Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Greenfield Care Center Of South Gate during CMS and state inspections, most recent first.
The facility failed to prevent verbal and mental abuse when a cognitively impaired resident with bipolar disorder and dementia repeatedly used profanity and offensive language toward two cognitively intact roommates. One roommate, who required only setup assistance with ADLs, reported feeling scared and mentally exhausted by frequent profanity directed at staff and visitors. The other roommate, who was largely independent with ADLs, reported being repeatedly called offensive names, feeling neglected and verbally abused, and believing the facility should have intervened earlier. Facility leadership and policies defined abuse to include verbal and emotional harm such as yelling, profanity, name-calling, and intimidation, and affirmed the responsibility to protect all residents from such abuse regardless of cognitive status.
The facility failed to administer medications as ordered and within the accepted one-hour window for multiple residents with conditions including DM, HTN, CHF, atrial flutter, end stage renal disease, and hydrocephalus. An LVN attempted to give a diabetic medication nearly two hours late, which a resident refused, stating it should be taken with the last bite of breakfast. Other residents received or were about to receive blood pressure, cardiac, diuretic, and seizure medications significantly past their scheduled times, as confirmed by LVNs who reported being behind on medication passes. Staff and the ADON acknowledged that medications must be given on time per physician orders and facility policy, and that late administration of diabetic, BP, pain, and seizure medications can affect symptom control and seizure risk.
An LVN failed to disinfect a glucometer and blood pressure cuff between use on two residents, one with Type 2 DM and HTN and another with muscle weakness and HTN. After checking one resident’s blood sugar and blood pressure, the LVN placed the glucometer and cuff on a medication cart and later stored the glucometer in a cart drawer without cleaning it. The LVN then used the same blood pressure cuff on another resident without disinfecting it before or after use. In interviews, the LVN acknowledged not disinfecting the equipment between residents, while the ICN and ADON stated that facility policy and practice require glucometers and blood pressure cuffs to be cleaned and disinfected before and after each use, consistent with manufacturer instructions.
The facility failed to provide required abuse, neglect, and exploitation training to a registry CNA before the CNA began providing resident care. The CNA reported not receiving any abuse prevention training or in-service prior to the shift. The DSD acknowledged that temporary registry staff who work only a few shifts are not given education on the facility’s abuse policies and procedures before starting work. The DON stated that registry staff should receive facility abuse training to ensure appropriate knowledge of abuse identification, reporting, and prevention. Review of facility records showed no documentation of mandatory abuse training for temporary registry staff, despite a written policy requiring all staff to receive abuse and neglect prevention training during orientation and ongoing.
A resident with significant cognitive and psychiatric diagnoses repeatedly refused showers and complete bed baths, but the facility did not notify the responsible party as required by the care plan and facility policy. Staff interviews and record reviews confirmed that refusals and notifications were not documented, leaving the responsible party unaware of the resident's hygiene needs.
Two residents with severe cognitive impairment experienced repeated nonconsensual sexual contact after the facility failed to conduct an IDT meeting, update care plans, or implement interventions following an initial incident. Staff did not provide adequate supervision or immediate intervention during a subsequent event, and required assessments and training were not completed, allowing the inappropriate contact to recur.
Staff failed to report an incident of non-consensual sexual contact between two cognitively impaired residents, despite facility policy requiring immediate notification to the Administrator and CDPH. The event was documented by nursing staff and observed by a CNA, but no report was made, resulting in a delayed investigation and ongoing risk to the resident involved.
Two residents with severe cognitive impairment were involved in an incident where one kissed and climbed into the other's bed, but staff did not investigate the event or interview witnesses, despite facility policy requiring investigation of nonconsensual sexual contact. The DON and abuse coordinator confirmed that the incident met the definition of sexual abuse and should have been investigated, but no action was taken.
Nursing staff failed to document vital signs as required for a resident with blood pressure medication orders, and did not remove a dialysis AV fistula dressing within the required timeframe for another resident. Additionally, a resident received oxygen at a higher rate than ordered, and oxygen saturation was not assessed on room air as specified. These actions did not comply with physician orders or facility policy, as confirmed by interviews and record reviews.
A resident with severe cognitive impairment and high care needs was left unsupervised in a room with another resident known to be capable of physical aggression. After the first resident refused a shower, the second resident became agitated and, while staff was briefly absent, slapped and punched the first resident. Staff interviews confirmed that the resident was not protected from abuse, and the incident was preventable according to facility policy.
Multiple infection control deficiencies were identified, including the absence of required Enhanced Barrier Precautions signage, staff failing to use appropriate PPE when entering rooms of residents on isolation or respiratory precautions, a catheter drainage bag found touching the floor, and overfilled sharps containers on medication carts. These lapses occurred despite physician orders, care plans, and facility policies specifying the necessary precautions and procedures.
A resident with chronic respiratory failure and obstructive sleep apnea was receiving oxygen therapy per physician order, but staff failed to develop and implement a care plan for oxygen administration. The DON confirmed that interventions such as head elevation and oxygen monitoring were not documented or addressed in a care plan.
A resident with diabetes and hypertension received amlodipine and lisinopril without clear hold parameters for pulse rate, resulting in the medications being administered multiple times when the resident's pulse was below 60 bpm. Nursing staff followed standard practice to sometimes hold the medications for low pulse, but the physician's orders did not specify this, and staff did not seek clarification. This led to inconsistent medication administration and a lack of adherence to facility policy for safe medication practices.
A resident who was continent and preferred to use a urinal was instead kept in an incontinence brief, preventing independent toileting and compromising dignity. Staff failed to verify the resident's continence status or preference, and no urinal was provided at the bedside, despite facility policy requiring respect for resident choices.
Residents were not provided with sufficient information or understanding about their health status, care, and treatments. This resulted in residents lacking the necessary knowledge to make informed decisions about their care.
A resident who was dependent on staff for ADLs and had intact cognition was found lying in bed with the call light out of reach, preventing her from requesting assistance. The resident's care plan and facility policy both required the call light to be within reach, but this was not followed, as confirmed by a nurse during observation and interview.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a deficiency related to timely communication.
Two residents were not given the required SNF ABN form when their Medicare Part A coverage ended and they chose to continue skilled nursing services. Both had cognitive impairments and required significant assistance with daily activities. The Business Office Manager did not provide the notice due to a misunderstanding about required forms, resulting in the residents not being informed in writing of their potential financial liability for non-covered services.
The facility failed to ensure accurate MDS assessments for two residents, resulting in the omission of oxygen therapy, significant weight loss, and a stage 4 pressure sore from their records. These inaccuracies were confirmed by the DON and were not in line with facility policy, as documented through interviews, record reviews, and observation.
A resident was incorrectly assessed as incontinent and placed on a care plan requiring incontinence briefs, despite being able to use a urinal independently. The care plan was not updated to reflect the resident's actual continence status, resulting in continued use of briefs that limited the resident's independence and dignity. The DON confirmed the care plan should have been revised according to facility policy.
A resident with multiple comorbidities and a stage 4 pressure ulcer was found lying on a low air loss mattress set at 305 lbs, despite weighing only 100 lbs. Staff and documentation confirmed that the mattress should have been set to the resident's actual weight to ensure proper pressure redistribution, as required by facility policy and the manufacturer's instructions. The incorrect setting resulted in a mattress that was too firm for the resident's needs.
A resident who was able to request and use a urinal was incorrectly assessed as incontinent and placed in an incontinence brief, preventing him from voiding with dignity and maintaining continence. Staff did not verify the resident's needs or provide a urinal, contrary to facility policy supporting ADLs.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss on two occasions, but staff did not reweigh the resident to confirm the loss as required by facility policy. Both the RNA and DON acknowledged that the reweighing procedure was not followed, which could have led to improper management of the resident's nutritional needs.
Two residents did not receive oxygen therapy at the rates ordered by their physicians. One resident with chronic respiratory failure and sleep apnea was observed receiving oxygen at a higher rate than prescribed, while another resident with pleural effusion and pneumonia received a lower rate than ordered. Nursing staff confirmed the discrepancies, and facility policy required adherence to physician orders for oxygen administration.
A resident with severe cognitive impairment and total dependence on staff was provided with bilateral side rails without the facility obtaining or documenting informed consent from the resident's representative. Despite facility policy requiring assessment, education on risks and benefits, and signed consent prior to side rail use, staff interviews and record reviews confirmed these steps were not completed.
