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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Haven Care Center during CMS and state inspections, most recent first.
A facility failed to monitor three residents receiving opioid pain meds for adverse effects and did not document interventions identifying side effects to watch for during administration. One resident received Tramadol for pain and two residents received Hydrocodone-Acetaminophen (Norco); the record review noted diagnoses including COPD, DM, osteoporosis, and polyneuropathy, with one resident cognitively intact, one moderately impaired, and all receiving PRN pain regimens.
Improperly Stored Dry Food in Kitchen: During a kitchen observation, a plastic container of dehydrated pudding was found open in dry storage with the lid not on. The DS stated the food was exposed to air and could be contaminated, and noted that serving contaminated pudding could result in foodborne illness. The facility policy required opened products to be stored in containers with tight fitting lids.
A resident with hemiplegia/hemiparesis after a CVA, impaired decision-making, and visual loss was observed in bed without her call light within reach. She stated she could not see well and could not locate it, while the CNA confirmed it was not accessible and the LVN noted the cord had been wrapped around the bed, making it too short and tight for use. The facility policy stated the call cord should be placed within the resident’s reach.
Failure to Provide Written Bed-Hold Notice: A resident with dementia and severe cognitive impairment was transferred to a GACH for abnormal vital signs, but the hard chart contained no bed-hold documentation. The DON confirmed no signed bed-hold form was present and it was unknown whether the RP or conservator was notified, despite the facility policy requiring written notice of the bed-hold policy.
Incomplete Dementia Care Plan: A resident with dementia, unspecified psychosis, and severe cognitive impairment had a care plan that used generic interventions such as keeping routine consistent and reminiscing with photos, but did not identify resident-specific behaviors, triggers, communication needs, safety risks, or individualized responses. Staff stated the resident could not verbally communicate needs, used eye gestures and hand movements, and became frustrated and agitated several times a week when needs were unmet, yet the care plan did not guide staff on how to respond.
A resident with hemiplegia/hemiparesis, impaired mobility, and cognitive impairment required substantial to maximal assistance with ADLs and oral hygiene. A CNA set up the meal tray while the resident remained leaning to one side in bed, despite stating she was supposed to ensure proper positioning for eating. After breakfast, another CNA did not provide oral care, and the resident was later observed with food traces on the gums and mouth open.
Improper Hand Placement During PROM Exercises: An RNA provided PROM to a resident with spondylosis, bilateral knee contractures, and severe cognitive impairment without proper hand placement. The RNA was observed supporting the lower extremities incorrectly during flexion and extension, and both the RNA and PT stated the hands should have been placed under the thigh and ankle to support the leg.
A resident with COPD, asthma, and chronic respiratory failure was ordered BiPAP and titrated oxygen, but staff observed the resident repeatedly receiving oxygen via NC without an active order for NC oxygen. The resident refused BiPAP because it felt suffocating, and staff stated the resident mostly used NC oxygen instead. Interviews and record review showed the care plan for BiPAP noncompliance was not resident-specific and there was no documented care plan for NC oxygen use, despite facility policy requiring oxygen orders and a comprehensive care plan with specific interventions.
Bed rail use was not properly managed for two residents. One resident with encephalopathy, morbid obesity, and left below-knee amputation had bilateral full side rails ordered for mobility and safety, but the record did not show review of alternatives, resident/RP discussion, or monitoring of rail placement and function. Another resident with asthma, seizures, and dementia had padded full side rails ordered for mobility and seizure safety, but the entrapment assessment was incomplete and the record did not show attempted alternatives or monitoring of safe rail use.
Licensed nursing staff and the physician did not act on the pharmacist’s MRR recommendations for a resident receiving morphine sulfate ER for severe pain. The MRR identified the scheduled pain regimen as a potential respiratory depression risk and recommended assessing pain and considering respiratory monitoring, but the DON stated staff were not following those recommendations.
Failure to obtain ordered urine tests for a resident with dysuria. A resident with a history of UTI, COPD, and impaired cognition reported burning with urination, and the MD ordered a urinalysis and urine culture before starting Macrobid. The tests were not collected as ordered, and record review found no evidence the antibiotic was given; the resident continued to report burning when urinating.
A resident who required maximal assistance for transfers due to cognitive and physical impairments was transferred by a responsible party using a Hoyer lift without staff assistance. Although staff identified and discussed this safety concern with the family, the care plan was not updated to address the unauthorized use of the lift or its storage in the resident's room, contrary to facility policy requiring individualized care planning.
A resident with moderate cognitive impairment, communication challenges, and a history of impaired vision and fall risk was found without a functioning call light, which was observed on the floor and not within reach. Staff confirmed the call light was non-functional and had not been reported as defective, despite facility policy requiring immediate action and alternative safety measures when the primary call system fails.
A resident receiving Quetiapine for paranoid delusions was not properly monitored for the effectiveness of the medication or adverse reactions, as required by the facility's policy. Despite a care plan indicating the need for monitoring, there was no documented evidence of such actions, placing the resident at risk of unnecessary medication use and potential side effects.
A resident with COPD exacerbation and a history of pneumonia experienced severe respiratory distress with oxygen saturation dropping to 72%. The facility failed to monitor and adjust oxygen therapy as per physician orders, and the LVN did not document or report the resident's condition to the physician. Emergency services were not notified immediately, and the resident's refusal to go to the hospital was not communicated to the physician. These deficiencies resulted in the resident's death after unsuccessful CPR.
The facility failed to update the medical records of three residents to reflect their wishes regarding advance directives and POLST. A resident's records did not show evidence that the option of an advance directive was informed or offered, and another resident's POLST form lacked a physician's signature. Additionally, a third resident's POLST form was missing a physician's signature, and the advance directive was incomplete. Staff acknowledged these deficiencies, and the facility's policies and procedures for ensuring complete documentation were not followed.
A resident with COPD and a history of pneumonia experienced severe respiratory distress with an oxygen saturation of 72%. Despite the resident's refusal to be transferred to the hospital, the facility failed to notify the physician or call 911, as required by their policies. The resident was later found unresponsive and pronounced dead after unsuccessful CPR efforts.
Two residents with indwelling catheters were not provided appropriate care, as sediments in their urine were not documented or reported to a physician. Despite care plans requiring monitoring for UTI symptoms, the facility failed to assess and flush the catheters as needed. Observations confirmed sediments in the tubing, but these were not documented, and the physician was not notified, leading to a deficiency in care.
The facility did not post nurse staffing information in a highly visible and prominent place accessible to residents, staff, and visitors. Observations revealed the absence of staffing information in the front lobby and nursing stations. The Director of Staff Development and the Director of Nursing confirmed the information was not posted in visible areas, contrary to the facility's policies.
The facility failed to properly store and manage medications, resulting in expired Tylenol suppositories, Ondansetron HCL tablets, and N95 masks being found in storage areas. An opened Lidocaine cream lacked an open date label. Staff interviews revealed lapses in routine checks and adherence to facility policy, contributing to these deficiencies.
A resident with COPD and other conditions experienced respiratory distress and died after the facility failed to monitor, document, and respond to their condition. The facility did not follow physician orders or notify emergency services, and the incident was not investigated as part of the QAPI program.
A resident experienced a 20-minute delay in receiving his meal tray compared to others at the same table, violating facility policy that requires simultaneous service. Staff interviews revealed a lack of awareness about the delay, and the Registered Dietitian confirmed that such delays are unacceptable. The facility's policies emphasize the importance of serving meals at the same time to promote dignity.
The facility failed to ensure that call lights were within reach for two residents, both with severe cognitive impairments and dependent on staff for daily activities. One resident's call light was frequently out of reach due to movement, while another was unable to access the call light due to being seated in a Geriatric chair with a lap table. Staff interviews confirmed the oversight, and the facility's policy requires call cords to be within reach.
A resident with Alzheimer's and diabetes was placed in a Geri chair with a lap table that they could not remove, effectively restraining them without a physician's order or consent. Staff admitted it was for convenience, despite the resident's ability to walk with assistance. The facility's policy against restraints for convenience was not followed.
A facility failed to complete a required PASARR Level II evaluation for a resident with mental health diagnoses, including depression, anxiety, and psychosis. Despite receiving medications for these conditions, the necessary evaluation was not documented, as confirmed by staff interviews. The facility's policy mandates a Level II evaluation following a positive Level I screen, which was not adhered to, risking the resident's care.
