Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Downey Post Acute during CMS and state inspections, most recent first.
Food safety practices were not followed when pre-plated milk and flan were observed at 51.8 F to 61.8 F during tray line service, despite the DS stating cold PHFs had to be held at or below 41 F. During the same meal service, an aide wore a red beaded bracelet while plating food, and a bottle of Martinelli's Sparkling Cider in the walk-in lacked a received date label, contrary to facility policy for safe food handling and dating.
An indwelling catheter bag was observed touching the floor for a resident with impaired cognition and urinary diagnoses. An LVN failed to perform hand hygiene after preparing medications and before giving them to one resident, then used an unsanitized BP cuff from one resident on another. A CNA also provided direct care to a resident on EBP without the required gown and gloves during a brief change.
A resident with impaired cognition, weakness, repeated falls, and a prior elbow fracture became acutely confused and partially slid off the bed while on overnight supervision. The LVN notified the DON but did not promptly notify the RP or MD, and the physician was later informed hours after the event; the record also did not show timely MD notification when the resident later developed left arm bruising. The resident was subsequently hospitalized and diagnosed with a displaced left distal humeral supracondylar fracture.
A resident with impaired cognition, muscle weakness, repeated falls, and dependence for multiple ADLs developed left arm bruising after being caught sliding from bed. The LVN did not document an assessment or initiate a care plan for the change in condition, and later hospital records showed swelling, bruising, pain with elbow ROM, and a left distal humeral supracondylar fracture.
Care plans for two residents did not reflect their need for a Hoyer Lift during transfers. Both residents had severe cognitive impairment and required maximal assistance with transfers, and PT documentation plus the facility’s special needs list identified the Hoyer Lift as the transfer method. However, the care plans only referenced staff or physical assistance with transfers and did not specify the Hoyer Lift, which the DON and nursing staff said made the plans non-specific and potentially confusing for staff.
A resident who required a Hoyer Lift for transfers was moved from a shower chair to bed without the lift, and staff later found two trauma wounds on her lower left leg. The facility also did not hold an IDT meeting after the incident. In a separate event, another resident developed acute confusion, one-to-one supervision was started but not maintained during a staff break, and the resident was later found sliding from the bed; the physician was not notified at the time of the change in condition.
Improper Oxygen Delivery: A resident with hypoxia and a stroke history was ordered continuous oxygen at 2 L/min via nasal cannula for shortness of breath, but surveyors observed the resident receiving only 1 L and the cannula was not properly positioned in the nostrils. The RNS stated the cannula must remain properly positioned to deliver oxygen as ordered, and the DON stated the issue could lead to low O2 levels, SOB, respiratory decline, and risk for harm.
Incomplete Controlled Medication Documentation: A resident receiving Norco for pain had a discrepancy between the number of tablets remaining in bubble packs and the Controlled Record. An LVN stated he administered the dose but did not document it on the Controlled Sheet, while the DON stated licensed nurses were responsible for documenting the date, time, quantity on hand, quantity used, and quantity remaining for controlled meds.
Incomplete documentation of change in condition and new wounds. A resident with confusion, falls, and anticoagulant therapy had an episode of acute confusion and partially slid from bed, but the LPN did not document the confusion, interventions, one-to-one supervision, or the incident, and later bruising to the arm was also not recorded in the nursing notes. Another resident with severe cognitive impairment sustained two trauma wounds to the lower leg during a transfer, but the initial skin assessment did not document the wounds or provide a baseline description and measurements.
Incomplete Privacy Curtain in Resident Bedroom: A resident's bedroom had a wrong-size privacy curtain that did not provide full visual privacy for all occupants. The resident had intact cognition, was independent with toileting, bathing, and lower body dressing, and had the capacity to make decisions. Staff stated the curtain was the wrong size and that privacy curtains are important to protect privacy and dignity during care.
A resident with severe cognitive impairment, ESRD, and dependence in ADLs did not receive care consistent with professional standards when an LVN administered Tylenol for reported pain but failed to document the dose, assessment, and reassessment in the MAR in a timely manner, contrary to facility medication administration policy. In addition, the same resident, who had a Foley catheter and a care plan addressing prior hematuria, was observed without a StatLock or other securement device, despite a care plan intervention to secure the catheter to promote urine flow and prevent kinking and accidental removal. Staff acknowledged that the care plan and standard of care were not followed, and the DON noted the resident’s risk for penile trauma due to prolonged Foley use and the need for a securement device.
Failure to develop a timely, resident-centered care plan for a resident with bowel and bladder incontinence led to MASD of the coccyx, perineum, and right ischium. The resident had DM, limited sensory perception, immobility, and frequent bowel movements, and staff interviews confirmed he was constantly soiled. The record showed the MASD was identified before a specific care plan was started, and the resident reported prolonged periods in urine and feces when call lights were not answered.
A resident with a history of falls, cognitive impairment, and recent femur fracture was left unsupervised on the toilet by a CNA, despite requiring maximal assistance and supervision. The resident attempted to stand, fell, and sustained a head laceration requiring sutures. Staff interviews confirmed the resident should not have been left alone, and the care plan lacked specific instructions for supervision during toileting.
Nurses and nurse aides failed to demonstrate the competencies needed to care for residents in a manner that maximizes their well-being, resulting in a deficiency related to staff qualifications and resident care.
The facility failed to develop comprehensive care plans for four residents, leading to potential delays and negative impacts on their care. A resident did not receive a prescribed nutritional supplement due to staff unfamiliarity, while two residents with vision impairments had inappropriate or missing care plans. Another resident's medication refusal was not addressed with a care plan, risking delays in necessary treatment.
The facility failed to document a resident's medication refusal and educate them on the risks, while also not informing a physician of another resident's change in condition. One resident refused medications due to timing issues, and the staff did not document or educate as required. Another resident's brownish urine was noted post-dialysis, but the staff failed to notify the doctor, potentially delaying care.
A resident with cataracts was not referred to an ophthalmologist as recommended by an optometrist, due to the Social Services Director's failure to review consultation notes and follow up on the referral. This oversight delayed necessary treatment for the resident's eye condition.
A resident requiring dialysis did not receive appropriate post-dialysis care when the facility failed to remove the pressure dressing from the AV shunt site as ordered. The resident, with conditions including ESRD and diabetes, returned from dialysis with the dressing still intact, leading to potential complications. The oversight was acknowledged by the LVN and ADON, highlighting a failure to adhere to the facility's post-dialysis care policy.
