Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glendora Canyon Transitional Care Unit during CMS and state inspections, most recent first.
A resident with sepsis and DM, intact cognition, and functional limitations requiring assistance with ADLs did not have all meal intakes documented by CNAs as required. Review of documentation showed that while most meals had recorded intake amounts, several meals over two months lacked any meal intake entries. A CNA and the DON confirmed that CNAs were expected to chart meal intake, including refusals, after each meal and before the end of the shift, and that this was required by the CNA job description and the facility’s charting and documentation policy.
A resident with a lower leg fracture, hypertension, and dependence on staff for most ADLs lost health insurance coverage for skilled services after Medicare ended because the SSD did not follow through on assisting with a Medi-Cal application. During an IDT meeting, a family member requested help with Medi-Cal, and the SSD said the Business Office Manager would assist, but no effective follow-up occurred. This failure did not comply with the SSD job description and facility policy requiring social services staff to inform and educate about Medicare/Medi-Cal and financial assistance programs and to assist with related financial matters, resulting in the resident personally paying for skilled nursing services after Medicare coverage stopped.
Residents were labeled as "feeders" instead of being addressed by their legal, proper, or preferred names. One resident had cerebral infarction, DM, HTN, and severely impaired cognition with extensive assistance needs; another had UTI, prostate cancer, acute kidney failure, and severely impaired cognition; and a third had Alzheimer's disease, dementia, hospice services, and was dependent for eating. Staff, including a CNA, RN, and LVN, referred to these residents as feeders, while the IPN, ADON, and DON stated residents should be addressed by name to preserve dignity.
Call lights were not accessible in four private shower areas, where the emergency pull cords were located outside the shower area and were not reachable for residents. A resident with glaucoma, legal blindness, severely impaired vision, and severely impaired cognition also had a call light wrapped around the bed siderails and could not locate it. Staff stated the resident needed an accessible call system, and facility policy required shower pull cords to be within reach.
A facility failed to develop and implement specific, resident-centered CPs for residents with dementia, psychosis, a stage 4 pressure ulcer, and smoking-related needs. The records showed missing CP details for dementia meds, a low air loss mattress order, and smoking supervision/protective equipment. Staff and leadership stated the CPs should have been specific and used to guide care, but the resident smoking observation showed the resident outside without a smoking apron while the AA remained inside and did not provide direct supervision.
Improper LALM Settings for Residents With Pressure Ulcers: The facility failed to set LALMs correctly for two residents with skin breakdown. One resident with hemiplegia, impaired cognition, and active wounds had a LALM set at 400 lbs despite staff stating it should have been set much lower or per comfort, and the resident said the bed was uncomfortable. Another resident with a stage 4 pressure ulcer and obesity weighed 266 lbs, but the LALM was set at 350 lbs; the resident reported discomfort, and staff confirmed the setting was too high and not aligned with the order to set it by weight or comfort.
The facility failed to provide appropriate catheter care for two residents. One resident with a Foley catheter was observed with the tubing not secured to the thigh, despite the care plan and facility policy requiring stabilization to prevent trauma. Another resident with a suprapubic catheter had scattered redness and excoriation around the site, and staff stated the site should have been monitored for skin breakdown and infection as directed by the care plan and facility policy.
Respiratory Equipment and Oxygen Safety Deficiencies: A facility failed to manage oxygen therapy and breathing-treatment equipment for multiple residents. One resident receiving oxygen had tubing stored on the bed rail, no physician order was found for the oxygen, and no Oxygen in Use sign was posted. Another resident’s inhalation tubing was left unlabeled on the bedside table and no care plan was developed for the breathing treatments. Additional residents receiving oxygen or nebulizer therapy also lacked required Oxygen in Use signage or had unlabeled, overdue tubing and mask equipment, despite staff acknowledging the expected practices.
Two residents with severely impaired cognition and significant care needs had bilateral 1/4 side rails ordered and in use without documentation that less restrictive alternatives were tried first. One resident had a right arm fracture and sling, and the other had epilepsy, osteoarthritis, and a history of falling; staff and the IPN confirmed there was no record that appropriate alternatives were attempted before the rails were applied.
Improper glove use was observed during beverage preparation when a dietary aide handled residents' drinks without gloves, did not wash hands after retrieving a new carton of prune juice, and did not wash hands or change gloves after touching the refrigerator door before covering the cups. The DNS and IPN confirmed that staff should wear gloves when handling ready-to-eat items and preparing food and drinks, and the aide stated gloves should be used for infection control and changed after touching different surfaces.
Licensed nurses failed to document IV antibiotic administrations on the MAR for two residents. One resident had sepsis and bacteremia and was ordered IV ampicillin q6h, while another resident had osteomyelitis and was ordered IV piperacillin sod-tazobactam q6h. In both cases, MAR review showed missed documentation for a scheduled dose, and RN 1 confirmed there were no corresponding NPN entries. The ADON and DON stated the nurse should document the MAR after administration and complete it before leaving the facility.
Failure to follow EBP precautions occurred for two residents with indwelling devices. An ADON was observed assessing a resident with a suprapubic catheter without wearing a gown, despite the resident being on EBP for a foley catheter and the care plan calling for gown and glove use during high-contact care. In another room, a resident with a foley catheter had no EBP signage posted outside the door, and the IPN and DON stated residents with indwelling devices required PPE precautions and room signage to alert staff.
Fruit flies were observed in the kitchen dry storage area around banana and white onion storage containers during separate observations with dietary staff and the DNS. Staff stated fruit flies were not acceptable in the kitchen because they were pests that could contaminate food, and the facility’s pest control policy stated the building should be kept free of insects.
A resident with dementia, a right arm fracture, and a history of falls had a bed alarm ordered and was observed in bed with a pad alarm in place. The chart review found no documentation that the resident or responsible party signed consent before the alarm was applied, despite facility policy requiring informed consent for physical restraint devices such as mobility alarms. The IPN and ADON both stated consent should be obtained before use.
Advance Directive Not Readily Accessible: A resident with type 2 DM, dysphagia, and a GT, and with severely impaired cognition and dependence for multiple ADLs, did not have an AD located in the chart or PCC. The IPN could not find an existing AD, the SSD stated none was completed on admission, and the DON stated the AD needed to be readily accessible as a legal document reflecting the resident's medical wishes. The facility policy required staff to inquire about an AD at admission and keep a copy in the medical record.
Failure to Revise Care Plan After Isolation Discontinued: A resident admitted with UTI, prostate cancer, and acute kidney failure had a care plan for contact isolation related to ESBL UTI, but the isolation was later discontinued after antibiotics were started and the resident showed no signs or symptoms of infection. The IPN stated the care plan needed to be revised to reflect the resident’s current care and treatment needs, while the DON stated the care plan should be updated to determine the appropriate current care. The resident also had severely impaired cognition and was dependent for multiple ADLs.
A resident with blindness, psychosis, schizophrenia, parkinsonism, and impaired cognition was assessed as needing supervision and a smoking apron while smoking, but was observed outside smoking without an apron while the AA remained inside the doors looking at a phone. The AA stated he did not provide direct supervision, stayed inside because he disliked smoke, and did not offer a smoking apron because none were available; the DON stated the resident needed staff directly next to him during smoking time.
GT Site Care Not Provided as Ordered: A resident with a GT, dysphagia, and diabetes had an order for licensed staff to clean the GT site, pat dry, and apply a dry dressing daily, but during observation the GT site had no dressing in place. The ADON, TN, and DON all confirmed the site should have had a dry dressing to keep the area clean and dry and to protect the skin, and the resident's care plan called for enteral feeding via GT.
A resident with severe cognitive impairment and legal blindness was physically pushed to the floor by another resident following a verbal altercation, resulting in a comminuted fracture of the hand. Staff and documentation confirmed the incident, and the facility's abuse prevention policy was not effectively implemented to prevent this event.
A resident with severe cognitive impairment and legal blindness alleged being pushed to the floor by another resident, an event witnessed and reported by an LVN. Despite facility policy and mandated reporting requirements, the incident was not reported to the state agency within the required timeframe, as the DON confirmed the delay in notification.
Surveyors observed that two resident shower rooms had temperatures above the facility's policy range, with one room at 82°F and another at 85°F. Both a CNA and an LVN reported the rooms felt hot and stuffy, and the Maintenance Supervisor confirmed ongoing AC issues affecting these areas.
A resident with diabetes and severe cognitive impairment experienced a critically high blood sugar level and required an additional dose of insulin. Facility staff failed to notify the resident's responsible party, did not document the event in the medical record, and did not complete the required SBAR Communication Form, contrary to facility policy.
During an outbreak of COVID-19 and influenza, multiple staff members, a medical provider, and a visitor failed to wear masks properly or at all, and a staff member did not perform hand hygiene before entering a room under enhanced barrier precautions. Despite clear facility policies and public health recommendations requiring mask use and hand hygiene, these protocols were not consistently followed or enforced, even in areas with residents who had active infections.
