Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Foothill Heights Care Center during CMS and state inspections, most recent first.
Failure to Address Pharmacist MRR Recommendations: The DON and record review showed that pharmacist MRR findings were not timely reviewed or documented by the physician for multiple residents. One resident remained on Benadryl despite the pharmacist noting it is not recommended in the elderly, another resident on lamotrigine did not have the recommended anticonvulsant side effect monitoring, and a third resident remained on high-dose ergocalciferol despite a high vitamin D level and a recommendation to consider discontinuation.
Kitchen food handling and sanitation practices were deficient when food items were not consistently labeled with the item name and use-by date, refrigerator temperature logs were left incomplete, and expired food was found on the counter. Staff also observed pooled water on the kitchen floor from the dishwashing machine and noted that the ice machine drainpipe lacked an air gap. The DS and IPN stated these conditions involved improper food storage, possible contamination concerns, and stagnant water in the kitchen area.
Improper Dumpster Garbage Disposal: Two dumpsters in the facility parking lot were observed overfilled with trash bags and left uncovered during an observation with the Dietary Supervisor. The DS stated the dumpsters should have lids on them for infection control, and the facility P&P required outside dumpsters to be kept closed and free of surrounding litter.
Laundry staff failed to verify accurate washer and dryer temperatures and processed soiled linens without confirming that Washer 2 maintained 160°F for at least 25 minutes. Staff observed the hot water line thermometer reading 120°F while the water heater gauge was set at 160°F, and the dryer log for Dryer 1 contained copied temperatures even though no thermometer was present to measure them. The IPN and ADM confirmed the laundry policy was not followed and that no specific facility policy guided washer/dryer temperature settings or documentation.
Advance Directive Information Not Documented: A resident with schizophrenia, right-sided hemiplegia/hemiparesis, and GERD had severely impaired cognitive skills and needed assistance with multiple ADLs. Review of the AHCD acknowledgment form showed it did not document whether the RP received information about the right to make an AHCD, whether the resident had an AHCD, or whether the RP wanted information about formulating one; the DON and SSD stated the form should have been completed to show this information.
A resident with protein-calorie malnutrition and dementia had a 7-lb weight loss over 30 days, but the RNA did not notify the charge nurse after recording the weight. Record review showed no documented evidence that the weight loss was assessed, monitored, or reported to the physician, and the LVN and DON stated the physician should have been notified of the change in condition.
Failure to Provide Medicare Coverage Notice and ABN: A resident with encephalopathy, Alzheimer’s disease, and dementia had severely impaired decision-making skills, and the RP was the decision maker. The SNF beneficiary review showed Part A skilled coverage was ending, but the ABN was not provided to the RP. The BOM said she left one voicemail, did not follow up, and did not send the ABN by mail.
Missed Restorative Nursing Services for a resident with multiple contractures and severe ROM loss. The resident had orders for PROM to both UEs and LEs and splints to both knees, but the documentation survey showed 10 missed treatments over several weeks. RNA staff stated there were no notes explaining the missed services and that no charting meant the restorative care was not provided; the DOR and DON both confirmed the importance of the ordered RNA services for maintaining joint mobility and function.
Failure to Care Plan for Wandering Risk: A resident with dementia, psychosis, and severely impaired cognition was assessed as at risk for elopement/wandering, but the chart did not show a care plan with wandering-specific interventions. Staff observed the resident wandering into another resident’s room, approaching the bedside while the other resident slept, and handling items from the nightstand; interviews confirmed the resident had a pattern of wandering and asking for her son.
A resident with dementia, dysphagia, GERD, and metabolic encephalopathy had a care plan to monitor intake and record each meal, but staff failed to document PO intake for multiple meals. The resident had severely impaired cognition, swallowing symptoms, and severe weight loss from 127 lbs to 113 lbs. LVN and DON interviews confirmed the missing meal documentation, and facility policy required ongoing monitoring and documentation of dietary intake.
A resident with a GT, dementia, and protein calorie malnutrition was observed with the enteral pump running while the tube was not connected and formula was spilling to the floor. An LVN confirmed the pump was on and disconnected, and later stated another nurse may have restarted the feed after a shower without checking tube placement or secure connection as required by the enteral feeding procedure.
A resident with a physician order for continuous O2 at 4 LPM via NC was found in bed without the NC in place while the concentrator was on and the tubing was stored in a plastic bag. The resident said he needed oxygen and it was hard to breathe, and the DSD measured an O2 saturation of 88%. The DON and ADM stated CNAs are not allowed to remove or reapply the oxygen device, but a CNA reported removing it before a bed bath and placing it in the bag.
A resident with PTSD, schizoaffective disorder, and anxiety disorder did not have trauma history, triggers, or PTSD-specific interventions documented in the social service assessments or care plan. The SSD said the resident reported PTSD but it was not documented or assessed, a CNA said he did not know what PTSD was, and the DON confirmed there was no PTSD assessment or care plan despite the facility policy requiring trauma-informed, individualized care.
A resident with type 2 DM, leukemia, and HTN was observed receiving carvedilol without food even though the order said to give it with food. The LVN stated she did not see the resident eating or ask when the resident last ate, and the DON stated the medication should have been given with crackers, applesauce, or the dinner tray as ordered.
Medication Cart 1 was observed unlocked and unattended while an LVN was inside residents' rooms during medication administration. The LVN stated the cart should be locked whenever staff leave it, and the DON stated carts must be locked as soon as the nurse's back is turned to the cart. Facility P&Ps also stated medication carts are to be locked when not in use and kept closed and locked when out of sight of the medication nurse or aide.
Failure to Post Daily Nurse Staffing Information: The facility did not update and post the daily nurse staffing information on two consecutive days, and the posted form still reflected an earlier date when observed at the Business Office door. The DSD stated she was responsible for posting the staffing information but did not work weekends, so the daily posting was not completed until she returned to work. The facility policy required daily shift staffing data to be completed and posted within 2 hours of the start of each shift.
A resident with schizoaffective disorder, anxiety, unsteadiness of feet, and moderately impaired cognition was care planned as at risk for wandering/elopement, with interventions including door monitoring each shift. Despite this, staff interviews and records showed that the unsecured, non-alarmed front door—located on a busy street and expected to be continuously supervised and locked at night—was left unsupervised for a period, during which the resident left the building through that door. The resident, last seen in a wheelchair near the nurse’s station, was later confirmed to have exited via the front door and stated an intention to travel out of state, demonstrating a failure to implement required supervision and environmental safety measures to prevent elopement.
A resident with severe cognitive impairment and multiple wounds did not have wound care treatments accurately documented on the TAR for two dates, despite physician orders for daily dressing changes. The treatment nurse stated the care was provided but not recorded, which resulted in incomplete medical records and potential miscommunication among staff.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
A resident with a history of fluctuating mental status and cognitive intactness made allegations of sexual abuse upon readmission. The family reported these allegations to the DON, but the DON and Administrator did not acknowledge or report them to required authorities, contrary to facility policy.
A resident with multiple medical conditions and moderate cognitive impairment was left waiting for assistance for about an hour due to a non-functional call light system. The call light failed to produce an audible or visual signal, and staff confirmed its malfunction. Facility policy requires call lights to be operational at all times, but this was not ensured, resulting in delayed care.
Surveyors observed that opened containers of dressing and syrup, as well as multiple bags of frozen vegetables, were not labeled with the required use by date or food name. The Dietary Supervisor confirmed that this was not in accordance with facility policy, and acknowledged that the lack of labeling could lead to expired or incorrect food being served.
Staff did not consistently use full PPE, including N95 respirators, gowns, gloves, and eye protection, when entering rooms of residents on COVID-19 precautions, and soiled items were left on the floor instead of being properly contained, in violation of facility policy and CDC guidance.
A resident with moderate cognitive impairment had personal snacks removed from her bedside table and her boots washed by a CNA without her permission, despite her explicit refusal. The resident became upset after discovering her belongings were taken without consent. Staff interviews and facility policy confirmed that permission should have been obtained before removing or handling the resident's property.
A resident with severe joint mobility loss and at risk for contractures did not consistently receive or have documented restorative nursing care, including passive range of motion exercises and application of bilateral knee splints, as ordered. Staff interviews and record reviews confirmed lapses in both the provision and documentation of these interventions during multiple days, contrary to the resident's care plan and facility policy.
A resident with a g-tube, severe cognitive impairment, and a history of dysphagia and pneumonia did not receive appropriate care when an LVN failed to verify tube placement before administering a water flush and medications, contrary to physician orders and facility policy. The LVN only checked tube placement after the flush, and interviews confirmed that proper protocol was not followed.