A registered nurse did not immediately document the administration, refusal, or holding of scheduled medications for a resident with diabetes and hypertension, instead recording these actions several hours later on the MAR. This delay in documentation made it appear as though the resident had not received their medications, contrary to facility policy and standard nursing practice.
A resident with multiple chronic conditions, including ESRD, diabetes with polyneuropathy, and COPD, was prescribed Cymbalta for neuropathy pain. Facility staff did not implement or document monitoring for side effects of this antidepressant, despite facility policy and staff acknowledgment of its necessity. Interviews confirmed that licensed nurses were responsible for monitoring and physician notification, but this was not carried out.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
A resident's responsible party repeatedly requested copies of documents signed by the resident, including a Notice of Medicare Non-Coverage, but facility staff did not respond or provide the requested records despite receiving multiple emails. The facility's policy required records to be provided within 24 hours, but this was not followed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not develop or implement complete care plans for two residents—one requiring two-person assistance for safe repositioning due to chronic respiratory failure and hypotension, and another needing substantial mobility assistance who experienced a possible verbal abuse incident. The absence of these care plans meant that staff lacked documented guidance for providing appropriate, individualized care and interventions.
A nursing home area was not kept free from accident hazards, and staff did not provide adequate supervision to prevent accidents, resulting in a deficiency.
Nurses and nurse aides did not have the appropriate competencies to care for every resident in a manner that maximizes each resident's well-being, resulting in a deficiency.
A resident with a history of orthostatic hypotension and multiple comorbidities experienced repeated episodes of low blood pressure during therapy sessions, which were reported to nursing staff but not communicated to the physician after initial treatment. The physician was also not involved in the decision to discontinue PT and OT services, with orders placed by the health plan and rehabilitation staff instead. These failures led to a delay in medical intervention, lack of appropriate physician oversight, and premature termination of Medicare coverage.
A resident with a history of orthostatic hypotension and multiple comorbidities did not have an individualized care plan addressing their condition, despite experiencing symptomatic episodes during therapy and being prescribed Midodrine. Facility staff confirmed that a care plan with specific interventions, such as timing therapy after medication and monitoring orthostatic vital signs, was necessary but not implemented.
A resident with dementia and legal blindness, who was fully dependent on staff, developed bruising that was not promptly addressed with a care plan. Despite facility policy requiring immediate documentation and care planning after a change in condition, staff failed to initiate a care plan or monitor the bruising in a timely manner, resulting in delayed interventions and monitoring.
A resident with severe cognitive impairment and total dependence on staff developed bruising on multiple body areas. A CNA discovered the bruises but did not report them or complete a skin assessment form, while a treatment nurse later identified the bruising but failed to document or monitor the findings as required. These omissions delayed care and services for the resident.
A resident with impaired mobility and cognition was left soiled and not promptly assisted by a CNA, who also acted aggressively and removed the call light, preventing further requests for help. The resident expressed anger over the treatment, and staff interviews revealed a pattern of similar behavior by the CNA, including previous incidents of not changing residents. Facility policies require staff to promote dignity and respond promptly to resident needs, which was not followed in this case.
A resident with significant physical and cognitive impairments was allegedly roughly handled by a CNA, as reported by a family member. The RN on duty did not report the allegation to the DON, Administrator, or CDPH within the required timeframe and did not immediately suspend the CNA, contrary to facility policy. The DON and Administrator were not informed until days later, resulting in delayed investigation and potential risk to other residents.
A resident with end stage renal disease and a history of hyperkalemia did not receive appropriate follow-up for a critical potassium lab order. After a high potassium level was reported, staff administered Kayexalate and attempted to order a repeat potassium test, but incorrectly completed the lab requisition, resulting in a Keppra level being drawn instead. Nursing staff did not identify or correct the error, nor did they notify the physician of the missing potassium result, leading to a delay in care.
A resident with severe cognitive impairment reported to a CNA that another CNA was rough during care, causing pain and discomfort. The CNA failed to report the allegation to the LVN or notify authorities as required by the facility's Abuse and Neglect Prevention Policy. The incident was only reported after the resident's son informed the facility, leading to a delay in investigation and potential for further abuse.
A resident with severe cognitive impairment and multiple health conditions alleged rough treatment by a CNA, but the facility failed to promptly investigate or protect the resident. CNA 2, aware of the complaint, did not report it, delaying the investigation and allowing the CNA to continue working. The facility's policy mandates immediate action, which was not followed.
A resident with chronic conditions and impaired cognitive skills was at high risk for falls, yet the facility failed to develop a care plan addressing their non-compliance with using the call light. This oversight was evident when the resident experienced an unwitnessed fall while attempting to go to the restroom without assistance. Interviews with staff confirmed the absence of a care plan for this behavior, despite facility policy requiring timely development and updates of care plans.
A resident requiring substantial assistance with ADLs was not provided with the prescribed 4-6 ounces of water every two hours, as per physician's orders. Despite being at risk for recurrent UTIs, the facility failed to document the provision of water, and staff reported the resident often refused water. However, the resident's representative noted the resident would ask for water during visits. The facility's policies on hydration and ADLs were not followed, contributing to the deficiency.
Two residents involved in an altercation were not monitored according to the facility's policy, which required documentation of changes in condition every shift for 72 hours. The nursing notes lacked entries for several shifts, which was crucial for notifying doctors and addressing psychosocial needs. The facility's policy mandates continuous assessment and documentation until the condition stabilizes, but this was not followed, potentially leading to serious harm.
A resident with a history of hypertension and heart conditions received amiodarone and metoprolol tartrate despite physician orders to withhold these medications if the pulse was below 60 BPM. The MAR showed multiple instances of administration when the resident's pulse was below the specified threshold. The DON confirmed the error and the facility's policy required adherence to physician orders.
A resident with underlying health conditions was not tested for Covid-19 despite showing symptoms, leading to a delayed positive test. Additionally, a CNA worked while symptomatic without reporting her condition, contrary to facility protocols. These lapses in infection control increased the risk of spreading Covid-19 within the facility.
Two residents in an LTC facility experienced deficiencies in care due to staff failing to respond to call lights and honor preferences. A resident with paraplegia felt neglected as CNAs ignored or canceled his call light without assistance. Another resident, with heart conditions, was not given a timely shower despite requests, leading to frustration. The DON confirmed that these actions violated facility policies, resulting in delayed care.
The facility failed to provide adequate ROM and mobility services for residents, including not monitoring ROM upon admission and not providing recommended exercises. A resident developed preventable ankle contractures due to these deficiencies. Other residents also did not receive necessary ROM exercises as per physician orders, leading to potential undetected declines in ROM.
A facility failed to provide necessary OT, PT, and ST services to residents with mobility and swallowing issues, despite physician orders. One resident, with diagnoses including psychosis and requiring G-tube feedings, did not receive evaluations, leading to dependence on staff for ADLs. Another resident with diabetes and hemiplegia also did not receive ordered evaluations, contributing to a decline in function.
Failure to Protect Residents From Verbal and Mental Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse when it did not prevent one resident from repeatedly directing profanity and offensive language toward her roommates. One resident with bipolar disorder and dementia with behavioral disturbance, who lacked capacity to understand and make decisions and had severely impaired cognitive skills for daily decision making, became verbally aggressive and yelled profanity during an attempted interview. This same resident was reported by a roommate to be not mentally stable and to frequently use profanity toward staff and visitors, creating a sad experience for the roommate, who reported feeling scared and mentally exhausted. Another cognitively intact resident, who was independent or required minimal assistance with ADLs and had capacity to understand and make decisions, reported that the verbally aggressive resident repeatedly called her offensive names. This resident stated she felt neglected and verbally abused and expressed that the other resident’s mental condition was not a justification for exposing others to verbal abuse and yelling, and that the facility should have intervened from the beginning. Facility leadership, including the Administrator and DON, acknowledged that abuse includes verbal and emotional harm such as yelling, profanity, name-calling, and intimidation, and that the facility is responsible for protecting all residents from abuse, regardless of cognitive status, as reflected in the facility’s Abuse and Neglect Prevention Management policy.