The facility failed to create comprehensive care plans for two residents, one with thrombocythemia on antiplatelet therapy and another exhibiting challenging behaviors. The absence of care plans led to potential health risks due to inconsistent monitoring and interventions, as confirmed by interviews with the DON and LVN.
A resident with multiple medical conditions, including diabetes and amputations, did not receive required dermatology and podiatry consultations for nail care, leading to severe infection and pain. Facility staff failed to document or address the resident's nail condition, violating care protocols.
A resident with Alzheimer's and epilepsy, admitted with intact skin, developed a Stage 3 pressure injury due to inadequate preventive care. Despite being high-risk and fully dependent on staff for repositioning and incontinence care, the resident's pressure injury healed but later reopened. The facility failed to adhere to its pressure ulcer prevention policy, leading to the development and recurrence of the injury.
A resident with a G-tube and a history of dementia and anxiety repeatedly pulled out her G-tube, leading to multiple hospitalizations. The facility's care plans were not adequately revised to address the behavior, and interventions such as mitten restraints and an abdominal binder were ineffective. Staff interviews revealed inconsistent supervision and monitoring, and the facility failed to conduct IDT meetings to explore alternative interventions.
A resident with COPD and pneumonia experienced respiratory distress, with oxygen levels dropping to 72%. Despite administering a breathing treatment, an LVN failed to notify the physician or escalate the situation, leading to the resident's death. The facility's policies and procedures for emergency response were not followed, as confirmed by interviews with the DON and the resident's primary physician.
A resident with epilepsy and intellectual disabilities exhibited agitation and yelling, leading to an incident where a CNA attempted to redirect the resident physically, increasing agitation. The CNA did not seek assistance, and the intervention violated the resident's rights. Staff interviews highlighted the need for verbal de-escalation techniques and respecting the resident's wishes, as per facility policy.
A facility failed to document the justification for the continued use of Ativan PRN beyond the 14-day limit for a resident with severe cognitive impairment and epilepsy. The resident was prescribed Ativan for seizures and anxiety, but the facility did not adhere to its policy requiring PRN orders for psychotropic drugs to be limited to 14 days unless extended by documented physician rationale.
Two residents in an LTC facility did not receive their prescribed medications, resulting in a 7.14% medication error rate. One resident with vitamin D deficiency did not receive their Vitamin D3 via G-tube due to an LVN mistakenly marking it as administered. Another resident with metabolic encephalopathy did not receive their multivitamin because it was not listed in the computer system. The facility's policy requires medications to be administered per physician's orders.
A resident with cognitive impairment and early dementia did not receive drinks consistent with their preferences, despite clear instructions on their tray card. The resident repeatedly informed staff of their dietary restrictions, yet milk was still provided. The Certified Dietary Manager acknowledged the error, and the Registered Dietitian emphasized the importance of honoring residents' preferences.
A resident with Diabetes Mellitus Type 2 was admitted to an LTC facility without proper orders for blood sugar monitoring and insulin administration. The facility staff failed to review hospital discharge records and verify diabetes care orders with the attending physician. This oversight led to the resident's severe health deterioration, resulting in an emergency hospital transfer and subsequent death due to Diabetic Ketoacidosis.
A resident with Diabetes Mellitus was admitted to a facility without proper review of their medical history and necessary diabetes management, including insulin and blood sugar monitoring. The facility failed to implement its admission assessment policy, leading to a lack of necessary diabetes care. The resident experienced a severe change in condition and died from diabetic ketoacidosis.
A resident with diabetes was not properly monitored or administered insulin during their stay at the facility, despite having a care plan that required such actions. The resident's condition deteriorated, leading to an emergency hospital transfer and subsequent death from diabetic ketoacidosis. The facility failed to adhere to its policies requiring physician oversight and monitoring of blood sugar levels.
A resident with Diabetes Mellitus Type 2 was admitted to a facility with a plan to continue insulin medication, but the insulin was discontinued without justification, and blood sugar levels were not monitored. The pharmacy consultant failed to review the resident's medication regimen thoroughly, leading to a lack of necessary diabetes management. This oversight resulted in the resident developing Diabetic Ketoacidosis and subsequently passing away after being transferred to a hospital.
The facility failed to report a COVID-19 outbreak involving five residents to the CDPH within the required 24-hour period, only notifying the local health department. This oversight prevented timely investigation and intervention. The affected residents had various medical conditions and decision-making capacities. Interviews revealed a lack of understanding of reporting procedures by the Infection Preventionist and miscommunication with the Director of Nursing.
A resident with a history of seizures and cognitive impairments experienced multiple falls due to the facility's failure to implement seizure precautions and update care plans. Despite being at high risk for falls, necessary safety measures like side rails and floor mats were not consistently used, leading to a severe fall with head injury and seizure activity.
A resident with a history of seizures, dementia, and Parkinson's disease was admitted to an LTC facility without a comprehensive care plan addressing these conditions. Despite known risks, the facility did not implement interventions to prevent injury during seizures or address the resident's cognitive impairments and noncompliance. This oversight led to the resident falling during a seizure, resulting in a major head injury. Interviews with staff and record reviews confirmed the absence of a care plan, violating the facility's care planning policy.
The facility failed to ensure that licensed nursing staff did not administer expired insulin to six residents. Insulin for multiple residents was found to be expired during an inspection of medication carts, and it was confirmed that the expired insulin had been administered on several occasions. Additionally, Resident 14's Basaglar insulin was not administered according to the manufacturer's specifications, leading to multiple doses being given after the insulin had expired. The facility's policy is to discard insulin 28 days after it is opened, but this was not followed, increasing the risk of side effects for the residents.
The facility failed to ensure expired and discontinued medications were discarded and disposed of properly. Expired insulin was not removed for 10 residents, medications for a discharged resident were not removed from active supply, and a discontinued medication was not disposed of with a witness or documented. These failures increased the risk of ineffective treatment and medication errors.
The facility failed to post accurate daily nurse staffing information, as required by its policy. Observations and interviews revealed that the staffing information was outdated, which could lead to misinformation and a sense of insecurity among residents and visitors.
Failure to Monitor Opioid Side Effects
Penalty
Summary
The facility failed to monitor three residents for adverse side effects related to opioid pain medications and failed to implement interventions identifying what side effects to watch for while the residents were receiving those medications. Resident 7 was admitted and later readmitted with diagnoses including COPD, Type 2 DM, and polyneuropathy. The MDS indicated the resident had intact cognitive skills, was dependent for ADLs such as toileting, showering, and repositioning in bed, had frequent pain, and was on a scheduled pain medication regimen with PRN pain medication. The order summary showed Tramadol HCL 50 mg, 1 tablet by mouth every 12 hours as needed for moderate to severe pain. Resident 67 was admitted and later readmitted with diagnoses including COPD, osteoporosis, and polyneuropathy. The MDS indicated moderately impaired cognitive skills, a pain medication regimen, and that the resident denied pain at the time of assessment; the order summary showed Hydrocodone-Acetaminophen (Norco) 5-325 mg, 1 tablet by mouth every 6 hours as needed for moderate to severe pain. Resident 82 was also reviewed for pharmacy services and was receiving Hydrocodone-Acetaminophen for pain. The report states the facility did not monitor Residents 7, 67, and 82 for adverse side effects such as respiratory depression, nausea, increased drowsiness, lethargy, and sedation, and did not implement interventions to identify those side effects while the residents were receiving the pain medications.
Improperly Stored Dry Food in Kitchen
Penalty
Summary
The facility failed to ensure food was properly stored and sealed in accordance with its policy and procedure titled, Food storage, preparation, distribution and serving food. During a concurrent initial kitchen observation and interview with the Dietary Supervisor on 1/13/2026 at 9:20 AM, the dry food storage area was observed with a plastic food container holding dehydrated bread pudding left open, with the lid not on. The Dietary Supervisor stated the container with dehydrated banana pudding was not properly closed and was exposed to air, which would contaminate the food contents. The Dietary Supervisor also stated that if the pudding was contaminated and served to residents, it could result in foodborne illness. The facility policy revised 1/1/2026 stated that food items will be stored, thawed, and prepared in accordance with good sanitary practice and that any opened products should be placed in storage containers with tight fitting lids.
