Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden Crest Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, Parkinsonism, and impaired decision-making was assessed as at risk for wandering on admission, but no initial care plan for wandering/elopement was created or implemented. Staff later confirmed the resident had been identified as a wandering risk from day one, yet there were no documented interventions in place. The resident subsequently eloped from the facility, was found outside after a fall, and was sent to the ER/ED with abrasions and a right elbow injury.
A resident with DM and dementia returned from a GACH with a new right elbow fracture, right arm splint and sling, and discharge instructions for orthopedic follow-up and a right posterior long arm splint. Nursing documentation showed the readmission and new fracture, but there was no evidence the attending physician was notified of the readmission, new diagnosis, or right arm device. The DON stated nurses are expected to notify physicians of readmissions and changes in condition, and the treatment nurse acknowledged she did not notify the physician because she forgot, contrary to facility policy requiring communication of assessment findings and obtaining admission orders.
A resident with severe cognitive impairment and multiple comorbidities was sent to the hospital after staff noted inability to move the right arm and severe pain, and later returned with an arm splint/immobilizer and sling for a suspected elbow fracture. On readmission, staff observed the right arm device and later its removal after an X‑ray reportedly ruled out fracture, but no comprehensive assessment was completed, no PCP order was obtained for use and monitoring of the right arm device, no resident‑centered care plan was developed or implemented for the device, and no monitoring of its use was documented, contrary to facility policy and stated expectations for post‑hospital readmissions.
Medication pass error rate exceeded the allowed threshold when an LPN failed to give a resident’s scheduled Aspirin on time because only enteric coated tablets were available for g-tube use, and also gave Simethicone late because he was busy. The resident had multiple complex diagnoses, including colon cancer aftercare, intestinal obstruction, stroke-related dysarthria, atherosclerotic heart disease, and GERD, and the MAR showed both medications were due at specific times. The DON confirmed the Aspirin was given 3 hours late and the Simethicone 30 minutes late, resulting in a 7.14% observed med error rate.
OTC medications were stored in a stockroom without a thermometer or known temperature control. RN 1 and the DON confirmed the room held multiple OTC meds and supplements, but the DON stated she did not know the actual temperature or whether it was appropriate for storage. The facility policy required medications to be stored at proper temperatures, including room-temperature meds between 59 and 86 degrees Fahrenheit.
Food storage and handling practices were not sanitary in the kitchen. Three dry storage containers for rice, flour, and sugar were observed without use by dates, seven scoops for dry foods were stacked together with visible powder residue, and 19 food dome covers were stored next to a trash receptacle used for paper towels. The DS, DA, IP, and DON confirmed the storage conditions could lead to cross-contamination and infection control concerns, and facility policy and the FDA Food Code required clean equipment and utensils to be stored in a clean, dry location protected from contamination.
A resident reported that about $2,000 was missing from his room, but the facility only notified local law enforcement and did not report the allegation to CDPH or the Ombudsman as required by its abuse/misappropriation policy. The resident had multiple chronic conditions including DM, ischemic cardiomyopathy, morbid obesity, glaucoma, and oxygen dependence, and the record also noted fluctuating capacity. Facility leadership later acknowledged the allegation was not reported to the state survey agency or Ombudsman.
Resident rooms failed to meet the required square footage per resident in 14 of 18 rooms. A room variance request showed multiple rooms with less than 80 square feet per bed, and a MS later measured two rooms at 150.5 and 146.5 square feet for 2 residents each. During observations, staff were able to provide care and residents reported the rooms were big enough, but the facility policy required at least 80 square feet per resident in multiple-occupancy bedrooms.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
A resident with severe cognitive impairment and multiple chronic conditions did not receive an accurate Joint Mobility Assessment (JMA) because the physical therapist relied solely on observation and staff interviews, without performing passive range of motion (PROM) or physically assessing the resident. Both the Director of Rehab and DON confirmed that PROM is necessary for an accurate JMA, and facility policy requires complete and objective documentation of services provided.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
The facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in injuries. After the incident, a CNA overheard the resident accuse staff of pushing her, but this allegation was not recognized or reported as abuse by the LVN until the following day due to miscommunication. As a result, the required notification to the SSA and Ombudsman was delayed beyond the mandated two-hour window.
A resident with multiple chronic conditions and intact decision-making capacity was not properly informed or involved in their discharge planning. Although the care plan and facility policy required resident participation and communication, documentation showed only the family was contacted, with no evidence that the resident was included in the process.
A resident was placed in isolation without a physician's order upon readmission to the facility, despite testing negative for Influenza A. Staff interviews confirmed the lack of an active order and acknowledged the potential negative effects of isolation. Facility policies emphasize the need for physician orders and the use of the least restrictive measures.
The facility failed to ensure staff performed proper hand hygiene, as observed with a CNA handling trash and touching high-touch areas, an RN entering a resident's room without hand hygiene, and a housekeeping staff member entering a room after touching a mop bucket. Staff interviews confirmed awareness of the importance of hand hygiene in preventing infections.
The facility failed to submit accurate Payroll-Based Journal (PBJ) data for the 3rd quarter of 2024, as required by their policy. The previous payroll staff submitted the PBJ in August, but omitted the rehabilitation department. Despite resubmitting the report in October, the Administrator could not confirm the original submission date due to a lack of documentation. This resulted in inaccurate reporting of direct care staffing information.
The facility failed to provide emergency dialysis kits at the bedside for residents on hemodialysis, as observed in three residents with end-stage renal disease. Despite care plans requiring monitoring and immediate intervention for complications, the necessary emergency supplies were missing. The absence of these kits was confirmed by staff, including a registered nurse and the DON, who acknowledged the risk of delayed treatment during emergencies.
