Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dreier's Nursing Care Center during CMS and state inspections, most recent first.
Informed consent for psychotropic meds was not obtained by the prescriber for two residents. One resident with Parkinson’s disease and schizophrenia had an Ativan consent form missing the prescriber’s signature, while an LVN documented obtaining verbal consent from the RP. Another resident with encephalopathy, hemiplegia, hemiparesis, and aphasia had two lorazepam consent forms missing the prescriber’s signature. Interviews showed facility nurses, not the prescriber, were obtaining the consents, which did not match the facility’s Informed Consent policy.
Incomplete medication disposition records and missing E-kit usage log: The facility failed to complete the non-controlled medication disposition log with the required date and witnessing nurse signature, and staff could not locate a separate E-kit usage log. RN 1 and the DON stated the E-kit process relied on slips and copies filed in different places, but there was no separate record to identify who accessed the E-kit, what was removed, or for which resident.
Unlabeled and Undated Resident Beverages in Refrigerator: The facility failed to properly label and date cups of milk and juice stored in a refrigerator. An observation found about 17 cups of milk and 30 cups of juice on meal trays without resident identifiers, prep dates, or discard dates, and the DS stated staff could not verify the age of the beverages or whether they were within safe storage timeframes.
Failure to Inform a Resident of Advance Directive Rights: A resident with depression, schizophrenia, and HTN was found to have an incomplete Advance Directive Acknowledgement, with no initials or signature indicating the resident had been informed of the right to formulate an AD. The SSD stated the form should have been completed upon admission and that the resident had not been offered the choice to complete an AD; the resident did not recall being offered help, and the DON stated the AD guides care when a resident can no longer make decisions.
Incorrect Wall Clock in Resident Room: The facility failed to maintain a homelike environment when a wall clock in a resident’s room showed the wrong time. The resident had psychosis, insomnia, visual hallucinations, lacked decision-making capacity, and had severely impaired cognition. RN observed the clock was one hour late, and both the RN and DON stated an incorrect clock could disorient the resident and lead to agitation. The MS said he was responsible for ensuring clocks showed the correct time and that the clock was old and needed replacement.
PRN Psychotropic Medication Given Without Adequate Documentation: A resident with CVA-related aphasia, severe cognitive impairment, and inability to verbalize needs had PRN lorazepam ordered for anxiety manifested by excessive restlessness, but the DON found behavior episodes and doses given without documentation of the behavior, triggers, nonpharmacological interventions, or the reason for administration. Psychiatric notes also lacked medical history, and there was no documentation showing the resident’s baseline restlessness, paranoia, or other underlying causes were considered.
Delayed reporting and investigation of suspected abuse allegation: A resident with a recent femur fracture and intact cognition alleged that a CNA struck his foot while stopping his wheelchair from rolling down a ramp. A charge nurse witnessed the event and reported no contact with the resident’s foot, and another resident gave the same account. The facility did not start its abuse investigation or report the allegation to CDPH and the Ombudsman until later, and the DON acknowledged the report was not made within the required timeframe.
Failure to transmit completed discharge MDS assessments occurred for two residents. One resident had asthma and lymphedema, and the other had PVD and DM2. The MDS Nurse said the assessments were completed, but the DON selected the option not to transmit them to CMS. The DON stated the discharge MDSs should have been sent immediately after completion, while the facility policy required all MDS assessments and discharge records to be electronically encoded and transmitted to CMS IQIES.
Incomplete Care Planning for a Resident With CVA and G-Tube: A resident with severe cognitive impairment, dysphagia, a G-tube, and dependence for care did not have a comprehensive care plan developed for EBP, despite facility staff stating that EBP should be initiated for residents with feeding tubes and should include gloves and gowns during care. The resident’s non-pharmacological care plan was also described as generic and lacking interventions tailored to the resident’s stroke-related cognitive impairment and inability to verbalize needs.
A resident’s MRR identified the need to clarify the diagnosis for aspirin EC 81 mg, but the LPN/physician did not act on the pharmacist’s recommendation. The resident’s order listed aspirin EC 81 mg daily for cardiovascular prophylaxis, and the DON stated that cardiovascular is a system, not a diagnosis, while the resident’s H&P noted the resident lacked capacity to understand and make decisions.
Incomplete Dialysis Communication Documentation for Resident with Diabetes: A resident with DM and ESRD who received dialysis had blank blood sugar entries in the dialysis communication log on multiple occasions. An LVN and the DON reviewed the forms and confirmed the BG values were not documented, and the DON stated the missing information could affect coordination with the dialysis provider and limit monitoring of diabetes management.
Failure to Use EBP During Resident Care: A resident with a G-tube, severe cognitive impairment, and dependence for bed mobility was observed being repositioned by two CNAs without gowns, despite EBP signage at the room entrance. The resident’s chart did not include an EBP order on readmission, and staff interviews confirmed the resident should have been on EBP with gloves and gowns used for high-contact care.
A resident with intact cognition and multiple medical conditions, including post-surgical amputation, acute osteomyelitis, and DM, filed several grievances documented on GCT forms. Although the forms reflected that grievances, investigations, and resolutions occurred, they lacked written investigation findings, dates or documentation that the resident was informed of those findings, and details of corrective actions. The resident reported never being told the outcomes of the investigations, and the DON confirmed there was no documentation in the GCT forms, social service notes, or medical record showing that the resident was informed, despite facility policy requiring oral and written communication of grievance findings and actions.
The facility failed to follow its abuse reporting policy when an allegation was made by a cognitively intact resident, who had a right patella fracture and acute respiratory failure with hypoxia, that therapy staff had hit her and forced her to walk. The SSD learned of the allegation from the resident’s representative after a dialysis center reported the resident’s statements, and the SSD informed the DON and the IDT. Despite the facility policy requiring suspected abuse to be reported to state authorities within two hours, the allegation was not reported to CDPH within that timeframe, even though police later arrived after receiving a related report from APS.
A resident with limited English proficiency and a preference for Farsi was not provided with appropriate interpretation services, resulting in ineffective communication and incomplete assessment of care needs. Staff relied on gestures and did not utilize interpreter services as required by facility policy.
Several residents did not have individualized care plans addressing their specific needs, including food preferences for a resident with significant weight loss, oxygen therapy for three residents with respiratory conditions, and epilepsy medication management for another resident. Staff and DON interviews confirmed that care plans were not created as required by facility policy, resulting in a lack of guidance for staff on how to meet these residents' needs.
Surveyors found that staff failed to label opened insulin and over-the-counter medications with the date they were first accessed, as required by facility policy and professional standards. An insulin pen for a resident with diabetes and two bottles of multi-dose medications were found in medication carts without opened dates, and staff confirmed that all multi-dose medications must be labeled and discarded within specified timeframes.
Surveyors found that staff did not consistently monitor or document refrigerator and dry storage room temperatures, and failed to discard opened prune juice after five days as required by facility policy. The Dietary Supervisor and kitchen staff confirmed lapses in daily temperature checks and unclear labeling of food items, resulting in expired juice being stored and incomplete temperature logs.
Surveyors identified infection control deficiencies involving three residents: a resident on contact precautions for an MDRO had a nonfunctional hand sanitizer dispenser in their room; another resident receiving IV antibiotics had an uncapped IV line port touching the bedside curtain; and a third resident with a gastrostomy tube had an uncapped feeding tube port hanging exposed on an IV pole. Staff interviews confirmed these lapses, and facility policies required proper hand hygiene and equipment handling.
A resident with intact cognition and multiple serious health conditions was administered a hypnotic medication without a signed informed consent form. Facility staff confirmed that the required consent process was not completed, meaning the resident may not have been fully informed of the medication's risks and benefits, in violation of facility policy.
A resident with multiple chronic conditions and intact cognition was not provided with required information about the right to formulate an Advance Directive. Facility records and interviews revealed inconsistent documentation regarding the resident's AD status, and both the DON and Social Worker confirmed that the resident had not received the necessary information, in violation of facility policy.
A resident with significant limitations in range of motion (ROM) and a history of muscle weakness and neurological conditions did not receive restorative nursing (RNA) services as indicated in their care plan after readmission. Despite assessments and care plans identifying the need for RNA to prevent further decline, staff interviews and record reviews confirmed that RNA services were not provided for several months due to discontinued and unrenewed physician orders. Facility policy required such interventions, but the lapse was not addressed, resulting in a deficiency in care.
A resident with chronic pulmonary edema and acute respiratory failure experienced significant weight loss and poor meal intake after the facility failed to assess and document their food preferences during both admission and comprehensive nutritional assessments. The resident reported dissatisfaction with the food, and observations confirmed the meals were unappealing. Staff interviews revealed that food preferences were not considered or included in the care plan, contrary to facility policy.
Two residents receiving oxygen therapy did not receive care according to physician orders, including the lack of routine oxygen administration and missing 'No Smoking/Oxygen in Use' signage in their rooms. Both the DON and an LVN confirmed that facility policy required such signage for safety, and records showed that staff did not consistently follow orders for routine oxygen therapy.
A nurse failed to accurately check the gastric residual volume (GRV) for a resident with a G-tube, aspirating only 20 mL instead of all available gastric contents as required by facility policy and physician orders. The resident, who had severe cognitive impairment and required all medications via G-tube, was at risk due to this incorrect practice, which was later acknowledged by the nurse after re-assessment revealed a higher GRV.
A CNA was found to be providing direct resident care despite having an expired certification. The DSD confirmed the lapse in monitoring and follow-up, and the CNA acknowledged working scheduled shifts after her certification expired while awaiting renewal. Facility policy and the DON both require current certification for staff providing care, but this was not enforced in this instance.
The facility did not maintain a medication error rate below 5%, with errors identified during medication administration for two residents. One resident did not have their G-tube flushed after receiving methimazole, and another received ophthalmic medications without pressure applied to the inner eye as required. These actions were contrary to physician orders and facility policy, resulting in a cumulative error rate of 10.3%.