Call Light Not Within Reach for Resident With Limited Mobility and Vision Loss
Penalty
Summary
The facility failed to ensure that Resident 30’s call light was within reach and easily accessible. Resident 30 was admitted with diagnoses including hemiplegia and hemiparesis following a CVA affecting the left dominant side, major depressive disorder, and unspecified visual loss. The MDS dated 12/25/2025 indicated moderately impaired cognitive skills for daily decision making and that Resident 30 required substantial to maximal assistance with oral hygiene, personal hygiene, and upper body dressing. During an observation and interview on 1/13/2026, Resident 30 was lying in bed and stated she needed assistance to be placed in a comfortable position and to reposition her left arm. She also stated she could not see well and could not locate her call light. At that time, CNA 1 stated the call light was not within reach and that Resident 30 could not move her left arm on her own, making it important to keep the call light within reach at all times. LVN 1 stated Resident 30 required maximum assistance for most ADLs and that call lights should be within reach so residents can call for help, and that the cord should not be wrapped multiple times around the bed because it would shorten and tighten the cord and prevent access. The facility’s policy stated the call cord would be placed within the resident’s reach in the resident’s room.
Failure to Provide Written Bed-Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to ensure that Resident 11 was provided written notice of the bed-hold policy when the resident was transferred to a general acute care hospital on 1/4/2026. Resident 11 was admitted to the facility on 9/7/2024 with diagnoses including dementia with behavioral disturbance and hypertension. The resident's H&P dated 10/18/2025 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 12/8/2025 indicated severe cognitive impairment. A review of Resident 11's physician discharge summary showed the transfer to the GACH occurred for abnormal vital signs, including a documented heart rate of 110 bpm. On 1/15/2026, review of the resident's hard chart found no bed-hold documentation. During a concurrent interview, the DON stated there was no bed-hold document signed or present in Resident 11's medical record hard chart and it was unknown whether the responsible party or conservator was notified regarding the bed hold. The facility's Bed Hold policy, revised 9/1/2023, states residents or their representatives are to be advised in writing that the facility has a bed-hold policy and will hold the resident's bed for up to seven days if transferred to a GACH.
Incomplete Dementia Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan with resident-specific interventions for one resident with dementia and unspecified psychosis. The resident was admitted with diagnoses including dementia and unspecified psychosis, and the history and physical indicated the resident did not have the capacity to understand and make decisions. The MDS dated 12/10/2025 indicated severe cognitive impairment. The care plan for impaired cognitive functions/impaired thought processes, initiated on 3/13/2025, included general interventions such as keeping the resident's routine consistent, monitoring and reporting PRN changes, and reminiscing with photos, but did not identify resident-specific behaviors, triggers, communication needs, safety risks, or individualized approaches related to the resident's dementia needs. During interview, a CNA stated the resident could not verbally communicate needs and used eye gestures and hand movements, and that the resident became frustrated and agitated 2 to 3 times a week, waving hands and grunting when needing something, then calming once needs were met. An LVN, the DSD, and the DON reviewed the dementia care plan and stated it lacked specific, individualized treatments and interventions to address the resident's behaviors and care needs, including how to respond when the resident was frustrated or agitated. The facility policy on care planning stated that each resident's comprehensive care plan will describe interventions and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Oral Care and Proper Meal Positioning
Penalty
Summary
The facility failed to provide necessary care and services to Resident 30, who had self-care deficits, impaired physical mobility, moderately impaired cognitive skills for daily decision making, and required substantial to maximal assistance with oral hygiene and other ADLs. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a CVA affecting the left dominant side, major depressive disorder, and unspecified visual loss. The care plan identified the need for oral care to keep the teeth and mouth free of odor and debris, and the resident’s physician orders included a regular diet with soft and bite-sized texture and thin liquids. On 1/14/2026 at 12:38 PM, CNA 2 was observed assisting Resident 30 to high Fowler’s position and then setting up the meal tray while the resident remained sitting in the center of the bed leaning to the right upper bed rail. CNA 2 stated the resident was only able to feed herself with the right arm and also stated she was supposed to help and make sure the resident was in the correct position for the meal. The care plan and facility policy on eating and swallowing indicated that body positioning is a critical component of self-feeding and swallowing, and that the resident’s trunk, neck, and head should be supported in midline. On 1/15/2026 at 9:30 AM, Resident 30 was observed sleeping in bed in semi-Fowler position with the mouth open and visible traces of food on the gums. CNA 3 stated the resident was not provided oral care after breakfast that morning and stated she was supposed to provide oral care after meals as part of maintaining residents in good hygiene. During interview, LVN 1 stated Resident 30 required maximal assistance on the majority of ADLs including oral hygiene, and the DSD stated the assigned CNA should have provided oral care after the meal and ensured proper positioning during feeding.
Improper Hand Placement During PROM Exercises
Penalty
Summary
Facility staff failed to ensure Resident 13 received appropriate restorative nursing services when the Restorative Nursing Assistant provided passive range of motion exercises to the resident's lower extremities without proper hand placement. Resident 13 was admitted with diagnoses including spondylosis, contractures of both knees, and difficulty walking. The resident's H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment, dependence on staff for all self-care and functional abilities, and receipt of restorative nursing programs. During observation, the RNA was seen performing flexion and extension PROM to both lower extremities, but placed one hand under the lower thigh and the other hand on the resident's toes on one leg, and on the other leg placed one hand under the lower thigh and the other under the ball of the foot. In interview, the RNA stated the hands should have been under the thigh and ankle, and the PT stated proper hand placement would be one hand under the ankle and the other at the lower thigh to support the entire leg. Facility policies stated ROM should be performed by holding the body part securely but gently above and below the joint, not on the joint, and that hip and knee flexion/extension should be supported at the knee and ankle joints.
Respiratory Care and Oxygen Therapy Not Managed per Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice and its own policies for a resident with COPD, asthma, chronic hypercapnic and hypoxemic respiratory failure, and use of continuous oxygen therapy and BiPAP. The resident was admitted and later readmitted with these diagnoses, and the MDS indicated intact cognition, dependence for several ADLs, continuous oxygen therapy, and use of a BiPAP machine as a non-invasive ventilator. Nursing progress notes documented a change in mental status and that the resident appeared tired, with the PCP notified and transfer to the hospital recommended. Hospital records noted hypoxemia with oxygen saturation in the upper 80s while on oxygen therapy. The resident’s hospital orders directed continuation of BiPAP on and off during the day and continuously at night, with oxygen titrated to keep saturation around 92%. Later physician notes directed oxygen therapy to keep saturations above 92% and to alternate oxygen between NC and BiPAP, and an order summary indicated BiPAP at bedtime continuously and as needed during the day. Despite these orders, the resident was observed multiple times in the room receiving oxygen via NC connected to an oxygen concentrator set at 4 LPM, and the resident stated she had always used oxygen through the NC and felt it was hard to breathe without it. The resident also stated she did not like the BiPAP because it felt like it was suffocating her. Staff interviews and record review showed there was no active physician order for oxygen therapy via NC, even though the resident was receiving oxygen through the NC. The LVN stated the resident continuously used oxygen via NC because it was more comfortable than BiPAP and rarely used BiPAP at night. The LVN also stated there was no documented care plan for oxygen delivered via NC, and the BiPAP noncompliance care plan was not resident-specific and did not identify specific behaviors or negative outcomes to monitor. The DON confirmed the resident had an order for BiPAP but no order for oxygen via NC, and stated there was no resident-specific care plan or interventions to help staff monitor and manage the resident’s COPD and oxygen therapy. The facility policy required oxygen orders for all residents receiving oxygen, and the care planning policy required the comprehensive care plan to describe interventions and services to be furnished.
Bed Rail Use Lacked Alternative Measures, Assessment, and Monitoring
Penalty
Summary
The facility failed to ensure proper use of bed rails for two residents by not documenting attempts to use nonrestrictive measures and other alternatives before the rails were installed, not completing the entrapment risk assessment for one resident, and not documenting monitoring for safe bed rail use. Resident 4 was admitted and later readmitted with diagnoses including encephalopathy, morbid obesity, and acquired absence of the left leg below the knee. The record showed a physician order for bilateral full side rails as an enabler for bed mobility, repositioning, transferring, ADL care, and safety, and the nursing admission assessment indicated the resident was alert but confused and could not follow commands or remember the use and purpose of bed rails. For Resident 4, the care conference record did not show review of bed rail use, and the nursing progress notes did not show that alternative measures were attempted before bed rails were used. There was also no documented evidence of monitoring proper placement and function of the bilateral full side rails. During observation, the resident was sleeping in bed with both full side rails up, and an LVN stated the rails were up because the resident requested it. The LVN later stated there was no documentation of discussion with the resident or responsible party regarding feasible alternatives and no documentation of attempted alternatives or monitoring for safe use of bed rails. Resident 6 was admitted and later readmitted with diagnoses including asthma, seizure, and dementia. The order summary indicated bilateral padded full side rails were to be used as an enabler for bed mobility and safety from potential seizure. The quarterly nursing assessment showed the resident was alert but confused, could not follow commands or remember the use and purpose of bedside rails, and could not use call alarms, but the entrapment-related measurement for head, neck, and chest breadth was left blank. The record also did not show review of bed rail use at the care conference, did not show that alternatives were attempted before bed rails were used, and did not show monitoring of proper placement and function of the rails. During observation, the resident was lying in bed with both side rails up, and staff stated the rails were needed for fall precaution and seizure prevention.
