care staff were not fit-tested. Additionally, rooms with COVID-19 positive residents were not properly isolated, and the outbreak was not reported to the CDPH as required.
A facility failed to report an allegation of physical abuse involving a resident to the CDPH, Ombudsman, and law enforcement within the required timeframe. The resident, who was cognitively intact, reported an incident of hair-pulling, but the facility did not document monitoring or investigation. The DON was aware of the allegation but did not report it, citing unsubstantiated claims and changing details.
A resident reported an abuse incident involving hair pulling, but the facility failed to conduct a thorough investigation. Despite the resident's cognitive intactness, the DON concluded the allegation was unsubstantiated without further inquiry, contrary to the facility's policy. This oversight potentially exposed the resident to further harm.
The facility failed to document treatment orders for two residents, potentially worsening their skin conditions. One resident with an ileostomy did not have documented care for 15 days, while another with severe cognitive impairment and MASD lacked documentation on four days. Staffing issues and workload were cited as reasons for the oversight, contrary to the facility's policy requiring timely documentation.
The facility failed to document physician-ordered treatments for pressure injuries for two residents. One resident, cognitively intact, did not receive documented care for a sacrococcyx ulcer for 14 days, while another with severe cognitive impairment had inconsistent treatment documentation for multiple pressure injuries. The absence of documentation was due to treatment nurses being out sick and heavy caseloads, contrary to the facility's policy requiring timely documentation.
The facility failed to arrange necessary medical consults for four residents as per physician orders, potentially delaying their care. A resident with lymphedema and anxiety disorder did not receive a follow-up with an orthopedic surgeon, while another with hemiplegia and diabetes had no follow-up for a clogged G-tube removal. A resident with multiple sclerosis required a cardiology consult due to falls, and another with hypertension needed a urology consult for urinary issues, but neither was arranged. Staff interviews revealed communication lapses, and the Administrator acknowledged the oversight.
A resident was admitted to the facility without a timely obtained list of home medications, resulting in the resident not receiving routine medications. Despite attempts to contact the resident's PCP, the facility staff failed to follow up adequately, leading to a potential adverse effect on the resident's health.
A visitor and a staff member failed to wear PPE before entering rooms with contact isolation precautions, leading to a breach in infection control. The visitor was not informed by staff about the need for PPE, and the Social Service Director entered a room without PPE despite knowing the requirements. The Infection Preventionist noted the risk of infection spread due to this oversight. The residents involved required isolation for rashes and a Methicillin-resistant Staphylococcus aureus infection.
A resident with multiple medical conditions, including diabetes and hemiplegia, did not receive necessary fingernail care, resulting in long, discolored nails with debris. The facility's policy required daily cleaning and trimming, but staff interviews revealed confusion over responsibility for nail care, leading to the deficiency.
A resident with a history of hemiplegia and other conditions developed untreated skin irritation on the neck due to the facility's failure to provide necessary services. Staff, including an LVN, CNAs, and a TN, were unaware of the issue, despite care plans requiring regular skin assessments. The facility's policies on skin integrity and ADLs were not followed, leading to this deficiency.
The facility failed to ensure timely responses to call lights, as observed with a resident who waited 15 minutes for assistance. Interviews with CNAs confirmed that the expected response time should be between three to ten minutes, and 15 minutes was deemed too long.
The facility failed to ensure appropriate care for pressure injuries for two residents. One resident did not receive weekly wound assessments, and another did not receive an air mattress as ordered. These failures led to potential worsening of their conditions.
The facility failed to ensure that a resident had floor mats on both sides of the bed, increasing the risk of injury if the resident fell out of bed on the right side. Despite the resident's history of falls and a care plan that included fall mats, only one mat was observed during an unannounced visit. Interviews with CNAs confirmed that floor mats should be on each side of the bed.
The facility failed to ensure that two residents did not share a bathroom with residents of the opposite sex, leading to complaints and an incident where one resident was walked in on by another of the opposite sex. Facility directors were unaware of the issue despite the policy against such sharing.
The facility failed to complete Level II mental health evaluations for two residents with positive Level I screenings. Despite having diagnoses that required further evaluation, the staff did not follow up with the state as required, resulting in incomplete assessments.
Failure to Maintain Clean Shared Equipment and Properly Manage Soiled Linens in Shower Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to dirty shared equipment and improper handling of soiled linens and trash. During an unannounced visit, a sit-to-stand lift blocking a shower room was observed with a shower pad/sling that had a whitish substance on it, and the footboard of the lift contained crumbs, debris, dirt, dust, and hair, which were confirmed when wiped with a glove. The DON acknowledged that the sit-to-stand lift and sling were dirty and stated that the sling should be sent to laundry to be washed and the equipment wiped down after use. The facility’s Infection Prevention and Control Program policy indicated that an IPCP is to be established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors also observed that shower rooms contained linen and trash bins full of used linens with a strong, pungent urine smell, and carts with urine and trash odor present after morning care. CNAs reported that they placed trash and dirty linen bins in the shower areas after morning rounds and that the linen bins should be emptied after morning rounds due to the strong smell of stool and urine. The IP similarly stated that linen and trash should be taken out after morning rounds, that the smell of trash and dirty linens in the shower area should not be present, and that shared resident equipment should be disinfected after each use with all slings washed between uses. These observations and interviews showed that the facility did not implement its infection prevention and control measures as outlined in its policy.
Failure to Maintain Safe and Sanitary Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary physical environment in multiple shower rooms used by up to 92 residents. During an unannounced visit, surveyors observed one shower room marked "out of service" that contained missing floor tiles and peeled-off baseboards on the shower wall, as well as a trash bin containing used razors. Another shower room was observed with an overflowing sharps container filled with used razors that could not be closed, and shower tiles and grout with visible brown to black buildup. These conditions were directly observed by surveyors during the visit. In interviews conducted during the observations, the DON stated that razors should be disposed of in sharps containers and not in regular trash bins. CNAs reported that sharps containers should not be allowed to become too full because they would not close properly, and the IP confirmed that sharps containers should not be overfilled and that it was unsafe to have used razors sticking out. The Director of Maintenance stated that nursing staff had reported issues with the shower room, that he had removed additional tiles after identifying missing tiles and broken base of the shower wall, and that the room was not in use at that time. He also acknowledged that although he had reported the issues to management and ordered new tiles, he had not entered a work order into the facility’s system and had no documentation of work done, despite facility policies requiring maintenance of the building in good repair, maintenance records, and clean tubs and showers.
