Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fortuna Rehabilitation And Wellness Center, Lp during CMS and state inspections, most recent first.
Failure to follow standardized recipes during meal prep affected meals for 87 residents and resulted in food described by residents and a family member as bad, tough, and lacking variety. Staff prepared frozen chicken in a convection oven, made pureed bread and potatoes by sight with unmeasured ingredients, omitted seasonings from vegetables, and prepared fish and potatoes inconsistently with the written recipes. The CDM stated he misread one recipe and was cooking by visual consistency rather than exact measurements.
Unsanitary Kitchen Conditions and Improper Food Storage: Dietary staff failed to maintain a sanitary kitchen and properly store food. A CK wore a cap with exposed hair and no hairnet, the floor, mats, shelves, handwashing sink, recipe holder, and shelf above the prep area were dirty, and expired or improperly dated food was found in the refrigerator, including produce, shredded coconut, pudding, a chef salad, and a resident's cereal.
Improper Trash Storage and Overflowing Dumpsters: Trash dumpsters were observed open because they were overfilled, and a bag of rubbish was left on the ground next to the bins. The CDM stated the covers should be closed at all times and that rodents could move in, while the ADM observed staff throwing the rubbish into a dumpster and said it did not meet expectation. The facility policy required containers to be closable and food waste to be placed in covered garbage and trash cans.
Infection prevention and control failures included staff not offering hand hygiene before meals, improper glucometer disinfection, an unavailable IPCP binder with no documented annual review, dusty oxygen concentrators and filters, and a coughing resident with pneumonia/COPD who was not placed on source control precautions while sharing a room with roommates. CNAs and an IP confirmed hand hygiene was expected before meal trays, an LPN used the wrong cleaning process for a glucometer, and the DON and IP acknowledged concerns with the dirty oxygen equipment.
Failure to Develop Care Plan for Pressure Ulcer: A resident with diabetes and severe protein-calorie malnutrition had a coccyx pressure ulcer that was observed during a wound dressing change and had recently progressed from an unstageable wound to a Stage 4 ulcer. Review of the care plan showed no plan for the pressure ulcer present on admission, and the DON confirmed licensed nurses had not initiated a care plan upon readmission.
A resident with bipolar disorder and anxiety disorder had an outdated care plan that was not revised after IDT discussions about behavior management, distress related to increased assistance and rehab placement, and social isolation. The IDT planned psychotherapy to reduce depressive and anxious symptoms, but the MDS Nurse and SSD could not find an updated care plan reflecting that intervention or evidence that a psychotherapy referral had been initiated.
The DON and Consultant Pharmacist failed to ensure controlled medications ready for destruction were securely stored when 30 hydrocodone tablets and 19 hydromorphone tablets were found missing from the locked medication box. The DON stated she was the only person with keys, but the file cabinet lock was broken, the internal lockbox was not fully closed, and the office door did not meet double-lock requirements; she also demonstrated the lock box could be opened with a spoon if not firmly engaged.
Failure to Obtain Valid Informed Consent for Psychotropic Medications: A resident with multiple mental health diagnoses had psychotropic medication consents signed by an RP even though the resident was his own RP and could answer for himself, and two consent forms did not even identify the drug name. Another resident was started on lorazepam without documented informed consent, and a third resident received mirtazapine and lorazepam before consents were obtained. The DON confirmed the consents were invalid or obtained after medication administration.
Inaccurate admission MDS documentation led to two residents' hearing and vision needs being misrecorded. One resident with COPD, Parkinsonism, and schizoaffective disorder said he wore hearing aids, but the MDS and care plan did not reflect this. Another resident with CHF, COPD, and pneumonia had a hearing aid listed in the inventory and was observed wearing glasses, yet the MDS and care plan did not document hearing aid or corrective lens use. The MDS Nurse acknowledged the errors.
Failure to Coordinate Hospice Care Plan: Licensed nurses did not ensure communication of hospice care needs between facility staff and the hospice provider for a resident admitted on hospice with adult failure to thrive and dementia. The hospice binder had no hospice care plan, the DON stated the care plan was not received and was not followed up on, and the hospice agency reported that the face sheet, POC, med list, initial admin note, initial orders, and CTI were faxed to the facility.
A resident with severe dementia eloped from the facility and was found walking on a public sidewalk outside the building before being redirected back inside. The DON said staff were unfamiliar with the newly admitted resident and mistook her for a visitor, while the Case Manager stated the resident had a high elopement risk score, no signaling device was applied, and the elopement care plan was not completed until after the incident.
A resident with cognitive decline, gait abnormalities, and documented high fall risk experienced multiple falls while the facility failed to implement and document key fall risk and post-fall care plan interventions. Despite repeated falls and high fall risk scores, required measures such as q2h location checks, q2h toileting while awake, a documented root cause analysis of prior falls with education to the care team, and a PT eval ordered after a serious unwitnessed fall were not supported by documentation. The Administrator confirmed that records of these interventions could not be located, contrary to the facility’s person-centered care planning policy.
A resident with dementia, major depressive disorder, PTSD, and suicidal ideations, and a moderately impaired BIMS score, was struck twice in the shoulder by another resident, triggering a change in condition. Subsequent notes documented that the resident expressed uncertainty about being hurt versus upset and later reported ongoing distress and worry that the other resident would continue to bother him. Although a COC was initiated, the DON confirmed that 72-hour monitoring notes were not documented every shift as required, and completion of the monitoring could not be verified, contrary to facility policy requiring licensed nurse documentation each shift for at least 72 hours after a change in condition.
A resident receiving palliative care with CHF, muscle weakness, hearing loss, and a left below-knee amputation, and with slight memory impairment per MDS, was subjected to verbal abuse by a CNA during a shower. The CNA was overheard yelling and swearing at the resident, who was visibly bothered and later reported disliking how he was treated. The resident’s care plan documented that he was a victim of alleged abuse, with the CNA having called him a derogatory name, in violation of the facility’s abuse prevention policy that prohibits verbal abuse and the use of disparaging or derogatory terms toward residents.
A resident with palliative care needs, CHF, muscle weakness, hearing loss, and a left below-knee amputation was involved in an alleged abuse incident, but staff did not follow the facility’s abuse policy. The DON reported that LNs were expected to complete and document a change of condition assessment, notify the MD and family, update the care plan, and perform 72-hour monitoring with alert charting and psychosocial documentation, with Social Services also conducting daily psychosocial follow-up. Record review and interviews showed that no assessment, progress notes, or required 72-hour checks by nursing or Social Services were documented, despite written policies and lesson plans directing these actions.
A resident with chronic kidney disease had her call light and bed remote removed by an LN while in her room because she was repeatedly adjusting her bed and pressing the call light. The LN documented the removal in a nursing note, indicating an expectation that the behavior would stop. In an interview, the DON stated this action was inappropriate, affirmed that the call light and bed remote were considered the resident’s personal property, and identified the incident as a resident rights issue. Review of the facility’s Resident Rights policy showed staff are required to treat residents with kindness, respect, and dignity and to honor residents’ exercise of their rights, which did not occur in this case.
A resident with significant medical conditions reported severe pain and feeling abused during a treatment performed by a nurse, who did not stop when asked. The incident was documented and reported internally, but the facility failed to submit the required abuse report to authorities within the mandated two-hour window, as confirmed by staff interviews and policy review.
Incorrect Oxycodone Dose Administered: A resident with dementia and asthma received the wrong oxycodone dose when an LPN gave a 20 mg tablet that belonged to another resident instead of the ordered 5 mg dose. The nurse verified the resident on the MAR but did not check the medication itself, and the DON confirmed the wrong tablet was popped from the other resident’s bubble pack.
RN coverage was not maintained as required. A review of staffing records showed no RN worked on multiple days, and the ADM acknowledged the facility was struggling to find RNs and could not admit residents needing procedures only an RN could perform. Facility policy required at least one RN awake and on duty at all times in addition to the DON.
Failure to provide baseline care plan summaries and medication lists within 48 hours of admission. Three cognitively intact residents, each acting as their own RP, had baseline care plans completed by the MDSC with blank signature areas, and none could confirm receiving a reviewed copy of the care plan and med list. One resident had pneumonia, alcohol dependence, and DM2; another had metabolic and Wernicke’s encephalopathy with rectal cancer; and the third had epileptic syndrome, DM2, and an intestinal obstruction.
Incomplete Care Plans and Missing Discharge Planning: The facility failed to develop care plans for a resident receiving O2 and RNA services, and failed to initiate discharge care plans for three newly admitted residents after their initial IDT care conferences. One resident had diagnoses including discitis, osteomyelitis, CHF, and DM2, while the others had conditions including pneumonia, alcohol dependence, encephalopathy, cancer, epileptic syndrome, and intestinal obstruction. Staff interviews confirmed the missing care plan elements and discharge planning gaps.
Medication storage was not maintained in a clean, safe, and orderly manner. An LPN left a prepared dose of crushed medication mixed with pudding in Med Cart 4 and loose pills were found in the cart drawers, while Med Cart 1 was observed unlocked and unattended in two locations. The DON confirmed prepared meds should not be stored in the cart, loose pills should be removed, and carts should be locked when unattended.