Failure to Act on Pharmacist MRR Recommendations for Morphine Therapy
Penalty
Summary
Licensed nursing staff and the physician failed to act on the pharmacist’s Medication Regimen Review recommendations for Resident 5. The resident was admitted with diagnoses including bipolar disorder, depression, and anxiety disorder, and the H&P stated the resident had the capacity to understand and make decisions. The MDS dated 11/8/2025 indicated cognition was intact and listed active diagnoses of anxiety, depression, and bipolar disorder, with the resident receiving antipsychotic, antianxiety, and antidepressant medications. The pharmacist’s MRR dated 11/29/2025 and 11/30/2025 identified that the resident was on a scheduled pain management regimen that could increase the risk of respiratory depression and recommended assessing the resident’s pain condition and considering respiratory monitoring. A physician’s order dated 12/17/2025 ordered morphine sulfate ER 30 mg by mouth every 12 hours for severe pain. During interview and record review on 1/16/2026, the DON stated facility staff was not following the pharmacist’s recommendations to assess the resident’s pain condition and add respiratory monitoring to the physician’s order.
Failure to Obtain Ordered Urine Tests for Resident with Dysuria
Penalty
Summary
The facility failed to obtain urinalysis and urine culture tests as ordered by the attending physician for Resident 67 after the resident complained of burning and discomfort with urination. Resident 67 was admitted and later readmitted with diagnoses including UTI, COPD, and osteoporosis, and the MDS indicated moderately impaired cognitive skills. The care plan identified a UTI and included interventions to monitor and report signs and symptoms such as dysuria, obtain and monitor lab or diagnostic work as ordered, and report results to the MD. On 1/7/2026, the SBAR communication form documented that Resident 67 verbalized a burning sensation upon urination, and Physician 1 ordered a urinalysis and urine culture before starting Macrobid 100 mg twice daily for five days after the urine was collected. The order summary report showed the urinalysis and urine culture were uncollected. When interviewed on 1/14/2026, Resident 67 stated she had told nurses that it burned when she urinated and that she had not yet received the medication for the burning sensation, and she was still experiencing burning that morning. Review of records with LVN 2 and the DON found no documented evidence that the urine tests were collected or that Macrobid was administered.
Failure to Update Care Plan After Safety Concern with Mechanical Lift Use
Penalty
Summary
The facility failed to develop a resident-centered care plan after identifying a safety concern involving a resident who required substantial to maximal assistance for transfers and activities of daily living due to muscle wasting, abnormal posture, and moderately impaired cognitive skills. The resident's responsible party was observed using a Hoyer lift to transfer the resident from bed to chair without staff assistance, despite the resident's lack of capacity to understand and make decisions. The care plan in place addressed general fall risk and included interventions such as frequent safety reminders and education for the resident, family, and caregivers, but did not specifically address the issue of unauthorized use of the Hoyer lift by the responsible party or the storage of the lift in the resident's room. Interdisciplinary team meeting notes documented that staff had discussed the safety concern with the resident's family after observing the unauthorized transfer. However, the care plan was not updated to reflect this specific risk or to provide clear instructions regarding the use and storage of the Hoyer lift. The Director of Nursing confirmed that a care plan for non-compliance or lack of knowledge was not initiated, and the facility's policy required comprehensive, individualized care planning based on assessed needs and changes in condition or behavior.
Failure to Provide Functioning Call Light for Resident with Communication and Fall Risk
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, communication difficulties, and a history of impaired vision and fall risk was not provided with a functioning call light. The resident's care plans specifically required that a call light be within reach to ensure safety and facilitate communication with staff. During observation, the call light was found on the floor and not within the resident's reach. Both a CNA and an RN confirmed that the call light was non-functional, with the button stuck and unable to be pressed, and no light or sound was produced when tested. The resident reported that the call light did not work, and staff interviews confirmed the importance of a working call system for residents to request assistance. The maintenance supervisor stated that weekly inspections were conducted and that no issues had been reported for this resident's call light during the last check. However, there was no documentation or notification of the malfunction prior to the surveyor's observation. Facility policy required immediate reporting and replacement of defective call lights, as well as alternative systems and hourly safety checks if the primary system was inoperable, but these measures were not documented as being implemented for this resident.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring of a resident who was receiving Quetiapine for paranoid delusions associated with schizophrenia. The resident, who had moderately impaired cognition and lacked the capacity to make decisions, was admitted with diagnoses including schizophrenia, mood disorders, and dementia. Despite a physician's order for Quetiapine to address paranoid delusions, the facility did not document monitoring of these specific behaviors in the Medication Administration Report or nursing progress notes for January and February 2025. The care plan for the resident indicated that behavior should be monitored for effectiveness every shift, and adverse reactions to Quetiapine should be observed. However, interviews with an LVN and the DON revealed that there was no documented evidence of such monitoring. The facility's policy required daily monitoring of psychotropic drug use and target behaviors, but this was not adhered to, leading to a risk of unnecessary medication use and potential side effects for the resident.
Failure to Provide Adequate Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide necessary respiratory care and implement interventions for a resident diagnosed with chronic obstructive pulmonary disease (COPD) exacerbation and a history of pneumonia. The resident experienced severe respiratory distress, with oxygen saturation dropping to 72% while receiving oxygen via nasal cannula at 2 liters per minute. Despite the resident's condition, the facility did not monitor and evaluate the effectiveness of the oxygen provided, nor did they follow physician orders to adjust the oxygen therapy to maintain oxygen blood levels at 92%. The Licensed Vocational Nurse (LVN) on duty did not document the resident's respiratory distress or report the change in condition to the physician, as required by the facility's policy and procedure. The LVN also failed to notify emergency services immediately when the resident exhibited signs of respiratory distress and refused to go to the hospital. The resident's refusal to be transferred to the hospital was not communicated to the physician, and no alternative interventions were discussed or documented. As a result of these deficiencies, the resident did not receive immediate respiratory care and interventions, leading to their death after unsuccessful CPR was administered. The California Department of Public Health identified an Immediate Jeopardy situation due to the facility's failure to notify the physician and provide necessary respiratory care and monitoring for the resident.
Removal Plan
- The Director of Nursing (DON) conducted a full house audit to identify all residents with a diagnosis of COPD, those on continuous and PRN oxygen. The audit identified 10 residents with COPD and 18 residents receiving oxygen therapy. The DON reviewed the care plans and physician's orders for these residents to ensure appropriate interventions such as following MD orders, oxygen therapy orders, repositioning of patients, checking oxygen saturation, assessment of signs and symptoms of hypoxia respiratory failure for effectiveness of the intervention and monitoring for signs and symptoms of respiratory distress, verifying respiratory status using objective data such as oxygen saturation were in place. The DON will also review the communication to the Primary Care MD, if no response, the medical director and or emergency services will be called immediately. No additional residents were found to be at immediate risk.
- A one to one in-service regarding MD notification, Medical Director notification, and emergency services was provided to the Night Shift Licensed Nurse assigned to Resident 77 by the facility's DON. The Licensed Nurse was also suspended pending the facility's investigation.
- The Pharmacy Consultant initiated Medication Regimen Reviews for all residents receiving Oxygen Therapy and with COPD/SOB.
- The facility conducted a root cause analysis (RCA) which included interviews with involved staff. The RCA revealed the following contributing factors: Lack of staff education on monitoring and reporting changes in respiratory status, and inadequate communication between nursing staff and physicians regarding significant changes in condition.
- The Certified Nursing Assistant (CNA) assigned to Resident 77 during the night shift was provided a one-to-one in-service regarding Emergency Care Policy and Procedure.