Failure to Follow PRN Pain Medication Parameters and Document Accurate Pain Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management by not administering pain medications according to physician orders and not performing accurate pain assessments for a resident with significant pain. A resident admitted with a right humerus fracture and additional diagnoses including neuropathic pain, severe back pain, and sciatica reported being in constant pain and expecting around-the-clock pain medication, stating that his pain was not controlled. The resident had physician orders for acetaminophen 325 mg, two tablets by mouth every four hours PRN for mild pain (1–4), and oxycodone 10 mg, one tablet by mouth every four hours PRN for moderate to severe pain (5–10). The resident’s care plan directed staff to evaluate pain characteristics (quality, severity, location), medicate as ordered, and monitor for effectiveness and side effects. Review of the Medication Administration Record (MAR) for February 2026 showed that oxycodone was administered in ways that did not follow the ordered pain parameters and without accurate documentation of pain levels. Oxycodone was given on one occasion with the pain rating documented as “NA,” and on two other occasions when the documented pain rating was 4, which fell within the range for which acetaminophen, not oxycodone, was ordered. During an interview, the DON confirmed that acetaminophen should have been administered when the resident’s pain level was 4/10 and acknowledged that documenting “NA” for pain level when oxycodone was administered did not accurately reflect the resident’s pain assessment. The facility’s pain management policy required pain presence to be documented on the MAR, but this was not consistently done for this resident.
Improper Preparation of Thickened Liquids for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink in a form designed to meet an individual resident’s needs, specifically for a resident with oropharyngeal dysphagia and Alzheimer’s disease. The resident’s MDS documented coughing and choking during meals and when swallowing medications, pain when swallowing, and the need for a mechanically altered diet with changes in texture of food and liquids. The physician’s orders, effective October through December, specified a regular diet with regular texture, mildly thick consistency liquids, and fortified food, and the resident had active care plans for dysphagia and nutritional risk that included providing the diet as ordered and 1:1 assistance when needed. During an observation at lunchtime, the resident was seen receiving a meal tray and drinking water that had been thickened. A nurse brought another glass of water with thickener added, but the thickener had visibly settled at the bottom of the glass, leaving the water on top thinner than ordered. When the resident drank the liquid, he began coughing and choking and required assistance to be positioned upright at a 90-degree angle and leaned forward, and the nurse was called. In interviews, the DON stated that nursing staff are permitted to add thickener but that the process requires a few minutes for the liquid to reach the proper consistency, and the LN acknowledged adding thickener to the resident’s water without allowing sufficient time for it to thicken properly. This was inconsistent with the facility’s Diet and Nutritional Care Manual guidelines for serving thickened liquids and the ordered mildly thick (IDDSI Level 2) consistency.
Damaged Ceiling and Exposed Cable Outlet in Resident Room
Penalty
Summary
During an unannounced visit, surveyors observed that a resident room had significant environmental deficiencies. The ceiling above one bed in the room displayed an irregular, circular, warped protrusion with peeling paint and a central crack that exposed the underlying board. Additionally, a television cable outlet located between two closets near the foot of the beds was missing a plate cover, leaving the cable wire exposed and the inner wall visible through the opening. Both beds in the room were occupied by residents at the time of the observation. Interviews with facility staff revealed that the Maintenance Director identified the ceiling damage as likely resulting from a previous water leak, possibly due to heavy rains earlier in the year, and acknowledged that it should have been repaired. The Maintenance Director also confirmed that the cable outlet should have had a cover. The Administrator stated that maintenance staff are expected to conduct monthly rounds in every room and that department heads and all staff are responsible for reporting environmental issues. A review of the facility's maintenance policy indicated that the Maintenance Department is responsible for keeping the building in good repair and free from hazards at all times.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of physical, mental, and psychosocial well-being for residents, as required by regulatory standards.
Failure to Address Missed IV Antibiotic Order Through QAPI
Penalty
Summary
The facility failed to have a written Quality Assurance Performance Improvement (QAPI) plan in place to address the issue of not carrying out a physician's order for IV antibiotics for a resident following a surgical procedure. Despite identifying that the resident did not receive the IV antibiotic ordered by the orthopedic surgeon, the facility did not initiate a QAPI process to investigate or address the missed administration. The missed IV antibiotic order was not discussed in the QAPI meeting held after the issue was identified, and the Administrator was unaware of the problem until it was brought up during a complaint investigation. Facility records showed that QAPI meetings were held regularly and attended by key staff, but the specific issue of the missed IV antibiotic was not included in the agenda or addressed by the committee. The facility's policy indicated that the QAPI committee is responsible for overseeing and implementing the program, with the Administrator ultimately responsible for interpreting findings to the governing body. However, the lack of action and communication resulted in the resident not receiving the prescribed IV antibiotic for 35 days, leading to the identification of Immediate Jeopardy and substandard quality of care.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program indicates that antibiotic prescribing and administration were not being systematically monitored or assessed by the facility staff.
Failure to Maintain Adequate CNA Coverage During Lunch Breaks
Penalty
Summary
The facility failed to provide sufficient nursing staff coverage to meet residents' needs and ensure their safety when multiple Certified Nursing Assistants (CNAs) took extended lunch breaks without adequate coverage. On several occasions, including April 15, 16, and 27, 2025, documentation and timecard reviews showed that groups of CNAs clocked out for lunch simultaneously, leaving entire hallways or large portions of the facility without CNA coverage for periods ranging from 16 to 30 minutes. During these times, the remaining staff were insufficient to safely care for the number of residents present, with as few as two CNAs and one Restorative Nursing Assistant left to care for up to 96 residents. Interviews with the Director of Staff Development (DSD) confirmed that the facility's practice was to stagger CNA lunch breaks to maintain coverage, but this was not consistently followed. The DSD acknowledged that the number of staff left on the floor during these periods was not adequate to ensure resident safety or meet their needs. Payroll and schedule reviews corroborated that CNAs took extended or simultaneous breaks, and in at least one instance, a CNA attempted to adjust their timecard after taking a longer break. The facility's job description for CNAs emphasized the importance of providing care in a manner conducive to safety and comfort, which was not maintained during these uncovered periods.
Staff Use of Personal Cell Phones in Patient Care Areas
Penalty
Summary
Two nursing staff members were observed using their personal cell phones in patient care areas, contrary to facility policy. One LVN was seen at a nurse's station looking at her cell phone with an earbud in her ear, and admitted she should not have been using her phone or earbud while on duty. Another CNA was observed texting on her cell phone at a different nurse's station and acknowledged that cell phone use was not permitted while working on the floor, stating that staff were supposed to use their phones only in the break room. The Director of Staff Development confirmed that personal cell phone use is discouraged on the floor to prevent staff distraction and ensure attention to residents, and that use is only allowed before or after shifts or during breaks. The facility's employee handbook also restricts the use of personal electronic devices in work areas, especially those with cameras or recording capabilities. These observations and staff admissions demonstrate a failure to adhere to professional standards of quality regarding the use of personal electronic devices in resident care areas.
Failure to Schedule Follow-Up Appointments and Labs per Hospital Discharge Orders
Penalty
Summary
The facility failed to ensure that follow-up appointments and laboratory work were completed according to the discharge instructions from the acute hospital for one resident. Upon admission, the resident had a history of chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, and had recently undergone surgical repair of an inguinal hernia. The hospital discharge summary specified the need for weekly CBC (complete blood count) tests and follow-up appointments with a surgeon, cardiologist, and pulmonologist. However, a review of the resident's medical record revealed that only one CBC was completed, and there was no documentation of any follow-up appointments being scheduled or conducted with the required specialists. Interviews with facility staff, including the Social Services Director, Licensed Vocational Nurse, RN supervisor, and MDS nurse, confirmed that the process for reviewing and implementing hospital discharge orders was not followed. The Social Services Director stated that nursing staff were responsible for scheduling appointments and notifying social services for transportation, but there was no record of such actions for this resident. The RN supervisor and MDS nurse both acknowledged that the necessary orders for ongoing labs and specialist appointments were missed during the admission process and were not entered into the system. The facility's policy required support in scheduling specialty healthcare appointments and arranging transportation, with documentation in the electronic medical record. Despite this policy, there was no evidence that the required follow-up care was arranged for the resident, resulting in a delay in care and treatment. The deficiency was identified during an unannounced complaint investigation, and the lack of follow-up had the potential to affect the resident's overall health condition.