Untimely Medication Administration for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered by physicians and within the facility’s own one-hour before/after administration window for five sampled residents. The facility’s policy on medication administration, dated July 2013, states that drugs must be administered in accordance with written physician orders and within one hour before or after the scheduled administration time. Interviews with nursing staff and the ADON confirmed their understanding that medications must be given on time, within a one-hour window, and that certain medications, such as diabetic, blood pressure, and seizure medications, have specific timing and food-related requirements. For one resident with type 2 DM and HTN admitted in February 2026, the MAR showed metformin 1000 mg scheduled for 7:30 a.m. On the survey date at 9:55 a.m., an LVN stated she was going to administer the metformin and acknowledged it was late. At 10:00 a.m., the LVN handed the metformin to the resident, who refused it, stating that his PCP instructed him to take metformin with the last bite of breakfast and not two hours later. Another resident with type 2 DM and HTN had clonidine 0.1 mg scheduled for 9:00 a.m.; at 10:18 a.m., an LVN reported he was preparing this medication and acknowledged it was scheduled for 9:00 a.m. but that he was running behind on passing medications. A resident with CHF and atrial flutter had glipizide 2.5 mg scheduled for 7:30 a.m., yet an LVN was observed administering this medication at 10:40 a.m. Another resident with HTN and CHF had carvedilol 25 mg scheduled for 7:30 a.m. and furosemide 20 mg scheduled for 9:00 a.m.; at 10:28 a.m., an LVN stated he was preparing and going to administer both medications at that time. A further resident with end stage renal disease and hydrocephalus had levetiracetam 500 mg and valproic acid 250 mg both scheduled for 9:00 a.m.; at 10:45 a.m., an LVN stated he was preparing and going to administer these medications then. Staff interviews documented that late administration of pain, diabetic, blood pressure, and seizure medications can affect pain control, blood sugar control, blood pressure control, and seizure risk, and that medications must be given on time, especially those given multiple times per day, to avoid doses being too close together.
Failure to Disinfect Glucometer and Blood Pressure Cuff Between Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper disinfection of reusable resident-care equipment. One LVN was observed exiting a resident’s room after checking the resident’s blood sugar and blood pressure, placing the glucometer and blood pressure cuff on top of a medication cart without disinfecting either device. The resident had been admitted with diagnoses including Type 2 DM and HTN. A few minutes later, the LVN administered medications to the same resident, then placed the same glucometer into a medication cart drawer without disinfecting it. The LVN then moved the medication cart to another resident’s room. Shortly thereafter, the LVN stated he was going to check the second resident’s blood pressure before medication administration and used the same blood pressure cuff taken from the medication cart, again without disinfecting it before or after use. The second resident had been admitted and re-admitted with diagnoses including muscle weakness and HTN. In a later interview, the LVN acknowledged he had not disinfected the glucometer after use on the first resident or the blood pressure cuff before and after use on the second resident, and stated that not disinfecting these items between residents could result in contagious infections being passed from one resident to another. The ICN and ADON both stated that facility practice and expectations were that glucometers and blood pressure cuffs are cleaned and disinfected between residents and before and after each use. Review of facility policy and the glucometer manufacturer’s instructions confirmed that reusable items, including the glucometer, are to be cleaned and disinfected between residents to prevent transmission of blood-borne pathogens.
Failure to Provide Abuse Prevention Training to Registry CNA Before Resident Care
Penalty
Summary
The facility failed to ensure that a temporary registry CNA received required training on abuse, neglect, exploitation, and the facility’s abuse prevention policies and procedures prior to providing care to residents. During an interview, the CNA reported that no abuse prevention training or in-service was provided before starting her shift. The Director of Staff Development stated that some staff are used as registry fillers for one or two shifts and confirmed that these temporary staff were not given education on the facility’s abuse policy and procedures before beginning work. The DON stated that registry staff should receive facility abuse training to ensure they have the expected level of abuse training and knowledge, and acknowledged that hiring staff without such training could potentially result in lack of abuse identification, reporting, and prevention. Review of facility records showed no documentation of mandatory abuse training for temporary registry staff, despite the facility’s Abuse and Neglect Prevention Management policy stating that all staff will be trained on abuse and neglect prevention protocol during orientation and ongoing. The deficient practice involved one of one registry CNAs reviewed and was based on interviews with the CNA, the DSD, and the DON, as well as review of training records and the written policy dated 2/2018, which requires abuse prevention training for all staff.
Failure to Notify Responsible Party of Resident's Repeated Refusals of Bathing
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident who lacked capacity to make medical decisions about the resident's repeated refusals of showers and complete bed baths. The resident, who had diagnoses including schizophrenia, traumatic subdural hemorrhage, major depressive disorder, and metabolic encephalopathy, refused seven out of eight showers or complete bed baths over a one-month period. The care plan for the resident specifically required that the medical doctor and RP be notified in cases of non-compliance, and the facility's policy and procedure (P&P) on refusal of treatment required documentation of the refusal, the resident's response, education provided, and notification of the RP. Despite these requirements, there was no documentation in the resident's progress notes indicating that the RP was notified of the refusals. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the care plan and P&P were not followed, and that the refusals and subsequent notifications were not properly documented. The lack of notification resulted in the RP being unaware of the resident's hygiene needs and refusals of care.
Failure to Prevent Recurrence of Nonconsensual Sexual Contact Between Residents
Penalty
Summary
The facility failed to prevent the recurrence of nonconsensual sexual contact between two residents with severe cognitive impairment. After an initial incident in which one resident kissed another and attempted to climb into the other's bed, the facility did not conduct an Interdisciplinary Team (IDT) meeting or create a care plan with interventions to address the incident. Both residents' records lacked documentation of consent for a relationship, and their care plans were not updated to include interventions to prevent further incidents or monitor their interactions and locations. Subsequently, a second incident occurred in which a staff member observed one resident placing his hand on the other's upper thigh in a common area, again without staff supervision. The staff member did not immediately intervene, instead leaving the area to notify another staff member, which allowed the inappropriate contact to continue. Interviews with staff and review of records confirmed that neither resident had the capacity to consent to sexual activity, and that the facility's policies regarding abuse prevention and response were not followed after the initial incident. Family members of both residents were notified of the incidents and expressed that they did not consent to their relatives having sexual contact with other residents and did not want them unsupervised together. The facility's Director of Nursing and other staff acknowledged that required assessments, care plan updates, and staff training were not completed following the first incident, and that these failures contributed to the recurrence of nonconsensual sexual contact between the residents.
Failure to Timely Report Allegation of Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents, both of whom had severe cognitive impairment and lacked the capacity to consent. One resident was found kissing and attempting to climb into the bed of another resident who was dependent on staff for personal care and mobility. The incident was documented in progress notes but was not reported to the facility Administrator or the California Department of Public Health (CDPH) as required by facility policy and state regulations. Interviews and record reviews revealed that nursing staff, including a registered nurse and a licensed vocational nurse, were aware of the incident but did not follow the abuse reporting policy. The Director of Nursing acknowledged being informed of the event but did not instruct staff to report it to CDPH. The facility's policy clearly defined non-consensual sexual contact as sexual abuse and mandated immediate reporting to both the Administrator and the state agency within two hours of the allegation. Despite multiple staff members, including a certified nursing assistant, recognizing their responsibility as mandated reporters, the incident was not escalated appropriately. The lack of timely reporting resulted in a delay in investigation by the CDPH and left the affected resident at risk for further abuse. Documentation confirmed that neither resident could provide consent, and the event met the facility's definition of sexual abuse, yet the required notifications were not made.
Failure to Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving two residents, one of whom lacked the capacity to consent due to severe cognitive impairment. The incident involved one resident kissing another resident and attempting to climb into the resident's bed. Documentation showed that the resident who was kissed was dependent on staff for personal hygiene, mobility, and had a history of hemiplegia, hemiparesis, and aphasia, further indicating a lack of capacity to consent. The other resident involved also had severe cognitive impairment and required assistance with transfers. Progress notes documented the incident but did not indicate that any investigation was conducted, nor were interviews with the residents or potential witnesses performed. Staff, including the assigned RN and CNA who witnessed the event, confirmed that no investigation or written statements were completed. The DON acknowledged that the facility's policy defined nonconsensual sexual contact as sexual abuse and required investigation, but stated that no investigation was initiated because the resident who initiated the contact had forgotten the incident and there were no complaints from residents or their representatives. The facility's abuse coordinator and investigator was not notified of the incident, and no investigation was conducted as required by the facility's policy. The policy specified that all allegations of abuse, including resident-to-resident altercations, must be investigated objectively, timely, and completely, with written findings reported to the department of public health within five days. This process was not followed in this case.