- The Director of Nursing/ Staff Development Coordinator (DSD) started to provide in-services to all Licensed Nursing staff for all shifts including CNAs, LVNS, RNs on Emergency Medical Response: A. Monitoring and reporting changes in respiratory status B. Following physician orders for oxygen titration and maintaining target oxygen saturation levels, and C. Facility policy and procedure for responding to respiratory distress, including immediate notification of the primary physician, emergency services, and medical director.
- The DON reviewed the facility's policy and procedure for responding to respiratory distress to ensure clarity and consistency with current standards of practice.
- The DON created a monitoring tool related to COPD and Oxygen Therapy to ensure clarity and consistency with current standards of practice.
Deficiencies in Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to ensure that the medical records of three residents were updated to reflect their wishes regarding advance directives and Physician Orders for Life-Sustaining Treatment (POLST). Resident 19's records did not show evidence that the option of an advance directive was informed or offered to the resident or their responsible party (RP). Additionally, Resident 20's POLST form lacked a physician's signature, and there was no documentation indicating that the advance directive option was explained to the resident or their RP. Resident 1's POLST form was also missing a physician's signature, and the advance directive was not filled out completely. The facility's staff, including a registered nurse (RN), the Social Services Director (SSD), and the Medical Records Director (MRD), acknowledged these deficiencies during interviews. The RN stated that the POLST should be signed by a physician within 72 hours of admission, and the SSD admitted to forgetting to check the completeness of the POLST and advance directive forms. The facility's policies and procedures require that a completed and signed POLST form be a legal physician order and that the advance directive be explained to the resident or their RP. However, these procedures were not followed, leading to incomplete documentation and a lack of clarity regarding the residents' wishes for life-sustaining treatment and resuscitation.
Failure to Notify Physician and Emergency Services for Resident in Respiratory Distress
Penalty
Summary
The facility failed to adhere to its Policies and Procedures regarding Change of Condition Notification for a resident with chronic obstructive pulmonary disease exacerbation and a history of pneumonia. The resident exhibited signs of respiratory distress, including labored breathing and an oxygen saturation level of 72%, which is significantly below the normal range. Despite these critical symptoms, the facility did not notify the physician or emergency services immediately, as required by their protocols. The resident, who was alert and capable of making decisions, refused to be transferred to the hospital despite experiencing severe respiratory distress. The Licensed Vocational Nurse (LVN) on duty administered a breathing treatment, which temporarily improved the resident's condition, but did not reach out to the physician or call 911. The LVN believed the resident's condition had improved sufficiently and was also occupied with other residents, which contributed to the lack of immediate action. The facility's failure to notify the physician or emergency services resulted in the resident not receiving timely medical intervention. The resident was later found unresponsive, and despite CPR efforts, was pronounced dead by paramedics. The facility's policies clearly outlined the steps to be taken in such emergencies, including notifying the physician and calling 911, but these were not followed, leading to the resident's death.
Failure to Monitor and Document Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling catheters, leading to a deficiency in care. Resident 65, who was admitted with metabolic encephalopathy and acute kidney failure, had severely impaired cognition and was dependent on assistance for all activities of daily living. The resident's care plan required monitoring for signs of urinary tract infections (UTIs), including sediments in the urine. However, the Treatment Administration Record (TAR) for December 2024 did not document the presence of sediments, and the catheter was not flushed as needed, despite observations of sediments in the tubing. Similarly, Resident 36, admitted with encephalopathy and an overactive bladder, also had severely impaired cognition and required dependent assistance for all activities. The resident's care plan included monitoring for UTI symptoms, but the TAR for December 2024 failed to document sediments in the urine, and the catheter was not flushed as required. Observations confirmed the presence of sediments in the catheter tubing, which were not reported or documented, and the physician was not notified of these findings. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed a lack of awareness and documentation regarding the sediments in the residents' catheters. The facility's policies and procedures required notification of the physician for any abnormal findings, such as sediments, but this was not followed. The failure to assess, document, and report the sediments in the urine could lead to complications, including UTIs, which were not addressed in a timely manner.
Failure to Post Nurse Staffing Information in Visible Location
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a highly visible and prominent place that was readily accessible to residents, staff, and visitors daily. During observations on December 3, 2024, at 8:30 AM in the front lobby and at 9:00 AM in Nursing Stations 1, 2, and 3, there was no nurse staffing information posted. This was confirmed during a concurrent observation and interview on December 6, 2024, at 6:50 PM with the Director of Staff Development (DSD), who acknowledged that the staffing information was posted next to the facility's shadow box frame by the main entrance, which was not easily visible to residents and visitors. The Director of Nursing (DON) also confirmed during an interview on December 6, 2024, at 7:30 PM that the nurse staffing information was not posted in a highly visible area such as the nursing station or by the front lobby. The facility's policies and procedures, revised on October 24, 2022, indicated that nurse staffing data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. The failure to comply with this policy had the potential to prevent residents and visitors from accessing the facility's staffing information to ensure safe and sufficient staffing levels.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and manage medications and biologicals, leading to the presence of expired and unlabeled items in the medication storage areas. During an observation, thirteen expired Tylenol suppositories were found on a shelf in the Medication Storage Room in Station 1, with expiration dates ranging from June to December 2024. Additionally, a container of Ondansetron HCL oral tablets, prescribed to a resident for nausea and vomiting, was found expired on Medication Cart 2. Furthermore, nine expired N95 face masks and an opened Lidocaine cream without an open date label were also found on the same cart. Interviews with staff revealed that the licensed nurses were responsible for removing expired medications but did so only when they had time. The Director of Nursing stated that licensed nurses should routinely check expiration dates every shift and that a system was in place for weekly audits, which failed to identify the expired items. The facility's policy required medications to be stored safely and securely, with opened medications labeled with an open date, but these procedures were not followed, leading to the deficiencies observed.
Failure to Investigate Respiratory Distress Leading to Resident's Death
Penalty
Summary
The facility failed to develop a system to systematically identify adverse events, monitor, investigate, analyze root causes, and evaluate its Quality Assurance and Performance Improvement Program (QAPI) related to respiratory care for one of the sampled residents. This deficiency was highlighted by the case of a resident who experienced a change in condition leading to death, which was not investigated to determine if it was due to the facility's failure to notify the physician and emergency services, follow oxygen orders, monitor, and document the resident's condition, and respond appropriately to severe respiratory distress. The resident, who had been admitted with diagnoses including COPD with exacerbation, pneumonia, and hypertensive heart disease, experienced shortness of breath, labored breathing, and an oxygen saturation of 72% while on oxygen via nasal cannula at 2 LPM. The facility did not follow physician orders to adjust the resident's oxygen levels, failed to monitor and document the resident's respiratory distress, and did not notify the physician or emergency services when the resident exhibited signs of respiratory distress. The facility's QAPI program did not include adverse events, and the cause of death was not investigated to determine if quality deficiencies existed.
Resident Meal Service Delay
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 48, received his meal tray at the same time as other residents seated at the same table. During an observation in the dining room, it was noted that Resident 48 had to wait an additional 20 minutes for his meal tray while others were already eating. This delay was confirmed by Resident 48, who expressed feelings of being hurt due to consistently being the last to receive his meal. The facility's policy requires that all residents at the same table be served simultaneously, which was not adhered to in this instance. Interviews with staff, including the Activity Director and Dietary Supervisor, revealed a lack of awareness and understanding of why Resident 48's meal was delayed. The Registered Dietitian also confirmed that it was unacceptable for residents to wait longer than 2-5 minutes for their meals. The facility's meal service policy, dated 2023, and the privacy and dignity policy, dated 2017, both emphasize the importance of serving meals simultaneously to promote independence and dignity. Despite these policies, the facility's meal delivery process, which involves delivering trays based on room numbers, contributed to the delay experienced by Resident 48.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a critical component for residents to alert staff when they need assistance. Resident 45, who was admitted with severe cognitive impairment and was dependent on assistance for daily activities, had a care plan that required the call light to be within reach to prevent falls. However, during an observation, the call light was found hanging on the bedside, out of reach. Interviews with staff, including an LVN and a CNA, revealed that the call light frequently fell due to the resident's movements, and it was the responsibility of the nursing staff to ensure it was accessible. The Director of Nursing emphasized the importance of the call light being within reach to prevent potential harm. Similarly, Resident 46, who had Alzheimer's disease and severe cognitive impairment, was observed seated in a Geriatric chair with a lap table, making it impossible for the resident to reach the call light. The care plan for this resident also required the call light to be within reach to prevent falls or injuries. Interviews with a CNA and an LVN highlighted that the resident was unable to use the call light due to the restrictive setup, and the call light should be placed within reach to allow the resident to call for assistance. The facility's policy on the call system mandates that call cords be within the resident's reach, which was not adhered to in these cases.
