Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Shepherd Health Care Center Of Santa Monica during CMS and state inspections, most recent first.
Advance directive and POLST documentation were not updated for two residents. One resident with COPD, epilepsy, and bipolar disorder had records showing an AD was available and reviewed, but the AD acknowledgment form incorrectly stated no AD had been executed. Another resident with dementia, bronchitis, and metabolic encephalopathy had DNR status documented in the H&P and OSR, but the POLST in the chart showed full code and was missing the conservator's signature, creating conflicting code status documentation.
Incomplete Care Plans Lacked Measurable Goals and Timeframes: The facility failed to develop comprehensive, person-centered care plans for multiple residents with needs including schizophrenia/dementia with quetiapine use, a scattered rash treated with topical steroid cream, dialysis and renal/diabetic diet needs, insulin therapy, lorazepam use, and a suprapubic urinary catheter. Records and staff interviews showed the care plans lacked measurable objectives, individualized interventions, and target timeframes, and in some cases staff stated no specific care plan had been initiated for the treatment or medication.
Incomplete Comprehensive Care Plans for Oxygen and Repositioning Needs: The facility did not develop or revise comprehensive care plans for two residents with significant care needs. One resident with COPD and SOB was observed in bed with O2 running and the NC off the nose, yet the care plan did not address oxygen use or removing the NC. Another resident with blindness, dementia, and encephalopathy had orders for PRN O2, turning every 2 hours, and cushioning body prominences, but staff did not have a care plan in place or revised to reflect those orders, and the IDT record showed no changes were made.
Failure to assess and document resident skin conditions and wound status. One resident with DM, heart disease, venous insufficiency, anemia, and impaired cognition had generalized scabs and itching, but the TXN stated weekly wound documentation was incomplete and the generalized skin condition was not initially documented. A second resident on hospice had records showing multiple open blisters and wounds, yet the TXN, CNA, and DON stated the resident had no active wounds and was not bedbound, and the chart did not show when the wounds were resolved.
Incomplete and Non-Individualized Care Plans: The DON and RN 1 failed to develop comprehensive, person-centered care plans with measurable goals, individualized interventions, and timeframes for multiple residents. Care plans for residents with diagnoses such as dementia, schizophrenia, heart failure, CKD, DM, COPD, anxiety, and a suprapubic catheter were missing key details, and staff stated the facility relied on broad categories and physician orders instead of individualized care plan content.
The facility failed to properly document disposal of non-controlled medications and failed to administer medications as ordered for two residents. A waste container was observed in a locked cabinet, and the medication destruction record was missing required details such as destruction method, witness information, quantity, and reasons for disposal. In addition, one resident with dementia, schizophrenia, major depressive disorder, and DM had insulin glargine held without documented reason despite the ordered parameters, and another resident received an incorrect dose of sodium bicarbonate.
Failure to Fully Close Privacy Curtain During Personal Care: An RN did not fully close the privacy curtain while providing personal hygiene care to a resident who was alert, oriented, and required assistance with multiple ADLs. The resident had diagnoses including hemiplegia, hemiparesis, cerebral infarction, and major depressive disorder. The RN acknowledged the curtain was not fully closed, and the DON stated residents should receive privacy during care; facility policy required privacy curtains to be fully drawn during personal care.
A facility failed to provide a private space for Resident Council meetings for 5 of 5 residents. The dining/activity room used for the meetings was open to a hallway with access to the staff restroom, kitchen, and resident rooms, with no barrier at the entrance. The AD stated the room is used for RC meetings, and RC members said staff or others passing by could overhear discussions and that they did not feel free to openly discuss issues and concerns because the meetings were not held in a private closed room.
Failure to provide vision-related assistive supports: A resident with bilateral legal blindness, dementia, and metabolic encephalopathy required substantial to maximal help with ADLs and partial help with eating, yet was observed in bed with the call light on the floor and no visual sign identifying the impairment. Staff stated the resident could not use the call light, needed full assistance for many tasks, and should have a communication binder and visual board at bedside, while the SSD noted the resident is seen yearly by optometry and that a visual sign should be present.
Incorrect Sodium Bicarbonate Dose Administered: An LVN gave a resident the wrong dose of sodium bicarbonate during medication administration. The resident had multiple chronic conditions including CKD, GERD, HTN, epilepsy, and type II DM, and had moderately impaired cognitive skills with maximal ADL assistance needs. The LVN acknowledged the ordered dose was sodium bicarbonate 650 mg, two tablets PO three times daily, but administered two 325 mg tablets instead; the DON reviewed the facility policy requiring safe and accurate medication administration and the five rights.
Failure to document and follow a resident’s food preferences. A resident with COPD, severe protein-calorie malnutrition, and MDD was observed eating only small portions of meals, and the meal card did not list preferred or non-preferred foods. The resident stated specific likes and dislikes, including preferred eggs, fruits, oatmeal, egg salad, salad, hamburger patty, and fries, and disliked chili, spicy foods, and ground meat. The DS said food preference assessments were completed on admission and quarterly, but quarterly assessments were missed and the resident’s documented preference of “American food” was not specific enough.
Dishwasher sanitizer concentration was tested at 25 ppm, below the facility’s required 50 to 100 ppm range, and staff stated dishes would need to be re-washed and re-sanitized. Surveyors also found undated or expired food items in dry storage, the refrigerator, and the freezer, including a baking powder container with an unreadable date, expired lemon juice concentrate, and multiple frozen items with no expiration dates. Staff stated these items should not be used and should be discarded.
The facility failed to complete antibiotic surveillance logs for two residents who received mupirocin, including a resident with heart failure, CVA, altered mental status, and impaired cognition, and another resident with DM, heart disease, venous insufficiency, and anemia. The IPN stated mupirocin should have been tracked in the antibiotic stewardship process but was not documented for the identified months. The facility also did not follow its WMP as written because the MS did not test water for chlorine or pH throughout the facility and there were no logs for required water monitoring.
Failure to obtain a current informed consent before giving an influenza vaccine to a resident with DM, heart disease, venous insufficiency, anemia, and moderately impaired cognition. The IPN stated consent had been signed months earlier, but a new consent was needed before the vaccine was administered because the resident or representative could have changed their mind. Facility policy required education and informed consent before vaccination.
The facility failed to maintain documented evidence for two sampled staff members, including the Medical Director and RD, showing COVID-19 vaccination status, education on vaccine benefits and potential side effects, and that the vaccine was offered. During record review with the IPN, both employees' vaccination records lacked this documentation, and the IPN stated that staff should be offered the vaccine and refusals documented. The facility policy required vaccination status to be tracked, documented, and monitored for all personnel providing services.
Room size requirements were not met in multiple resident rooms. A review of the facility's waiver and accommodations analysis showed that 23 rooms, including double-occupancy rooms and one room documented for 3 residents, provided less than the required square footage per resident. During observation, staff had enough space to provide care and rooms had direct corridor access, with no noted privacy, care, or safety concerns.
A resident in an LTC facility developed a stage 1 pressure ulcer that progressed to stage 4 due to inadequate care and failure to update care plans. Despite being at risk for skin breakdown, the facility did not implement effective interventions to address the resident's non-compliance with turning and repositioning. The care plans remained unchanged as the ulcer worsened, leading to severe tissue damage requiring debridement.