A resident with Parkinson's disease requested their medication, Pramipexole Dihydrochloride, be administered at 7:30 a.m. to manage tremors. Despite the request being acknowledged by the ADON during an IDT meeting, the facility continued to administer the medication at 9 a.m. until the time was changed days later. This failure to adhere to the resident's care plan potentially increased the resident's tremors.
A resident's medications were found unattended at their bedside, posing a risk due to the resident's severe cognitive impairment. An LVN confirmed the oversight, and the DON noted a similar past incident, highlighting a lapse in medication administration procedures.
Three residents in the facility were found with call lights that were not within reach, contrary to the facility's policy. One resident with hemiplegia had a call light stuck behind bed rails, another with a recent femur fracture could not find their call light, and a third with Alzheimer's had to go around the bed to access it. Staff interviews confirmed that call lights should be easily reachable to ensure timely assistance.
The facility failed to implement its Advance Directives Policy for four residents, resulting in missing or incomplete documentation in their medical records. This included missing Advance Directives and Acknowledgement Forms, which are crucial for ensuring residents' treatment preferences are respected. Interviews with staff confirmed these deficiencies and highlighted the importance of having these documents readily available.
Two residents in an LTC facility faced communication barriers due to ineffective implementation of the facility's language assistance policy. One resident, with heart failure and hypotension, preferred Turkish but was documented as preferring English, leading to communication issues with staff. Another resident, with dementia and hypertension, faced similar issues as the assigned CNA only spoke Spanish and relied on Google Translate without a communication board, contrary to policy.
The facility failed to implement a care plan for a resident with arterial ulcers by not offloading their heels, risking delayed wound healing. Additionally, the facility did not arrange transportation for another resident's medical appointment, resulting in a missed fistulagram. Both deficiencies were due to non-compliance with facility policies on repositioning and transportation.
A resident with Parkinson's disease and multiple pressure ulcers did not receive prescribed wound care for an unstageable pressure ulcer on the right midback for eight days. The treatment, which included cleansing with Normal Saline and applying a hydrocolloid dressing, was not administered due to a registry RN mistakenly discontinuing the order. The DON was unaware of the ulcer until it was inspected, revealing eschar and slough. The facility's policy required MD-ordered treatments, which were not followed, potentially delaying healing.
The facility failed to follow its Policy and Procedure for siderail use for two residents, leading to a deficiency. One resident had siderails installed without a doctor's order or consent, and no alternative interventions were attempted. Another resident had siderails as a mobility aid without a proper assessment or consideration of alternatives. Both residents were at risk for entrapment and injury due to these oversights.
The facility failed to follow its policies on psychotropic medication use for two residents. A resident received Lorazepam without a 14-day stop date, risking unnecessary use. Another resident was given Haloperidol without monitoring for target behavior or side effects, and the medication lacked a specific diagnosis. These actions did not comply with the facility's P&P, which requires stop dates and monitoring for psychotropic medications.
The facility failed to follow proper sanitation practices by allowing a staff member's personal lunch bag in the residents' refrigerator, risking cross-contamination. Additionally, a dome drying rack was found rusty and dirty, with no cleaning schedule in place, violating the facility's policies on equipment maintenance.
A resident's MDS was inaccurately coded, listing English as their preferred language instead of Turkish. This error was discovered when the resident, who has heart failure and hypotension, was observed speaking Turkish and unable to communicate in English. A CNA also struggled to communicate with the resident due to this language barrier. The MDS Coordinator admitted the mistake, acknowledging the need for accurate coding to ensure quality care.
A facility failed to create a baseline care plan for a resident with Parkinson's disease and other medical conditions within 48 hours of admission, as required by policy. The resident had severely impaired cognitive abilities and was dependent on staff for care. The Director of Nursing confirmed the oversight, acknowledging the risk of interrupted care due to the absence of a guiding care plan.
A facility failed to create an individualized care plan for a resident on Haloperidol, despite the resident's severe cognitive impairment and need for assistance with daily activities. Interviews with the IPN and DON confirmed the lack of a comprehensive care plan, contrary to the facility's policy requiring such plans within seven days of assessment.
A facility failed to monitor a resident's indwelling catheter for white sediments, a potential sign of UTI, as required by their care plan and facility policy. The resident, with spinal stenosis and hypertension, had a catheter with visible sediments, which were not reported or documented. The Infection Prevention Nurse and DON acknowledged the oversight, highlighting a lapse in monitoring and documentation.
The facility did not follow its policy to update the Daily Nursing Staff Posting (DNSP) within two hours of each shift's start. During a tour, it was found that the DNSP displayed was for the previous day. The Director of Staff Development acknowledged the oversight, stating that the night shift staff should have updated the DNSP. The facility's policy requires the DNSP to be updated and posted in a prominent location accessible to residents and visitors.
A resident with severe cognitive impairment and End Stage Renal Disease was allowed to sign a binding arbitration agreement without verifying their capacity to understand and make decisions. The Admission Coordinator did not check the resident's assessments, leading to a potential denial of the resident's rights.
A resident with MRSA was placed on Contact and Droplet Precautions, but an LVN failed to wear the required PPE while administering medication. The facility's policy required staff to wear a disposable gown and gloves to prevent infection spread, but this protocol was not followed, risking transmission of infectious microorganisms.
A resident's call light system was found to be non-functional, potentially delaying needed care. Despite the resident's capacity to understand and make decisions, and requiring assistance for personal hygiene and transfers, the call light had been non-functional for months. Staff confirmed the issue, and the Maintenance Supervisor acknowledged a communication failure and lack of documentation regarding the problem.
A facility's lack of specific guidelines in its Abuse Prevention Policy led to staff receiving and cashing checks from a resident, resulting in potential financial abuse. The resident, who was cognitively intact and had chronic health issues, signed checks to a CNA and an Activity Aide. Interviews confirmed that accepting money from residents was against policy, but the facility's policy lacked specific instructions on handling residents' money.
A facility failed to follow its policy for nail care by not ensuring a resident was referred to a podiatrist for toenail trimming. The resident, with conditions including gout and peripheral vascular disease, had long, overgrown toenails, raising concerns about infection risk. Despite the care plan's directive for daily foot inspections and podiatrist referrals, the necessary actions were not taken, as confirmed by staff observations and interviews.
A resident at high risk for falls, with conditions like muscle weakness and cognitive impairment, experienced an unwitnessed fall. Despite being confused and needing a sitter, the necessary supervision was not arranged by the LVNs. The MD was informed of the fall but not the resident's confusion, leading to inadequate supervision. The facility's policy on safety and supervision was not followed.
A resident with a history of gout and amputation-related pain was not reassessed for pain relief after receiving acetaminophen, contrary to facility policy. The resident later reported severe pain, and the LVN admitted to not following the protocol for reassessment. The DON confirmed the requirement for reassessment within one hour, highlighting a lapse in pain management procedures.
A CNA worked with an expired certification at a facility, as the DON failed to verify the certification status before scheduling. The facility's policy requires verification of licenses or certifications prior to employment and annually, which was not followed, potentially leading to inadequate resident care.
A resident with end-stage renal disease was transferred multiple times between rooms without documented notification to the resident or responsible party, as required by the facility's policy. Interviews with staff confirmed the lack of documentation and notification.
The facility failed to provide appropriate pressure ulcer care for a resident by not setting the LAL mattress correctly, not turning and repositioning the resident every two hours, and not providing timely incontinent care. These deficiencies were confirmed through observations, interviews, and record reviews.
Failure to Consistently Document Resident Meal Intake in Medical Record
Penalty
Summary
Facility staff failed to consistently document a resident’s meal intake in the medical record as required by facility policy and CNA job expectations. The resident was admitted with sepsis and diabetes mellitus and had intact cognition and decision-making capacity. According to the MDS, the resident required setup assistance with eating, supervision with oral hygiene, moderate assistance with toileting hygiene, showering/bathing, and personal hygiene, and maximal assistance with bed-to-chair transfers. Review of the Documentation Survey Report (DSR) for January 2025 showed CNAs documented the resident’s meal intake for 90 of 93 meals, and for February 1–15, 2025, CNAs documented meal intake for 40 of 45 meals, leaving multiple meals without recorded intake amounts. During interview, a CNA stated that CNAs were expected to document after each meal, including when a resident refused to eat, and that documentation should be completed before the end of the shift as a standard of practice. The CNA further stated that if there was no documentation on the DSR, staff would not know how much residents ate and that incomplete documentation would affect continuity of care. The DON similarly stated that without documentation, nursing staff would not know if the resident ate or refused the meal. The CNA job description required recording residents’ food and fluid intake, and the facility’s Charting and Documentation policy required that all services provided to residents be documented completely in the medical record, including date, time, and the signature and title of the person documenting. Despite these requirements, staff did not document the amount of meal intake for all meals during the review period for this resident.