A facility failed to accurately document the administration of lorazepam for a resident with multiple diagnoses, including seizure disorder and major depressive disorder. The MAR showed three doses administered, but a review revealed a missing nurse's signature and an incorrect tablet count. An LVN admitted to not signing the NCS immediately, which was confirmed as a medication error by the ADON. The facility's policy requires immediate documentation, which was not adhered to, resulting in the deficiency.
A resident with a history of stroke and gastrointestinal issues was nearly given a chewable aspirin tablet instead of the prescribed delayed-release form by an LVN, who did not have a physician's order for the change. The LVN was stopped by a surveyor, and the ADON confirmed the need for physician clarification before altering medication forms.
The facility failed to implement proper infection control practices for two residents. A resident's nebulizer mask was improperly stored on a nightstand without a protective bag, contrary to infection control policies. Another resident's dirty clothes and linen were left unattended on the bed, violating the facility's procedures for handling soiled items. Staff acknowledged these lapses, which posed potential infection risks.
A facility failed to conduct weekly skin IDT meetings for a resident who developed redness on the left hip and iliac crest. Despite the resident's dependency on staff and a history of pressure-induced damage, no meetings were held between January 2025 and February 2027, contrary to facility policy. The DON confirmed that meetings should have been conducted, especially after a change in the resident's skin condition was noted.
The facility failed to meet the required room size of 80 sq. ft. per resident in multiple-resident rooms, with four rooms measuring below the standard. Despite this, observations showed that residents had privacy, space for personal items, and maneuverability for wheelchairs. The administrator acknowledged the deficiency, and a room waiver was recommended by the California Department of Public Health.
A resident with dementia and other medical conditions sustained a fractured wrist of unknown origin, but the facility did not report the injury to CDPH within the required two-hour timeframe or submit the investigation results within five working days, as mandated by policy. The delay in reporting was confirmed through staff and family interviews and review of facility records.
A resident with dementia and psychotic disorder exhibited erratic behaviors, including thrashing arms and striking furniture, but did not have a care plan addressing these actions. Staff and family observed the resident guarding a painful wrist over several days, but a change of condition assessment and pain interventions were not provided, resulting in an undiagnosed wrist fracture and hospital transfer.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency. One resident's call light was clipped to a curtain, and they rely on it for assistance due to a history of falls and other conditions. Another resident also had their call light out of reach and often cannot find it, despite needing assistance due to difficulty walking. Both residents have the mental capacity to make medical decisions, and the facility's policy requires call lights to be accessible.
A resident's legal representative requested medical records, but the LTC facility failed to release them within the 24-hour timeframe as per policy. Despite multiple follow-ups, the records were delayed by about a month, violating the resident's rights. The facility's policy requires records to be accessible within 24 hours of a request.
A resident fell and sustained a femur fracture due to a CNA's failure to provide a two-person assist during a Hoyer Lift transfer. The CNA did not inspect the sling, which broke during the transfer. Facility staff did not follow procedures for checking and maintaining lift slings, contributing to the incident.
A resident experienced a fall due to a broken Hoyer lift sling, resulting in a right distal femur fracture. Despite severe pain and an X-ray confirming the fracture, the transfer to a general acute care hospital was delayed by 10 hours. The facility's Director of Nursing acknowledged the delay and the risk it posed for delayed care and treatment.
A facility failed to provide restorative nursing exercises as ordered for three residents, leading to a deficiency in care. Residents with conditions like hemiplegia and end-stage renal disease were not consistently receiving prescribed range of motion exercises. Documentation showed multiple days without exercises, marked as not applicable or resident refused. Interviews confirmed the lack of adherence to physician orders, with residents not receiving exercises as frequently as required.
Two residents with moisture-associated skin damage (MASD) did not have individualized care plans developed, despite receiving treatment. Interviews with staff revealed that care plans are essential for guiding treatment and preventing further skin breakdown, but the facility's policies were not followed, leading to potential negative impacts on care delivery.
The facility failed to obtain authorization from the responsible party of a resident with severe cognitive impairment before discharging the resident to another facility. The primary emergency contact was not notified, and the discharge was not properly documented, contrary to the facility's policy.
A resident with impaired cognitive skills and complete dependence on staff developed a Stage III pressure ulcer. Despite documented high risk and ongoing treatments, the facility failed to create a care plan for over a month, as confirmed by the Treatment Nurse and Director of Nursing.
Food Safety Deficiencies During Tray Line and Storage
Penalty
Summary
Food safety and food preparation practices were not maintained for all 95 residents when cold food items were observed at unsafe temperatures during tray line service. During a concurrent observation and interview on 5/5/2026 at 12:15 p.m., one pre-plated glass of milk measured 53.2 F and another measured 51.8 F. One bowl of flan measured 60.4 F, and another bowl of flan measured 60.2 F, 61.8 F, and 60.8 F. The Dietary Supervisor stated the milk and flan had been pre-plated about five minutes earlier and were potentially hazardous foods that were required to be maintained at or below 41 F. The facility's Food Preparation policy and the Food Code 2022 both indicated cold food was to be held at 41 F or below, and the Dietary Supervisor confirmed the elevated temperatures were not identified before the surveyor's checks. The facility also failed to follow food handling and labeling practices during kitchen operations. During tray line service on 5/5/2026 at 12:07 p.m., Dietary Aide 1 was observed wearing a red beaded bracelet while serving food onto plates, and the Dietary Supervisor stated bracelets during tray line could harbor bacteria and lead to cross contamination. In addition, during a kitchen observation on 5/4/2026 at 8:10 a.m., one bottle of Martinelli's Sparkling Cider stored in the walk-in refrigerator did not have a received date label. The Dietary Supervisor stated every item stored in the refrigerator should have a received date label, and the facility's Labeling and Dating of Foods policy required food items in storage to be labeled and dated according to established procedures.