A resident with a history of heart failure and pulmonary embolism experienced shortness of breath and low oxygen saturation throughout the day, but did not receive oxygen therapy as ordered by the physician. Despite repeated complaints and low O2 readings, staff delayed administering oxygen for over eight hours, only providing it when the resident's condition became critical and required emergency transfer to a hospital.
A facility failed to maintain the confidentiality of a resident's medical records by mistakenly sending them with another resident to a hospital. During an emergency transfer, the records of a resident with chronic conditions and a DNR order were sent instead of the correct resident's records. The error was identified by hospital staff, and it was noted that both the RN supervisor and LVN on duty were from a Nursing Registry, contributing to the mix-up.
A resident with severe cognitive impairment was transferred to a GACH due to a change in condition, but the facility sent incorrect medical records meant for another resident. This error led to confusion and a delay in obtaining the correct information, as the resident arrived without proper identification. The RN on duty, from a nursing registry, was responsible for the mistake, which violated the facility's policy requiring accurate transfer records.
A resident with severe cognitive impairment was transferred to a GACH without proper identification and with incorrect medical records, leading to potential delays in treatment. The facility failed to follow its policy on transfers, as the RN supervisor, unfamiliar with procedures, sent the wrong records. The resident was not wearing an ID wristband, contributing to the mix-up.
The facility failed to maintain a safe environment due to multiple leaks and water damage in residents' rooms, the kitchen, and shared areas. Observations showed paint bubbling and water leaks, with staff using temporary measures like tarps and buckets. Despite the damage, the kitchen continued to operate, posing infection risks. Interviews revealed a lack of awareness and communication among staff, with no external contractors contacted for repairs.
The facility failed to provide a safe environment during a rainstorm, leading to water damage in the rooms of three residents. A resident with schizoaffective disorder and anxiety disorder felt anxious due to water leaking onto her roommate's bed. Another resident with hypertension and depression experienced anxiety from water leaks in her room and the activity room. A third resident with cerebral infarction and hemiplegia was worried about water pooling at the foot of her bed. The Maintenance Supervisor placed a tarp on the roof but did not inspect resident rooms due to kitchen damage.
A facility failed to develop and implement a comprehensive care plan for a resident following hip reduction surgery. Despite physician orders for a knee immobilizer and abduction pillow, the resident, who had severe cognitive impairment, was often found without these devices. Staff interviews revealed inconsistent use, and there was no care plan addressing the resident's refusal to wear them, potentially exposing the resident to complications.
A resident with a history of cerebral infarction and hemiplegia was not treated with dignity during routine care. Two CNAs made inappropriate comments about the resident's relationship with her boyfriend during diaper changes, which was against the facility's dignity policy. The incident was reported, but no formal investigation or documentation was conducted by the DSD, and the grievance logs showed no entries for this incident.
A resident with dementia was improperly discharged from a facility to another without proper documentation or consent from responsible parties. The facility failed to provide necessary information and resources, and did not involve the resident's family in the discharge planning process. The resident was returned after refusing to stay at the new facility, highlighting deficiencies in communication and adherence to discharge policies.
A facility failed to provide a written notice to a resident with dementia and their responsible party before transferring the resident to another SNF. The transfer occurred without notifying the Ombudsman in writing, violating the facility's policy. The DON confirmed there was no urgent need for the transfer, and no interdisciplinary team meeting was held for discharge planning.
A facility failed to create a care plan for a resident's left eye injury after an altercation with another resident. Despite documentation of the incident, no care plan was developed to address the injury. Interviews with staff confirmed the oversight, which was acknowledged as necessary by the RN and DON. The facility's policy requires ongoing assessments and revisions of care plans, which was not followed in this instance.
A resident with type 2 diabetes had consistently elevated blood sugar levels over several days, but the facility failed to notify the physician promptly. The resident's blood sugar levels were significantly above normal, yet the facility's staff did not report these levels due to a lack of specific parameters for notification. The facility's policy required prompt notification of significant changes, but this was not followed, leading to a deficiency.
A resident with severe sepsis and pneumonia, using an indwelling urinary catheter, was not monitored for fluid intake and output as per facility policy, leading to hospitalization for a UTI and sepsis. The facility's failure to document daily urine output, as required by their catheter care policy, resulted in a deficiency.
A facility failed to provide adequate respiratory care to a resident by not assessing respiratory status, obtaining a physician's order for oxygen, or reassessing the effectiveness of oxygen therapy. The resident, with pneumonia and respiratory failure, experienced fluctuating oxygen saturation levels, and despite receiving oxygen therapy, there was no documented reassessment or physician order, contrary to facility policy.
A resident reported being threatened and possibly hit, but the LTC facility failed to report the allegation to law enforcement as required by their policy. Staff interviews revealed confusion about the reporting process, and the DON, responsible for the investigation, was unaware of the need to report to law enforcement. The facility's policy mandates immediate reporting of abuse allegations to various authorities, including law enforcement.
A resident with multiple diagnoses reported being threatened, but no care plan was developed to address the allegation of abuse. Despite the facility's policy requiring a comprehensive care plan, interviews revealed that no plan was initiated, and there was no documentation of monitoring the resident for emotional distress. The deficiency was acknowledged by the DSD and DON, highlighting a lapse in the facility's practices.
The facility failed to protect the privacy and dignity of eight residents by allowing other residents to use their designated shower rooms, leading to discomfort and embarrassment. Despite awareness of the issue, staff cited a lack of alternative facilities as the reason for this practice, which contradicted the facility's policies on resident rights and dignity.
Two residents in an LTC facility were not accommodated in their preferences for private showering arrangements, affecting their privacy and dignity. One resident's bathroom was used as the sole male shower room, despite his preference for privacy. Another resident, who required moderate assistance, found the situation embarrassing. Staff interviews confirmed the lack of alternative shower facilities, despite awareness of privacy issues.
A resident with epilepsy and a history of falls was not placed on a low bed as required by their care plan, leading to a fall and injury during a seizure. Despite the care plan's intervention for a low bed, staff confirmed it was not implemented, resulting in a deficiency in care.
A resident with severe cognitive impairment and contractures was injured due to inadequate supervision and care planning. The facility failed to communicate the resident's specific needs for assistance with bathing and transfers, resulting in the resident being showered inappropriately, leading to multiple fractures and hospitalization. Staff were not informed of the resident's limitations, and no care plan was developed to address the resident's needs.
A resident experienced a significant change in condition, including decreased blood pressure, increased heart rate, and severe pain, but the facility failed to notify the physician or conduct appropriate assessments. The resident, with a history of severe cognitive impairment, continued to decline and eventually died. The facility did not adhere to its policies for managing changes in a resident's condition, leading to inadequate care.
A resident with a history of TIA and CVA was not properly assessed or monitored by the facility's staff, leading to a failure to notify the physician of significant changes in vital signs and pain levels. The resident's condition deteriorated, resulting in their death. The facility did not follow its policies for pain management and change of condition notification, nor did it develop a care plan for the resident's medical conditions.
The facility failed to designate a medical director for six months, affecting all residents, including one who died without a thorough evaluation of their change in condition. Outdated healthcare policies had not been reviewed or approved by a medical director, potentially leading to substandard care.
Informed consent for psychotropic medications not obtained by prescribers
Penalty
Summary
The facility failed to ensure that prescribers obtained informed consent before psychotropic medications were administered to two sampled residents. The report states that the facility’s policy titled Informed Consent required the physician to obtain informed consent for psychotherapeutic drugs and to notify nursing after consent was received, but the documented process for the two residents did not follow that requirement. Resident 5 was admitted with diagnoses including Parkinson’s disease without dyskinesia and schizophrenia. The resident’s H&P stated the resident did not have the capacity to understand and make decisions. A physician order dated 7/16/2026 directed Ativan 0.5 mg by mouth every 8 hours as needed for anxiety for 14 days, with a start date of 7/09/2026. The psychotherapeutic drug informed consent form for Ativan was reviewed with the prescriber’s name written on it and dated 7/08/2026, but the prescriber signature section was blank. A progress note dated 7/09/2026 stated an LVN spoke to the resident’s RP and obtained verbal consent for continuation of Ativan, and the form was completed and signed by the LVN and witnessed by the RN supervisor. The RP later stated she received calls from facility nurses for medication informed consents and had never spoken with a facility provider for consent. Resident 3 was initially admitted on 1/30/2026 and later re-admitted, with diagnoses including encephalopathy, hemiplegia, hemiparesis following cerebral infarction, and aphasia. The resident had two informed consent forms for lorazepam dated 6/18/2026 and 7/9/2026, and both forms were missing the prescriber’s signature. During interviews, the DON and RN stated the facility nurses obtained consent from residents or responsible parties, while the DON later acknowledged that the licensed practitioner who prescribed the psychotropic medication should be the person obtaining consent from the resident or family.
Incomplete medication disposition records and missing E-kit usage log
Penalty
Summary
The facility failed to provide pharmacy services that ensured the non-controlled medication disposition log was completed with the date of disposition and the witnessing nurse’s signature. During a review of the log, the top page dated 7/13 had one nurse’s signature, and a later page between entries dated 6/25 and 6/30 had no disposition date. When questioned, RN 1 stated there should be a date. The facility policy titled, Discarding and Destroying Medications, stated that the medication disposition record contains the date medication destroyed and the signatures of witnesses, and California regulations required the date of destruction and signatures to be recorded. The facility also failed to keep a separate record of emergency drug supply E-kit usage. RN 1 stated she could not find an E-kit usage log in the medication room or at the nursing station. The DON stated nurses completed an E-kit slip with a carbon copy, left the copy in the E-kit for pharmacy record, and kept the original for the medical record, but there was no separate log for E-kit usage. The DON further stated the facility could not reconcile or verify medications removed from the E-kits, including controlled substances, without knowing who accessed the E-kit, what time it was accessed, what medication was removed, and for which resident. The facility policy on Emergency Pharmacy Service and Emergency Kits did not mention keeping such a record, while California regulations required separate records of use for drugs administered from the emergency supply.