A resident with a documented DNR order was administered CPR against their wishes when found unresponsive. The POLST, signed by the resident's family member, was not honored due to the absence of a code status order in the electronic health record. Facility policies on POLST and DNR orders were not followed, and the resident's dignity was compromised.
A facility failed to include a resident's preferred activities, such as reading, in their care plan, despite the resident's dependence on others for mobility and their expressed interest in reading materials. The resident, who had no cognitive impairment, was observed reading a magazine in bed and reported limited access to reading materials. The Activity Director acknowledged the oversight, noting the care plan should have been updated to reflect the resident's interests.
Two residents in an LTC facility did not receive necessary assistance with ADLs, leading to deficiencies in care. One resident, with paraplegia, was left unattended for over an hour after requesting a diaper change, while another resident, dependent on staff for oral hygiene, showed signs of neglect with dry lips and unclean teeth. Staff interviews and documentation revealed inconsistencies in care provision and record-keeping.
A facility failed to conduct a monthly drug regimen review for a resident on psychotropic medications, as required by policy. The resident, diagnosed with major depressive disorder and bipolar disorder, did not have their medications reviewed for three months. The pharmacist did not send a list of reviewed residents with no recommendations, leading to missing documentation. The DON confirmed the oversight, acknowledging the risk of potential medication interactions.
The facility failed to properly label and date food items, including a pitcher of apple juice and multiple cups of juice and milk, in accordance with professional standards. This was observed during a kitchen tour and follow-up visit with the Dietary Supervisor, who acknowledged the importance of labeling to prevent foodborne illness. The facility's policy requires refrigerated and dry foods to be labeled and dated, which was not adhered to, placing residents at risk.
The facility failed to meet the required 80 square feet per resident in 14 rooms, potentially impacting safe nursing care and privacy. Measurements confirmed the deficiency, although feedback from residents and staff varied. One resident felt the room was tight, while another had no issues. An LVN reported no complaints and stated room change requests were addressed promptly.
A resident with dementia and other conditions was prescribed Meclizine for dizziness, but the facility failed to develop a person-centered care plan or monitor the medication's effects. The resident received Meclizine on a scheduled basis for nearly three months without appropriate interventions or monitoring, contrary to facility policies requiring comprehensive care plans and monitoring for changes in condition.
A facility failed to conduct a pain assessment for a resident with chronic pain syndrome after a change in condition involving pain in the head, chest, and hip. Despite the resident's fluctuating cognitive capacity and transfer to a hospital for further evaluation, the required pain assessment was not completed, as confirmed by the DON. This oversight was against the facility's policy, which mandates assessments upon significant changes in condition.
A resident with dementia, chronic pain syndrome, and Type II diabetes was administered Meclizine 25 mg four times a day for dizziness from June to August without any recommendations for change from the Pharmacy Consultant (PC). The PC failed to notice the continuous prescription during monthly reviews, leading to potential risks of adverse side effects. The Director of Nursing confirmed the lack of recommendations, highlighting a failure to adhere to the facility's medication review policies.
The facility failed to implement effective infection control measures, as staff did not discard N95 masks after exiting COVID-19 positive rooms and a CNA was not fit tested for N95 masks upon hire. Observations showed an LVN reused an N95 mask across different resident rooms, contrary to the facility's Mitigation Plan and policies. This oversight could contribute to the spread of COVID-19 within the facility.
A facility failed to maintain documentation of a current nursing license for an LVN, whose license had expired. Despite this, the LVN was assigned to care for and administer medications to numerous residents on multiple occasions. The deficiency was confirmed through interviews with the LVN, the DSD, and the DON, who acknowledged the lapse in adhering to state licensure requirements.
The facility failed to document the administration of medications and vital signs for several residents, leading to potential risks of double dosing and inaccurate medication records. Medications were not recorded on MARs and narcotic sheets, and blood pressures were not taken prior to administering BP medications.
The facility failed to ensure that an LVN maintained a valid CPR certification while providing care to residents. Despite reminders, the LVN continued to work without a current CPR card, and the DSD did not follow up to ensure renewal. The DON confirmed that all nursing staff must have a current CPR card to perform their duties.
The facility failed to develop and implement a care plan for a resident with a right leg contracture. Despite the resident's multiple diagnoses and need for maximum assistance, the care plan did not address the contracture, leading to inadequate guidance for staff. The DON confirmed the omission, which was against the facility's policy for comprehensive, person-centered care plans.
Failure to Develop Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident identified on admission as being at risk for wandering and elopement. The resident was admitted with diagnoses including parkinsonism, Alzheimer’s disease, dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, a history of TIA, and cerebral infarction without residual deficits. The H&P dated 5/8/2026 stated the resident lacked capacity to make and understand decisions and could not make known ADLs. The resident’s record showed a wandering risk assessment was completed on admission, and staff later confirmed the resident was at risk for wandering from day one. However, the Care Plan Report contained no initial care plan for wandering/elopement risk in the resident’s medical record. RN 1 stated that when the resident was assessed as at risk for wandering on 5/7/2026, a care plan was not created, and there were no interventions in place to prevent elopement. RN 1 also stated care plans were part of staff communication and without one, staff would not have known how to monitor the resident. On 5/11/2026, the resident was found missing from the wheelchair location in Station B, staff searched the facility and surrounding area, 911 was called, and the resident’s wife and physician were notified. The resident was later found at a local intersection, taken to the ER for skin abrasions related to a fall outside the facility, and then transferred to the ED, where documentation stated the resident had wandered from the facility, fallen, and injured the right elbow. The DON stated care plans were to be created immediately upon admission and that the resident’s diagnoses and assessment supported wandering/elopement risk, but the care plan for that risk was not created until after the elopement.