Failure to Timely Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to notify the California Department of Health (CDPH) within the required two-hour timeframe after an allegation of abuse was reported against a Certified Nursing Assistant (CNA) by a resident. The incident involved a resident with end stage renal disease and diabetes mellitus, who was cognitively intact as indicated by a BIMS score of 15. The resident reported that a male CNA repeatedly placed her cell phone in his pocket without permission, and she informed her family about the incident during their visit. The family then reported the allegation to facility staff. Despite the facility's policy requiring immediate or within two-hour reporting of abuse allegations to CDPH, the report was not made in a timely manner. Interviews with facility staff, including the Social Service Director (SSD) and the Administrator, confirmed that the Registered Nurse Supervisor (RNS) did not report the abuse allegation to CDPH immediately or within the required timeframe after being informed. Review of the resident's records and care conference notes further indicated delays in communication and documentation of the incident.
Failure to Accurately Document and Review Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure accurate and complete documentation of residents' wishes regarding their care, specifically related to Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) forms, for 12 out of 18 residents reviewed. In several cases, POLST forms were either missing required physician signatures, lacked physician information or license numbers, or were signed by a physician different from the one listed on the form. For example, one resident's POLST was not signed by the physician since January, and another's form was missing both the physician's information and signature. These omissions were confirmed through record reviews and interviews with the Social Services Director (SSD) and Director of Nursing (DON), who acknowledged that the forms should have been properly completed and signed according to facility policy. Additionally, the facility did not consistently document periodic reviews of POLST forms as required by policy. For multiple residents, there was no evidence that the POLST had been reviewed quarterly or annually, either during interdisciplinary team (IDT) meetings or care conferences. The SSD and DON both stated that POLST forms are supposed to be reviewed every three months and at annual assessments, but admitted that this documentation was lacking for several residents. Facility policy requires that the IDT review advance directives with residents during quarterly care planning sessions and document any changes, but this was not done in these cases. Furthermore, there was no documented evidence that residents or their representatives were offered information about formulating an Advance Directive upon admission, nor that ongoing reviews of advance directives were conducted as required. This was the case for all 12 residents identified in the report, regardless of their cognitive status. The facility's own policies and job descriptions require that residents be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive, and that these discussions and any changes be documented in the care plan and medical record. However, interviews with facility staff confirmed that this documentation was not present.
Failure to Provide Palatable, Preferred, and Timely Meals and Snacks
Penalty
Summary
The facility failed to provide food and drink that met residents' preferences for temperature, flavor, consistency, and appearance. Multiple residents reported that meals were unpalatable, unattractive, and often served at inappropriate temperatures. Specific complaints included food being tasteless, poor in appearance, and either too hot or too cold. One resident, who was on a pureed diet despite being able to swallow without difficulty, repeatedly requested a regular diet and expressed dissatisfaction with the pureed food. Another resident reported not receiving preferred flavors of nutritional supplements, while others noted missing or insufficient meal components, such as eggs at breakfast, and a lack of meat options. Residents also indicated they were not informed of menu changes and were unaware of available alternatives. Observations during meal service revealed significant delays, with lunch arriving nearly an hour late, and residents expressing dissatisfaction with both the taste and presentation of the food. Some residents resorted to using their own food or having family bring meals from outside due to dissatisfaction with facility offerings. Additionally, there were issues with the availability and distribution of snacks. One resident reported being denied a snack at night because the facility had run out, and others noted that snacks were not consistently available or distributed, especially if not specifically labeled for individual residents. Interviews with dietary staff and review of facility records confirmed that resident food preferences were not consistently entered or followed in the dietary system, particularly after a recent menu and program change. The dietary manager acknowledged missing or incomplete entries of resident preferences. The facility's policy required identification and accommodation of individual food preferences, timely provision of alternatives, and consistent snack availability, but these standards were not met, as evidenced by resident complaints and staff interviews.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food preparation and storage practices in the kitchen. Specifically, an open box of breakfast patties was found exposed to air in the walk-in freezer, which the Dietary Manager acknowledged could result in cross-contamination and food deterioration. Facility policy requires all foods to be stored wrapped or in covered containers to prevent cross-contamination, but this was not followed in this instance. Additionally, black wet debris was found where the metal walls met the flooring on all four sides of the walk-in refrigerator. The Dietary Manager confirmed the presence of this debris and stated it should not be present, as it poses a risk for cross-contamination with food stored in the refrigerator. Facility policy mandates that the kitchen, including floors and walls, be maintained in a clean and sanitary manner, and that staff are knowledgeable in proper cleaning and sanitizing procedures to prevent cross-contamination.