Failure to Honor Resident Food Preferences: A resident with rectal cancer and two other residents were served foods listed as dislikes on their meal cards, including raw fruits and vegetables, carrots, and cauliflower. The resident with cancer stated she kept receiving raw fruits and vegetables despite knowing she was not supposed to have them, while the other residents said they would not eat or would pick out the disliked items. The RRD stated the items should not have been served and that dietary staff should have checked trays against meal cards; the RD stated the CDM was responsible for ensuring preferences were honored and updated.
A resident’s BSC was observed soiled with a brown substance and not kept in a clean, sanitary condition, despite staff stating it should be cleaned and disinfected after each use. A metal ice scoop on a hydration cart was left exposed instead of being stored in a closed container, and a CNA used the same vital sign machine for multiple residents without disinfecting it between uses. The IP nurse and DON acknowledged the expected infection control practices were not followed.
Pest Control Program Not Effective: Flies were observed throughout the facility, including in the Garden Dining Room during lunch, in a resident's room, and in the kitchen. The Garden Dining Room door to the patio was left wide open without a screen, allowing easy access for flies to enter, and staff noted flies in the kitchen were an infection control issue when near food prep areas. The ADM stated warm weather had brought flies, but the facility's pest control program was not effective in keeping the building free of pests.
Failure to timely report and investigate multiple abuse allegations. The facility did not notify CDPH within the required 2 hours or submit investigation summaries within 5 working days for several incidents involving resident-to-resident altercations, resident-to-staff allegations, and staff-to-resident allegations. Incidents included a resident breaking another residents’ belongings, a resident throwing water at another resident, a CNA yelling at a resident about incontinence, a resident slapping another resident, a CNA allegedly telling a resident to urinate in her brief, and a CNA allegedly hurting a resident during personal care. The ADM stated several reports were late because they were sent to an incorrect email address.
A resident with dementia, depression, anxiety, and metabolic encephalopathy received haloperidol and quetiapine with inadequate indications listed as stroke/TIA and stroke/TBI. The PharmD consult and MD both stated the indications were not proper, while staff observed the resident repeatedly sleeping in bed or dozing off in a wheelchair, and the RP reported the resident had slowed down and been sleeping more over the past 6 months.
A resident with multiple chronic conditions, including DM2, hypothyroidism, CHF, CKD, and malnutrition, lost 9.8 lbs in one month and the weight change was not timely reported or addressed. Although the care plan and facility policy required nursing to monitor and report significant weight loss to the MD, RD, and DON, the chart showed no documented notification for several days after the weight loss was identified, and the nutrition assessment was delayed. Interviews confirmed staff expected the RNA to report the loss to nursing, and nursing to notify the MD and RD, but this did not occur when the weight variance first triggered.
The facility failed to keep routine and emergency meds available. A resident with chronic pain syndrome missed scheduled buprenorphine-naloxone doses because the medication was unavailable, and the DON and PharmD confirmed the refill process had not prevented the shortage. In addition, oral and insulin e-kits were found opened without proper internal documentation, and staff did not follow the expected 72-hour replacement process for emergency kits.
A resident with Alzheimer’s disease, DM2, protein calorie malnutrition, and dysphagia was placed on a liquified pureed diet and observed being fed liquified foods through a straw from mugs. The RP said the diet was unappetizing and lacked dignity and was concerned about weight loss, while records showed the resident’s weight declined from 107.6 lbs. to 102.6 lbs. The DON, ST, MD, and RD all stated a pureed texture would be more appetizing than a liquified texture, and the facility policy required diet changes and reasons to be explained to the resident and/or RP.
Unsealed Frozen Vegetables in Freezer: Three boxes of frozen carrots, green beans, and corn were found opened and not sealed in the walk-in freezer, with the original plastic bags left open to air inside the cardboard boxes. The CDM stated unsealed frozen items could get freezer burn, and the RD stated she was concerned about possible cross contamination if something spilled inside the bag. The facility policy required frozen foods to be stored in airtight containers or wrapped appropriately.
A resident with cerebral infarction and PTSD had a call light found on the floor and out of reach during observations by CNA and SSD. The resident’s care plan directed staff to keep the call light within reach due to fall risk and impaired mobility, and the DON confirmed call lights should always be accessible. The facility policy also stated call cords will be placed within the resident’s reach.
Failure to Protect Residents from Abuse and Neglect: Staff failed to protect residents from physical and verbal abuse and neglect when one resident slapped another, a resident entered two roommates' room yelling and breaking belongings, another resident threw water at a roommate, and a CNA told a severely cognitively impaired resident to urinate in her brief instead of assisting her to the restroom. The affected residents had significant cognitive and behavioral diagnoses, and records and staff interviews confirmed the incidents and the fear, distress, and inappropriate staff response involved.
Failure to assess a resident for emotional distress after an alleged abuse incident. A resident with CHF, chronic respiratory failure, and muscle wasting reported that a CNA was rough during care, pushed into her shoulder, held her feet down, and leaned on her so hard that she screamed in pain. Another resident heard the screaming, and record review showed no progress notes or care plan entries addressing the allegation, despite the facility abuse policy requiring an LPN assessment for physical injury or emotional distress.
Failure to complete ordered neuro checks after unwitnessed falls. Two residents with significant neuro/cognitive diagnoses had falls, including one with a head injury and hospital transfer. The record showed missing neuro checks for the required monitoring period, despite the facility fall policy calling for 72 hours of neuro checks and a provider order for q30 min checks after return to the facility.
Three residents with mental health or developmental diagnoses did not receive appropriate PASRR evaluations. Despite documented histories of mental illness, cognitive impairment, or developmental delay, PASRR Level 1 screenings were either incorrectly completed or not properly reviewed, resulting in the absence of required Level II screenings. Facility staff acknowledged that errors in hospital-completed PASRRs were common and not always corrected, leading to incomplete assessments for these residents.
Three residents with complex medical conditions did not receive required in-person physician visits at least every 60 days, as only telehealth visits or no visits occurred during the review period. Staff interviews and record reviews confirmed the deficiency, and the facility's administrator acknowledged the issue with the prior contracted physician services.
Licensed nurses did not administer medications on time for two residents, including one receiving palliative care and another with epilepsy, due to severe staffing shortages. Medications were given more than an hour late on multiple occasions, exceeding the facility's policy window. Staff and the DON confirmed that high resident assignments per nurse and failure to meet state staffing requirements made timely medication administration impossible, and a resident reported anxiety and discomfort as a result.
The facility failed to provide adequate staffing to meet residents' wound care needs, resulting in missed treatments for several residents. Interviews and record reviews revealed that treatments were not documented as completed, indicating they were not performed. Staffing challenges, including the absence of a Treatment Nurse, contributed to this deficiency.
A resident with a history of falls and high fall risk was left unsupervised on the toilet by a CNA, resulting in a fall and fracture of the right distal fibula and tibia. The resident's medical history included conditions that increased her fall risk, and her care plan required supervision during toileting. Despite this, the CNA left the resident alone, leading to the incident. Interviews with staff confirmed the need for supervision, which was not provided, resulting in the injury.
The facility failed to report an abuse allegation within the required timeframe after a CNA witnessed a resident hitting another with a shoe. The incident was reported three days late, contrary to the facility's policy requiring a two-hour notification to the Department, Ombudsman, and Law Enforcement. This delay decreased the potential to ensure resident safety and caused a delayed response by enforcement agencies.
A resident fell and broke her arm due to an improperly positioned transition strip at a doorway, which created a trip hazard. The resident was walking without her walker and tripped on the uneven threshold, leading to a fall. Observations confirmed the hazardous condition, and the DON acknowledged the issue, assuming it had been repaired. The facility's safety policy was not effectively followed, contributing to the deficiency.
A resident with Type 2 Diabetes Mellitus and Essential Hypertension did not receive regular showers as scheduled, leading to a missed and infected wound on their shoulder, which developed into sepsis. Despite being dependent on staff for bathing, the resident only received two bed baths in July and none in early August. Facility staff confirmed the lack of documentation and care, acknowledging that shower refusals should be documented. The facility's policies on skin observation during bathing were not followed, contributing to the missed and infected wound.
A resident in a long-term care facility developed an infected wound on the shoulder due to inadequate skin assessments and irregular showering. Despite weekly checks, the wound was not documented or treated, leading to sepsis and hospitalization. Staff were unaware of the wound, and facility policies on skin care and hygiene were not followed.
A resident was administered an extra dose of Oxycodone HCL 5 mg without a physician's order, resulting in a significant medication error. The nurse claimed to have received a verbal order, which the physician could not recall. The facility's policy requires medications to be administered only upon a physician's order.