Unlabeled and Undated Resident Beverages in Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards by not ensuring resident beverages were properly labeled and dated. During an initial kitchen observation with the Dietary Supervisor, Refrigerator #1 contained multiple cups of milk and juice stored on pink meal trays without resident identifiers, preparation dates, or discard dates. There were approximately 17 cups of milk and 30 cups of juice, including red and yellow-colored juices, covered with plastic wrap or lids, but none were labeled to identify when the beverages were prepared. During interview, the Dietary Supervisor stated that without appropriate labeling and dating, dietary staff could not verify the age of the beverages or ensure they were discarded within safe food storage timeframes. The Dietary Supervisor also stated that the facility did not ensure resident beverages were properly labeled and dated, which would increase the risk of residents being served expired or contaminated food items. The facility's Food Receiving and Storage policy, revised 11/2022, stated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated with a use-by date, and that refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to provide information on the right to formulate an advance directive for one sampled resident. Resident 5 was admitted and readmitted with diagnoses including depression, schizophrenia, and hypertension. The resident's H&P dated 10/24/2025 stated that the resident did not have the capacity to understand and make decisions, while the MDS dated 4/15/2026 indicated intact cognition and that no advance directive had been completed. Review of Resident 5's Advance Directive Acknowledgement showed the resident was to initial each statement, including acknowledgment of being informed of the right to formulate an advance directive, but the document had neither initials nor a signature. During interview and record review, the SSD stated the form was incomplete, should have been completed upon admission, and that she had not offered Resident 5 the choice to formulate an advance directive. Resident 5 stated she did not recall being offered help to complete one, and the DON stated that if the resident was not offered the opportunity to formulate an advance directive, the resident's care may not be what she would want when she can no longer make decisions for herself.
Incorrect Wall Clock in Resident Room
Penalty
Summary
The facility failed to promote a homelike environment for one resident when the wall clock in the resident’s room did not show the correct time. Resident 45 was originally admitted and later readmitted with diagnoses that included psychosis, insomnia, and visual hallucinations. The resident’s H&P dated 2/14/2026 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 5/19/2026 indicated severely impaired cognition. During a concurrent observation and interview on 7/14/2026 at 11:20 AM, RN 1 observed that the wall clock in Resident 45’s room showed 10:20 AM instead of 11:20 AM. RN 1 stated the clock was one hour late and that a wrong clock could potentially disorient the resident. The DON stated that for a cognitively impaired resident such as Resident 45, clocks should show the correct time, and that clocks not set correctly could further disorient the resident and lead to agitation. The MS stated he was responsible for ensuring clocks showed the correct time and said the clock in Resident 45’s room was an old clock that needed to be replaced. The facility’s Homelike Environment policy stated residents are provided with a safe, clean, comfortable and homelike environment and that staff maximize characteristics reflecting a personalized, homelike setting, including a clean, sanitary, and orderly environment.
PRN Psychotropic Medication Given Without Adequate Behavioral Documentation
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication had an adequate indication for use and was supported by documentation of the resident’s behaviors, significant episodes, and reasons for administration for one resident. The resident had a history of CVA with encephalopathy, hemiplegia, hemiparesis, aphasia, severe cognitive impairment, was nonverbal, and could not express or verbalize needs. The record showed PRN lorazepam 0.5 mg every 6 hours as needed for anxiety manifested by excessive restlessness, along with a standing order for quetiapine for psychosis manifested by paranoia and physical outburst. During review of the July 2026 eMAR and nurses’ notes, the DON identified behavior episodes on multiple dates and doses of lorazepam that were administered, but there was no documentation describing what the behavior was, what triggered it, or what nonpharmacological interventions were attempted. The DON stated there was also no documentation supporting the reason for giving lorazepam on those dates, and no documentation showing whether any interventions were effective. The DON could not define the resident’s baseline restlessness or explain what was considered excessive restlessness, and could not describe the resident’s paranoia. The psychiatric evaluations reviewed had blank medical history sections, and there was no documentation showing the resident’s underlying medical conditions, including aphasia, were considered, reviewed, or ruled out as possible causes of the behaviors. There was also no documentation describing the resident’s paranoia or how it was expressed nonverbally. The facility policy stated psychotropic medications are not to be given PRN unless necessary to treat a diagnosed specific condition documented in the clinical record, and that medication administration should include the symptoms for which the drug was given, the results achieved, and when those results were observed.
Delayed reporting and investigation of suspected abuse allegation
Penalty
Summary
The facility failed to report a suspected abuse allegation to the State agencies and police department and failed to thoroughly investigate the allegation in a timely manner for one resident who alleged that a CNA struck his right foot while stopping his wheelchair from rapidly rolling down a ramp. The resident had been readmitted with a right femur fracture, psychoactive substance abuse history, and documented intact cognition and capacity to understand and make decisions. The resident stated that while he was trying to wheel himself down the ramp to use the restroom, the CNA rushed toward him and struck his right foot during the intervention. Facility documentation showed that the incident occurred when the resident did not follow staff instructions to wait for assistance and instead propelled his wheelchair down the ramp. A charge nurse witnessed the event and reported that the CNA stopped the wheelchair by holding the underside of the footrests to prevent injury to the resident’s surgically repaired right leg, and that no contact with the resident’s foot occurred. The resident’s right lower extremity was observed afterward and no visible injury, redness, or swelling was noted. Another resident also stated that the CNA did not strike the resident’s foot and that the resident yelled profanity at the CNA after the intervention. The Social Services Designee stated that the facility did not begin its abuse investigation until two days later and could not explain the delay. The DON stated that the allegation was not reported to CDPH or the Ombudsman until two days after the incident and acknowledged that the report should have been made within the required timeframe for an allegation of abuse that did not result in serious bodily injury. The DON also stated that the delay did not comply with facility policy or regulatory requirements and could have delayed regulatory oversight, staff interviews, preservation of witness recollections, and identification of corrective actions.
Failure to Transmit Completed Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure that MDS assessments were completed and submitted timely to the CMS system for 1 of 2 sampled residents, involving two discharge-return not anticipated MDS assessments for Resident 36 and Resident 40. Resident 36 was admitted with diagnoses including asthma and lymphedema, and Resident 40 was admitted with diagnoses including peripheral vascular disease and type 2 diabetes mellitus. The record review showed Resident 36's discharge MDS had an ARD of 3/21/2024 and was completed on 3/07/2026, but it was not transmitted to CMS when completed. Resident 40's discharge MDS had an ARD of 3/17/2026 and was completed on 3/03/2026, but it was not transmitted to CMS when completed. During interview and concurrent record review, the MDS Nurse stated she was responsible for ensuring all residents' MDS assessments were completed and said the facility had 14 days from discharge to complete and submit the discharge MDS to CMS. She stated the discharge MDSs for Resident 36 and Resident 40 had been completed on time, but the DON had signed and selected the option not to transmit them to CMS. During interview, the DON stated the discharge MDSs should have been transmitted immediately after completion and said she did not notice that she had chosen the option not to transmit them to CMS when she reviewed them as complete. The facility policy titled Electronic Transmission of the MDS stated that all MDS assessments and discharge and re-entry records are completed and electronically encoded into the facility's MDS information system and transmitted to CMS IQIES in accordance with current OBRA regulations.
Incomplete Care Planning for Resident With CVA and G-Tube
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of CVA, dysphagia, gastrostomy, sepsis, severe cognitive impairment, and dependence for care activities. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition, dependence for personal hygiene, bathing, and bed mobility, and the presence of a feeding tube. A physician order also directed care for the G-tube site with cleansing, drying, and a dry dressing each shift. During record review and interview, RN 1 stated there was no care plan developed for EBP and that such a care plan should have been initiated on admission because the resident had a G-tube. The IPN stated that when a resident with a G-tube is admitted, the admitting nurse must initiate a care plan for EBP, and that the care plan should include staff wearing gloves and a gown before providing care. The DON also stated that residents admitted with a G-tube must have a care plan for EBP and that care plans guide staff in rendering care. The report also identified that the resident’s care plan for non-pharmacological interventions lacked documentation of interventions tailored to the resident’s condition. The DON stated the resident had a history of CVA resulting in severe cognitive impairment and could not express or verbalize needs, and acknowledged that the interventions listed were generic. The facility policy stated that comprehensive, person-centered care plans must include measurable objectives and timetables and, when possible, address the underlying source of problem areas rather than only symptoms or triggers.
Failure to Act on Pharmacist Recommendation for Aspirin Order
Penalty
Summary
Licensed nursing staff and the physician failed to act on the consultant pharmacist’s Medication Regimen Review recommendation for Resident 5’s aspirin EC 81 mg order. The pharmacist’s MRR, completed on 5/18/2026 to 5/19/2026, recommended clarifying the resident’s diagnosis for aspirin EC 81 mg and to assess and consider clarifying the diagnosis. Resident 5’s record showed admission to the facility on [DATE], and the History and Physical dated 10/24/2025 stated the resident did not have the capacity to understand and make decisions. A physician’s order dated 7/16/2026 listed aspirin EC oral tablet delayed release 81 mg, 1 tablet by mouth daily for cardiovascular prophylaxis, with an order start date of 5/20/2026. During a concurrent interview and record review on 7/16/206 at 4:35 PM, the DON stated the aspirin order did not include a proper diagnosis and that “cardiovascular” was a system, not a diagnosis. The facility’s Medication Therapy policy stated that each resident’s medication regimen shall include only those medications necessary to treat existing conditions and address significant risk.
Incomplete Dialysis Communication Documentation for Resident with Diabetes
Penalty
Summary
The facility failed to accurately document blood glucose levels in the Dialysis Communication Log for one resident with type 2 diabetes mellitus and end-stage renal disease who was receiving dialysis on Tuesdays, Thursdays, and Saturdays. The resident’s admission record, history and physical, MDS, and order summary report identified the resident as having diabetes, intact cognition, and a dialysis schedule. However, the Dialysis Communication Forms for 7/4/2026, 7/8/2026, and 7/14/2026 had the section for “Blood Sugar if Diabetic” left blank. During a concurrent interview and record review on 7/16/2026, an LVN reviewed the resident’s Dialysis Communication Forms and confirmed that the blood glucose values were not documented on those dates. The LVN stated that the missing documentation could delay identification of hypoglycemia or hyperglycemia and could affect the resident’s safety if left untreated. The DON also reviewed the forms and confirmed that the blood sugars were not recorded. The DON stated that without documented blood glucose levels, nursing staff would be unable to effectively identify whether the resident was having blood sugar issues such as hypoglycemia or hyperglycemia. The DON further stated that incomplete dialysis communication documentation could affect coordination of care between the facility and the dialysis provider and limit the interdisciplinary team’s ability to monitor diabetes management and identify clinical trends over time. The facility’s policy on care of a resident with ESRD stated that information would be exchanged between the facility and the contracted ESRD facility, and the documentation policy required resident records to be current and detailed.