A resident with respiratory disorders and on continuous oxygen therapy did not have a No Smoking/Oxygen in Use sign posted outside their room, as required by facility policy. Staff and the DON confirmed the omission, and the policy review indicated that such signage is necessary for safe oxygen administration.
A resident with severe cognitive impairment and incontinence was incorrectly documented as always voiding appropriately in their bowel and bladder assessment, despite other records indicating incontinence. This documentation error was confirmed by the DSD and DON, who acknowledged the assessment did not accurately reflect the resident's condition.
A resident with severe cognitive and physical impairments, including Alzheimer's disease and dependence on staff for daily activities, was found to have their call light out of reach despite care plan and facility policy requirements. The resident was unaware of the call light's location, and staff confirmed it was not accessible, resulting in the resident being unable to request assistance when needed.
Thirteen resident rooms were found to be below the required minimum square footage per resident, with both two-bed and four-bed rooms not meeting regulatory standards. Staff, including a CNA and an LVN, reported having enough space to provide care, and residents did not express concerns about room size. The facility submitted a waiver request, and the Department indicated it would recommend approval.
A facility failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement. The resident, with diagnoses including diabetes mellitus type 1 and schizoaffective disorder, made the allegation on March 5, 2025. Interviews with staff revealed a lack of adherence to the facility's policy on abuse reporting, as the Administrator did not initiate an investigation or report the allegation promptly. The facility's policies required immediate reporting of abuse allegations, but these were not followed, resulting in a deficiency.
The facility did not post accurate and complete DHPPD information as required. On a specific day, the DHPPD form was missing, and forms from previous days were incomplete, showing only projected hours. The DSD and APPD acknowledged their roles in this oversight, with the APPD citing illness as a reason for not completing the forms. The facility's policy requires posting within two hours of each shift, which was not followed.
A resident with impaired cognitive skills and mobility issues was found without a call light within reach, posing a risk for delayed assistance with ADLs. Staff confirmed the call light was misplaced behind curtains, contrary to facility policy requiring it to be easily accessible.
A resident with dementia and a history of falls fell while attempting to transfer to bed without assistance, despite requiring partial to moderate assistance for such activities. The CNA present did not assist, and the care plan lacked specific interventions for bed transfers. The facility's policies on fall risk assessment and intervention were not adequately followed, contributing to the incident.
A resident was not readmitted to the facility after hospitalization despite available beds, violating their right to return. The facility required the resident to be on hospice care for readmission, citing frequent hospitalizations and isolation needs. This decision contradicted the facility's policy allowing residents to return if a bed is available.
A facility failed to report an alleged abuse incident involving a resident with legal blindness, anxiety disorder, and type 2 diabetes mellitus within the required two-hour timeframe. The resident reported that a Social Services staff member made hurtful and insulting statements, which was recognized as emotional abuse by the Director of Staff Development (DSD). However, the DSD did not report it to the Administrator due to being busy, and the Administrator later decided not to report it to the California Department of Public Health, considering it a grievance instead.
A facility failed to suspend a Social Services staff member after an alleged abuse incident involving a resident with legal blindness, anxiety disorder, and type 2 diabetes. The resident reported that the staff member made hurtful statements, but the administrator did not suspend the staff member or submit a required investigation report to CDPH, violating the facility's policy.
The facility failed to submit MDS Discharge Tracking Forms to CMS within the required 31-day period for two residents, leading to potential inaccuracies in quality indicators. The MDS Consultant confirmed the oversight, and a review of the facility's manual and job description highlighted the importance of timely submission.
The facility failed to discard ground beef from the refrigerator after it was past the use-by date, as per the facility's policy. The Cook and Dietary Supervisor confirmed that the expired meat could cause foodborne illness, and the facility's policy requires supervisors to ensure food items are not expired.
The facility failed to ensure informed consent for Binding Arbitration Agreements for three residents. One resident signed without understanding the agreement, another had conflicting signatures indicating both agreement and refusal, and a third had a signature discrepancy and fluctuating decision-making capacity.
The facility staff failed to sanitize a blood pressure cuff between uses for two residents, leading to a potential risk of bacterial transmission. An LVN admitted to not disinfecting the cuff, and the Infection Preventionist confirmed the importance of this practice. The facility's policy requires reusable items to be cleaned and disinfected between residents.
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, violating their right to be fully informed about their treatment. One resident was prescribed Seroquel without consent, and another was administered quetiapine and lorazepam without consent, contrary to the facility's policy.
The facility failed to ensure that call lights were within sight and reach for four residents, all of whom had impaired cognitive skills and were dependent on others for ADLs. Observations revealed that the call lights were clipped to the sides of pillows and had cords that were too short, preventing residents from calling for assistance.
The facility failed to ensure that the responsible party for a resident with dementia, who lacked the capacity to understand medical conditions, received information regarding the resident's right to formulate an advance directive. The resident signed the Advance Directives Acknowledgement Form despite being severely cognitively impaired, and there was no documentation that the advance directive was discussed with the responsible party as required by the facility's policy.
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, admitted with anxiety disorder, schizophrenia, and malnutrition, was dependent on staff for ADL care and receiving nutrition through a G-tube. Both an LVN and an MDS Consultant confirmed the absence of the required care plan.
The facility failed to position a nephrostomy bag below kidney level for a resident with acute kidney failure and an infection related to the nephrostomy catheter. Observations and interviews confirmed that the bags were placed at the same level as the kidneys, contrary to facility policy, risking urine backflow and potential infection.
The facility failed to act on a pharmacist's recommendation for an A1C blood test for a resident with type 2 diabetes and psychosis. Despite the recommendation, no A1C test was performed from January to May, potentially compromising the resident's health. The facility's policy requires acting on and documenting pharmacist recommendations, which was not done in this case.
A facility failed to ensure the safe keep of medications when an LVN left medications unattended on a medication cart in an open hallway while taking a resident's blood pressure. The DON confirmed that medications should not be left unattended as it poses a risk of other residents or visitors taking them, potentially causing harm.
The facility failed to document a resident's influenza and pneumococcal vaccine administration in the Immunization Record and did not monitor the resident for side effects post-vaccination as required by the facility's P&P. The resident, admitted with colon cancer and intact cognitive skills, reported soreness after the influenza shot, but no documentation or monitoring was found in the clinical record.
Failure to Address Pharmacist MRR Recommendations
Penalty
Summary
The facility failed to ensure that the physician reviewed and responded in a timely manner to medication regimen review (MRR) irregularities identified by the consultant pharmacist for three residents. The report states that the facility’s policy required the attending physician to review and respond to the pharmacist’s MRR, document any actions taken, and that if no timely or adequate response was provided, the consultant pharmacist would contact the medical director or administrator. For one resident with COPD, schizoaffective disorder, and schizophrenia, the order summary showed Benadryl 50 mg at bedtime for pruritis. The consultant pharmacist’s MRR noted that diphenhydramine has anticholinergic properties and is not recommended for use in the elderly population, and suggested assessing whether the regimen remained clinically warranted and documenting a risk-versus-benefit assessment if continued. The DON stated the 3/17/2026 MRR was not addressed, and the resident’s progress notes did not show physician notification or follow-up. The DON stated the MRR should have been addressed within 72 hours. For another resident with schizophrenia, right-sided hemiplegia and hemiparesis, and GERD, the order summary showed lamotrigine 125 mg at bedtime for mood disorder manifested by angry outbursts. The consultant pharmacist’s MRRs stated that Lamictal is an anticonvulsant with a side effect profile different from an antipsychotic and recommended updating side effect monitoring to reflect anticonvulsant monitoring. The DON stated the resident’s chart did not show anticonvulsant side effect monitoring or documentation explaining why the recommendation was not followed, and stated the recommendation was not carried out. For a third resident with protein calorie malnutrition, osteoporosis, and dementia, the order summary showed ergocalciferol 50,000 units weekly. The consultant pharmacist’s MRR noted the most recent vitamin D level was greater than 150 and recommended considering discontinuation because laboratory results had normalized and high-dose therapy may no longer be warranted. The DON stated there was no documented physician notification in the progress notes addressing the MRR and that the physician was not notified within 72 hours after the review. The DON also stated that not following the recommendation could result in increased calcium, nausea, vomiting, and weakness for the resident.