Failure to Notify Physician of Resident’s New Fracture and Treatment After Hospital Readmission
Penalty
Summary
The facility failed to immediately notify a resident’s primary care physician of a change in condition and treatment following the resident’s return from a General Acute Care Hospital (GACH). The resident, who had type 2 diabetes mellitus and dementia with severely impaired cognition, was dependent for toileting, lower body dressing, and footwear. According to the electronic medical record progress note dated 12/27/2025 at 22:25, the resident returned from the hospital via ambulance with a right arm splint and sling due to a right elbow fracture. The GACH after-visit summary documented a new diagnosis of a radius fracture and right elbow joint pain, with discharge instructions for a follow-up orthopedic appointment and a nursing communication order for application of a right posterior long arm splint. Record review showed there was no documentation that the attending physician was notified of the resident’s readmission, the new elbow fracture diagnosis, or the presence of the right arm device. During interview, the DON stated that all licensed nurses are expected to notify the physician when residents are readmitted from the hospital or when there is a change of condition, and confirmed there was no such documentation in the resident’s progress notes. The treatment nurse reported that she did not notify the physician about the right arm device because she forgot. The facility’s policy titled “Admission Assessment and Follow up: Role of the Nurse,” revised 01/2025, requires contacting the attending physician to communicate and review findings of the initial assessment and other pertinent information and to obtain admission orders based on these findings.
Failure to Assess, Obtain Orders, and Care Plan for Arm Immobilizer After Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, and to complete required assessments and care planning for a resident following readmission from a general acute care hospital (GACH). The resident had diagnoses including peripheral vascular disease, type 2 diabetes mellitus, and a non‑pressure chronic ulcer on the right foot, and had severe cognitive impairment with dependence on staff for toileting hygiene, lower body dressing, and footwear. The resident’s history and physical documented that the resident did not have capacity to understand and make decisions. An SBAR form showed that on one date the resident was found unable to move the right arm and complained of severe pain with movement, and the PCP was notified and ordered transfer to the hospital via 911. Progress notes documented that the resident returned from the GACH later that evening with an arm splint and sling on the right arm due to a right elbow fracture and was experiencing discomfort in the affected arm. Staff interviews indicated that when an LVN started her shift the next day, she observed the resident back from the hospital with a cast on the right arm due to a radial head fracture, but on a later shift the cast was no longer present. The LVN reported being informed by the DON that the cast had been removed because an X‑ray had ruled out a fracture. The Director of Rehabilitation stated that the resident returned with an immobilizer on the right arm but that he did not conduct an assessment upon the resident’s return, explaining that because the fracture was ruled out, he did not consider this a change in condition requiring assessment. During interview and record review with the DON, it was confirmed that the resident returned from the GACH with an immobilizer on the right arm and that facility expectations upon readmission included notifying family and physician, documenting notifications, obtaining pertinent records from the GACH, and conducting comprehensive and skin assessments, as well as initiating and implementing a care plan for any change in condition. However, the record showed no documentation of a comprehensive assessment upon readmission, no physician order for use and monitoring of the right arm device, no resident‑centered care plan addressing the right arm device, and no monitoring of the device’s use. The facility’s policy on comprehensive person‑centered care plans stated that the interdisciplinary team reviews and updates the care plan when a resident is readmitted from a hospital stay, but this was not carried out for this resident.
Medication pass error rate exceeded threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during an observed medication pass for Resident 53. On 12/16/2025, LVN 1 prepared and administered multiple medications to the resident, including Amlodipine, Atorvastatin, Losartan Potassium, MiraLAX, Potassium Chloride, Vitamin C, Zinc Sulfate, Calcium and Vitamin D3, Metformin, Metoprolol, Hydralazine, Simethicone, and Peridex Mouth/Throat Solution. During the observation, LVN 1 did not administer Aspirin at the scheduled 9:00 AM time and later stated the medication was not given because the cart only contained enteric coated Aspirin that could not be crushed for g-tube administration. Resident 53 was admitted with diagnoses including malignant neoplasm of the large intestine, surgical aftercare following digestive system surgery, intestinal obstruction, dysarthria following cerebral infarction, atherosclerotic heart disease, and GERD. The resident’s orders included Aspirin 325 mg via g-tube daily for antiplatelet therapy and Simethicone 1.8 ml via g-tube three times daily for gas relief. The MAR showed Aspirin was due at 9:00 AM and Simethicone at 8:00 AM, 12:00 PM, and 9:00 PM. LVN 1 stated Simethicone was given late because he was busy and could not administer it on time. During interview and record review, LVN 1 stated the facility did not have the non-enteric coated Aspirin available in the supply room and he contacted the pharmacy for delivery. He later administered 325 mg of non-enteric coated Aspirin at 1:04 PM, which was 3 hours late, and stated he should have notified the DON when the supply was low. The DON stated the Simethicone was given 30 minutes late and that the Aspirin should have been given on time. The DON also stated medications should be administered within one hour before or after the scheduled time, and the facility policy stated medications are administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
OTC Medications Stored Without Temperature Monitoring
Penalty
Summary
The facility failed to store over-the-counter medications at proper temperature controls in one medication stockroom, as required by its Policy and Procedure titled Storage of Medications dated 5/2025. During an interview, RN 1 stated the facility had one medication room and a stockroom where OTC medications were stored. During a concurrent observation and interview with the DON, the stockroom was observed to contain shelves with bottles of Citrate, Vitamin D3, [NAME]-Vite, Ferrous Sulfate, Benadryl, Loratadine, Aspirin, Vitamin B12, Multivitamins and Minerals, Zinc, Vitamin C, Cranberry pills, Vitamin B1, Bisacodyl, Docusate Sodium, Geri-tussin, Lactobacillus, Clear lax, Sorbitol, and Tylenol. No thermometer was observed in the stockroom. The DON confirmed the stockroom did not have a thermometer and stated she did not know the temperature of the room or whether it was appropriate for medication storage. The DON also stated the room felt comfortable but there was no way of knowing the actual temperature. A record review of the facility's policy stated medications must be stored under appropriate conditions and temperatures, and room-temperature medications must be stored between 15 degrees Celsius (59 degrees Fahrenheit) and 30 degrees Celsius (86 degrees Fahrenheit).
