Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at East Terrace Rehabilitation & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with dementia and muscle weakness reported that her cognitively impaired roommate hit her on the forehead, and staff documented a raised, purplish forehead injury and later green-yellow discoloration across the forehead and upper eye area. A CNA stated she immediately informed an LVN and the DON of the allegation, and documentation noted resident-to-resident contact and an allegation that one resident pushed the other in the head. Despite these facts and a facility policy requiring all abuse allegations be reported to law enforcement, the ombudsman, and CDPH within two hours using an SOC 341, the DON concluded the event did not meet reporting criteria, in part based on an interpretation that abuse between residents with dementia did not require reporting. As a result, the allegation was not reported to external authorities, delaying CDPH investigation and placing the resident at risk for continued abuse.
A resident with schizophrenia, depression, moderately impaired cognition, and documented wandering behavior, who was independent with mobility and used a Wander Guard, eloped from the facility while still wearing the device. The care plan and MD orders required daily checks of Wander Guard function and placement and monitoring for exit-seeking behaviors, but the resident was later found to be missing. Doors leading directly into the building had Wander Guard alarms, while two front doors to the street and parking lot did not, and the front gate operated on a timed open/close cycle. An RN reported that no staff were assigned to continuously monitor the front door video and that resident rounds were done but not formally documented, allowing the resident to leave without arrangements for medical care or housing.
A resident with muscle weakness, Alzheimer’s disease, anemia, and a known Stage III sacral pressure ulcer was readmitted with detailed hospital wound care orders, but facility staff failed to accurately assess, document, and care plan for the sacral pressure injury. The admission assessment noted only sacral redness without measurements and left the pressure ulcer section blank, and the post-readmission care plan lacked interventions for the wound. The treatment nurse used wound treatments that differed from transfer instructions, did not understand key wound assessment terminology such as “violaceous,” admitted to signing the TAR for a treatment on a day she was off duty, and did not obtain required wound photographs. The wound MD expressed concerns about the nurse’s assessment quality, and the medical record lacked the photographs required by the treatment nurse job description.
A resident with a known Stage III sacral pressure ulcer and multiple risk factors, including muscle weakness, incontinence, and Alzheimer’s disease, was admitted with specific hospital wound care orders, but staff did not fully assess and document the wound on admission, did not create a resident-centered care plan for the existing pressure injury, and did not update the care plan as the wound worsened or as MD orders changed. The existing care plan only addressed general skin integrity risk, and the turning program, specific wound treatments, and nutritional interventions were not incorporated. The RD and dietary department did not assess or address the pressure injury despite facility policy requiring RD evaluation with significant skin changes. Over time, the sacral wound progressed from a deep tissue pressure injury to an unstageable ulcer that increased in size, while required interdisciplinary care planning and policy-directed skin integrity management were not implemented, resulting in documented worsening of the wound and stated risk for infection and other complications.
A resident with COPD, generalized muscle weakness, moderate cognitive impairment, and dependence for ADLs was observed with yellowish‑purplish discoloration on the dorsal hand, which the resident vaguely associated with a BP cuff being applied too tightly. A treatment LVN first noted redness on the hand and later reassessed it without documenting the findings, while a CNA observed similar discoloration and reported it to an LVN. A wound MD subsequently identified the area as ecchymosis. Despite multiple staff observations and the resident’s inability to clearly explain the cause, the facility did not timely report this injury of unknown source to the proper authorities, delaying external investigation.
A resident with COPD, generalized muscle weakness, moderate cognitive impairment, and total dependence for ADLs developed yellowish‑purplish discoloration and later ecchymosis on the dorsal surface of the left hand that staff observed and reported to an LVN. Progress notes contained no evidence that the discoloration or ecchymosis were investigated, despite facility policy and staff statements that skin discolorations and injuries of unknown source require assessment, change of condition documentation, MD notification, and immediate investigation by the DON and Administrator to rule out abuse and determine the cause.
A resident with COPD, generalized muscle weakness, and moderate cognitive impairment experienced multiple documentation and follow-up failures. After redness was noted on the back of the hand and the MD ordered daily monitoring with Y/N documentation for 30 days, staff did not record the required observations on the TAR or in progress notes. Later, when the resident had self-inflicted lacerations to both lower legs, staff documented that they were awaiting an MD response but did not document any follow-up contact or orders. Additionally, the treatment LVN failed to include the hand redness in weekly skin checks, later altered skin notes to match a wound MD’s assessment, and created a backdated skin check weeks after the original assessment, contrary to facility policies requiring timely, accurate, and complete documentation of skin status, treatments, and MD notifications.
A facility failed to develop comprehensive person-centered care plans for four residents with significant medical and psychosocial needs. One resident had major weight loss with malnutrition, CHF, and bipolar disorder; another had schizophrenia, major depressive disorder, psychosis, and epilepsy; a third had a colostomy with an active ostomy care order; and a fourth had COPD, acute respiratory failure, dementia, psychosis, and oxygen needs. Staff stated the relevant care plans were missing or not active for these conditions, despite the residents’ diagnoses and care requirements.
Improper Use of One Scooper for Two Foods During Tray Line: A dietary aide was observed using one scooper for both brussels sprouts and corn during tray line while placing food on residents' trays. The DSS stated one scooper should be used for one food only and acknowledged that using the same scooper for different foods could lead to food contamination or a potential allergic reaction if a resident was allergic to one of the foods.
Failure to provide podiatry care for a resident with long, thick, elongated toenails. The resident had diagnoses including OA, difficulty walking, and psychosis, and a physician order for podiatry service as clinically indicated was entered, but the resident was not seen by the podiatrist during scheduled visits. CNA reported the resident had long toenails and had not been endorsed for podiatry care, and the resident stated she had requested to see a foot doctor long ago but nothing had been done.
Failure to administer ordered oxygen to a resident with COPD and acute respiratory failure. The resident had an order for 2 L O2 via NC every shift, but staff observed the oxygen machine at the bedside was not running and confirmed the resident was not receiving oxygen. The resident stated he did not know why he was not getting oxygen, and an LPN verified the order and the missed oxygen administration.
The facility failed to complete annual competency skill checks for two CNAs whose files were reviewed. The DSD confirmed both staff members had no yearly competency assessment on file and stated she was responsible for completing the checks. The DON stated annual competency skills are important to validate staff competency for resident care, and the Facility Assessment stated skills competency are done yearly and as needed.
Missing Annual CNA Performance Evaluations: The facility failed to ensure yearly Performance Evaluations were completed for two CNAs whose records lacked the required documentation. The DSD stated she was responsible for annual validation of CNA evaluations and that these reviews are used to assess performance, identify weaknesses, and support resident safety and well-being. Facility policy and the Facility Assessment both described ongoing staff competency validation and monitoring during employment.
Failure to Monitor Psychotropic Medication Use: A resident with psychosis, dementia, and a GT received Quetiapine Fumarate for psychosis, but the MAR and chart lacked documented monitoring of behavior and antipsychotic side effects. The ADON stated there was no evidence the resident’s psychotic behavior or medication side effects were monitored, and the DON stated this monitoring was needed for the physician to determine whether the medication was effective.
A floor stock bottle of Geri-Lanta in a med cart was found without an opened date during observation and interview with an RN. The RN confirmed the bottle was unlabeled, stated the open date is needed to verify medication validity, and noted that without it the medication could be expired and ineffective. Facility P&P on medication labels required meds to be labeled per facility, state, and federal requirements.
Failure to complete ordered monthly laboratory tests: A resident with bipolar disorder, epilepsy, and CHF had physician orders for monthly CBC, CMP, and Depakote levels, along with Depakote 125 mg BID. Record review and interview showed the labs were not drawn for two months, and there was no documentation that the MD was notified or that follow-up occurred with the lab. The ADON and DON confirmed the missed labs and stated the tests were needed to monitor the resident’s condition and Depakote therapeutic level.
Hand hygiene was not performed before two CNAs donned an isolation gown, mask, and gloves and entered a resident’s room to transfer the resident from a Geri Chair to bed. The resident had metabolic encephalopathy, acute respiratory failure with hypoxia, severe protein-calorie malnutrition, and was on Enhanced Barrier Precautions with gowns and gloves required for personal care. The CNAs stated they should have performed hand hygiene before putting on PPE, and the facility policy required hand hygiene before donning PPE.
Facility Assessment Not Updated to Reflect Actual Census: The facility failed to revise the Facility Assessment Tool to reflect the actual average daily census. During record review, the census showed 96 residents, while the updated Facility Assessment listed an average daily census of 91. The DON stated 5 residents were not accounted for and acknowledged the tool was inaccurate for staffing and care planning purposes.
A central supply staff member failed to perform hand hygiene before entering and after exiting a resident's room, despite touching the resident's bedding and clothing. The resident had significant cognitive impairment and required extensive assistance with daily activities. Facility policy required hand hygiene upon entering and exiting resident rooms, which was not followed.
A resident with mental health diagnoses was transferred to a hospital for psychiatric evaluation, and although a physician ordered a 7-day bed hold and the resident's representative was notified, the facility failed to reserve a bed as required by policy. Staff confirmed that the bed was given to a new admission and no bed was held for the resident's return during the required period.