Failure to Provide Social Services Assistance for Continuity of Health Insurance Coverage
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to assist a resident in maintaining mental and psychosocial well-being by ensuring continuity of health insurance coverage. The resident was admitted with a displaced bimalleolar fracture of the left lower leg and hypertension, and was dependent on staff for most ADLs. The resident had decision-making capacity. During an IDT meeting, the resident’s family member expressed interest in applying for Medi-Cal once Medicare coverage for skilled nursing services was ending, and the Social Services Director (SSD) stated they would refer the family member to the Business Office Manager (BOM) for assistance with the Medi-Cal application. The facility issued a Notice of Medicare Non-Coverage indicating the last day of Medicare coverage for skilled services. The SSD reported that they referred the family member to the BOM but did not follow up on the Medi-Cal application or otherwise assist the resident in applying for health insurance. The Assistant DON/Case Manager confirmed that the SSD told the family member during the IDT meeting that the BOM would assist with the Medi-Cal application. The DON reviewed the SSD’s job description, which required the SSD to provide information to residents and families about Medicare/Medi-Cal and other financial assistance programs and to refer them to appropriate social service agencies when needed, and stated the SSD did not follow this job description. The facility’s social services policy required provision of medically related social services, including informing and educating residents and families about health care options and assisting with financial matters. As a result of these failures, the resident had no health insurance after Medicare coverage ended and personally bore the cost of skilled nursing services received thereafter.
Residents Were Labeled as "Feeders" Instead of Being Addressed by Name
Penalty
Summary
The facility failed to ensure residents were called by their legal, proper, and preferred names for three sampled residents, and instead staff referred to them as "feeders." Resident 132 was admitted with diagnoses including cerebral infarction, DM, and HTN, had severely impaired cognition, and required substantial to maximal assistance with eating and dependent assistance with oral hygiene, toileting, showering, and dressing. During observation, a CNA passed the lunch tray to Resident 132 and stated the resident was a feeder. The IPN stated residents should be treated with dignity and respect and referred to by their legal, proper, and preferred names or nicknames, and the ADON stated residents should not be labeled as feeder because it would affect dignity. Resident 96 was admitted with diagnoses including UTI, malignant neoplasm of the prostate, and acute kidney failure, and his MDS indicated severely impaired cognition with dependence for oral hygiene, toileting, showering, dressing, and footwear. His OSR showed an order for 1:1 feeder with all meals every shift, and an RN stated he was a feeder and that he should not have been addressed that way for dignity. Resident 14 was admitted with Alzheimer's disease and dementia, was on hospice services with a goal to maintain dignity and autonomy, and was rarely or never understood and dependent during eating. Her OSR indicated she needed assistance with meals, and an LVN stated she was a feeder and that all residents who needed help feeding were feeders. The DON stated residents should be called by their last name or preferred name and should not be called or labeled as feeder, and the facility policy stated staff should address residents by name of choice and not label them by room number, diagnosis, or care needs.
Call Lights Not Accessible in Shower Areas and for a Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that call lights were accessible in four of four private shower areas. During a concurrent observation and interview with the DON, the emergency call light cord in Room A’s private shower area was located outside the shower area and was not reachable for residents during showering. The DON stated the cord was not within resident reach and that all staff were responsible for ensuring call light cords were within reach and easily accessible at all times. During a later observation with the MS, the same shower area still had the emergency call light cord outside the shower area, and the MS stated none of the four private shower areas had reachable emergency call light cords for residents in the shower. The facility policy stated the emergency pull cord in shower areas must be within three feet of the shower head and hang two to six inches from the floor. The facility also failed to ensure that the call light was accessible for Resident 92, who had glaucoma, legal blindness, severely impaired vision, and severely impaired cognition. Resident 92’s MDS showed the resident required assistance with eating, oral hygiene, dressing, personal hygiene, toileting, and showering. During observation, Resident 92 was trying to get out of bed, and the call light was wrapped around the bed siderails. Resident 92 stated the call light could not be seen and the resident did not know where it was. CNA 3 stated the resident was blind and needed to know where the call light was to call for help. The IPN stated Resident 92 should have the call light in the resident’s possession and accessible at all times, and the ADON stated visually impaired residents should have an appropriate call light intended for their special needs. The care plan identified severely impaired vision and included assistance with ADLs and a goal for the resident to remain physically safe.
Incomplete and Non-Specific Care Plans
Penalty
Summary
The facility failed to develop and implement specific, resident-centered care plans for four sampled residents. For Resident 3, the record showed diagnoses of dementia and psychosis, lack of decision-making capacity, and severely impaired cognition. The resident required assistance with eating, oral hygiene, toileting hygiene, showering/bathing, and bed-to-chair transfers. The medication record showed active orders for memantine HCL and rivastigmine, but the care plan did not include specific interventions addressing either medication. During review, RN 1 stated the care plan should have been specific and resident-centered and should have included those medications because they were part of the resident’s care. For Resident 49, the record showed diagnoses of dementia and psychosis and moderately impaired cognition. The resident required assistance with eating, oral hygiene, walking, toileting hygiene, personal hygiene, bed-to-chair transfers, and showering/bathing. The medication record showed active orders for donepezil and memantine HCL, but the care plan did not contain specific interventions for either medication. RN 1 stated those medications should have been included in the care plan because they were part of the resident’s care. The DON stated that specific care plans were beneficial to staff and residents, would guide care for residents with dementia and psychosis, and should individualize care to monitor medication side effects. For Resident 48, the record showed a diagnosis of stage 4 pressure ulcer and a need for assistance with personal care. The resident had intact cognition and capacity to understand and make decisions. The medication and treatment record showed an order for staff to set the low air loss mattress according to the resident’s weight or comfort every shift, and the resident was observed lying on the mattress. LVN 2 stated the low air loss mattress prevented pressure ulcers and should have had a care plan, but no specific care plan for its use was present. LVN 2 stated the licensed nurse should have developed a specific care plan upon receiving the order, and that staff would not be able to follow the plan of care without it. For Resident 95, the record showed blindness in both eyes, psychosis, schizophrenia, parkinsonism, and a need for assistance with personal care. The resident used tobacco and required substantial/maximal assistance while eating. The smoking assessment recommended supervision while smoking and measures such as a smoking apron or cigarette extension. The care plan identified the resident as a smoker who needed supervision and included interventions related to smoking protection and burn prevention, but during observation the resident was smoking outside without a smoking apron while the AA remained inside the doors looking at a phone. The AA stated direct supervision required being next to or very close to the resident, which was not done, and stated smoking aprons were unavailable so one was not offered. The ADON and DON both stated the resident needed supervision and would benefit from a smoking apron, and the DON stated the apron was a necessary shield from cigarette ashes.
Improper LALM Settings for Residents With Pressure Ulcers
Penalty
Summary
The facility failed to ensure low air loss mattresses (LALM) were set accurately for two residents with pressure ulcers and other skin issues. Resident 117 had diagnoses including hemiplegia, hemiparesis after a stroke, hypertension, fluctuating mental status, and was assessed as at risk for pressure ulcers. Records showed active orders for a LALM and for staff to set the mattress according to the resident’s weight or comfort every shift. On observation, Resident 117 was lying on a LALM set at 400 lbs with a sticker indicating 200-300 lbs, and the resident stated the bed was not comfortable. The MDS nurse stated the mattress should not have been set at 400 lbs and should have been on 200-300 lbs, while the ADON stated 400 lbs was inappropriate and that the mattress should have been set between 100-200 lbs or based on comfort. Resident 48 had diagnoses including a stage 4 pressure ulcer and obesity, with intact cognition and dependence for several activities of daily living. The resident had a left buttock stage 4 pressure ulcer and an order for licensed staff to set the LALM according to weight or comfort every shift. The resident’s weight was documented as 266 lbs, but observations showed the LALM set at 350 lbs. Resident 48 stated the mattress was not comfortable and described uneven air pockets on the back. Treatment Nurse 1 stated the mattress was set for a resident who weighed 350 lbs and that it was not beneficial for the resident’s stage 4 pressure ulcer if the mattress was set too high because it was firm. Facility staff and records confirmed the mattress settings were not aligned with the residents’ weights or comfort as ordered. The DON stated the licensed nurse should verify the LALM order with the physician and should have set the mattress per Resident 48’s weight. The facility policy required staff to follow the LALM manufacturer’s instructions and adjust comfort or weight settings when indicated, and the manufacturer’s manual directed users to select the correct patient weight.