Failure to Follow Physician Orders and Document Care for Two Residents
Penalty
Summary
Licensed nursing staff failed to follow physician's orders and facility policies in the care of two residents, resulting in multiple deficiencies related to assessment, documentation, and implementation of care. For one resident with diagnoses including dementia, anxiety, and major depressive disorder, blood pressure and heart rate readings were not recorded or documented on the Medication Administration Record (MAR) for several days, despite orders to hold antihypertensive medications if certain parameters were not met. Both the licensed nurse and the Director of Nursing confirmed that vital signs should have been documented to ensure resident safety and continuity of care, as required by facility policy. Another resident, with end stage renal disease, congestive heart failure, and chronic respiratory failure, experienced several lapses in care. After returning from dialysis, the resident's arteriovenous (AV) fistula dressing was not removed within the required four-hour window, as observed and confirmed by both the resident and nursing staff. The failure to remove the dressing prevented proper assessment of the AV fistula site for complications such as infection or bleeding, contrary to facility policy and standard nursing practice. Additionally, this resident was administered oxygen at a rate higher than ordered, and oxygen saturation levels were not assessed on room air as specified in the physician's orders and care plan. Nursing staff acknowledged these errors and stated that oxygen should have been administered and monitored according to the orders. Facility policies and job descriptions reviewed during the investigation confirmed the expectations for accurate documentation, adherence to physician orders, and proper assessment procedures. Interviews with nursing staff and the Director of Nursing consistently indicated that these standards were not met in the cases reviewed, resulting in deficiencies in nursing competency and care delivery for the affected residents.
Resident Not Protected from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and major depressive disorder, who had severely impaired cognitive skills and required significant assistance with daily activities, was left unsupervised in a room with another resident diagnosed with dementia, anxiety, and major depressive disorder. The first resident was in a wheelchair and had been informed by a CNA that it was time for a shower, to which the resident responded negatively. The second resident became upset by this response, displaying signs of agitation before the CNA left the room to retrieve a Hoyer lift, leaving both residents alone together. Within seconds of the CNA leaving, the second resident verbally cursed at the first resident, who questioned the behavior. The second resident then got out of bed, slapped the first resident on the right side of the face, and punched the resident in the stomach. The CNA returned quickly, intervened, and separated the residents. Staff interviews confirmed that the first resident was not protected from physical abuse, and that it was not acceptable to leave a vulnerable resident alone with an upset roommate, especially given the known risk of aggression. Facility staff, including the CNA, LVN, RN, and Administrator in Training, acknowledged that the incident was preventable and that the first resident was not adequately protected. The facility's abuse policy required immediate intervention and protection of residents from harm, but this was not followed, resulting in the first resident being subjected to physical abuse by another resident.
Failure to Implement and Maintain Infection Control Measures
Penalty
Summary
The facility failed to maintain and implement proper infection control measures for multiple residents, as evidenced by the absence of required Enhanced Barrier Precautions (EBP) signage outside several rooms. Despite physician orders and care plans specifying the need for EBP due to conditions such as open wounds and colonization with multidrug-resistant organisms (MDROs), no EBP signage was posted outside the rooms of several residents. Instead, only droplet precaution signage was observed, which does not communicate the need for gowns and gloves as required by EBP. Interviews with the Infection Preventionist Nurse confirmed the importance of correct signage to prevent the spread of infection, and the lack of signage was acknowledged as a potential cause for the spread of infection. Staff also failed to don the required personal protective equipment (PPE) before entering rooms of residents on isolation or respiratory precautions. Certified Nursing Assistants (CNAs) entered the room of a resident on novel respiratory precautions for COVID-19 without wearing a respirator-type mask, face shield/goggles, or gown, as required by physician orders and care plans. In another instance, a CNA entered the room of a resident on droplet isolation precautions and assisted with meal setup without wearing a gown or gloves, despite posted signage and facility policy requiring such PPE. Staff interviews revealed a lack of awareness or attention to posted precaution signs, contributing to these lapses in infection control. Additional deficiencies included improper management of medical equipment and waste. A resident's suprapubic catheter drainage bag was observed touching the floor during multiple observations, contrary to facility policy and staff statements that the bag should be secured off the floor to prevent infection. Furthermore, sharps containers attached to medication carts were found to be overfilled beyond the manufacturer's fill line, posing an infection control risk. Staff interviews confirmed awareness of the risks associated with overfilled sharps containers and the need for timely replacement, as outlined in facility policy.
Failure to Develop and Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for oxygen therapy for a resident with chronic respiratory failure and obstructive sleep apnea. The resident was admitted with these diagnoses and had a physician's order for oxygen therapy at two liters per minute as needed. Observations on two separate occasions confirmed that the resident was receiving oxygen therapy via nasal cannula at the bedside. Despite this, a review of the resident's care plans revealed that there was no current care plan addressing oxygen administration. During interviews, the DON confirmed that a care plan for oxygen therapy should have been in place, including interventions such as keeping the resident's head elevated and monitoring oxygen levels. The DON acknowledged that the absence of a care plan was an oversight and that the MDS should have prompted staff to create one. This lack of a care plan meant that necessary interventions for the resident's oxygen therapy were not formally documented or implemented.
Failure to Clarify Hold Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to clarify hold parameters for the administration of amlodipine and lisinopril, both antihypertensive medications, for a resident with diagnoses including type 2 diabetes mellitus and hypertension. The resident's medication orders specified to hold the medications if systolic blood pressure was less than 110 mmHg, but did not include instructions regarding pulse rate. Despite this, the electronic medication administration record prompted nurses to check both blood pressure and pulse prior to administration, and it was standard practice among nursing staff to hold these medications if the pulse rate was less than 60 bpm. However, there were multiple documented instances where the resident received both medications even when their pulse rate was below 60 bpm, as well as instances where the medications were held for low pulse without a corresponding order parameter. Nursing staff, including the RN interviewed, acknowledged that the lack of specific hold parameters for pulse rate in the physician's orders should have prompted them to notify the physician for clarification. The Director of Nursing also confirmed that the orders should have included parameters to hold the medications for low pulse. Facility policy required medications to be administered safely and in accordance with effective order writing, but the absence of clear instructions regarding pulse rate led to inconsistent administration practices and a failure to clarify orders with the physician when indicated.