The facility failed to ensure kitchen staff were trained and competent in meeting residents' nutritional needs, particularly for those on puree diets. Staff did not follow recipes or portion sizes, serving puree scrambled eggs instead of the intended ham and potato casserole, leading to potential nutritional deficiencies. Additionally, the facility's freezer was found to be unsanitary, posing a risk of foodborne illness.
The facility failed to properly prepare and serve meals, affecting both regular and puree diets. The ham and potato casserole was not cut to the specified size and lacked garnish, while puree diet residents received dry scrambled eggs instead of the intended casserole. Additionally, puree wheat toast and raisin bran were too sticky, failing consistency tests. These deficiencies could lead to poor food intake and weight loss.
The facility failed to maintain safe food storage and preparation practices, with issues such as improper freezer temperatures, unsanitary kitchen equipment, and damaged utensils. Turkey was stored incorrectly, and various kitchen surfaces were not cleaned properly, leading to potential cross-contamination. Additionally, expired food was found in the resident's refrigerator, and staff used personal cellphones in the kitchen.
The facility failed to properly dispose of garbage by not covering a dumpster and maintaining cleanliness in the trash area, potentially attracting pests and spreading infection among residents. Interviews with staff confirmed the importance of keeping dumpsters closed and the area clean, as per facility policies and the Food Code 2017.
The facility did not submit Payroll Based Journal (PBJ) data to CMS for a required quarter in 2023, missing the deadline for the first fiscal quarter. The Director of Staff and Development/Infection Preventionist Nurse stated that the corporate office failed to complete the submission properly. Facility policies require quarterly submissions, and CMS guidelines stress the importance of timely and accurate data.
The facility did not deliver mail to residents on Saturdays, as confirmed by several residents and staff. Mail delivered by the post office on weekends was held until Monday for sorting and delivery by Social Services, contrary to the facility's policy on resident rights.
The facility failed to manage pain effectively for two residents. One resident did not have a lidocaine patch removed as ordered, while another missed multiple doses of Buprenorphine due to pharmacy delays. Interviews confirmed severe pain levels and inadequate medication administration, highlighting a failure to follow physician orders and ensure timely delivery.
The facility failed to follow the prescribed puree menu and portion sizes for residents on a puree diet. Instead of serving the pureed ham and potato casserole, staff served plain pureed scrambled eggs, which lacked essential nutrients. Additionally, incorrect portion sizes were used, potentially depriving residents of necessary calories and nutrients. A resident reported issues with portion sizes, indicating insufficient food on previous occasions.
The facility failed to prepare puree foods to meet IDDSI Level 4 requirements for residents with swallowing difficulties. Observations showed that puree eggs were too dry, and puree bread and cereals were too sticky, failing the spoon tilt test. This posed a risk of aspiration and choking for residents on this diet.
The facility did not meet the required room size of 80 square feet per resident in double occupancy rooms and 100 square feet in single rooms, affecting 23 out of 24 rooms. Despite this, observations showed no issues with privacy or care, and residents reported no concerns. The facility had requested a waiver for the non-compliant rooms.
A facility failed to obtain proper consent for the use of bilateral bed siderails as a restraint for a resident with a history of falls and moderate cognitive impairment. The resident was observed with siderails up, but there was no physician order or complete consent form. Staff interviews indicated the siderails were used for mobility and repositioning, although the resident could not use them effectively. This violated the resident's rights to respect and dignity.
A facility failed to ensure a resident was free from physical restraints by using bilateral bed siderails without a physician's order. The resident, with chronic kidney disease and pressure ulcers, was observed with siderails up, despite needing assistance for daily activities and having impaired cognitive skills. Staff interviews revealed the siderails were used to prevent falls, contrary to facility policy, which requires a physician's order for such use.
A resident with cognitive impairment and mobility limitations was found with an unexplained injury, but the LTC facility failed to report the incident to the state agency as required by their policy. The resident, who was non-verbal and required assistance for daily activities, was discovered hanging from the side of her bed with an open ecchymosis on her arm. The facility's failure to report the incident delayed an inspection by the Department of Public Health.
A facility failed to maintain a resident's dignity by not covering their urinary catheter drainage bag, as observed during a survey. The resident, who required maximal assistance for daily activities and had intact cognitive skills, was seen with an uncovered catheter bag in a shared room. The facility's policy required such bags to be covered to protect resident privacy, a standard confirmed by both an LVN and the DON.
A resident in an LTC facility reported missing packages and receiving opened mail, leading to feelings of anger. The facility's Social Service Director confirmed that residents did not receive mail on weekends, and the Director of Nursing was unaware of these issues. The facility's policy emphasized residents' rights to access mail and be free from misappropriation of property.
A resident with chronic kidney disease and weakness did not have a handroll applied to her right hand as ordered, despite needing moderate to maximum assistance with daily activities. Observations showed the handroll was only applied to the left hand. The RNA failed to report or document the resident's refusal to wear the right handroll, and the LVN was unaware of any refusals, risking the resident's hand becoming contracted.
A resident with an indwelling urinary catheter was at risk of infection due to improper placement of the Foley catheter bag above the bladder level, contrary to facility policy. The resident expressed concern, and both an LVN and the DON confirmed the incorrect placement, which hindered proper urine drainage.
A facility failed to provide necessary respiratory care for a resident with COPD by not ensuring a physician's order for oxygen therapy and not maintaining the humidifier as per policy. The resident was observed using an oxygen concentrator with an empty humidifier bottle, and no physician's order was found for the therapy. The DON confirmed the humidifier should be replaced weekly and as needed, and the facility's policy required a physician's order and sufficient water in the humidifier.
A facility failed to ensure proper oversight of Food and Nutrition Services when a resident with chronic kidney disease and pressure ulcers experienced significant weight loss without a comprehensive care plan. The RD provided recommendations but did not develop a care plan, citing time constraints. The DS did not act on the RD's notes or contact the physician, and the DON confirmed the DS lacked the credentials to perform RD duties. The RD's job responsibilities included reviewing care plans, which were not fulfilled, leading to the deficiency.
A resident reported feeling very cold in their room, which was observed to be below the facility's policy range for comfortable temperatures. The Maintenance Supervisor admitted to incomplete temperature logs and uncertainty about the last repair of the heating system. The Director of Nursing acknowledged that cold temperatures could make residents sick and uncomfortable.
Advance directive and POLST documentation not updated
Penalty
Summary
The facility failed to update advance directive documentation for two sampled residents. For Resident 7, the admission record showed a readmission with diagnoses including COPD, epilepsy, and bipolar disorder. The MDS indicated the resident's AD was available and reviewed, and the POLST showed an AD dated [DATE] that was reviewed with the resident representative on [DATE]. The health record also contained a copy of the resident's AD dated [DATE]. However, the facility's AD acknowledgement form dated [DATE] stated the resident had not executed an AD and declined to execute one. During interview, the SSD stated the form was not filled out correctly to reflect that Resident 7 had an AD as shown on the MDS and POLST, and that the incorrect information had been overlooked and needed to be updated. For Resident 50, the admission record showed diagnoses including bronchitis, dementia, and metabolic encephalopathy. The H&P stated the resident did not have capacity to understand and make decisions and documented DNR status, and the OSR also listed a DNR order. However, the POLST in the chart indicated Attempt Resuscitation and noted missing AD information. The SSD stated the POLST was not completed because the conservator's signature was missing and that, if POLST was not completed, the resident would be treated as full code and life-sustaining measures would be done during an emergency. The DON stated the resident arrived with DNR orders from the previous facility but without a current POLST confirming DNR status, and that the current POLST in the chart was not valid because it lacked the conservator's signature.