Failure to Follow Standardized Recipes During Meal Preparation
Penalty
Summary
Dietary staff failed to follow standardized recipes during meal preparation for 87 residents who ate meals from the kitchen on 6/23/26 and 6/24/26. The report states this resulted in unpalatable meals and decreased the facility's potential to prevent malnutrition and weight loss. Residents and a family member described the food as bad, lacking variety, or not very good, and one resident's tray was observed untouched while a CNA stated the resident did not like to eat it. During observation, the CK prepared frozen chicken breasts by placing them directly into a convection oven and stated frozen food could be cooked that way. The CK also prepared pureed bread by adding bread and a milk-and-butter mixture by sight rather than following the recipe, stating he was looking for smoothness and believed the nutritional value was the same regardless of ingredient ratios. The survey team later tasted the baked chicken and found it dry, tough, and without flavor. A family member stated the chicken was super tough, the resident spit it out, and the apples were hard. The CDM was observed preparing scalloped potatoes, pureed scalloped potatoes, Italian Herb Vegetables, Fish Italiano, and mashed potatoes with multiple departures from the recipes. He used unmeasured amounts of potatoes and sauce, added paprika without following the full recipe steps, did not add butter or seasonings to vegetables, and placed frozen fish directly into a pan when there was not enough thawed fish. He also stated he was cooking by sight and looking for consistency. The CDM later stated he misread the fish recipe and acknowledged it could have affected palatability. Facility recipes and policy required standardized recipes, including adjustments for therapeutic and consistency modifications, and the menu system guide directed temperature and time changes for convection ovens.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The dietary staff failed to store, prepare, and maintain food and kitchen areas in a sanitary manner for a census of 87 residents. During an initial kitchen observation, the Certified Kitchen worker was wearing a baseball cap with exposed hair and no hairnet, the kitchen floor and mats were visibly dirty, and the silver storage shelves had dried white matter on the surfaces and legs. The handwashing sink had a brown/yellow substance along the back edge and crusted buildup in the grouting, and the recipe holder had a sticky substance on it. Food splatter was also observed under a shelf above the food preparation station. Expired and improperly dated food was found in the refrigerator, including cut cabbage past its use-by date, greens past their use-by date, an opened container of shredded coconut with dates indicating it was expired, a container of chocolate pudding with conflicting dates, a chef salad without clear dating to show whether it was the preparation date or use-by date, and a resident's cereal that was not dated when opened. The Certified Dietary Manager confirmed the hairnet issue was not common practice, acknowledged the expired food, and stated the sticky recipe holder and dirty sink area needed cleaning. The Registered Dietitian also observed and confirmed the dirty handwashing sink.
Improper Trash Storage and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure trash was stored in a sanitary manner for a census of 87 residents when trash dumpsters were observed overflowing with rubbish and filled rubbish bags were left on the ramp next to the container. On 6/23/26 at 5:46 a.m., the trash dumpster was observed open because it contained too much rubbish. During a concurrent observation and interview on 6/23/2026 at 10:42 a.m., the Certified Dietary Manager stated that the trash bin covers should be closed at all times and that someone should have put the bags in the other container, adding that rodents could move in. The dumpsters were again observed open due to overfilling on 6/24/26 at 6:59 a.m. and 6/26/26 at 7:06 a.m., and on 6/26/26 at 7:06 a.m. a bag of rubbish was observed on the ground next to the trash bins. During a concurrent observation and interview on 6/26/2026 at 7:25 a.m., the Administrator observed maintenance staff throwing the rubbish from beside the bin into a dumpster on security camera and stated that this was not right and did not meet expectation. The facility policy titled Waste Management, dated 4/21/22, indicated containers must be closable, puncture resistant, and leakproof, and that food waste would be placed in covered garbage and trash cans.
Infection Prevention and Control Failures
Penalty
Summary
Hand hygiene was not offered or reminded to residents before lunch service or eating. During observation and interview, residents stated staff had not offered to clean or wash their hands before meal trays were served, and one resident said he would wash his hands himself. Another resident and her roommate were observed eating at bedside, and the Director of Rehabilitation brought hand wipes into the room and wiped both residents’ hands after the concern was raised. Additional residents in the hallway stated staff had not reminded them to wash or sanitize their hands before lunch, and several said staff had never offered to do so before meals. Two CNAs assigned to those rooms confirmed they had not offered hand hygiene to their residents that day, and the Infection Preventionist stated staff were expected to offer hand hygiene before meal trays were served. The facility policy stated hand hygiene is the primary means to prevent the spread of infection and is required before eating. Resident glucometers were not sanitized using the appropriate disinfecting agent. During observation, an LPN removed a glucometer from a medication cart, obtained a blood sample from a resident, and cleaned the device with wipes from a Super Sani-cloth container before immediately returning it to the drawer. The LPN stated she was unaware the glucometer surface needed to remain visibly wet for at least two minutes for the germicide to be effective. Another nurse stated Sani-cloth Plus wipes were used to clean glucometers, and the Infection Preventionist stated glucometers should be cleaned after each use. The facility’s Assure Platinum glucometers were identified as the devices in use, and the manufacturer’s manual specified Super Sani-cloth Germicidal Disposable wipes as the recommended wipes for cleaning and disinfecting the glucometers. The facility’s glucometer cleaning instructions also directed staff to use Super Sani-cloth wipes and allow a 2-minute wet time. The facility did not maintain an Infection Prevention and Control Program binder that could be located at either nurse’s station, and the Administrator could not provide documented evidence that the program had been reviewed at least annually. Oxygen concentrators for residents with COPD had visible dust and debris, including dust buildup in the vent of one concentrator and brown dirt and dust buildup on another resident’s oxygen condenser filter. The DON stated the Treatment Nurse was responsible for changing tubing and humidifiers and cleaning the filters, and the IP stated dusty filters were a concern because of inhaling dust, oxygen concentration issues, and infection possibilities. In addition, a resident with COPD and pneumonia was observed coughing in her room without a mask for source control while sharing the room with two roommates. Records showed she had been prescribed doxycycline for left lower lobe pneumonia and COPD exacerbation, and the CDC guidance cited in the report stated droplet precautions are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets and that source control includes placing a mask on the patient.
Failure to Develop Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a care plan for Resident 9, who was admitted with diagnoses including diabetes and severe protein-calorie malnutrition. During a concurrent observation of a wound dressing change and interview with the Wound Nurse, Resident 9 was noted to have a pressure ulcer on the coccyx that had been an unstageable pressure ulcer and had recently evolved to a Stage 4 pressure ulcer. The Wound Nurse cleansed and covered the wound during the observation. A review of Resident 9's care plans did not show a care plan for the unstageable or Stage 4 pressure ulcer present on admission. During interview, the DON confirmed licensed nurses had not initiated a care plan for Resident 9's unstageable pressure ulcer upon readmission and stated the lack of a care plan did not ensure continuity of care for the resident's wound. The facility policy on Person-Centered Care Planning stated the facility must develop and implement a comprehensive person-centered care plan for each resident with measurable objectives and timeframes to meet medical, nursing, and mental and psychosocial needs.
Failure to Update Care Plan After IDT Discussion
Penalty
Summary
The interdisciplinary team failed to review and revise the comprehensive care plan for one resident after recent IDT discussions. The resident was admitted with bipolar disorder and anxiety disorder, among other medical conditions, and had care plans initiated to improve psychosocial well-being. Those original care plans were not updated to incorporate the interventions discussed in the resident’s recent IDT meetings. IDT notes documented that the team met to discuss the resident’s behavior management related to increased need for assistance and rehabilitation placement, which was causing marked distress, significant difficulties with social relationships, and social isolation. The team’s plan was for the resident to receive psychotherapy to decrease depressive and anxious symptoms, but during record review the MDS Nurse could not find an updated care plan reflecting that intervention and could not find documented evidence that a psychotherapy referral had been initiated. The SSD also confirmed the care plan was not updated after the IDT meetings, and the facility policy stated comprehensive care plans must be reviewed and revised by the IDT after each assessment.
Missing Controlled Medications Were Not Securely Stored
Penalty
Summary
The DON and Consultant Pharmacist failed to ensure controlled drugs that were ready to be disposed of were securely stored inside the facility when 30 tablets of hydrocodone and 19 tablets of hydromorphone hydrochloride were discovered missing from the facility’s locked box of controlled medications. The report states the DON received hydrocodone and hydromorphone from a licensed nurse and later, during narcotic destruction, the DON and Consultant Pharmacist identified that the two controlled drugs were missing from the controlled substance count sheets and cards. During interview and observation, the DON stated she was the only person with keys to the lock boxes used to store controlled medications for destruction. She also stated that when the Consultant Pharmacist arrived to assist with narcotic destruction, she observed the bar lock on the file cabinet was broken at the bottom and the internal lockbox was not fully closed. The DON further stated the office door did not meet double-lock requirements and could be opened with a credit card, and she demonstrated that the internal lock box could be opened with a spoon if the lid was not firmly pushed down to engage the lock. The facility policy stated controlled substances remaining in the facility after discontinuation or discharge are to be retained in a securely locked area with restricted access until destroyed.
Failure to Obtain Valid Informed Consent for Psychotropic Medications
Penalty
Summary
Licensed nurses failed to ensure three residents were fully informed in advance of the risks and benefits of psychotropic medications before treatment was started. Resident 11 was admitted with diagnoses including bipolar disorder, other psychotic disorder, adjustment disorder with mixed anxiety and depressed mood, depression, and schizoaffective disorder, and the face sheet indicated he was his own responsible party. His psychotherapeutic drug informed consent forms for trazodone, escitalopram, and divalproex sodium were dated 4/1/26 and signed by his RP rather than by Resident 11, and two of the five consent forms did not identify the drug name for which consent was supposedly obtained. During interview, the DON reviewed the chart and stated the consents were not valid and confirmed Resident 11 was not informed of his own care. The RP stated she had been hired by Resident 11 to be an advocate but that he could answer for himself. Resident 9 was admitted with a diagnosis of depression and was prescribed lorazepam for anxiety, panic attack, or trouble sleeping, but the chart contained no documented evidence that informed consent was obtained before the medication was started. Resident 30 was admitted with a diagnosis of depression and had orders for mirtazapine and lorazepam; the MAR showed mirtazapine was administered throughout May 2026 and lorazepam was also given, while the informed consents for both medications were not obtained until 5/28/26, after the medications had already been administered. The DON acknowledged Resident 9’s consent could not be found and stated Resident 30’s consents were obtained after the medications were first administered. The facility’s policies required written informed consent for psychoactive drugs and that the licensed nurse confirm informed consent before the first dose of psychoactive medication.