A resident with Parkinsonism, dementia, and epilepsy was discharged to a lower level of care without the required Notice of Proposed Transfer and Discharge being signed or provided to the resident or their family. The resident lacked capacity to make medical decisions, and the family was not included in discharge planning or informed prior to the transfer. The facility did not follow its policy to ensure proper notification and preparation for discharge.
A resident with moderate cognitive impairment and mobility issues experienced an unwitnessed fall resulting in a head injury. The incident was documented and the resident was sent to the hospital, but facility leadership was unaware and the event was not reported to CDPH within the required 24-hour timeframe, contrary to facility policy.
A resident with cognitive impairment and multiple mental health diagnoses sustained a hand injury requiring sutures, but the facility did not develop or implement a care plan to address wound care as ordered by the physician. Staff confirmed that no interventions or goals were documented for the injury, despite facility policy requiring comprehensive, individualized care planning.
Three residents with complex medical conditions who tested positive for COVID-19 did not have individualized care plans addressing their infection. Nursing staff confirmed that care plans specific to COVID-19 were not created, despite facility policy requiring comprehensive, person-centered care planning for all residents.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with cognitive impairment was sexually abused by another alert resident after staff failed to monitor the new resident's whereabouts and enforce policies prohibiting male residents from entering female residents' rooms. The incident was discovered by an RN during routine rounds, and there was no prior assessment or consent process for sexual relationships between the involved residents.
Staff failed to report a sexual abuse incident between two residents within the required two-hour timeframe, despite facility policy mandating immediate notification to CDPH, law enforcement, and the Ombudsman. The delay in reporting was acknowledged by both the RN and ADM, and the incident was not communicated to authorities as required, resulting in a delayed investigation and increased risk to other residents.
A resident who was totally dependent on staff for bed mobility and had significant medical conditions, including morbid obesity and paraplegia, was being repositioned by two CNAs who both stood on the same side of the bed, contrary to facility policy and training. This improper technique led to the resident falling from the bed, resulting in a femur fracture, severe pain, and hospitalization. Staff interviews confirmed that established safety protocols were not followed during the incident.
A facility failed to implement its abuse prevention policies for a resident with severe cognitive impairment, resulting in unreported bruises and skin tears. The DON admitted the facility did not follow its protocol for reporting injuries of unknown origin, which required immediate investigation and notification to relevant authorities.
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's and dementia, experienced several instances of skin discoloration and tears. Despite facility protocols requiring investigations for such occurrences, no investigations were conducted, as confirmed by interviews with staff. This failure to investigate had the potential to increase the risk of abuse for the resident and others.
A resident with multiple health conditions was admitted to a facility but did not receive proper orientation, assessment, or medication for 22 hours. The facility failed to notify the attending physician for admission orders, and the resident was left without necessary care, leading to a 911 call and transfer back to a hospital. The staff was inadequately trained on the admission process, and the facility lacked sufficient staffing to meet the resident's needs.
A resident's personal belongings were moved without permission during a transfer to a GACH, resulting in missing items upon return. The facility failed to complete an inventory list as required by policy, violating the resident's rights and potentially impacting their psychosocial well-being.
A resident in an LTC facility refused Olanzapine for 22 days without the physician being notified, as required by policy. This led to the resident, diagnosed with schizophrenia, engaging in physical aggression towards another resident, causing severe pain. The incident was reported to the police, and the aggressive resident was arrested. The facility failed to adhere to its policy on notifying physicians of significant changes in a resident's condition.
A resident with schizophrenia and bipolar disorder was denied readmission to the facility after being arrested following an altercation. Despite the facility's policy to readmit residents requiring skilled nursing care, the DON and LVN insisted on the arrest and later refused the resident's return, violating the facility's policy and state guidance on equal access to care.
A resident with dementia and Alzheimer's Disease, requiring a 1:1 sitter for safety, was observed wandering unsupervised in the facility. Despite physician orders and care plan interventions for constant monitoring, the resident was seen entering other residents' rooms without supervision, posing potential safety and privacy risks.
A resident with Parkinson's, schizoaffective disorder, and diabetes, identified as a high fall risk, fell and sustained a forehead laceration due to the facility's failure to provide a 1:1 sitter as required by the care plan. The assigned sitter was responsible for monitoring four high-risk residents, which was deemed a safety risk by staff.
A resident with Parkinson's, schizophrenia, and DM returned from a hospital transfer to find personal belongings missing, with no inventory list completed by the facility. CNAs were responsible for maintaining this list, but it was not done, violating facility policy.
A facility failed to provide a privacy bag for a resident's foley catheter, compromising dignity and posing an infection risk. Another resident felt trapped by bedrails, which were not discussed with them, affecting their dignity. The facility's policies on dignity and privacy were not followed.
A resident's essential personal items, including reading glasses and dentures, were not replaced after going missing, and two residents experienced a lack of a homelike environment due to unresolved maintenance issues. The facility failed to adhere to its policies for safeguarding personal property and maintaining a comfortable environment.
The facility failed to develop comprehensive care plans for two residents, leading to a G-tube being dislodged multiple times for one resident and missing dentures affecting another's ability to chew. The care plans lacked necessary interventions and documentation, contrary to facility policy.
A resident with a G-tube was hospitalized twice due to the tube's dislodgement. The facility failed to provide an abdominal binder to secure the G-tube, as confirmed by interviews with nursing staff. This oversight was contrary to the facility's policy on enteral tube management, which mandates ensuring the safety of such tubes.
A resident's G-tube was dislodged three times due to the facility's failure to secure it properly. Despite the resident being a candidate for an abdominal binder, which could have prevented the dislodgement, no such preventive measure was ordered or implemented. Facility staff acknowledged that the repeated dislodgement was not in accordance with nursing standards of care.
The facility failed to update and transfer an accurate POLST form for a resident, did not obtain an Advance Directive acknowledgment for another, and neglected to update the code status for a third resident who could no longer make medical decisions. These deficiencies could have led to delays in care and actions contrary to the residents' wishes.
A resident with multiple health conditions was found unable to reach their call light, a necessary tool for requesting assistance, during an observation. Staff interviews confirmed the importance of the call light being within reach, as per facility policy, to ensure the resident's needs are met and to prevent feelings of isolation.
A facility failed to submit an accurate PASRR for a resident with psychosis and other mental health issues, as required by federal regulations. The resident's PASRR inaccurately indicated no mental illness due to incorrect information, and a new PASRR was not submitted. This oversight was acknowledged by the QA Nurse, who stated that the lack of a proper PASRR could result in the resident not receiving necessary mental health services.
A facility failed to resubmit a PASRR for a resident with mental health diagnoses, including bipolar disorder and schizophrenia, after the initial screening indicated unresponsiveness from staff. The resident was dependent on staff for daily activities, and the oversight was acknowledged by the QA Nurse, highlighting a lapse in following the facility's policy for PASRR updates.
A resident with multiple health conditions was found to have long, untrimmed toenails, despite being dependent on staff for personal hygiene. The facility's policy required CNAs to maintain short and manageable nails, but this was not adhered to, leading to potential discomfort for the resident.
A resident's LAL mattress was incorrectly set at 350 pounds despite the resident weighing 142 pounds, risking pressure injuries. The resident, with conditions like osteomyelitis and MRSA, was dependent on staff for care and at risk for pressure ulcers. The DON and an LVN confirmed the incorrect settings could lead to skin breakdown, contrary to the facility's policy requiring proper mattress inflation.
A resident with dementia and muscle weakness did not have their splints applied as scheduled, which are necessary to prevent contractures. Observations showed the splints were not applied during specified hours on two days, and there was no documentation of their application. Interviews with the RNA and PT confirmed the importance of the splints and the lack of adherence to the facility's policy on documentation.
A resident with a history of wandering and bipolar disorder entered another resident's room, resulting in an altercation where she was pushed out. Despite the facility's knowledge of her behavior, supervision was insufficient, leading to the incident. An LVN witnessed the event, and observations showed the resident continued to wander, being redirected by staff.
Failure to Report Resident-to-Resident Abuse Allegation Involving Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-to-resident abuse to the California Department of Public Health (CDPH) as required. Resident 3, who had dementia, muscle weakness, and was usually able to understand and be understood, reported that her roommate, Resident 4, who also had dementia and muscle weakness, hit or pushed her on the forehead. On 3/30/2026, an SBAR for Resident 3 documented a raised, purplish marking to the mid-forehead, and an IDT note the next day recorded that Resident 3 stated she was pushed in the head by Resident 4 and had a raised, purplish marking to the mid-forehead. On 4/6/2026, Resident 3 was observed with green and yellowish discoloration extending from the hairline to the bridge of the nose and across the upper eye sockets, and she again stated she had been hit on the forehead by Resident 4 and had informed staff. CNA 5 reported that Resident 3 told her Resident 4 hit her on the forehead with a fist, and CNA 5 stated she immediately reported this allegation to the LVN and DON. Despite these documented and reported allegations and visible injury, the facility did not report the incident to CDPH, law enforcement, or the ombudsman within the required timeframe. The IDT note for Resident 3 stated that, given the absence or suspicion for abuse or a reportable allegation, the incident did not meet criteria for reporting to CDPH. The DON stated that the incident was not reported because, based on the facility’s interpretation of the SOC 341 form, abuse involving residents with dementia did not have to be reported and because the facility determined after its own investigation that no abuse occurred. This decision conflicted with the facility’s Abuse Prevention and Management policy, which required that for all allegations of abuse, the Administrator or designee notify law enforcement immediately or within two hours and send a written SOC 341 report to the Ombudsman, law enforcement, and CDPH within two hours. The failure to report resulted in a delay in investigation by CDPH and placed Resident 3 at risk for continued abuse, as stated in the report.