Incomplete Care Plans Lacked Measurable Goals and Timeframes
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans with measurable goals, individualized interventions, and target timeframes for six sampled residents. The deficiency involved residents with schizophrenia and dementia receiving quetiapine, a resident with a scattered rash treated with Triamcinolone Acetonide cream, a resident receiving dialysis with a renal/diabetic diet, a resident receiving insulin for type 2 DM, a resident receiving lorazepam, and a resident with a suprapubic urinary catheter. In each case, the care plans lacked documentation of measurable objectives, individualized interventions, and/or timeframes for evaluation. For the resident with schizophrenia, dementia, major depressive disorder, and no capacity to make medical decisions, the record showed an order for quetiapine 25 mg every evening for schizophrenia and aggressive, combative behavior, but the care plan did not address schizophrenia, dementia, or quetiapine use. For the resident with heart failure, cerebral infarction, altered mental status, and metabolic encephalopathy, the record showed an order for Triamcinolone Acetonide cream 0.1% applied to the upper body for scattered rash, and the treatment nurse stated the skin check was incomplete and that this was why a care plan was not initiated for the treatment. For the resident with chronic kidney disease stage 4, diabetes mellitus, and heart failure, the record showed dialysis care and a renal, no added salt, consistent carbohydrate diet order, but the dialysis and nutrition/diet care plans did not include measurable goals, individualized interventions, or target timeframes. For the resident receiving insulin glargine at bedtime and regular insulin before meals, staff stated there was no care plan for insulin use and that the interventions listed were not sufficient. For the resident receiving lorazepam, the care plan was missing measurable objectives and timeframes. For the resident with a suprapubic urinary catheter for urinary retention, the care plan also lacked measurable goals, individualized interventions, and target timeframes. The DON stated care plans should be developed on admission and revised as needed, and the facility policy required comprehensive, person-centered care plans with measurable objectives and timetables.
Incomplete Comprehensive Care Plans for Oxygen and Repositioning Needs
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed within 7 days of the comprehensive assessment for two residents. Resident 22 was admitted and re-admitted with diagnoses including COPD, pulmonary edema, and shortness of breath. The MDS dated 12/28/2025 showed the resident needed partial/moderate assistance with some ADLs. During observations on 2/23/2026 and 2/24/2026, Resident 22 was in bed with oxygen running at 2 liters per minute, and on one occasion the nasal cannula was resting on the resident’s chin. Review of the care plans showed no comprehensive care plan addressing oxygen use or the resident’s behavior of removing the nasal cannula, although an older care plan noted oxygen therapy for COPD with interventions to provide oxygen per MD orders, give medications as ordered, and monitor for signs and symptoms of ineffective gas exchange. Resident 29 was admitted with diagnoses including bilateral legal blindness, dementia, and metabolic encephalopathy. The MDS dated 1/23/2026 showed the resident required substantial/maximal assistance with ADLs and partial assistance with eating. An OSR dated 2/25/2026 included orders for oxygen concentrator use PRN to keep oxygen saturation above 92 percent and to turn every 2 hours with cushioning of body prominences and a low bed position. During observation on 2/23/2026, Resident 29 did not have an oxygen concentrator at the bedside, and no visual indicators of legal blindness were present; the resident’s head rested on a white pillow with no additional cushions observed. Staff interviews and record review showed the care plan had not been initiated or revised to reflect the oxygen and repositioning orders, and the IDT conference record indicated the care plan was reviewed with no changes made.
Failure to assess and document resident skin conditions and wound status
Penalty
Summary
The facility failed to ensure ongoing assessment, monitoring, and accurate documentation of skin condition and wound healing for two residents. One resident had diabetes, heart disease, venous insufficiency, anemia, and moderate cognitive impairment, and was observed with generalized scabs on the neck, upper chest, arms, and legs. The resident reported lesions for several weeks and itching, and staff noted the resident was receiving hydrocortisone cream for scabbed areas. The treatment nurse stated that wound assessments were documented weekly, but the most recent documented entry was from 02/13/2026, that an assessment had been performed on 02/19/2026 but not yet documented, and that there was no initial documentation of the generalized scabs. During interview, the treatment nurse stated that wound assessments should include measuring the wound, noting color, tissue type, and drainage, and that skin assessments are essential for evaluating wound progression and determining treatment. The nurse also stated that the assessment for the generalized wound was planned after completion of hydrocortisone treatment. The DON reviewed the facility policy requiring assessment, documentation, treatment, and monitoring in accordance with applicable regulations, and stated that nursing staff are responsible for admission, weekly, and significant-change skin assessments, measuring and documenting wound characteristics, implementing ordered treatments, and notifying the physician of new or worsening wounds. The DON stated that the treatment nurse missed the assessment for the generalized wound and did not adhere to the facility policy. A second resident with blindness, dementia, metabolic encephalopathy, and hospice services had documentation that was not consistent with the resident’s current condition. A skin check assessment documented multiple open blisters on the arms and thighs, and a hospice re-certification assessment described the resident as bedbound with multiple wounds, including skin tears and an ulcer. However, the treatment nurse stated the resident had no active wounds and that the wounds had resolved in 2025, while also stating the electronic record did not show when the wounds were resolved and that weekly wound assessments should have been done to monitor progress. The CNA and DON both stated the resident was not bedbound and had no open skin areas, and the DON stated the hospice re-certification assessment was not accurate because it did not reflect the resident’s current condition.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to ensure that staff, including the DON and RN 1, demonstrated the competencies and skills needed to develop comprehensive, person-centered care plans with measurable goals, individualized interventions, and defined evaluation timeframes for six sampled residents. During record review and interviews, RN 1 and other staff identified that multiple care plans were missing required elements, and the facility’s practice was to rely on broad categories and physician orders rather than detailed, individualized care plan content. For Resident 2, the records showed diagnoses including dementia and schizophrenia, and a physician note stated the resident did not have capacity to understand and make medical decisions. The MDS showed the resident required supervision or touching assistance with all ADLs. During review with RN 1, the care plan was found to have no comprehensive, person-centered plan addressing schizophrenia, dementia, or the use of quetiapine. For Resident 4, the records showed diagnoses including heart failure, cerebral infarction, altered mental status, and metabolic encephalopathy. The MDS showed moderately impaired cognitive skills for daily decisions and maximal assistance with ADLs. The TXN stated the resident’s treatments should be care planned, but the skin check assessment was incomplete and that was the reason a care plan was not initiated for Triamcinolone Acetonide Cream. For Resident 5, the records showed chronic kidney disease stage 4, DM, and heart failure, and the H&P stated the resident did not have capacity to understand and make decisions. The care plans for dialysis treatment and nutrition/diet lacked measurable goals, individualized interventions, and target timeframes, and the RD stated the nutrition/diet care plan did not indicate all measurable goals and interventions. For Resident 6, the records showed type II DM, heart disease, venous insufficiency, and anemia, and the MDS showed moderately impaired cognitive skills and maximal assistance with ADLs. RN 1 stated there was no care plan for insulin use and that the listed interventions were not sufficient. For Resident 8, the records showed cerebral infarction, depression, and anxiety, with the MDS indicating partial/moderate assistance or supervision for multiple ADLs and moderately impaired cognitive skills. The care plan for lorazepam had no measurable objectives or timeframes, and RN 1 confirmed those elements were missing. For Resident 33, the records showed COPD, benign prostatic hyperplasia, and chronic pain syndrome, with intact cognition and partial/moderate assistance for several ADLs. The care plan for the suprapubic urinary catheter had no measurable goals, individualized interventions, or target timeframes. RN 1 and the DON stated that care plans were generally broad, grouped by category, and that detailed interventions and measurable goals were placed in physician orders rather than in the care plan itself.