Failure to Use EBP During Resident Care
Penalty
Summary
The facility failed to prevent the spread of MDROs for a resident with a G-tube who was readmitted to the facility and placed on enhanced barrier precautions (EBP). The resident’s record showed diagnoses including dysphagia, gastrostomy, and sepsis, and the resident was documented as having severely impaired cognition, lacking capacity to understand and make decisions, and being dependent for care such as personal hygiene, bathing, and rolling in bed. The resident’s physician orders included care for the G-tube site, but the orders reviewed did not include an order for EBP when the resident was readmitted. During observation, a sign at the resident’s room indicated that staff must wear gloves and a gown for high-contact care activities. When two CNAs repositioned the resident in bed, neither wore a gown, and their clothing was observed in physical contact with the resident’s body and clothing. In follow-up interviews, both CNAs stated they forgot to wear a gown and acknowledged they should have worn one because the resident was on EBP. An LVN stated staff must wear gloves and a gown when providing care to the resident, and the RN, IPN, and DON each stated that residents with a G-tube must have an EBP order and that gowns and gloves are required for care activities such as repositioning.
Failure to Inform Resident of Grievance Investigation Findings and Actions
Penalty
Summary
The facility failed to honor a resident’s right to be informed in writing of the findings and corrective actions related to multiple grievances, as required by its grievance policy. The resident, who had intact cognitive function and no documented behavioral symptoms, had been admitted with conditions including post-surgical amputation, acute osteomyelitis of the right ankle and foot, and diabetes mellitus. Review of nine Grievance/Complaint/Theft and Loss (GCT) forms filed by this resident over several months showed documentation of the grievance, investigation, recommended corrective action, and resolution, but did not include the investigation findings, the date or documentation that the resident was informed of those findings, or the corrective actions that would be taken. The forms also lacked a date indicating when the resident signed in acknowledgment of resolution. During interview, the resident reported signing the GCT forms when the former Social Service Director initially presented them but stated he was never informed of the investigation findings or actions taken. The DON’s review of the GCT forms, Social Service Progress Notes, and the medical record confirmed there was no documentation that the resident was informed of the investigation findings or corrective actions. The DON stated that the resident had signed the form at the time of filing the grievance, but in the section designated for resolution, and that no follow-up actions were relayed to the resident regarding the filed grievances. The facility’s written policy required that the resident or representative be informed of the investigation findings and corrective actions, both orally and in writing, and that a written summary be provided to the resident and filed in the Social Service office, which did not occur in this case.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a cognitively intact resident with decision-making capacity who had diagnoses including a right patella fracture and acute respiratory failure with hypoxia. The resident’s Change in Condition Evaluation noted behavioral changes with false allegations toward staff. On 1/7/2026, the Social Services Director (SSD) documented that the resident’s representative reported receiving a call from the dialysis center stating the resident claimed that “the walking ladies” at the facility hit her and forced her to walk. The representative told the SSD she believed the allegation was not true and that family had not observed any signs of abuse. The SSD reported the allegation to the Director of Nursing (DON), and the interdisciplinary team was made aware, but the allegation was not reported to the California Department of Public Health (CDPH) within two hours as required by the facility’s abuse reporting policy. Later that evening, a registered nurse documented that the police arrived and stated they had received a report from Adult Protective Services that the resident had reported to the dialysis center that three female physical therapy staff were forcing her to walk. The facility’s policy titled “Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating” required that all suspected abuse be reported immediately to the administrator and appropriate officials, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. During interview and policy review, the DON acknowledged that the policy was not followed because the incident was not reported to CDPH within two hours, explaining that the resident was not in the facility at the time the allegation was received.
Failure to Provide Language-Appropriate Communication Services
Penalty
Summary
The facility failed to ensure that a resident whose preferred language was Farsi was provided with appropriate communication and interpretation services. The resident, who was cognitively intact and able to make decisions, had a medical history including a right patella fracture, acute respiratory failure, and diabetes. Despite documentation indicating the resident's language preference as Farsi, the comprehensive care plans did not address the resident's communication needs or language preference. Additionally, the psychosocial assessment incorrectly listed Armenian as the primary language/interpreter. Interviews with staff revealed that the resident could not communicate effectively in English and only responded with simple yes or no answers and hand gestures. Staff members assumed the resident was 'ok' based on mannerisms and did not utilize interpreter services or contact the resident's family for interpretation. The facility's policy required access to translation services for residents with limited English proficiency, but this was not followed in the resident's case, resulting in a failure to accurately assess and address the resident's needs.
Failure to Develop Person-Centered Care Plans for Nutrition, Oxygen Therapy, and Epilepsy Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, resulting in deficiencies related to individualized care. For one resident with chronic pulmonary edema and acute respiratory failure, there was a significant weight loss and poor meal intake, yet the nutritional screening and care plans did not include the resident's food preferences. Interviews with the resident and staff confirmed that food preferences were never assessed or incorporated into the care plan, despite the resident expressing dissatisfaction with the food and the facility's policy requiring person-centered care planning. Three residents receiving oxygen therapy did not have care plans initiated after physician orders for oxygen were placed. These residents had varying degrees of cognitive function and required different levels of assistance, but in each case, the care plans failed to address the specifics of their oxygen therapy, including interventions, goals, and monitoring. Staff interviews confirmed the absence of these care plans and acknowledged that this omission could result in staff not knowing the full regimen for oxygen therapy or the specific needs of each resident. Another resident with epilepsy was prescribed multiple anticonvulsant medications, including Lacosamide, Keppra, and Lamictal, but no care plans were developed for these medications after the orders were placed. The DON confirmed that care plans should have been created to guide staff in monitoring for side effects and managing the resident's condition. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not followed, as evidenced by the lack of individualized care plans for the residents involved.
Failure to Label and Store Medications According to Policy
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications in accordance with professional standards and facility policy for two residents. Specifically, one insulin pen belonging to a resident with diabetes mellitus and a pressure ulcer was found in a medication cart without a label indicating the date it was first opened or when it should be discarded. The resident's records showed they had moderately impaired cognition and received insulin as part of their treatment. The nurse interviewed was unaware of when the insulin was first opened and acknowledged that all medications, including insulin, must be labeled with the opened date, as insulin should be discarded 28 days after opening. Additionally, another medication cart contained two bottles of over-the-counter medications, Naproxen Sodium and Vitamin B1, that were opened but not labeled with the date they were first accessed. Both the nurse and the Director of Nursing confirmed that multi-dose medications must be labeled with the opened date, and that some medications require discarding before the manufacturer’s expiration date once opened. Review of facility policies confirmed the requirement for labeling and timely discarding of multi-dose vials and containers.
Failure to Monitor Food Storage Temperatures and Discard Expired Juice
Penalty
Summary
The facility failed to adhere to professional standards for food storage and safety by not consistently monitoring and documenting refrigerator and dry storage room temperatures, as required by federal guidelines. During a kitchen tour, surveyors observed that temperature logs for the refrigerators and freezer were not completed for certain days, and staff interviews confirmed that daily temperature checks and documentation were sometimes missed. The Dietary Supervisor acknowledged that it was the responsibility of the morning cook to check and log temperatures daily, but this was not always done. Additionally, the facility did not follow its own policy regarding the storage of opened fruit juice. A jar of prune juice labeled with a date indicating it had been opened more than five days prior was found in the refrigerator, contrary to the facility's policy that opened fruit juices must be discarded after five days. The Dietary Supervisor was unsure whether the dates on food items referred to the opening or use-by dates and stated that staff should clearly label items. These practices were not in accordance with the facility's written policies and placed residents at risk for foodborne illness due to expired juice and inconsistent temperature monitoring.
Infection Control Deficiencies: Hand Hygiene, IV Line, and Enteral Feeding Tube Practices
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices for three residents. For one resident on contact precautions due to a multidrug-resistant organism (MDRO) in a foot wound, the alcohol-based hand sanitizer dispenser in the room was not functional, with the pump lever falling off when used. Staff interviews confirmed the importance of having a working hand sanitizer dispenser in the room for infection control, and facility policy required hand hygiene products to be readily accessible. Another resident, also on contact isolation for MRSA of the left leg and receiving IV antibiotics, was observed with an uncapped IV tubing port hanging from the IV pole and touching the bedside curtain. The nurse acknowledged the absence of a protective cap and stated she could not find one. Facility policy required all administration set connections to be secured, but this was not followed in this instance. A third resident with a gastrostomy tube (GT) for enteral feeding was observed with the GT administration set disconnected from the resident and hanging on an IV pole, with the tube port uncapped and exposed. The nurse responsible stated she did not cap the port, despite being responsible for preventing contamination. The Director of Nursing confirmed that all licensed nurses are required to follow infection prevention protocols, including proper handling and covering of feeding tube ports when not in use.
Failure to Obtain Informed Consent for Hypnotic Medication
Penalty
Summary
The facility failed to ensure that a resident with intact cognition and decision-making capacity was fully informed and provided with an opportunity to give informed consent prior to the administration of a hypnotic medication, specifically Zolpidem Tartrate (Ambien). The resident, who had significant medical conditions including acute respiratory failure with hypoxia, end stage renal disease, and heart failure, was admitted and readmitted to the facility. Documentation review revealed that the required informed consent form for the use of psychotropic and hypnotic medications was not signed by the resident, despite the resident's ability to understand and make decisions, as indicated in the medical record and assessment tools. Interviews with facility staff, including an LVN and the DON, confirmed that the informed consent process was not completed as required by facility policy. Both staff members acknowledged that the consent should have been obtained and that the omission meant the resident may not have been aware of the risks, benefits, or potential adverse effects of the medication. The facility's policy mandates that residents or their representatives must be informed and provide consent prior to the initiation of such medications, but this process was not followed in this instance.