Failure to Secure Foley Catheter and Monitor Suprapubic Catheter Site
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents with urinary catheters. Resident 132 was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had an order for an indwelling Foley catheter for neurogenic bladder. The care plan identified the Foley catheter and stated the resident was to remain free from catheter-related trauma, and the MDS showed severely impaired cognition and dependence for multiple activities of daily living. During observation, Resident 132 was lying in bed with the Foley catheter in place, and the Infection Prevention Nurse stated the catheter was not secured to the resident’s thigh. The nurse stated the tubing should be secured to the thigh to prevent accidental pulling during bed mobility and to avoid trauma and injury. The ADON also stated the Foley catheter should be kept secured on the resident’s thigh to prevent dislodgement, irritation, and injury at the insertion site. The facility policy titled Catheter Care, Urinary stated the catheter should remain secured with a leg strap or stabilization device and tubing should be strapped to the resident’s inner thigh. Resident 33 was admitted and readmitted with diagnoses including neuromuscular dysfunction of the bladder and heart failure, and had a suprapubic catheter with orders for daily irrigation and daily cleansing of the site with NS and dressing application. The care plan directed nursing staff to monitor for signs and symptoms of skin breakdown. During observation, the suprapubic catheter site had scattered redness around the area, and the ADON stated there was scattered redness on the abdomen. The Treatment Nurse stated there was excoriation around the suprapubic catheter site and that signs and symptoms of infection and skin breakdown should have been monitored. The DON stated residents with suprapubic catheters were at high risk for skin breakdown and that the site and skin should have been monitored every shift for changes such as redness, drainage, and temperature. The facility policy titled Suprapubic Catheter Care, Urinary stated the purpose was to prevent skin irritation and urinary tract infection and required recording the results of skin assessment around the stoma site.
Respiratory Equipment and Oxygen Safety Deficiencies
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for five sampled residents receiving oxygen therapy or breathing treatments. For Resident 33, the record showed an order for oxygen at 2 LPM via nasal cannula was not present, even though the resident was observed receiving oxygen at 2 LPM. The resident’s nasal cannula tubing was hanging on the bed rail and a plastic bag was hanging on the oxygen concentrator, rather than being stored in a designated plastic bag when not in use. Staff also observed that there was no Oxygen in Use sign posted outside the room. The ADON stated the tubing and bag should be changed weekly and that the tubing should be placed in the plastic bag when not in use. For Resident 68, the resident had an order for DuoNeb inhalation treatments for shortness of breath and wheezing. During observation, the inhalation tubing set was on the bedside table, was not labeled with a date, and was not being used. The IPN stated there was no care plan developed for the resident’s inhalation breathing treatments. Staff stated the tubing set should be labeled with the date it was changed, stored in a clear plastic bag when not in use, and that a care plan should be developed to communicate resident-specific interventions. For Resident 76, the resident had an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath and was observed in bed receiving oxygen, but there was no Oxygen in Use sign posted outside the room. For Resident 117, the care plan addressed handheld nebulizer use and required the HHN and bag to be changed weekly and dated, but the tubing and mask were observed unlabeled on the nightstand in a bag dated 11/24/2025. For Resident 131, the resident had an order for continuous oxygen at 3 LPM via nasal cannula and was observed receiving oxygen, with an oxygen tank in the room, but there was no Oxygen in Use sign outside the room and none in the room. The DON stated the sign should have been posted outside the door as soon as the oxygen was in the room.
Failure to Attempt Alternatives Before Using Side Rails
Penalty
Summary
The facility failed to attempt appropriate alternatives before using bilateral 1/4 side rails for two residents, Residents 76 and 94, and did not document that less restrictive measures were tried and found ineffective before the rails were installed. Resident 76 was admitted with diagnoses including a right arm fracture, dementia, and a history of falling, and the MDS showed severely impaired cognition and need for assistance with multiple activities of daily living. Resident 76 had an order for bilateral 1/4 partial side rails to improve functional ability when in bed, and during observation was lying in bed with the rails up while wearing a sling on the right shoulder; the LVN stated the resident could not hold on to the side rails with the right arm. Resident 94 was admitted with diagnoses including epilepsy, osteoarthritis, and a history of falling, and the MDS showed severely impaired cognition with assistance needs for eating, oral hygiene, dressing, toileting, showering, and personal hygiene. Resident 94 also had an order for bilateral 1/4 partial side rails to aid functional ability when in bed, and during observation was in bed with the rails up while a CNA stated the resident was confused. The IPN reviewed both residents’ charts and initial siderail use assessments and stated there was no record showing appropriate alternatives were attempted and did not meet the residents’ needs before the side rails were applied; the ADON also stated least restrictive appropriate alternatives should have been attempted first.
Improper Glove Use During Beverage Preparation
Penalty
Summary
Safe and sanitary food preparation was not maintained in the kitchen during observation with the Director of Nutritional Service present. A dietary aide was observed preparing residents' beverages without wearing gloves. The aide then walked to the dry storage area for a new carton of prune juice and did not wash hands or wear gloves before pouring the prune juice into residents' beverage cups. After touching the refrigerator door, the aide again did not wash hands or wear gloves before covering the beverage cups with plastic food wrap. During interview, the dietary aide stated gloves should be worn while handling residents' food for infection control and that gloves should be changed if a different surface was touched. The DNS stated dietary staff should wear gloves when handling ready-to-eat items. The facility's Glove Use Policy dated 2023 was reviewed with the IPN, who stated the policy indicated staff should wear disposable gloves when preparing and serving any ready-to-eat food and that kitchen staff should wear gloves when preparing food and drinks. The IPN also stated the aide's hands were considered not clean after touching the prune juice carton and the refrigerator.
Failure to Document IV Antibiotic Administrations on MAR
Penalty
Summary
Licensed nurses failed to document IV antibiotic administrations on the MAR for two residents. For Resident 42, the record showed admission with sepsis and bacteremia, an H&P stating the resident could not make decisions, and an MDS indicating moderate cognitive impairment with assistance needed for several activities of daily living. The care plan directed licensed nursing staff to administer antibiotic medication as ordered, and the OSR showed an order for IV ampicillin every six hours starting 12/24/2025. During record review and interview, Resident 42's MAR showed 21 of 23 doses of IV ampicillin were documented from 12/25/2025 through 12/30/2025, but the 6 AM doses on 12/28/2025 and 12/30/2025 were not documented. RN 1 stated the MAR did not show those administrations and that the RN should document IV medication administration on the MAR to prove the action was done. RN 1 also stated there were no corresponding IV ampicillin entries in the nursing progress notes for those times. For Resident 48, the record showed diagnoses including osteomyelitis, with an MDS indicating intact cognition and an H&P stating the resident had capacity to understand and make decisions. The care plan directed licensed nursing staff to administer medication as ordered and document the progress of therapy, and the OSR showed an order for IV piperacillin sod-tazobactam every six hours starting 1/7/2026. The MAR showed 31 of 32 doses documented from 1/7/2026 through 1/15/2026, but the 5 AM dose on 1/13/2026 was not documented, and RN 1 stated there was no corresponding entry in the nursing progress notes. The ADON and DON stated the licensed nurse should document on the MAR after medication administration and complete the MAR before leaving the facility.
Failure to Follow Enhanced Barrier Precautions for Residents With Indwelling Devices
Penalty
Summary
The facility failed to implement infection prevention and control procedures for two residents with indwelling medical devices. Resident 33 was admitted and readmitted with diagnoses including neuromuscular dysfunction of the bladder and heart failure, and the record showed an order to place the resident on Enhanced Barrier Precautions due to the presence of a foley catheter. The care plan also directed nursing staff to initiate EBP and to perform hand hygiene and wear PPE, including gown and gloves, before and after high-contact care activities. During an observation, the Assistant Director of Nursing was seen touching Resident 33's bed and bedding while assessing the suprapubic catheter site without wearing a gown. In interview, the ADON stated the gown was forgotten and that protective gown should have been worn to prevent the spread of infection to residents. The Infection Preventionist Nurse stated staff needed to wear gown, gloves, and mask prior to touching Resident 33, who was on EBP, and the Director of Nursing stated staff should wear proper PPE such as gown and gloves before touching a resident with an indwelling device such as a catheter. Resident 132 was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and the record showed an order for an indwelling foley catheter for neurogenic bladder. The MDS indicated severely impaired cognition and dependence for multiple activities of daily living, and also documented an indwelling catheter. During a concurrent observation and interview, the Infection Preventionist Nurse noted there was no EBP signage posted outside Resident 132's room, and stated residents with indwelling medical devices like a foley catheter were at high risk for infection and should be placed on EBP. The Assistant Director of Nursing stated all residents with indwelling medical devices should have signage posted outside the room to alert staff to wear recommended PPE.
Fruit flies observed in kitchen dry storage area
Penalty
Summary
The facility failed to ensure the kitchen dry storage area was free of fruit flies on 1/13/2026 and 1/14/2026. During an initial observation of the kitchen and interview with Dietary Aide 1, multiple fruit flies were seen flying around the open banana and white onion storage containers in the dry storage area, and the aide stated it was not acceptable to have fruit flies in the kitchen for infection control and that fruit flies could lay eggs on food. During a later observation with the Director of Nutritional Services, multiple fruit flies were again seen in the dry storage area, this time flying around the closed banana and white onion storage containers. The facility’s Policy and Procedure titled Pest Control for Fruit Flies, dated 5/2020, stated the facility maintains an ongoing pest control program to keep the building free of insects, and the Infection Prevention Nurse stated the facility should be free of pests and insects.