Food Storage and Utensil Handling Deficiencies
Penalty
Summary
Safe and sanitary food storage and distribution practices were not maintained in the kitchen dry storage room and food service area. During an initial kitchen tour with the Dietary Supervisor, three dry storage containers labeled rice, flour, and sugar were observed without a use by date. Seven scoops used for dry storage foods were also observed stacked together, with each scoop placed inside or on top of another and a white powder-like substance on the bottom scoop. The Dietary Supervisor stated the scoops should not be placed on top of or inside each other, that each scoop had to be placed on a tray, and that each scoop had to be designated to a dry storage bin and kept clean. The Dietary Supervisor also stated the dry storage containers had to be dated and labeled with the prepared and use by date. During a separate observation in the kitchen, a trash receptacle used for disposal of paper towels after handwashing was positioned directly next to a cart holding 19 food dome covers. A Dietary Aid confirmed the food dome covers were stored next to the trash receptacle and could cause cross contamination of residents' food, and stated the covers would be rewashed. The Dietary Supervisor, Infection Preventionist, and DON each confirmed that storing the food dome covers adjacent to the trash receptacle could create cross-contamination or infection control concerns and could contaminate residents' food. Facility policy and the 2022 FDA Food Code were reviewed and indicated cleaned utensils and equipment must be stored in a clean, dry location protected from contamination.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property immediately, and no later than 2 hours after the allegation was made, to the California Department of Public Health (CDPH) for one resident. The allegation involved missing money that the resident reported as approximately $2,000, and the facility’s failure delayed an onsite inspection by CDPH to ensure the allegation was investigated. The report states this deficiency had the potential to place the resident at further risk for abuse. Resident 63’s record showed an original admission on 1/13/2021 and a readmission on 12/11/2025. Diagnoses listed in the record included type 2 DM, acute respiratory failure with hypoxia, ischemic cardiomyopathy, morbid obesity, myocardial infarction type 2, unspecified glaucoma, and dependence on oxygen. The MDS dated 10/7/2025 indicated the resident had the ability to understand others and make himself understood, while the H&P dated 12/12/2025 described fluctuating capacity to understand and make decisions. Progress notes dated 5/16/2025 documented that the resident spoke with staff about an investigation into missing money and stated the amount was around $2,000. During interviews, the resident said he had reported the missing money to the Administrator and Social Services Director, and that the facility reported the matter to police. The SSD stated he reported the allegation to local law enforcement only and did not report it to the Ombudsman or CDPH. The SSD later confirmed the allegation was not reported to the Ombudsman or CDPH, and the ADM stated the allegation was not reported because she was not aware of the facility’s Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy. Facility leadership reviewed the policies and acknowledged that the allegation should have been reported to CDPH and the Ombudsman.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure 14 of 18 resident rooms met the required 80 square feet per resident in multiple-occupancy rooms. A room waiver letter dated 12/4/2025 showed the facility was requesting a variance for rooms [ROOM NUMBER], 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, and 38, with listed floor areas ranging from 146.06 to 289.53 square feet and capacities of 2 or 4 residents. The letter stated the rooms were in accordance with the special needs of the residents and would not inhibit residents from getting in and out of wheelchairs or affect their health, safety, or highest practicable well-being. During an observation on 12/15/2025, the Maintenance Supervisor measured rooms [ROOM NUMBER] and found one room measured 150.5 square feet for 2 residents and another measured 146.5 square feet for 2 residents. During multiple observations of nursing care in rooms [ROOM NUMBER], nursing staff were observed with adequate space to provide care, and residents had privacy curtains, working call-lights, storage, and bedside tables with personal belongings stored in each resident's chosen location. Interviews with Resident 90, LVN 1, and Resident 91 indicated the rooms were big enough, residents had not experienced problems with space, and staff had been able to provide care without issues. The facility policy titled Resident bedrooms, revised 8/2024, stated resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy and must measure at least 80 square feet per resident in multiple resident bedrooms.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Inaccurate Joint Mobility Assessment Due to Lack of Hands-On Evaluation
Penalty
Summary
The facility failed to accurately conduct a Joint Mobility Assessment (JMA) for a resident with multiple diagnoses, including dementia, type 2 diabetes, osteoporosis, osteoarthritis, and contracture. The resident was admitted with severe cognitive impairment and required substantial to maximal assistance with most activities of daily living. The JMA, dated 5/27/2025, indicated the resident had minimal to severe loss of lower extremity passive range of motion (PROM) and was at risk for contracture development. The assessment recommended a physical therapy evaluation and RNA services for PROM of both upper extremities. During interviews and record reviews, it was revealed that the physical therapist performed the JMA through observation and interviews with CNAs, without physically touching or moving the resident to assess PROM. The physical therapist confirmed that PROM was not performed during the assessment, and acknowledged that joint integrity could not be determined by observation alone. The Director of Rehab stated that PROM must be performed during a JMA to accurately assess joint condition, and that failing to do so results in an inaccurate assessment. The Director of Nursing also confirmed that inaccurate JMAs could result in residents not receiving necessary care. Facility policy required all services and changes in resident condition to be documented objectively, completely, and accurately in the medical record.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive program but does not provide specific details about individual residents, staff actions, or particular infection control lapses observed during the survey.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
A facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency (SSA) and the Ombudsman within the required two-hour timeframe. The incident involved a resident with multiple diagnoses, including dementia, diabetes, anxiety, osteoarthritis, and chronic kidney disease, who had severely impaired cognition and required significant assistance with daily activities. The resident experienced an unwitnessed fall, resulting in a forehead laceration and bilateral elbow skin tears, and was subsequently transferred to a general acute care hospital for evaluation and treatment. Following the resident's return to the facility, it was discovered during the investigation that a Certified Nurse Assistant (CNA) had overheard the resident say, "you pushed me," in Spanish, directed at the CNA who found her after the fall. This information was initially communicated by the CNA to a Licensed Vocational Nurse (LVN) on the night of the incident, but the LVN misunderstood the statement and did not recognize it as an abuse allegation. The next day, the CNA repeated the statement to the LVN and a Registered Nurse (RN), at which point the allegation was reported to the facility Administrator and Director of Nursing (DON). The facility's policy required immediate reporting of abuse allegations to the SSA, Ombudsman, and other authorities within two hours if the allegation involved abuse or resulted in serious bodily injury. However, due to miscommunication and misunderstanding between staff members, the abuse allegation was not reported until the following day, well beyond the required timeframe. This delay was confirmed through interviews with the involved staff and review of facility documentation.