Infection Control Lapses During Catheter Care, Medication Administration, Equipment Use, and EBP Care
Penalty
Summary
Resident 10 had an indwelling urinary catheter ordered for gravity drainage for BPH and obstructive uropathy. The resident’s history and physical indicated he did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition and dependence on staff for multiple activities of daily living. During observation in the resident’s room, the catheter collection bag was hung on the side of the bed frame while the bed was in its lowest position and the bag was touching the floor. The Infection Preventionist Nurse and the DON stated the bag should not touch the floor and that touching the floor increased the resident’s risk for infection. Resident 86 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and dementia, with fluctuating capacity to understand and make decisions. During medication administration, an LVN prepared nine medications for the resident, then returned to the room without performing hand hygiene after preparing the medications and before administering them. The LVN acknowledged he forgot to perform hand hygiene before reentering the room and stated he should have done so prior to putting on gloves and assisting with the medications. The IPN stated hand hygiene was essential during medication administration and that the lack of hand hygiene increased the risk of spreading bacteria and infection to the resident. Resident 101 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and low back pain, and the MDS indicated intact cognition. After using a blood pressure cuff on Resident 86, the LVN placed the cuff on the medication cart and later picked it up and entered Resident 101’s room with the cuff unsanitized. The LVN stated he did not sanitize the cuff after using it on Resident 86 and should have sanitized it before using it on Resident 101. The IPN and DON stated the cuff should have been disinfected between residents to prevent transfer of bacteria. Resident 82 had a surgical site and was on Enhanced Barrier Precautions, with physician orders and the care plan directing staff to use gowns and gloves for personal care. During observation, CNA 1 was seen cleaning and changing the resident without wearing PPE while the surgical site was exposed. The IPN and DON stated PPE was required for direct care activities under EBP, including brief changes and hygiene care, and that PPE was intended to protect the resident.
Failure to Timely Notify RP and Physician of Change in Condition and Injury
Penalty
Summary
The facility failed to timely notify the resident’s responsible party and physician after the resident showed increased confusion and partially slid off the bed during the early morning hours. The resident had been admitted and later readmitted to the facility with diagnoses including a displaced comminuted supracondylar fracture, osteoarthrosis, muscle weakness, and repeated falls. The resident’s assessment showed moderately impaired cognitive skills, and the history and physical stated the resident could make needs known but could not make medical decisions. According to the record and staff interviews, the resident became acutely confused around 2:00 a.m., repeatedly stated she needed to go to an appointment, and was placed on one-to-one supervision. During rounds around 3:00 a.m., the LVN heard the resident moan and found her in the act of sliding off the bed with her legs dangling off the left side. The LVN stated she notified the DON but did not notify the physician, believing the DON would do so. The DON later stated she was notified around 2:30 a.m. to 3:00 a.m. that the resident had partially slid off the bed, but the responsible party was not promptly notified and the DON attempted to contact the responsible party later in the morning without verifying understanding of the incident. The record also showed the physician was not informed of the resident’s acute confusion before the bed incident and was not made aware of the partial slide until many hours later. When the physician later reviewed the situation, she stated she had not been notified of the confusion or the bed incident in a timely manner and expected immediate notification so she could evaluate the resident and consider additional interventions. The resident later developed bruising to the left arm, but the records did not show physician notification of that bruising. The resident was subsequently hospitalized and diagnosed with a left distal humeral supracondylar fracture with displacement, and the hospital notes described left arm swelling, bruising, redness, and pain with elbow movement.
Failure to Care Plan New Bruising and Related Change in Condition
Penalty
Summary
The facility failed to ensure a care plan was initiated for a resident’s development of a bruise to the left arm. Resident 58 was admitted and later readmitted with diagnoses including a displaced comminuted supracondylar fracture, osteoarthrosis, muscle weakness, and repeated falls. The MDS dated 4/30/2026 indicated moderately impaired cognitive skills for daily decision making and maximal assistance was required for bed mobility, showering, toileting, and upper body dressing. The H&P dated 3/11/2026 stated the resident could make needs known but could not make medical decisions. On 4/20/2026 at 7:00 a.m., the DON documented that Resident 58 was caught in the process of sliding from the bed. On 4/22/2026, the resident developed bruising to the left arm, which was later observed by the resident’s granddaughter during a visit. Review of the nursing progress notes, SBAR notes, and changes in condition notes showed no documented assessment by LVN 4 and no care plan was initiated for the bruising. The resident was later hospitalized, and GACH records dated 4/24/2026 documented left arm swelling, bruising, mild redness, pain with elbow range of motion, and a recent fall; x-ray results showed an impacted transverse comminuted left distal humeral supracondylar fracture with approximately 1.2 centimeters of medial displacement.
Care plans did not reflect Hoyer Lift transfer needs
Penalty
Summary
The facility failed to revise the care plans for two residents to reflect their need for a Hoyer Lift during transfers. Resident 52 had diagnoses including generalized muscle weakness, Alzheimer’s disease, and major depressive disorder, and was documented as lacking decision-making capacity with severely impaired cognition. Resident 52’s MDS showed dependence for ADLs and maximal assistance for chair/bed-to-chair transfers, and PT documentation and the facility’s Special Needs List indicated the Hoyer Lift was required for transfers. However, the care plan for ADL self-care performance deficit only stated that staff participation was needed for transfers and did not specify the Hoyer Lift. Resident 10 had diagnoses including end stage renal disease, obstructive and reflux uropathy, and benign prostatic hyperplasia, and was also documented as lacking decision-making capacity with severely impaired cognition. Resident 10’s MDS showed maximal assistance was needed for bathing, dressing, and chair/bed-to-chair transfers, and PT documentation and the Special Needs List indicated the Hoyer Lift was required for transfers. The care plan for ADL self-care performance deficit stated that physical assistance was needed for transfers, but it did not identify the Hoyer Lift as the transfer method. During interviews, PT staff stated the Hoyer Lift was used for these residents to maximize safety and prevent falls and other injuries, and nursing staff stated care plans should be resident-specific and detailed. The DON stated care plans guided staff on how to provide care and should be individualized and specific, and that not specifying the residents’ level of transfer assistance created a risk of miscommunication on how to perform a safe transfer. The facility policy on comprehensive resident-centered care plans stated that a comprehensive person-centered care plan should be developed and implemented for each resident with measurable objectives and timeframes to meet medical, nursing, mental, and psychological needs.
Unsafe Transfers and Inadequate Supervision
Penalty
Summary
Resident 52 had diagnoses including generalized muscle weakness, Alzheimer’s disease, and major depressive disorder, and the record showed she lacked capacity to understand and make decisions. Her care plan and therapy documentation indicated she required staff assistance for transfers, with maximal assistance needed for chair/bed-to-chair transfers. The facility’s special needs list also identified that she required a Hoyer Lift during transfers. On 4/29/2026, Resident 52 was showered and then transferred from the shower chair to the bed without use of the Hoyer Lift. CNA 2 stated she and CNA 3 assisted the resident into a standing position, turned her to the bed, and laid her down. CNA 2 later stated she did not use the Hoyer Lift because she wanted to save time. After the transfer, staff found two injuries on Resident 52’s lower left leg, including open skin and a skin flap, and the change-in-condition documentation identified trauma wounds to the left lower posterior leg and left lower lateral leg. The wound consult and skin assessment documented the wounds and their measurements. The record also showed that the facility did not conduct an IDT meeting after the incident. The DON stated the resident’s event should have had an IDT meeting with other departments and the resident representative to discuss the incident and prevent recurrence, but the care plan review indicated no IDT meeting was required. For Resident 58, the record showed acute confusion and repeated attempts to get out of bed during the night shift. CNA 4 initiated one-to-one supervision, but it was not maintained when CNA 4 left for lunch. LVN 3 later observed Resident 58 sliding from the bed in an upside down 'L' position with her legs dangling off the side. LVN 3 stated the physician was not notified, and the DON stated supervision should have been maintained and the physician should have been notified after the change in condition.