Failure to Provide Resident with Advance Directive Information
Penalty
Summary
The facility failed to provide a resident with information regarding the right to formulate an Advance Directive (AD), as required by policy and regulation. Upon review, the resident's AD Acknowledgement Form indicated that an AD had been executed, but the facility did not have a copy on file. The resident's admission record showed multiple diagnoses, including congestive heart failure, Type 2 diabetes, and vascular dementia, and assessments confirmed the resident had the capacity to make decisions. However, during an interdisciplinary team conference, it was noted that the resident was not aware of having an AD, and the POLST form indicated no AD was present. Interviews with the DON and Social Worker confirmed that the documentation was inconsistent and that there was no evidence the resident had been provided with information about ADs. Further review of facility policy revealed that written information about the right to accept or refuse treatment and to formulate an AD should have been provided to the resident or their representative upon admission. The DON acknowledged that the facility was not following its own policy, which required inquiry about existing ADs and provision of information in an understandable manner. The resident also stated she did not have an AD and did not recall receiving information about it from the facility. This series of actions and inactions led to the deficiency, as the facility did not ensure the resident was informed of her rights regarding advance directives.
Failure to Resume Restorative Nursing Services for Resident with Limited Range of Motion
Penalty
Summary
A resident with a history of metabolic encephalopathy, generalized muscle weakness, and epilepsy was admitted and later readmitted to the facility with documented limitations in range of motion (ROM) in both upper and lower extremities. Assessments indicated moderate to severe ROM limitations, and the care plan specified the need for a Restorative Nursing Program (RNA) to maintain or prevent further decline in joint mobility. However, upon readmission, the physician's order for RNA exercises was discontinued and not reinstated, despite subsequent assessments and care plans continuing to indicate the need for such services. Observations and interviews with facility staff, including a CNA, LVN, RN Supervisor, and the Director of Rehabilitation, confirmed that the resident had not received RNA services for several months following readmission. Staff were unable to locate active orders for RNA in the resident's records, and several staff members acknowledged that the resident should have been receiving these services due to their limited ROM. The Director of Rehabilitation was unaware that the resident had returned to the facility without an active RNA order, and the DON could not explain why the RNA program was not resumed upon readmission. Facility policy and procedures required that residents with limited ROM receive restorative nursing care and interventions to prevent further decline. Despite these policies and the resident's documented needs, the facility failed to ensure the continuation of RNA services as indicated in the care plan and assessments. This lapse was identified through record review, staff interviews, and direct observation, demonstrating a failure to provide appropriate care to maintain or improve the resident's ROM.
Failure to Assess and Provide for Resident's Food Preferences During Nutritional Assessment
Penalty
Summary
A resident with chronic pulmonary edema and acute respiratory failure, who was cognitively intact and able to make decisions, was admitted to the facility. Upon review of the resident's records, it was found that neither the admission nor the comprehensive nutritional assessments included documentation of the resident's food preferences. The resident reported that no one had asked about their food preferences and expressed dissatisfaction with the food, specifically noting a desire for more meat, fresh vegetables, and less salty or overcooked food. Observations of meal trays confirmed that the food served was salty, mushy, and unappealing. Further review of the resident's records showed a significant weight loss of 7.54 lbs over approximately one month, with meal intake averaging only 25-50%. Interviews with the Director of Nursing and the Dietary Supervisor confirmed that the resident's food preferences were not assessed or incorporated into the care plan, and no measures were developed to address the resident's nutritional needs or prevent further weight loss. The facility's policy required that food preferences and dislikes be identified as part of the nutritional assessment, but this was not done for the resident.
Failure to Provide Routine Oxygen Therapy and Required Safety Signage
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who were receiving oxygen therapy. For one resident with diagnoses including acute respiratory failure with hypoxia, end stage renal disease, and heart failure, the physician's order specified routine oxygen therapy at three liters per minute via nasal cannula with a goal oxygen saturation above 92%. However, the resident was not consistently receiving routine oxygen therapy as ordered, and the oxygen saturation summary indicated only intermittent use. Additionally, there was no signage posted in the resident's room to indicate oxygen was in use, contrary to facility policy and safety protocols. For another resident with chronic obstructive pulmonary disease, dependence on supplemental oxygen, and atherosclerosis, the physician's order required routine oxygen therapy at two liters per minute via nasal cannula, with titration to maintain oxygen saturation above 92%. Observations revealed that this resident's room also lacked the required signage indicating oxygen use. Both the LVN and the DON confirmed that facility policy required a 'No Smoking/Oxygen in Use' sign to be posted outside the rooms of residents receiving oxygen therapy, and acknowledged that the absence of such signage was a safety hazard. Review of facility policies confirmed that 'No Smoking/Oxygen in Use' signs are necessary equipment when administering oxygen. The DON and LVN both stated that staff were not following physician's orders for routine oxygen therapy and were not adhering to facility policy regarding safety signage. These failures were identified through observation, interview, and record review, and were not in accordance with the facility's established procedures for oxygen administration.
Failure to Ensure Nurse Competency in Checking Gastric Residual Volume
Penalty
Summary
A deficiency was identified when a Licensed Vocational Nurse (LVN) failed to demonstrate appropriate competency in checking the gastric residual volume (GRV) for a resident with a gastrostomy tube (G-tube). The resident in question had diagnoses including dysphagia, muscle weakness, and required all medications via G-tube, with physician orders specifying that GRV should be checked every shift and tube feeding held if GRV exceeded 100 mL. During a medication pass, LVN 3 was observed aspirating only 20 mL from the resident's G-tube and stated that he routinely aspirated only 15 to 20 mL when checking GRV, unaware that more should be aspirated to obtain an accurate measurement. Further interviews revealed that another LVN and the Director of Nursing (DON) confirmed the correct procedure was to aspirate as much gastric content as possible until no more could be withdrawn or resistance was met. Upon re-assessment, LVN 3 found the actual GRV to be 110 mL, significantly higher than the initial 20 mL, acknowledging that the initial method was incorrect. Review of facility policies and procedures (P&P) confirmed that staff were required to aspirate all available gastric contents and take specific actions based on the volume obtained. The resident's records indicated severely impaired cognition and an inability to make decisions, further emphasizing the need for accurate and competent care. Although LVN 3's training records showed prior demonstration of the correct procedure, the observed practice did not align with facility policy or physician orders, resulting in a failure to ensure staff competency in a critical aspect of resident care.
CNA Provided Resident Care with Expired Certification
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) was found to be working with an expired certification. Record review and interviews with the Director of Staffing Development (DSD) confirmed that the CNA's certification had expired and had not been renewed, yet the CNA continued to provide direct resident care. The DSD acknowledged responsibility for monitoring certification status and stated that although the CNA was informed of the upcoming expiration, there was no follow-up to ensure renewal. The CNA herself confirmed she was aware of the expiration, had submitted a renewal application, but had not yet received the renewed certification, and continued to work scheduled shifts during this period. Further review of facility policies and job descriptions indicated that CNAs are required to maintain current certification in accordance with state laws and facility procedures. The Director of Nursing (DON) also confirmed that only staff with current, non-expired certifications or licenses are permitted to provide resident care. Despite these policies, the lapse in monitoring and enforcement allowed the CNA to work with an expired certification, contrary to facility and regulatory requirements.
Medication Error Rate Exceeds 5% Due to Improper Administration Techniques
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less during a medication pass, resulting in a cumulative error rate of 10.3% based on three medication errors out of 29 opportunities. Two residents were directly affected by these errors during observed medication administration by licensed nursing staff. The errors were identified through observation, interview, and record review. For one resident with a gastrostomy tube and diagnoses including diabetes mellitus, muscle weakness, and hyperthyroidism, the nurse did not flush the G-tube with the prescribed amount of water after administering methimazole. The resident's physician orders and facility policy required flushing the tube before and after medication administration to ensure the full dose was delivered. The nurse acknowledged forgetting to flush the tube, and the DON confirmed that failure to flush could result in the resident not receiving the correct medication dose. Another resident with glaucoma and diabetes mellitus received ophthalmic medications, Brimonidine and Brinzolamide, without the nurse applying pressure to the inner eye after administration. Physician orders and manufacturer instructions specified that pressure should be applied to the inner eye to ensure proper medication delivery and absorption. The nurse admitted to forgetting this step, and the DON confirmed its importance in medication administration for ophthalmic treatments.
Failure to Timely Administer Oxygen Therapy for Resident with Shortness of Breath
Penalty
Summary
A deficiency occurred when a resident with a history of hypertensive heart disease, heart failure, shortness of breath (SOB), and pulmonary embolism did not receive oxygen therapy as ordered by the physician. The resident had a physician's order for PRN oxygen at 2 liters per minute for SOB and wheezing, with the option to titrate up to 3-4 liters. On the morning in question, the resident began experiencing SOB and reported feeling unwell to staff at approximately 8 AM. Despite these complaints and a documented oxygen saturation as low as 88% on room air, oxygen was not administered until approximately 4:30 PM, resulting in an 8.5-hour delay. Throughout the day, multiple staff members, including a CNA, LVN, and RN, were made aware of the resident's symptoms. The resident continued to complain of SOB and headache, and family members were also informed by the resident of her distress and lack of oxygen administration. Vital signs taken during this period showed fluctuating oxygen saturation levels, with a notable drop to 91% and 88% at different times. Despite these findings and the resident's ongoing complaints, staff did not initiate oxygen therapy as per the physician's order, and instead, the resident was referred for a psychiatric consult for possible anxiety. It was not until the resident's condition worsened, with labored breathing, bilateral wheezing, and use of accessory muscles, that oxygen was finally administered using a non-rebreather mask, and emergency services were called. The resident was subsequently transferred to a general acute care hospital for respiratory distress, where further evaluation revealed edema and infection. Interviews with staff and the resident confirmed that oxygen was not provided in a timely manner, despite clear indications and physician orders.