Failure to Obtain Consent for Bed Pad Alarm
Penalty
Summary
The facility failed to implement its policy and procedure on informed consent for physical restraint when it used a bed pad alarm for Resident 76 without documentation that the resident or the resident’s family member or responsible party had signed consent. Resident 76 was admitted with diagnoses including a right arm fracture, dementia, and a history of falling. The resident’s MDS dated 12/23/2025 indicated severely impaired cognition, and the OSR dated 12/18/2025 showed an order for a bed alarm. During a concurrent observation and interview on 1/13/2026, Resident 76 was observed lying in bed with the pad alarm in place. The LVN stated the resident had a history of falling. On 1/14/2026, the IPN reviewed the chart and EHR and stated there was no record showing consent had been obtained before the bed pad alarm was applied. The IPN stated consent should be obtained so the resident or responsible party is informed and the purpose of the bed pad alarm is explained. The ADON stated the bed pad alarm was a mobility alarm that could restrict mobility while in bed, the alarm sound could cause anxiety, and it should be consented before application.
Advance Directive Not Readily Accessible
Penalty
Summary
The facility failed to ensure the Advance Directive for one of eight sampled residents, Resident 10, was readily accessible in accordance with its Advance Healthcare Directives/POLST policy. Resident 10 was admitted with diagnoses including type 2 diabetes mellitus, dysphagia, and encounter for attention to gastrostomy. The Minimum Data Set dated 12/23/2025 indicated Resident 10 had severely impaired cognition for daily decision making and was dependent on staff for oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During interview and record review, the Infection Prevention Nurse stated there was no Advance Directive in Resident 10's chart or in PCC and could not find an existing Advance Directive in either location. The Social Service Director stated there was no Advance Directive completed upon admission for Resident 10. The DON stated the resident's Advance Directive needed to be readily accessible in the chart or PCC in case of emergency and that it was a legal document indicating the resident's medical wishes. The facility policy stated that at the time of admission, staff or designee would inquire about the existence of an Advance Healthcare Directive and maintain a copy as part of the resident's medical record.
Failure to Revise Care Plan After Isolation Discontinued
Penalty
Summary
The facility failed to revise Resident 96’s care plan after contact isolation precautions for an ESBL UTI were discontinued. Resident 96 was admitted with diagnoses including UTI, malignant neoplasm of the prostate, and acute kidney failure. The untitled care plan initiated on 12/6/2025 directed nursing staff to explain the reasons for isolation precautions and to implement appropriate isolation techniques by staff, the resident, and visitors. However, during review of the medical record, the Infection Prevention Nurse stated that contact isolation had been stopped 10 days after antibiotics were started because the resident did not show signs or symptoms of infection, and that the care plan needed to be revised to reflect the resident’s current care and treatment needs. Resident 96’s MDS dated 12/10/2025 indicated severely impaired cognition and dependence for oral hygiene, toileting, showering, upper and lower body dressing, and putting on/taking off footwear. During observation on 1/13/2026, the resident was awake and lying in bed in the room. The DON stated the resident’s care plan needed to be revised or updated to determine the appropriate care and treatment currently needed by the resident. The facility policy on comprehensive person-centered care plans stated that each resident must have a comprehensive care plan developed and implemented with measurable objectives and timetables to meet physical, psychosocial, and functional needs.
Smoking Supervision and Protective Equipment Not Provided
Penalty
Summary
The facility failed to implement its Smoking Policy-Residents for one sampled resident who smoked and required supervision. Resident 95 was admitted with diagnoses including blindness in both eyes, psychosis, schizophrenia, parkinsonism, and a need for assistance with personal care. The resident’s H&P stated he had the capacity to understand and make decisions, while the MDS indicated moderately impaired cognition, substantial/maximal assistance with eating, and tobacco use. A Smoking Assessment dated 12/15/2025 recommended supervision while smoking and measures such as a smoking apron or cigarette extension. During an observation on 1/15/2026, Resident 95 was seated in a wheelchair outside the facility smoking a cigarette without a smoking apron, with his back to the doors. The Activities Assistant was inside the double doors looking down at a phone and stated he was instructed to supervise residents by lighting their cigarettes and observing them from inside through a window because he disliked the smoke. He stated he did not stay next to or very close to Resident 95, did not provide direct supervision, and smoking aprons were unavailable so he did not offer one. The DON stated Resident 95 needed supervision and a smoking apron for safety, and that direct supervision meant staff should be directly next to the resident and outside with the resident during smoking time.
GT Site Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a gastrostomy tube (GT) as ordered by the physician and as indicated in the care plan. Resident 10 was admitted with diagnoses including type 2 diabetes mellitus, dysphagia, and encounter for attention to gastrostomy. The history and physical stated the resident did not have the capacity to understand and make decisions. The order summary included a treatment order for licensed staff to clean the GT site with normal saline, pat dry, apply a dry dressing daily, and inspect the site for signs and symptoms of infection, drainage, swelling, or irritation. The care plan also indicated the resident required enteral feeding via GT and that licensed nursing staff were to provide enteral feeding as ordered. During a concurrent observation and interview, the resident was awake and lying in bed, and the Assistant Director of Nursing stated there was no GT dressing on the site and that there should have been a dry dressing in place as ordered. The Treatment Nurse stated the GT site should have a dry dressing to protect the resident's skin from irritation. The Director of Nursing stated the purpose of the dry dressing was to prevent infection and maintain cleanliness of the GT site, and that the dressing should be changed and applied daily by the licensed nurse as ordered. The facility policy on enteral feedings stated the skin around the exit site should be kept clean, dry, and lubricated as necessary.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its abuse prevention policy. One resident, who had a history of schizoaffective disorder, legal blindness, and severely impaired cognition, was involved in a verbal exchange with another resident. During this interaction, the second resident pushed the first, causing the resident to fall to the floor. The incident was unwitnessed, but the injured resident reported being pushed, and this was corroborated by the other resident's admission and staff observations immediately following the event. Following the fall, the injured resident complained of pain and was assessed by staff, who noted significant discomfort and inability to get up. The resident was transferred to a general acute care hospital for evaluation, where imaging confirmed an acute comminuted fracture of the right 5th metacarpal. Staff interviews and documentation indicated that the resident who pushed the other had a disagreement and admitted to the physical act, with staff witnessing the aftermath and hearing the resident verbally acknowledge the push. The facility's policy and procedure on abuse prevention explicitly states that residents must be protected from abuse, including by other residents. Despite this, the incident occurred, resulting in physical harm to a resident with significant cognitive and physical vulnerabilities. The documentation and interviews confirm that the facility did not prevent the abusive act, leading to the resident's injury.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged physical abuse involving a resident with schizoaffective disorder and legal blindness. The resident, who had severely impaired cognition and required assistance with activities of daily living, reported being pushed to the floor by another resident. This allegation was corroborated by a Licensed Vocational Nurse (LVN), who witnessed the accused resident admitting to the act and observed the victim on the floor requesting help. The LVN notified the Administrator and Director of Nursing (DON) of the incident, and was instructed not to complete the abuse reporting form, as the Administrator and DON would handle the reporting. Despite facility policy requiring the reporting of abuse allegations within specified time frames, the incident was not reported to the California Department of Public Health (CDPH) within the required two-hour window. The DON confirmed that the facility failed to meet the mandated reporting timeline for this incident, as outlined in their Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy.
Failure to Maintain Safe and Comfortable Temperatures in Shower Rooms
Penalty
Summary
The facility failed to maintain safe and comfortable room temperatures in two resident shower rooms, as observed during a survey. On the third floor, the shower room thermostat read 82°F, and a CNA described the room as hot and stuffy. Similarly, the second-floor shower room was observed at 85°F, with an LVN also noting the room felt hot and stuffy. The Maintenance Supervisor confirmed that the air conditioning was malfunctioning and that high temperatures in the shower rooms had been noted, with repairs scheduled. Facility policy requires that resident areas, including bathing and shower rooms, maintain temperatures between 71°F and 81°F to ensure a safe, clean, and comfortable environment.
Failure to Notify Responsible Party and Document Change in Condition for Resident with Critically High Blood Sugar
Penalty
Summary
The facility failed to follow its policy and procedure regarding changes in a resident's condition or status by not informing a resident's responsible party when the resident experienced a critically high blood sugar level of 480 and required an additional dose of insulin. The responsible party was not notified of this significant change, despite the resident lacking the mental capacity to make medical decisions and being dependent on staff for most activities of daily living. The facility's policy required notification of the resident's representative in such circumstances. Additionally, the facility did not document the resident's blood sugar level of 480 in the medical record, nor did staff complete an SBAR Communication Form or a Change of Condition note as required by facility policy. The Director of Nursing confirmed that there was no documentation of the event, no SBAR form, and no notification to the responsible party in the resident's record. These omissions were identified during a review of the resident's records and interviews with facility staff.