Incomplete Medication Disposal Records and Medication Administration Errors
Penalty
Summary
The facility failed to ensure proper documentation of disposal of non-controlled medications in the medication storage area. During observation, the pharmaceutical waste container was found inside a locked cabinet. The LVN stated that when a non-controlled medication is discontinued, the licensed nurse must document the prescription number, medication name, count, and have the disposal witnessed by two licensed staff on the medication destruction record. Review of the Medication Destruction Record and the facility's policy for discarding and destroying medications showed that the required documentation was incomplete. The policy required the resident's name, date disposed, medication name and strength, dispensing pharmacy, quantity disposed, method of disposition, reason for disposition, and witness signatures. The DSD stated that multiple entries were missing required information, including the destruction method, second witness, licensed staff name, signature, quantity destroyed, and reasons for disposition. The DON stated that the DON, DSD, and/or licensed nurses handled disposal of non-controlled medication and that two licensed staff should witness the disposal for accountability. The facility also failed to administer medications as prescribed for two residents. One resident had diagnoses including dementia, schizophrenia, major depressive disorder, and DM, and a physician note stated the resident did not have capacity to understand and make medical decisions. The MAR showed insulin glargine was ordered at bedtime with instructions to hold only if blood sugar was less than 100, but the resident's blood sugar was 102 and the insulin was marked as held with code 5; the progress notes did not explain why it was held. Another resident received an incorrect dose of sodium bicarbonate when LVN 1 administered 650 mg instead of the ordered 1300 mg.
Failure to Fully Close Privacy Curtain During Personal Care
Penalty
Summary
The facility failed to ensure that one sampled resident received personal care in a manner that maintained dignity and respect when RN 1 did not fully close the privacy curtains during care. Resident 18 was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction unspecified, and major depressive disorder. The resident's MDS indicated the resident needed supervision and touching assistance with multiple activities of daily living, including eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, footwear, rolling, transfers, and walking, and the resident was alert, oriented, and had a BIMS score of 15. During an observation in the resident's room, RN 1 was preparing to provide personal hygiene care and pulled the privacy curtain, but it was not completely closed and did not provide full privacy. During interview, RN 1 acknowledged the curtain was not closed all the way and stated that complete closure was important to protect the resident's dignity. The DON stated that if a resident is exposed during care because the curtain is not pulled all the way or is too short, the resident may feel embarrassed and bad, and that residents should get privacy when care is provided. The facility policy on Resident Rights stated residents have the right to dignity, respect, privacy, and confidentiality, and the Patient Privacy Curtains policy stated curtains must be fully drawn during personal care, treatments, dressing, and assessments.
Resident Council Meetings Held Without Privacy
Penalty
Summary
The facility failed to provide a private space for Resident Council meetings for 5 of 5 residents. During observation, the dining/activity room used for the meetings was open to a hallway with access to the staff restroom, facility kitchen, and resident rooms, and there was no barrier at the hallway entrance to provide privacy. The Activity Director stated this room is where Resident Council meetings are held and that a sign is posted to alert staff that a meeting is in progress. During interview, Resident Council members stated the area is open to the hallway, staff or others passing by may overhear discussions, and they do not feel free to openly discuss issues and concerns because the meetings are not held in a private closed room. The facility policy for Resident Council Meetings stated meetings shall be held free from interference in an accessible and private location.
Failure to Provide Vision-Related Assistive Supports
Penalty
Summary
The facility failed to ensure that Resident 29 was provided with assistive devices to maintain independence in ADLs and support communication with staff. Resident 29 was admitted with bilateral legal blindness, dementia, and metabolic encephalopathy. The MDS dated 01/23/2026 indicated the resident required substantial to maximal assistance for ADLs and partial assistance for eating. During observation on 2/23/2026 at 8:13 a.m., Resident 29 was lying in bed at the lowest position with the call light on the floor, and there was no oxygen concentrator at bedside or any visual sign indicating that the resident was legally blind. The resident’s head was resting on a white pillow, and no other cushions were observed. During interviews, CNA 2 stated that staff must do everything for Resident 29 because he is blind and cannot select his own clothes or feed himself, and that he walks with assistance and should not be left alone. CNA 3 stated that staff cannot always stay with Resident 29, that there should be a communication binder and a visual board at bedside, and that the resident cannot use the call light in his room because he does not know how to use it. CNA 3 also stated that Resident 29 is continent of bladder and that staff must borrow a walker from therapy to take him to the restroom. The SSD stated that the resident is seen once a year by the optometrist, that the optometrist does not make recommendations, and that the facility staff cannot implement interventions to assist with ADLs. The SSD also stated that vision is important because it can affect ADLs and that there should be a visual sign in the room to notify others of the resident’s impairment.
Incorrect Sodium Bicarbonate Dose Administered
Penalty
Summary
The facility failed to ensure that an LVN administered the correct dosage of sodium bicarbonate as ordered for one resident. The resident was admitted with diagnoses including epilepsy, CKD, HTN, GERD, and type II DM, and the MDS indicated moderately impaired cognitive skills for daily decisions and maximal assistance needed for ADLs. The physician order in the medical record directed sodium bicarbonate oral tablet 650 mg, give two tablets by mouth three times a day for supplement. During a medication administration observation, the LVN gave two tablets of sodium bicarbonate 325 mg to the resident instead of the ordered dosage. When questioned, the LVN acknowledged the order was for sodium bicarbonate 650 mg, give two tablets by mouth three times a day, and stated, "my bad." The LVN also explained that not giving the ordered dosage reduces the medication's effectiveness as an antacid. The DON reviewed the facility's medication administration policy, which requires medications to be administered safely and accurately in accordance with physician orders and the five rights of medication administration.