Failure to Honor Resident's Preference for Urinal Use
Penalty
Summary
A deficiency was identified when staff failed to accommodate a resident's preference to use a urinal, resulting in the resident being required to wear and void into an incontinence brief despite being continent. The resident, who was admitted with diagnoses of pleural effusion and pneumonia, was documented as incontinent in the admission nursing assessment, but both the resident and a registered nurse later confirmed that the resident was not incontinent. The care plan noted the resident's preference for a urinal, but this preference was not honored. During interviews, the resident expressed that the use of an incontinence brief prevented him from voiding in a dignified manner, as he was unable to remove the brief independently. Observations confirmed that no urinal was present at the bedside, and a CNA admitted to assuming incontinence without verifying the resident's ability or preference. The facility's policy required staff to honor resident preferences and promote dignity, but this was not followed in the resident's care.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not having the necessary knowledge to make informed decisions about their care. The deficiency was identified through observations and interviews, which revealed that residents did not receive clear explanations or updates about their health status and treatment plans.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident was observed lying in bed with the call light placed on the left side of the bed, out of the resident's reach. The resident, who was dependent on staff for activities of daily living and had intact cognition, stated she was unable to reach the call light to request assistance with personal care. The resident's admission record indicated diagnoses of seizure and acute respiratory failure. The care plan for this resident, who was at risk for falling, specified that the call light should be kept within reach. During a concurrent observation and interview, a registered nurse confirmed that the call light was not within the resident's reach and acknowledged that it should have been accessible to the resident. The facility's policy and procedure also required that the call light be provided and placed within reach when the resident is in bed. The failure to ensure the call light was accessible constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Provide SNF ABN Notice When Medicare Coverage Ended
Penalty
Summary
The facility failed to provide a written notice of financial liability, specifically the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), to two residents when their Medicare Part A coverage ended and they chose to continue receiving skilled nursing services. For one resident, records showed severe cognitive impairment and a need for substantial assistance with daily activities, while another resident had moderate cognitive impairment and was entirely dependent on staff for several activities of daily living. Both residents remained in the facility after their Medicare Part A coverage ended, but did not receive the required SNF ABN form informing them of potential financial responsibility for non-covered services. During interviews, the Business Office Manager (BOM) acknowledged that the SNF ABN form should have been provided to these residents but was not, due to a misunderstanding of an email from corporate which led her to believe the SNF ABN had been replaced by the Detailed Explanation of Non-Coverage (DENC) form. As a result, the BOM had not provided the SNF ABN form to any residents since January of that year. Facility policy required that residents be informed in advance of changes to their billing and potential liability for non-covered services, but this procedure was not followed in these cases.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in the transmission of incorrect data to CMS regarding their health status. For one resident with chronic respiratory failure and obstructive sleep apnea, the Discharge MDS did not indicate the use of oxygen therapy, despite physician orders and oxygen saturation monitoring flowsheets confirming that oxygen therapy was administered during the lookback period. The Director of Nursing (DON) acknowledged that the MDS should have reflected the oxygen therapy and that the absence of this information led to the lack of a corresponding care plan for oxygen therapy. For another resident with multiple myeloma, cauda equina syndrome, and chronic kidney disease, the Discharge MDS failed to accurately report significant weight loss and the presence of a stage 4 pressure sore. The resident's weight records showed fluctuations, including a loss of more than 5% in one month, which was not captured in the MDS. Additionally, weekly skin integrity assessments documented a stage 4 pressure sore at discharge, but this was not reflected in the MDS. The DON confirmed these omissions and stated that the MDS should have included the most current weight and the presence of the pressure sore. Facility policies required all MDS assessments to be accurate and all services provided to be documented in the medical record. The DON stated that the MDS guides the resident's plan of care and that inaccuracies in the MDS could affect the care provided. The findings were based on observation, interview, and record review, and the facility's own policies were not followed in these cases.
Failure to Revise Incontinence Care Plan Based on Accurate Assessment
Penalty
Summary
The facility failed to revise the incontinence care plan for one resident following inaccurate documentation of the resident's continence status. Upon admission, the resident was assessed and documented as having bladder incontinence by a registered nurse, and a care plan was developed instructing staff to apply and change incontinence briefs every two hours and as needed. However, the resident was actually continent and able to use a urinal independently, as confirmed by both the resident and the registered nurse who observed the resident's ability to request and use a urinal without issue. Despite this, the care plan continued to reflect incontinence, and the resident was kept in incontinence briefs, which hindered his ability to use a urinal independently. The Director of Nursing acknowledged that the care plan was not updated to reflect the resident's actual continence status, and that revisions should have been made to ensure appropriate interventions. The facility's policy required ongoing assessment and timely revision of care plans as resident information changed, but this was not followed in this case.
Failure to Set Low Air Loss Mattress to Resident's Weight
Penalty
Summary
A deficiency occurred when staff failed to ensure that a low air loss mattress (LALM) was set according to a resident's actual weight. Multiple observations revealed that the LALM was set at 305 lbs, while the resident's documented weight was 100 lbs. Interviews with nursing staff confirmed that the mattress should be adjusted to the resident's weight to provide appropriate pressure redistribution. The facility's own policy and the manufacturer's user manual both required the LALM to be set according to the individual's weight. Despite these requirements, the mattress remained set at a much higher weight, resulting in a firmer surface than appropriate for the resident. The resident involved had significant medical conditions, including end stage renal disease, type 2 diabetes with polyneuropathy, and chronic obstructive pulmonary disease. The resident was dependent on staff for activities of daily living and had a stage 4 pressure ulcer on the sacral coccyx. Staff interviews acknowledged that the incorrect mattress setting could increase pressure on the resident's existing wound and body, contrary to the intended use of the LALM for wound healing and pressure ulcer prevention.
Failure to Provide Appropriate Toileting Assistance and Equipment
Penalty
Summary
Staff applied an incontinence brief to a resident who was admitted with diagnoses including pleural effusion and pneumonia. The resident's admission nursing assessment inaccurately documented him as incontinent of bladder, despite the resident being able to request and use a urinal independently. The resident reported that the use of an incontinence brief prevented him from voiding with dignity and made it difficult for him to use a urinal, which he preferred. Staff interviews revealed that the resident was continent and that the initial assessment was not accurate. Observations confirmed that no urinal was present at the resident's bedside, and staff admitted to assuming incontinence without verifying the resident's actual needs or preferences. The facility's policy required support for activities of daily living to prevent unnecessary decline, but staff failed to provide appropriate toileting assistance and equipment, resulting in the resident being unnecessarily placed in an incontinence brief.
Failure to Confirm Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to reweigh a resident after significant weight loss was recorded on two separate occasions. According to the facility's policy, any weight change of five pounds or 5% or greater within 30 days requires a confirmation weight to be retaken the next day. However, the resident, who had diagnoses including multiple myeloma, cauda equina syndrome, and chronic kidney disease, was not reweighed after a 16.27% weight loss and a 7.48% weight loss were documented. Staff interviews confirmed that the reweighing procedure was not followed, and the weights were not confirmed as required. The resident in question was severely cognitively impaired and dependent on staff for all activities of daily living, including eating. Both the Restorative Nursing Assistant and the Director of Nursing acknowledged that the resident should have been reweighed to confirm the weight loss and to allow for timely notification of the physician and appropriate intervention. The failure to reweigh was contrary to the facility's written policy and could have resulted in improper management of the resident's nutritional status.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by the physician for two residents. For one resident with chronic respiratory failure and obstructive sleep apnea, the physician's order specified oxygen therapy at 2 liters per minute (L/min) as needed. However, observations on two separate occasions showed the resident receiving oxygen at 4 L/min. A registered nurse confirmed that the oxygen should have been set to 2 L/min at all times when in use, as per the physician's order. For another resident with pleural effusion and pneumonia, the physician's order required oxygen therapy at 2 L/min, with the option to increase up to 5 L/min. During observation, this resident was receiving oxygen at 1.5 L/min, which was below the minimum rate specified in the order. The registered nurse acknowledged that the therapy should have been administered at a rate of at least 2 L/min. The facility's policy required staff to ensure oxygen therapy was administered as ordered by the physician.
Failure to Obtain Informed Consent for Bedside Rail Use
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of bedside rails for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, and hypertension. The physician ordered bilateral side rails for turning, repositioning, and injury prevention, and the care plan required that the risks and benefits of side rail use be explained to the resident or their representative, with informed consent obtained prior to use. However, observations confirmed that the resident was using bilateral side rails, and interviews with the resident's representative revealed that no explanation of risks or benefits was provided, nor was informed consent obtained or documented. A review of the resident's clinical records confirmed the absence of a completed or signed informed consent for side rail use. The facility's policies, revised in 2024 and 2025, clearly required assessment, education, and documented consent before applying side rails. Staff interviews further confirmed that the required discussion and documentation did not occur, resulting in the resident and their representative not being given the opportunity to make an informed decision regarding the use of side rails.
Failure to Immediately Document Medication Administration on MAR
Penalty
Summary
A registered nurse failed to immediately document the administration of scheduled medications on the Medication Administration Record (MAR) for a resident with diagnoses including type 2 diabetes mellitus and hypertension. The resident was prescribed amlodipine, ClearLax, and Paxlovid, all scheduled for administration at 9 a.m. On the day in question, there was no documentation on the MAR to indicate whether these medications were given at the scheduled time. Upon review, it was found that the nurse documented the administration, refusal, or holding of these medications several hours after the actual events occurred. The nurse acknowledged not following the facility's established process of pouring, passing, and immediately documenting medication administration. Both the nurse and the Director of Nursing confirmed that immediate documentation is required to communicate which medications have been administered, held, or refused. The facility's policy also specifies that the individual administering the medication must initial the MAR after giving each medication and before administering the next. The delay in documentation created a situation where it appeared the resident had not received their scheduled medications.