Kitchen Food Handling and Sanitation Deficiencies
Penalty
Summary
The facility failed to follow proper food handling practices in the kitchen by not consistently labeling food items with the item name and use-by date, not keeping the refrigerator temperature log updated every shift, and not discarding expired food. During observation and interview, meat in the refrigerator was found labeled only with the received date and a use-by date of 4/30/2026, and the Dietary Supervisor stated the ground beef had been pulled out on 5/3/2026 and was not labeled with the food name and the correct use-by date while it was thawing in the refrigerator. The Dietary Supervisor also reviewed the refrigerator temperature log and confirmed that the morning temperature entries for 5/3/2026 and 5/4/2026 were missing. Expired food was also observed in the kitchen. During observation with the Dietary Supervisor, mashed potatoes were found on the kitchen counter with a use-by date of 4/31/2026, and the Dietary Supervisor told the Dietary Aide that the item needed to be discarded. The Dietary Supervisor stated that food items should be labeled with the product name and use-by date, and that thawed food should be labeled and used by the third day. The Dietary Supervisor also stated that food beyond the use-by date needed to be discarded because of the growth of germs and bacteria. The kitchen floor was observed to be wet with puddled water, including water overflowing from the dishwashing machine strainer and leaking onto the floor. The Dietary Aide stated the floor gets wet when dishes are washed in the sink, and the Dietary Supervisor confirmed the floor was wet because water was coming out from the washing machine strainer. The Maintenance Supervisor later observed that the ice machine drainage pipe went directly into the floor and did not have an air gap, stating the pipe was supposed to have an air gap and that it was needed to prevent backflow of bacteria into the ice machine. The Infection Prevention Nurse stated that food and utensils could become contaminated from splatters of water on the floor when water overflowed onto the kitchen floor, and that stagnant water could support bacterial growth.
Improper Dumpster Garbage Disposal
Penalty
Summary
The facility failed to ensure garbage was properly disposed of in accordance with its policy and procedure titled, Food-Related Garbage and Refuse Disposal. During a concurrent observation and interview on 5/4/2026 at 8:30 AM with the Dietary Supervisor in the facility parking lot, two dumpsters were observed overfilled with trash bags and left uncovered. The Dietary Supervisor stated the dumpsters were supposed to be covered with lids and that they should be covered to prevent infection control. A record review of the facility’s policy and procedure dated 1/26/2026 indicated that outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.
Laundry Temperature Monitoring and Linen Processing Failure
Penalty
Summary
The facility failed to obtain an accurate water temperature reading and ensure that one load of soiled linens was washed at 160°F for a minimum of 25 minutes in Washer 2, as required by the facility’s laundry policy. During observation in the laundry room, Laundry Staff 1 stated the thermometer attached to the hot water line behind Washers 1 and 2 read 120°F, while the water heater gauge in the boiler room was set at 160°F. Laundry Staff 1 also stated the temperature readings from the hot water line thermometer and the water heater gauge should be the same, and that the washers’ temperature should be at 160°F. Record review and interview showed the dryer temperature log for Dryer 1 contained recorded temperatures even though Dryer 1 did not have a built-in thermometer or temperature gauge. Laundry Staff 1 stated the temperatures for Dryer 1 had been copied from previous logs without actually measuring them, and the Maintenance Supervisor confirmed that recording temperatures without measuring them was not acceptable and was not accurate. The Infection Prevention and Control Nurse stated the laundry policy required high-temperature processing of linens in water at least 160°F for a minimum of 25 minutes, and that the observed temperatures of 120°F, 148°F, 120°F, and 160°F did not follow the policy. The Administrator stated there was no specific facility policy addressing washer and dryer temperature and time settings or documentation of temperatures for washers and dryers.
Advance Directive Information Not Documented
Penalty
Summary
The facility failed to ensure that advance directives were discussed and written information was provided to one resident reviewed for advance directives. Resident 7 was admitted with diagnoses including schizophrenia, right-sided hemiplegia and hemiparesis, and GERD. The quarterly MDS dated 4/3/2026 indicated the resident had severely impaired cognitive skills for daily decision making and required assistance with oral and personal hygiene, toileting hygiene, self-bathing/showering, and lower body dressing. During interview and record review, the resident’s Advance Healthcare Directive Acknowledgment Form dated 3/3/2026 did not indicate whether the resident’s RP received information about the right to make an AHCD, whether the resident had an AHCD, or whether the RP wanted information about formulating an AHCD. The DON stated the form should have been completed upon admission so staff would know whether the resident had an advance directive and that information to formulate one was given to the RP, per facility policy. The SSD stated the acknowledgment form needed to be completed and signed by the resident or RP to show whether the resident had an advance directive and/or wanted additional information to make one.
Failure to Report Significant Weight Loss to Physician
Penalty
Summary
The facility failed to notify the physician of a change in condition related to weight loss for one resident who was admitted with diagnoses including protein-calorie malnutrition, thrombocytopenia, and dementia. The resident’s care plan identified risk for altered nutritional status due to medication effects, malnutrition, need for assistance with meals, and dementia, and it directed staff to weigh the resident per policy, notify the physician of changes, and monitor weights. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and dependence for eating, toileting hygiene, and bed mobility. The resident’s weight summary showed a weight of 123.0 lbs on 4/1/2026 and 116.0 lbs on 5/4/2026, a loss of 7 lbs or 5.69% in 30 days. During interview and record review, the RNA stated he did not inform the charge nurse of the 7-lb weight loss after obtaining and recording the weight, and the LVN stated there was no documented evidence that the weight loss was assessed, monitored, or reported to the physician. The DON stated the physician should have been notified right away when there was a weight loss of 3 lbs or more within 30 days.
Failure to Provide Medicare Coverage Notice and ABN
Penalty
Summary
The facility failed to ensure that one sampled resident, who was admitted with encephalopathy, Alzheimer's disease, and dementia and had severely impaired cognitive skills for daily decision making, was informed of changes in Medicare coverage and provided the SNF Advanced Beneficiary Notice (ABN) when Medicare Part A skilled services were ending. The resident's record identified the responsible party as the decision maker, and the SNF Beneficiary Notification Review form showed the Part A skilled services episode began on 1/5/2026 and the last covered day ended on 3/16/2026, but the SNF ABN form was not provided to the responsible party. During interview, the Business Office Manager stated she called the responsible party once to discuss the ending Part A coverage and left a voice message, but did not follow up and did not send a copy of the SNF ABN. She also stated there was no address on file for the responsible party, although she believed there should have been an address available to send the information. The facility policy stated that written notices of the likelihood of Medicare payment denial are to be provided to the resident or beneficiary as soon as the facility determines Medicare payment probably will not be made and before the item or service is furnished.
Missed Restorative Nursing Services for Resident with Contractures
Penalty
Summary
The facility failed to provide Restorative Nursing Services for one resident with multiple contractures and limited range of motion. The resident was admitted with diagnoses including muscle wasting and atrophy, and contractures of the left knee, left shoulder, right shoulder, left elbow, and right elbow. A joint mobility screening documented severe loss of mobility in both knees and the right elbow, with moderate loss in the left elbow, and the resident’s care plan identified altered joint mobility with interventions for range of motion exercises and positioning to prevent further contractures. The resident’s orders included RNA services for passive range of motion exercises to both upper and lower extremities in all planes as tolerated five times per week, and application of splints to both knees five times per week for four hours or as tolerated. The documentation survey report for March and April 2026 showed 10 missed treatments for these ordered restorative services across multiple weeks. The missed treatments included several missed sessions in weeks 2 and 3, and additional missed treatments in weeks 4 through 7. During interview and record review, the RNA stated the missing documentation meant the restorative services were not provided and that there were no notes explaining the missed treatments. The DOR stated the resident had multiple contractures and that RNA services performed according to the physician’s order were needed to maintain the resident’s joints and quality of life. The DON stated RNAs needed to document completion of the services and that if there was no documentation, the treatment was not done for the resident.
Failure to Care Plan for Wandering Risk
Penalty
Summary
The facility failed to follow its policy to develop and implement a care plan with strategies and interventions to maintain the safety of a resident who was assessed as at risk for elopement/wandering. Resident 36 was admitted with diagnoses including dementia, unspecified psychosis, and adult failure to thrive. The resident’s elopement risk evaluation dated 4/18/2026 identified the resident as at risk for elopement/wandering and listed frequent visual checks as an intervention. The MDS dated 4/24/2026 indicated severely impaired cognitive skills for daily decision making and need for assistance with eating, oral and personal hygiene, and toileting hygiene. The resident’s care plan dated 4/30/2026 addressed hallucinations with an intervention for staff to intervene as necessary to protect the rights and safety of others, but the electronic medical chart reviewed from 4/18/2026 through 5/7/2026 did not indicate a care plan developed for wandering/elopement. On 5/4/2026, Resident 36 was observed entering Resident 28’s room, approaching the bedside while Resident 28 slept, picking up shoes from the nightstand, and speaking to Resident 28 while leaning on the bed. Staff interviews confirmed Resident 36 had a pattern of wandering and asking where her son was, and the DON stated the resident was assessed to be at risk for wandering/elopement and should have had a care plan with implemented interventions.