Improper Oxygen Delivery
Penalty
Summary
The facility failed to ensure a resident received the volume of oxygen ordered by the physician. Resident 61 was admitted and later readmitted to the facility with diagnoses including hypoxia and cerebral infarction. The physician order dated 8/8/2024 directed oxygen at 2 liters per minute via nasal cannula continuously every shift for shortness of breath. The resident’s MDS indicated moderately impaired cognition, dependence with toileting, bathing, and lower body dressing, and the need for oxygen therapy. The H&P also noted fluctuating capacity to understand and make decisions. During observations on 5/4/2026 at 8:27 a.m. and 12:02 p.m., Resident 61 was lying in bed receiving 1L of oxygen via nasal cannula, and the cannula was not attached properly in the nostrils. In interview, the RNS stated the resident was on supplemental oxygen to prevent shortness of breath and that the cannula should remain properly positioned to receive oxygen as ordered. The DON stated that failure to provide the ordered 2L oxygen and an improperly positioned nasal cannula may result in low oxygen levels, shortness of breath, respiratory decline, and risk for harm. The facility policy titled Oxygen, Use of, revised 3/2023, indicated oxygen should be administered to promote safety.
Incomplete Controlled Medication Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the Controlled Record for one sampled resident receiving Norco 5-325 mg as needed for pain. The resident was admitted with diagnoses including generalized muscle weakness, peripheral vascular disease, and hypertension, and the H&P stated the resident had the capacity to understand and make decisions. The physician order dated 5/2/2026 directed Norco 5-325 mg by mouth every four hours as needed for moderate to severe pain. During observation on 5/5/2026 at 1:48 p.m. at the East Medication Cart, the resident had two bubble packs of Norco with 37 tablets remaining. A concurrent review of the Controlled Record and MAR showed the Controlled Record indicated 38 tablets should have remained and that the last administration had been on 5/4/2026 at 5:52 p.m., while the MAR showed Norco was administered again on 5/5/2026 at 9:45 a.m. The LVN stated he administered the Norco but did not document it on the Controlled Sheet, and the DON stated licensed nurses were responsible for documenting the date, time, quantity on hand, quantity used, and quantity remaining on the Controlled Record.
Incomplete Documentation of Change in Condition and New Wounds
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents by not documenting significant changes in condition and skin findings. For Resident 58, the record showed a history of displaced comminuted supracondylar fracture, osteoarthrosis, muscle weakness, repeated falls, and anticoagulant therapy with care plan instructions to monitor and document bruising and new confusion. On 4/20/2026, the DON documented that Resident 58 was caught sliding from the bed, and LVN 3 later stated that around 2:00 a.m. the resident became acutely confused, repeatedly tried to get out of bed, and one-to-one supervision was started by a CNA. LVN 3 also stated that the CNA later left for lunch and supervision was not maintained, and that during rounds she heard moaning and saw the resident in an upside-down 'L' position with her legs dangling off the bed. The record review and staff interviews showed that LVN 3 did not complete documentation of the resident’s acute confusion, the nursing interventions, the one-to-one supervision, or the incident involving the resident partially sliding from the bed. The SBAR note later documented left arm pain and an x-ray order, and the resident was subsequently transferred to a hospital where records showed left arm swelling, bruising, mild redness, pain with elbow motion, and x-ray findings of an impacted transverse comminuted left distal humeral supracondylar fracture with medial displacement. On 4/22/2026, the resident’s granddaughter reported observing swelling and bruising to the left arm, but the facility’s nursing progress notes, SBAR notes, and changes in condition notes did not document bruising or the earlier change in condition. Staff interviews confirmed the documentation was incomplete and not timely. For Resident 52, the record showed severe cognitive impairment, dependence for multiple ADLs, and maximal assistance needed for transfers. On 4/29/2026, the resident sustained two wounds to the left lower leg during transfer from the shower chair to the bed, described in the change in condition note as open ecchymosis on the left lower posterior and left lower lateral leg. Staff interviews described that the resident’s legs were lifted and the resident was turned and laid into bed, after which wounds and blood were noticed on the bed frame. A wound consult the next day documented a trauma wound on the left lower lateral leg with measurements, and a skin issues assessment later documented both wounds, but the initial skin issue assessment for 4/29/2026 did not include the two left leg wounds and instead listed a lower abdominal surgical wound. The DON and treatment nurse stated the initial wound assessment should have documented the description and measurements to provide a baseline, but it was not recorded.
Incomplete Privacy Curtain in Resident Bedroom
Penalty
Summary
The facility failed to ensure that Resident 65's bedroom had a privacy curtain that provided full visual privacy. During observation on 5/4/2026 at 10:52 a.m., a wrong-size privacy curtain was seen on the horizontal track along the foot of Resident 65's bed, and it only provided full visual privacy for two of the room's three occupants. Resident 65 was admitted and later readmitted to the facility, and his diagnoses included spinal stenosis and muscle weakness. Resident 65's MDS dated 2/3/2026 indicated his cognition was intact and that he was independent with toileting, bathing, and lower body dressing. His H&P dated 4/11/2026 stated he had the capacity to understand and make decisions. During interview, Resident 65 stated the incomplete privacy curtain did not bother him. The Housekeeper stated the curtain was the wrong size and may affect the resident's visual privacy and dignity, and the RNS stated privacy curtains are important to protect privacy and dignity during care and may cause the resident to feel uncomfortable. The facility policy titled Resident Rights stated employees were to treat all residents with respect and dignity and that all residents and staff are continually informed and aware of resident rights.