Infection Control Lapses in Equipment Handling and IV Site Labeling
Penalty
Summary
Staff failed to adhere to infection prevention and control practices in several observed instances. One certified nursing assistant was seen placing a metal ice scoop on top of a transport cart instead of returning it to the designated ice bag cover while refilling residents' water pitchers. Both the CNA and the DON acknowledged that this action was not in line with facility policy, as the cart surface could be contaminated and potentially transfer germs or bacteria to the scoop. A resident with a peripheral intravenous (IV) saline lock was observed without a date or licensed nurse's initials on the IV site. The DON and Director of Staff Development confirmed that facility policy requires IV sites to be labeled with the date and initials of the nurse who inserted it, to ensure timely changes and reduce the risk of infection. The resident's medical record indicated recent IV hydration, and the lack of labeling was not consistent with the facility's procedures for infection control. During medication administration, an LVN was observed not disinfecting a blood pressure machine between resident uses and not following proper infection control practices when administering medications to a resident on enhanced barrier precautions. The LVN handled used medical equipment and medication cups without appropriate PPE and failed to disinfect the plastic tray after use. The DON confirmed that these actions did not meet the facility's infection control standards, which require disinfection of equipment between uses, proper use of PPE, and adherence to hand hygiene protocols.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive and updated care plans were developed and maintained for several residents, as required. Specifically, no discharge care plans were developed or updated for four residents, despite ongoing discharge planning activities and changes in their discharge status. For example, one resident with dementia and fluctuating decision-making capacity had a care plan that was not updated to reflect changes in discharge arrangements, even after multiple placement attempts and behavioral concerns. Another resident, admitted with congestive heart failure and respiratory failure, had no documented discharge care plan despite being informed of a short-term stay and receiving resources for post-discharge needs. Additional residents, including one with osteomyelitis and another with encephalopathy and kidney failure, also lacked documented discharge care plans, even as discharge planning and placement activities were underway. Interviews with staff confirmed that care plans should have been initiated and updated as discharge processes progressed, but this was not done. The facility also failed to develop a care plan for the use of an indwelling catheter for a resident with multiple urinary diagnoses, including benign prostatic hyperplasia and urinary retention. Despite physician orders for daily catheter care and specific instructions for catheter management, there was no care plan addressing the resident's catheter use. Observations confirmed the presence of cloudy urine with sediment, and both nursing staff and the DON acknowledged the absence of a care plan for this intervention. Additionally, the facility did not develop a care plan to address a change in condition for a resident who developed a urinary tract infection (UTI). The resident reported symptoms, and diagnostic testing confirmed a UTI caused by E. coli, but there was no documented care plan to address this new condition. The DON confirmed that a care plan should have been developed in response to the change in condition. Facility policies and job descriptions reviewed indicated that care plans should be developed and updated by the interdisciplinary team to reflect residents' needs and changes in condition, but this was not consistently done.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
Multiple residents who were dependent on staff for activities of daily living (ADLs), including toileting and hygiene, were left soiled, wet, and unchanged for extended periods. For example, one resident, who was cognitively intact and required substantial to maximal assistance for personal care, reported being left in urine and feces for 35-40 minutes after a CNA failed to respond to her request for help. This was corroborated by the resident's roommate and another CNA, who confirmed the resident and her linens were soiled and that the resident felt uncared for. Another resident stated that her call light was not answered in a timely manner and that she was not changed from morning until mid-afternoon, resulting in her bed being wet from incontinence. This resident, also cognitively intact and dependent for ADLs, expressed feeling terrible and dehumanized by the experience. A third resident reported being left wet and soiled in urine for an entire day shift, and recalled a previous incident of being left in stool. This resident also indicated that call lights were not answered and that staff and administration did not follow up after being informed of the issue. A registered nurse confirmed seeing soiled sheets and stated that CNAs are expected to check and clean residents before shift changes. A fourth resident, who was nonverbal and dependent for ADLs, was reported via an anonymous complaint to have not received care for an entire day, as witnessed by his roommate. Staff interviews revealed that all staff are responsible for answering call lights and that residents should not wait more than ten minutes to be changed. Facility policies reviewed emphasized the importance of timely response to call lights, maintaining resident dignity, and providing care that promotes well-being and self-worth. Despite these policies, the documented events show that residents were left soiled and unattended, with their needs for hygiene and dignity unmet.
Failure to Provide Sufficient Nursing Staff and Timely ADL Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple resident interviews, staff interviews, and record reviews. Several residents reported that their call lights were not answered in a timely manner, and that they were left soiled in urine and stool for extended periods. One resident stated that call lights were not answered 30% of the time, and that there was no coverage when CNAs went to lunch. Another resident reported being left wet and soiled for an entire day shift, and that staff did not respond to complaints. Additional residents described being left in urine and stool multiple times, particularly on weekends, and feeling that administration did not care. Residents involved had significant medical conditions, including morbid obesity, acute respiratory failure, heart failure, diabetes, amputations, and mobility limitations, and were dependent on staff for activities of daily living (ADLs) such as toileting, bathing, and dressing. Record reviews confirmed that the facility did not meet the required minimum Actual Total Direct Care Service Hours (DCSH) of 3.5 and CNA DCSH of 2.4 hours for multiple days in March. On several dates, the number of residents assigned to each CNA exceeded the facility's own guidelines, with some CNAs responsible for up to 16 residents per shift. Staff interviews corroborated these findings, with CNAs reporting high resident assignments, feeling rushed, and being short-staffed on both weekdays and weekends. The Director of Staff Development (DSD) and Director of Nursing (DON) acknowledged that staffing levels and direct care hours were not met, and that this affected the quality of resident care. Facility policies and job descriptions reviewed indicated that staff were expected to respond to call lights promptly and ensure that residents' needs were met in accordance with their care plans. However, the documented staffing shortages, high resident-to-CNA ratios, and failure to meet direct care hour requirements resulted in residents not receiving timely assistance with ADLs, leading to frustration, anger, and negative impacts on their quality of care.
Call Light Not Accessible to Resident
Penalty
Summary
A deficiency was identified when a resident's call light was found tucked away in a bedside drawer, out of the resident's reach, during an observation. The resident, who was alert, oriented, and able to make his needs known, had a history of cerebral infarction, seizures, and ulcerative colitis, and required substantial to maximal assistance with activities of daily living. The resident expressed concern about not being able to reach the call light when needed, confirming that this had occurred previously. Interviews with facility staff, including a CNA and the Director of Nursing, confirmed that the call light was not accessible to the resident and acknowledged that it should always be within reach. The facility's job description for CNAs and its policy on answering call lights both require that the call light be kept within easy reach of residents to ensure timely response to their needs. The failure to ensure the call light was accessible represented a lack of reasonable accommodation for the resident's needs and preferences.
Failure to Protect Resident's Dentures from Loss
Penalty
Summary
The facility failed to exercise reasonable care to protect a resident's personal property, resulting in the loss of the resident's lower dentures. The resident, who had dementia and depression and was assessed as having moderately impaired cognition, reported the dentures missing to a nurse the morning after they were lost. Despite this, the Director of Nursing (DON) was not made aware of the missing dentures until several days later, and there was no immediate search or notification to administration as required by facility policy. The resident expressed distress over the loss, and staff were unable to locate the dentures after the incident. Record review showed that the resident required assistance with denture hygiene and was encouraged to wear dentures. Facility policies required prompt investigation and reporting of lost property, as well as timely referral for dental services if dentures were lost. However, these procedures were not followed, as the loss was not promptly reported to the DON, and there was no documentation of immediate efforts to replace the dentures or ensure the resident's oral health needs were met following the loss.
Inaccurate MDS Coding for Hospice Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a history of congestive heart failure, chronic kidney disease stage 3, and an automatic cardiac defibrillator. The resident was admitted without hospice or dialysis services, later placed on hospice, and never received dialysis. However, a review of the MDS Section O dated January 22, 2025, incorrectly indicated the resident was on dialysis, despite documentation and staff interviews confirming the resident was only on hospice care at that time. The MDS Nurse acknowledged the error, stating the resident was never on dialysis and that the assessment should have reflected hospice care. The Director of Nursing also confirmed that the MDS should have been coded to match the resident's actual status. Facility policy requires that MDS assessments accurately reflect information in progress notes, care plans, and resident observations, which was not followed in this instance.
Failure to Notify Physician of UTI Lab Results and Initiate Treatment
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely physician notification of a resident's urine culture and sensitivity results, resulting in a lack of prompt treatment for a urinary tract infection (UTI). The resident, who had a history of diabetes and stage 3b chronic kidney disease, reported burning during urination, prompting a physician order for urinalysis with culture and sensitivity. The urinalysis, collected the following day, showed signs of infection, and the subsequent urine culture confirmed the presence of Escherichia coli sensitive to several antibiotics. Despite these findings, there was no documented evidence that the physician was notified of the results, no antibiotic was prescribed, and no care plan was initiated for the UTI. Interviews with the resident and staff confirmed that the resident was not informed of the results and had not received any antibiotics. Nursing staff stated that although attempts were made to notify the physician, there was no documentation of these communications, and no orders were obtained. The Director of Nursing acknowledged that the expected protocol—notification of the physician, obtaining orders, and care planning—was not followed, and the facility's policy required immediate notification of significant changes in a resident's condition, which did not occur in this case.