Failure to Document and Follow Resident Food Preferences
Penalty
Summary
The facility failed to receive input from one resident regarding preferred and non-preferred foods. The resident was admitted and later readmitted with diagnoses including COPD, severe protein-calorie malnutrition, and major depressive disorder. The resident’s MDS indicated the resident was alert and oriented with a BIMS score of 15, and also required assistance with eating and multiple activities of daily living. During observations, the resident ate only small portions of several meals, including limited intake at lunch and breakfast, and the meal card did not list the resident’s preferred or non-preferred foods. During interview, the resident stated staff had been informed of preferred foods in the past and identified specific breakfast and lunch/dinner items the resident liked and disliked, including a dislike for oatmeal, chili, spicy foods, and pureed/ground meat. The Dietary Supervisor stated the facility maintained resident preferred and non-preferred food lists and completed food preference assessments on admission and quarterly, but acknowledged that quarterly assessments were missed between documented dates. The Dietary Supervisor also stated the resident’s documented preference of “American food” was not specific enough. Facility policy stated meals should incorporate resident preferences, cultural considerations, religious practices, and individualized dietary needs.
Dishwasher sanitizer concentration below required level and food items left undated or expired
Penalty
Summary
The facility failed to ensure the dishwasher sanitizer machine had the correct chlorine concentration for cleaning dishware. During observation in the kitchen, the chlorine concentration of the dishwasher sanitizer machine was tested three times and the test strip indicated 25 ppm each time. During interview, the staff member stated the correct chlorine concentration should be at least 50 ppm and that the sanitizer concentration needed to be adjusted if it was below that level. The Dietary Supervisor also stated the chlorine sanitizer reading should be 50 ppm to ensure dishes were sanitized well, and that breakfast dishes would need to be manually re-washed and re-sanitized before being used for the next meal. The facility also failed to date food items and discard expired or undated food stored in the refrigerator, freezer, and dry storage areas. Observations identified a baking powder container with an unreadable expiration/used-by date in the dry food storage cabinet, a lemon juice concentrate bottle labeled used by 2/18/2026 in the refrigerator, broccoli florets bags and Japanese vegetables bags in the freezer with no expiration dates, and a banana extract bottle with no expiration date in the dry storage room. During interview, staff stated unlabeled, expired, or undated food items should not be used and should be discarded. The facility policy stated opened, refrigerated, and frozen food must be labeled with product name, use-by date, and date opened or prepared, and that expired and spoiled food must be discarded immediately.
Incomplete antibiotic surveillance and water management monitoring
Penalty
Summary
The facility failed to follow its infection prevention and control program by not completing antibiotic surveillance logs for two residents who were receiving mupirocin. Resident 4 had diagnoses including heart failure, cerebral infarction, altered mental status, and metabolic encephalopathy, and the MDS showed moderately impaired cognitive skills for daily decisions and maximal assistance needed for ADLs. The resident’s OSR showed mupirocin ointment was ordered for the left index finger, but the Infection Preventionist Nurse stated that antibiotic surveillance was not completed during the months the resident received the medication. Resident 6 had diagnoses including type II DM, heart disease, venous insufficiency, and anemia, and the MDS showed moderately impaired cognitive skills for daily decisions and maximal assistance needed for ADLs. The medical record showed mupirocin was ordered for a right lower leg venous stasis ulcer and also for an abdominal wall non-pressure chronic ulcer. During interview and record review, the Infection Preventionist Nurse stated that surveillance was not completed when Resident 6 was receiving mupirocin during the identified months, and that mupirocin is considered an antibiotic that should have been included in surveillance. The facility also failed to implement and maintain its Water Management Program as written. During interview, the Maintenance Supervisor stated he did not test facility water for chlorine and pH levels and that pH testing was only done in the kitchen dishwasher, not throughout the facility. The Infection Preventionist Nurse stated there were no logs for water testing for temperature readings, chlorine, or pH as required by the WMP. The DON stated the maintenance supervisor was responsible for monitoring the water system, including checking the water source, inspecting for pipe leaks, and verifying water temperatures, and also stated that the facility had a Water Safety Plan intended to control Legionella and other waterborne pathogens.
Failure to Obtain Current Informed Consent for Influenza Vaccination
Penalty
Summary
The facility failed to obtain a current informed consent from the resident or the resident's representative when the influenza vaccine was administered for one sampled resident. Resident 6 was admitted with diagnoses including type II diabetes mellitus, heart disease, venous insufficiency, and anemia. The resident's MDS dated 01/01/2026 indicated moderately impaired cognitive skills for daily decisions and maximal assistance needed from staff for ADLs such as toileting hygiene and showering/bathing. A physician's order dated 12/26/2025 authorized influenza vaccine 0.5 ml IM every year. During a concurrent interview and record review on 02/25/2026, the Infection Preventionist Nurse stated that informed consent is important because it informs residents about the risks, benefits, potential side effects, and consequences of not getting vaccinated, and that consent should be obtained as soon as the vaccine becomes available. The IPN stated that consent for the influenza vaccine was obtained on 09/25/2025, but the vaccine was administered on 01/24/2026, and that a new informed consent was needed before administration because the resident or representative could have changed their mind since the earlier consent was obtained four months prior. The facility's Influenza Vaccine policy stated that prior to vaccination, the resident or legal representative will be provided information and education regarding benefits and potential side effects, and the Informed Consent policy stated that informed consent must be obtained before treatments, procedures, medications, or care changes requiring consent under federal or state law.
Missing COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to provide documented evidence for two of four sampled employees, the Medical Director and the Registered Dietitian, regarding COVID-19 vaccination status and education on the benefits and potential side effects of the COVID-19 vaccine. During a concurrent interview and record review with the Infection Prevention Nurse, the Employee's Vaccination Record 2025 for both employees was reviewed and showed no documentation of COVID-19 vaccination status, no documentation that education had been provided, and no documentation that the vaccine had been offered. During the interview, the Infection Prevention Nurse stated that all staff members should be offered the COVID-19 vaccine and that if staff refuse the vaccine, it should be documented. The nurse also stated that knowing vaccination status is important because staff have contact with residents and other staff. Review of the facility's policy titled Staff Vaccination Program showed that it applies to employees, contractors, agency personnel, volunteers, and individuals providing services within the facility, and that vaccination status shall be tracked, documented, and monitored to promote resident and staff safety.
Room Size Requirement Not Met in Multiple Resident Rooms
Penalty
Summary
The facility failed to meet the required room size of 80 square feet per resident in multiple occupied rooms and 100 square feet per resident in a single occupancy room. A review of the facility's room waiver letter and client accommodations analysis form completed on 2/23/2026 showed that 23 of 24 resident rooms did not meet the minimum space requirement. The listed rooms included one room documented for 1 resident, 21 rooms documented for 2 residents each, and one room documented for 3 residents, with room sizes of 138.7 sq. ft. for the 2-bed rooms and 150.7 sq. ft. for the 3-bed room, resulting in less than 80 sq. ft. per resident in those rooms. During an observation on 2/25/2026 at 8:52 a.m., rooms 2 through 25 were observed, and nursing staff had enough space to provide care to the residents, with direct access to the corridors. The observation noted no concerns with privacy, nursing care, or safety to the residents. The facility submitted a request for continuation of the waiver for the 23 rooms that did not meet the room size requirement.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development and progression of a pressure injury. The resident, who was admitted with conditions including paraplegia and polyneuropathy, was identified as at risk for skin breakdown due to non-compliance with turning and repositioning. Despite having a care plan in place, the facility did not implement effective interventions to address the resident's non-compliance, resulting in the development of a stage 1 pressure injury on the coccyx, which progressed to a stage 4 pressure injury within 16 days. The care plans for the resident's pressure injuries were not updated with new interventions as the condition worsened. The interventions remained the same from stage 1 through stage 4, despite the resident's refusal to comply with turning and repositioning. The facility's staff, including a Licensed Vocational Nurse, acknowledged that the care plans should have been revised with individualized interventions to address the resident's non-compliance and prevent the worsening of the pressure injury. The facility's policies and procedures required ongoing review and updating of care plans to ensure they were effective in meeting the resident's needs. However, the facility did not adhere to these policies, resulting in the resident's pressure injury progressing to a stage 4 with necrosis of muscle and bone, requiring debridement. The Director of Nursing confirmed that the care plans were not individualized or updated as required, contributing to the deficiency in care.