Failure to Document Meal Intake for Resident With Weight Loss
Penalty
Summary
The facility failed to provide nutritional care and services for one sampled resident with dementia, dysphagia, GERD, and metabolic encephalopathy by not monitoring and documenting meal intake in accordance with the care plan. The resident’s nutrition assessment identified a weight goal of 125 pounds or greater and a plan to monitor the adequacy of oral intake. The RD/IDT weight review later noted significant weight loss likely related to variable PO intake, and the care plan directed staff to provide the ordered diet, monitor intake, and record each meal. The resident’s MDS showed severely impaired cognitive skills for daily decision making, setup or clean-up assistance with eating, and swallowing disorder symptoms including coughing or choking during meals, holding food in the mouth, and loss of liquids or solids from the mouth. The resident’s weight decreased from 127 pounds to 113 pounds, reflecting severe weight loss. A record review found missing documentation of PO intake for multiple meals in April and May 2026, and LVN 2 confirmed there was no documented intake for those meals and that it should have been documented. The DON stated meal intake should have been monitored and documented every shift, and facility policy required nursing staff to monitor and document weight and dietary intake in a format that permits comparison over time.
GT Feeding Not Properly Connected Before Pump Restarted
Penalty
Summary
The facility failed to ensure that one sampled resident with a gastrostomy tube received GT feeding in accordance with the physician’s order. Resident 5 was admitted with diagnoses including protein calorie malnutrition, gastrostomy, and dementia, and the MDS dated 2/18/2026 indicated severely impaired cognitive skills, dependence for eating and multiple activities of daily living, and receipt of 51% or more of nutrition and 501 cc through a feeding tube. On 5/4/2026 at 12:24 PM, Resident 5 was observed lying in bed with the tube feeding pump on, but the GT feeding was not connected to the resident’s GT and the enteral formula was spilling to the floor. During the concurrent observation, LVN 2 confirmed the pump was switched on, not connected to the resident, and the formula was spilling to the floor. LVN 2 later stated that another nurse may have disconnected the feeding before the resident went for a shower and may have restarted the pump without checking that the tube was securely connected, which did not follow the facility’s enteral tube feeding procedure requiring verification of tube placement and connection before starting feeding.
Continuous Oxygen Not Maintained as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for one sampled resident who had a physician's order for continuous oxygen at 4 liters per minute via nasal cannula to keep oxygen saturation above 92%. The resident had a history including hemiplegia and hemiparesis following cerebral infarction and was assessed as having severely impaired cognitive skills for daily decision making, with extensive assistance needed for multiple activities of daily living. During observation, the resident was found awake in bed without the nasal cannula on his nostrils while the oxygen concentrator was powered on and the cannula and tubing were inside a clear plastic bag. The resident stated he needed oxygen and it was hard to breathe. When the DSD assessed the resident, the oxygen saturation was 88%, and the DSD confirmed that the oxygen order was continuous and that the cannula was not on the resident's nostrils. The DSD stated the order for continuous oxygen was not followed and that the resident was at risk for change of condition and hospitalization. During later interview and record review, an LVN stated the resident's oxygen had been changed and placed on the resident's nostrils, but after morning care by two CNAs, neither CNA approached him to remove or reapply the oxygen cannula. One CNA stated she removed the cannula before providing a bed bath and placed the cannula and tubing in a plastic bag. The CNAs stated they did not know and were not educated that they could not touch or remove the oxygen cannula. The DON and ADM both stated unlicensed staff cannot remove or put back oxygen devices, and the ADM's reviewed policy stated CNAs may observe and report changes in breathing, ensure the oxygen device stays in place, and never adjust oxygen flow rates.
Failure to Assess and Care Plan PTSD Using Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care for one sampled resident who had diagnoses including PTSD, schizoaffective disorder, and anxiety disorder. The resident’s MDS dated 1/29/2026 indicated intact cognitive skills for daily decision making and no mood or behavior symptoms, but also identified PTSD as a psychiatric/mood disorder. Social service assessments dated 1/22/2026 and 4/28/2026 did not include the resident’s history of trauma or identify stressors that could trigger trauma-related events, and the care plans dated from 1/21/2026 to 5/6/2026 did not include any care plan for PTSD. During interviews, the SSD stated the resident had told her about having PTSD, but she did not document it or complete an assessment. CNA 5 stated he did not know what PTSD was and could not provide the best possible care for the resident with that diagnosis. LVN 2 stated the resident’s care plan should include the history related to PTSD, triggers, and trauma-informed interventions, but there was no specific care plan for PTSD. The DON reviewed the resident’s record and the facility’s Trauma-Informed and Culturally Competent Care policy and stated there was no documentation of an assessment of trauma and triggers or a care plan for PTSD, despite the policy calling for assessment of trauma, identification of triggers, and an individualized care plan developed in collaboration with the resident and family as appropriate.
Medication Given Without Ordered Food
Penalty
Summary
Pharmaceutical services were not provided as ordered for one resident who was observed receiving carvedilol 3.125 mg without food. Resident 42 was admitted with diagnoses including type 2 diabetes, leukemia, and essential primary hypertension. The resident’s MDS dated 2/12/2026 indicated moderately impaired cognitive skills for daily decision making, dependence with toileting, bathing, and personal hygiene, and independence with eating. The order summary showed carvedilol oral tablet 3.125 mg, one tablet by mouth twice a day for essential primary hypertension, with the instruction to give with food, starting 4/10/2026. During an observation on 5/5/2026 at 4:54 PM, LVN 5 administered carvedilol to Resident 42 without food. In an interview immediately afterward, LVN 5 stated she did not give the medication with food, did not see the resident eating, and did not ask when the resident last ate before giving the medication. LVN 5 stated the medication should have been given with food and that it should have been administered once the resident was eating dinner. The DON later stated medications are to be given as prescribed and that carvedilol should have been given with crackers, applesauce, or the dinner tray when ordered with food. The facility policy on administering medications stated medications are to be administered in a safe and timely manner, and as prescribed.
Unlocked Medication Cart Left Unattended During Medication Administration
Penalty
Summary
Medication Cart 1 was observed unlocked and unattended during medication administration on 5/5/2026 while LVN 5 was inside Resident's Room A at 3:48 PM and again while LVN 5 was inside Resident's Room B at 4:22 PM. During interview, LVN 5 stated that per facility protocol the medication cart should be locked every time staff leave it and go anywhere, because anyone could access the medications from an unlocked cart and take them. During interview on 5/7/2026, the DON stated that medication carts must be locked as soon as the nurse's back is turned to the cart to ensure resident safety and prevent residents from accessing medications. Review of the facility's Policy and Procedure titled Medication Labeling and Storage, dated 1/29/2026, showed that medications and biologicals are stored in locked compartments and that carts containing medications and biologicals are locked when not in use and not left unattended if open. Review of the Policy and Procedure titled Administering Medications, dated 1/26/2026, showed that during medication administration the medication cart is kept closed and locked when out of sight of the medication nurse or aide.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the nurse staffing information was updated and posted daily on 5/2/2026 and 5/3/2026, according to its policy. During an observation on 5/4/2026 at 7:49 AM, the staffing information posted at the Business Office door still showed the date of 5/1/2026. During an interview on 5/7/2026 at 2:01 PM, the Director of Staff Development stated she was responsible for posting the daily nurse staffing information and that it was posted on the Business Office door, but she did not work on Saturdays or Sundays, so the staffing information was not posted on 5/2/2026 and 5/3/2026. She stated she updated and posted the staffing once she returned to work on Mondays. The facility policy titled, Posting Direct Care Daily Staffing (nurse staffing informational) Numbers, dated 1/29/2026, required daily posting of nurse staffing data for each shift and stated that within two hours of the beginning of each shift, the charge nurse or designee would compute the number of direct care staff and complete and post the Nurse Staffing information form in the designated location.