Failure to Document Pain Medication Timely and to Secure Foley Catheter per Care Plan
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not ensuring timely documentation of pain assessment and medication administration, and by not following the resident’s catheter care plan. The resident had severe cognitive impairment, lacked decision-making capacity, and was dependent for ADLs, with diagnoses including metabolic encephalopathy, muscle weakness, and ESRD. On one observed date, an LVN stated she had administered Tylenol 325 mg for the resident’s 2/10 pain but did not document the administration, assessment, or reassessment in the MAR right away because she had to attend to another resident. The facility’s own Medication Administration policy required the person administering the medication to record the administration on the MAR after the medication pass and to review the MAR at the end of each pass to ensure doses were administered and documented. Another LVN acknowledged that late documentation of medication administration could result in another dose being given. The facility also failed to follow the resident’s care plan related to an episode of blood in the urine. During an observation, the resident was noted to have an indwelling Foley catheter without a StatLock or other securement device in place. Review of the resident’s care plan titled “Resident with an episode of blood in the urine” showed an intervention to secure the catheter to facilitate urine flow and prevent kinking and accidental removal. An LVN confirmed that the facility did not follow the resident’s care plan or the standard of care when the catheter was not secured. The DON stated that the resident was at risk for penile trauma due to long-term Foley catheter use and needed a StatLock to prevent trauma and skin irritation. The facility’s Indwelling Urinary Catheter policy indicated that residents with indwelling catheters receive catheter care daily and PRN, and that staff may secure the tubing with a securement device PRN to prevent migration, friction, or tension of the catheter.
Failure to Develop Timely Person-Centered Care Plan for Incontinence-Related MASD
Penalty
Summary
The facility failed to ensure a resident-centered care plan was developed and implemented for a resident who was incontinent of bowel and bladder and later developed moisture-associated skin damage (MASD). The resident had a history of muscle weakness, diabetes mellitus, and a subarachnoid hemorrhage with loss of consciousness. On admission, the resident was documented as having very limited sensory perception, being constantly moist, completely immobile, and at high risk for skin breakdown based on a Braden Scale score of 12. The resident was also documented as not continent of bowel and bladder, with moderate cognitive impairment and dependence for toileting hygiene and rolling in bed. The resident’s care plan initially addressed potential skin impairment related to the Braden score, with interventions such as treatments as ordered, repositioning, and avoiding excessive moisture. However, the record showed the resident had frequent bowel movements, and the surgical consult documented MASD on the peri-wound area of the coccyx and right ischium beginning after the skin issue was identified. The care plan specific to MASD was not started until several days after MASD was first identified, and the later care plan focused on treatment and identifying causative factors rather than a comprehensive plan to keep the resident clean and dry. Staff interviews confirmed the resident was constantly soiled and that the incontinence-related care plan was not enough to prevent skin breakdown and MASD. The resident stated he developed a red, painful, stinging rash while at the facility and reported frequent bowel movements and prolonged periods of sitting in urine and feces when call lights were not answered for hours at night. The medical provider stated the resident’s MASD on the buttocks, perineum, right ischium, and peri-wound areas was caused by bowel and bladder incontinence and that the resident was at high risk for skin breakdown and wound infection. The DON stated the care planning policy required a comprehensive person-centered care plan with measurable objectives, timeframes, interventions, planned services, treatment, and resident goals, and acknowledged that care plans should have been created to address the resident’s needs after MASD developed.
Failure to Provide Adequate Supervision During Toileting for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident, assessed as high risk for falls due to a history of right femur fracture, Alzheimer's disease, osteoporosis, and severely impaired cognition, was left unsupervised on the toilet by a CNA. The resident required maximal assistance with toileting hygiene and was dependent on staff for toilet transfers, as documented in the Minimum Data Set and care plan. Despite these documented needs, the CNA left the resident alone in the restroom to inform another resident she was assisting the high-risk resident, during which time the resident attempted to stand, fell, and sustained a forehead laceration requiring five sutures at a general acute care hospital. Interviews with facility staff, including the CNA, LVN, RN, Director of Rehabilitation, and Assistant Director of Nursing, confirmed that the resident should not have been left unattended due to cognitive deficits, poor understanding of safety measures, and toe-touch weight-bearing status following a recent femur fracture. Staff acknowledged that supervision should have been maintained, and the CNA admitted it was unsafe to leave the resident alone. The care plan for the resident lacked specific instructions regarding the type and level of assistance required during toileting, which staff indicated could lead to miscommunication and increased risk of avoidable mistakes. The facility's policy on fall management required individualized care plans and interventions for high fall risk residents, but the care plan in this case did not specify the necessary supervision or assistance. The lack of clear guidelines and staff adherence to supervision protocols directly contributed to the resident's fall and injury while using the toilet.
Nursing Staff Lacked Required Competencies
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 due to a lack of appropriate skills and knowledge among the nursing staff, which impacted the quality of care provided to residents. There were no specific details provided about individual residents, their medical histories, or their conditions at the time of the deficiency. The report focuses on the general failure of staff to meet competency requirements necessary for resident care.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential delays and negative impacts on their care. Resident 27, who had severe cognitive impairment and was entirely dependent on staff for activities of daily living, did not receive a magic cup, a nutritional supplement, with his lunch as ordered by his physician. This oversight was due to a lack of awareness among the staff, as the Certified Nursing Assistant (CNA) was unfamiliar with the magic cup, and the Dietary Supervisor confirmed that it was not included on the meal tray. Resident 71, who was legally blind due to diabetic retinopathy, had a care plan that included inappropriate activities such as playing cards, cooking, and gardening, which were not suitable for someone with vision impairment. The Assistant Director of Nursing (ADON) acknowledged that these interventions were not resident-centered and did not cater to the resident's needs, highlighting a failure to develop a care plan that was beneficial and safe for the resident. Resident 78, who had cataracts and required bifocal glasses, did not have a care plan addressing his vision impairment, which could affect his quality of life and the meeting of his needs. Similarly, Resident 62, who had end-stage renal disease and other conditions, refused several medications on multiple occasions, yet there was no care plan to address this refusal. The ADON confirmed that a care plan should have been developed to manage the medication refusal, as it is standard practice to ensure proper care and avoid delays in necessary treatment.