Elopement of Wander-Guard Resident Due to Unmonitored, Unalarmed Exits
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement for one resident identified as an elopement risk and wearing a Wander Guard device. The resident was admitted with schizophrenia, depression, cellulitis, and a local skin infection, and a subsequent H&P documented that the resident could make needs known but could not make medical decisions. The resident’s MDS showed moderately impaired cognition and independence with mobility, including walking and transfers, and indicated daily use of a wander/elopement alarm. An elopement evaluation documented that the resident wandered, and the care plan identified the resident as an elopement risk with interventions to check Wander Guard placement on the right wrist and document wandering behavior. Physician orders directed staff to check Wander Guard functioning and placement every night shift and to monitor for exit-seeking behaviors and related signs every shift. Despite these identified risks and interventions, a health status note documented that the charge nurse was unable to locate the resident at 6:21 p.m., and the resident had eloped from the facility while wearing a Wander Guard device. The Maintenance Supervisor reported that all doors leading directly into the facility had Wander Guard alarms that were checked and audible, but the two front doors leading to the street and the parking lot did not have Wander Guard alarms. The front entrance gate to the parking lot took 25 seconds to open and 25 seconds to close. An RN stated that no one was assigned to watch the front door monitor at the nursing station and that rounds were conducted in the morning, afternoon, and evening to ensure residents were not missing, but there was no official documentation of these rounds. As a result of these conditions, the resident was able to leave the facility with no arrangements for medical care or housing.
Inadequate Wound Care Competency and Documentation for Sacral Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed staff possessed and used appropriate wound care competencies for a resident who was readmitted with a sacral pressure injury. The resident had multiple diagnoses, including muscle weakness, a Stage III sacral pressure ulcer, anemia, and Alzheimer’s disease, and had fluctuating capacity to understand and make decisions. Assessments showed the resident had high risk for pressure ulcers due to occasionally moist skin, chairfast activity level, very limited mobility, and dependence on staff for toileting and bathing. Upon readmission, the interfacility transfer report from the hospital specified a wound care regimen using Vashe, Therahoney, and Optifoam for the sacral Stage III pressure injury, but the facility’s clinical admission assessment only noted a sacral wound with redness and did not describe the wound’s appearance or measurements, and the documented pressure ulcer section was left blank. Subsequent facility documentation showed inconsistencies and omissions in wound assessment and care planning. A skin and wound evaluation the day after readmission described a medical device–related pressure injury on the sacrum with specific measurements and characteristics, and listed xeroform as the primary dressing, which differed from the hospital’s transfer instructions. The resident’s care plan after readmission did not include interventions addressing the sacral pressure injury, despite the presence of the wound. Physician orders later directed cleansing the sacral pressure injury with normal saline, applying Santyl, and covering the wound. Over time, the wound progressed from a deep tissue pressure injury with smaller measurements to an unstageable pressure injury with larger dimensions and a wound bed containing both epithelial tissue and slough, with documentation of violaceous skin and concern for possible osteomyelitis. Interviews and record reviews revealed gaps in the treatment nurse’s wound care competencies and documentation practices. The treatment nurse stated that all licensed nurses were responsible for initiating and implementing resident-centered care plans when wounds were identified, yet acknowledged that the resident had no care plan interventions for the sacral pressure injury on readmission. The treatment nurse did not understand the term “violaceous” in the wound physician’s assessment and incorrectly equated it with simple skin redness, and stated that without understanding prior wound assessments, she would not know if the wound was improving or worsening. She also admitted to mistakenly signing the treatment administration record for providing sacral wound care on a day she was off duty and confirmed she never photographed the resident’s pressure injury, despite a job description requiring photographs of residents with specified pressure ulcers. The wound physician reported concerns about the quality of the treatment nurse’s assessments, noting her inability to differentiate violaceous skin from redness, and the medical records director confirmed there were no wound photographs in the resident’s record, contrary to facility policy and job expectations.
Failure to Care Plan and Manage Sacral Pressure Injury Resulting in Wound Worsening
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary services and resident-centered care planning to manage and promote healing of a sacral pressure injury for one resident. The resident was admitted and later readmitted with diagnoses including muscle weakness, a Stage III sacral pressure ulcer, anemia, and Alzheimer’s disease with fluctuating decision-making capacity. An interfacility transfer report from an acute care hospital specified a detailed wound care regimen for the sacral Stage III pressure injury, including cleansing with Vashe, application of Therahoney, and coverage with Optifoam. Upon admission, the facility’s clinical admission assessment documented a sacral wound with redness but did not include a description of the wound’s appearance or measurements, and the section for documented pressure ulcers was left blank. A subsequent skin and wound evaluation identified a medical device–related pressure injury at the sacrum with specific measurements and characteristics, but the primary dressing listed was Xeroform, differing from the hospital’s recommended treatment. The resident’s existing care plan addressed only a general risk for potential impairment to skin integrity related to anticoagulant use, poor bed mobility, and advanced age, with broad interventions such as education, encouraging nutrition and hydration, following facility protocols, and keeping skin clean and dry. After the resident’s readmission, there was no care plan with specific interventions for the sacral pressure injury, and the turning program and wound treatments were not incorporated into the care plan. Physician orders were written to cleanse the sacral pressure injury with normal saline, apply Santyl, and cover, but these changes and later modifications were not reflected in updated care plan interventions. Over time, the resident’s sacral wound worsened. Skin checks documented that the sacral pressure ulcer became unstageable and increased in size from the initial measurements to 4 cm by 4.5 cm. Wound physician assessments showed progression from a deep tissue pressure injury to an unstageable wound with a mix of epithelial tissue and slough, violaceous skin, and concern for further decline, prompting an order for an x-ray to evaluate for osteomyelitis. Interviews with the treatment nurse and an RN confirmed that nursing staff did not create a resident-specific care plan for the sacral pressure injury at admission and did not update the care plan when the wound worsened or when physician orders changed. The wound physician stated that the resident’s risk factors, including incontinence, muscle weakness, and cognitive limitations, placed the resident at high risk and that the wound was not assessed and measured by nursing staff upon admission. The registered dietitian reported that neither she nor the dietary department addressed the pressure injury after it was identified, and no RD assessment or nutritional recommendations were made despite facility policy requiring RD evaluation upon significant changes in skin condition. Facility policies on skin integrity management, comprehensive person-centered care planning, and the treatment nurse’s job description all required development and updating of a plan of care, weekly skin evaluations, RD involvement, and interdisciplinary discussion, which were not implemented for this resident’s sacral pressure injury. The facility’s failure to develop and update a comprehensive, resident-centered care plan for the sacral pressure injury, to accurately assess and document the wound on admission, to integrate physician orders into the care plan, and to involve the RD and IDT as required by policy resulted in the resident’s sacral wound worsening. The report states that this failure resulted in the resident’s worsening sacral wound condition and placed the resident at risk for wound infections and other complications, including hospitalizations.
Failure to Report Injury of Unknown Source on Resident’s Hand
Penalty
Summary
The facility failed to timely report an injury of unknown source for one of five sampled residents, delaying investigation by the California Department of Public Health. The resident had COPD, generalized muscle weakness, moderate cognitive impairment, and was dependent on staff for ADLs and bed mobility. On observation, the resident had yellowish‑purplish discoloration on the left dorsal hand and stated it occurred after someone took her blood pressure too tightly on that hand, but could not recall when or who did it. The discoloration met the definition of an injury of unknown source because the event was not observed, could not be clearly explained by the resident, and involved suspicious discoloration. The Treatment LVN reported first identifying redness on the resident’s left dorsal hand on 1/2/2026, attributing it to a BP cuff being too tight, and stated the resident could not provide when or who caused it. The Treatment LVN reassessed the left dorsal hand on 1/21/2026 but did not document this in the progress notes. A wound MD later examined the area and identified it as ecchymosis. A CNA reported that on 1/21/2026 she observed yellowish‑purplish discoloration on the same hand and notified an LVN. A photograph taken on 1/23/2026 showed discoloration consistent with what the CNA had seen earlier. Despite these observations and notifications, the injury of unknown source was not reported as required, resulting in a delay in external investigation.