Failure to Supervise Exit Door Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent elopement for a resident with known wandering and elopement risk. The resident was admitted with diagnoses including unsteadiness of feet, schizoaffective disorder, and an anxiety disorder, and was assessed on the MDS as having moderately impaired cognitive skills for daily decision-making. The resident’s care plan, initiated on 1/2/2026, identified risk for wandering/elopement based on prior attempts to leave the facility unattended and impaired safety awareness, including an incident on 1/2/2026 when the resident drifted away from a smoking group and was redirected back. The care plan interventions included door monitoring every shift and maintaining a safe, hazard-free environment. An Elopement Risk Evaluation dated 1/2/2026 documented a total score of 9 and noted that the resident had verbally expressed a desire to go home, packed belongings, or stayed near exit doors, and the summary of review stated the resident was at risk for elopement/wandering. On 3/14/2026, the resident was last observed at approximately 8:40 PM sitting in a wheelchair near the nurse’s station while a CNA supervised the front door. At approximately 9:00 PM, the charge nurse went to the resident’s room to administer scheduled nighttime medications and found the resident was not present. Immediate attempts were made to locate the resident within the unit and surrounding areas, but the resident was not found. Staff noted a bus in front of the facility and searched for it as part of the elopement search, but the resident was still not located. The Elopement Incident form indicated that the elopement occurred via the front door, and later documentation showed the resident stated she left through the front door and reported she was going to Oregon. Interviews with staff revealed that the front door did not have an alarm and was supposed to be supervised by staff and locked at night for safety reasons. CNAs and the LVN reported that staff routinely supervised the front door to prevent residents from leaving, and one CNA stated she supervised the front door from 8:00 PM to 8:30 PM on the night of the incident and did not see the resident near the front door or nurse’s station during that time. The LVN reported that when she returned to the nurse’s station after not finding the resident in the room, the resident’s wheelchair was present but the resident was not, and the front door was not supervised by the CNA who had previously been assigned there. The Social Services Director and DON both stated that the front door was to be supervised and monitored by staff to ensure residents’ safety and that it should not be left unattended, with the DON noting that the front door opens directly to a busy street and that the resident would not have been able to leave if the door had been supervised at the time of the incident. Facility policies on wandering/elopements and safety and supervision of residents stated that the facility would identify residents at risk, make the environment as free from accident hazards as possible, and ensure that supervision and interventions to reduce accident risks were implemented. Resident 1 was returned to the facility on 3/15/2026 at 1:15 PM.
Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate documentation of wound care treatments for one of two sampled residents, as required by facility policy and professional standards. Specifically, the Treatment Administration Record (TAR) for a resident with severe cognitive impairment and multiple wounds did not reflect wound care treatments on two separate dates, despite physician orders for daily dressing changes to the left great toe and left fifth metatarsal. The treatments included cleansing with normal saline, application of Betadine, Medi Honey, collagen alginate, abdominal pad, and gauze bandage roll. During interviews, the treatment nurse acknowledged providing the wound care but admitted to forgetting to document the treatments in the TAR. The facility's policy required that all services provided to residents be documented in the medical record with objective, complete, and accurate information, including the date, time, and signature of the individual providing care. Both the DON and Administrator confirmed that wound care treatments should be accurately documented to confirm care was provided as ordered. The lack of documentation resulted in an inaccurate representation of the care provided to the resident and had the potential to cause miscommunication among staff.
Incomplete and Non-Measurable Care Plan Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident to the California Department of Public Health, the Ombudsman, and local law enforcement as required by its own policy and procedure. The resident, who had a history of fluctuating mental status and was cognitively intact at the time of assessment, made allegations of sexual abuse upon readmission to the facility. The resident's family member reported these allegations to the Director of Nursing (DON) and requested to be kept informed of any further abuse allegations. Despite this, the DON stated there were no known allegations of sexual abuse or inappropriate behavior by the resident, attributing any such reports to fabrication. The Administrator also indicated that the resident's abuse allegations were part of their past history. A review of the facility's policy confirmed that all abuse allegations must be reported to the appropriate authorities immediately or within 24 hours, depending on the severity, but this protocol was not followed in this case.
Non-Functional Call Light System Results in Delayed Resident Assistance
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional. The resident, who had diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and schizophrenia, was moderately cognitively impaired and required supervision or assistance with toileting hygiene. During an observation and interview, the resident reported waiting for help for about an hour, stating that the call light was not working. The resident was observed pressing the call light with no audible or visual response, and the call light was noted to have come out of the wall. Further interviews with the Director of Nursing and the Maintenance Supervisor confirmed the importance of a functioning call light system for resident care and safety. Review of facility policy indicated that call lights should be plugged in and functioning at all times. The failure to ensure a working call light system in the resident's room led to a delay in response to the resident's request for assistance.
Failure to Properly Label and Date Food Items in Kitchen and Freezer
Penalty
Summary
The facility failed to ensure that food items were stored in safe and sanitary conditions according to its own policies and procedures. During an observation of the kitchen with the Dietary Supervisor, it was found that an opened container of Creamy Italian Dressing and an opened container of Pancake & Waffle Syrup were labeled only with the delivery or received date, not the required use by date. Additionally, sixteen bags of frozen green vegetables stored in the freezer were not labeled with the name of the food item or the use by date, making it difficult to distinguish between similar items such as green beans and asparagus. The Dietary Supervisor confirmed during interviews that the facility's policy requires all food items in the kitchen, refrigerator, and freezer to be labeled and dated with the use by date to prevent serving expired food and to ensure correct menu items are used. The supervisor acknowledged that the lack of labeling could result in staff using the wrong ingredients and that the facility's policy was not followed in these instances. A review of the facility's policy confirmed the requirement for proper labeling and dating of all stored foods.
Failure to Follow Infection Control Protocols and Proper PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control measures for five of nine sampled residents, as required by facility policy and CDC guidance. Specifically, staff did not consistently don full personal protective equipment (PPE), including N95 respirators, gowns, gloves, and face shields or goggles, before entering rooms of residents who were either COVID-19 positive or under transmission-based precautions due to exposure. Observations revealed that a certified nursing assistant entered the rooms of multiple residents wearing only an N95 mask, without a gown, gloves, or eye protection. Additionally, a housekeeping staff member was observed inside a COVID-19 isolation room wearing only a gown, gloves, and a surgical mask, without the required N95 mask or eye protection. These actions were in direct contradiction to both facility policy and CDC recommendations, which require full PPE for staff entering rooms of residents with suspected or confirmed COVID-19 infection. The residents involved had varying degrees of cognitive and physical impairment, with some being dependent on staff for most activities of daily living. Physician orders and care plans for these residents specifically indicated the need for transmission-based precautions due to either confirmed COVID-19 infection or exposure. Facility signage outside the affected rooms clearly indicated the need for contact and droplet precautions, including the use of gowns, gloves, and appropriate respiratory and eye protection. Despite these clear directives, staff interviews confirmed that the required PPE was not always used when entering these rooms. In a separate incident, a certified nursing assistant left a soiled diaper and dirty clothes on the floor in a resident's room, rather than immediately placing them in appropriate bags and hampers as required by facility policy. Staff interviews confirmed that soiled items should not be left on the floor due to the risk of contamination and cross-transmission. Facility policy mandates that all soiled laundry and personal items be handled as potentially contaminated and placed in designated containers at the point of use. The failure to follow these procedures was acknowledged by both the staff involved and the facility's infection preventionist.
Failure to Respect Resident's Rights and Dignity During Personal Property Handling
Penalty
Summary
Certified Nursing Assistant 4 (CNA 4) failed to provide dignity and respect to a resident by removing personal food items and washing the resident's boots without obtaining permission. The resident, who had moderately impaired cognitive skills for daily decision making but was independent in most activities, reported that she had won several individually packed Moon Pies during facility activities and stored them in her bedside table. CNA 4 cleaned the resident's closet and bedside table, taking the Moon Pies without informing or seeking consent from the resident. The resident expressed that this action was an invasion of her privacy and requested that her belongings be left alone. Additionally, CNA 4 took the resident's boots to be washed despite the resident's explicit refusal. The CNA stated that she noticed the boots were wet and smelled bad, and after the resident declined to have them washed, she reported the odor to the Charge Nurse, who instructed her to take the boots to laundry. The CNA did not inform the resident before removing the boots, which caused the resident distress when she discovered her boots were missing. The boots were returned two days later. Interviews with other staff, including LVNs and the Activities Director, confirmed that the resident was upset by these actions and that staff should have obtained permission before removing personal belongings or food items. Facility policy also required staff to explain procedures, answer questions, and obtain permission before implementing any care or removing resident property. The failure to follow these procedures resulted in a lack of respect for the resident's rights and dignity.