Inadequate Training and Sanitation in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff were adequately trained and competent in meeting the nutritional needs of residents, particularly those on puree diets. Observations revealed that staff did not follow the recipe for puree ham and potato casserole, instead serving puree scrambled eggs, which lacked the necessary protein and nutrients. The Dietary Supervisor confirmed that the puree scrambled eggs did not provide the same nutritional value as the intended casserole, potentially leading to weight loss among residents. Additionally, the staff used incorrect portion sizes for puree eggs, serving two ounces instead of the required three ounces, further contributing to inadequate nutrition. Interviews with staff indicated a lack of understanding and adherence to recipes and portion sizes. One staff member admitted to not preparing the puree ham and potato casserole due to some residents' dietary restrictions and preferences, but acknowledged that this decision could affect the taste and nutritional content of the food. The Dietary Supervisor had previously provided in-service training on reading spreadsheets and preparing puree food, but the staff did not follow these guidelines on the day of observation. Furthermore, the facility's freezer was found to have dust and food residue, indicating poor sanitation practices. A staff member acknowledged the presence of dirt and debris but was unaware of the potential consequences for residents. The facility's policies and procedures required routine cleaning of refrigerator equipment, but this was not adhered to, posing a risk of foodborne illness. The competency test for kitchen staff did not include questions on following menus, spreadsheets, and recipes, highlighting a gap in training and oversight.
Deficiencies in Food Preparation and Presentation
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved flavor and appearance, as observed during a breakfast service. The ham and potato breakfast casserole, intended for residents on a regular diet, was served using a scoop instead of being cut to the specified portion size of 2 1/2 x 2 inches. It was also served in a bowl rather than on a plate, and lacked the parsley garnish that was supposed to enhance its presentation. The Dietary Supervisor noted that the presentation was unappetizing and could lead to residents not eating the meal, potentially resulting in weight loss. For residents on a puree diet, the facility did not follow the prescribed menu, which called for a puree ham and potato breakfast casserole. Instead, residents received puree scrambled eggs, which were described as too dry. The Dietary Supervisor acknowledged that the puree scrambled eggs lacked the nutritional components of the intended casserole, such as ham, potatoes, onions, and mustard, which could affect the taste and lead to poor food intake and potential weight loss. Additionally, the puree wheat toast and puree raisin bran were found to be too sticky, failing the spoon tilt test, which assesses the cohesiveness of pureed foods. The Dietary Supervisor indicated that the puree items did not meet the required consistency standards, making them unappetizing and potentially leading to poor food intake and weight loss. The facility's policies and procedures, as well as standardized recipes, were not adhered to, resulting in these deficiencies.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The reach-in freezer was found to have fluctuating temperatures, ranging from 10 to 52 degrees Fahrenheit, instead of the required 0 degrees Fahrenheit, which is necessary to ensure food items remain frozen for infection control. Additionally, turkey was improperly stored on the bottom of beef without trays in between, violating the facility's policy on meat storage hierarchy, which could lead to cross-contamination. The kitchen was also found to have multiple cleanliness issues. Food preparation surfaces and kitchen equipment, including the reach-in refrigerator, ice machine, and juice machine racks, were not cleaned and sanitized properly. Observations revealed dirt, dust, and food debris on various equipment, such as the knife storage box, mixer, and scoop tray. The facility's policies and procedures were not followed, as these areas were supposed to be cleaned daily and deep cleaned weekly to prevent bacterial growth and cross-contamination. Furthermore, the facility used utensils and kitchen equipment that were damaged, including chopping boards with scratches, trays with cracks and chips, and a can opener blade with a chip. These conditions made it difficult to clean the surfaces properly, increasing the risk of bacterial growth and cross-contamination. Additionally, staff were observed using personal cellphones in the kitchen, and dented cans were stored with non-dented cans, both of which could lead to contamination. Expired yogurt and juice were also found in the resident's refrigerator, which could result in foodborne illness if consumed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that one of the two black dumpsters was completely covered and by not maintaining the cleanliness of the surrounding area. During an observation, it was noted that the dumpster was overflowing with trash and not fully closed, which could potentially attract pests and spread infection among the 46 residents of the facility. Interviews with the Dietary Supervisor and Maintenance Supervisor confirmed that the dumpster should always be closed and not overflowing, as this could attract pests and lead to foodborne illnesses. The facility's policies and procedures, as well as the Food Code 2017, require that garbage and trash cans be inspected daily to ensure no debris is on the ground and that lids are closed. The Maintenance Supervisor acknowledged that the trash area should be cleaned daily, but it was not done on the day of the observation. The failure to maintain the cleanliness of the trash area and ensure dumpsters are properly covered and not overflowing is a direct violation of these guidelines, posing a risk of attracting rodents and potentially causing illness among residents.
Failure to Submit PBJ Data for Required Quarter
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) for one of the required quarters in 2023. Specifically, the facility did not submit the PBJ data for the first fiscal quarter, which was due on February 14, 2024. This deficiency was identified through a review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER), which showed no PBJ data submission from October 1, 2023, to December 1, 2023. Additionally, a review of the CMS Staffing Data Report confirmed the absence of data submission for the quarter. During an interview, the Director of Staff and Development/Infection Preventionist Nurse (DSD/IP) revealed that the PBJ reporting for the first quarter of 2024 was supposed to be completed by the facility's corporate office but was not done properly and was not submitted to CMS. The facility's policy and procedure documents indicated that direct staffing information should be submitted to the CMS payroll-based journal system at least once a quarter, with specific deadlines outlined. The CMS PBJ Policy Manual also emphasized the importance of timely and accurate data submission, noting that noncompliance could lead to enforcement actions by CMS.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had reasonable access to their mail, as evidenced by the lack of mail delivery on Saturdays. During a resident council meeting, several residents, including Residents 11, 30, 33, and 41, confirmed that they did not receive mail on Saturdays. Resident 33 specifically mentioned that Social Services delivered mail only from Monday through Friday. The Social Services Director (SSD) corroborated this, stating that mail delivered by the post office on weekends was held until Monday for sorting and delivery. The Director of Nursing (DON) also confirmed that mail delivery occurred only on weekdays. This practice was contrary to the facility's policy on resident rights, which indicated that residents have the right to communication and access to services both inside and outside the facility.