Inaccurate Admission MDS Documentation for Hearing and Vision Needs
Penalty
Summary
Licensed nursing staff failed to ensure the admission MDS was accurately completed for two residents by incorrectly documenting hearing aid and vision use. Resident 6 was admitted with diagnoses including COPD, Parkinsonism, and schizoaffective disorder, bipolar type. His MDS indicated minimal hearing difficulty and did not show that he wore a hearing aid, and his care plan also did not identify hearing aid use. However, during observation and interview, Resident 6 stated he wore hearing aids during the day and needed the surveyor to speak louder because he did not hear well. The MDS Nurse later acknowledged the hearing aid information on the MDS was in error and stated that if correct information is not assessed or obtained, staff would not be able to provide proper care needs. Resident 51 was admitted with diagnoses including chronic diastolic CHF, COPD, and pneumonia. His admission inventory listed a hearing aid, and during observation he was seen wearing glasses and stated he could not hear, that he wore a hearing aid, and that the hearing aid needed batteries. The hearing aid was observed in a case on the bedside table. Despite this, the MDS documented minimal hearing and vision impairment but did not indicate use of a hearing aid or corrective lenses, and the care plan also did not identify either item. LN 6 and LN 7 were unaware of the hearing aid use, and the MDS Nurse later acknowledged the MDS was in error because Resident 51 did use a hearing aid and glasses.
Failure to Coordinate Hospice Care Plan
Penalty
Summary
Licensed nurses failed to ensure communication of hospice care needs between facility staff and the hospice provider for one resident, identified as Resident 98, who was admitted to the facility in June 2026 on hospice care with diagnoses of adult failure to thrive and dementia. A review of the hospice binder at the nurse's station on 6/25/26 showed there was no hospice care plan for Resident 98. During interviews, the Hospice Admitting Nurse stated that when a resident is placed on hospice, she completes an assessment, develops a care plan, evaluates and orders medications, and sends the documents to her office so the medication list and care plan can be faxed to the facility, stating that every hospice patient has a care plan. The DON stated that the resident's care plan was not sent to the facility and that she did not monitor to follow up. The hospice agency stated that on 6/11/26 its medical records coordinator faxed the face sheet, plan of care, medication list, initial admin note, initial orders, and CTI to the facility. The facility's Hospice and Nursing Facility Services Agreement stated that the DON is responsible for working with the hospice representative to coordinate care for each hospice patient, and the facility policy stated that the hospice and facility will collaborate on a care plan for the resident.
Failure to Supervise Resident at High Risk for Elopement
Penalty
Summary
The facility failed to ensure the safety of one of five sampled residents when it did not provide adequate supervision and monitoring to prevent the resident from leaving the facility. The resident, who had diagnoses including severe dementia, was admitted on [DATE] and eloped from the facility on 5/9/26 at 7:45 p.m. Staff later observed the resident on the sidewalk on the public road outside the facility and redirected the resident back inside. A nurse completed an assessment and did not observe any physical injuries. During interviews and record review, the DON stated the resident was a newly admitted resident and staff were unfamiliar with her, and staff thought she was a visitor when she walked out the front doors and let herself out of the secure front gate. The DON stated she was unaware the resident had any risk for elopement. The Case Manager stated the elopement care plan was not completed until 5/12/26, after the elopement occurred, and that the resident's admission elopement assessment had a score of 5, which she identified as high risk. She stated a signaling device was not applied and that there was not enough supervision or monitoring. The MDS staff stated the elopement assessment was not completed in a way that triggered a care plan at admission, and that if it had been done, it might have stopped the resident from eloping.
Failure to Implement and Document Fall Risk and Post-Fall Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document comprehensive, person-centered fall risk and post-fall care plan interventions for one resident. The resident was admitted with diagnoses including progressive cognitive decline with anxiety, generalized muscle weakness, insomnia, impaired communication, and gait and mobility abnormalities. An MDS dated 12/25/25 showed memory impairment on the BIMS and two or more falls since the prior assessment. SBAR forms dated 4/15/25, 4/28/25, 5/3/25, 7/24/25, 10/3/25, and 10/12/25 documented six fall incidents in 2025. Fall risk evaluations from 3/4/25 to 12/12/25 showed scores ranging from 10 to 20, confirming the resident was at high risk for falls. The resident’s care plan, initiated 3/5/25 for high fall risk, included specific interventions such as verifying and documenting the resident’s location every two hours, offering toileting every two hours while awake after a fall on 7/24/25, and performing a root cause analysis of past falls with documentation of possible root causes and education of the resident, family, caregivers, and IDT. Additional post-fall care plans initiated on 1/26/26 and 1/28/26 directed staff to continue fall-risk interventions and obtain a PT evaluation after an unwitnessed fall with serious injury. During interviews, the Administrator confirmed the facility could not produce documentation that the root cause analysis was performed, that the resident’s location was monitored and toileting was offered every two hours, or that a PT evaluation was completed as ordered in the care plan. The facility’s own person-centered care planning policy required development and implementation of a comprehensive care plan describing services to attain or maintain the resident’s well-being, but documentation of implementation of the specified interventions was absent.
Failure to Complete 72-Hour Change-in-Condition Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to complete required 72-hour monitoring and documentation following a change in condition for one resident after an altercation. The resident, who had dementia, major depressive disorder, post-traumatic stress disorder, and suicidal ideations, was admitted with significant mental health diagnoses. His MDS dated 11/4/25 showed a BIMS score of 11, indicating moderately impaired cognition, and documented that he felt down, depressed, or hopeless nearly every day during the assessment period. On 1/11/26 at 3:45 p.m., a progress note documented that the resident was struck twice in the left front shoulder with a closed fist by another resident, constituting a change in condition that triggered the facility’s change in condition process. Subsequent documentation showed that on 1/12/26 at 1:19 p.m., an IDT note recorded the resident stating, "I don't know if I am hurt or just upset," and on 1/13/26 at 8:35 a.m., a progress note indicated he remained upset about the altercation and was very worried the other resident would continue to bother him. During an interview and record review on 2/26/26 at 11:45 a.m., the DON reviewed the resident’s documentation following the 1/11/26 altercation and acknowledged that although a change in condition had been initiated, continuous 72-hour monitoring notes were not charted for every shift after the incident, so completion of the monitoring could not be verified. This failure occurred despite the facility’s policy titled "Change in Condition," effective 8/25/22, which required a licensed nurse to document each shift for at least 72 hours when there is a change in a resident’s condition.
Failure to Protect a Resident From Verbal Abuse During Shower Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a certified nursing assistant (CNA) yelled and swore at the resident during care. The resident, who had been admitted with diagnoses including encounter for palliative care, acute chronic systolic (congestive) heart failure, muscle weakness, hearing loss, and absence of the left leg below the knee, had a Minimum Data Set indicating slight memory impairment. During a shower, CNA 1 was overheard yelling and swearing at the resident, and the resident was later described as visibly bothered when interviewed about the incident. In a subsequent interview, the resident reported that CNA 1 yelled and swore at him and that he did not like how he was treated. The resident’s care plan documented that he was a victim of alleged abuse related to CNA 1 yelling at him in the shower and calling him an "asshole." The facility’s Abuse Prevention and Management policy, effective 2024, stated that the facility does not condone any form of resident abuse, including verbal abuse, and defined verbal abuse as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms directed to a resident. The substantiated incident of yelling and use of derogatory language toward the resident constituted a failure to ensure the resident was free from abuse as required by facility policy.
Failure to Implement Abuse Assessment and 72-Hour Monitoring After Alleged Incident
Penalty
Summary
The facility failed to implement its abuse prevention and management policy for one resident following an alleged abuse incident. Resident 1, admitted in October 2025 with diagnoses including encounter for palliative care, acute chronic systolic congestive heart failure, muscle weakness, hearing loss, and absence of the left leg below the knee, had a Minimum Data Set dated 1/10/26 indicating slight memory impairment. After an allegation of abuse on 1/9/26, the DON stated she expected licensed nurses to complete and document a change of condition assessment, including a physical and psychosocial assessment, document when the physician and family were notified, update the resident’s care plan, and initiate 72-hour monitoring. However, record review and the DON’s concurrent interview confirmed there was no documented assessment or progress notes and that the required 72-hour monitoring and alert charting were not completed. The facility’s own Abuse Reporting and Documentation lesson plan directed licensed nurses to complete an assessment and skin assessment of the alleged victim, notify the MD, add the resident to alert charting for 72 hours with appropriate monitors for increased distress, and document psychosocial status every shift, with Social Services documenting psychosocial status daily and the IDT promptly reviewing allegations. The facility’s Abuse Prevention and Management policy, revised 5/30/24, required that the resident be assessed by a licensed nurse for any physical injuries or emotional distress and that the physician be notified and treatment provided as ordered. The DON confirmed that social services 72-hour checks were lacking and that there was no assessment documented or progress notes for Resident 1 following the alleged abuse incident.