Failure to Provide and Document Restorative Nursing Care for Resident with Limited ROM
Penalty
Summary
The facility failed to provide and document restorative nursing care for a resident with limited range of motion (ROM) and mobility, as ordered by the physician and outlined in the resident's care plan. The resident, who had diagnoses including secondary parkinsonism, type 2 diabetes mellitus, and muscle wasting, was assessed as having severe joint mobility loss in both hips and knees, and was at risk for contracture development. Orders and care plans specified that the resident should receive passive range of motion (PROM) exercises to both upper and lower extremities and have bilateral knee splints applied for four hours, five times a week, or as tolerated. Observations on multiple dates revealed that the resident was not wearing the prescribed knee splints, and staff interviews confirmed that the splints were not consistently applied as ordered. One RNA admitted to forgetting to apply the splints on a specific day, and another stated that the splints were not reapplied after a shower due to a lunch break. Additionally, staff interviews indicated that documentation of the application of splints and provision of PROM exercises was not performed daily as required, but only once a week in progress notes. A review of the resident's documentation for the relevant period showed no evidence that the restorative nursing interventions were provided from 4/1/2025 to 4/8/2025 and 4/10/2025 to 4/13/2025. The Director of Nursing confirmed the lack of documentation and stated that if it was not documented, it was not done. The facility's policy required restorative nursing care to be provided as needed to promote optimal safety and independence, but this was not followed for the resident during the specified periods.
Failure to Verify G-Tube Placement Prior to Water Flush and Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders and facility policy regarding the care of a resident with a gastrostomy tube (g-tube). The resident, who had diagnoses of dysphagia and pneumonia and was assessed as severely cognitively impaired and fully dependent for activities of daily living, had orders requiring that g-tube placement be checked prior to administering formula, medications, or water flushes. The care plan and facility policy also specified that tube placement and gastric residuals should be checked before any administration through the tube. During a medication pass, the LVN was observed pausing the resident's feeding and administering a 50 ml water flush through the g-tube without first verifying tube placement as required. Only after the flush was given did the LVN attempt to check tube placement by pushing air through the tube and listening for a sound in the abdomen. The LVN acknowledged not checking placement prior to the flush and was under the impression that either checking for residual or listening for a sound after air injection was sufficient. Interviews with the Director of Nursing (DON) and review of facility policies confirmed that tube placement should be verified before any flush or medication administration, and that checking residuals is also necessary to assess feeding tolerance. The facility's written procedures emphasized the importance of these steps to ensure safe administration and prevent complications. The failure to follow these protocols constituted a deficiency in providing appropriate care for a resident with a feeding tube.
Failure to Post Oxygen in Use Sign for Resident on Continuous Oxygen Therapy
Penalty
Summary
The facility failed to post a No Smoking/Oxygen in Use sign outside the entrance door of a resident's room who was receiving continuous oxygen therapy, as required by the facility's policy and procedure. The resident had a history of respiratory disorders, dyspnea, and atelectasis, and was admitted with orders for continuous oxygen at 2-3 liters per minute via nasal cannula or face mask. Observations confirmed that the resident was on oxygen therapy, but there was no sign posted outside the room to indicate oxygen use. Interviews with the treatment nurse and the Director of Nursing confirmed that the facility's policy was not followed, and both acknowledged the importance of posting the sign to inform staff and visitors of the oxygen in use. The facility's policy, reviewed during the investigation, specifically required the placement of a No Smoking/Oxygen in Use sign on the outside of the room entrance door and in a designated place over the resident's bed. The absence of the required signage was directly observed and confirmed by staff.
Inaccurate Bowel and Bladder Assessment Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of a bowel and bladder assessment for one resident, as required by its own policy. The resident in question had a history of metabolic encephalopathy and Alzheimer's Disease, was severely cognitively impaired, bed bound, and dependent on staff for all activities of daily living. Multiple records, including the Minimum Data Set (MDS) and Admission/Re-admission Data Tool, consistently indicated that the resident was always incontinent of both bowel and bladder. However, the Bowel and Bladder Assessment for this resident incorrectly documented that the resident always voided appropriately without incontinence. This discrepancy was identified during interviews and record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), both of whom confirmed the assessment was inaccurate and did not reflect the resident's actual condition. The facility's policy required documentation to be objective, complete, and accurate, but this was not followed in the resident's assessment.
Call Light Not Within Reach for Cognitively and Physically Impaired Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including rhabdomyolysis, lack of coordination, and Alzheimer's disease, was assessed as severely impaired in cognitive skills and dependent on staff for most activities of daily living. The resident's care plans specifically required that the call light be kept within reach and that staff respond promptly to requests for assistance. However, during observations, the call light was found hanging against the wall to the left side of the resident's bed and out of the resident's reach. The resident was unaware of the location of the call light, and this was confirmed by a Certified Nursing Assistant who acknowledged that the call light was not accessible to the resident. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed the importance of having the call light within reach to ensure residents can request help when needed. Review of the facility's policy also indicated that the call light should be within easy reach of residents who are in bed or confined to a chair. The failure to follow these care plan interventions and facility policy resulted in the resident being unable to access the call light to request assistance.
Resident Rooms Below Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 13 out of 21 resident rooms met the required minimum square footage of 80 square feet per resident in multiple occupancy rooms. Observations confirmed that rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21 did not meet this requirement, with two-bed rooms ranging from 137.61 to 142.50 square feet (below the 160 square feet minimum for two residents) and four-bed rooms ranging from 283.40 to 294.70 square feet (below the 320 square feet minimum for four residents). Despite these measurements, staff and residents reported that there was sufficient space for mobility, care provision, and necessary furnishings and equipment. A review of the facility's room waiver request indicated that the facility believed the current room sizes were adequate for resident needs and did not adversely affect health and safety. Interviews with nursing staff, including a CNA and an LVN, confirmed that they had enough space to provide safe and proper care in the affected rooms. Residents interviewed from these rooms did not express concerns about room size. The Department indicated it would recommend the room waiver for the identified rooms as requested by the facility.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement. The incident involved a resident who had been admitted with diagnoses including diabetes mellitus type 1, schizoaffective disorder, and anxiety disorders. The resident had modified independence in cognitive skills for daily decision-making and required supervision or assistance with various activities of daily living. The allegation of sexual abuse was made by the resident on March 5, 2025, but the facility did not report it promptly as required by their policy. Interviews with facility staff, including a Licensed Vocational Nurse, the Director of Nursing, the Administrator, and the Director of Staff Development, revealed a lack of adherence to the facility's policy on abuse reporting. The LVN acknowledged the responsibility to report any abuse incidents or allegations to the Administrator and other authorities. The Administrator admitted to not initiating an investigation or reporting the allegation to the State Survey Agency when the facility became aware of it. The Director of Staff Development confirmed that staff are mandated reporters and emphasized the need to report any abuse incidents or allegations within two hours. The facility's policies and procedures on abuse investigation and reporting were reviewed and indicated that all alleged violations involving abuse should be reported immediately, but not later than two hours if the alleged violation involves abuse. The policies specified that reports should be made to the State licensing/certification agency, the local/state ombudsman, the resident's representative, Adult Protective Services, and law enforcement officials. Despite these clear guidelines, the facility did not comply with the reporting requirements, leading to a deficiency in handling the abuse allegation.