Deficient Pain Management for Two Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, Resident 12 and Resident 42, as observed through various deficiencies in medication administration. For Resident 12, the facility did not adhere to the physician's order to remove a lidocaine patch after 12 hours of application. The patch was applied at 9:22 AM and was supposed to be removed by 9 PM the same day, but it was not removed until 9:36 PM. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the physician's order was not followed, resulting in inadequate pain management for Resident 12. Resident 42 experienced multiple instances where the prescribed pain medication, Buprenorphine HCI, was not administered as ordered. The resident missed a total of 45 doses over several periods in November and December due to the medication not being available on hand and delays in pharmacy delivery. Interviews with the resident and nursing staff revealed that the resident experienced severe pain levels, reaching 10/10, when the medication was not administered. The Director of Nursing confirmed that the pharmacy was expected to deliver medications promptly and that the nursing staff should have followed up to ensure the availability of the pain medication. The facility's policy on administering pain medications requires staff to administer medications as ordered and to report any adverse consequences. However, the failure to follow these procedures resulted in inadequate pain control for both residents. The deficiencies in pain management were identified through observations, interviews, and record reviews, highlighting the facility's failure to adhere to physician orders and ensure timely medication delivery.
Failure to Follow Puree Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed puree menu for residents on a puree diet, as observed on December 28, 2024. Instead of serving the pureed ham and potato casserole as indicated in the nutritional spreadsheet, staff served plain pureed scrambled eggs. The Dietary Supervisor confirmed that the puree scrambled eggs did not provide the same nutritional value as the casserole, lacking essential ingredients like ham, potatoes, onions, and mustard. This deviation from the menu could potentially lead to inadequate protein and carbohydrate intake for residents on a puree diet. Additionally, the facility did not follow the correct portion sizes for puree scrambled eggs. Staff used a #16 scoop, which measures 2 ounces, instead of the #12 scoop, which measures 3 ounces, as specified in the spreadsheet. This resulted in smaller portion sizes than required, potentially depriving residents of the necessary calories and nutrients. Resident 21, who was on a renal, no added salt, consistent carbohydrate diet, and required double portions for breakfast, reported issues with portion sizes, indicating that he received insufficient food on previous occasions. The facility's policies and procedures, including those for food preparation, standardized recipes, and portion control, were not followed. The policies clearly outlined the need for using approved recipes and specific portion control equipment to ensure residents receive the correct portion sizes. The failure to adhere to these guidelines and the menu specifications could lead to malnutrition and weight loss among residents, as they may not receive the necessary nutrients and calories.
Failure to Provide Properly Prepared Puree Diet
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree diet, specifically those requiring IDDSI Level 4 consistency. Observations revealed that puree eggs were too dry, and both puree bread and puree bran cereals were too sticky, failing the spoon tilt test, which is used to assess the stickiness and cohesiveness of food. This deficiency was identified during a review of the facility's daily menu and through direct observation and testing by the Dietary Supervisor, who confirmed that the food did not meet the required smooth, pudding-like consistency necessary for residents with swallowing difficulties. The facility's policies and procedures, as well as the diet manual, specify that pureed foods should be smooth, free of lumps, and not sticky, aligning with IDDSI Level 4 requirements. However, the food items served did not adhere to these guidelines, posing a risk of aspiration and choking for residents on this diet. The deficiency was noted for 8 out of 46 residents on the puree/IDDSI Level 4 diet, highlighting a significant lapse in ensuring the safety and nutritional adequacy of meals provided to residents with specific dietary needs.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in double occupancy rooms and 100 square feet in single occupancy rooms. Out of 24 resident rooms, 23 did not meet the required space per resident, with most rooms providing only 69.35 square feet per resident. One room even accommodated three residents, offering only 50.25 square feet per resident. This deficiency was identified through a review of the facility's room waiver letter and client accommodations analysis form, which confirmed the inadequate space allocation. Despite the deficiency, observations during the annual recertification survey indicated no noted concerns with privacy, nursing care, or safety for the residents. Residents interviewed, including those residing in rooms with waivers, denied having any issues with the care received. The Director of Nursing confirmed that the facility had requested a continuation of the waiver for the rooms that did not meet the size requirements. The facility's policy, reviewed earlier in the year, stated that bedrooms should measure at least 80 square feet per resident in double rooms and 100 square feet in single rooms.
Failure to Obtain Consent for Siderail Use as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint by not completing the necessary consent for the use of bilateral bed siderails. The resident, who had a history of falls and was moderately cognitively impaired, was observed with bilateral siderails up on multiple occasions. Despite the siderails being used to prevent falls, there was no physician order for their use, and the consent form in the resident's chart was incomplete, lacking the resident's name and date of signing. Interviews with staff, including CNAs and the Director of Nursing, revealed that the siderails were intended for mobility and repositioning, although the resident was unable to use them for these purposes due to limited upper extremity strength. The facility's policy required consent for the use of siderails as restraints, which was not properly obtained in this case, leading to a violation of the resident's rights to be treated with respect and dignity.
Improper Use of Bed Siderails as Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not having a physician's order for the use of bilateral bed siderails. The resident, who was admitted with chronic kidney disease and pressure ulcers, was observed on multiple occasions with the siderails up, despite having moderately impaired cognitive skills and requiring moderate assistance for activities of daily living. The facility's policy stated that siderails are considered restraints if used to limit a resident's freedom of movement without a physician's order. Interviews with staff, including CNAs and an LVN, revealed that the siderails were used to prevent the resident from falling, despite the resident's inability to use them for mobility or repositioning due to lack of upper extremity strength. The Director of Nursing confirmed that siderails should not be used as restraints without a physician's order and consent. The facility's policy emphasized that siderails should only be used as mobility aids and not as restraints unless necessary for medical symptoms, highlighting the deficiency in following proper procedures for siderail use.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to adhere to its policy regarding the reporting of an injury of unknown source for a resident, leading to a delay in an onsite inspection by the Department of Public Health. The resident, who was non-verbal and required assistance for daily activities, was found with an open ecchymosis on her outer right arm after being discovered hanging from the side of her bed. The incident was unwitnessed, and the resident was unable to explain how she ended up in that position. The resident had a history of chronic kidney disease and pressure ulcers and was moderately impaired cognitively, requiring moderate assistance from staff for activities of daily living. Despite the presence of an unexplained injury, the facility did not report the incident to the State Agency as required by their policy. Interviews with staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, confirmed that the resident could not move independently and required staff assistance for repositioning and feeding. The facility's policy on investigating injuries and abuse prevention mandates reporting such incidents to the state agency and other relevant authorities within 24 hours. However, the Director of Nursing acknowledged that the incident was not reported, which is a violation of the facility's procedures. This oversight had the potential to place residents at further risk for injuries due to the lack of timely investigation and intervention.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to protect the privacy and dignity of a resident by not ensuring that the resident's indwelling urinary catheter drainage bag was covered. This deficiency was observed during a survey when Resident 97 was seen with an uncovered foley catheter drainage bag while sharing a room with another resident. The lack of a privacy cover for the catheter bag was noted during an observation on December 27, 2024, at 6:34 p.m. Resident 97 was admitted to the facility with diagnoses including acute kidney failure and benign prostatic hyperplasia. The resident's cognitive skills for daily decisions were intact, and they required maximal assistance for activities of daily living. The facility's policy on dignity, dated January 31, 2024, explicitly stated that urinary catheter bags should be covered to maintain resident dignity. Interviews with the LVN and the DON confirmed that the absence of a privacy cover was a violation of the resident's privacy and dignity.