Failure to Involve Resident in Discharge Planning
Penalty
Summary
The facility failed to follow its policy and procedures for discharge planning for one resident. The resident, who had diagnoses including diabetes mellitus, hypertension, atrial fibrillation, hyperlipidemia, and chronic kidney disease, was assessed as having the capacity to understand and make decisions, with intact cognitive skills for daily decisions. The resident was independent in bed mobility and required varying levels of assistance with other activities of daily living. The care plan for discharge planning included interventions such as providing written and verbal instructions at the patient/family's level of understanding and reviewing and discussing the discharge plan with the resident and family as appropriate. Despite these requirements, a review of the case manager's progress notes revealed that only the resident's family member had been contacted regarding discharge planning, with no documentation indicating that the resident was informed or involved in the discharge plan over the previous three months. The case manager confirmed there was no evidence in the notes to show the resident's involvement. Facility policies reviewed stated that residents have the right to be informed of and participate in their care planning and treatment, and that post-discharge plans should be developed with the assistance of the resident and family. This lack of documentation and involvement constituted a failure to ensure the resident was properly informed and involved in their discharge plan.
Resident Isolated Without Physician's Order
Penalty
Summary
The facility failed to honor the right of a resident to be free from involuntary seclusion by placing a resident in isolation without a physician's order. The resident, who was admitted with diagnoses including dementia, COPD, and dysphagia, was initially placed under droplet and contact isolation precautions upon admission due to a diagnosis of Influenza A. However, after being readmitted from a General Acute Care Hospital, the resident was placed in isolation again despite testing negative for Influenza A and without an active physician's order. Interviews with facility staff, including the Infection Prevention Nurse and a Licensed Vocational Nurse, confirmed that the resident was placed in isolation upon readmission without a physician's order. The staff acknowledged that residents should not be isolated without such orders and recognized the potential negative effects of isolation, such as anxiety and depression. The Director of Nursing also confirmed the absence of an active isolation order upon the resident's readmission. The facility's policy and procedures on isolation and abuse prevention emphasize the use of the least restrictive measures and the necessity of physician orders for isolation. Despite these guidelines, the resident was isolated without proper authorization, which could lead to psychological harm. The Medical Doctor interviewed stated that isolation for influenza should typically last five days, but the resident should not have been isolated upon readmission as there was no active infection warranting such measures.
Failure to Implement Hand Hygiene Practices
Penalty
Summary
The facility failed to implement its infection control policy by not ensuring that staff members performed proper hand hygiene. Observations revealed that a Certified Nursing Assistant (CNA) handled trash and touched high-touch areas such as curtains and bedside tables without applying hand hygiene. Similarly, a Registered Nurse (RN) entered a resident's room, touched a bedside table, and donned gloves without performing hand hygiene before or after the procedure. Additionally, a Housekeeping staff member was observed touching a mop bucket and entering a resident's room without applying hand hygiene. Interviews with the staff confirmed their awareness of the importance of hand hygiene in preventing the spread of infections. The CNA acknowledged the need to apply hand hygiene after handling trash and before touching high-touch areas. The RN admitted to not performing hand hygiene before entering a resident's room and recognized its importance in infection control. The Director of Staffing Development and the Director of Nursing both emphasized the necessity of hand hygiene practices among staff to prevent infection outbreaks, as outlined in the facility's Infection Prevention and Control Program policy.
Failure to Submit Accurate PBJ Data for 3rd Quarter 2024
Penalty
Summary
The facility failed to ensure the accurate and timely submission of the Payroll-Based Journal (PBJ) for the 3rd quarter of 2024, covering the period from April 1 to June 30. This deficiency was identified through a review of the Certification and Survey Provider Enhanced Reports (CASPER) for the PBJ Staffing Data Report, which indicated a failure to submit data for the quarter. During an interview, the Administrator (ADM) and payroll staff (Staff 1) revealed that the previous payroll staff had submitted the PBJ in August 2024, but there were issues with the submission, including a failure to include the rehabilitation department. The facility attempted to rectify this by resubmitting the report in October, but the ADM could not confirm the exact date of the original submission due to a lack of documentation. The facility's policy and procedure for reporting direct care staffing information, dated August 2022, required that staffing data be submitted electronically to CMS no later than 45 days after the end of the reporting quarter, with the deadline for the 3rd quarter being August 14. Despite the ADM's efforts to verify the submission date, the CASPER Reports Submit printout did not include a date, and the ADM was unable to produce evidence of the submission date. This lack of documentation and failure to adhere to the facility's policy resulted in the inaccurate reporting of direct care staffing information, potentially placing the facility at risk of not implementing their policy effectively.