Failure to Post Accurate DHPPD Information
Penalty
Summary
The facility failed to post accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD) information in a prominent location accessible to residents and visitors, as required by their policy. On 9/16/2024, it was observed that the DHPPD form was not posted at the facility entrance, and the Director of Staff Development (DSD) admitted to not updating or posting the form for that day. Additionally, the DHPPD forms for the dates 9/8/2024 to 9/12/2024 were incomplete, only showing projected hours without the actual direct service hours. The DSD and the Accounts Payable and Payroll Director (APPD) both acknowledged their roles in this oversight, with the APPD citing illness as a reason for not completing the forms. The facility's policy requires that the DHPPD form be posted within two hours of the beginning of each shift, detailing the number of licensed and unlicensed nursing staff directly responsible for resident care. However, the DSD was preoccupied with other duties, and the APPD, who was working remotely due to illness, did not complete the actual DHPPD forms. The DSD stated that if the APPD is unavailable, she should cover the responsibility, but this was not done. The facility's policy also mandates that previous shift forms be maintained with the current shift form for a total of 24 hours in a single location, which was not adhered to in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach of a resident, identified as Resident 2, which could lead to delayed provision of services and assistance with activities of daily living (ADLs). Resident 2, who was initially admitted with diagnoses including difficulty in walking, lack of coordination, malnutrition, and dementia, was observed without a call light within reach. The resident expressed unawareness of the call light's location, indicating it had been taken away, which posed a risk in case of a fall or need for assistance. During observations and interviews, it was confirmed by multiple staff members, including a Certified Nurse Assistant (CNA1), Licensed Vocational Nurse (LVN1), Registered Nurse (RN), Director of Nursing (DON), and Director of Staff Development (DSD), that the call light was not within reach and was found behind privacy curtains. This was against the facility's policy, which mandates that call lights be within easy reach to ensure timely responses to residents' needs. The staff acknowledged the importance of having the call light accessible to prevent accidents and ensure resident safety.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a fall for one of the residents, who was identified as being at risk for falls due to several factors including dementia, a history of falling, and impaired cognitive skills. The resident required partial to moderate assistance for activities of daily living, including transfers. On the day of the incident, the resident attempted to transfer to bed without assistance, despite a Certified Nurse Assistant (CNA) being present in the room. The CNA did not assist the resident, resulting in the resident falling and sustaining a laceration on her left eyebrow. The resident's care plan included several interventions to mitigate fall risks, such as attaching a call light within reach and placing the resident close to the nursing station for observation. However, the care plan did not specify the need for assistance during bed transfers, which was a critical oversight given the resident's condition and history. The facility's policies required regular assessments for fall risks and appropriate interventions, but these were not adequately implemented in this case. Interviews with facility staff, including the MDS Consultant and the Director of Nursing, revealed that the resident's need for assistance during transfers was known, yet not acted upon. The post-fall evaluation incorrectly assessed the resident as low risk for falls, missing key indicators such as the resident's history of falls. This misassessment contributed to the lack of necessary precautions and supervision, ultimately leading to the resident's fall.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, violating the resident's right to return to the facility. The resident, who had been living at the facility since January 2022, was hospitalized and had a bed-hold order for seven days. Despite the availability of beds, the facility did not allow the resident to return, citing the need for hospice care as a condition for readmission. This decision was made despite the facility's policy allowing residents to return after hospitalization if a bed is available. The resident had multiple medical conditions, including type 2 diabetes, hemiplegia, acute kidney failure, acute respiratory failure, and ALS. The resident was moderately impaired cognitively and required assistance with daily activities. The facility initially agreed to readmit the resident and provided a bed assignment, but later rescinded the offer, stating that the resident needed to be on hospice care due to frequent hospitalizations and the need for isolation upon return. Interviews with facility staff revealed inconsistencies in the facility's bed availability and admission policies. The Business Office Manager stated that empty rooms could be assigned to any resident regardless of gender, while the Administrator and Director of Nursing cited full occupancy and the need for isolation as reasons for not readmitting the resident. The facility's policy indicated that residents could return to their previous room or the first available semi-private room, but this was not adhered to in the resident's case.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged violation of abuse within the required two-hour timeframe and did not notify the California Department of Public Health (CDPH) as per their policy and procedure. The incident involved a resident who reported that a Social Services staff member screamed, yelled, and made hurtful and insulting statements. The resident, who has legal blindness, anxiety disorder, and type 2 diabetes mellitus, reported the incident to the Director of Staff Development (DSD) shortly after it occurred. Despite recognizing the incident as emotional abuse, the DSD did not report it to the Administrator, who is the facility's abuse coordinator, due to being busy with work. The facility's policy mandates immediate reporting of such incidents to the Administrator and other relevant authorities. The Administrator, upon being informed, decided not to report the incident to CDPH, considering it a grievance rather than abuse. The Social Services staff member involved stated that during a conversation with the resident, she suggested that if the facility was not meeting his needs, they could find another place for him, which the resident perceived as a threat. The facility's policy, revised in 2017, clearly outlines the requirement to report all alleged violations involving abuse, neglect, exploitation, or mistreatment immediately, but not later than two hours if the alleged violation involves abuse. This failure to adhere to the policy resulted in the incident not being reported to all necessary entities as required.
Failure to Suspend Staff and Report Alleged Abuse
Penalty
Summary
The facility failed to prevent further allegations of abuse against a Social Services (SS) staff member by not suspending the staff member after an initial alleged violation and not submitting a required 5-day follow-up investigation report to the California Department of Public Health (CDPH). This deficiency was identified during a review of a resident's admission record and interviews with the resident and facility administrator. The resident, who was admitted with diagnoses including legal blindness, anxiety disorder, and type 2 diabetes mellitus, reported that the SS staff member screamed, yelled, and made hurtful statements to him. Despite being informed of the allegation, the facility administrator chose not to suspend the SS staff member and did not submit the investigation report to CDPH as required by the facility's policy. The facility's policy, titled 'Abuse Investigating and Reporting,' revised in July 2017, mandates the immediate suspension of any employee accused of resident abuse pending the outcome of an investigation. It also requires the administrator or designee to provide a written report of the investigation findings to the appropriate agencies, including CDPH, within five working days of the incident. The facility's failure to adhere to these procedures resulted in a lack of evidence that the alleged abuse was thoroughly investigated and posed a potential risk of failing to protect the resident from further abuse.
Failure to Submit Discharge Tracking Forms Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) Discharge Tracking Forms (DTFs) to the Centers for Medicare and Medicaid Services (CMS) within the required 31-day period for two residents. Resident 17, who had multiple diagnoses including type 2 diabetes mellitus, dementia, and hyperlipidemia, was discharged from the facility on December 29, 2023, but the DTF was not submitted. Similarly, Resident 37, who had diagnoses including Huntington's disease, dementia, and acute respiratory failure, was discharged to a General Acute Care Hospital on January 20, 2024, but the DTF was also not submitted. The MDS Consultant confirmed these oversights during an interview on May 4, 2024, stating that the DTFs should have been submitted within 14 days of discharge but were not. A review of the facility's manual and job description for the MDS Coordinator indicated that the Discharge Tracking Forms are essential for tracking resident movements and should be submitted no later than 31 days after discharge. The manual specifies that these forms are crucial for providing accurate data to CMS, which uses this information to monitor the quality of care and resident outcomes. The failure to submit these forms as required could lead to inaccuracies in the facility's quality indicators and care area concerns for review.
Failure to Discard Expired Ground Beef
Penalty
Summary
The facility failed to remove and discard ground beef from the refrigerator after it was past the use-by date according to the facility's policy and procedure titled, Refrigerators and Freezers. During an observation, interview, and record review, a package of unfrozen ground beef was found in the refrigerator with a label indicating it was for dinner on a specific date. The Meat Thawing Schedule indicated that the ground beef should have been used by a certain date, but it was not discarded even though it was past the three-day limit for thawed meat. The Cook acknowledged that the ground beef was expired and should have been discarded to prevent potential foodborne illnesses among residents. In an interview with the Dietary Supervisor, it was confirmed that kitchen staff are responsible for placing frozen meat in the refrigerator to thaw and that thawed ground meats are only good for one or two days. The Dietary Supervisor stated that all thawing meats needed to have a use-by date and that any meat not used by this date should be thrown away to prevent foodborne illness. The facility's policy and procedure indicated that supervisors are responsible for ensuring food items in the pantry, refrigerators, and freezers are not expired or past their perish dates.
Failure to Ensure Informed Consent for Binding Arbitration Agreements
Penalty
Summary
The facility failed to comply with requirements for Binding Arbitration Agreements for three residents. Resident 12 signed an Arbitration Agreement without understanding its meaning, as it was late at night and no one explained it to her. This agreement was signed on the same day she was admitted to the facility, and her cognitive skills were unimpaired according to her Minimum Data Set (MDS). However, she was not informed about the implications of the agreement before signing it. Resident 19's Arbitration Agreement was signed in two conflicting locations, indicating both agreement and refusal to enter into a Binding Arbitration Agreement. This resident was severely impaired in cognitive skills and dependent on staff for all care, as indicated by the MDS. The conflicting signatures on the agreement suggest a lack of clarity and proper explanation during the signing process. Resident 200's Arbitration Agreement was also signed in two conflicting locations, and the signature on the document did not match the resident's other signatures on file. This resident had fluctuating capacity to understand and make decisions, as noted in their History and Physical (H&P) records. The discrepancy in signatures and the resident's statement that they would never agree to such an agreement indicate that the facility failed to ensure the resident's informed consent.