Resident Restrained Without Proper Authorization
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed in the case of a resident who was placed in a Geri chair with a lap table that the resident could not easily remove. The resident, who was admitted with diagnoses including Alzheimer's disease and diabetes mellitus, was observed from 11 AM to 2:35 PM in the Geri chair with the lap table attached. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for assistance with daily activities, but did not document the use of restraints. There was no physician's order for the use of the Geri chair with a lap table, and the resident was unable to remove the lap table independently, effectively making it a restraint. Interviews with staff revealed that the resident was typically seated in the Geri chair with the lap table from 11 AM to 2 PM, which restricted the resident's movement and limited their freedom to move and ambulate. The CNA stated that it was easier to care for the resident in this manner, despite the resident's ability to walk with assistance. The Director of Nursing confirmed the lack of a physician's order, consent, or documentation for the use of the Geri chair with a lap table, and acknowledged that the inability of the resident to remove the lap table constituted a restraint. The facility's policy indicated that restraints should only be used for medical symptoms and not for convenience, yet this policy was not followed in this instance.
Incomplete PASARR Evaluation for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the completion of a Preadmission Screening and Annual Resident Review (PASARR) for a resident with mental health diagnoses, including depression, anxiety, and psychosis. The resident was admitted with these conditions and was receiving antipsychotic, antidepressant, and antianxiety medications. Despite a Department of Health Care Services letter indicating the need for a Level II mental health evaluation, there was no record of this evaluation in the resident's chart or electronic health record. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASARR process. The Director of Nursing stated that the California State DHCS manages the scheduling and execution of PASARR evaluations, while the Admission Coordinator acknowledged the facility's responsibility to ensure the completion of the PASARR assessment. The facility's policy requires that a positive Level I screen necessitates a Level II evaluation before admission, but this was not completed for the resident, placing them at risk of not receiving necessary care and services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential health risks. Resident 54, who had a history of thrombocythemia and was receiving antiplatelet therapy, did not have a care plan to monitor for signs and symptoms of bleeding. Despite the presence of orders to monitor for bleeding every shift, the care plan was not created, which could result in inconsistent monitoring and care. Interviews with the LVN and DON confirmed the absence of a care plan and highlighted the importance of having one to ensure consistent and person-centered care. Resident 16, who exhibited behaviors such as agitation, screaming, and attempting to hit staff, also lacked a care plan to address these behaviors. The resident had been admitted with diagnoses including epilepsy and intellectual disabilities, and a psychiatric consult had been ordered due to the challenging behaviors. However, no care plan was developed to manage these behaviors, which could lead to inconsistent responses from staff and increased risk of harm. Interviews with the DON and LVN emphasized the necessity of care plans for managing challenging behaviors and ensuring effective interventions. The facility's policies and procedures on care planning, revised in 2022, indicated that care plans should include measurable objectives and timetables to address residents' medical, nursing, mental, and psychosocial needs. The lack of care plans for both residents indicates a failure to adhere to these policies, potentially compromising the residents' well-being and the consistency of care provided by the staff.
Failure to Provide Nail Care Leads to Infection
Penalty
Summary
The facility failed to provide appropriate care and services for a resident, identified as Resident 54, who was admitted with several medical conditions including orthopedic aftercare following surgical amputation, Type 2 Diabetes Mellitus with diabetic neuropathy, bilateral glaucoma, and acquired absence of both legs above the knee. The resident's care plan included orders for dermatology and podiatry consultations every two months and as needed for mycotic and hypertrophic nails. However, there was no documented evidence that these consultations were conducted, and the resident's nails were not properly managed, leading to severe infection and pain. Observations and interviews revealed that Resident 54's fingernails were thickened, dry, brittle, and broken, with some nails falling off and causing pain. Despite the resident's condition, there was no record of nail care or treatments in the resident's medical records. Interviews with staff, including CNAs and LVNs, indicated a lack of awareness and action regarding the resident's nail condition. The staff failed to notify the physician or document any change of condition, and there were no nursing progress notes or care plans addressing the issue. The facility's policies and procedures required high-risk residents with nail issues to be referred to a podiatrist, and any significant change in a resident's condition should be reported to the physician. However, these protocols were not followed for Resident 54, resulting in untreated fungal infections and overgrown nails. The lack of timely intervention and communication with healthcare providers contributed to the resident's deteriorating condition, which could have led to hospitalization.
Failure to Prevent and Manage Pressure Injury in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development and recurrence of a Stage 3 pressure injury in a resident who was admitted with intact skin. The resident, who had Alzheimer's disease and epilepsy, was identified as high risk for pressure injuries due to being bedbound and having very limited mobility. Despite this, the resident developed a deep tissue pressure injury on the sacrum, which progressed to a Stage 3 pressure injury. The facility's records indicated that the pressure injury healed but later reopened, suggesting inadequate preventive measures were in place. The resident was fully dependent on staff for repositioning and incontinence care, as they were unable to communicate when wet or soiled. The Treatment Nurse noted that there were instances when the resident was found with soiled incontinent briefs that had not been changed overnight, which could have contributed to the delay in healing and reopening of the pressure injury. The facility's policy on pressure ulcer prevention required identifying residents at risk and providing appropriate care, but this was not effectively implemented for this resident. The facility's failure to adhere to its own policy and provide necessary care, such as regular repositioning and timely incontinence care, led to the development and recurrence of the pressure injury. The Treatment Nurse acknowledged that the wound was avoidable with proper care and that the resident's condition required diligent staff intervention to prevent such occurrences.
Inadequate Management of G-tube in Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure that a resident with a Gastrostomy Tube (G-tube) received appropriate treatment and services to prevent complications such as peritonitis and perforation. The resident, who had a history of muscle wasting, dementia, and major depressive disorder with severe psychotic symptoms, repeatedly pulled out her G-tube due to confusion and anxiety. This resulted in seven hospitalizations for G-tube dislodgement, with the potential for trauma and infection at the G-tube stoma, as well as dehydration and malnutrition. The facility's documentation and care plans for the resident were inconsistent and lacked detailed information about the G-tube site location. Despite the resident's behavior of pulling out the G-tube, the care plans were not adequately revised to include effective interventions. The facility attempted to use bilateral hand mitten restraints and an abdominal binder, but these measures were insufficient as the resident was able to remove them and continue dislodging the G-tube. The facility did not conduct Interdisciplinary Team (IDT) meetings after each incident to determine the cause of the behavior and explore alternative interventions. Interviews with facility staff revealed a lack of consistent supervision and monitoring of the resident. The Director of Nursing acknowledged the need for more frequent supervision to prevent G-tube dislodgement. The facility's policies and procedures required daily inspection of the G-tube site for signs of irritation or infection, but there was no evidence that these inspections were consistently documented or that the care plans were updated with new interventions after each incident.
Inadequate Response to Respiratory Distress Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) had the appropriate competencies and skills to provide adequate nursing care to a resident experiencing respiratory distress due to Chronic Obstructive Pulmonary Disease (COPD) and pneumonia. The resident, who had a Physician Orders for Life-Sustaining Treatment (POLST) indicating a wish for Cardiopulmonary Resuscitation (CPR), experienced a significant drop in oxygen levels to 72%. Despite administering a breathing treatment, the LVN did not notify the physician or escalate the situation appropriately, leading to the resident's condition declining and resulting in death. The LVN, upon noticing the resident's labored breathing and low oxygen levels, offered to transfer the resident to a hospital, but the resident declined. The LVN administered a breathing treatment, which temporarily improved the resident's oxygen levels, but failed to continuously monitor the resident or notify the physician of the critical situation. The LVN also instructed a Certified Nurse Assistant (CNA) to monitor the resident, but did not follow up with the necessary medical interventions or communication with the physician. Interviews with facility staff, including the Director of Nursing (DON) and the resident's primary physician, revealed that the LVN did not follow the facility's policies and procedures for handling such emergencies. The DON stated that the LVN should have notified the physician and continuously monitored the resident's condition. The primary physician confirmed that he was not informed of the resident's condition until after the resident had passed away, indicating a failure in communication and adherence to clinical standards of practice.