Failure to Monitor for Side Effects of Cymbalta in a Resident
Penalty
Summary
The facility failed to monitor for side effects in a resident who was prescribed Cymbalta, a medication used to treat depression and chronic pain. The resident had multiple diagnoses, including end stage renal disease, type 2 diabetes mellitus with diabetic polyneuropathy, and chronic obstructive pulmonary disease. The resident's Minimum Data Set indicated moderate cognitive impairment and dependence on staff for daily activities. Despite an active order for Cymbalta, there was no documentation or order for monitoring the resident for potential side effects associated with the medication. During interviews, both a registered nurse and the Director of Nursing confirmed that monitoring for side effects of Cymbalta was necessary and should be performed by licensed nurses, with any observed side effects to be reported to the physician. The facility's policy required monitoring for side effects of psychotropic medications, but this was not implemented for the resident in question. The lack of monitoring was identified through record review and staff interviews, with the Director of Nursing acknowledging the importance of such monitoring to assess the resident's tolerance to the medication.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Provide Medical Records Upon Request
Penalty
Summary
The facility failed to provide copies of medical records to the responsible party of a resident upon repeated requests. The resident, who was admitted with muscle wasting, atrophy, lack of coordination, and generalized muscle weakness, did not have cognitive impairments and required substantial to maximal assistance with mobility. The responsible party made multiple requests via email to various facility staff, including the Business Office Manager, Social Services Director, Administrator, and Medical Records Director, specifically asking for copies of documents signed by the resident, such as the Notice of Medicare Non-Coverage (NOMNC). Despite these requests, there was no response or provision of the requested records. Interviews with facility staff confirmed that the emails were received by the relevant personnel, but no action was taken to fulfill the requests. The Medical Records Director stated that she was instructed by the Administrator in Training not to respond to the responsible party's emails. The Social Services Director and Business Office Manager also acknowledged receipt of the requests but did not provide the records or follow up to ensure the request was addressed. The facility's policy required providing access to or copies of records within 24 hours, but this policy was not followed in this instance.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop and Implement Complete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in a deficiency. For one resident, the admission record showed diagnoses of chronic respiratory failure and hypotension, with the Minimum Data Set (MDS) indicating a need for two-person assistance for repositioning in bed. The MDS Nurse confirmed that this level of assistance was necessary for safety and should have been included in the care plan, but no such care plan was present. The absence of this care plan meant that staff did not have documented guidance on the required assistance level for safe care. For another resident, the admission record listed muscle wasting, lack of coordination, and generalized muscle weakness, with the MDS indicating substantial to maximal assistance needed for mobility. A progress note documented a verbal exchange between the resident and a responsible party, which was considered possible verbal abuse. The Licensed Vocational Nurse and the Director of Nursing both stated that incidents of suspected or alleged abuse should be care planned to prevent psychosocial harm and future incidents. However, no care plan was developed to address the suspected abuse, contrary to facility policy requiring care plan updates for such events.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in which a nursing home area was not maintained free from accident hazards, and adequate supervision was not provided to prevent accidents. The report notes that the facility failed to ensure the environment was safe and that appropriate oversight was in place to minimize the risk of accidents for residents. This lack of supervision and failure to address potential hazards directly contributed to the deficiency cited by surveyors.
Nursing Staff Lacked Required Competencies
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of appropriate skills and knowledge among the nursing staff, which impacted the quality of care provided to residents. There were no specific details provided about individual residents, their medical history, or their condition at the time of the deficiency in the report.
Failure to Notify Physician of Ongoing Orthostatic Hypotension and Lack of Physician Involvement in Therapy Discontinuation
Penalty
Summary
The facility failed to notify the physician of a resident's ongoing episodes of orthostatic hypotension (OH) and did not ensure physician involvement in the discontinuation of Physical and Occupational Therapy (PT, OT) services. The resident, who had a history of OH, falls, pleural effusion, diabetes mellitus, postprocedural pneumothorax, and muscle wasting, was admitted with intact cognitive skills and required substantial assistance with activities of daily living. Despite being prescribed PT and OT services, the resident experienced repeated episodes of OH during therapy sessions, which were reported to nursing staff but not communicated to the physician after an initial notification and medication order. The lack of further physician notification occurred even though the resident continued to have symptoms despite treatment with Midodrine. The PT progress notes documented the resident's ongoing need for therapy and the presence of OH during sessions, but there was no evidence that the physician was informed of the continued symptoms or the ineffectiveness of the prescribed medication. Interviews with nursing staff revealed that they were aware of the resident's ongoing OH but could not recall why the physician was not notified. The physician confirmed that he was not made aware of the continued episodes and would have considered additional interventions if informed. The failure to communicate these changes in the resident's condition resulted in a delay in appropriate medical intervention and placed the resident at risk for adverse outcomes. Additionally, the discontinuation of PT and OT services was not properly coordinated with the physician. The order to discontinue therapy was placed by the health plan and the Director of Rehabilitation, not by the physician, and the physician was not aware of or involved in the decision to end therapy services. Facility policy required physician involvement in the rehabilitation plan of care and communication of changes in condition, but this was not followed. The lack of physician involvement in both the management of the resident's OH and the discontinuation of therapy services contributed to the premature termination of Medicare coverage and compromised the resident's care.
Failure to Develop Individualized Care Plan for Orthostatic Hypotension
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident with orthostatic hypotension (OH), despite the resident's history of symptomatic OH that interfered with participation in physical therapy. The resident was admitted with multiple diagnoses, including OH, history of falls, pleural effusion, diabetes mellitus, postprocedural pneumothorax, and muscle wasting. Documentation showed that the resident required substantial assistance with activities of daily living and had intact cognitive skills. Orders were in place for physical and occupational therapy, and the resident experienced episodes of low blood pressure during therapy sessions, which were communicated to nursing staff. A physician ordered Midodrine to address the low blood pressure episodes. Despite these clinical findings and the administration of Midodrine, the facility did not create a care plan specific to the resident's diagnosis of OH or the use of Midodrine. Review of care plans revealed no individualized interventions addressing OH, such as timing therapy sessions after medication administration or monitoring orthostatic vital signs. Interviews with facility staff, including the MDS nurse and DON, confirmed that a care plan for OH was necessary and should have included specific interventions to ensure resident safety and support therapy participation. Facility policies required care plans to address all resident needs based on assessments and changes in condition, but this was not followed in this case.
Failure to Timely Develop Care Plan After Discovery of Bruising
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan after bruising was observed on a resident. The resident, who had diagnoses including dementia and legal blindness, was dependent on staff for all activities of daily living and had severely impaired cognitive skills. On review of the resident's records, skin discoloration was first noted on the left mid-arm, under the left breast, and chest, and later spread to the left rib and back. Despite these findings, there was no documentation in the Treatment Administration Record (TAR) that the Treatment Nurse monitored the skin discoloration from the time it was first observed. The care plan addressing the resident's skin discoloration was not developed until two days after the initial discovery of the bruising, following the resident's return from the hospital. Interviews with nursing staff revealed confusion regarding responsibility for initiating the care plan, with one nurse stating she did not develop the care plan because she was not the assigned nurse, and another stating she created a care plan on the day the bruises were discovered. The Director of Nursing confirmed that the care plan should have been developed immediately upon discovery of the bruises, in accordance with facility policy and the Treatment Nurse's job description. Facility policy required licensed nurses to document changes in a resident's condition and update the care plan accordingly. The delay in developing a care plan resulted in a lack of timely interventions and monitoring for the resident's bruising, as evidenced by the absence of documentation in the TAR and the late creation of the care plan. This lapse potentially affected the delivery of care to the resident.
Failure to Report and Document Resident Bruising
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to report the discovery of bruising on a resident's chest, left breast, flank, and left arm to the charge nurse or supervisor. The CNA found the bruises during a shower and did not complete the required skin assessment form or notify the appropriate staff, stating she became busy and did not follow through. The CNA acknowledged the importance of reporting such changes as it constitutes a change of condition that requires staff awareness and monitoring. Additionally, the treatment nurse (TN) who later discovered the resident's bruising did not document her findings in the resident's records. The TN admitted she was supposed to document the location and color of the bruises, as well as monitor and record any changes, but failed to do so. The TN stated she notified the Director of Nursing (DON) verbally but did not complete the necessary documentation or ongoing monitoring in the Treatment Administration Record (TAR) for the relevant period. The resident involved had significant cognitive impairment, was nonverbal, and was dependent on staff for all activities of daily living. The facility's policies and job descriptions required timely reporting and documentation of changes in resident condition for immediate intervention. The lack of reporting and documentation by both the CNA and TN delayed the resident's care and services, as staff were not made aware of the change in condition in a timely manner.