Failure to Investigate Injury of Unknown Source to Resident’s Hand
Penalty
Summary
The facility failed to investigate an injury of unknown source when a resident developed yellowish‑purplish discoloration and later ecchymosis on the dorsal (back) surface of the left hand. The resident, who had COPD, generalized muscle weakness, moderate cognitive impairment, and was dependent on staff for ADLs and bed mobility, was originally admitted and later readmitted to the facility. Review of progress notes from 1/21/2026 to 1/23/2026 showed no documentation that the discoloration noted on 1/21/2026 or the ecchymosis noted on 1/23/2026 were investigated. During observation and interview on 1/23/2026, the resident had yellowish‑purplish discoloration on the left dorsal hand and stated it happened after someone took her blood pressure too tightly on that hand, but could not recall when. A CNA reported observing the same yellowish‑purplish discoloration on the resident’s left dorsal hand on 1/21/2026 and stated she notified an LVN at that time. The Treatment LVN reported that on 1/23/2026 the wound MD saw ecchymosis on the resident’s left dorsal hand. The LVN interviewed later stated that when staff report discoloration on a resident’s skin, the LVN should notify the DON and Administrator for investigation due to the possibility of abuse. The DON stated that when staff see skin discolorations, the charge nurse should assess the resident, ask how it happened, complete a change of condition assessment, and notify the MD, and that injuries of unknown origin must be investigated and reported to CDPH. The Administrator stated he was not aware of the unexplained bruising and described that an injury of unknown origin requires investigation and may need to be reported to CDPH if determined to be alleged abuse. The facility’s Abuse Prevention and Management policy defined injury of unknown source and required the Administrator or designee to immediately initiate an investigation upon receiving such a report; however, no such investigation was documented for this resident’s hand injury.
Failure to Monitor Skin Condition, Follow Up on Change in Condition, and Maintain Accurate Skin Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards for one resident with COPD, generalized muscle weakness, and moderate cognitive impairment who was dependent on staff for ADLs and mobility. On a change in condition (COC) dated 1/2/2026, the resident was noted to have redness on the left dorsal hand during treatment, and the resident reported that the blood pressure cuff on the wrist was too tight. The physician ordered monitoring of the left dorsal hand discoloration for hematoma formation, skin breakdown, and pain/discomfort, with instructions to document "Y" if observed and notify the MD, or "N" if not observed, on every shift for 30 days. Review of the Treatment Administration Record (TAR) and progress notes for January 2026 showed no documentation of the required Y/N monitoring or any indication that the left dorsal hand was monitored as ordered. A second deficiency occurred on 1/20/2026 when the resident experienced a change in condition involving self-inflicted lacerations to both lower legs. The COC note documented that staff were awaiting the MD’s response. However, review of the resident’s progress notes for that date did not show any follow-up with the MD for treatment orders for the bilateral lower leg wounds. Interviews with nursing staff indicated that if staff were unable to reach the MD, they should attempt to contact the MD’s nurse practitioner or the facility’s Medical Director, and if still unsuccessful, endorse the issue to the oncoming shift, but such follow-up and documentation were not evident in the record. The DON confirmed that the progress notes did not show that staff had followed up with the MD after this change in condition. A third deficiency involved inaccurate and late skin assessment documentation by the Treatment LVN. Weekly skin checks dated 1/4/2026, 1/9/2026, 1/16/2026, and 1/23/2026 did not include the status or description of the left dorsal hand redness. The Treatment LVN stated she could not explain why the left hand status was not documented and acknowledged that on 1/23/2026 she changed her skin check notes to "ecchymosis" to match the wound MD’s assessment from that date, even though this was not her original assessment, making the documentation inaccurate. On 1/27/2026, the Treatment LVN created another skin check form with an effective date of 1/2/2026 to reflect the redness that had been present on 1/2/2026 but not documented at that time, and she acknowledged that charting 25 days after the assessment made the documentation inaccurate. Facility policies required entries to be written promptly in chronological sequence, weekly skin evaluations with documentation of treatments and effectiveness, and detailed documentation of MD notification for changes in condition, including time, method, response time, and whether orders were received, which were not followed in these instances.
Incomplete Person-Centered Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four sampled residents. Resident 1 had diagnoses including protein calorie malnutrition, CHF, and bipolar disorder, and the record showed a significant weight loss of 39 pounds, or 19.7%, over 6 months. The ADON reviewed the monthly weights and stated the resident’s weight decreased from 198 pounds to 159 pounds, but no comprehensive care plan was developed to address the weight loss. The ADON stated the interdisciplinary team was responsible for developing the care plan and that it should have included a problem, goal, and interventions. Resident 11 had diagnoses including schizophrenia, major depressive disorder, psychosis, and epilepsy. The record showed the resident could make decisions for ADLs and had intact cognitive skills, but was dependent on staff for ADLs. During interview, LVN 1 stated care plans were initiated upon admission and with changes in condition, and stated there was no care plan for Resident 11’s psychiatric diagnoses. LVN 1 stated the psychiatric diagnoses should have been care planned. Resident 14 had diagnoses including major depressive disorder, a colostomy, and legal blindness, and the order summary directed colostomy care daily, every day shift, and as needed. The TN reviewed the open and closed electronic care plans and stated the care plan had been closed even though the ostomy care order remained active. Resident 53 had diagnoses including COPD, acute respiratory failure, dementia, and psychosis, and the record showed moderate cognitive impairment and partial/moderate assistance with ADLs. LVN 1 stated there was no oxygen care plan for Resident 53 and that the resident should have had one. The facility policy stated the comprehensive person-centered care plan must include measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
Improper Use of One Scooper for Two Foods During Tray Line
Penalty
Summary
The facility failed to ensure dietary staff did not use one scooper for two different food items during tray line. During observation on 12/17/2025 at 12:32 p.m. in the kitchen, Dietary Aide 1 was observed using one scooper for both brussels sprouts and corn while placing vegetables on residents' trays. During a concurrent interview on 12/17/2025 at 12:35 p.m., the Dietary Services Supervisor stated that one scooper should be used for one food during tray line and should not be used for different foods. The supervisor stated that using one scooper for two foods could result in a potential allergic reaction if a resident was allergic to one of the foods and/or food contamination. Review of the facility's Dietary Department policy dated 6/1/2024 stated the Dietary Manager was responsible for day-to-day education of dietary staff regarding sanitation and food preparation, and the Dietary Department-Infection Control policy dated 6/4/2024 stated the dietary department must be maintained in a sanitary condition to prevent food contamination and the growth of disease producing organisms and toxins.
Failure to Provide Podiatry Care for Elongated Toenails
Penalty
Summary
The facility failed to ensure that Resident 102 received podiatry care for long, thick, elongated toenails. Resident 102 was admitted and later readmitted with diagnoses including osteoarthritis, difficulty walking, and psychosis. The resident's H&P dated 12/10/2025 indicated she did not have the capacity to understand and make decisions, while the MDS dated 9/8/2025 indicated her cognitive skills were intact and that she was independent with oral hygiene, toileting hygiene, and upper and lower body dressing. The physician entered a telephone order on 12/10/2025 for podiatry service as clinically indicated, but during observation on 12/16/2025, Resident 102 was noted to have long thick elongated toenails on both feet. The resident stated she had requested to see a foot doctor a long time ago, but nothing had been done. CNA 2 stated on 12/18/2025 that Resident 102 had long thick toenails on both feet and that she did not endorse the resident to the SSD for podiatry care services. The SSD stated the resident was not seen by the podiatrist on visits on 11/20/2025 and 12/11/2025 and that he was responsible for referring residents who needed foot care to the podiatrist.
Failure to Administer Ordered Oxygen
Penalty
Summary
The facility failed to ensure oxygen was administered as prescribed for Resident 53. Resident 53 was admitted and later readmitted with diagnoses including COPD, acute respiratory failure, dementia, and psychosis. The history and physical dated 10/4/2025 stated the resident was able to make needs known but could not make medical decisions. Physician orders dated 10/4/2025 directed oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath and COPD, and the MDS dated 10/11/2025 indicated the resident had moderately impaired cognitive skills and required partial/moderate assistance with ADLs. During observation on 12/16/2025, Resident 53 had an oxygen machine at the bedside that was not running, and the resident stated he did not know why he was not receiving oxygen. During a later observation on 12/18/2025, LVN 1 observed the oxygen machine and stated the resident was not receiving oxygen. In a concurrent interview and record review, LVN 1 confirmed the physician orders required 2 liters of oxygen via nasal cannula every shift and stated the resident was not receiving oxygen upon earlier observation. The facility policy titled Oxygen Therapy stated oxygen and oxygen saturation levels are to be administered as ordered by the provider.