Failure to Implement Appropriate Behavior Management for a Resident
Penalty
Summary
The facility failed to implement appropriate behavior management and interventions for a resident, identified as Resident 16, who exhibited behaviors of agitation, yelling, and attempts to hit staff. The resident, who was admitted with diagnoses including epilepsy and intellectual disabilities, was observed walking in the hallway without pants, exposing her private area. A Certified Nurse Assistant (CNA 7) attempted to redirect the resident back to her room by holding her shoulders, despite the resident's verbal protests to be left alone. This physical intervention increased the resident's agitation, leading to the resident scratching the CNA. Interviews with staff revealed that CNA 7 did not seek assistance from other staff members, believing the task needed to be handled alone. The CNA's actions were intended to protect the resident's dignity and privacy but resulted in increased agitation. The Licensed Vocational Nurse (LVN 2) and the Director of Nursing (DON) indicated that the CNA should have used verbal and non-verbal de-escalation techniques and respected the resident's wishes not to be touched. The DON emphasized that physical intervention should only occur when necessary and after efforts to calm the resident verbally have been made. The facility's policy on behavior management requires staff to assess behavioral symptoms and implement non-drug interventions before initiating psychotherapeutic medications. The policy also emphasizes the importance of person-centered care that maximizes the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. The failure to adhere to these guidelines resulted in a deficiency in providing necessary behavioral health care and services to Resident 16.
Failure to Document Justification for Extended Use of Ativan PRN
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not documenting the justification for the continued use of Ativan PRN beyond the 14-day limit. The resident, who was admitted with diagnoses including seizures/epilepsy and intellectual disabilities, was prescribed Ativan to be administered as needed for seizures and anxiety related to epilepsy. However, the facility did not adhere to its policy that requires PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician documents a rationale for extending the order. The resident's cognitive skills for daily decision-making were severely impaired, necessitating supervision and extensive assistance from staff for activities of daily living. Despite this, the Director of Nursing acknowledged that the physician's order for Ativan PRN was not limited to 14 days and indicated plans to contact the physician for verification and possible reevaluation. The facility's policy requires that if a PRN order is to be extended beyond 14 days, the attending physician must document their rationale and indicate the duration for the PRN order, which was not done in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as prescribed to two residents, resulting in a medication error rate of 7.14%. Resident 45, who was admitted with a diagnosis of vitamin D deficiency and had severely impaired cognition, did not receive their prescribed Vitamin D3 oral tablet via G-tube. During a medication administration observation, the LVN responsible for administering the medication mistakenly checked off the Vitamin D3 as administered in the electronic Medication Administration Record (e-MAR) without actually giving it to the resident. Similarly, Resident 61, who was admitted with metabolic encephalopathy and had intact cognition, did not receive their prescribed multivitamin oral tablet. The LVN failed to administer the multivitamin because it did not appear in the computer system when checking the scheduled medications for the resident. The facility's policy requires medications to be administered by a licensed nurse per the physician's order, but this was not followed in these instances.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide a resident with drinks that accommodated their preferences, which had the potential to result in decreased fluid intake and lead to dehydration. The resident, who has moderately impaired cognition and early dementia, expressed dissatisfaction with receiving milk despite repeatedly informing staff of their dietary preferences, which included no cheese, milk, pork, or beef. The resident's tray card clearly indicated these preferences, yet milk was still provided. The Certified Dietary Manager acknowledged the error upon reviewing the tray card but did not provide an explanation for why milk was included. The Registered Dietitian confirmed that residents' hydration needs and preferences should be honored. The facility's policy stated that meals should be consistent with residents' preferences as indicated on the tray card, but this was not adhered to in the case of the resident in question.
Failure in Diabetes Management Leads to Resident's Death
Penalty
Summary
The facility failed to ensure proper diabetes management for a resident with a diagnosis of Diabetes Mellitus Type 2 upon admission. The attending physician did not include necessary orders for blood sugar monitoring and insulin administration, which are critical for managing diabetes. The licensed staff did not review the resident's hospital discharge records to verify and implement appropriate diabetes care orders, nor did they confirm these orders with the attending physician upon the resident's admission to the facility. The resident, who had a history of diabetes, encephalopathy, dementia, and hypertension, was admitted to the facility without the necessary orders for diabetes management. The facility's records showed that an order for Insulin Lispro was discontinued without valid justification, and there was no evidence of blood sugar monitoring or insulin administration during the resident's stay. The resident's care plan included monitoring for signs of hyperglycemia and hypoglycemia, but there was no documentation that this was done. As a result of these deficiencies, the resident experienced a severe deterioration in health, leading to an emergency transfer to a hospital where they were diagnosed with Diabetic Ketoacidosis and subsequently passed away. The facility's failure to ensure continuity of diabetes care and proper medication management directly contributed to the resident's critical condition and eventual death.
Failure to Provide Adequate Diabetes Management
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Diabetes Mellitus (DM) received appropriate treatment and services in accordance with professional standards of practice, the care plan, physician orders, and the facility's policies and procedures. The resident, who had a history of DM, was admitted to the facility without a proper review of their medical history and discharge orders from the previous acute care hospital, which indicated the need for insulin and blood sugar monitoring. The facility did not verify with the physician whether these treatments should continue, leading to a lack of necessary diabetes management. The facility also failed to implement its policy and procedure for admission assessment, as a licensed nurse did not complete a drug regimen review upon the resident's admission. This oversight resulted in the failure to identify clinically significant medication issues, such as the need for insulin and blood sugar monitoring. Additionally, the facility did not follow its diabetic care policy or the resident's care plan, which required monitoring for signs and symptoms of hypoglycemia and hyperglycemia. The interdisciplinary team, including the Director of Nursing, was not aware of or did not review the resident's care plan to ensure it was being followed. As a result of these failures, the resident experienced a change in condition, including an altered level of consciousness, oxygen desaturation, and a critically high blood sugar level. The resident was transferred to a general acute care hospital, where they were diagnosed with diabetic ketoacidosis and subsequently died. The facility's pharmacist consultant also did not provide documented recommendations for managing the resident's diabetes, further contributing to the lack of appropriate care and monitoring.
Failure to Monitor and Manage Diabetes in Resident
Penalty
Summary
The facility failed to ensure that the attending physician assessed and evaluated the total program of care for a resident with diabetes. The resident's blood sugar was not monitored, and insulin medication was not administered during their stay at the facility. This oversight occurred despite the resident having a documented diagnosis of diabetes mellitus and a care plan that required monitoring and reporting of blood sugar levels. The resident was admitted to the facility with a history of diabetes mellitus, encephalopathy, dementia, and hypertension. Upon admission, the resident's care plan included monitoring for signs of hyperglycemia and hypoglycemia. However, the Minimum Data Set did not reflect the resident's diabetes diagnosis, and there was no order for insulin or blood sugar monitoring. The physician's orders for insulin were discontinued without documented clarification, and the interdisciplinary team did not discuss the resident's diabetes management. As a result of these failures, the resident experienced a severe deterioration in health, leading to an emergency transfer to a hospital with a blood sugar level of 500 mg/dL. The resident was diagnosed with diabetic ketoacidosis and subsequently passed away two days after hospital admission. The facility's policies required physician oversight and monitoring of blood sugar levels, which were not adhered to in this case.
Failure to Monitor and Administer Insulin Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that the pharmacy consultant thoroughly reviewed and reported irregularities in the medication regimen of a resident diagnosed with Diabetes Mellitus Type 2. The resident was admitted to the facility with a plan to continue insulin medication to manage blood sugar levels. However, the insulin was discontinued without clear justification, and there was no monitoring of the resident's blood sugar levels. This oversight led to the resident not receiving necessary insulin and blood sugar monitoring, which are critical for managing diabetes. The resident's medical records from the facility and the General Acute Care Hospital (GACH) indicated a lack of documented evidence that insulin was administered or that blood sugar levels were monitored. The Medication Administration Record (MAR) and the Medication Regimen Review (MRR) did not reflect any recommendations or actions taken to address the resident's diabetes management. The pharmacy consultant admitted to only reviewing current medications and not considering discontinued medications or the resident's diagnoses, which contributed to the oversight. As a result of these failures, the resident experienced a severe medical emergency, with a blood sugar level of 500, leading to a diagnosis of Diabetic Ketoacidosis (DKA) and subsequent transfer to a hospital. Despite receiving emergency treatment, the resident's condition deteriorated, resulting in death. The facility's policies and procedures for drug regimen review were not adequately followed, leading to a critical lapse in care for the resident.