Failure to Provide Timely and Respectful Care to Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide timely and respectful care to a resident who required substantial assistance with toileting hygiene, bathing, and bed mobility due to a left hip fracture, history of falls, lack of coordination, and urinary retention. The resident, who had moderately impaired cognitive skills, pressed the call light during the night shift to request assistance with being changed after becoming soiled. The CNA entered the room, looked at the resident, and left without providing care. When the resident pressed the call light again, the CNA returned, aggressively pulled the call light away, instructed the resident not to use it, and did not provide the requested care. The resident was eventually changed by staff on the following shift. The resident expressed feelings of anger towards the CNA and described the CNA's actions as aggressive and disrespectful, including separating the resident's legs forcefully and fanning the soiled brief in a manner that suggested disgust. Interviews with other CNAs and the Director of Staff Development (DSD) revealed a pattern of similar behavior by the same CNA, including previous disciplinary actions for not changing residents and leaving them soiled. Other staff reported that the CNA often failed to complete assigned tasks and was not a team player, leading to delays in resident care. Facility policies reviewed indicated that staff are required to promote dignity, respect, and timely response to resident needs, including responding to call lights and providing explanations if care is delayed. The Director of Nursing (DON) confirmed that the CNA's actions did not align with facility expectations for resident dignity and timely care. The failure to provide prompt and respectful assistance, as well as the manner in which the resident was treated, constituted a lack of respect and dignity for the resident.
Failure to Timely Report and Respond to Alleged Abuse
Penalty
Summary
The facility failed to follow its Abuse and Neglect Prevention Management policy for one resident when a family member reported that a certified nursing assistant (CNA) roughly handled the resident. The incident was reported by the family member to a registered nurse (RN), who did not notify the Administrator, Director of Nursing (DON), or the California Department of Public Health (CDPH) within the required timeframe. The RN also failed to immediately suspend the CNA involved, allowing the CNA to continue working the remainder of the shift. The DON and Administrator were not informed of the allegation until days later, and the required reporting to CDPH was not completed as outlined in the facility's policy. The resident involved had significant medical conditions, including chronic respiratory failure with hypoxia, hemiplegia, hemiparesis, muscle wasting, difficulty walking, and a history of falls. The resident was cognitively moderately impaired and fully dependent on staff for toileting, transfers, and hygiene. The facility's policy required immediate suspension of the accused staff member and prompt reporting of abuse allegations, but these steps were not followed, resulting in a delay in investigation and potential risk to other residents.
Failure to Ensure Timely Follow-Up and Communication of Potassium Lab Results for Dialysis Resident
Penalty
Summary
Nursing staff failed to ensure appropriate follow-up and communication regarding a resident's potassium (K) laboratory order and results. After the resident, who had a history of end stage renal disease and hyperkalemia, was reported by the dialysis center to have a critically high potassium level, the medical director ordered Kayexalate and a repeat potassium level. The medication was administered, and a lab requisition was completed for a repeat potassium test. However, the requisition was incorrectly filled out, resulting in a Keppra (Levetiracetam) level being drawn instead of the required potassium level. The error in the lab requisition was not identified or corrected by the nursing staff. There was no documentation that the potassium result was received, nor was there evidence that the medical director was notified of the missing or incorrect lab result. The facility's policy required nurses to follow up on lab orders, notify the physician of abnormal results, and ensure that lab reports were received and acted upon. In this case, the lack of follow-up and communication led to a delay in identifying and addressing the resident's ongoing hyperkalemia. Interviews with nursing staff, the director of nursing, the medical director, and the laboratory director confirmed that the potassium test was not properly ordered or followed up on. The laboratory director indicated that the requisition was unclear, and the error was not clarified with the facility. The nursing staff acknowledged that the potassium box on the requisition was not checked, and the error was not discovered until days later. This series of actions and inactions resulted in the resident not receiving timely and appropriate monitoring for a potentially life-threatening condition.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to adhere to its Abuse and Neglect Prevention Policy when a Certified Nursing Assistant (CNA) did not report an allegation of rough handling by another CNA within the required two-hour timeframe. Resident 1, who had severe cognitive impairment and required assistance with daily activities, informed CNA 2 that CNA 1 was rough during care, causing pain in her arm and discomfort from hot water. Despite being informed of the complaint, CNA 2 did not report the incident to the Licensed Vocational Nurse (LVN) or notify the appropriate authorities, including the California Department of Public Health (CDPH), law enforcement, and the ombudsman. The incident was only brought to the facility's attention when Resident 1's son reported it. Interviews with the involved staff revealed that CNA 2 acknowledged the failure to report the abuse allegation, which is a requirement for all staff as mandated reporters. The facility's policy clearly states that any known or suspected abuse must be reported immediately, yet this protocol was not followed, resulting in a delay in the investigation and the potential for further abuse by CNA 1 while continuing to work their shift.
Failure to Promptly Investigate Abuse Allegation
Penalty
Summary
The facility failed to adhere to its Abuse and Neglect Prevention Policy when a resident alleged that a Certified Nursing Assistant (CNA) was rough during care. The incident involved a resident with severe cognitive impairment and multiple health conditions, including muscle weakness, spinal stenosis, and diabetes mellitus. The resident's son reported that the resident had complained about a male CNA being rough, causing pain, and using hot water during care. Despite this, the facility did not initiate a prompt investigation or take immediate protective measures. CNA 2, who was aware of the resident's complaint, failed to report the allegation to the appropriate authorities or facility staff, delaying the investigation and allowing the alleged perpetrator to continue working. Interviews with facility staff revealed that CNA 2 only informed a Licensed Vocational Nurse (LVN) about the resident's request for a pain pill but did not mention the abuse allegation. The LVN, unaware of the incident, did not take any action to report or investigate the matter. The facility's administrator confirmed that all staff members are mandated reporters and should have acted immediately upon learning of the allegation. The facility's policy requires immediate investigation and protective measures, including suspending the alleged perpetrator, which were not followed in this case.
Failure to Develop Care Plan for Call Light Non-Compliance
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was non-compliant with using the call light, which is essential for requesting assistance. This deficiency was identified during a review of the resident's records and interviews with staff. The resident, who had a history of chronic respiratory failure, generalized muscle weakness, COPD, and major depressive disorder, was admitted to the facility and later readmitted. Despite having the capacity to understand and make decisions, the resident's cognitive skills for daily decision-making were severely impaired, requiring supervision and assistance with daily activities. The resident was assessed as being at high risk for falls, yet no care plan was developed to address the non-compliance with call light use. The deficiency was highlighted when the resident experienced an unwitnessed fall while attempting to go to the restroom without assistance, as noted in the nurse's progress notes and fall investigation form. Interviews with the LVN and MDS RN confirmed the resident's forgetfulness and non-compliance with call light use, and the absence of a care plan addressing this behavior. The facility's policy required care plans to be developed within 72 hours of admission and updated as necessary, but this was not adhered to in the resident's case. The Director of Nursing acknowledged the need for a care plan to address the resident's behavior to prevent falls, which was not completed in a timely manner.
Failure to Provide Prescribed Hydration
Penalty
Summary
The facility failed to ensure that a resident who required substantial assistance with activities of daily living (ADLs) was provided with water every two hours, as per the physician's order and care plan. The resident, who had diagnoses including diabetes mellitus, hypothyroidism, and legal blindness, was at risk for recurrent urinary tract infections (UTIs). Despite the physician's order to provide 4-6 ounces of water every two hours, the medical records for October and November 2024 did not indicate that this was done. Interviews with facility staff and the resident's representative revealed that the resident often refused water, but the representative noted that the resident would ask for water during visits. The facility's Director of Nursing confirmed the lack of documentation supporting that the resident was offered the prescribed amount of water. The facility's policies on hydration and ADLs emphasized the importance of encouraging fluid intake and providing appropriate care for residents unable to perform ADLs independently. However, the facility did not adhere to these policies, as evidenced by the absence of documentation and the resident's repeated UTIs, which the representative attributed to inadequate hydration.