Breach of Medical Record Confidentiality
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of medical records for one of its residents, Resident 2, by mistakenly sending their medical records to a general acute care hospital (GACH) with another resident, Resident 1. This incident occurred during an emergency situation when Resident 1 experienced a change in condition and required transfer to the hospital. The records sent included Resident 2's Face Sheet, MD Orders, POLST, and History and Physical, which were not relevant to Resident 1's condition. Resident 1 was admitted to the facility with diagnoses including influenza and dementia, and lacked the capacity to make medical decisions. Resident 2, on the other hand, had diagnoses of chronic obstructive pulmonary disease and pleural effusion, and had a POLST indicating a Do Not Resuscitate order. The mix-up of records was discovered when the emergency room case manager at the GACH noted that the records did not match Resident 1's condition, raising concerns about the accuracy of the information provided. The Director of Nursing (DON) stated that the RN supervisor was responsible for ensuring the correct medical records were sent with the resident during transfers. However, on the day of the incident, the RN supervisor and the LVN charge nurse were both from a Nursing Registry, and the RN supervisor, RN 1, admitted to sending the wrong records due to the emergency situation and lack of familiarity with the facility's resources. The facility's policy on confidentiality of information, which mandates safeguarding resident records, was not adhered to in this instance.
Resident Transferred with Incorrect Medical Records
Penalty
Summary
The facility failed to ensure that appropriate information and documentation were communicated to the receiving health care institution for a resident who was transferred to a General Acute Care Hospital (GACH) emergency room due to a change in condition. The resident was transferred with incorrect records meant for another resident, which included another resident's Advance Directive, history and physical, medication orders, and laboratory results. This error had the potential to result in a delay in treatment, inappropriate medical interventions, or the GACH not being able to follow the resident's wishes regarding life-sustaining treatments. The resident in question was initially admitted to the facility with diagnoses including influenza and dementia, and was noted to have severe cognitive impairment, requiring substantial assistance for daily activities. On the day of the transfer, the resident experienced a change in condition, including a decreased level of consciousness, hypotension, and tachycardia, prompting the transfer to the GACH for further evaluation. However, the records sent with the resident were for a different individual, leading to confusion and a delay in obtaining the correct medical information. Interviews with facility staff revealed that the error occurred because the registered nurse on duty, who was from a nursing registry, mistakenly sent the wrong records. The facility's Director of Nursing confirmed that the RN supervisor was responsible for ensuring the correct documentation was sent with the resident. The facility's policy requires that a complete and accurate transfer record accompany the resident to ensure continuity of care, but this protocol was not followed in this instance.
Failure to Ensure Safe Transfer of Resident to Hospital
Penalty
Summary
The facility failed to ensure a safe and orderly transfer of a resident to a General Acute Care Hospital (GACH) following a change in condition. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was transferred without proper identification and with incorrect medical records. The resident's medical history and medication information were not accurately communicated to the receiving facility, which could have led to delays in treatment or incorrect medical interventions. The incident occurred when the resident experienced a change in condition, including hypotension and tachycardia, and was transferred via emergency services. However, the medical records sent with the resident belonged to a different resident, who was the roommate of the transferred resident. This error was discovered after the resident arrived at the GACH, leading to confusion and a delay in obtaining the correct medical records. The facility's Director of Nursing (DON) confirmed that the RN supervisor was responsible for ensuring the correct documentation was sent, but the RN on duty was from a Nursing Registry and unfamiliar with the facility's procedures. Interviews with facility staff and the GACH ER Case Manager revealed that the facility identified residents by room and bed numbers, which contributed to the mix-up. The resident was not wearing an identification wristband, which was against the facility's policy. The DON acknowledged the error and the potential for delayed treatment due to the incorrect records being sent. The facility's policy on transfers and discharges was not followed, leading to this deficiency.
Facility Fails to Address Water Leaks and Safety Hazards
Penalty
Summary
The facility failed to maintain a safe environment for residents, staff, and the public, as evidenced by multiple leaks and water damage observed in various areas of the facility. Observations revealed plastic tarps covering parts of the roof, indicating potential water leaks. In Resident 2's room, paint was bubbling and discolored above bed B, and the resident reported a steady water leak that staff attempted to manage with bed linens and towels. Similar issues were noted in the activity room, where water was leaking from the ceiling near the entrance to the administrative office, and in the shared bathroom, where paint was bubbling and cracking above the toilet area. In the facility kitchen, paint was observed bubbling and cracking around the ceiling directly over the mechanical washing area, posing a potential infection control risk. The Dietary Supervisor confirmed that the roof started leaking, and despite the damage, the kitchen continued to operate and serve food. The Maintenance Supervisor acknowledged the leaks and placed plastic tarps on the roof but did not take further action to address the internal damage or contact an outside contractor for repairs. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of awareness and communication regarding the leaks. The Administrator instructed the Maintenance Supervisor to place tarps but did not notify the State Agency or seek external assistance. The facility's policy on safety and supervision emphasized the importance of maintaining an environment free from hazards, yet the observed conditions and staff responses indicated a failure to adhere to these standards.
Water Damage Causes Anxiety Among Residents
Penalty
Summary
The facility failed to provide a safe environment for residents during a rainstorm, resulting in water damage to the rooms of three residents. Resident 1, who has schizoaffective disorder and anxiety disorder, experienced anxiety due to water leaking from the ceiling onto her roommate's bed and the floor. The staff attempted to manage the situation by removing soaked linens, placing a plastic bag over the bed, and using a bucket to collect the water. Despite these efforts, Resident 1 remained in her room all day, feeling anxious about her safety. Resident 2, diagnosed with hypertension and depression, also experienced anxiety due to water leaking in her room and the activity room. The water was leaking from the ceiling and pooling on the floor, with staff using towels and linens to soak up the water. Resident 2 expressed concern about the potential for the ceiling to collapse due to the water damage. Similarly, Resident 3, who has cerebral infarction and hemiplegia, felt anxious when water started pooling at the foot of her bed. The staff used linens and towels to manage the water, but Resident 3 remained worried about the ceiling leaking over her bed. The Maintenance Supervisor acknowledged the water damage and took action by placing a tarp on the facility's roof. However, the supervisor did not have time to inspect the resident rooms due to significant damage in the kitchen. The facility's policy on safety and supervision emphasizes the importance of maintaining an environment free from accident hazards, but the water damage and subsequent anxiety experienced by the residents indicate a failure to uphold this policy.
Failure to Implement Post-Surgical Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident following a right hip reduction surgery. The resident, who was readmitted to the facility after surgery, had orders from the orthopedic surgeon to use a knee immobilizer and an abduction pillow to prevent further dislocation of the hip. However, the facility did not ensure that these devices were consistently used, as there was no documentation or care plan addressing the resident's use of the knee immobilizer or the abduction pillow. The resident, who had severe cognitive impairment and was unable to follow commands due to dementia, was noted to be restless and non-compliant with the post-surgical treatment plan. Despite the physician's orders, the resident was often found without the knee immobilizer or abduction pillow, and staff interviews revealed that the resident frequently removed these devices. The Director of Nursing and other staff members could not confirm consistent use of the knee immobilizer or the abduction pillow, and there was no care plan in place to address the resident's refusal to wear these devices. The facility's policies and procedures require the development of comprehensive, person-centered care plans based on resident assessments. However, in this case, the interdisciplinary team did not create a care plan to address the resident's specific needs post-surgery, including the use of the knee immobilizer and abduction pillow. This lack of a care plan and failure to implement physician orders potentially exposed the resident to post-surgical complications, such as recurrent hip dislocation.
Failure to Ensure Resident Dignity During Care
Penalty
Summary
The facility failed to ensure that Resident 2 was treated with dignity and respect during routine care. Resident 2, who was admitted with a diagnosis of cerebral infarction and hemiplegia, required moderate assistance with toileting hygiene. The care plan for Resident 2 included maintaining cleanliness and providing perineal care as needed. However, during diaper changes, two CNAs, CNA3 and CNA4, engaged in inappropriate behavior by teasing Resident 2 about her relationship with her boyfriend, making demeaning comments about her age and sexual activity. This behavior was reported by Resident 2 to her social worker and the Director of Staff Development (DSD), but no formal investigation or documentation was conducted by the DSD. The facility's policy on dignity, revised in February 2021, mandates that residents be treated with respect and prohibits demeaning practices. Despite this policy, the DSD did not investigate the incident further or address the behavior of CNA3 and CNA4. The employee records for these CNAs showed no past corrections or in-services related to resident dignity. Additionally, the grievance logs for 2023 and 2024 did not contain any entries regarding this incident, indicating a lack of formal grievance filing. This deficiency in ensuring resident dignity and respect was identified through observation, interview, and record review.
Improper Discharge of Resident Without Consent or Adequate Documentation
Penalty
Summary
The facility failed to properly manage the discharge of a resident, identified as Resident 1, from Skilled Nursing Facility (SNF) 1 to another facility, SNF 2. Resident 1, who had a history of dementia and was at risk for wandering, was discharged without adequate documentation or the consent of the resident or their responsible parties (RP 1 and RP 2). The discharge was initiated by SNF 1 due to their inability to meet Resident 1's need for supervision, but the necessary documentation outlining the specific needs that could not be met, the efforts made to meet those needs, and the services SNF 2 would provide was not completed. Additionally, the discharge occurred without the required 30-day advance written notice to the resident and their responsible parties, and without a proper interdisciplinary team (IDT) meeting to discuss the discharge plan. The discharge process was mishandled, as evidenced by the lack of communication and documentation. Resident 1 was transferred to SNF 2 without the knowledge or approval of RP 1 and RP 2, leading to distress and refusal of care by Resident 1 upon arrival at SNF 2. The facility's staff, including the Admissions Coordinator (ADC 1) and Case Coordinator (CC 1), failed to provide the necessary information and resources to the responsible parties, and did not involve them in the discharge planning process. The facility also did not have a wander guard system in place, which contributed to their decision to discharge Resident 1. The facility's actions resulted in Resident 1 being returned to SNF 1 after refusing to stay at SNF 2. Interviews with staff and responsible parties revealed a lack of communication and coordination in the discharge process. The facility did not follow its own policies and procedures regarding discharge planning and notification, leading to a deficiency in the care provided to Resident 1.