Failure to Document Medication Refusal and Report Change in Condition
Penalty
Summary
The facility failed to meet professional standards of care for two residents, Resident 62 and Resident 142, as identified in a survey. For Resident 62, the facility did not document the resident's refusal of medications in the Progress Notes, nor did they educate the resident on the risks and benefits of refusing medications. Resident 62, who had diagnoses including end-stage renal disease, peripheral vascular disease, and diabetes mellitus, refused medications such as auryxia, clopidogrel, atorvastatin, and Rena Vite on multiple occasions in March 2025. The resident expressed a preference to take medications with dinner and reported that the nursing staff did not offer the medications at the appropriate time or provide an explanation for the delay. Interviews with the Licensed Vocational Nurse and the Assistant Director of Nursing confirmed that the standard practice of documenting medication refusals and educating the resident was not followed. Additionally, the facility failed to inform Resident 142's doctor of a change in the resident's condition, specifically the presence of brownish urine, which was noted on the Nurse's Dialysis Communication form. Resident 142, who was dependent on renal dialysis and had diabetes mellitus, reported brown urine and pain during urination to the nursing staff. However, the licensed nurse did not review the dialysis communication form or notify the physician of this change, which could indicate a potential urinary tract infection. The Assistant Director of Nursing acknowledged that the licensed nurses should have reviewed the dialysis nurse's comments and informed the doctor of the change in condition. The facility's policies and procedures, as well as job descriptions, emphasize the importance of documenting medication refusals, educating residents on medication compliance, and reporting changes in residents' conditions to physicians. The failure to adhere to these standards resulted in deficiencies in the care provided to Residents 62 and 142, potentially delaying necessary medical care.
Failure to Refer Resident for Ophthalmology Consultation
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 78, was referred to an ophthalmologist as recommended by an optometrist. Resident 78, who was admitted with diagnoses including diabetes mellitus and a left below-the-knee amputation, was found to have cataracts in both eyes during an optometry consultation. The optometrist recommended bifocal glasses and an ophthalmology referral due to the cataracts. However, the Social Services Director (SSD) was not aware of the need for this referral and did not review the consultation notes, resulting in a failure to make the necessary appointment. Interviews with the SSD and the Assistant Director of Nursing (ADON) revealed that the optometry consultation notes were supposed to be followed up by the SSD, who should have informed the nursing staff to obtain an order for the referral. The ADON emphasized the importance of timely follow-up on referrals to prevent further vision impairment. The facility's job description for the social services manager indicated that the SSD was responsible for referring residents to appropriate services when needed. The lack of follow-up on the ophthalmology referral delayed necessary treatment for Resident 78's cataracts.
Failure to Provide Appropriate Post-Dialysis Care
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for a resident, identified as Resident 62, who required dialysis treatment. The deficiency occurred when the facility did not remove the pressure dressing from Resident 62's arteriovenous (AV) shunt site as ordered by the physician. The physician's order specified that the pressure dressing should be removed two hours after dialysis on designated days. However, observations and interviews revealed that the dressing was not removed until the following day, which was contrary to the care plan and physician's orders. Resident 62, who had diagnoses including end-stage renal disease, peripheral vascular disease, and diabetes mellitus, returned from dialysis with the pressure dressing still intact. The resident reported itching at the AV shunt site and confirmed that the dressing had not been changed after returning from dialysis. The Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) acknowledged the oversight, noting that the failure to remove the dressing could lead to complications such as clotting of the shunt, fluid overload, and electrolyte imbalance. The facility's policy on post-dialysis care was not followed, resulting in this deficiency.
Failure to Document Lorazepam Administration
Penalty
Summary
The facility failed to accurately account for and document the administration of lorazepam, a controlled medication, for a resident. The resident, who was admitted with diagnoses including seizure disorder, autistic disorder, and major depressive disorder, had an active order for lorazepam to be administered as needed for crying without apparent reason. The Medication Administration Record (MAR) indicated that the resident received three doses of lorazepam over two days. However, a discrepancy was found during a review of the Narcotic Count Sheet (NCS) and the bubble pack, revealing one missing nurse's signature and an incorrect count of tablets. During an interview, a Licensed Vocational Nurse (LVN) admitted to forgetting to sign the NCS after administering the medication, acknowledging it as a medication error and dangerous practice. The Assistant Director of Nursing (ADON) confirmed that the nurse should sign the MAR and NCS immediately after administration to ensure the narcotic count is correct and to avoid medication errors. The facility's policy on controlled substances requires immediate documentation of administration details, which was not followed in this instance, leading to the deficiency.
Medication Error Due to Unauthorized Change in Aspirin Form
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Vocational Nurse (LVN) administered a chewable aspirin tablet without a physician's order. During a medication pass observation, the LVN was stopped by a surveyor from administering a crushed mixture of aspirin chewable tablet and applesauce to the resident. The resident's active aspirin order indicated the administration of an 81 mg delayed-release (DR) tablet once daily for stroke prevention, which should not be crushed. The LVN admitted to changing the medication form without physician approval, mistakenly believing the chewable and DR forms were the same. The resident involved had a history of cerebral infarction, gastritis with bleeding, and gastroesophageal reflux disease (GERD). The resident's care plan highlighted the risk of bleeding or bruising related to anticoagulant therapy, specifically aspirin. The Assistant Director of Nursing (ADON) confirmed that the nurse should have clarified the order with the physician before changing the medication form, as the DR tablet was likely prescribed to minimize gastrointestinal risks. The facility's policy required medications to be administered according to the physician's written orders.
Infection Control Deficiencies in Nebulizer and Linen Handling
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, leading to potential risks of infection. For Resident 33, the deficiency involved the improper handling of a nebulizer mask. The mask, which was used to deliver medication for respiratory conditions, was repeatedly observed placed directly on the nightstand surface without being stored in a plastic bag as required by the facility's infection control policy. This oversight was noted during multiple observations and interviews, where both the resident and staff acknowledged the improper storage of the nebulizer mask. The resident expressed concerns about the risk of infection and feelings of neglect due to the nurse's actions. In the case of Resident 62, the deficiency involved the improper handling of dirty clothes and linen. Observations revealed that dirty clothes and linen were left unattended on the resident's bed for extended periods. Despite the resident's preference for staff to clean the bed in his presence, the staff failed to remove the soiled items in a timely manner. Interviews with the resident and staff confirmed that the dirty clothes and linen were not properly managed, which was against the facility's infection control policy. The staff acknowledged the importance of removing soiled items to prevent infection and maintain resident dignity. The facility's infection control policies were not adhered to in both cases, as evidenced by the improper storage of medical equipment and the mishandling of soiled linen. The Infection Preventionist Nurse and other staff members recognized the deficiencies and the potential for infection due to these lapses in protocol. The facility's policies clearly outlined the need for proper storage and handling of items to prevent infection, yet these guidelines were not followed, leading to the identified deficiencies.