Missing Annual CNA Competency Checks
Penalty
Summary
The facility failed to ensure annual competency assessment skill checks were completed for two of five randomly selected staff members. During a concurrent interview and record review with the Director of Staff Development, Certified Nurse Assistant 1, hired on 7/27/2002, was found to have no yearly competency assessment skill check on file, and Certified Nurse Assistant 2, hired on 12/11/2023, also had no yearly competency assessment skill check on file. The Director of Staff Development stated she was responsible for completing the annual competency skill checks for CNAs and stated that these checks were important to assess job knowledge to ensure resident safety and provide the highest quality of care. The Director of Nursing also stated that annual competency skills were important to validate staff competency for caring for residents. The facility’s Facility Assessment, dated 11/20/2025, stated that skills competency are done yearly and as needed.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure yearly Performance Evaluations were completed for two of five randomly selected staff members. During a concurrent interview and record review on 12/17/2025 at 3:26 p.m. with the Director of Staff Development (DSD), the records for CNA 1, hired on 7/27/2002, and CNA 2, hired on 12/11/2023, did not contain yearly Performance Evaluations. The DSD stated she was responsible for validating CNA Performance Evaluations once a year and explained that Performance Evaluations are used to rate staff performance and identify areas for improvement and weaknesses. The DSD also stated she oversaw CNA in-service training and that yearly staff Performance Evaluations were important for the safety and well-being of residents. The facility policy titled Staff Competency Validation, dated 6/4/2024, stated competency validation is completed to evaluate an individual's performance, evaluate group performance, meet regulatory standards, address problematic issues, and enhance performance reviews. The Facility Assessment, dated 11/20/2025, stated the Director of Staff Development and/or designee should strictly follow facility guidelines and protocol in providing training and education, and that it should be ongoing and monitored/validated during staff employment.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident 8’s drug regimen was free from unnecessary drugs by not monitoring the resident’s behavior and the side effects of Quetiapine Fumarate, a psychotropic medication ordered for psychosis. Resident 8 was admitted and later readmitted to the facility with diagnoses including psychosis, dementia, and a gastrostomy tube. The admission history and physical indicated the resident could make needs known but could not make medical decisions, and the MDS showed moderately impaired cognitive skills for daily decision making, with the ability to make self-understood and understand others. The physician ordered Quetiapine Fumarate 25 mg via GT at bedtime for psychosis. During interview and record review, the ADON stated there was no documented evidence that Resident 8’s psychotic behavior was monitored and no documented evidence that licensed nurses monitored side effects of the antipsychotic medication. The ADON stated that residents on psychotropic medications should have behaviors monitored and documented on the MAR, and that monitoring was important to track whether medication needed adjustment. The DON also stated that monitoring behaviors and side effects was important for the physician to determine if the medication was effective, and that lack of adequate monitoring of psychotropic medication would be considered unnecessary medication. The facility policy stated psychoactive medication orders must include a specific behavior manifestation and that residents should be observed and/or monitored for side effects and adverse consequences, including sedation.
Unlabeled Floor Stock Medication Bottle
Penalty
Summary
A floor stock bottle of Geri-Lanta in Medication Cart 1 was found unlabeled with an opened date during a concurrent observation and interview with RN 1 at 7:42 a.m. RN 1 verified that the bottle did not have an opened date and stated that medications must be labeled with an opened date to determine the validity of the medication. RN 1 also stated that without an open date, Geri-Lanta could be expired and ineffective, and that residents receiving it could be placed at risk for possible harm. A review of the facility policy and procedure titled Medication Labels, dated 5/2022, showed that medications should be labeled in accordance with facility requirements and state and federal requirements.
Failure to Complete Ordered Monthly Laboratory Tests
Penalty
Summary
The facility failed to implement the physician’s orders for monthly laboratory testing for one resident with bipolar disorder, epilepsy, and congestive heart failure. The resident’s record showed orders for a CBC, CMP, and Depakote level every month, along with Depakote 125 mg by mouth twice daily for bipolar disorder. The resident’s H&P indicated the resident could make needs known but could not make medical decisions, and the MDS showed moderately impaired cognitive skills for daily decision making and a need for substantial assistance with toileting hygiene, showering, and upper and lower body dressing. During interview and record review, the ADON confirmed the resident did not have CBC, CMP, or Depakote level labs drawn for November and December 2025. The ADON also stated there was no documentation that the physician was notified of the missed labs and no documented follow-up with the diagnostic laboratory. The DON stated the routine blood tests were important to monitor and treat the resident’s medical diagnoses and that the Depakote level was important to track the therapeutic level of the medication to better manage behavior. The facility policy stated laboratory services should be provided in an accurate and timely manner to meet residents’ needs per attending physician orders.
Hand Hygiene Not Performed Before Donning PPE
Penalty
Summary
Failure to perform hand hygiene before donning PPE occurred during care for Resident 96. Resident 96’s admission record dated 9/25/2025 indicated diagnoses of metabolic encephalopathy, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. The H&P dated 11/17/2025 stated the resident could make needs known but could not make medical decisions. The order summary dated 9/25/2025 indicated the resident may sit in a Geri Chair as tolerated, and the care plan dated 10/15/2025 indicated the resident was on Enhanced Barrier Precautions and should use gowns and gloves for all personal care, with limited physical mobility related to weakness. During a concurrent observation and interview on 12/16/2025 at 11:24 a.m., CNA 3 and CNA 4 were observed putting on an isolation gown, mask, and gloves without performing hand hygiene. They then entered Resident 96’s room to transfer the resident back to bed from the Geri Chair. Both CNAs stated they should have performed hand hygiene before putting on the isolation gown, mask, and gloves, and stated they could transfer an infection to Resident 96 or to themselves. The facility’s Hand Hygiene policy dated 9/1/2020 stated staff, healthcare personnel, residents, visitors, and volunteers must perform hand hygiene before donning and after doffing PPE.
Facility Assessment Not Updated to Reflect Actual Census
Penalty
Summary
The facility failed to revise and provide an updated average daily census on the Facility Assessment Tool, which is used to evaluate the resident population and identify the resources needed to provide care and services. During a review of the facility census on 12/17/2025, the census showed 96 residents in the facility. In a concurrent interview and record review with the DON, the Facility Assessment Tool last updated on 11/20/2025 was reviewed, and the DON stated the tool listed an average daily census of 91 residents. The DON stated the Facility Assessment was not accurate because the average daily census was below the actual census of residents residing in the facility, and that 5 residents were not accounted for in the assessment. The DON stated it was important to indicate the correct average daily census in the Facility Assessment tool so the facility can adequately plan for staffing needs and provide the highest quality care to residents. The facility policy titled Facility Assessment, dated 4/15/2021, stated the Administrator should review and update the Facility Assessment annually and as necessary whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment.
Failure to Perform Hand Hygiene Before and After Resident Contact
Penalty
Summary
A deficiency was identified when a central supply staff member entered a resident's room without performing hand hygiene, touched the resident's bedding and clothing, and then exited the room without performing hand hygiene. This was observed during a concurrent observation and interview, where the staff member stated they were attempting to help identify the resident's name. The facility's policy and procedure on hand hygiene, dated 9/1/2020, requires staff to perform hand hygiene immediately upon entering and exiting a resident's room. The resident involved had a history of psychosis, dementia, and schizophrenia, with documentation indicating fluctuating capacity to understand and make decisions, and moderately impaired cognition. The resident required substantial to maximum assistance from staff for activities such as toileting, showering, and lower body dressing. The Director of Nursing confirmed during an interview that hand hygiene should be performed before and after touching residents, their clothing, or linen.
Failure to Implement Bed Hold Policy for Hospitalized Resident
Penalty
Summary
The facility failed to implement its Bed Hold Policy and Procedure for a resident who was transferred to a General Acute Care Hospital (GACH) for psychiatric evaluation following aggressive behavior. The resident, who had diagnoses including schizophrenia, psychosis, and dementia, was assessed as able to make her needs known and understand others. Upon transfer, the physician ordered a 7-day bed hold, and the resident's representative was notified and provided verbal consent for the bed hold. Documentation indicated that the Bed Hold Agreement was completed at the time of transfer. Despite these actions, facility records and census data showed that the resident's bed was given to a newly admitted resident immediately after the transfer, and no bed was held for the returning resident during the 7-day period as required by the facility's policy. Interviews with staff, including the Business Office Manager and Administrator, confirmed that the bed hold policy was not followed, and the resident did not have a bed available to return to during the designated period. The facility's policy required that a bed be reserved for up to seven days for residents transferred to an acute care hospital, but this was not implemented in this case.
Failure to Provide Proper Notice and Discharge Planning for Resident Transfer
Penalty
Summary
The facility failed to ensure that the Notice of Proposed Transfer and Discharge form was properly completed and provided to a resident or their family representative prior to discharge to a lower level of care. Specifically, the notice was not signed by the resident or their representative, did not indicate the reason for discharge, and was not provided before the discharge occurred. The resident in question had diagnoses including Parkinsonism, dementia, and epilepsy, and was noted to be confused and lacking the mental capacity to make medical decisions. Despite this, the notice indicated the resident was self-responsible and capable of verbalizing needs. The facility's Social Service Director (SSD) did not contact the resident's family member as documented, and only left a message after the discharge had already taken place. Additionally, the discharge planning process did not include a tour or offer of a tour of the receiving facility to the resident or their family, and the family was not included in the interdisciplinary meeting or discharge planning. The receiving facility was not a board and care home and required residents to care for themselves, which was not communicated to the family prior to discharge. The facility's policy and procedure required that the notice be provided to the resident or representative prior to discharge, which was not followed in this case.
Failure to Timely Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury involving one resident to the California Department of Public Health (CDPH) as required. The resident, who had a history of polyarthritis, muscle weakness, difficulty walking, and moderate cognitive impairment, experienced an unwitnessed fall in their room and was found by a CNA with a significant bump on the forehead. The incident was documented in the resident's records, and the resident was transferred to the hospital for further evaluation. Despite the facility's policy requiring reporting of unusual occurrences and injuries of unknown source within 24 hours, the incident was not reported to CDPH in a timely manner. Interviews with facility leadership confirmed that the administrator was unaware of the fall and injury, and the assistant director of nursing acknowledged that the event met the criteria for mandatory reporting. The facility's policies on unusual occurrence reporting and abuse prevention both specified that such incidents affecting resident welfare, health, or safety must be reported promptly to state authorities. The failure to report the unwitnessed fall with injury resulted in a delay in investigation by CDPH.