Resident Rights Violated When Call Light and Bed Remote Removed
Penalty
Summary
A resident admitted in March 2023 with chronic kidney disease experienced a violation of resident rights when a licensed nurse (LN 1) removed her call light and bed remote while she was in her room. According to LN 1’s nursing note dated 11/30/25, the nurse took these items because the resident had been moving her bed up and down and repeatedly pressing her call light, and the nurse expected this behavior to stop. During an interview, the Director of Nursing stated that LN 1’s actions were inappropriate, acknowledged that the facility is the resident’s home, and considered the call light and bed remote to be the resident’s personal property and a resident rights issue. Review of the facility’s Resident Rights policy, revised 1/1/12, showed that employees are required to treat all residents with kindness, respect, and dignity and to honor the exercise of residents’ rights, which was not followed in this incident. This failure resulted in the resident not having access to her call light and bed remote as documented in the nursing note and confirmed by the DON, constituting a lack of respect for the resident’s dignity and self-determination as outlined in the facility’s own policy.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The incident involved an 81-year-old resident with multiple diagnoses, including heart failure and venous insufficiency, who reported that a nurse performed an incorrect treatment using scissors to debride thick dry skin on her legs, causing severe pain. The resident expressed multiple times for the nurse to stop due to 9/10 pain, but the nurse refused. The resident later stated that what happened was abuse and that she felt unsafe. This information was documented in a nurse's progress note and reported internally to the facility administrator. Despite the internal reporting, the facility did not submit the required Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the Department within the mandated two-hour timeframe. The report was received by the Department nearly two hours after the incident was identified during a chart review. Both the nurse and the administrator acknowledged during interviews that allegations of abuse must be reported to the Department within two hours, as required by facility policy and state regulations. The delay in reporting constituted a failure to comply with mandated reporting requirements.
Incorrect Oxycodone Dose Administered
Penalty
Summary
Resident 1, who was admitted to the facility with diagnoses including dementia and asthma, had a physician order for oxycodone HCL 5 mg by mouth two times a day. On 11/10/25 at approximately 9 a.m., Licensed Nurse 1 administered oxycodone to Resident 1, but the resident later received an incorrect dose. A progress note documented that Resident 1 was given a 20 mg oxycodone tablet that belonged to Resident 2, while Resident 1’s actual ordered dose was 5 mg. The note stated the error was made on the morning shift by a nurse prior and was discovered during shift change report at 7 p.m. During interview, Licensed Nurse 1 acknowledged she gave the wrong medication to Resident 1 and stated she verified the resident’s name on the MAR but did not look at the medication to confirm it was the resident’s medication. She stated she may have picked Resident 2’s oxycodone instead of Resident 1’s. The DON also acknowledged the error and stated the nurse did not look at the bubble pack a second time and popped the wrong medication from Resident 2’s bubble pack. The DON reported the two medications were right next to each other, and copies of the bubble packs showed a size difference between the medications. The facility policy required verification of the resident’s identity using two identifiers and verification of the medication against the MAR and pharmacy label.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure an RN provided services at least 8 consecutive hours a day, 7 days a week for 6 days in April 2025. A review of the facility’s license showed it was licensed for 104 skilled nursing beds, and a review of the PBJ Staffing Data Report for April 1 through June 30, 2025 showed no RN worked at the facility on 4/5/25, 4/6/25, 4/12/25, 4/13/25, 4/19/25, and 4/20/25. During an interview, the Administrator acknowledged the facility did not have RN coverage on those dates because it was struggling to find RNs in April 2025 and stated the facility was unable to admit residents with procedures only RNs could perform. The facility policy stated that facilities licensed for 100 or more beds must have at least one RN awake and on duty at all times, day and night, in addition to the DON.
Failure to Provide Baseline Care Plan and Medication List Within 48 Hours
Penalty
Summary
The facility failed to provide three residents with a summary of their baseline plan of care and a list of medications within 48 hours of admission. Resident 41 was admitted with diagnoses including pneumonia, alcohol dependence, alcohol use with withdrawal, and type 2 diabetes, and was his own RP. His baseline care plan, completed by the MDSC, indicated he was provided a current medication list, but the resident signature area was blank. Resident 41’s admitting MDS showed a BIMS of 14, indicating he was cognitively intact, but during interview he could not recall whether a nurse had reviewed his baseline care plan and medication list with him and provided copies within 48 hours of admission. Resident 46 was admitted with diagnoses including metabolic encephalopathy, Wernicke’s encephalopathy, and malignant neoplasm of the rectum, and was her own RP. Her baseline care plan, completed by the MDSC, also indicated she was provided a current medication list, but the representative signature and date were left blank. Her MDS showed a BIMS of 15, indicating she was cognitively intact, and she stated communication among staff was very bad and could not recall whether the baseline care plan and medication list had been reviewed with her and copied within 48 hours. Resident 96 was admitted with diagnoses including epileptic syndrome, type 2 diabetes, and unspecified intestinal obstruction, and was his own RP. His baseline care plan, completed by the MDSC, showed the representative signature and date were blank. His admitting MDS showed a BIMS of 14, and he stated he had been on new seizure medications at the hospital, became delusional and paranoid, and thought someone reviewed his medications with him, but he did not receive a copy of the medication list.
Incomplete Care Plans and Missing Discharge Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents. For Resident 62, who was readmitted with diagnoses including discitis, osteomyelitis, back pain, CHF, type 2 diabetes, legal blindness, OSA, and moderate protein calorie malnutrition, the MDS indicated oxygen therapy and restorative nursing services, including active ROM and splint brace assistance. The order summary showed oxygen at 2 to 4 liters by nasal cannula and RNA services for active ROM to all extremities and splinting to both hands, but the care plans did not document a plan for oxygen use or RNA services. During interviews, the DOR, MDSC, and DON acknowledged that a care plan should have been developed for the RNA program and oxygen therapy. The facility also did not develop discharge care plans for newly admitted residents after their initial multidisciplinary care conferences. Resident 41 was admitted with pneumonia, alcohol dependence, alcohol withdrawal, and type 2 diabetes. His baseline care plan was completed, and his initial care conference documented that he was living on the streets because his trailer was infested with rats and that he expected to return to the community after therapy and find safe housing, with the SSD planning to contact community resources. However, no discharge care plan had been initiated. The SSD stated the resident was homeless and that the discharge plan had not been completed. Resident 46 was admitted with metabolic encephalopathy, Wernick's encephalopathy, and malignant neoplasm of the rectum. Although a baseline care plan and multidisciplinary care conference were completed, the social service and resident/family expectation sections were blank, and there was no indication of discharge plans. Resident 96 was admitted with epileptic syndrome, type 2 diabetes, and unspecified intestinal obstruction. His social service assessment and care conference documented a plan to return to the community with support from IHSS, PACE, friends, therapy, and nursing, but no discharge care plan had been initiated after the conference. The facility policy required comprehensive, person-centered care planning that included the resident's preference and potential for future discharge, and the social service coordinator job description included assisting with discharge planning and updating the resident care plan.
Medication carts left unsecured and stored with loose and prepared medications
Penalty
Summary
Drugs and biologicals were not stored in a clean, safe, and orderly manner in Med Cart 4. During observation on 9/16/25, a 30 ml plastic medication cup containing a brown chunky substance was found in the top drawer of the cart, and one loose capsule plus 8.5 loose tablets were found in various drawers. The LN stated the cup contained crushed medications mixed with chocolate pudding that had been prepared for resident administration earlier that morning, and confirmed that prepared medications were not supposed to be left in the cart. The LN also acknowledged that loose pills should have been removed from the med cart to keep it clean and orderly. Med Cart 1 was also observed unlocked and unattended on 9/17/25 at the nursing station and later in the hallway outside a room. LN 3 returned to the cart and confirmed it was unlocked and unattended, and the DON and DSD also confirmed the cart was unlocked and unattended. The DON stated med carts should be locked when unattended to prevent unauthorized access to medications. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, that medication carts are kept locked when not attended, and that medication storage areas are kept clean.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor resident food preferences for three sampled residents, including a resident with rectal cancer who had a nutritional risk assessment indicating she did not like raw fruits and vegetables. Her MDS showed a BIMS score of 15, and she stated during interview that she continued to receive raw fruits and vegetables on her meal trays even though she knew she was not supposed to have them. She also stated she had not seen the RD or CDM and that she did not always receive everything she requested from the menus sent to residents. During tray line observation, one resident’s dinner plate was served with mixed vegetables containing carrots even though his meal card listed carrots as a dislike, and another resident’s dinner plate was served with mixed vegetables containing cauliflower even though her meal card listed cauliflower as a dislike. The first resident stated he would not eat the carrots because they were too soft and had the texture of baby food, and the second resident stated she simply picked the cauliflower out of the mixed vegetables. The RRD stated the residents should not have been served those disliked items and that the dietary aide should have checked the plate against the meal cards to ensure disliked foods were not placed on the trays. The RD stated the CDM was responsible for making sure residents’ food preferences were honored and updated.