Lack of Emergency Dialysis Kits for Residents on Hemodialysis
Penalty
Summary
The facility failed to ensure that residents receiving hemodialysis had an emergency dialysis kit at their bedside, which is crucial for immediate intervention in case of accidental bleeding. This deficiency was observed in three residents, each with a diagnosis of end-stage renal disease and dependence on renal dialysis. The absence of these kits was confirmed during observations and interviews with the facility's staff, including a registered nurse and the Director of Nursing (DON). Resident 46, admitted with end-stage renal disease, had a care plan that required daily monitoring of the dialysis access site and immediate intervention for any complications. However, during an observation, no emergency kit was found at the bedside. Similarly, Resident 9, also on dialysis, did not have an emergency kit available, as confirmed by a registered nurse. The care plan for Resident 9 included monitoring for signs of infection and bleeding, yet the necessary emergency supplies were missing. Resident 32, with a moderately impaired cognition and on dialysis, was also found without an emergency kit at the bedside. The facility's Director of Nursing acknowledged the importance of having these kits readily available to prevent delays in treatment during emergencies. The report highlights that the facility did not have a policy for dialysis emergency kits, which contributed to the oversight in providing these essential supplies for residents on dialysis.
Failure to Honor DNR Order for a Resident
Penalty
Summary
The facility failed to honor the Physician's Order for Life-Sustaining Treatment (POLST) for a resident, identified as Resident 58, who had a documented Do Not Resuscitate (DNR) order. Despite the POLST indicating that no cardiopulmonary resuscitation (CPR) should be performed if the resident had no pulse and was not breathing, CPR was administered when Resident 58 was found unresponsive. This action was contrary to the resident's documented wishes and the POLST signed by the resident's family member, who was the surrogate decision maker. The deficiency was further highlighted by the lack of a code status order in the resident's electronic health record, which was confirmed by both a registered nurse and the Director of Nursing (DON). The facility's policies on POLST and DNR orders were not followed, as the POLST instructions were not added to the resident's admitting orders for physician review. The facility's policy on dignity, which emphasizes honoring resident goals and preferences, was also not adhered to in this instance.
Failure to Include Resident's Activity Preferences in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident, identified as Resident 16, which resulted in the omission of the resident's preferred activities in their care plan. Resident 16 was admitted with diagnoses including muscle wasting, a sacral pressure ulcer, and dependence on oxygen. The Minimum Data Set (MDS) assessment indicated that reading materials such as books, newspapers, and magazines were important to Resident 16, who had no cognitive impairment but was totally dependent on others for bed mobility and transfers. However, the Activities care plan, revised on 10/10/2024, did not include these interests, focusing instead on inviting the resident to scheduled activities without considering their specific preferences. During an observation and interview, Resident 16 was found reading a magazine in bed and expressed that they had not been able to leave their room due to mobility issues and discomfort from hemorrhoids and a wound on their lower back. The resident mentioned that magazines were offered only once or twice. The Activity Director confirmed that the facility provided various recreational activities but acknowledged that Resident 16's care plan should have been updated to reflect their current interests. The facility's policy on comprehensive person-centered care plans, revised in July 2024, mandates the inclusion of measurable objectives and timeframes to meet residents' needs, which was not adhered to in this case.
Deficiencies in ADL Assistance and Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, Resident 31 and Resident 214, leading to deficiencies in care. Resident 31, who was admitted with paraplegia, Type II diabetes, and end-stage renal disease, required total assistance for toileting and personal hygiene. On the evening of November 11, 2024, Resident 31 requested a diaper change due to a bowel movement, but the assigned CNA did not return to assist, leaving the resident unattended until the next shift. Interviews with staff confirmed that the call light was acknowledged but not acted upon, resulting in a delay of over an hour before the resident received the necessary care. Resident 214, admitted with nontraumatic intracerebral hemorrhage and hemiparesis, was dependent on staff for oral hygiene. Observations revealed that Resident 214 had dry lips and a thick substance on the teeth, indicating a lack of oral care. The resident reported that oral care was last provided by a family member a week prior. The facility's oral hygiene records showed inconsistencies, with several instances marked as non-applicable, suggesting that oral care was not provided as required. Interviews with staff confirmed that oral care was supposed to be provided once per shift, but this was not consistently documented or performed. The Director of Nursing acknowledged the deficiencies in both cases, noting the importance of timely assistance to prevent skin breakdown and maintain dignity. The facility's policies on ADLs and mouth care were reviewed, highlighting the need for staff to report and document care accurately. The discrepancies in documentation and the lack of timely assistance contributed to the deficiencies observed in the care of Residents 31 and 214.
Failure to Conduct Monthly Drug Regimen Review for Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review (DRR) for a resident, identified as Resident 6, who was on psychotropic medications. Resident 6, diagnosed with major depressive disorder and bipolar disorder, was admitted to the facility and was prescribed Venlafaxine and Quetiapine. However, the facility's records showed that the DRR for Resident 6's medications was not conducted for the months of August, September, and October 2024. This oversight was confirmed during a review of the DRR binder and interviews with the Director of Nursing (DON) and the pharmacist. The pharmacist admitted to not sending a list of residents reviewed with no recommendations each month, which led to the absence of DRR documentation for Resident 6. The facility's policy required a monthly medication regimen review for each resident, regardless of whether changes were recommended. The DON acknowledged that the pharmacist was supposed to send the DRR for each resident monthly, and the absence of this review posed a risk of potential medication interactions. The medical director also stated that it was his responsibility to review the medications, but he was unaware of the frequency of the pharmacist's reviews.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards of food storage, as observed during a kitchen tour with the Dietary Supervisor (DS). Several food items, including a full pitcher of brown liquid identified as apple juice, were found unlabeled and undated in the walk-in refrigerator. The DS acknowledged the importance of labeling to prevent potential foodborne illness from consuming food past its use-by date. Additionally, three packs of bread in the Dry Storage Room were also found undated, which the DS confirmed should have been labeled with a delivery date to track freshness. During a follow-up visit, further deficiencies were noted with at least 79 cups of juice and milk in the walk-in refrigerator being unlabeled and undated. The DS reiterated the necessity of labeling and dating these items to avoid the risk of foodborne illness. A review of the facility's policy on Food Receiving and Storage, revised in July 2024, indicated that refrigerated foods should be labeled, dated, and monitored for use-by dates, and dry foods should be labeled and dated upon delivery. The facility's failure to comply with these standards placed residents at risk for foodborne illness or contamination.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 14 out of 29 rooms met the required 80 square feet per resident in multiple occupancy rooms. During an observation, the Maintenance Supervisor measured the rooms and found that the square footage per resident was below the required standard in rooms 21, 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, and 38. The measurements were confirmed to match the client accommodation analysis. This deficiency had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents. Interviews with residents and staff provided mixed feedback regarding the room sizes. One resident mentioned that the room felt tight and had requested a move to a larger room, although they had not followed up on the request. Another resident stated there was no issue with the room size, and there was enough space for care and visitors. A Licensed Vocational Nurse indicated that there were no issues performing tasks in the rooms and that any requests for room changes were addressed promptly. Despite these observations, the facility's policy required bedrooms to measure at least 80 square feet per resident in double rooms, which was not met in the identified rooms.