Failure to Document Change of Condition After Resident Altercation
Penalty
Summary
The facility failed to adhere to its policy of documenting changes of condition (COC) every shift for two residents involved in an altercation. Resident 1, who has a history of seizures, dementia, anxiety disorder, and insomnia, was involved in an altercation with Resident 2, resulting in a care plan that required monitoring every shift for any changes in condition. However, the nursing notes for Resident 1 lacked documentation for several shifts, including the night shift on 10/8/2024, the evening shift on 10/9/2024, the evening shift on 10/10/2024, and the night shift on 10/10/2024. Both the Registered Nurse (RN 1) and the Director of Nursing (DON) confirmed the absence of documentation, which was crucial for notifying the doctor and addressing any psychosocial needs. Similarly, Resident 2, who has diagnoses including hypertension, diabetes mellitus, congestive heart failure, and cardiomyopathy, was also involved in the same altercation. The facility's policy required monitoring and documentation every shift for 72 hours following the incident. However, the nursing notes for Resident 2 were missing documentation for the night shift on 10/9/2024, the night shift on 10/10/2024, and the morning shift on 10/11/2024. RN 1 and the DON acknowledged the lack of documentation, which was necessary to monitor Resident 2's emotional state and ensure no negative outcomes from the incident. The facility's policy, revised in 2012, mandates that the licensed nurse responsible for a resident must continue assessment and documentation every shift for 72 hours or until the condition stabilizes. The failure to document the COC for both residents as per the policy had the potential to result in serious harm, such as another episode of aggression or a delay in necessary treatments. The DON emphasized the importance of documentation to prevent further altercations and to monitor the residents' emotional well-being.
Medication Administration Error Due to Non-Compliance with Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering amiodarone and metoprolol tartrate outside the parameters ordered by the physician. The physician had instructed that these medications should be withheld if the resident's pulse was less than 60 beats per minute (BPM). However, the Medication Administration Record (MAR) indicated that amiodarone was administered on multiple occasions when the resident's pulse was below 60 BPM, specifically at 56 BPM and 54 BPM. Similarly, metoprolol tartrate was also administered several times when the resident's pulse was below the specified threshold, with recorded pulses of 56 BPM, 54 BPM, and 53 BPM. The resident involved had a medical history that included hypertension, diabetes mellitus, congestive heart failure, and cardiomyopathy. The resident's cognitive skills for daily decision-making were intact, and they used a cane or crutch for mobility. The Director of Nursing (DON) confirmed that the medications should have been withheld when the pulse was below 60 BPM and acknowledged that administering them under these conditions could lead to a decrease in pulse and potential loss of consciousness. The facility's policy and procedure on medication administration required compliance with the physician's written orders, particularly for medications with specific parameters.
Infection Control Lapses in Covid-19 Testing and Staff Screening
Penalty
Summary
The facility failed to maintain infection prevention and control when a resident, who was admitted with conditions including type 2 diabetes mellitus, chest pain, and nephrotic syndrome, was not tested for Covid-19 after showing symptoms such as phlegm and a runny nose. Despite having a physician's order for Covid-19 testing as needed, the resident was not tested until three days after symptoms were first reported, resulting in a positive Covid-19 test. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Preventionist Nurse, confirmed that the resident should have been tested when symptoms appeared, as per the facility's Covid-19 guidance. Additionally, a Certified Nursing Assistant (CNA) worked two shifts while experiencing Covid-19 symptoms, including congestion, without reporting these symptoms to anyone. The CNA was aware that symptomatic staff should not work but did not notify the facility until after testing positive for Covid-19 following her shifts. The facility's Office Assistant and Infection Preventionist Nurse confirmed that staff were supposed to self-screen for symptoms and report them, even when screening forms were not in use. The facility's documentation, including the OSHA C19 Healthcare Emergency Temporary Standard Policy and Procedure Manual and the Employee Daily Screening Tool, indicated that staff were required to be screened for symptoms before each shift and to report any symptoms that developed during their shift. The Director of Nursing emphasized the importance of identifying symptomatic staff to prevent infection transmission, but the failure to adhere to these protocols resulted in a risk of spreading infection within the facility.
Failure to Respond to Call Lights and Honor Resident Preferences
Penalty
Summary
The facility failed to respond to call lights in a timely manner and did not honor residents' preferences, leading to deficiencies in care for two residents. Resident 1, who has paraplegia and depression, reported that CNAs did not assist him as needed, often ignoring or canceling his call light without checking if he required help. This lack of response made Resident 1 feel unimportant and neglected, as he was dependent on staff for various daily activities, including toileting hygiene and personal care. Resident 2, diagnosed with atrial fibrillation and heart failure, experienced similar issues. Despite requesting a shower by a specific time due to expected visitors, his call light was ignored, and his request was not fulfilled. CNA 1 admitted to canceling the call light without verifying the resident's needs and failing to communicate delays, which left Resident 2 upset and waiting without explanation. The Director of Nursing confirmed that the facility's policy requires call lights to be answered promptly and not canceled without addressing residents' needs. The failure to adhere to these policies resulted in delayed care and unmet needs for the residents, as observed and reported during the survey.
Failure to Maintain and Monitor Range of Motion in Residents
Penalty
Summary
The facility failed to provide adequate services to maintain and improve the range of motion (ROM) and mobility for several residents, including Resident 53, who had limited ROM and mobility. The facility did not monitor Resident 53's ROM in each joint of both arms and legs upon admission, quarterly, and annually, as required by the facility's policies and procedures. Additionally, Resident 53 did not receive active assistive range of motion (AAROM) exercises from the time of admission until several months later, despite recommendations in the admission Rehab Screening Form. Furthermore, the facility did not provide passive range of motion (PROM) exercises for Resident 53's ankles as per physician orders. Resident 53's medical history included psychosis, major depressive disorders, seizures, starvation, and attention to gastrostomy. Upon admission, Resident 53 was noted to have a ROM impairment in one leg, with tightness in the right leg's hip. Despite this, the facility's records indicated that AAROM exercises were not performed for several months, and PROM exercises were not conducted according to physician orders. Observations revealed that Resident 53 developed ankle contractures, which were preventable according to the facility's staff. The facility also failed to assess and monitor the ROM of other residents, such as Residents 3, 56, and 61, upon admission, quarterly, and annually. Resident 3 did not receive PROM exercises for both elbows, wrists, hands, knees, and the left ankle as per physician orders. Similarly, Resident 56 did not receive active range of motion (AROM) exercises for the right wrist and hand as ordered. These deficiencies resulted in a lack of proper monitoring and exercises, potentially leading to undetected declines in ROM and the development of contractures.
Failure to Provide Required Rehabilitative Services
Penalty
Summary
The facility failed to provide necessary rehabilitative services, including Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST), to a resident with range of motion and swallowing problems. Despite physician orders and admission notes indicating the need for these evaluations, the resident did not receive any PT, OT, or ST services. This lack of intervention resulted in the resident's dependence on staff for mobility and activities of daily living (ADLs), leading to a decline in physical and psychosocial well-being. The resident was admitted with diagnoses including psychosis, major depressive disorders, seizures, and required gastrostomy tube feedings. Physician orders were issued for PT and OT evaluations upon admission, and later for a Speech-Language Pathologist (SLP) evaluation. However, these evaluations were not conducted, and the orders were discontinued without completion. Observations revealed the resident was unable to move arms or legs upon request and was dependent on staff for care, highlighting the absence of therapy services. Another resident also did not receive PT and OT evaluations as ordered, with the orders being discontinued without completion. This resident had a history of type 2 diabetes, myocardial infarction, hemiplegia, and dysphagia, and was dependent on staff for ADLs. Despite the facility's policy requiring assessments for residents with therapy orders, these were not carried out, contributing to the residents' decline in function and independence.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Gate
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Huntington Park Nursing Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Bell Convalescent Hospital | 1.9 mi | ★★★★★ | 31 | 0 |
| Lighthouse Healthcare Center | 2 mi | ★★★★★ | 2 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 2.1 mi | ★★★★★ | 25 | 0 |
| Briarcrest Nursing Center | 2.3 mi | ★★★★★ | 17 | 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.