Failure to Maintain Sanitary Equipment and Disinfect Shared Devices
Penalty
Summary
The facility failed to maintain sanitary conditions for a resident’s bedside commode. Resident 1 was admitted in December 2023 with diagnoses including muscle weakness and unstable gait and mobility. During observations in the resident’s room, the bedside commode was seen positioned next to the bed with a brown splattered substance streaked on the top and backside of the seat and on the armrests. A CNA acknowledged the commode was soiled and needed to be cleaned, and stated it should have been cleaned and disinfected after each use. The resident also confirmed using the commode and expected it to be cleaned and ready for the next use. The facility also failed to store the metal ice scoop on the mobile hydration station in a sanitary manner. During observations in the hallway and dining room, the scoop was seen exposed and accessible to anyone. The Infection Preventionist confirmed the scoop should have been kept in a plastic bag to protect it and the ice from pathogens and contamination. The DON acknowledged the scoop should not be left out in the open and stated it should have been kept in a clean, closed container when not in use. Staff also failed to disinfect the vital sign machine and equipment between use for five residents. A CNA was observed obtaining vital signs for one resident and then using the same machine for other residents without disinfecting it between residents. The CNA acknowledged not disinfecting the equipment between residents and stated cleaning medical equipment between patient contact is the expectation. The Infection Prevention nurse and DON stated staff were expected to clean or disinfect equipment between residents to prevent transmission of infections through indirect contact.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program when flies were observed throughout the building, including in resident dining areas, resident rooms, the kitchen, and at the nurse's station. During a dining room observation, the door from the Garden Dining Room to the outside resident patio was wide open during lunch and had no screen to prevent pests from entering, and flies were noted in the dining room. A fly was photographed on a resident's arm and another on a resident coffee dispenser during the meal. Additional observations showed three flies buzzing around Resident 14 while the resident swatted at them, two flies in Resident 65's room bothering the resident and touching her face as she tried to brush them away, and two flies in the kitchen. The Regional Registered Dietician and Certified Dietary Manager stated that flies in the kitchen were an infection control issue, especially if they landed on food prep countertops and food. The Administrator stated the warm weather had brought flies, and the surveyor pointed out that the open Garden Dining Room door and lack of a screen allowed easy access for flies into the facility and kitchen. The facility policy stated it maintained an ongoing pest control program to keep the building and grounds free of insects, rodents, and other pests.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the California Department of Public Health within 2 hours and that investigation summaries were submitted within 5 working days for multiple incidents involving residents and staff. The report identified 11 residents involved in allegations including resident-to-resident altercations, resident-to-staff allegations, and staff-to-resident allegations. These incidents included a resident entering two other residents’ room and breaking belongings while cursing and yelling, a resident throwing water at another resident, a resident being yelled at by a CNA about urinating on herself, a resident slapping another resident’s hand, a resident allegedly grabbing another resident after being called “dude,” a CNA allegedly instructing a resident to urinate in her brief instead of assisting her to the restroom, and a CNA allegedly hurting a resident while providing personal care. For several incidents, the facility’s notifications and investigation summaries were not received by the Department until months after the allegations were known to the Administrator. In one case, the Administrator stated the abuse involving three residents was initially sent to an incorrect email address rather than the Department’s address. Other incidents were documented on SOC 341 forms and later appeared in the Department’s message log only when the investigation summaries were received. One resident-to-resident incident had no documented evidence that the investigation summary was sent by the required deadline. Another allegation involving a resident and a CNA was not reported until the investigation summary was received by the Department months later. For the allegation involving a CNA and a resident who said she was hurt during personal care, the resident reported the concern to nursing staff after breakfast, and a CNA acknowledged being told about it that morning. The CNA said she informed the Director of Staff Development later that day, and the Administrator acknowledged notifying the Department that afternoon after already interviewing the resident. The Administrator also acknowledged that the notifications and investigation summaries for the other listed allegations were submitted late because the email address used was incorrect.
Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that one sampled resident was free of unnecessary psychotropic medications when the resident received haloperidol and quetiapine fumarate with inadequate indications for prescribing. The resident had a history of metabolic encephalopathy, unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorder, and the record showed prior use of haloperidol lactate PRN for agitation and quetiapine at bedtime. The resident’s MDS also documented use of antipsychotic, anti-anxiety, antidepressant, and anti-convulsant medications, with an indication noted. The resident’s active orders as of 9/18/25 included haloperidol 0.5 mg at bedtime for stroke with TIA and quetiapine fumarate 50 mg at bedtime for stroke with TBI. The PharmD consult’s medication regimen review identified the indications as inadequate and noted that if an antipsychotic was necessary to treat delirium and agitation, quetiapine and risperidone were considered safer alternatives. The physician response to the consult was documented as disagree, with the note that the indication was wrong for the medication. The consultant pharmacist later stated the current indications for both quetiapine and haloperidol were inadequate. During observations, the resident was repeatedly found sleeping in bed or dozing off in a wheelchair, including while breakfast was in front of her and she was not eating. CNA staff stated the resident had a 24-hour one-to-one sitter, stayed awake for a couple of nights and then slept for two or three days, and that behaviors were monitored and managed by the sitter and medications. The DON stated the resident exhibited verbal and physical behaviors and was hard to redirect, and the medical director stated the indications for quetiapine and haloperidol were not proper indications. The resident’s responsible party stated the resident had slowed down a lot since entering the facility and had been sleeping more over the past 6 months.
Failure to Report and Address Significant Weight Loss
Penalty
Summary
The facility failed to recognize, report, and address the nutritive needs of a resident who lost 9.8 pounds between 8/6/25 and 9/5/25. The resident was admitted with multiple diagnoses including discitis, osteomyelitis, congestive heart failure, type 2 diabetes, hypothyroidism, moderate protein calorie malnutrition, GERD, and chronic kidney disease. Her care plan identified her as being at risk for altered endocrine status and weight loss, and it directed nursing staff to obtain a dietary consult and to monitor, document, and report significant weight loss to the MD and RD. The resident had previously been seen by the RD for a significant weight loss earlier in the stay, and the RD noted variable meal intake, acceptance of evening snacks, and an order for Glucerna. The RD recommended that nursing document food intake percentages, encourage the resident to eat and drink, and have kitchen staff offer preferred foods. The resident later weighed 169.8 pounds and then 160 pounds, and a warning note was triggered showing a 5% weight change. The MDS dated 9/8/25 documented that she had lost 5% or more in the last month, required setup or clean-up assistance with eating, had upper extremity impairment, and was on a therapeutic diet. Despite the weight loss and the facility’s policy requiring IDT evaluation and notification of the responsible party, attending physician, and RD for a 5% weight change in 30 days, the chart showed no documented notification from nursing staff or the MDS Coordinator to the DON, MD, or RD between 9/5/25 and 9/14/25. The MD was not notified until 9/16/25, and no nutrition/dietary assessment of the weight variance was documented until 9/17/25. Interviews with the resident, the RRD, LN 2, the MDSC, the DON, and the RD confirmed that the weight loss should have been reported and addressed sooner, and that the resident’s severe weight loss had not been handled when it was first identified.
Medication Availability and Emergency Kit Documentation Failures
Penalty
Summary
The facility failed to ensure routine and emergency medications were available for residents. One resident admitted with chronic pain syndrome and anxiety disorder had an order for buprenorphine-naloxone 8-2 mg sublingually four times daily for pain, but the medication was unavailable for administration. On 9/17/25, the resident did not receive the 12 p.m. or 4 p.m. scheduled doses, and the MAR also showed the 8 p.m. dose was not given. A one-time dose was later received and administered that evening. The DON acknowledged the missed doses occurred because the medication was unavailable, and the pharmacist stated the resident’s medications should be available as ordered. The record review and interviews showed staff did not ensure the controlled medication was refilled before it ran out. The DON stated licensed nurses were expected to review and request reorders before the last dose, and the pharmacy manager stated controlled scheduled medications should be refilled two to three days before running out. The pharmacist also stated missed doses could cause the resident aches and pains and acute distress if doses continued to be missed. The facility also failed to maintain proper control and timely replacement of emergency medication kits. An oral medication e-kit was found opened with no documentation inside showing when it was last accessed or what medication was removed. An insulin e-kit was also found opened, with the access form taped to the outside rather than documented inside the kit. The DON acknowledged e-kits should be replaced within 72 hours and that documentation should identify who opened the kit, what medication was taken, and for which resident. The facility policy stated opened kits are to be replaced with sealed kits within 72 hours of opening.
Liquified diet provided despite family concern and resident weight loss
Penalty
Summary
The facility failed to provide nourishment that was palatable, textured, and attractive for one resident with Alzheimer’s disease, type 2 diabetes, protein calorie malnutrition, and dysphagia. The resident was admitted with a care plan directing staff to modify the diet according to food tolerances and preferences. Records showed the resident required complete assistance with eating, had no signs or symptoms of a possible swallowing disorder on the MDS, weighed 107.6 lbs. in early July, and later weighed 102.6 lbs. in early September. Speech therapy notes indicated there were no contraindications for pureed texture foods, and the order summary later reflected a pureed texture, regular/thin liquids, and a liquified pureed diet. During observation, the resident was seen in bed with the head of bed elevated and being fed liquified foods from mugs through a straw. The meal ticket listed liquified items such as cottage cheese, cheesecake, ice cream, pie cream, pudding, sherbet, and cream soup. The resident’s RP stated the liquified diet was unappetizing and lacked dignity, and also expressed concern about weight loss. The DON stated that a pureed texture would be more appetizing than a pureed liquid diet, the ST stated the resident had been changed to a pureed liquid diet because food movement in the mouth was delayed and that the resident had never had a swallow study, and the MD and RD both stated a pureed texture would be better or more appetizing than a liquified texture. The facility policy stated diet changes and reasons for changes should be explained to the resident and/or responsible party.