Failure to Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) within the required 24-hour timeframe. Five residents tested positive for COVID-19, but the facility only reported the outbreak to the local health department, not the CDPH. This failure to report prevented the CDPH from conducting a timely on-site investigation to ensure proper precautions were being taken to protect residents and staff. The report details the medical conditions and decision-making capacities of the affected residents. Resident 1, who tested positive on January 15, 2024, had hemiplegia and hemiparesis following a cerebral infarction and lacked decision-making capacity. Resident 2, also testing positive on the same date, had chronic obstructive pulmonary disease and similarly lacked decision-making capacity. Resident 3, who had muscle wasting and atrophy, was capable of making decisions and tested positive on January 15, 2024. Resident 4, who was readmitted with COVID-19, lacked decision-making capacity and was transferred to a general acute care hospital (GACH) where they tested positive. Resident 5, with a femur fracture, left the facility against medical advice after testing positive. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed a lack of communication and understanding of reporting procedures. The IP admitted to not knowing how to contact the CDPH and only reported to the local health officer. The DON was under the impression that the CDPH had been notified. The facility's policy on communicable disease outbreaks required reporting to both the CDPH and local health officer, which was not followed in this instance.
Failure to Implement Seizure Precautions and Fall Management
Penalty
Summary
The facility failed to prevent a high-risk resident from falling and sustaining injuries due to inadequate care planning and supervision. The resident, who had a history of seizures, Parkinson's disease, and cognitive impairments, was admitted to the facility without a care plan for seizure monitoring and precautions. Despite a physician's order for bilateral side rails and the facility's policy requiring seizure precautions, these measures were not implemented upon admission. The resident experienced multiple falls, including incidents on March 7 and March 18, which resulted in injuries. The facility did not conduct an Interdisciplinary Team (IDT) Falls Committee meeting within 72 hours of these falls to update the care plan and implement necessary interventions. This lack of timely assessment and intervention contributed to a subsequent fall on May 2, where the resident was found on the floor with a head injury and seizure activity, requiring emergency hospital transfer. Interviews with facility staff revealed that the resident was known to be at high risk for falls due to forgetfulness and confusion, yet appropriate safety measures such as floor mats and side rails were not consistently used. The facility's policies on fall management and seizure precautions were not followed, and there was no documented evidence of care plans addressing the resident's non-compliance and dementia. The failure to reassess and adjust interventions after each fall incident further exacerbated the risk of injury.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, leading to a significant health deficiency. The resident, who had a history of head injury, cardiac arrest, seizures, Parkinson's disease, and dementia, was admitted to the facility without a care plan addressing these conditions. Despite the resident's known history of seizures and dementia, the facility did not establish appropriate interventions to prevent major injury during seizure activity or address the resident's cognitive impairments and noncompliance with care instructions. Interviews with facility staff, including CNAs and RNs, revealed that the resident was known to be confused, forgetful, and noncompliant with instructions to call for help before getting up. The staff acknowledged that a care plan should have been developed upon admission to address the resident's seizure history and noncompliant behaviors, but no such plan was in place. The lack of a care plan resulted in the resident experiencing a fall during a seizure, leading to a major laceration and bleeding on the head. The facility's own care planning policy, revised in October 2022, mandates the development of a comprehensive person-centered care plan for each resident based on their assessed needs. However, the facility failed to adhere to this policy, as evidenced by the absence of a care plan for the resident's seizures, dementia, and noncompliance. This oversight was confirmed through record reviews and interviews with the Infection Prevention Nurse and the Director of Nursing, who both acknowledged the lack of appropriate care planning for the resident.
Expired Insulin Administration
Penalty
Summary
The facility failed to ensure that licensed nursing staff did not administer expired insulin to six out of ten residents. During an inspection of two medication carts, it was found that insulin for Residents 5, 6, 7, 8, 12, and 14 was expired. Licensed Vocational Nurse (LVN) 3 confirmed that insulin has an expiration date of 28 days once opened, and administering expired insulin could result in ineffective blood sugar control. Resident 14's Basaglar insulin was also not administered according to the manufacturer's specifications, which require it to be injected once daily at the same time every day. Instead, it was administered as a sliding scale insulin, leading to multiple doses being given after the insulin had expired. Resident 14's medical records indicated that the resident did not have the capacity to understand and make decisions, and the expired insulin was administered on several occasions in April 2024, as documented in the Medication Administration Record (MAR). Similarly, Resident 12 was administered expired Insulin Lispro on multiple occasions between April 17 and April 22, 2024, despite the insulin being expired since April 16, 2024. LVN 3 confirmed that the expired insulin was still in the medication cart and had been administered to the resident. Resident 12's medical records also indicated that the resident did not have the capacity to understand and make decisions. The inspection of Medication Cart 1 on Station 1 revealed that insulin for Residents 5, 6, 7, and 8 was also expired and available for use. LVN 1 confirmed that the insulin was expired and should not have been administered. Resident 7's Novolog insulin, Resident 8's Humalog insulin, Resident 6's Insulin Lispro, and Resident 5's Insulin Glargine were all found to be expired and had been administered to the residents on multiple occasions. The Director of Nursing (DON) confirmed that the facility's policy is to discard insulin 28 days after it is opened, and administering expired insulin increases the risk of side effects such as uncontrolled blood glucose, acidosis, hospitalization, coma, and death. The facility's policy and procedure for medication storage indicated that all expired medications should be removed from the active supply and destroyed, and that insulin should be used within 28 days of being opened.
Failure to Properly Discard and Dispose of Medications
Penalty
Summary
The facility failed to ensure expired and discontinued medications were discarded and disposed of properly according to the facility's policy and procedure. During an inspection of two medication carts, it was found that expired insulin was not removed and discarded for 10 out of 12 residents. Specifically, insulin vials and pens were either not labeled with an open date, stored improperly, or available for use beyond their expiration date. This included insulin for Residents 1, 5, 6, 7, 8, 9, 11, 12, 13, and 14. The Licensed Vocational Nurses (LVNs) acknowledged the discrepancies and confirmed that expired insulin could be ineffective in controlling blood sugar levels, posing a risk to the residents' health. The facility also failed to remove and securely store medications for Resident 10 after the resident was discharged. During an inspection, multiple bubble packs of medications labeled for Resident 10 were found mixed with current residents' medications in a medication cart. The Director of Nursing (DON) confirmed that these medications should have been removed immediately upon the resident's transfer and placed in a designated location in the medication storage room. The medications included treatments for conditions such as epilepsy, high cholesterol, and heartburn. Additionally, the facility did not properly dispose of a discontinued medication for Resident 15. The LVN was observed discarding Eliquis 2.5 mg tablets without a witness and without documenting the disposal, contrary to the facility's policy. The DON stated that all medication destruction must be documented and witnessed by a second nurse. The failure to follow proper disposal procedures for discontinued medications increased the risk of inadvertent administration, misuse, and medication errors.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. This information was not posted in a prominent location readily accessible to residents and visitors for viewing, as required by the facility's policy and procedure. The deficiency was identified during an observation on 4/23/24, where the facility's projected daily nursing staffing was found to be outdated. The census at that time was 86 residents. Interviews with the Director of Staff Development consultant and the Director of Nursing confirmed that the daily staffing should be updated daily and that the failure to do so could lead to misinformation and a sense of insecurity regarding adequate staffing among residents and visitors. A review of the facility's policy and procedure titled Nursing Department-Staffing, Scheduling & Postings, revised on 10/24/2022, indicated that the facility is required to post the nursing staffing data daily at the beginning of each shift. The Director of Nursing acknowledged that the daily nursing staffing posting observed on the wall at the nurses' station was not updated, which could create a sense of insecurity for adequate staffing among visitors and family members. The Director of Staff Development consultant also emphasized the importance of keeping staffing assignments updated to provide accurate information for everyone involved.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 6,200 citations issued within 25 miles in the last 12 months — including the 33 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadway Manor Care Center | 1.1 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 1.1 mi | ★★★★★ | 35 | 0 |
| Dreier's Nursing Care Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Autumn Hills Health Care Center | 1.3 mi | ★★★★★ | 7 | 0 |
| Glendale Post Acute Center | 1.4 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.