Failure to Coordinate Timely Optometry Services for Resident with Broken Glasses
Penalty
Summary
The facility failed to coordinate optometry services for a resident who requested them, resulting in the resident wearing eyeglasses with a missing right lens for an extended period. The resident, who was cognitively intact and had diagnoses including major depressive disorder and diabetes cellulitis, was readmitted to the facility with broken glasses. Documentation showed that the broken glasses were noted upon readmission, and a physician's order for an ophthalmology consult and treatment was present. Despite this, the resident reported waiting months to see the optometrist, and the facility did not arrange for the resident to be seen during the optometrist's scheduled visit. Interviews with facility staff revealed that the resident had communicated the need for optometry services to a CNA, and the Social Services Director confirmed the optometrist's regular schedule but acknowledged the resident was not seen. The Director of Nursing stated that an authorization for ancillary care should have been requested sooner after the broken glasses were identified. The facility's policy required social services to coordinate referrals for medical services based on physician orders and to document these referrals, but this process was not followed in this case.
Failure to Assess and Address Catheter Complications and Missed Urology Follow-Ups
Penalty
Summary
Two residents with indwelling urinary catheters experienced deficiencies in care related to the identification, assessment, and management of catheter complications. For one resident with a suprapubic catheter, excessive sediment was observed in the tubing, and the resident reported pain. Despite repeated reports from CNAs about the catheter's condition and the resident's discomfort, there was no documented assessment, care plan, or follow-up by licensed nursing staff. The resident also missed a scheduled urology follow-up appointment, and there was no documentation of weekly catheter care or physician notification regarding the catheter's condition. Another resident with an indwelling Foley catheter was observed to have increasing amounts of white sediment in the catheter tubing over several days. The resident had a history of urinary retention and a recent surgical procedure, with a physician order for a urology follow-up within two weeks of admission. However, the follow-up appointment was not scheduled in a timely manner, and staff failed to report the changes in the catheter tubing to the physician as required by the care plan. Both the Infection Preventionist and the DON confirmed that staff should have recognized and reported the changes in the catheter tubing and that the follow-up appointment should have been arranged promptly. Facility policy required daily assessment and documentation of catheter care, including monitoring for unusual appearance, sediment, and signs of infection, as well as prompt reporting of changes to supervisors and physicians. In both cases, there was a lack of timely assessment, documentation, and physician notification regarding catheter complications, and scheduled urology follow-up appointments were missed or delayed.
Failure to Follow Physician Order for Diet Consistency
Penalty
Summary
A resident with a history of an open wound of the left cheek and temporomandibular area, resulting in limited jaw movement, was admitted to the facility and initially placed on a pureed texture diet. Despite a speech therapy evaluation recommending a regular texture (chopped meat) diet and a physician order specifying a regular, no added salt, regular texture, thin liquid consistency diet, the resident continued to receive a pureed diet. The resident reported consuming only 25% of meals and expressed dissatisfaction, stating he should be receiving a regular diet as per his previous habits at home. The deficiency was identified when it was observed that the facility failed to update the resident's diet in accordance with the physician's order and the speech therapy recommendation. The DON confirmed that the resident should have been on a regular textured, thin liquid consistency diet following the speech therapy evaluation. The facility's policy requires that individual dining and food preferences be identified and that meal plans be adjusted after consultation with the resident, but this was not followed, resulting in the resident not receiving the appropriate diet for a period of time.
Annual Performance Evaluation Not Completed for Direct Care Staff
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of eight direct care staff members reviewed. During an interview and review of the personnel file with the Director of Staff Development, it was confirmed that the staff member had been employed since January 3, 2012, but there was no documentation of an annual performance evaluation in the file. The facility's policy requires performance evaluations after the first 90 days of employment and annually thereafter, but this was not followed for the staff member in question.
Expired Medical Supplies and Medications Found in Medication Carts
Penalty
Summary
Surveyors observed that four Biopatch IV dressings, with two past their expiration date and two expiring soon, were found inside the Station 1 IV cart and readily available for use. During the inspection, a registered nurse confirmed that the expired IV dressings should not have been present in the cart. Additionally, a bottle of Fluocinonide 0.05% topical solution with a torn and faded label and an open date was found in the treatment cart. A licensed vocational nurse confirmed that this medication was expired and should not have been in the cart. The Director of Nursing also acknowledged that both the Biopatch dressings and the Fluocinonide solution should have already been discarded and not stored in the carts. Review of the facility's policy indicated that outdated, contaminated, or deteriorated medications and supplies are to be immediately removed from stock and disposed of according to procedures. The presence of expired medical supplies and medication in accessible storage areas constituted a failure to follow national standards and facility policy regarding the storage and labeling of drugs and biologicals.
Failure to Secure and Report Exposed Wiring in Resident Room
Penalty
Summary
Loose hanging wires were observed at the base of the back wall in a resident's room. The resident, who had a history of surgical amputation, muscle weakness, unsteadiness, and diabetes mellitus, required the use of a wheelchair and walker and needed partial to moderate assistance with personal care. The wires were identified as low voltage but were not properly secured, covered, or reported to maintenance. The Maintenance Director confirmed that the wires should not have been exposed and acknowledged the potential for fire, stating that no one had reported the issue through the facility's maintenance reporting system. The resident expressed concern about the open wires, specifically mentioning the risk of fire. Interviews with the DON and Maintenance Director revealed that staff were trained to report such hazards using the facility's maintenance application or by calling maintenance directly. Facility policy required hazardous areas and equipment to be identified and addressed to ensure resident safety, including securing or covering exposed wiring. Despite these protocols, the wires remained unsecured and unreported, creating a hazardous environment for the resident.
Failure to Arrange Transportation Resulting in Missed Dialysis Treatments
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease did not receive scheduled hemodialysis treatments due to the facility's failure to arrange necessary transportation. The resident was admitted with physician orders specifying dialysis days, times, and transportation requirements. Documentation showed that transportation was not finalized or authorized, resulting in missed dialysis appointments. Nurses' progress notes and interviews confirmed that the resident missed multiple treatments because transportation was not arranged, and the issue was not followed up by responsible staff. The case manager acknowledged responsibility for arranging and verifying transportation for dialysis residents and admitted to not following up, which led to the missed treatments. The director of nursing stated that facility policy required arranging transportation upon admission and communicating this to avoid missed treatments. The facility's policy on dialysis care also specified the need to arrange transportation as ordered by the attending physician, but this was not carried out, resulting in the resident missing several dialysis sessions.