Failure to Provide Proper Notice for Resident Transfer
Penalty
Summary
The facility failed to adhere to its Policies and Procedures regarding the transfer or discharge of a resident, specifically Resident 1, who was diagnosed with dementia and exhibited wandering behavior. The facility did not provide a written notice to Resident 1 or their responsible party (RP 1) prior to discharging Resident 1 to another Skilled Nursing Facility (SNF 2). Additionally, the facility did not send a copy of the notice to the Ombudsman, as required by their policy. Resident 1 was admitted with diagnoses including dementia, altered mental status, and mobility issues. The facility's records indicated that a physician ordered a lateral transfer to SNF 2 on January 28, 2025, with the notice of transfer/discharge dated the same day, and the effective date set for January 31, 2025. However, Resident 1 was transferred on January 29, 2025, without the required written notice being provided to RP 1 or the Ombudsman. Interviews revealed that RP 1 was only informed of the transfer over the phone, and the Ombudsman was not notified in writing, which is a violation of the facility's policy. The Director of Nursing (DON) confirmed that there was no urgent need for the transfer, as Resident 1 had not endangered themselves or others, and there was no documentation from a physician or psychiatrist recommending an urgent transfer. The DON also acknowledged that there was no interdisciplinary team meeting for discharge planning, and Resident 1 missed a scheduled medication due to the transfer. The facility's policy requires a 30-day advance written notice for planned transfers, which was not followed in this case.
Failure to Develop Care Plan for Resident's Eye Injury
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for Resident 2 after an altercation with Resident 1, which resulted in Resident 2 being hit in the left eye. Despite the incident being documented in Resident 2's progress notes and SBAR Communication Form, there was no evidence of a care plan addressing the injury to Resident 2's left eye. Interviews with Resident 2, a CNA, and an RN confirmed the absence of a care plan for the injury, which was acknowledged as necessary by the RN and the Director of Nursing (DON). Resident 1, who has diagnoses including psychosis, altered mental status, and dementia, was noted to have severely impaired cognition and required supervision and assistance with daily activities. Resident 2, with diagnoses of diabetes mellitus, hypertension, and weakness, was noted to have intact cognition and the capacity to make decisions. The facility's policy on care plans emphasizes the need for ongoing assessments and revisions as residents' conditions change, which was not adhered to in this case, leading to the deficiency.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with type 2 diabetes mellitus, whose blood sugar levels were consistently elevated over a three-day period. Despite the resident's blood sugar levels being significantly above the normal range, the facility did not inform the physician until a day after the elevated levels were first recorded. The resident's blood sugar levels ranged from 212 mg/dL to 495 mg/dL, which is well above the normal range of 80 to 120 mg/dL. The facility's records did not show any notification to the physician about these elevated levels on the first two days. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the facility's standard practice was to notify the physician if blood sugar levels exceeded 400 mg/dL, despite the facility's policy requiring prompt notification for any significant change in condition. The LVN admitted to not reporting the elevated levels because there was no specific parameter set by the physician for when to report such levels, and the resident was receiving routine diabetes medications. The physician, however, stated that he should have been notified if the blood sugar level exceeded 200 mg/dL, as it could lead to serious health complications.
Failure to Monitor Urinary Catheter Output
Penalty
Summary
The facility failed to implement its policy and procedure for the care of a resident with a urinary catheter, resulting in a deficiency. The facility did not maintain an accurate record of the resident's daily urine output, which is crucial for preventing urinary catheter-associated urinary tract infections. This oversight was identified for a resident who was admitted with severe sepsis and pneumonia and had an indwelling urinary catheter. The care plan for the resident included monitoring and documenting fluid intake and output to prevent urinary tract infections, but this was not done according to the facility's policy. The deficiency was highlighted when the resident was hospitalized due to a urinary tract infection, sepsis, and a sudden decline in health condition. Interviews with the Director of Nursing and a review of the resident's medical records confirmed the lack of documentation for fluid intake and output monitoring. The primary physician emphasized the importance of monitoring to detect potential complications such as obstructions in the urinary system. The facility's policy on catheter care, revised in 2014, also underscored the need for accurate daily output records to prevent infections.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care to a resident by not assessing the respiratory status and reporting to the physician when the resident's oxygen saturation decreased to 92%. The facility also did not obtain a physician's order to administer oxygen and failed to reassess the effectiveness of the oxygen intervention. The resident, who was admitted with pneumonia and respiratory failure, had a severely impaired cognition and was observed with labored breathing and shortness of breath. Despite administering oxygen therapy, there was no documented physician order for this intervention, and the resident's condition was not reassessed to determine the effectiveness of the oxygen therapy. The resident's oxygen saturation levels fluctuated, and the facility did not document reassessment of the resident's respiratory status after administering oxygen. The RN eventually placed the resident on a high concentration of oxygen via a non-rebreather mask while waiting for emergency services, but again, there was no documentation of reassessment of the resident's oxygen saturation. Interviews with the DON and the physician confirmed the lack of documentation and reassessment, which was against the facility's policy on oxygen administration.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its abuse prevention policy for a resident by not reporting an allegation of abuse to law enforcement as required by their policy. The resident, who was admitted with diagnoses including Diabetes Type II, dysphagia, and cirrhosis of the liver, reported to a CNA that she was hit the previous night. The CNA informed an RN, who then assessed the resident and found no injuries. The resident was unable to provide details about the alleged perpetrator and later stated that she was threatened but not hit. Interviews with facility staff revealed a lack of clarity regarding the reporting process for allegations of abuse. An LVN was unsure if the allegation should be reported to law enforcement and needed to verify the process with the DON. An RN also did not know which agencies to report to and would defer to the DON. The DON, who was responsible for the investigation, reported the allegation to the California Department of Public Health and the ombudsman but did not report it to law enforcement, as she was unaware of this requirement. The facility's policy, revised in September 2022, mandates that suspicions of abuse, neglect, exploitation, or misappropriation must be reported immediately to the administrator and other officials, including law enforcement, according to state law. The policy specifies that such reports should be made within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. The failure to report the allegation to law enforcement as per the policy constitutes a deficiency in the facility's abuse prevention practices.
Failure to Develop Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to develop a resident-centered care plan and monitor a resident after an allegation of abuse. The resident, who was admitted with diagnoses including Diabetes Type II, dysphagia, and cirrhosis of the liver, reported to a CNA that she was hit the previous night. However, when questioned by the RN, the resident was unable to provide details about the alleged incident and later stated that she was threatened but not hit. A thorough body assessment revealed no injuries, and the incident was reported to the DON and the Administrator. Despite the report of the incident, the facility did not initiate a care plan for the resident to address the allegation of abuse. Interviews with the LVN, DSD, and RN confirmed that no care plan was developed, and there was no documentation of monitoring the resident for emotional distress. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timetables to meet the resident's needs. The lack of a care plan and monitoring for emotional distress was acknowledged by the DSD and DON, who stated that the licensed nurses should have developed a care plan and monitored the resident for emotional distress every shift. The Social Worker also noted that if she was unavailable, the nurses should have monitored the resident. The failure to develop a care plan and monitor the resident for emotional distress after the allegation of abuse was identified as a deficiency in the facility's practices.
Privacy and Dignity Violations in Shared Shower Rooms
Penalty
Summary
The facility failed to protect the privacy and dignity of eight residents by allowing other residents to use their designated shower rooms. Specifically, male residents were observed using the shower room located in the room of two residents, while female residents were using the shower room located in the room of three other residents. This practice was confirmed through observations and interviews with the residents, who expressed discomfort and embarrassment due to the lack of privacy and the presence of other residents in their personal spaces. The report details the medical conditions and cognitive statuses of the affected residents, highlighting their varying levels of dependency and need for assistance with personal care activities. Despite these needs, the facility's practice of using shared shower rooms compromised the residents' rights to privacy and dignity. Interviews with staff members, including CNAs and LVNs, revealed an awareness of the issue, but they cited the lack of alternative shower facilities as the reason for this practice. The facility's policies on resident rights and dignity emphasize the importance of maintaining privacy and respect for each resident's individuality. However, the longstanding practice of using shared shower rooms for all male and female residents, as confirmed by the maintenance supervisor and the Director of Nurses, directly contradicted these policies. The report concludes with the acknowledgment of the privacy and dignity concerns by the Director of Nurses, who indicated an intention to discuss the issue with the facility administrator.
Failure to Accommodate Shower Preferences Affects Resident Privacy
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents regarding their showering arrangements, which affected their privacy and dignity. Resident 1, who was admitted with conditions such as cerebral infarction, COPD, and cirrhosis of the liver, expressed a preference for not having other residents use his bathroom for showering. Despite being alert and oriented, Resident 1 required substantial assistance with bathing. However, the facility used his bathroom as the sole male shower room, leading to other residents, including Resident 3, using it regularly. Resident 3, who had been living in the facility for 21 months, also preferred to shower in a private room. Diagnosed with acute embolism and thrombosis, cervical spinal stenosis, and muscle weakness, Resident 3 required moderate assistance with personal hygiene. Despite his cognitive status being intact, he was subjected to showering in Resident 1's bathroom, which he found embarrassing, especially when other residents were lined up to use the shower. Interviews with staff, including a CNA, LVN, and the Director of Nurses, revealed that the facility had only one male shower room located in Resident 1's room. The staff acknowledged the privacy and dignity issues but believed there was a waiver in place. The facility's policies on resident rights and dignity emphasized the importance of personal privacy and maintaining residents' dignity, which were not upheld in this situation.