Lack of Person-Centered Care Plan for Dizziness and Medication Administration
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan for a resident who was experiencing dizziness and was prescribed Meclizine four times a day. The resident, who had a history of dementia, chronic pain syndrome, and Type II diabetes mellitus, was admitted to the facility and required substantial assistance with daily activities. Despite being prescribed Meclizine for dizziness, there was no individualized care plan developed to address the resident's condition or the administration of the medication. The resident's medical records indicated that Meclizine was administered on a scheduled basis for nearly three months without a care plan or monitoring for potential side effects. The facility's Pharmacy Consultant expressed surprise at the prolonged scheduled administration of Meclizine, which is typically prescribed as needed. The Director of Nursing acknowledged the absence of a care plan and monitoring, which should have been initiated following the resident's change in condition. The facility's policies required comprehensive person-centered care plans and monitoring for changes in a resident's condition. However, these were not followed, resulting in a lack of monitoring and appropriate services for the resident. The deficiency was identified through interviews and record reviews, highlighting the facility's failure to develop and implement a care plan for the resident's dizziness and medication administration.
Failure to Conduct Pain Assessment After Change of Condition
Penalty
Summary
The facility failed to provide a pain assessment for a resident diagnosed with chronic pain syndrome after a change in condition, which involved pain on the right side of the head, chest, and hip. The resident, who had a history of dementia and fluctuating cognitive capacity, was admitted with chronic pain syndrome and was receiving scheduled pain medication. Despite the resident's condition worsening, as indicated by the need for transfer to a General Acute Care Hospital for further evaluation, the facility did not complete a required pain assessment. The Director of Nursing confirmed that the licensed staff did not complete a Pain Assessment form following the resident's change of condition, which was a requirement according to the facility's policy. The facility's policy, revised in October 2022, mandates pain assessments upon admission, at quarterly reviews, and whenever there is a significant change of condition or onset of new or worsening pain. The failure to conduct a pain assessment after the resident's change of condition was identified as a deficiency, potentially impacting the resident's care and pain management.
Failure in Medication Regimen Review for Resident
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant (PC) thoroughly completed a monthly Medication Regimen Review (MRR) for a resident, leading to the administration of medication that was not optimal for the resident's medical condition. The resident, who was admitted with diagnoses including dementia, chronic pain syndrome, and Type II diabetes mellitus, was prescribed Meclizine 25 mg four times a day for dizziness. This medication was administered daily from June to August without any recommendations for change from the PC, despite the resident experiencing symptoms such as severe headache, dizziness, and fluctuating blood pressure. The PC admitted to not noticing the continuous prescription of Meclizine 25 mg four times a day during the reviews conducted in June, July, and August. The PC expressed shock upon realizing that the medication was given on a scheduled basis for almost three months and acknowledged the failure to re-evaluate the order based on the resident's symptoms. The Director of Nursing (DON) confirmed that the PC did not make any recommendations regarding the resident's medications during this period, which could have placed the resident at risk for adverse side effects. The facility's policy and procedure on Medication Utilization and Prescribing-Clinical Protocol indicated that the consultant pharmacist should review medication usage patterns and make recommendations for medications that present higher risks. However, the PC did not adhere to these guidelines, as evidenced by the lack of recommendations for the resident's medication regimen. The facility's policy also required the PC to have access to the resident's complete medical records, which should have facilitated a more thorough review of the medication regimen.
Inadequate Infection Control Practices for COVID-19
Penalty
Summary
The facility failed to implement effective infection prevention and control measures to prevent the spread of COVID-19 among residents and staff. Specifically, the facility did not ensure that staff discarded and did not reuse their N95 masks after exiting rooms in the Red Zone, which is designated for residents who have tested positive for COVID-19. An observation revealed that a Licensed Vocational Nurse (LVN) did not change their N95 mask after exiting a COVID-19 positive resident's room and continued to wear the same mask while attending to other residents. The LVN was unaware of the requirement to change N95 masks after exiting droplet/contact isolation rooms, which was confirmed by the Infection Preventionist Nurse who incorrectly stated that N95 masks could be worn all day unless soiled. Additionally, the facility failed to perform fit testing for N95 masks for a Certified Nursing Assistant (CNA) upon hire, which is necessary to ensure the mask provides a proper seal and protection against airborne illnesses. The CNA had been employed for two months and had been assigned to care for both COVID-19 positive and negative residents without having undergone fit testing. The Director of Staff Development confirmed that fit testing was not performed upon hire, and the Director of Nursing acknowledged that this oversight could contribute to the spread of infection. The facility's Mitigation Plan and policies required staff to fully doff all personal protective equipment (PPE) and don new PPE when moving between different sections of the facility, particularly when crossing from the Red Zone to other areas. The plan also specified that face masks should be used only once and discarded in the appropriate receptacle. However, these protocols were not followed, as evidenced by the observations and interviews conducted during the survey, leading to a potential risk of spreading COVID-19 within the facility.