Unsealed Frozen Vegetables in Walk-In Freezer
Penalty
Summary
The facility failed to ensure frozen vegetables stored in the freezer were sealed for 90 residents who received food from the facility's kitchen. During the initial kitchen tour on 9/15/25 at 8:50 a.m., three boxes of frozen vegetables—carrots, green beans, and corn—were found opened and not sealed in the walk-in freezer. The frozen vegetables remained in their original blue plastic bags, which were open to air and placed back inside their original cardboard boxes. The Certified Dietary Manager stated that if frozen items are not sealed tightly, they could get freezer burn. On 9/16/25 at 12:30 p.m., the Regional Registered Dietician stated that if a frozen vegetable was not sealed tightly, she would be concerned that something could spill inside the bag causing cross contamination more than freezer burn affecting the nutritional value. The facility policy titled Food Storage and Handling, revised 2/29/24, stated that foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers.
Call Light Left Out of Reach for Resident 6
Penalty
Summary
The facility failed to ensure that a working call system was available within reach in a resident’s bathroom and bathing area when Resident 6’s call light was found on the floor and out of reach. Resident 6 was admitted in April 2022 with diagnoses including cerebral infarction and PTSD. His care plan identified a risk for falls and impaired physical mobility, and included interventions to ensure the call light was within reach and available for use when assistance was needed. During a concurrent observation and interview, CNA 5 observed Resident 6’s call light on the floor on the right side of the bed and acknowledged it was out of reach. On a later observation and interview, the SSD again observed the call light on the floor and out of reach and stated residents need the call light within reach so they can call for help. The DON also confirmed the call light should always be within reach so residents can call for help or signal staff when they need assistance. The facility policy titled Communication - Call System stated that call cords will be placed within the resident’s reach.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect when Resident 2 slapped Resident 74 on the hand. Resident 2 had diagnoses including metabolic encephalopathy, dementia, cerebral infarction, and cognitive communication deficit, and was assessed as severely cognitively impaired with a BIMS score of 6. Resident 74 had diagnoses including subdural hemorrhage, encephalopathy, Alzheimer's disease, and cognitive communication deficit. Facility documentation recorded that Resident 2 slapped another patient and that Resident 74 was slapped on the hand, and an Activities Assistant later stated he witnessed Resident 2 hit Resident 74 while they were seated in wheelchairs near Nurse's Station 1. The facility also failed to protect two residents when Resident 00 entered their room, broke belongings, cursed, yelled, and caused fear. Resident 00 had diagnoses including psychosis and dementia with behavioral disturbance and was assessed as severely cognitively impaired with a BIMS score of 6. Resident 101 had chronic heart failure, chronic hepatic failure, and anxiety disorder, with a BIMS score of 12, and Resident 83 had aphasia, recurrent major depressive disorder, and anxiety disorder, with a BIMS score of 9. Records and interviews showed Resident 00 had increased behaviors including hitting, throwing objects, screaming, and yelling; Resident 83 stated she was scared and did not want Resident 00 in her room, Resident 101 expressed anxiety about the other resident returning, and a CNA described Resident 00 leaning over Resident 101, screaming in her face, and grabbing belongings. The facility further failed to prevent abuse and neglect when Resident 90 threw water at Resident 105 and when CNA 4 told Resident 68 to urinate in her brief instead of assisting her to the restroom. Resident 90 had bipolar disorder, schizophrenia, and autistic disorder and was severely cognitively impaired with a BIMS score of 7; Resident 105 had Alzheimer's disease and congestive heart failure and was severely cognitively impaired with a BIMS score of 5. Documentation stated Resident 105 reported Resident 90 threw water at him, water was observed on the floor, and Resident 105's clothing was wet; Resident 90 later confirmed he threw water at his roommate because he was upset. Resident 68 had dementia, depression, and cognitive communication deficit and was severely cognitively impaired with a BIMS score of 4. An SBAR note stated staff overheard CNA 4 telling Resident 68 to pee in her pants, and an RNA reported hearing CNA 4 instruct Resident 68 to go to the bathroom in her brief before intervening and assisting the resident to the bathroom.
Failure to Assess Resident After Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure for one resident when licensed nurses and the social service worker did not assess the resident for emotional distress after she reported an allegation of abuse. The resident, who was admitted with diagnoses including heart failure, chronic respiratory failure, and muscle wasting and atrophy, stated that a CNA was rough during care, made her feel afraid, pushed fingertips into her right shoulder after she asked him to be careful because of chronic shoulder pain, held her feet down while she tried to move up in bed, and leaned against her so hard that she screamed in pain. The resident reported the incident to another CNA, and another resident stated she heard the resident screaming, "Ow, ow, ow. You're hurting me." During interview and record review, the LN stated residents are expected to be monitored for sadness or pain every shift for 72 hours after an allegation of abuse, but the resident's progress notes from the relevant period did not mention an allegation of abuse. The LN also acknowledged there were no care plans initiated regarding the resident's allegation of abuse, and the facility policy stated the resident will be assessed by the licensed nurse for any physical injuries or emotional distress.
Failure to Complete Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure licensed nurses completed neurological assessments after unwitnessed falls for two residents. Resident 2 was admitted with diagnoses including metabolic encephalopathy, dementia, cerebral infarction, and cognitive communication deficit. After an unwitnessed fall on 4/27/25, the record indicated neurological checks were due because the incident was unwitnessed, and the interdisciplinary note stated to monitor for delayed injuries. However, the record review showed no documented neurological check at 9:00 p.m. on 4/27/25 and no neurological checks after 3:39 a.m. on 4/28/25 through 4/30/25, despite the facility’s fall policy requiring neurological checks for 72 hours after such an event. Resident 74 was admitted with diagnoses including subdural hemorrhage, encephalopathy, Alzheimer’s disease, and cognitive communication deficit. Her care plan for fall risk directed staff to follow the facility fall protocol. After an unwitnessed fall with a head injury on 8/11/25, the hospital CT noted a superficial left frontal cephalohematoma. The SBAR summary documented that the resident was to be placed on every-half-hour neurological checks on return to the facility, and the provider ordered neurological checks on returning to the facility. The record showed that Resident 74 was found on the floor with a forehead hematoma and a small right elbow laceration, left the facility by ambulance at 2:00 a.m., and then returned from the hospital. However, there were no documented neurological checks between the time she was found on the floor and the ambulance departure, and no documented neurological checks every half hour after her return as directed by the physician. Facility staff confirmed the missing neurological checks for both residents, and the administrator stated she was aware the checks had not been completed.
Failure to Complete Required PASRR Evaluations for Residents with Mental Health and Developmental Diagnoses
Penalty
Summary
The facility failed to ensure that three sampled residents received appropriate PASRR (Preadmission Screening and Resident Review) evaluations as required by federal regulations. For the first resident, documentation showed diagnoses including toxic encephalopathy, post-traumatic stress disorder, anxiety disorder, and chronic pain syndrome, with a BIMS score indicating moderate cognitive impairment. Despite these diagnoses and a history of mental health conditions, the PASRR Level 1 screening marked that the resident did not have a serious mental disorder, and no Level II screening was conducted, as confirmed by correspondence from the state agency. The second resident was admitted with diagnoses of toxic encephalopathy, cerebral palsy, depression, and developmental delay of scholastic skills, and also had a BIMS score indicating moderate cognitive impairment. Hospital records noted the need for coordination with the Regional Center due to developmental delay. The PASRR Level 1 screening indicated a developmental or intellectual disability and past Regional Center services, but did not identify a serious mental disorder, and no Level II PASRR was found in the resident's chart. The third resident had diagnoses of depression, hemiplegia and hemiparesis following cerebral infarction, and brain injuries, with a BIMS score indicating moderate cognitive impairment. Physician notes included toxic encephalopathy, anxiety disorder, and major depressive disorder. The PASRR Level 1 was positive for suspected mental illness, but the state agency determined no serious mental illness was present, and no Level II screening was conducted. Interviews with facility staff revealed that PASRR Level 1 screenings completed by acute hospitals were often incorrect, and the facility did not consistently review or correct these errors, resulting in missed Level II screenings for the affected residents.
Failure to Provide Required Face-to-Face Physician Visits
Penalty
Summary
The facility failed to ensure that residents received required face-to-face physician visits at least once every 60 days, as mandated by federal regulations. For three sampled residents, documentation and interviews confirmed that either the required in-person visits did not occur within the specified timeframes or that only telehealth/virtual visits were conducted instead of face-to-face encounters. Specifically, one resident did not have a face-to-face physician visit for an eight-month period, and for two other residents, all physician visits during the review period were conducted virtually. The residents affected had significant and complex medical histories, including acute respiratory failure, post-traumatic stress disorder, anxiety disorder, chronic pain syndrome, gastro-esophageal reflux disease, post laminectomy syndrome, toxic encephalopathy, quadriplegia, spastic cerebral palsy, depression, developmental disorder of scholastic skills, acute kidney failure, hemiplegia, hemiparesis, muscle weakness, and a history of falls. Their cognitive status ranged from moderately impaired to moderate cognitive impairment, as indicated by their BIMS scores. Interviews with facility staff, including a Registered Nurse Consultant and the MDS Nurse, confirmed that the required face-to-face physician visits were not provided, and that telehealth visits were used instead. The facility administrator acknowledged that the prior contracted physician services were terminated due to failure to provide agreed face-to-face services. Review of federal regulations and facility policy confirmed that in-person physician visits are required and that telehealth visits do not meet this requirement.