Failure to Monitor Residents After Falls
Penalty
Summary
The facility failed to ensure appropriate monitoring for three residents, A, B, and C, following falls, as per the facility's policy and procedure. Resident A, diagnosed with Parkinson's disease, subdural hemorrhage, and aphasia, fell in the dining room and complained of neck pain. Despite being assessed by an RN and the administrator, who found no apparent injuries, Resident A was not immediately sent to the hospital. Neurological checks were initiated but were not completed as per the recommended schedule before Resident A was eventually sent to the ER. Resident B, with diagnoses including encephalopathy and cerebral infarct, experienced two falls. On January 14, Resident B was found on the floor without pain, and on February 8, fell forward from a wheelchair. Despite recommendations for monitoring every shift for 72 hours, there was no documented evidence of such monitoring after either fall. Resident C, diagnosed with encephalopathy and dementia, was found on the floor on February 3 and again on February 9. Although a stat X-ray was requested after the first fall, there was no monitoring documented. After the second fall, neuro checks were initiated but not consistently documented according to the facility's protocol. The administrator confirmed that the residents should have been monitored according to the facility's policy, which mandates neurological evaluations for falls with potential head injuries.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Residents B and D, according to the physician's orders and their care plans. Resident B, who was admitted with encephalopathy and cerebral infarct, experienced a fall and exhibited signs of pain, such as groaning and guarding behavior. Despite having a physician's order for acetaminophen to be administered for mild to moderate pain, there was no documented evidence that the medication was given to Resident B following the fall and subsequent pain complaints. Resident D, admitted with congestive heart failure and an implanted cardiac defibrillator, reported pain associated with a wound on his backside. The physician's orders included acetaminophen for mild pain and tramadol for moderate pain, but there was no order for severe pain management. Resident D received tramadol for severe pain on two occasions, but there was no documentation of a call to the provider for further orders to address the severe pain level. The facility's policy on pain management emphasizes maintaining comfort and following physician's orders, which was not adhered to in these cases.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH). The resident, who was admitted with multiple serious health conditions including chronic respiratory failure, cirrhosis of the liver, and chronic kidney failure, was found to have maroon and purple discolorations on both upper extremities, lower abdomen, and left lateral trunk on March 10, 2025. The discolorations were first noted by a Certified Nursing Assistant (CNA) during a shower and reported to the Treatment Nurse. Despite the facility's policy requiring immediate reporting of such injuries to state authorities, the Director of Nursing (DON) and the Administrator acknowledged that the incident was not reported as required. The resident's medical records indicated a severely impaired cognitive function, with a Brief Interview for Mental Status (BIMS) score of 03, and the resident was dependent on staff for most daily needs. The discolorations were documented in the resident's shower sheets and body check records, but the facility did not notify CDPH, as the DON initially believed the discolorations were not unexpected due to the resident's multi-system failure. However, upon review, both the DON and the Administrator recognized that the incident should have been reported as an injury of unknown origin, in accordance with the facility's policy and state regulations.
Failure to Develop Care Plans for Residents with Rashes
Penalty
Summary
The facility failed to develop and implement care plans to address rashes for five residents, which was identified during an unannounced visit. The residents affected had various medical conditions, including aftercare following surgery, cerebral infarction, spastic quadriplegic palsy, Alzheimer's, and complications of urinary catheter use. Despite the identification of rashes through body checks, no care plans were developed to address these skin conditions. Resident 2, who required maximum assistance with activities of daily living (ADLs) and had no cognitive impairment, was found to have a posterior trunk rash with scattered papules. Similarly, Resident 6, with severe cognitive impairment, had liver spots and a rash on the posterior trunk. Resident 7, with moderate cognitive impairment and dependent on ADLs, was noted to have decreased scattered papules responding to treatment, yet no care plan was in place. Resident 8, with severe cognitive impairment, had scattered papules on the anterior and posterior trunk, and Resident 10, with moderate cognitive impairment, had a general body rash with scattered papules. Interviews with the Treatment Nurse and the Director of Nursing revealed that care plans should be created immediately after any changes in a resident's condition are identified. The facility's policy emphasized the importance of individualized comprehensive care plans to meet residents' needs and prevent declines in their functional status. However, the lack of care plans for the identified rashes indicated a failure to adhere to these guidelines, potentially resulting in unmet needs and worsening of the residents' conditions.
Failure to Protect Resident's Money from Theft
Penalty
Summary
The facility failed to protect a resident's money from theft and loss, as evidenced by the missing cash of $1,176 that was not accounted for after the resident's admission. The resident, who had no cognitive impairment, was admitted with a documented amount of cash on an Inventory Sheet, but subsequent documentation failed to account for the money. Interviews with staff revealed inconsistencies in the handling and documentation of the resident's cash, with CNA 3 claiming to have handed the money to an LVN, who denied receiving it. The facility's policy on preventing exploitation and misappropriation of resident property was not adhered to, as evidenced by the lack of proper documentation and safeguarding of the resident's money. The Director of Staff Development and the Administrator acknowledged the failure to review and validate the inventory sheet, which contributed to the misappropriation of the resident's funds. This deficiency highlights a lapse in the facility's procedures for protecting residents' belongings, as outlined in their policy.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control practices during a COVID-19 outbreak, affecting both residents and staff. The Director of Nursing (DON) was observed wearing an N95 respirator mask that was not fit-tested, and the presence of a beard further compromised the mask's effectiveness. The Infection Preventionist (IP) confirmed that the DON was fit-tested for a different brand of N95 mask and should not have facial hair when wearing it. This oversight was against the facility's policy, which requires proper fit-testing and no facial hair to ensure a secure fit. Additionally, a significant number of direct care staff were not fit-tested for N95 respirator masks, as required by the facility's policy and CDC guidelines. Out of 70 current direct care staff, 46 had not undergone fit-testing. Interviews with staff members revealed that some had never been fit-tested since their hire, and the IP acknowledged the lapse in ensuring all staff were fit-tested upon hire and annually. This lack of fit-testing compromised the staff's ability to safely care for residents during the outbreak. The facility also failed to maintain proper isolation protocols for rooms under SPECIAL DROPLET CONTACT PRECAUTIONS. Eight rooms with COVID-19 positive residents had open doors, contrary to the facility's policy and CDC guidelines, which require doors to be closed to prevent the spread of infection. Furthermore, the facility did not report the COVID-19 outbreak to the California Department of Public Health (CDPH) as required, indicating a lack of awareness among the administration about reporting obligations during an outbreak.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of physical abuse involving Resident 1 to the California Department of Public Health (CDPH), the Ombudsman, and law enforcement within the required timeframe. The incident was initially reported to Adult Protective Services (APS) by an external party, indicating that Resident 1 was allegedly assaulted by another resident. However, the facility did not report this allegation as required by their policy, which mandates immediate reporting, or within two hours if the allegation involves abuse. The Director of Nursing (DON) acknowledged awareness of the allegation but did not report it, citing a lack of substantiation and changing details in the resident's account. Resident 1, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported waking up on December 19, 2024, with someone pulling her hair. Despite this, there was no documented evidence of monitoring or investigation by the Interdisciplinary Team (IDT) following the allegation. The facility's policy, revised in July 2017, clearly outlines the requirement for prompt reporting of abuse allegations to various authorities, which was not adhered to in this case.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident who reported that someone pulled her hair. The incident was initially reported to the facility staff on December 20, 2024, but was not properly investigated. The Director of Nursing (DON) acknowledged awareness of the report but concluded the allegation was unsubstantiated without conducting further investigation, such as interviewing other residents and staff. The facility's policy requires all abuse allegations to be thoroughly investigated, which was not adhered to in this case. The resident involved had a history of traumatic subdural hemorrhage, multiple sclerosis, and cerebral palsy, and was cognitively intact with a BIMS score of 15. Despite the resident's capacity to understand and make decisions, there was no documented evidence of monitoring or a comprehensive investigation by the Interdisciplinary Team following the abuse allegation. The facility's failure to investigate the incident as per their policy potentially exposed the resident to further abuse and did not provide sufficient protection.