Failure to Conduct Weekly Skin IDT Meetings
Penalty
Summary
The facility failed to conduct weekly skin interdisciplinary team (IDT) meetings for a resident who developed redness on the left hip and left anterior iliac crest. This deficiency occurred between January 9, 2025, and February 27, 2027, for one of the six sampled residents. The resident, who was entirely dependent on staff for activities of daily living, had a history of dysphagia, cerebral infarction, hemiplegia, and pressure-induced deep tissue damage. Despite the facility's policy requiring weekly skin reviews and IDT meetings after any change in skin condition, no such meetings were conducted during the specified period. The Director of Nursing (DON) acknowledged that the normal practice was to conduct weekly skin IDT meetings and additional meetings whenever there was a change in the resident's skin condition. The DON confirmed that an IDT meeting should have been conducted after the resident developed skin redness on February 10, 2025. The facility's policy and procedure documents, revised in December 2023, also indicated the necessity of these meetings to monitor pressure injuries and document the collaboration in the resident's clinical record. The absence of these meetings had the potential to result in worsening skin impairments for the resident.
Room Size Deficiency in Multiple-Resident Rooms
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. During a review of the facility's Client Accommodations Analysis form dated March 24, 2025, it was found that four rooms did not meet this requirement. The rooms measured 217, 232, 238, and 234 square feet, respectively, and each housed three residents. Despite the deficiency in room size, observations indicated that the rooms provided privacy with curtains and had enough space for bedside tables, dressers, and maneuverability for wheelchairs. Interviews and observations conducted on March 27, 2025, revealed that the residents in these rooms were comfortable and had sufficient space for personal property, nursing care, and treatments. The administrator confirmed the deficiency, acknowledging that the rooms did not meet the size requirement but emphasized that the residents had privacy, dignity, and safety. The California Department of Public Health recommended a room waiver, indicating an acknowledgment of the deficiency but no immediate corrective action was detailed in the report.
Failure to Timely Report Injury of Unknown Source and Investigation Results
Penalty
Summary
The facility failed to report an injury of unknown source within the required two-hour timeframe to the California Department of Public Health (CDPH) for a resident who sustained a fractured right wrist. The resident, who had diagnoses including dementia, cerebral infarction, and a psychotic disorder with delusions, was noted to have a swollen right wrist during a therapy session. The injury was later confirmed by x-ray to be an acute, mildly displaced fracture of the distal radial metaphysis and an acute fracture of the ulnar styloid. Despite these findings, there was no documented evidence that the injury was reported to CDPH as required. Additionally, the facility did not ensure that the results of its internal investigation into the injury were reported to CDPH within five working days of the incident. Interviews with staff and family revealed that the resident had been observed guarding his right wrist and complaining of pain prior to the x-ray, and that these concerns had been reported to nursing staff. The facility's investigation concluded that the injury occurred during an episode of erratic behavior, but the reporting to CDPH was delayed until after the surveyor's initial visit. The facility's own policies require immediate reporting of all alleged violations involving abuse, neglect, or injuries of unknown source, especially those resulting in serious bodily injury, and mandate that investigation results be submitted to the state agency within five working days. The failure to adhere to these policies and regulatory requirements resulted in delayed notification to CDPH and delayed investigation by the authorities.
Failure to Develop and Implement Care Plan for Behavioral and Medical Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident exhibiting erratic behaviors, including thrashing and swinging arms, and did not address the resident's behavioral risks in the care plan. Despite staff observations and reports of the resident's impulsive and potentially harmful actions, such as striking furniture, these behaviors were not formally documented or targeted in the resident's care plan. The Director of Nursing confirmed that no care plan was in place to address these specific behaviors, which could have contributed to improper care. Additionally, the facility did not follow its own policy and procedure regarding significant changes of condition. The resident was observed by staff and family members to be guarding his right wrist and complaining of pain over several days. Although these changes were reported to nursing staff, a formal change of condition assessment was not completed in a timely manner, and pain-relieving interventions were not provided. The registered nurse acknowledged that a change of condition assessment should have been performed and that care should have been provided, as the resident's pain could have worsened. The lack of a care plan for the resident's behavioral issues and the failure to implement the facility's significant change of condition policy resulted in the resident not receiving appropriate interventions. This ultimately led to the resident sustaining an acute, mildly displaced fracture of the distal radius and ulnar styloid, requiring transfer to a general acute care hospital for further evaluation and treatment.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for two residents, leading to a deficiency in accommodating their needs and preferences. During an observation and interview, it was found that Resident 3's call light was clipped to a curtain and not visible, which was confirmed by a CNA who stated that the call light should be within the resident's reach. Resident 3, who has a history of falls, diabetes, and hypertension, and requires supervision for activities of daily living, stated that they rely on the call light to request assistance from nurses. Similarly, Resident 4's call light was also found clipped to a curtain, out of reach. The resident, who has a history of falls and difficulty walking, expressed that they often cannot find the call light and instead go directly to the nurses for help. Both residents have the mental capacity to understand and make medical decisions, as indicated in their medical records. The facility's policy requires call lights to be within residents' reach, which was not adhered to in these cases.
Delayed Release of Medical Records Violates Resident Rights
Penalty
Summary
The facility failed to release medical records requested by a resident's legal representative within the 24-hour timeframe as stipulated in their policy and procedure on Residents Rights, Release of Information. The resident, who had been admitted and readmitted with diagnoses including dementia, cardiac pacemaker, and hypertension, had fluctuating capacity to understand and make medical decisions. Despite the resident's ability to make themselves understood and understand others, the facility did not provide the requested medical records in a timely manner, resulting in a violation of the resident's rights. The request for the resident's medical records was initially sent by a legal services office via fax and followed up multiple times via email. The Medical Records Director acknowledged the delay, stating that the request was sent to the facility's legal team, which approved the release, but the records were not sent to the legal services office until nine days later. The Director of Nursing emphasized the importance of timely release of medical records, acknowledging that it was unacceptable for the resident and their representative to wait for about a month for the records to be released. The facility's policy indicated that residents should have access to their records within 24 hours of a written or oral request, excluding weekends or holidays.
Failure to Ensure Safe Transfer Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Hoyer Lift to transfer the resident from a wheelchair to the bed. This resulted in the resident falling and sustaining a right distal femur fracture, which required surgical intervention. The resident was admitted to a general acute care hospital for an open reduction internal fixation surgery. The incident occurred when the CNA attempted to transfer the resident alone, despite the resident's care plan indicating the need for a two-person assist. During the transfer, the Hoyer lift sling broke, causing the resident to fall. The CNA admitted to not checking the sling for damage prior to use and acknowledged that assistance should have been sought. The facility's Director of Nursing confirmed that the CNA should have asked for help and that CNAs were responsible for inspecting the lift sling before use. Interviews with staff revealed that the facility's procedures for checking and maintaining the Hoyer lift slings were not followed. The laundry aid and maintenance supervisor were responsible for inspecting and replacing damaged slings, but records showed no entries for sling checks during the days leading up to the incident. The facility's policy required a safe environment free of accident hazards, but the failure to inspect and maintain equipment contributed to the resident's fall and injury.