Failure to Enforce Mask Use and Hand Hygiene During Infectious Disease Outbreak
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies and procedures, specifically regarding hand hygiene, standard precautions, enhanced barrier precautions, and transmission-based precautions. Multiple staff members, including the receptionist, certified nurse assistants, social services director, maintenance assistant, and a medical doctor, were observed not wearing masks properly, with masks pulled down below the nose and mouth while inside the facility. Additionally, a family member visiting a resident was not wearing a mask, and staff failed to educate or enforce mask-wearing for visitors, despite clear signage and policy requirements during an outbreak of COVID-19 and influenza. Direct observations revealed that staff and visitors were not consistently following mask protocols, even in areas housing residents with active COVID-19 and flu infections. For example, a family member was seen assisting a resident with severe cognitive impairment and multiple comorbidities without a mask, after being told by staff that mask-wearing was optional. Several staff members, including those with direct resident contact and those in administrative or support roles, admitted awareness of the outbreak and the need for proper mask use but did not comply. In one instance, a certified nurse assistant entered an enhanced barrier precautions room without performing hand hygiene, despite posted instructions and facility policy. The facility's own infection control policies, as well as recommendations from the Department of Public Health, required all staff and visitors to wear appropriate masks and perform hand hygiene, especially during an outbreak. Interviews with staff, including the infection prevention nurse and director of nursing, confirmed knowledge of these requirements and the importance of compliance. However, repeated failures to follow these protocols were observed and acknowledged by staff, contributing to the potential for transmission of infectious diseases within the facility.
Failure to Administer Medication at Resident's Requested Time
Penalty
Summary
The facility failed to protect the right of a resident to participate in their treatment plan by not administering Pramipexole Dihydrochloride at the resident's requested time. The resident, who was admitted with diagnoses including Parkinson's disease, had the capacity to understand and make decisions. Despite the resident's request to have the medication administered at 7:30 a.m. to help manage tremors associated with Parkinson's disease, the facility continued to administer the medication at 9 a.m. until the time was finally changed on January 27, 2025. The Assistant Director of Nursing (ADON) confirmed awareness of the resident's request during an interdisciplinary team meeting on January 21, 2025, but the change was not implemented until January 24, 2025. The facility's policy on resident rights, which includes the right to participate in care planning and treatment, was not adhered to in this instance. This oversight had the potential to increase the resident's tremors due to the delayed administration of the medication.
Unattended Medications at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications for one of the sampled residents were kept locked in secure storage. During an observation, a medication cup containing three unidentified pills was found unattended at the bedside of a resident who was severely impaired in cognitive skills and required assistance for daily activities. The resident was unable to recall how long the medication had been there, indicating a lapse in proper medication administration and storage procedures. Licensed Vocational Nurse (LVN) 1 confirmed the unattended medications and identified LVN 2 as the responsible nurse, who was on a lunch break at the time. LVN 2 later acknowledged the oversight, admitting that they should have stayed with the resident to ensure the medications were taken. The Director of Nursing (DON) noted that this was not the first instance of such an oversight by LVN 2, emphasizing that staff are required to remain with residents during medication administration to ensure medications are swallowed and not left unattended.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, which is a violation of the facility's policy and procedure regarding the resident call system. Resident 14, who was admitted with hemiplegia and hemiparesis affecting the left side, was observed with a call light that was not accessible, as it was stuck at the back of the padded bed side rails. This resident was assessed as high risk for falls due to intermittent confusion and being chair-bound, and the care plan required the call light to be within reach to prevent falls and injuries. Resident 251, who had a recent fall resulting in a femur fracture and was at risk for falls, was also found with an inaccessible call light. The call light was placed at the upper right side of the bed, making it difficult for the resident to find and use it. The care plan for this resident specified that the call light should be within easy reach to ensure timely assistance from staff. Similarly, Resident 211, diagnosed with Alzheimer's disease and dementia, had a call light that was not within reach. The call light was rolled on the wall on the opposite side of the bed, requiring the resident to go around the bed to access it. The care plan for this resident indicated that the call light should be attached within reach to assist with activities of daily living and prevent falls. Interviews with staff confirmed the expectation that call lights should be placed within reach and on the strong side of the resident.
Failure to Implement Advance Directives Policy
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for four residents, leading to deficiencies in maintaining and documenting these critical legal documents. For Resident 47, the facility did not ensure that a copy of the Advance Directive was included in the resident's medical record or uploaded into the PointClickCare system. This oversight was confirmed during interviews with the Medical Records staff, the Social Services Director, and the Assistant Director of Nursing, all of whom acknowledged the necessity of having the Advance Directive readily available to guide care, especially in emergencies. Similarly, Resident 89's Advance Directive Acknowledgement Form was missing from the medical record. Interviews with the Infection Prevention Nurse, the Social Services Director, and the Director of Nursing revealed that the form was not initiated or included in the resident's chart, which is essential for understanding and respecting the resident's treatment preferences. The absence of this documentation could lead to care that does not align with the resident's wishes. For Resident 82, the facility did not complete the Advance Directive Acknowledgement Form upon admission, and the resident's family member reported that the purpose of an Advance Directive was not discussed. The Social Services Director confirmed that the form was blank, indicating a lack of education provided to the resident or responsible party. Additionally, Resident 92's Advance Directive was not found in the medical or electronic chart, despite the form indicating its existence. The Social Services Director and Director of Nursing both emphasized the importance of having this documentation to ensure the resident's wishes are known and respected.
Communication Barriers for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide an effective communication method for two non-English speaking residents, which had the potential to affect their quality of life and care. Resident 17, who was readmitted with heart failure and hypotension, was documented as having English as their preferred language in the Minimum Data Set (MDS), despite actually preferring Turkish. This discrepancy led to communication issues, as observed when a Certified Nursing Assistant (CNA) was unable to effectively communicate with Resident 17, relying solely on a communication board. The facility's policy indicated the use of bilingual staff, interpreters, and translation apps, but these were not effectively utilized in Resident 17's case. Similarly, Resident 92, who was admitted with dementia and hypertension, was also affected by communication barriers. Although Resident 92's MDS indicated English as the preferred language, a CNA assigned to provide one-on-one monitoring only spoke Spanish and used Google Translate to communicate. There was no communication board available at Resident 92's bedside, contrary to the facility's policy. This lack of effective communication tools posed a risk of unmet needs and potential emergencies, as noted by the Director of Nursing.
Failure to Implement Care Plans and Arrange Transportation
Penalty
Summary
The facility failed to implement the care plan for a resident with arterial ulcers on both feet. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed with their heels lying directly on the mattress, contrary to the care plan's directive to offload the heels to prevent worsening of the wounds. Certified Nursing Assistant 2 acknowledged the need for offloading to prevent further complications, and the Director of Nursing confirmed that not following the care plan could delay wound healing. Another deficiency involved the facility's failure to provide transportation for a resident to a scheduled medical appointment. The resident, who had severe cognitive impairments and was dependent on staff, missed a fistulagram appointment due to the facility's oversight in arranging transportation. The resident's family member reported swelling around the fistula site, which was the reason for the appointment. The Director of Nursing and Licensed Vocational Nurse 2 confirmed that the transportation was not arranged, and there was no documentation of the appointment in the facility's records. The facility's policies and procedures for repositioning and transportation were not followed, contributing to these deficiencies. The repositioning policy required staff to adhere to the care plan for specific positioning needs, while the transportation policy mandated assistance in arranging transportation for appointments. Both policies were not implemented, leading to potential risks for the residents involved.
Failure to Provide Ordered Wound Care for Unstageable Pressure Ulcer
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the Medical Doctor for an unstageable pressure ulcer on the right midback of a resident, identified as Resident 82. This resident was readmitted to the facility with multiple diagnoses, including Parkinson's disease and various pressure ulcers. The care plan for potential skin breakdown required treatment initiation as ordered by the MD. However, from 10/30/2024 to 11/7/2024, the resident did not receive the prescribed treatment for the unstageable pressure ulcer, which involved cleansing with Normal Saline and applying a hydrocolloid dressing every three days. Treatment Nurse 1 confirmed the absence of treatment during this period and noted that the wound could worsen without proper care. The Director of Nursing (DON) revealed that the treatment order was mistakenly discontinued by a registry RN on 10/31/2024, and all admission orders were reentered, leading to the oversight. The DON was unaware of the unstageable pressure ulcer until the issue was raised. Upon inspection, the ulcer was found to have eschar and slough, with measurements indicating a lack of depth. The facility's policy required MD-ordered wound treatments, which were not followed, potentially delaying wound healing. The DON acknowledged that missing treatments could worsen the wound.