Failure to Implement Low Bed Intervention for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who was at high risk for falls and had experienced an actual fall with injury. The resident, who had a history of epilepsy, COPD, and cirrhosis of the liver, fell from bed during a seizure and sustained a laceration above the right eye. Despite the care plan intervention specifying the use of a low bed for safety, observations and interviews revealed that the resident was not placed on a low bed, which was a critical measure to prevent further injury. Interviews with the Director of Staff Development, a Licensed Vocational Nurse, and the Director of Nurses confirmed that the low bed intervention was not implemented as required by the care plan. The facility's policy and procedure on care plans and fall risk management emphasized the importance of implementing resident-centered interventions based on comprehensive assessments to prevent falls and minimize complications. However, the failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility failed to ensure that a resident with severely impaired cognition and severe contractures was free from accidents and hazards. The resident, who was dependent on staff for all activities of daily living, was not provided with adequate supervision and care planning. The facility did not develop a care plan to address the resident's specific needs for assistance with bathing and transfers, nor did they ensure that staff were informed of the resident's limitations and the appropriate methods for providing care. On the day of the incident, a Certified Nurse Assistant (CNA) from a nursing registry, who was unfamiliar with the resident, was assigned to provide care. The CNA was not informed of the resident's need for a bed bath due to severe contractures and instead attempted to shower the resident using a shower chair. During the process, the resident experienced severe pain, and it was later discovered that the resident had sustained multiple fractures and injuries, including a displaced fracture of the left acetabulum and multiple pelvic fractures. Interviews and record reviews revealed that the facility staff, including the Licensed Vocational Nurse (LVN) and Registered Nurse (RN), failed to communicate the resident's care needs and limitations effectively. The facility's policies and procedures for safety and supervision were not followed, and there was no documented evidence of a care plan addressing the resident's bathing needs. The lack of communication and proper care planning led to the resident's injuries and subsequent hospitalization.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to implement its policy and procedure regarding the notification of a physician for a significant change in a resident's condition. Specifically, the facility did not ensure that the physician was immediately notified when a resident experienced a significant change in vital signs, including decreased blood pressure and increased heart rate, as well as new pain, moaning, fidgeting, and agitation. The Licensed Vocational Nurse (LVN) did not notify the Registered Nurse (RN) or the physician about these changes, which were significant deviations from the resident's baseline condition. The resident, who had a history of severe cognitive impairment and required assistance with daily activities, was found with a blood pressure and heart rate that indicated a significant change from their baseline. Despite these changes, there was no documented evidence that the physician was notified. Additionally, the resident was observed to be in pain, with a pain level of 7 out of 10, but the physician was not informed, and no stronger pain medication was administered beyond Tylenol. The resident's condition continued to deteriorate, leading to unresponsiveness and eventually death. The facility's failure to notify the physician and conduct appropriate assessments and interventions resulted in the resident not receiving the necessary care to address the significant changes in their condition. The lack of timely notification and documentation of the resident's condition changes contributed to the resident's continued decline and eventual death, as the facility did not adhere to its policies for managing changes in a resident's condition.
Removal Plan
- Current licensed nurses were re-in serviced in person regarding identifying abnormal vital signs and documentation for a change of condition, including changes in pain level, respiratory status, oxygen saturation rate, and out of range blood pressure. The DSD/Designee will in-service licensed staff in person to complete 100% in-service to licensed staff.
- Current licensed nurses were re-in serviced in person on timely notification of a RN or the Director of Nursing (DON) regarding a change of condition, including changes in vital signs. The DSD/Designee will in-service license staff in person to complete 100% in-service licensed staff.
- A follow up in-service will be conducted to determine knowledge retention for timely notification of a RN and physician regarding a change of condition.
- Licensed nurses will be assessed for documentation competency, including notification of RN and physician for a change in condition, using the Documentation Competency Checklist. Competencies for all licensed staff will be completed within 30 days from initiation of Documentation Competency Checklist, 90 days after first licensed staff evaluation, and then annually thereafter.
- Licensed nurses will be in-serviced in person by DON/DSD/Designee regarding new Documentation Competency Checklist. DON/DSD/Designee will in-service license staff in person to complete a 100% in-service to license staff.
- Competency Checklist will be added to all new hire LVN/RN orientation.
- Policy and Procedure will be updated to reflect new audit tool, including elements to be incorporated into the audit such a documentation of changes in condition notification of RN and physician, and completion of appropriate assessments.
- Policy and Procedure will be updated to reflect procedure for documentation of change in condition, including parameters for notifying RN or physician.
- DSD/Designee will complete random audits to test knowledge of in-service regarding notification of changes to RN and physician. Results will be logged on the spot check tool. Audits will be complete 3 times per week for 4 weeks, then weekly for 4 weeks, then monthly for 4 months.
- LVN 1 will be provided an additional 1:1 in-service on proper notification of a physician and the RN for any changes in condition.
- LVN 1 will meet with the DON/Designee on a regular basis to review any changes in condition during the scheduled shift for the next 30 scheduled workdays. 1:1 in-service will be provided as needed.
- Certified Nursing Assistants (CNAs) were re-in-serviced regarding reporting of changes in condition to the supervisor or charge nurse.
- A follow up in-service will be conducted to determine knowledge retention for reporting of changes in condition.
- Residents with any changes in condition will be reviewed in morning meeting by the IDT. Any findings on the audit tool (Exhibit 1.1) will be addressed, 1:1 in-service will be provided as needed.
- Review of documentation of changes in condition, including notification of RN and physician, will be completed at various times weekly by DON/Designee for the next 30 days then semi-monthly for 1 month then monthly for 1 month. Issues noted will be resolved. 1:1 in-service will be provided as needed. Information for which charts to review will be based on the audit tool (Exhibit 1.1).
- Consultant will review a random sampling of resident charts, based on audit tool (Exhibit 1.1) on a regular basis for 30 days or CDPH revisit, whichever is longer, to verify that documentation has been completed for patients with any changes in condition, including notification to RN and physician. Issues noted will be resolved and additional in-services will be provided as needed.
Failure to Monitor and Assess Resident with TIA and CVA
Penalty
Summary
The facility failed to properly assess and monitor a resident, identified as Resident 53, who had a history of transient ischemic attack (TIA) and cerebral vascular accident (CVA). The resident was recently hospitalized for a change in mental status and was diagnosed with TIA and CVA. The facility did not ensure that Licensed Vocational Nurses (LVN) 1 and 2 assessed and monitored the resident for signs and symptoms of TIA and stroke, such as changes in mental status, blood pressure (BP), heart rate (HR), and respiratory rate (RR). Additionally, the facility did not notify the physician of significant changes in the resident's vital signs, including a decrease in BP and an increase in HR. The report highlights that LVN 1 did not assess the source of the resident's pain when the resident exhibited a pain level of 7 out of 10. Furthermore, LVN 2 delayed calling for assistance and notifying the physician when the resident was found unresponsive, with no BP reading and diminished respirations. The facility also failed to develop a care plan for the resident to address monitoring and assessment for TIA, stroke, and atrial fibrillation (A-Fib). These deficiencies resulted in the resident not receiving immediate care and emergency interventions, leading to a continued decline in vital signs and mental status. The resident's condition deteriorated, and they were pronounced dead by paramedics. The facility's policies and procedures for pain assessment and management, as well as for changes in a resident's condition, were not followed. The report indicates that there was no documented evidence of a care plan addressing the resident's medical conditions, and the facility did not notify the physician of significant changes in the resident's condition, contributing to the resident's death.
Removal Plan
- Current licensed nurses will be re-in serviced in person regarding assessment, monitoring, evaluation for a history of TIA and stroke.
- DSD/Designee will in-service licensed staff in person to complete a 100% in-service to licensed staff.
- DSD/Designee will complete random audits to test knowledge of in-service regarding assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke. Results will be logged on the spot check tool.
- LVN 1, LVN 2, and RN 1 will be provided an additional 1:1 in-service on assessment, monitoring, and evaluation for a history of TIA and stroke, including documentation for any changes.
- Residents with any changes in condition, including those with TIA and stroke will be reviewed in morning meeting by the Interdisciplinary Team (IDT).
- Any findings on the audit tool will be addressed, 1:1 in-service will be provided as needed.
- Review of documentation, including assessment, monitoring, and evaluation for a history of TIA and stroke associated with a change in condition, will be completed at various times by DON/Designee. 1:1 in-service will be provided as needed.
- Consultant will review a random sampling of resident charts, based on a list provided by the facility, to verify that appropriate assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke associated with a change in condition has been documented. Issues noted will be resolved and additional in-services will be provided as needed.
Facility Lacks Medical Director and Updated Policies
Penalty
Summary
The facility failed to designate a physician to serve as the medical director responsible for implementing resident care policies and coordinating medical care. This deficiency persisted for six months, affecting all 46 residents, including a resident who was readmitted with significant medical conditions such as aftercare following surgery on the digestive system and dysphagia following a cerebral infarction. The facility did not have a designated medical director since June 2023, which led to a lack of thorough evaluation of the resident's change in condition and subsequent death. The resident's clinical record showed no evidence of investigation into whether the facility's failure to provide healthcare interventions within professional standards contributed to the resident's death. Additionally, the facility's healthcare policies and procedures were outdated and had not been reviewed or approved by a medical director to ensure they met current professional standards. Policies such as 'Change in a Resident's Condition or Status' and 'Pain Assessment and Management' had not been updated since 2017 and 2015, respectively. The facility's administrator acknowledged the absence of a medical director and was in the process of hiring one, but no decision or contract had been finalized. The lack of a medical director and outdated policies had the potential to result in substandard care delivery and failure to provide necessary care and services to 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 7,273 citations issued within 25 miles in the last 12 months — including the 21 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 Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Haven Care Center | 1.2 mi | ★★★★★ | 16 | 0 |
| Broadway Manor Care Center | 1.5 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 1.5 mi | ★★★★★ | 43 | 0 |
| Alameda Care Center | 1.7 mi | ★★★★★ | 32 | 0 |
| Burbank Healthcare & Rehab | 1.7 mi | ★★★★★ | 88 | 1 |
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 October 2026) and official state health department websites.