Delayed Transfer to Hospital After Resident's Fall
Penalty
Summary
The facility failed to transfer a resident immediately to a general acute care hospital (GACH) after the resident experienced an unavoidable fall that resulted in a right distal femur fracture. The incident occurred when a Certified Nursing Assistant (CNA) was transferring the resident from a wheelchair to a bed using a Hoyer lift, and the sling broke, causing the resident to fall. Despite the resident reporting severe pain and an X-ray confirming an acute comminuted supracondylar fracture, the transfer to the hospital was delayed by 10 hours. The resident, who had been admitted to the facility with diagnoses including diabetes, hypertension, and muscle weakness, was totally dependent on staff for transfers. After the fall, the resident reported a pain level of 10 out of 10, and the facility's Director of Nursing (DON) was notified. An X-ray was ordered, and the results, received at 11:00 p.m., confirmed the fracture. However, the resident was not transferred to the GACH until the following morning, resulting in a significant delay in receiving necessary medical evaluation and treatment. Interviews with the resident, the responsible party, and the DON revealed that the facility did not provide an explanation for the delay in transfer. The facility's policy and procedure for significant changes in condition and fall management were reviewed, indicating that immediate attention was warranted in such circumstances. The DON acknowledged that the facility should not have waited longer than one hour to transfer the resident, and the delay placed the resident at risk for delayed care and treatment.
Failure to Provide Prescribed Restorative Nursing Exercises
Penalty
Summary
The facility failed to provide restorative nursing exercises as per physician orders for three residents, leading to a deficiency in care. Resident 1, diagnosed with hemiplegia and hemiparesis, was ordered to receive passive range of motion (PROM) exercises five times a week. However, documentation showed that these exercises were not consistently provided, with several days marked as not applicable or resident refused. Similarly, Resident 2, with end-stage renal disease and diabetes, was ordered active assisted range of motion exercises, but records indicated multiple days without documentation of these exercises being performed. Resident 5, also diagnosed with hemiplegia and hemiparesis, was ordered PROM exercises five times a week. The documentation for Resident 5 showed numerous days without evidence of exercises being conducted, with some days marked as not applicable or resident refused. Interviews with the residents revealed that they were not receiving the prescribed exercises as frequently as ordered, with Resident 5 stating they only received exercises once or twice a week. During interviews, the RNA staff and the Director of Nursing acknowledged the lack of adherence to the physician's orders for restorative exercises. The RNA staff mentioned that residents often refused the exercises, but there was no indication that refusals were consistently reported to the charge nurse. The facility's policy on restorative care emphasized providing services according to individual needs and desires, but the documentation and interviews indicated a failure to meet these standards.
Failure to Develop Care Plans for Residents with MASD
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes, and interventions for two residents who had moisture-associated skin damage (MASD). This deficiency was identified during a review of the records and interviews with staff. Resident 1, who had peripheral vascular disease and was dependent on renal dialysis, did not have a care plan for MASD despite receiving treatment for it. Similarly, Resident 3, who had peripheral vascular disease and diabetes mellitus, also lacked a care plan for MASD, even though treatment was being administered. Interviews with the Treatment Nurse, Licensed Vocational Nurse, MDS Nurse, and Director of Nursing revealed that the facility's policy required all skin issues, including MASD, to be care planned. The staff emphasized the importance of care plans in providing guidance for treatment and prevention of further skin breakdown. However, the absence of care plans for these residents meant that staff might not have been fully informed about the residents' conditions and the necessary interventions. The facility's policies on change of condition reporting and comprehensive resident-centered care planning were not followed, as evidenced by the lack of updated care plans for the residents with MASD. This oversight had the potential to negatively affect the delivery of skin treatments and the prevention of further skin breakdown for the affected residents.
Failure to Obtain Authorization and Notify Responsible Party Before Resident Discharge
Penalty
Summary
The facility failed to ensure a written or verbal authorization was obtained from the responsible party of a resident prior to the resident's discharge to another facility. This resulted in the resident's primary responsible person not being aware of the discharge. The resident, who had severe cognitive impairment and was unable to make decisions, was admitted with diagnoses including dysphagia and cognitive communication deficit. The admission record indicated that the resident's family member 1 (FM1) was the first emergency contact person, and family member 2 (FM2) was the second emergency contact person. However, the facility did not document when FM2 requested the resident to be transferred out of the facility, nor did they notify FM1 of the discharge. Interviews with the Social Services Director (SSD), Licensed Vocational Nurse (LVN) 1, and the Director of Nursing (DON) revealed that the facility's protocol was to notify the first emergency contact person listed in the admission record if a resident was unable to make decisions. The DON emphasized that documentation of any communication with the family regarding discharge was necessary to protect the resident. A review of the facility's policy and procedure indicated that for resident-initiated transfers or discharges, the resident or their representative must provide verbal or written notice of intent to leave, and this must be documented in the medical record. The failure to follow these procedures led to the deficiency noted in the report.
Failure to Develop Timely Care Plan for Stage III Pressure Ulcer
Penalty
Summary
The facility failed to develop an individualized person-centered care plan addressing a Stage III pressure ulcer for a resident. The resident was admitted with moisture-associated skin damage, which progressed to a Stage II and then a Stage III pressure ulcer. Despite the resident's high risk for pressure ulcers and the presence of a Stage III ulcer documented in the Treatment Administration Record and Wound Doctor Notes, the care plan was not developed until over a month after the pressure ulcer was discovered. This delay in care planning was confirmed by both the Treatment Nurse and the Director of Nursing during interviews. The resident's Minimum Data Set indicated impaired cognitive skills and complete dependence on staff for all activities of daily living. The resident was receiving various interventions for pressure injury, including a pressure-reducing device, nutrition, hydration interventions, and topical treatments. However, the care plan for the Stage III pressure ulcer was only created after a significant delay, which the Director of Nursing acknowledged as a failure to provide timely and necessary care. The facility's policy required the development of a comprehensive care plan upon the discovery of such conditions, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Downey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paramount Convalescent Hosp. | 1.2 mi | ★★★★★ | 24 | 0 |
| California Post-acute Care | 1.4 mi | ★★★★★ | 65 | 0 |
| Lynwood Post Acute Care Center | 1.4 mi | ★★★★★ | 34 | 0 |
| Granada Post Acute | 1.4 mi | ★★★★★ | 2 | 0 |
| Lakewood Healthcare Center | 1.8 mi | ★★★★★ | 45 | 0 |
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