Failure to Follow Siderail Policy for Two Residents
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of siderails for two residents, leading to a deficiency. For Resident 26, the facility did not obtain a doctor's order or consent for the use of siderails, nor did it attempt appropriate alternative interventions before installing the siderails. Resident 26, who had diagnoses including osteomyelitis, peripheral vascular disease, and dementia, was observed with 1/4 siderails up on both sides of the bed without documented evidence of necessary assessments or consent. The Assistant Director of Nursing confirmed the lack of documentation and stated that siderails should not have been used without a physician's order and consent. Similarly, for Resident 28, the facility did not conduct a siderail use assessment or attempt alternative interventions before installing siderails. Resident 28, who had multiple rib fractures, hemiplegia, and hemiparesis, was also observed with 1/4 siderails up on both sides of the bed. Despite having an order for siderails as a mobility aid, there was no documented evidence of an assessment or consideration of less restrictive alternatives. The Assistant Director of Nursing acknowledged the absence of documentation for the necessary assessments and interventions, which placed both residents at risk for entrapment and injury.
Failure to Implement Psychotropic Medication Policies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the use of psychotropic and antipsychotic medications for two residents. For Resident 82, the facility did not ensure that the PRN order for Lorazepam, prescribed for restlessness and agitation, included a stop date of 14 days. This oversight was acknowledged by both a Registered Nurse and the Director of Nursing, who confirmed that the absence of a stop date could lead to unnecessary medication use. For Resident 96, the facility did not monitor the target behavior and adverse side effects associated with the use of Haloperidol, an antipsychotic medication. The medication order lacked a specific diagnosis, and there was no documentation of monitoring for agitation or side effects since the resident's admission. Both the Infection Prevention Nurse and the Director of Nursing confirmed the lack of monitoring and documentation, emphasizing the need for specific diagnoses and regular monitoring to assess the medication's effectiveness. The facility's P&P requires that PRN psychotropic medications have a stop date and that any continuation beyond 14 days must be justified by the practitioner. Additionally, the P&P mandates that staff observe, document, and report the effectiveness and side effects of antipsychotic medications to the attending physician. These requirements were not met for Residents 82 and 96, leading to the potential for unnecessary medication use and adverse consequences.
Improper Food Handling and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a survey. A staff member's personal lunch bag was found inside the walk-in refrigerator designated for storing residents' food. This action was acknowledged by the Dietary Aide (DA 3) who admitted that personal belongings should not be placed in the residents' refrigerator due to the risk of cross-contamination, which could lead to food-borne illnesses among residents. Additionally, the facility did not maintain cleanliness standards for kitchen equipment. The dome drying rack was found to be rusty and dirty, which was confirmed by both DA 3 and the Dietary Supervisor (DS). The DS admitted that there was no cleaning schedule for the dome drying rack, and it should be free from rust and debris to ensure health and safety. The facility's policies indicated that personal items should be stored separately from food and that effective maintenance management is essential for sanitation, but these were not followed.
Inaccurate MDS Coding for Language Preference
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident's language preference, which is a federally mandated resident assessment tool. This deficiency was identified for a resident who was readmitted to the facility with diagnoses including heart failure and hypotension. The resident's quarterly MDS inaccurately indicated that their preferred language was English, despite the resident's actual preference being Turkish. This discrepancy was discovered during an observation and interview where the resident was found speaking Turkish over the phone and was unable to communicate effectively in English. Further observations revealed that a Certified Nursing Assistant (CNA) was unable to communicate with the resident due to the language barrier, confirming the resident's limited English proficiency. The MDS Coordinator acknowledged the error in coding the resident's preferred language and admitted that the MDS should have been accurately coded to reflect the resident's current assessment and preference. The facility's policy and procedure for resident assessment, revised in 2019, mandates that the resident assessment coordinator ensures timely and appropriate assessments, which was not adhered to in this case.
Failure to Create Baseline Care Plan for Resident
Penalty
Summary
The facility failed to create a baseline care plan for a resident upon their admission, which was necessary to address the resident's immediate care needs within 48 hours. The resident, who was admitted and readmitted with conditions including Parkinson's disease, communication deficits, chronic non-pressure ulcers, and a stage three pressure ulcer, had severely impaired cognitive abilities and was dependent on staff for various activities. Despite these needs, the baseline care plan was not completed, as confirmed by the Director of Nursing during a review and interview. The absence of a baseline care plan was acknowledged by the Director of Nursing, who stated that it should have been completed to guide staff in providing appropriate care based on the resident's immediate needs. The facility's policy, revised in December 2016, mandates the development of a baseline care plan within 48 hours of admission to ensure the resident's immediate care needs are met. The failure to adhere to this policy placed the resident at risk of an interruption in care.
Failure to Develop Individualized Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for a resident who was prescribed Haloperidol, an antipsychotic medication. The resident, who was admitted with diagnoses of depression and dementia, had severely impaired cognition and required significant assistance with daily activities. Despite these needs, there was no clinical documentation indicating that a care plan was initiated and implemented to manage the use of Haloperidol, as required by the facility's policy and procedure. Interviews with the facility's Infection Prevention Nurse and Director of Nursing confirmed the absence of a comprehensive care plan tailored to the resident's specific needs for the use of Haloperidol. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of completing the required comprehensive assessment, but this was not done, potentially affecting the resident's treatment and care related to the medication.
Failure to Monitor Catheter for Signs of Infection
Penalty
Summary
The facility failed to properly assess and monitor a resident's indwelling catheter for the presence of white sediments, which could indicate a urinary tract infection (UTI). The resident, who was admitted with spinal stenosis and essential hypertension, had an indwelling catheter as part of their care plan. The care plan required staff to monitor and report any signs of UTI, such as changes in urine color, clarity, and odor, to the physician. However, during an observation, it was noted that the resident's catheter tubing and drainage bag contained white sediments, which were not reported or documented as required by the facility's policy. The Infection Prevention Nurse acknowledged the presence of white sediments and stated that it could be a sign of infection, requiring the tubing to be flushed and the physician to be notified. The Director of Nursing confirmed that the resident's catheter should have been monitored every eight hours for signs of infection, but there was no documentation of such monitoring. The facility's policy on catheter care emphasized the need to observe and report signs of urinary tract infection immediately, but this was not adhered to in the case of the resident.
Failure to Update Daily Nursing Staff Posting
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the posting of actual nursing hours within two hours of the start of each shift. On a tour conducted on 11/7/24, it was observed that the nursing hours posted in the facility's entrance lobby were for the previous day, 11/6/24, instead of the current date. During an interview, the Director of Staff Development (DSD) acknowledged that the Daily Nursing Staff Posting (DNSP) should have been updated to reflect 11/7/24 and admitted that the facility's policy was not followed. The DSD explained that the night shift staff were responsible for updating the DNSP, but this was not done. A review of the facility's P&P, revised in July 2016, confirmed that the DNSP should be updated within two hours of the beginning of each shift and posted in a prominent location accessible to residents and visitors.
Failure to Verify Resident Capacity Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 301, had the capacity to understand and make decisions before signing a Resident-Facility Arbitration Agreement (AA). Resident 301, who was admitted with diagnoses including pneumonia and End Stage Renal Disease, was assessed to have severely impaired cognitive skills for daily decision-making. The Minimum Data Set (MDS) indicated that the resident sometimes understood others and was sometimes self-understood, but was dependent on others for personal hygiene and transfers. Furthermore, the History and Physical (H&P) report confirmed that Resident 301 did not have the capacity to understand and make decisions. Despite these assessments, the Admission Coordinator allowed Resident 301 to sign the AA without verifying the resident's capacity to do so. The Admission Coordinator admitted to not checking the MDS assessment and H&P before allowing the resident to sign the legal document. An observation conducted later showed that Resident 301 was unable to communicate when asked questions, further indicating the resident's lack of capacity to make informed decisions. This oversight had the potential to result in the resident being unable to make an informed decision and having their rights denied.
Failure to Follow Isolation Precautions for MRSA-Infected Resident
Penalty
Summary
The facility failed to adhere to its Policy and Procedures regarding Isolation - Categories of Transmission-Based Precautions for a resident diagnosed with methicillin-resistant staphylococcus aureus (MRSA) infection. The resident, who had moderately impaired cognition and required assistance with daily activities, was placed on Contact and Droplet Precautions. However, during an observation, a Licensed Vocational Nurse (LVN) was seen administering medication to the resident without wearing the required personal protective equipment (PPE), such as gloves and a gown, which was necessary to prevent the spread of infection. Interviews with the LVN, the facility's Infection Preventionist Nurse, and the Director of Nursing confirmed that the staff was aware of the need to wear PPE when entering the resident's room. The facility's policy, dated 10/2018, clearly stated that staff and visitors should wear a disposable gown upon entering the room and remove it before leaving to avoid contamination. Despite this, the LVN did not follow the protocol, which had the potential to transmit infectious microorganisms and increase the risk of infection for other residents in the facility.