Failure to Develop Care Plan for Resident's Hand Injury
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who sustained an injury to the right hand, which required sutures. Despite physician orders for daily wound care, including cleansing with normal saline and application of betadine, there was no care plan or documented interventions addressing the care of the sutures. This omission was confirmed during interviews and record reviews with facility staff, who acknowledged the absence of a care plan specific to the resident's hand injury. The resident involved had a history of schizoaffective disorder, depression, and anxiety, with moderately impaired cognition and a need for partial to moderate assistance with activities of daily living. The lack of a care plan was identified through observation, interview, and record review, and staff confirmed that the care plan should have included goals and interventions to maintain suture care and prevent complications. The facility's own policy required a comprehensive, person-centered care plan for each resident, reflecting their needs and physician orders, which was not followed in this case.
Failure to Develop Individualized COVID-19 Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents who tested positive for COVID-19. Each of these residents had complex medical histories, including conditions such as hypertension, hyperlipidemia, polyarthritis, schizoaffective disorder, cerebral palsy, and transient ischemic attack. Despite documented positive COVID-19 test results and varying levels of assistance required for activities of daily living, there was no evidence in their records that care plans specific to COVID-19 infection were created. This was confirmed during interviews and record reviews with nursing staff, who acknowledged the absence of such care plans. The facility's own policy required the development of comprehensive, person-centered care plans with measurable objectives and timeframes to address residents' medical, nursing, and psychosocial needs. However, for these three residents, the care plans did not include interventions or monitoring related to their COVID-19 status. Nursing staff stated that care plans should have been created and updated to guide care and monitor health status, but this was not done for the affected residents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Prevent Sexual Abuse Due to Inadequate Resident Monitoring
Penalty
Summary
The facility failed to protect a resident from sexual abuse by not adequately monitoring the whereabouts of another resident who was newly admitted and alert. On the night of the incident, staff did not ensure that the male resident was accounted for, which allowed him to enter the female resident's room unsupervised. Facility policy prohibited male residents from entering female residents' rooms, but this was not enforced, and there was no system in place to monitor the new resident's movements during the night shift. The incident was discovered during a routine room check by a registered nurse, who found the male resident on top of the female resident, with her pants down and his face near her genital area. The nurse intervened immediately and separated the two residents. Interviews with staff confirmed that the female resident was confused, could follow simple commands, and was only oriented to her name, while the male resident was alert, able to make himself understood, and had no cognitive or physical impairments. Further review revealed that the facility did not have a policy or procedure for assessing or documenting consent for sexual relationships between residents, nor had an interdisciplinary team meeting or consent process been conducted for these two residents. Staff interviews indicated that abuse allegations should be reported immediately, and that new residents should be closely monitored, but these protocols were not followed in this case.
Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an act of sexual abuse involving two residents within the required two-hour timeframe as outlined in its Abuse Prevention and Management policy. The incident occurred when a registered nurse (RN) observed one resident on top of another in a resident's room, with the victim's pants down and the perpetrator's face near the victim's genital area. The RN intervened immediately and separated the residents. Despite being aware of the incident, the RN did not report it to the California Department of Public Health (CDPH) or the police, as required, after being told by the Director of Nursing (DON) that the Administrator (ADM) would handle the reporting. The victim had a history of schizophrenia, major depressive disorder, and anxiety disorder, and was assessed as unable to make medical decisions but able to make needs known. The Minimum Data Set indicated no cognitive impairment and a need for partial to moderate assistance with activities of daily living. The perpetrator was newly admitted, alert, and had no cognitive or physical impairments noted. The incident was documented in the Interdisciplinary Team meeting notes, and both the RN and ADM acknowledged during interviews that the event should have been reported to the appropriate authorities within two hours, as per facility policy. A review of the facility's policy confirmed that any allegation of abuse, including those without serious bodily injury, must be reported by telephone and in writing to CDPH, the Ombudsman, and law enforcement within two hours. The failure to report the incident in a timely manner delayed the investigation by CDPH and placed other residents at risk for abuse, as explicitly stated in the findings.
Failure to Provide Adequate Supervision and Safe Repositioning Results in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow established procedures for turning and repositioning a dependent resident, resulting in a significant accident. Two CNAs, both of whom had received in-service training on proper repositioning techniques, attempted to turn and reposition a resident who was totally dependent on staff for mobility and required two-person assistance. Both CNAs stood on the same side of the bed, contrary to facility policy and training, which required one staff member on each side of the bed to ensure safety during such procedures. The resident involved had a complex medical history, including morbid obesity, paraplegia, chronic pain syndrome, and was bedridden and unable to assist with movement. The care plan and MDS assessments clearly indicated the need for two-person assistance for all bed mobility and emphasized safety measures to prevent falls. Despite these documented needs and interventions, the CNAs repositioned the resident while both were on the left side of the bed, leaving the right side unsecured. During the maneuver, the resident slipped off the right side of the bed and fell to the floor. As a result of this incident, the resident sustained a displaced fracture of the right distal femur, a skin tear, and experienced severe pain and fear. The resident required urgent transfer to an acute care hospital for evaluation and treatment. Interviews with the CNAs, DON, and other staff confirmed that the proper technique was not followed and that the accident could have been prevented if the established safety protocols had been observed.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and procedures for preventing abuse, neglect, and injuries of unknown origin for one of the sampled residents. Resident 3, who was admitted with diagnoses including Alzheimer's disease, dementia, and psychosis, was found to have unknown bruises and skin tears. The resident's Minimum Data Set indicated severe cognitive impairment and a need for supervision with activities of daily living. Despite these needs, the facility did not follow its protocol for reporting injuries of unknown origin, as evidenced by the unreported skin discolorations and tears documented in the resident's records. The Director of Nursing (DON) acknowledged awareness of some of the resident's skin discolorations but admitted that the facility's policy was not implemented or followed. The facility's policy required immediate investigation and reporting to the ombudsman, law enforcement, and the California Department of Public Health within two hours of receiving a report of such injuries. However, the DON confirmed that the facility did not report the resident's skin tears and discolorations to the appropriate agencies, which could result in possible abuse and safety issues.
Failure to Investigate Skin Discoloration and Tears
Penalty
Summary
The facility failed to investigate all areas of skin discoloration and skin tears for one resident, which had the potential to place the resident and other vulnerable residents at increased risk of abuse. The resident, who was admitted with diagnoses including urinary tract infection, Alzheimer's disease, dementia, and psychosis, had several instances of skin discoloration and skin tears documented in their records. These included a light greenish discoloration on the left hip, a skin tear on the front left shoulder and left elbow, and discoloration on the left arm, right upper thigh, left elbow, and right buttock. Despite these findings, there was no evidence of a risk management assessment or investigation report being completed for these occurrences. Interviews with facility staff, including a Licensed Vocational Nurse, a Registered Nurse, and the Director of Nursing, revealed that the facility's protocol required investigations for unusual skin discoloration and skin tears. However, the staff were either unaware of the full extent of the resident's skin issues or confirmed that no investigations were conducted. The facility's policy on unusual occurrence reporting and abuse prevention required timely and thorough investigations into such incidents, but these procedures were not followed, leading to a deficiency in care.
Failure to Provide Adequate Admission Care and Services
Penalty
Summary
The facility failed to provide adequate care and services to a resident who was admitted with multiple diagnoses, including hypertension, diabetes mellitus, depression, anxiety, and suicidal ideation. Upon arrival, the resident was not oriented to the facility, and an initial admission assessment was not completed. The facility did not notify the attending physician to obtain necessary admission orders, and no medications were ordered or administered to the resident. Additionally, the resident did not receive any activities of daily living support, such as diaper changes, for approximately 22 hours. The nursing staff was inadequately prepared to handle the admission process. LVN 1, who was informed of the resident's pending arrival, did not know how to conduct an initial assessment and left the task for the incoming shift, which was short-staffed due to a call-off. As a result, the resident did not receive any medications, including insulin and antihypertensives, and was left without food or drink. The resident's emergency contact found the resident in a soiled state and in pain, prompting a call to 911 for transfer back to a hospital. The facility's policies and procedures for admission and orientation were not followed, and there was a lack of staff training on the admission process. The Director of Staff Development had not conducted in-service training on admissions for two years, and the facility did not have a staffing agency to address shortages. This lack of compliance with established procedures and inadequate staffing led to the resident's distress and subsequent transfer to a hospital for further evaluation and treatment.
Removal Plan
- The DSD/designee initiated immediate education to Licensed Nurses, certified nursing assistants (CNAs) on every shift and Department Managers on the following facility's policies and procedures: Resident Initial Admission Assessment, Admission and Orientation of Residents, and Admission Criteria.
- The DON will assign an LVN to conduct the initial assessment of new residents.
- The facility will attempt to replace the nursing staff who called off from their scheduled shift by calling other nursing staff who are not scheduled and are available to work, including licensed department managers, to ensure adequate staffing.
- Staff were in-serviced on the new admission process by the DSD.
Failure to Adhere to Policy on Handling Resident Belongings
Penalty
Summary
The facility failed to adhere to its policy regarding the handling of residents' personal belongings, specifically for one resident who was transferred to a general acute care hospital (GACH) and then returned to the facility. The resident, who had intact cognitive skills and required supervision for activities of daily living, reported that his personal belongings were moved without his permission during his absence. Upon his return, he discovered that some items, including eyeglasses and a phone charger, were missing, and the facility was unable to provide an inventory list of his belongings. Interviews with facility staff, including a social worker and a certified nursing assistant (CNA), revealed that the facility's policy required an inventory list of residents' belongings to be completed upon admission, readmission, and as needed. However, the CNA admitted that the inventory list for this resident was not completed, and there was no record of the resident's permission to move his belongings. This oversight violated the facility's policy and the resident's rights, potentially impacting his psychosocial well-being.