Failure to Deliver Resident Mail and Packages
Penalty
Summary
The facility failed to allow a resident to retain his personal possessions, specifically his mail and packages, which led to the resident feeling angry. The resident, who had been in the facility for eight months, reported missing two packages, one of which was a Christmas gift from a friend. The resident was able to show a photo indicating the package was delivered to the nurse's station, but he did not receive it. Additionally, the resident mentioned receiving opened mail approximately three months ago and not receiving mail on weekends. The resident's medical records indicated he had intact cognition and the capacity to make decisions. Interviews with facility staff revealed that the Social Service Director (SSD) was responsible for sorting and delivering mail, but residents did not receive mail on weekends due to staff not wanting to be responsible for business office mail. The SSD acknowledged that residents should receive their mail unopened and on weekends, and that failure to do so could cause residents to feel sad and angry. The Director of Nursing (DON) was unaware of the issues with mail delivery and acknowledged that such failures could lead to resident frustration and sadness. The facility's policy on resident rights emphasized the right to be free from misappropriation of property and to have access to mail.
Failure to Apply Handroll to Resident's Right Hand
Penalty
Summary
The facility failed to apply a handroll to the right hand of Resident 43, who was readmitted with diagnoses including weakness and chronic kidney disease. The resident's Minimum Data Set indicated a need for moderate to maximum assistance with various activities of daily living. An order summary report specified that bilateral handrolls should be applied for 4-6 hours per day as tolerated. However, observations on multiple occasions revealed that the handroll was consistently applied only to the left hand, not the right. Resident 43 expressed a desire to have the handroll applied to the right hand to prevent it from becoming contracted like the left hand. The Restorative Nurse Assistant (RNA) admitted to not applying the right handroll consistently and failing to report or document the resident's refusal to wear it. The Licensed Vocational Nurse (LVN) was unaware of any refusals and acknowledged the risk of the resident's hand becoming contracted if the handroll was not used as ordered. The facility's job description for the RNA emphasized the importance of implementing restorative care and accurately documenting activities, which was not adhered to in this case.
Improper Foley Catheter Placement Leads to Deficiency
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, admitted with acute kidney failure and benign prostatic hyperplasia, required maximal assistance for activities of daily living and had intact cognitive skills. A physician had ordered monitoring of the resident's Foley catheter every shift. However, during an observation, the resident's Foley catheter was found hanging on a moveable bedside rail above the level of the bladder, with the tubing twisted and urine not flowing into the drainage bag. The resident expressed concern about the catheter's placement, fearing it might be pulled out. Licensed Vocational Nurse (LVN) confirmed the improper placement of the Foley catheter bag, noting it was too high and not allowing urine to drain properly. The Director of Nursing (DON) also acknowledged that the drainage bag should be positioned below the bladder to prevent infection. The facility's policy on catheter care clearly stated that the urinary drainage bag must be positioned lower than the bladder to prevent backflow of urine, which was not adhered to in this instance.
Failure to Ensure Physician's Order and Maintain Humidifier for Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not ensuring a physician's order was in place for oxygen therapy and not maintaining the resident's humidifier according to the facility's policy. The resident, who had been admitted with chronic obstructive pulmonary disease (COPD), atrial fibrillation, and chronic kidney disease, was observed using an oxygen concentrator at 2 liters per minute with a nasal cannula and humidifier. However, the humidifier bottle was found empty, and there was no physician's order for the oxygen therapy, which was confirmed by a Licensed Vocational Nurse (LVN) during an observation. The Director of Nursing (DON) stated that the humidifier should be replaced weekly and as needed, and that an empty humidifier would not provide the necessary humidification. The facility's policy on oxygen therapy required verification of a physician's order and ensuring the humidifier had enough water to bubble as oxygen flowed through. The lack of a physician's order and the empty humidifier bottle indicated a failure to adhere to these protocols, potentially compromising the resident's respiratory care.
Inadequate Oversight of Nutrition Services Leads to Deficiency
Penalty
Summary
The facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel, specifically when the Registered Dietitian (RD) did not conduct a comprehensive care plan for a resident who experienced significant weight loss. The resident, who had chronic kidney disease and pressure ulcers, was readmitted to the facility and later experienced a 7-pound weight loss over 30 days. Despite the RD providing recommendations to increase nutritional supplements and consider an appetite stimulant, a care plan was not developed for the resident. The RD stated that care plans were typically developed by the nursing staff and Dietary Supervisor (DS) based on the RD's notes, but the RD did not personally develop a care plan due to time constraints. The DS confirmed that she did not develop a care plan based on the RD's notes nor did she contact the resident's physician for further recommendations. The Director of Nursing (DON) clarified that while nursing could develop care plans according to the RD's notes, the DS did not have the credentials to perform the roles and responsibilities of an RD. The facility's job description for the RD indicated responsibilities for reviewing and assessing nutritional risk reviews and care plans. However, the RD did not fulfill these responsibilities, leading to a lack of comprehensive care planning for the resident. The Academy of Nutrition and Dietetics' guidelines emphasize the importance of collaboration in developing nutrition intervention goals and monitoring progress, which was not adequately followed in this case.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperatures for Resident 44, who was readmitted with diagnoses including renal dialysis and essential hypertension. The Minimum Data Set indicated that Resident 44 had intact cognition and the capacity to make decisions. During an observation and interview, Resident 44 reported feeling very cold in his room, especially in the morning, which made him uncomfortable and reluctant to get up for breakfast. The thermostat in Resident 44's room was observed to be set at 70 degrees, which is below the facility's policy range of 71 to 81 degrees for comfortable and safe temperatures. The Maintenance Supervisor (MS) acknowledged that the resident room temperature logs were incomplete, with the last recorded temperature check on December 4, 2024. During a subsequent observation, room temperatures were recorded at 70 degrees, except for one room at 24 degrees. The MS admitted to not remembering the last time the air-conditioning and heating systems were repaired. The Director of Nursing (DON) confirmed that staff could adjust the thermostat settings and acknowledged that excessively cold temperatures could lead to residents becoming sick and uncomfortable. The facility's policy emphasized providing a homelike environment with person-centered care, including maintaining comfortable temperatures, which was not adhered to in this instance.
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What surveyors actually found near you
We read the 6,445 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Santa Monica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beachwood Post-acute & Rehab | 0.1 mi | ★★★★★ | 3 | 0 |
| Fireside Health Care Center | 0.6 mi | ★★★★★ | 19 | 0 |
| Ocean Pointe Healthcare Center | 0.6 mi | ★★★★★ | 32 | 0 |
| Berkley West Healthcare Center | 0.6 mi | ★★★★★ | 14 | 0 |
| Pacific Post Acute | 0.6 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.