Failure to Document Treatment Orders for Residents
Penalty
Summary
The facility failed to adhere to physician's treatment orders for two residents, leading to potential worsening of their skin conditions. Resident 3, who was cognitively intact and had a gastrostomy and ileostomy, did not receive documented care for their ileostomy and skin redness for a total of 15 days in January 2025. The Treatment Administration Record (TAR) lacked signatures from licensed nurses on specific dates, indicating that the required care might not have been provided. Treatment Nurse 1 acknowledged the oversight, citing workload and staffing issues as contributing factors. Resident 4, who had severe cognitive impairment and moisture-associated skin damage (MASD), also did not have documented care for their skin condition on four specific days in January 2025. The Director of Nursing (DON) and Nurse Consultant confirmed that Licensed Vocational Nurse (LVN) 1 was responsible for treatments during a period when both treatment nurses were out sick. However, LVN 1 failed to document the care provided, as required by the facility's policy. The facility's policy on nursing documentation mandates timely and accurate recording of care provided to residents. The DON and Nurse Consultant emphasized the importance of documenting treatments immediately after they are administered. The lack of documentation for both residents suggests a failure to comply with this policy, potentially impacting the residents' health outcomes.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that physician's orders for the treatment of pressure injuries were conducted for two residents. Resident 3, who was cognitively intact, had a sacrococcyx pressure ulcer that was not treated according to the prescribed regimen for a total of 14 days in January 2025. The Treatment Administration Record (TAR) lacked signatures from licensed nurses on multiple dates, indicating that the treatment was not documented as completed. The absence of documentation was attributed to both treatment nurses being out sick and a heavy caseload that prevented the remaining nurse from completing the documentation. Resident 4, who had severe cognitive impairment, also did not receive consistent treatment for pressure injuries on the right and left lateral malleolus and the sacrococcyx. The TAR for January 2025 showed missing signatures on several dates, suggesting that the prescribed treatments were not documented as administered. The Director of Nursing (DON) and a Nurse Consultant confirmed that the licensed nurses were expected to document treatments immediately after completion, but this was not done. The facility's policy on nursing documentation requires timely entry of care provided, but this was not adhered to, leading to a lack of accountability and potential worsening of the residents' conditions. The facility had 13 residents with pressure injuries, highlighting the importance of consistent and documented care. The failure to document care as per the facility's policy and procedure was a significant deficiency identified during the survey.
Failure to Arrange Medical Consults for Residents
Penalty
Summary
The facility failed to arrange necessary medical consults for four residents as per physician orders, potentially delaying their care and treatment. Resident 3, who was admitted with conditions including lymphedema and anxiety disorder, had a physician order for a follow-up appointment with an orthopedic surgeon related to a prosthetic limb, which was not arranged. Similarly, Resident 4, admitted with conditions such as hemiplegia and diabetes, had a physician order for the removal of a clogged G-tube, which was not followed up after the initial insurance call. Resident 6, with diagnoses including traumatic subdural hemorrhage and multiple sclerosis, required a cardiology consult due to multiple falls, as per physician orders, but this was not arranged. Resident 7, who had conditions like embolism and hypertension, had a physician order for a urology consult due to pain on urination and blood in the urine, which was also not arranged. Interviews with facility staff revealed a lack of communication and follow-up on these consults, with the Social Service Assistant and nurses acknowledging the oversight. The facility's policy required social services to coordinate referrals based on physician orders, collaborating with nursing staff to arrange necessary services. However, the Administrator admitted there was no excuse for the failure to process these consults, emphasizing the importance of addressing residents' health concerns for their safety and rights. The deficiency was identified during an unannounced visit to investigate a quality-of-care issue.
Failure to Obtain Timely Medication List for Resident
Penalty
Summary
The facility failed to ensure that a list of home medications was obtained in a timely manner for a resident upon admission, which resulted in the resident not receiving routine medications. The resident, who was admitted with diagnoses including a sprain in the right knee, falls, difficulty walking, pain in the right knee, and muscle weakness, did not have a medical history or home medication list on file upon admission. Despite attempts by the nursing staff to contact the resident's primary care physician for a medication list, there was no response, and the necessary medications were not administered. Interviews with nursing staff revealed that there was a lack of follow-up with the primary care physician and that the facility's policy for medication reconciliation was not adhered to. The policy required gathering information needed to reconcile the medication list and ensuring that medications the resident had been taking continued to be administered without interruption. The failure to follow this procedure had the potential to adversely affect the resident's health.
Infection Control Breach Due to Lack of PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices when a visitor and a staff member did not wear personal protective equipment (PPE) before entering rooms marked with contact isolation precautions. During an unannounced visit, a visitor was observed sitting on a resident's bed without wearing any PPE, despite the room having signage indicating contact isolation. The visitor stated that facility staff did not inform him of the need to wear a gown before entering the room. Additionally, the Social Service Director was observed inside another resident's room without PPE, despite the room also having contact isolation signage. The Social Service Director acknowledged the requirement for staff to wear gowns and gloves and to wash hands before and after donning and doffing PPE. The Infection Preventionist nurse confirmed that the visitor should have been stopped at reception and educated on wearing PPE, as not doing so could lead to the spread of infection and cross-contamination. The facility's policy on transmission-based precautions requires staff and visitors to wear disposable gowns upon entering rooms with contact isolation precautions. The residents involved had specific medical conditions requiring contact isolation: one had rashes, and the other had a Methicillin-resistant Staphylococcus aureus infection. The facility's infection prevention and control program emphasizes educating staff and ensuring adherence to proper techniques and procedures to prevent the spread of communicable diseases.
Failure to Provide Necessary Fingernail Care
Penalty
Summary
The facility failed to provide necessary services to maintain appropriate hygiene for a resident who was unable to perform activities of daily living independently. Specifically, the resident did not receive proper fingernail care, as observed during a survey. The resident's fingernails were found to be discolored, with dark debris underneath, long, and untrimmed. The resident, who was unable to trim and clean his fingernails on his own, reported that the staff had not provided nail care. This lack of care was confirmed by the observations and interviews conducted with the resident and staff members. The resident had a medical history that included hemiplegia, diabetes mellitus type II, cerebral edema, aphasia, and vascular dementia, which required assistance with personal hygiene. The facility's policy indicated that nail care should include daily cleaning and regular trimming, except for diabetic residents or those with circulatory impairments, who should have their nail care performed by a podiatrist. However, the facility failed to ensure that the resident received the necessary nail care, as there was no documentation of fingernail care in the resident's body check assessment. Interviews with staff revealed a lack of clarity and responsibility regarding who should perform the nail care, leading to the deficiency.