Failure to Notify Physician of Medication Refusal Leads to Resident Altercation
Penalty
Summary
The facility failed to notify the physician of a resident's refusal to take Olanzapine, an antipsychotic medication prescribed for schizophrenia, for 22 consecutive days. This oversight involved Resident 3, who was diagnosed with schizophrenia, bipolar disorder, hypertension, and muscle weakness. The resident's Minimum Data Set (MDS) indicated moderately impaired cognitive skills for daily decision-making and required assistance with activities of daily living. Despite the refusal of medication being documented in the Medication Administration Records (MAR), there was no evidence that the physician was informed, as required by the facility's policy. The deficiency led to a significant incident where Resident 3 engaged in physical aggression towards another resident, Resident 2. On the morning of the incident, Resident 3, who had not taken Olanzapine for 22 days, hit Resident 2 on the chest, resulting in Resident 2 experiencing severe pain. The incident was reported to the police, and Resident 3 was arrested for aggressive behavior. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed the altercation and the subsequent police involvement. The facility's policy and procedure for Change of Condition Notification and Medication Administration required that the physician be informed of any significant changes in a resident's condition, including medication refusal. However, the staff failed to notify the physician about Resident 3's non-compliance with the medication regimen, which potentially contributed to the resident's aggressive behavior and the altercation with Resident 2. This lack of communication and adherence to policy resulted in a deficiency in the facility's care practices.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to implement its policy and procedure regarding the readmission of residents, resulting in the denial of a resident's right to return to the facility after hospitalization. The facility's policy, revised in 2013, stated that residents requiring skilled nursing care should be readmitted. However, this policy was not followed for a resident who had been involved in an altercation and subsequently arrested. The resident, who had diagnoses including schizophrenia, bipolar disorder, and hypertension, was not allowed to return to the facility after being released from jail, despite the facility's policy indicating they should be readmitted. The incident began when the resident had an altercation with another resident, leading to police involvement. The Licensed Vocational Nurse (LVN) on duty reported the incident to the police, resulting in the resident's arrest. The Director of Nursing (DON) and the LVN insisted on the arrest, despite the police officer's suggestion for a psychiatric evaluation. The resident was taken into custody and later released, but the facility refused to readmit them, contrary to their policy. Interviews with facility staff, including the DON and Administrator, confirmed the decision not to readmit the resident. The police officer also confirmed that the facility refused to accept the resident back after their release from jail. This refusal was in direct violation of the facility's readmission policy and the guidance from the California Department of Public Health, which mandates equal access to care for all residents, regardless of their condition or payment source.
Failure to Implement 1:1 Sitter for Resident at Risk of Wandering
Penalty
Summary
The facility failed to implement resident-centered care plan interventions for a resident at risk for wandering, identified as Resident 5. Despite having physician orders for a one-to-one sitter to ensure safety, observations on multiple occasions revealed that Resident 5 was walking unsupervised throughout the facility, including entering other residents' rooms. This lack of supervision was noted on several dates, with no staff member assigned to monitor Resident 5 as required by the care plan. Resident 5, who was admitted with diagnoses including dementia, Alzheimer's Disease, depression, and muscle weakness, was assessed to have severely impaired cognitive skills and required supervision for activities of daily living. The facility's policy mandates comprehensive care plans to meet residents' health, safety, and psychosocial needs, yet the care plan intervention for one-to-one monitoring was not implemented. This oversight posed a potential safety risk and privacy invasion for other residents, as acknowledged by a registered nurse during an interview.
Failure to Provide 1:1 Sitter Leads to Resident Fall
Penalty
Summary
The facility failed to provide a one-on-one sitter for a resident as indicated in the care plan, resulting in the resident falling and sustaining a laceration on the forehead. The resident, who had a history of Parkinson's disease, schizoaffective disorder, and diabetes mellitus, was identified as having moderately impaired cognitive skills and was dependent on staff for activities of daily living. The care plan specifically required a one-on-one sitter due to the resident's high risk for falls, but this was not adhered to, leading to the incident. Observations and interviews revealed that the assigned sitter was responsible for monitoring four high fall risk residents simultaneously, which was acknowledged as a safety risk by the staff. The Director of Staff Development confirmed that the facility's failure to provide the necessary one-on-one supervision was a deficient practice, which directly contributed to the resident's fall and injury. The facility's policies on safety and fall management were not effectively implemented, as evidenced by the lack of adequate supervision for the resident.
Failure to Maintain Personal Belongings Inventory
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards, specifically regarding the personal belongings inventory list for a resident. The resident, who had been diagnosed with Parkinson's disease, schizophrenia, and Diabetes Mellitus, was transferred to a general acute care hospital and upon return, found that his personal belongings had been moved without his permission. The resident reported missing items such as eyeglasses and a phone charger, and the facility was unable to provide him with a personal belongings inventory list. Interviews with facility staff revealed that it was the responsibility of Certified Nursing Assistants (CNAs) to complete and maintain the personal belongings inventory list upon a resident's admission, readmission, and as needed. However, the CNA responsible for the resident's inventory admitted that the list was not completed. The facility's policy required that a personal property inventory be conducted and placed in the medical record, with a copy provided to the resident, but this was not adhered to in this case.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide a privacy bag for a foley catheter for one resident, which compromised the resident's dignity and potentially posed an infection control risk. The resident, who had intact cognitive skills and required supervision for various activities, was observed with an uncovered foley catheter bag in a pink basin. The resident reported not having a privacy bag since the catheter was inserted and was not informed about the necessity of such a bag. The Director of Nursing confirmed that all residents with foley catheters should be provided with a dignity bag, as per the facility's policy, and acknowledged the potential for cross-contamination and self-esteem issues due to the lack of a privacy bag. Another resident's dignity was compromised by the use of bilateral bedrails, which the resident could not easily release, making them feel trapped and confined. The resident, who could make needs known but not medical decisions, expressed that the bedrails made them feel isolated and were not discussed with them by the staff. The Director of Nursing stated that if the resident could not easily and voluntarily release the bedrails, their use would be considered a restraint. The facility's policy emphasized the importance of promoting dignity and avoiding practices that compromise it, which was not adhered to in this case.
Deficiencies in Personal Item Replacement and Homelike Environment
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 28, had their essential personal items, specifically reading glasses and dentures, replaced after they went missing. Resident 28, who has diagnoses including end-stage renal disease, diabetes mellitus, and heart failure, reported the loss of these items following a room change. Despite the resident's ability to communicate effectively, the staff did not assist in locating the missing items. The Director of Social Services confirmed the absence of the glasses and dentures and acknowledged that the facility's process for tracking resident inventory during admissions, discharges, and room changes was not followed. Additionally, the facility did not provide a homelike environment for two residents, identified as Residents 10 and 6. Resident 10, who has cognitive skills intact and is dependent on staff for various needs, reported a broken window latch and blinds in their room, which had not been repaired despite informing the staff. The Maintenance Supervisor confirmed the poor condition of the window and blinds, noting that no repair requests were logged. Resident 6 also experienced a lack of a homelike environment due to missing slats on the blinds covering a glass patio door, which led them to use paper towels for privacy. The Maintenance Supervisor was unaware of this issue, indicating a failure in the facility's repair request process. The facility's policies and procedures, including those for theft and loss, accommodation of needs, and maintaining a homelike environment, were not adhered to, resulting in these deficiencies. The policies outlined responsibilities for safeguarding personal property, accommodating residents' needs, and ensuring a comfortable environment, but these were not effectively implemented, leading to the residents' dissatisfaction and unmet needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to create individualized comprehensive nursing care plans for two residents, leading to significant issues. Resident 90, who had a gastrostomy tube (G-tube) for nutrition, experienced the tube being dislodged three times. The care plans for Resident 90, reviewed from August 2023 to July 2024, did not include interventions to prevent G-tube dislodgement, such as the use of an abdominal binder. Charge Nurse 1 confirmed that the care plan lacked necessary interventions for G-tube management, which should have been included upon admission. The facility's policy required a baseline care plan to be developed within 48 hours of admission, reflecting the resident's needs and goals. Resident 28, who had end-stage renal disease, diabetes mellitus, and heart failure, was dependent on staff for personal care and had dentures delivered to the facility. However, Resident 28 reported missing dentures, affecting her ability to chew food. The Director of Social Services stated that a care plan should have been developed to address the refusal to wear dentures, including education on the benefits of wearing them. Registered Nurse 1 acknowledged the resident's right to refuse dentures but emphasized the importance of documenting the refusal and monitoring weight and chewing issues. The facility's policy required comprehensive person-centered care plans based on assessed needs, which were not adequately developed for Resident 28.