Failure to Administer Medications Timely Due to Staffing Shortages
Penalty
Summary
Licensed Nurses failed to administer medications to residents according to physician orders, resulting in multiple instances of late medication administration for two residents. For one resident with diagnoses including palliative care and malignant neoplasm of the skin, medications such as propranolol, methadone, and gabapentin were documented as being given significantly later than scheduled, with delays ranging from over an hour to more than four hours. Another resident with epilepsy experienced late administration of medications including ropinirole, levetiracetam, and aspirin, with delays of over an hour past the scheduled times. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but these instances exceeded that window. Interviews with nursing staff and the Director of Nursing revealed that the late administration was due to severe staffing shortages, with each nurse assigned to care for 28 to 34 residents per shift. Staff reported that the high number of resident assignments made it impossible to administer all medications on time. The Director of Nursing confirmed that the facility had not met state staffing requirements during the relevant periods. One resident reported experiencing anxiety and discomfort due to the late administration of medications. The facility's own documentation and staff interviews confirmed the pattern of late medication administration and the underlying staffing issues.
Inadequate Staffing Leads to Missed Wound Care Treatments
Penalty
Summary
The facility failed to ensure adequate staffing with appropriate competencies to meet the physical needs of the residents, specifically in providing wound care treatments as ordered by physicians. This deficiency was identified through interviews and record reviews, revealing that treatments for wound care were not provided as ordered for four of nine sampled residents. The lack of documentation for wound care treatments on specific dates for these residents indicated that the treatments were not performed, which could potentially delay wound healing and increase the risk of infection. Resident 1 had multiple orders for wound care, including treatments for a malignant breast wound and pressure ulcers on the coccyx and sacro-coccygeal areas. However, the Treatment Administration Record (TAR) showed that these treatments were not documented as completed on several occasions. Similarly, Resident 2's TAR indicated missed treatments for a pressure ulcer on the right below-knee amputation stump. Resident 3's TAR also showed incomplete documentation for pressure ulcer treatments on the coccyx and upper buttocks. Resident 4's TAR revealed missed treatments for wounds on the left calf and right leg. Interviews with facility staff, including the Infection Preventionist and licensed nurses, highlighted staffing challenges, such as the absence of a Treatment Nurse and the inability of other staff to consistently perform wound care treatments. The Infection Preventionist noted that several staff members, including the Treatment Nurse, had quit simultaneously, leaving the facility unable to schedule a nurse specifically for treatments. Licensed nurses reported being unable to complete all required dressings due to time constraints and lack of documentation, further contributing to the deficiency.
Failure to Supervise Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who was left unsupervised on the toilet by a Certified Nursing Assistant (CNA). The resident, who had a history of falls and was identified as high risk for falls, was left alone in the bathroom while the CNA attended to another resident. This lack of supervision resulted in the resident falling and sustaining a fracture of the right distal fibula and tibia. The resident's medical history included hemiplegia, hemiparesis, epilepsy, and memory deficits following a cerebral infarction, all of which contributed to her high fall risk. The resident's care plan and assessments consistently indicated the need for supervision during toileting due to her fall risk and history of noncompliance with using the call light. Despite these documented needs, the CNA left the resident unsupervised, leading to the fall. Interviews with facility staff, including the Director of Nursing and Licensed Nurse, confirmed that the resident required assistance and supervision in the bathroom. The facility's policy on fall management emphasized the need for supervision for residents at high risk of falls. However, the CNA's actions did not align with these guidelines, resulting in the resident's injury.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for two residents involved in an incident. A Certified Nursing Assistant (CNA) witnessed one resident hitting another resident on the face with a shoe. This incident occurred at approximately 11:30 p.m. on November 15, 2024. However, the facility did not report this allegation of abuse to the California Department of Public Health until November 18, 2024, which was three days after the incident. During interviews, the Director of Staff Development (DSD) and the Administrator confirmed that the facility's policy required allegations of abuse to be reported to the Department within two hours. The DSD and the Administrator acknowledged that the incident was not reported within this timeframe. The facility's policy, revised in March 2018, also indicated that the Administrator or a designated representative should notify the Department, the Ombudsman, and Law Enforcement by telephone within two hours, followed by a written report. The delay in reporting decreased the facility's potential to ensure resident safety and caused a delayed response by enforcement agencies.
Unsafe Flooring Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to maintain a safe and functional environment, as evidenced by the improper positioning of transition strips at two doorways, which resulted in a hazardous threshold. This deficiency was directly linked to an incident where a resident fell and broke her arm. The resident was ambulating without her walker and tripped on the uneven threshold strip while attempting to return to her room to retrieve her walker. The fall caused her to land on her right side, resulting in a fracture of the right arm. The incident was documented in the resident's medical records, and the facility's investigation report noted the need for repairs at the affected doorways. Observations conducted by surveyors confirmed the hazardous conditions at the doorways, with uneven flooring and inadequate repairs, such as the use of black tape that did not effectively smooth the transition between different flooring types. The Director of Nursing acknowledged the trip hazard and expressed an assumption that the maintenance staff had already addressed the issue. The facility's policy on resident safety, which mandates immediate reporting of unsafe conditions, was not effectively implemented in this case, contributing to the deficiency.
Failure to Provide Regular Showers Leads to Infected Wound and Sepsis
Penalty
Summary
The facility failed to regularly provide showers for a resident, which contributed to the development and infection of a wound on the resident's right shoulder. The resident, who was admitted with diagnoses of Type 2 Diabetes Mellitus and Essential Hypertension, was dependent on staff for activities of daily living, including bathing. Despite being scheduled for showers twice a week, the resident only received two bed baths in July and no documented showers or bed baths in early August. Interviews with facility staff, including licensed nurses and certified nursing assistants, confirmed that the resident was not receiving showers as scheduled. Staff acknowledged that shower refusals should be documented, and if care was not documented, it was not provided. The lack of regular showers and skin assessments led to the resident's wound being missed and subsequently becoming infected, resulting in sepsis. The facility's policies on skin and wound management and showering and bathing emphasized the importance of skin observation during bathing. However, these procedures were not followed, as evidenced by the lack of documentation and care provided to the resident. The Assistant Director of Nursing verified the discrepancies in shower documentation and acknowledged that the failure to provide regular showers and assess the resident's skin contributed to the missed and infected wound.
Failure in Skin Assessment and Hygiene Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure thorough and accurate skin assessments for a resident, leading to a missed wound on the resident's right shoulder. Despite weekly skin checks, the wound was not documented or treated, resulting in the wound becoming infected. The resident was eventually hospitalized with a diagnosis of sepsis secondary to cellulitis and a small abscess on the right shoulder. The treatment nurse admitted that the skin assessments were inaccurate and that the wound was acquired at the facility. Additionally, the facility did not provide regular showers as scheduled for the resident, which contributed to the missed identification of the wound. The resident was supposed to receive showers twice a week, but documentation showed that only two bed baths were given in a month, and no showers or bed baths were provided in the days leading up to the resident's hospitalization. This lack of regular hygiene care was a factor in the development and worsening of the wound. Interviews with staff revealed a lack of awareness about the resident's wound, with both a CNA and a licensed nurse expressing surprise upon discovering the wound. The assistant director of nursing confirmed that the infection likely started at the facility and was not treated, leading to the resident's hospitalization for sepsis. The facility's policies on skin and wound management and showering were not followed, contributing to the oversight and subsequent health issues for the resident.
Significant Medication Error Involving Oxycodone Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an extra dose of Oxycodone HCL 5 mg was administered without a physician's order. The resident had an order for Oxycodone HCL 5 mg to be given every 6 hours as needed for pain, only when non-narcotic options were ineffective. On the day of the incident, the resident was given Oxycodone HCL 5 mg at 6:30 a.m. and again at 10 a.m., with the latter dose being a one-time dose ordered on that day. However, the Individual Narcotic Record indicated that another dose was administered at 9:15 a.m. by a different nurse, Licensed Nurse A, who claimed to have received a verbal order from an on-call physician, which the physician later could not recall giving. During an interview, Licensed Nurse A stated that she administered the extra dose because the resident was in excruciating pain and claimed to have received a verbal order from Physician C. However, Physician C could not recall giving such an order. The Director of Nursing (DON) confirmed that the administration of the extra dose was a medication error and that Licensed Nurse A was terminated as a result. The resident's progress notes and an investigation by the Medical Director confirmed that the extra dose was given without a proper physician's order. The facility's policy on medication administration, dated January 1, 2012, states that medications should be administered by a licensed nurse upon the order of a physician or licensed independent practitioner. The failure to adhere to this policy resulted in the administration of an unscheduled dose of Oxycodone HCL 5 mg, which was determined to be a medication error. Although the error did not result in physical harm to the resident, it had the potential to affect the resident's health and safety.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fortuna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seaview Rehabilitation & Wellness Center, Lp | 10.3 mi | ★★★★★ | 13 | 0 |
| Granada Rehabilitation & Wellness Center, Lp | 13.2 mi | ★★★★★ | 22 | 0 |
| Eureka Rehabilitation & Wellness Center, Lp | 13.6 mi | ★★★★★ | 30 | 0 |
| Jerold Phelps Comm Hosp Snf | 38.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.