Failure to Prevent Skin Breakdown in Resident
Penalty
Summary
The facility failed to provide necessary services to prevent skin breakdown for a resident who developed skin irritation on the neck. During an observation and interview, the resident was found to have a red area of skin irritation on the right side of the neck, which had not been treated. The resident confirmed that no treatment had been provided for the redness. Licensed Vocational Nurse (LVN) 1, Certified Nursing Assistant (CNA) 1, and the Treatment Nurse (TN) were unaware of the skin issue, despite the resident's care plan indicating a need for daily skin condition observation and weekly skin assessments by a licensed nurse. The resident's medical history included hemiplegia, diabetes mellitus type II, cerebral edema, aphasia, and vascular dementia, which increased the risk for skin breakdown. The facility's policy required skin inspections on admission and weekly, but the resident's records did not document the skin redness. Interviews with CNAs and a Registered Nurse (RN) revealed a lack of awareness and communication regarding the resident's skin condition, which was deemed unacceptable by RN 2. The facility's policies on skin integrity management and activities of daily living were not adhered to, contributing to the deficiency.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for one of nine residents, specifically Resident 5, who waited 15 minutes for the call light to be answered. This was observed during an unannounced visit to investigate four complaints and one Facility Reported Incident (FRI). Resident 5 reported that staff were terrible about responding to the call light, often turning it off and leaving without returning. This was corroborated by an observation where Resident 5 activated his call light at 11:40 a.m., and it was not addressed until 11:55 a.m. Interviews with multiple Certified Nursing Assistants (CNAs) revealed that the expected response time for call lights should be between three to ten minutes, with all CNAs agreeing that 15 minutes was too long. Resident 5's medical record indicated he had been admitted with serious conditions including pneumonia, sepsis, dysphagia, and acute kidney failure, and had the capacity to make decisions. The facility's policy on answering call lights, revised in March 2021, was reviewed but not detailed in the report.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure appropriate care and treatment services for pressure injuries for two residents. For Resident 1, the facility did not conduct weekly assessments of the intergluteal cleft linear and right buttock linear excoriations after the initial identification of the wounds. This lack of follow-up assessment meant that the facility could not determine if the wounds were healing or worsening. The resident had multiple serious conditions, including acute and chronic respiratory failure, pneumonia, and pulmonary fibrosis, and was capable of making decisions. Despite the initial wound care provided, there was no documented evidence of follow-up assessments from January 20, 2024, to January 23, 2024, when the resident was transferred to the hospital. Interviews with treatment nurses confirmed that weekly assessments should have been conducted but were not completed in this case. For Resident 5, the facility failed to place an air mattress on the bed at admission as per the physician's order and the wound care specialist's recommendation. The resident, who had diagnoses including pneumonia, sepsis, arthritis, muscle weakness, and acute kidney failure, was observed lying on a standard mattress instead of an air mattress. The resident's records indicated a sacrococcyx suspected deep tissue injury, and the treatment plan included pressure reduction and offloading. However, the air mattress was not provided until March 7, 2024, leading to a delay in the implementation of care and treatment. Interviews with the treatment nurse and the Director of Nursing confirmed that the air mattress should have been provided at admission to prevent worsening of the pressure injury. The facility's policy on pressure ulcers and skin breakdown required full assessment and documentation of pressure sores, including the use of pressure reduction surfaces. The National Pressure Injury Advisory Panel guidelines also emphasized the importance of support surfaces in preventing and treating pressure injuries. Despite these guidelines, the facility did not adhere to the required protocols, resulting in deficiencies in the care provided to Residents 1 and 5.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that Resident 7 had floor mats on both sides of the bed, increasing the risk of injury if the resident fell out of bed on the right side. During an unannounced visit, it was observed that Resident 7's bed was in the lowest position with only one floor mat on the left side. Interviews with the resident and Certified Nursing Assistants (CNAs) confirmed that floor mats should be on each side of the bed. Resident 7 had a history of falls, as indicated in her care plan, which noted a fall on January 29, 2024, with no injuries sustained. The care plan included interventions such as a low bed and fall mats, but these were not fully implemented as required. Resident 7's medical records showed she was readmitted to the facility with multiple diagnoses, including acute respiratory failure, chronic obstructive pulmonary disease (COPD), and epilepsy. Despite being alert and oriented, the resident was at risk for falls, as documented in her care plan. The facility's policy on fall management, dated May 26, 2021, stated that patients at risk for falls should receive appropriate interventions to reduce risk and minimize injury. However, the facility did not adhere to this policy, as evidenced by the lack of floor mats on both sides of Resident 7's bed.
Failure to Ensure Bathroom Privacy for Residents
Penalty
Summary
The facility failed to ensure that two residents, one with acute respiratory failure and type 2 diabetes mellitus, and another with cellulitis and muscle weakness, did not share a bathroom with residents of the opposite sex. Resident #56, who was cognitively intact and independent with toileting hygiene, complained about having to share a bathroom with residents of the opposite sex. Resident #296, who was alert and oriented and required limited assistance with toileting, reported an incident where a resident of the opposite sex walked in on them while they were using the bathroom, leading them to start locking the bathroom door. Interviews with the Executive Director and the Social Service Director revealed that the facility's policy was to ensure that bathrooms were not shared by residents of the opposite sex. However, both directors were unaware that such sharing was occurring. The Executive Director reviewed the facility's current census and did not find any instances of opposite-sex bathroom sharing, while the Social Service Director stated that they were not aware of the issue until the day of the interview.
Failure to Complete Level II Mental Health Evaluations
Penalty
Summary
The facility failed to ensure a Level II mental health evaluation was completed for two residents who had positive Level I screenings. Resident #41 was admitted with diagnoses including alcohol abuse with alcohol-induced anxiety disorder and post-traumatic stress disorder. Despite a positive Level I screening indicating the need for a Level II mental health evaluation, there was no evidence in the medical record that this evaluation was completed. Interviews revealed that the Social Service Director (SSD) and the Director of Nursing (DON) did not follow up with the state after the initial submission, as required by facility policy. The Executive Director (ED) confirmed that it was the facility staff's responsibility to follow up with the state if no response was received within four days. Similarly, Resident #17 was admitted with a diagnosis of bipolar disorder and had a positive Level I screening, necessitating a Level II mental health evaluation. However, the medical record showed no evidence of this evaluation being completed. The SSD admitted that no follow-up was conducted with the state for the Level II evaluation. Both the DON and the ED stated that they expected staff to follow up with the state within the specified timeframe to ensure the evaluation was completed. The lack of follow-up resulted in the failure to complete the required Level II mental health evaluations for both residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 314 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hemet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Jacinto Valley Post Acute | 0 mi | ★★★★★ | 14 | 0 |
| Hemet Valley Healthcare Center | 0.1 mi | ★★★★★ | 18 | 0 |
| Meadowbrook Post Acute | 1.4 mi | ★★★★★ | 34 | 0 |
| Ramona Rehabilitation And Post Acute Care Center | 1.7 mi | ★★★★★ | 15 | 1 |
| Hemet Hills Post Acute | 2.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.