Failure to Prevent G-tube Dislodgement
Penalty
Summary
The facility failed to prevent the hospitalization of a resident due to a dislodged gastrostomy tube (G-tube). The resident, who had a G-tube as part of their medical care, was sent to the hospital on two occasions due to the dislodgement of the tube. A review of the nursing progress notes from late July to mid-August 2024 revealed that the resident did not have an abdominal binder, which is a device used to secure the G-tube and prevent dislodgement. Interviews with a Licensed Vocational Nurse and a Charge Nurse confirmed that the resident should have had an abdominal binder upon admission to prevent such incidents. The facility's policy and procedure on enteral tube management, dated September 2023, indicated that it is the facility's responsibility to ensure the safety of enteral tubes before initiating feeding. However, the absence of an abdominal binder for the resident suggests a failure to adhere to this policy, leading to the resident's hospitalization.
Failure to Secure G-tube Leads to Repeated Dislodgement
Penalty
Summary
The facility failed to secure a gastrostomy tube (G-tube) for a resident, resulting in the tube being dislodged three times. The resident, identified as Resident 90, had a G-tube as part of their medical care. A review of the resident's nursing progress notes indicated that the G-tube was dislodged on three separate occasions. Despite the repeated dislodgements, there was no indication in the nursing notes that an abdominal binder, which could have helped secure the G-tube, was used. Interviews with facility staff revealed that the resident should have had an abdominal binder to prevent the G-tube from being dislodged. A Licensed Vocational Nurse (LVN) and a Charge Nurse (CN) both acknowledged that the resident was a candidate for an abdominal binder, and that the repeated dislodgement of the G-tube was not in accordance with nursing standards of care. The facility's policy and procedure for enteral tube management emphasized the responsibility of the facility to maintain the safety of enteral tubes, but preventive measures were not ordered or implemented for Resident 90.
Failure to Update Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that an updated Physician's Order for Life Sustaining Treatment (POLST) form was transferred to the hospital for a resident. This resident, who had severe cognitive impairment and was dependent on staff for daily activities, was transferred to the hospital with an outdated Advance Directive. The Registered Nurse Supervisor confirmed that the outdated document was sent, which could have resulted in a delay of care during a medical emergency. Another resident, who had intact cognitive skills but was dependent on staff for daily activities, did not have an Advance Directive acknowledgment form in their chart. The Registered Nurse Supervisor acknowledged this omission, which could have led to a delay in care and uncertainty about the resident's code status in an emergency. Additionally, the facility did not update the code status for a resident who had experienced a decline in health and could no longer make medical decisions. The responsible party for this resident had expressed the resident's wish not to be on a breathing machine, but the facility's Social Services failed to follow up and update the code status. This lack of communication could have resulted in actions contrary to the resident's wishes.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident had their call light within reach, which is a necessary accommodation for their needs and preferences. The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and spinal stenosis, was observed unable to reach the call light. This observation was made during a room visit, where the resident attempted to reach for the call light but could not. The resident's Minimum Data Set indicated that they were dependent on staff for personal hygiene, showering, and dressing, and could understand and be understood, but could not make medical decisions. Interviews with facility staff, including a Restorative Nurse Assistant, a Certified Nursing Assistant, and a Licensed Vocational Nurse, confirmed the importance of keeping the call light within reach for the resident. The staff acknowledged that without the call light within reach, the resident would not be able to call for assistance, potentially leading to unmet needs and feelings of isolation. The facility's policy and procedure on the communication-call system, dated October 2024, stated that the call alert device should be placed within the resident's reach, which was not adhered to in this instance.
Failure to Submit Accurate PASRR for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening Resident Review (PASRR) was submitted for a resident with a mental disorder, which is a federal requirement to ensure appropriate care placement. The resident, identified as having psychosis, altered mental status, violent behavior, and encephalopathy, was admitted without a proper PASRR submission. The resident's Minimum Data Set (MDS) indicated moderately intact cognitive skills and dependency on staff for various needs, including toileting and dressing. During an interview and record review, the Quality Assurance Nurse acknowledged that all residents with mental illnesses require a PASRR submission. It was revealed that the resident's PASRR, dated earlier, inaccurately indicated no mental illness due to incorrect information on the Level 1 screening. The Quality Assurance Nurse confirmed that a new PASRR should have been submitted with accurate information, as the lack of submission could result in the resident not receiving necessary mental health services. The facility's policy stated that a new PASRR should be completed upon readmission from an acute hospital if there is a significant change in the resident's condition.
Failure to Resubmit PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening Resident Review (PASRR) was resubmitted for a resident with mental health diagnoses, including bipolar disorder, schizophrenia, and major depressive disorder. The resident was readmitted to the facility with these diagnoses, and the Minimum Data Set (MDS) indicated that the resident's cognitive skills were intact, but they were dependent on staff for certain activities of daily living. Despite the requirement for all residents with mental illnesses to have a PASRR submitted, the facility did not resubmit the PASRR for this resident after the initial Level 1 PASRR indicated that facility staff were unresponsive to communication attempts within 48 hours of the screening. The Quality Assurance Nurse acknowledged the oversight, stating that the PASRR should have been resubmitted. The facility's policy, dated April 2024, assigns the responsibility of ensuring PASRR updates to the MDS Coordinator, but this was not adhered to in this case. The failure to resubmit the PASRR had the potential to result in the resident not receiving necessary mental health services.
Failure to Trim Resident's Toenails
Penalty
Summary
The facility failed to ensure that a resident's toenails were trimmed, which had the potential to cause discomfort. The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and knee contractures, was observed to have long, untrimmed toenails. The resident's Minimum Data Set indicated dependency on staff for personal hygiene, showering, and dressing, and the care plan included interventions for nail care on bath days. However, during an observation, the resident's toenails were found to be long and untrimmed. Interviews with staff revealed that the responsibility for trimming the resident's nails fell to the Certified Nursing Assistants (CNAs), as per the facility's policy and procedure. The Registered Nurse acknowledged the need for the toenails to be cut and the potential harm and discomfort caused by long nails. The facility's grooming policy emphasized maintaining short and manageable nails to improve hygiene, comfort, self-esteem, and dignity. Despite these guidelines, the resident's toenails were not trimmed, indicating a lapse in the execution of the care plan and facility policies.
Incorrect LAL Mattress Settings Risk Resident's Skin Integrity
Penalty
Summary
The facility failed to ensure that a resident's low air loss (LAL) mattress was set correctly, which placed the resident at risk for pressure injuries. The resident, who was initially admitted and later readmitted to the facility, had diagnoses including osteomyelitis, adult failure to thrive, and methicillin-resistant Staphylococcus aureus (MRSA). The resident was assessed as having the capacity to understand and make decisions and was dependent on staff for personal hygiene, showering, and dressing. The Minimum Data Set (MDS) indicated that the resident was at risk of developing pressure ulcers. During an observation, it was noted that the LAL mattress was set at 350 pounds, while the resident's weight was recorded as 142 pounds. The Director of Nursing (DON) confirmed that the mattress settings were incorrect and acknowledged that this could lead to the development of pressure ulcers. A Licensed Vocational Nurse (LVN) also stated that incorrect settings would prevent the mattress from serving its purpose of preventing pressure ulcers, thereby increasing the risk of skin breakdown. The facility's policy and procedure on mattresses emphasized the importance of ensuring that mattresses are inflated properly and checked routinely to prevent skin breakdown.
Failure to Apply Splints as Scheduled for a Resident
Penalty
Summary
The facility failed to ensure that a resident's splints were applied as scheduled, which is necessary to maintain or improve range of motion and prevent contractures. The resident, who has diagnoses including dementia, major depressive disorder, and muscle weakness, was observed without the required splints during specified hours on two consecutive days. The physician's orders indicated that the splints should be applied to the resident's upper extremities and ankles for four to six hours, three times a week. However, there was no documentation that the splints were applied on the scheduled days. Interviews with the Restorative Nurse Assistant (RNA) and the Physical Therapist (PT) confirmed the importance of applying the splints as scheduled to prevent contractures. The RNA acknowledged the lack of documentation and the potential consequences of not applying the splints. The facility's policy on the Restorative Nursing Program requires RNAs to document the frequency, duration, and tolerance of activities, which was not adhered to in this case.
Inadequate Supervision of Wandering Resident Leads to Altercation
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a known wandering behavior, which led to an incident involving another resident. Resident 89, who has a history of bipolar disorder with mood swings and wandering behavior, entered Resident 34's room. Despite the facility's awareness of Resident 89's tendency to wander and intrude on others' privacy, she was not adequately supervised, resulting in Resident 34 pushing her out of his room. This incident occurred after the facility had already documented Resident 89's behavior and had interventions in place to distract her from wandering. The incident was witnessed by LVN 2, who heard Resident 34 yelling and saw him push Resident 89, causing her to stumble. Resident 34 admitted to pushing Resident 89, stating she was not supposed to be in his room. Observations on a subsequent day showed Resident 89 continuing to wander through the facility hallways, being redirected by a staff member. The facility's failure to provide consistent supervision and prevent Resident 89 from entering other residents' rooms led to the potential for injury, as evidenced by the altercation with Resident 34.
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 6,787 citations issued within 25 miles in the last 12 months — including the 38 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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. John Of God Retirement | 0.1 mi | ★★★★★ | 32 | 0 |
| St Andrews | 0.4 mi | ★★★★★ | 0 | 0 |
| Western Convalescent Hospital | 0.6 mi | ★★★★★ | 15 | 0 |
| Sunnyview Care Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Sunray Healthcare Center | 0.9 mi | — | 32 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for East Terrace Rehabilitation & Wellness Centre, Lp.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.