Non-Functioning Call Light System for Resident
Penalty
Summary
The facility failed to ensure that a functioning call light system was available for a resident, identified as Resident 17, which could potentially delay the provision of needed care and services. Resident 17, who was readmitted to the facility with diagnoses including heart failure and hypotension, had the capacity to understand and make decisions, and required partial assistance for personal hygiene and transfers. During an observation, it was noted that Resident 17's call light was not functioning, and the resident's roommate confirmed that the call light had been non-functional for a couple of months. Both a Certified Nursing Assistant and a Licensed Vocational Nurse verified that the call light was not working, emphasizing the importance of a functioning call light for timely response to the resident's needs. The Maintenance Supervisor indicated that there was a Maintenance Log for reporting equipment issues, but no issue regarding Resident 17's call light was documented. The Maintenance Supervisor also noted a lack of a checklist or system to ensure all equipment was checked, and acknowledged a communication failure between the nursing staff and the maintenance department. The facility's policy stated that residents should have a means to call staff for assistance from their bed and other areas, but this was not adhered to in the case of Resident 17.
Deficiency in Abuse Prevention Policy Regarding Resident's Money Handling
Penalty
Summary
The facility failed to include specific guidelines in its Abuse Prevention Policy and Procedure on how staff should handle residents' property, particularly money, to prevent financial abuse. This deficiency was identified during a review of the facility's policies and procedures, which lacked detailed instructions on managing residents' financial matters. The absence of such guidelines contributed to a situation where staff members received and cashed personal checks from a resident, leading to potential financial abuse. The deficiency involved a resident who was cognitively intact and had a history of chronic obstructive pulmonary disease, chronic pain syndrome, and major depressive disorder. The resident's family member reported that the resident had signed checks to facility staff, which was inappropriate. Photocopies of the checks showed significant amounts of money were given to a Certified Nursing Assistant and an Activity Aide, who were no longer employed at the facility, except for the CNA who was suspended pending investigation. Interviews with various staff members, including Licensed Vocational Nurses and the Social Services Director, confirmed that it was against facility policy for staff to accept money or gifts from residents. The facility's Administrator acknowledged that the CNA involved felt uncomfortable taking the money and recognized the act as financial abuse, despite the resident's alleged consent. The facility's existing Abuse Prevention Policy did not provide specific actions for handling residents' money, which contributed to the deficiency.
Failure to Ensure Timely Podiatry Referral for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the care of fingernails and toenails for one resident, identified as Resident 4. This deficiency was observed when the facility did not ensure that the assigned Licensed Vocational Nurses (LVNs) notified the Social Services Director (SSD) to refer Resident 4 to a podiatrist for the cleaning and trimming of long and overgrown toenails. Resident 4, who was admitted with diagnoses including gout, infection of an amputation stump, and peripheral vascular disease, was dependent on assistance for various activities of daily living, including lower body dressing and putting on/taking off footwear. The resident's care plan, which was untitled, indicated that staff should inspect the resident's feet daily and refer them to a podiatrist for foot care needs, including toenail trimming. During an observation and interview, it was noted that Resident 4's left toenails were long, overgrown, and yellow, and the resident expressed concern about the risk of infection. LVN 7 acknowledged the condition of the toenails and stated the need to inform the SSD to schedule a podiatrist appointment. The Director of Nursing (DON) confirmed the importance of keeping toenails clean and trimmed to prevent infection and injury, and stated that CNAs were responsible for inspecting toenails and informing the LVN and SSD when trimming was needed. The facility's policy, revised in 2018, emphasized the importance of regular nail care to prevent infections and injuries, particularly for diabetic residents or those with circulatory impairments, whose nails should not be trimmed by staff unless permitted otherwise.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at high risk for falls. The resident, who had a history of falls and was diagnosed with conditions such as generalized muscle weakness, type II diabetes mellitus, and encephalopathy, experienced an unwitnessed fall. Despite being assessed as confused and needing a sitter, the necessary order for one-to-one supervision was not obtained by the Licensed Vocational Nurses (LVNs) involved. The resident's care plan indicated several risk factors for falls, including cognitive impairment and the use of cardiac and anti-hypertensive medications. After the fall, the resident was found to be confused and experiencing hallucinations, yet the LVNs did not update the care plan or complete the necessary documentation to secure a sitter. The Medical Doctor (MD) was informed of the fall but not of the resident's confusion or the need for a sitter, which could have prevented further incidents. Interviews with the nursing staff revealed a lack of communication and understanding of the process for obtaining a sitter. The Director of Nursing confirmed that the LVNs should have obtained a physician's order for a sitter following the fall. The facility's policy emphasized the importance of making the environment free from accident hazards and providing adequate supervision, which was not adhered to in this case.
Failure to Reassess Pain Management
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) reassessed the pain level of a resident after administering acetaminophen for mild pain, as per the facility's policy and procedure. The resident, who had a history of gout, infection of an amputation stump, and peripheral vascular disease, was admitted with acute pain related to amputation. The care plan for the resident included goals for adequate pain relief and interventions such as administering analgesia and monitoring its effectiveness. On the day of the incident, the resident complained of mild pain and was given acetaminophen. However, the LVN did not reassess the resident's pain level within the required 30 minutes to one hour after administration. Later, the resident reported experiencing severe pain, rated 9 out of 10, and stated that no one had checked if the pain medication was effective. The LVN acknowledged the failure to reassess the pain level and recognized that the resident's pain could worsen without proper evaluation. The Director of Nursing confirmed that the facility's process required reassessment of pain medication effectiveness within one hour of administration. The facility's policy indicated that nursing staff should assess pain whenever there is a significant change in condition or worsening of existing pain. The failure to follow this protocol resulted in unrelieved pain for the resident and placed them at risk for psychosocial harm.
Expired CNA Certification Leads to Deficiency
Penalty
Summary
The facility failed to ensure that one of its certified nursing assistants (CNA 1) had an active CNA certification while employed and performing resident care. This deficiency was identified during an interview and record review, where it was revealed that CNA 1 worked on multiple dates with an expired CNA certificate. The Director of Nursing (DON) acknowledged this oversight, admitting that they did not verify the certification status before scheduling CNA 1 for work. The facility's policy and procedure, titled 'Credentialing of Nursing Service Personnel,' requires nursing personnel to present verification of their license or certification prior to employment and annually by February 1st. However, the DON admitted to failing to adhere to this policy, resulting in CNA 1 working without a valid certification. This lapse in following established procedures had the potential to lead to inadequate and unsafe resident care due to a knowledge, training, and certification deficit.
Failure to Notify Resident and Responsible Party of Room Changes
Penalty
Summary
The facility failed to notify a resident and the resident's responsible party prior to room or bed changes, as required by the facility's policy and procedure. The resident, who had diagnoses including difficulty walking and end-stage renal disease, was transferred multiple times between rooms without documented evidence of notification. Interviews with the Infection Preventionist Nurse, Social Services Director, and Director of Nursing confirmed the lack of documentation and notification for these room changes. The resident's medical records indicated that the resident had the capacity to understand and make decisions, although later assessments showed moderately impaired cognition. Despite this, the facility's policy required advance written notice of room changes, which was not provided. The resident expressed that he did not remember being notified about the room changes and did not want to be moved. The facility's policy clearly stated that all parties involved in a room change should receive advance written notice, including the reasons for the change, but this procedure was not followed.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate care and necessary services to prevent pressure ulcers and promote healing. Specifically, the licensed nurses did not set Resident 3's low air loss (LAL) mattress settings accurately based on the resident's weight or comfort. The mattress was observed to be set at 240 lbs, while Resident 3's actual weight was 119 lbs. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an interview and observation. The Director of Nursing (DON) acknowledged that setting the mattress at the correct weight is crucial for wound healing. Additionally, the nursing staff did not turn and reposition Resident 3 every two hours as indicated in the resident's care plan. Resident 3 reported that she had not been turned since the morning, and this was confirmed during an observation and interview. The care plan specifically required turning and repositioning every two hours to prevent further skin breakdown. The facility also failed to provide timely incontinent care to Resident 3 after a bowel movement. Multiple observations showed that Resident 3 had to wait for extended periods before receiving incontinent care, resulting in soiled conditions that could exacerbate her pressure ulcers. The DON and other staff members acknowledged the importance of timely incontinent care and proper communication among staff to ensure that residents' needs are promptly addressed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 4,036 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesa Glen Care Center | 0.7 mi | ★★★★★ | 32 | 0 |
| Gladstone Sub-acute And Rehab Center | 1.4 mi | ★★★★★ | 4 | 0 |
| Glendora Grand, Inc | 1.9 mi | ★★★★★ | 31 | 0 |
| Arbor Glen Care Center | 2.1 mi | ★★★★★ | 24 | 0 |
| Emanate Health Inter-community Hospital- D/p Snf | 3.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.