Expired Nursing License Leads to Deficiency
Penalty
Summary
The facility failed to maintain documentation of state licensure for one of its Licensed Vocational Nurses (LVN 2), whose nursing license had expired. A review of LVN 2's employee file revealed that the license expired on a specific date, yet LVN 2 continued to be assigned to care for and administer medications to a significant number of residents on multiple occasions. This oversight was confirmed during an interview with the Director of Staff Development (DSD), who acknowledged that LVN 2 worked at the facility and was responsible for resident care on several specified dates despite the expired license. Interviews with LVN 2 and the Director of Nursing (DON) further confirmed the deficiency. LVN 2 admitted that her nursing license had expired and had not been renewed. The DON stated that all nurses were required to renew their licenses every two years and acknowledged that having staff without a current Vocational Nursing License could potentially result in residents receiving inadequate medical care. The facility's policy on staffing, which was updated recently, indicated that all nursing staff must meet the competency requirements defined by state law, which was not adhered to in this case.
Failure to Document Medication Administration and Vital Signs
Penalty
Summary
The facility failed to ensure that licensed nurses documented the administration of medications on residents' medication administration records (MAR) and controlled drug records (narcotic sheets). Specifically, 26 out of 26 medications were not documented as administered for three residents, and eight out of eight removed narcotic medications were not recorded for four residents. Additionally, blood pressures were not taken or recorded prior to the administration of blood pressure medications for two residents. These deficiencies had the potential to misrepresent the actual medications administered, undercount the actual narcotics taken, and misrepresent the narcotic medication inventory on hand for each shift. Resident 8, who was admitted with chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, and supraventricular tachycardia, had orders for diltiazem to be held for specific blood pressure and heart rate thresholds. However, the MAR indicated that blood pressures and heart rates were not recorded prior to the administration of diltiazem. Resident 9, who had severe cognitive impairment and was admitted with cerebral infarction and hemiplegia, had morphine sulfate not documented as administered or removed from the medication bottle, leading to discrepancies in the narcotic sheet. Resident 2, admitted with type 2 diabetes mellitus, peripheral vascular disease, and hypertensive chronic kidney disease, had multiple medications, including heparin sodium injection and hydralazine, not documented as administered. Blood pressures were also not recorded prior to the administration of hydralazine. Resident 5, who had atherosclerosis, essential hypertension, and polyneuropathy, had several medications, including hydromorphone, not documented as given. Interviews with the residents and licensed vocational nurses (LVNs) revealed that the medications were administered but not documented, leading to potential risks of double dosing and inaccurate medication records.
Expired CPR Certification for LVN
Penalty
Summary
The facility failed to ensure that one of its licensed nurses, LVN 4, maintained a valid CPR certification while providing care to residents. During an observation and record review, it was found that LVN 4's CPR card had expired. Despite being reminded by the Director of Staff Development (DSD) to renew the certification, LVN 4 continued to work in the facility without a valid CPR card. LVN 4 acknowledged the expiration and mentioned that although a CPR class was taken, the renewed card had not yet been received. The DSD admitted to not following up to ensure the renewal was completed, and the Director of Nursing (DON) confirmed that all nursing staff must have a current CPR card to perform their duties. The facility's schedule showed that LVN 4 worked multiple shifts after the CPR card had expired, including double shifts and overnight shifts. The deficiency was identified through interviews with LVN 4, the DSD, and the DON, as well as a review of the facility's schedules and LVN job description. The job description emphasized the necessity for nurses to have the appropriate licensure and certification to perform their tasks. The failure to ensure LVN 4's CPR certification was current had the potential to compromise the quality of care provided to residents, as it is crucial for nurses to stay updated on the latest CPR techniques to respond effectively in emergencies.
Failure to Develop and Implement Care Plan for Resident's Right Leg Contracture
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan for a resident with a right leg contracture. The resident, who was admitted with multiple diagnoses including Type II diabetes mellitus with diabetic chronic kidney disease, unspecified osteoarthritis, and other specified disorders of bone density and structure, had a care plan initiated that did not address the right leg contracture. The care plan only mentioned the resident's limited physical mobility and aimed to prevent complications related to immobility, but it did not include specific interventions for the contracture. The resident required maximum assistance with dressing, toilet use, and personal hygiene, and had an order for restorative nursing assistance to prevent decline in range of motion and strength, but these were not adequately addressed in the care plan. During an observation, it was noted that the resident's right leg was immobilized with a soft cast and pillows, but there was no corresponding care plan to guide this intervention. The Director of Nurses confirmed that no care plan was created for the right leg contracture and acknowledged that this omission meant other disciplines would not know how to properly care for the resident. The facility's policy required a comprehensive, person-centered care plan to be implemented within seven days of the MDS assessment and reviewed and updated as needed, but this was not followed in this case.
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What surveyors actually found near you
We read the 6,962 citations issued within 25 miles in the last 12 months — including the 38 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Virgil Rehabilitation & Skilled Nursing Center | 0.7 mi | ★★★★★ | 30 | 1 |
| Hollywood Presbyterian Medical Center D/p Snf | 1 mi | ★★★★★ | 22 | 0 |
| Temple Park Convalescent Hospital | 1.1 mi | ★★★★★ | 4 | 0 |
| The Meadows On Sunset Post Acute | 1.5 mi | ★★★★★ | 49 | 1 |
| Alexandria Care Center | 1.5 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.