Failure to Sanitize Blood Pressure Cuff Between Uses
Penalty
Summary
The facility staff failed to maintain proper infection control measures by not sanitizing a blood pressure cuff between uses for two residents. During a medication administration observation, a Licensed Vocational Nurse (LVN) used the same blood pressure cuff on two different residents without disinfecting it in between. This action was observed during the care of Resident 34, who had diagnoses including hypertensive heart disease with heart failure and respiratory failure, and Resident 12, who had an immune mechanism disorder and was recovering from surgery for neoplasm removal. The LVN admitted to not sanitizing the blood pressure cuff and acknowledged the importance of doing so to prevent bacterial transmission. The Infection Preventionist (IP) confirmed that staff should sanitize medical devices like blood pressure cuffs between residents' use to prevent the spread of bacteria. The facility's policy, revised in October 2018, also indicated that reusable items should be cleaned and disinfected or sterilized between residents. The failure to follow this policy was identified as a deficiency with the potential to spread communicable diseases among residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, violating their right to be fully informed about their treatment. Resident 44, who was admitted with dementia and psychosis, was prescribed Seroquel without obtaining informed consent from the responsible party. The Infection Preventionist confirmed that there was no informed consent in the medical record, acknowledging that it is required for psychotropic medications due to their impact on the mind, emotions, and behavior. Similarly, Resident 101, diagnosed with anxiety disorder and schizophrenia, was administered quetiapine and lorazepam without informed consent. The resident's medical records and interviews with staff revealed that informed consent was not obtained prior to administering these medications. The facility's policy mandates that informed consent must be obtained from the resident or responsible party before initiating or increasing psychotropic drugs, but this procedure was not followed in these cases.
Call Lights Out of Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call lights were within sight and reach for four residents while they were in bed. Resident 16, who was readmitted with dementia and Parkinsonism, was observed with the call light clipped to the right side of his pillow, out of his sight and reach. Resident 16's cognitive skills were severely impaired, and he was dependent on others for activities of daily living (ADL). This observation was made during a review of Resident 16's Admission Record and Minimum Data Set (MDS), and during an observation in his room on 5/3/2024 at 6:45 PM. Resident 35, admitted with cerebral infarction and encephalopathy, was also found with a call light that was out of reach. During an observation and interview on 5/3/2024 at 6:16 PM, Resident 35 stated needing something but could not reach the call light clipped to the right side of his pillow. The Assistant Director of Staff Development (ADSD) confirmed that the call light cord was too short and stated she would inform maintenance staff to replace it. Resident 35's cognitive skills were severely impaired, and he was dependent on others for ADL but needed only partial/moderate assistance for eating. Resident 41, readmitted with encephalopathy, and Resident 100, admitted with a fracture of the fourth lumbar vertebra and dementia, were also observed with call lights that were out of reach. Resident 41's call light was clipped to the left side of his pillow and was too short to reach him. Resident 100's call light was similarly clipped to the left side of her pillow and was out of her sight and reach. Both residents had impaired cognitive skills and were dependent on others for various ADLs. These observations were made during concurrent observations and interviews on 5/3/2024. The facility's policy and procedure titled 'Answering the Call Light' indicated that the call light should be within easy reach of the resident when they are in bed or confined to a chair.
Failure to Inform Responsible Party About Advance Directives
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident with dementia, who lacked the capacity to understand medical conditions, received information regarding the resident's right to formulate an advance directive. The resident, identified as Resident 38, was admitted with a diagnosis of dementia and was found to be severely impaired in cognitive skills for daily decision-making. Despite this, the Advance Directives Acknowledgement Form (ADAF) was signed by Resident 38, rather than being discussed with the RP as required by the facility's policy and procedure (P&P) on advance directives. During a review of Resident 38's clinical records, it was noted that the ADAF was signed by the resident on 1/22/2024, while the History and Physical (H&P) dated 1/23/2024 indicated that the resident was not competent to understand their medical condition. Further review of the Minimum Data Set (MDS) dated 3/10/2024 confirmed the resident's severe cognitive impairment. An interview with the Social Services Designee (SSD) revealed that there was no documentation showing that the advance directive was discussed with the RP, as required by the facility's P&P. This oversight had the potential to violate the rights of both Resident 38 and their RP to formulate an advance directive.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for Resident 101 within 48 hours of admission, as required by their policy. Resident 101 was admitted with diagnoses including anxiety disorder, schizophrenia, and malnutrition. Despite being able to make decisions for activities of daily living (ADL), Resident 101 was observed to be on contact isolation precautions and dependent on staff for ADL care. Additionally, Resident 101 was receiving nutrition through a gastrostomy tube (G-tube). During a review of Resident 101's clinical record, it was confirmed that no baseline care plan had been initiated or completed within the required timeframe. Licensed Vocational Nurse 2 (LVN 2) confirmed that Resident 101 was dependent on staff for ADL care. Minimum Data Set (MDS) Consultant 2 also confirmed the absence of a baseline care plan during a concurrent record review and interview. The facility's policy and procedure, dated December 2016, mandates that a baseline care plan must be developed within 48 hours of a resident's admission to meet their immediate needs. The failure to develop this plan had the potential to result in Resident 101 not receiving adequate and appropriate care.
Improper Positioning of Nephrostomy Bag
Penalty
Summary
The facility failed to ensure proper positioning of a nephrostomy bag for Resident 26, who was readmitted with acute kidney failure and an infection related to the nephrostomy catheter. During an observation, it was noted that the nephrostomy bags were placed on the bed next to the resident at the same level as the kidneys, which is against the facility's policy. This improper positioning was confirmed by LVN 3, who acknowledged that the bags should be placed below kidney level to prevent urine backflow and potential infection. Further interviews revealed that the Director of Nursing (DON) also confirmed that the nephrostomy bags should be positioned below kidney level to ensure proper drainage and prevent infection. The facility's policy, revised in October 2010, clearly states that the drainage bag should be below the level of the kidneys. This deficiency in care had the potential to cause significant health issues for Resident 26, including infection and inflammation of the kidneys.
Failure to Act on Pharmacist's A1C Test Recommendation
Penalty
Summary
The facility failed to act upon the pharmacist's recommendations for an A1C blood test for a resident with type 2 diabetes and psychosis. The pharmacist had recommended monitoring the A1C levels on the next convenient laboratory day and then every 3 to 6 months, depending on the treatment goals. However, a review of the resident's laboratory results from January to May revealed that no A1C test was performed during this period. The Infection Preventionist confirmed that the facility did not follow the pharmacist's recommendation, which is crucial for ensuring the resident receives the correct dose of blood sugar control medications. The resident's Minimum Data Set indicated that the resident had clear speech, sometimes understood others, and sometimes made themselves understood. Despite these communication abilities, the facility did not act on the pharmacist's recommendation, potentially compromising the resident's health. The facility's policy and procedure require that recommendations from the consultant pharmacist be acted upon and documented, but this was not done in this case, leading to a deficiency in care for the resident with diabetes.
Unattended Medications in Hallway
Penalty
Summary
The facility failed to ensure the safe keep of medications when a Licensed Vocational Nurse (LVN) left medications unattended during a medication administration observation for a resident. The incident occurred when the LVN took out six medications for the resident and placed them in medication cups on top of a medication cart. The LVN then left the medication cart unattended in the hallway, which was an open area with residents and visitors passing by, while the LVN went into the resident's room to take their blood pressure. The medication cart was out of the LVN's sight during this time. During interviews, the LVN acknowledged that the medications should not have been left unattended and that anyone passing by could have taken the medications, potentially causing harm. The Director of Nursing (DON) confirmed that licensed staff should not leave medications unattended in open areas, as it poses a risk of other residents or visitors taking the medications, which could lead to adverse reactions and harm to their health. A review of the facility's policy on the storage of medications indicated that drugs and biologicals should be stored in locked compartments under proper conditions.
Failure to Document and Monitor Vaccinations
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) for Influenza and Pneumococcal Vaccination for one of five sampled residents by not ensuring that the resident's vaccine administration was recorded in the Immunization Record and that the resident was monitored for side effects after receiving the vaccines. Specifically, Resident 12's influenza and pneumococcal vaccine administration were not documented in the Immunization Record, and there was no evidence that Resident 12 was monitored for side effects every shift for 72 hours post-vaccination as required by the facility's P&P. Resident 12, who was admitted with a diagnosis of colon cancer and had intact cognitive skills, reported receiving an influenza shot and experiencing soreness in the shoulder. However, the Infection Prevention Nurse (IPN) and Registered Nurse 1 (RN 1) confirmed that there was no documentation of the vaccine administration or monitoring for side effects in the resident's clinical record. The facility's P&P for Influenza and Pneumococcal Vaccination required documentation of vaccine administration and monitoring of the resident's response, which was not followed in this case.
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.
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What surveyors actually found near you
We read the 6,171 citations issued within 25 miles in the last 12 months — including the 29 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 Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pasadena Grove Health Center | 0.1 mi | ★★★★★ | 25 | 0 |
| Pasadena Nursing Center | 0.1 mi | ★★★★★ | 27 | 0 |
| Cedar Pine Post Acute | 0.2 mi | ★★★★★ | 11 | 0 |
| Saint Vincent Healthcare | 0.4 mi | ★★★★★ | 15 | 0 |
| Brighton Care Center | 0.4 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.