Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Griffith Park Healthcare Center during CMS and state inspections, most recent first.
Failure to Protect Residents from Sexual Abuse by a Wandering Resident: A resident with psychosis, depression, cognitive impairment, and a documented history of inappropriate sexual behavior repeatedly wandered into other residents’ rooms, stared at bedbound residents, touched his own genitals, made sexual remarks to staff, and allegedly engaged in sexual contact with other residents. Care plans called for close supervision, hourly monitoring, and behavior logs, but documentation was incomplete across multiple shifts, and staff interviews and resident statements showed the behavior was not prevented.
A resident with anxiety, psychosis, major depressive disorder, and moderate cognitive impairment made verbal threats to beat his roommate, threatened staff and roommates, and was documented as taking roommates’ belongings and acting aggressively. The DON and another LVN stated the incident should have been reported to CDPH, PD, and the ombudsman per policy, but the record showed only physician notification and no documentation of the required agency reports.
A resident with psychosis, depression, cognitive impairment, pacing, wandering, threats, and prior inappropriate sexual behavior was not properly supervised or consistently monitored per his care plan. Staff documentation was incomplete after behavioral incidents, and the resident was able to enter other residents’ rooms, stare at bedbound residents, expose himself, touch his genitals, kiss a resident’s feet, and threaten residents when confronted. The affected residents reported feeling uncomfortable, disgusted, helpless, and unsafe, and the DON stated the resident’s behavior monitoring was not complete.
A resident with dementia, protein-calorie malnutrition, and a G-tube had physician orders for enteral feeding with Jevity 1.2 via pump, but no corresponding care plan was developed or implemented to address G-tube use or care. The MDS documented moderately impaired cognition and the presence of a feeding tube, yet review of the care plans showed no interventions or goals related to G-tube management. During interviews, the DON and QAN acknowledged that care plans are essential to guide staff and monitor care, and facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables for each resident within a specified timeframe, which was not done for this resident’s G-tube.
A resident with significant cardiac history and a POLST indicating full code status became weak, developed shallow breathing, stopped talking, and became unresponsive after dinner. CNAs summoned nursing staff, but the RN focused on obtaining vital signs and verifying code status, left the resident sitting upright, and did not initiate CPR, citing a pain response as evidence of responsiveness. An LVN recognized abnormal breathing and the need to call 911 but did not start CPR, and another LVN was unaware that ventilation should be provided to an unresponsive resident with slow breathing; no staff performed chest compressions before EMS arrival. The crash cart contained only 8 L/min oxygen regulators, preventing proper BVM use at 15 L/min, and the RN could not determine that the oxygen tank was empty or correctly connect the suction machine. EMS arrived to find the resident pulseless, apneic, in asystole, and with no CPR in progress, leading surveyors to cite a deficiency for failure to provide immediate, effective BLS and CPR to a full-code resident.
A resident with severe cognitive impairment, multiple cardiac diagnoses, and full code status experienced respiratory distress and became unresponsive, but nursing staff failed to provide competent emergency care in accordance with facility policies. An RN could not determine that the crash cart oxygen tank was empty, did not know how to connect the suction machine, and could not state that a backboard was needed for CPR; competency records showed no evaluation for suction use, vital signs, or emergency response. An LVN reported the resident became weak and was breathing slowly, but did not initiate ventilation, was unable to document vital signs, and paramedics found that staff were not performing CPR, no backboard was in place, and the oxygen regulator delivered only up to 8 L/min. Facility policies required prompt assessment and intervention for respiratory and cardiac symptoms, immediate CPR by trained licensed staff when an individual is unresponsive and not breathing normally, and accurate documentation, as well as sufficient, competent nursing staff, which were not met in this event.
A resident with a documented history of schizophrenia, depression, anxiety, suicidal ideation, and impaired impulse control was admitted from a hospital without the LTC staff thoroughly reviewing or incorporating the hospital’s psychiatric records into the initial psychosocial assessment, baseline care plan, or IDT discussion. Social services left key psychosocial risk areas blank, and nursing staff did not clarify reported aggressive behavior, did not fully assess behavioral needs, and did not implement a behavior management care plan or timely psychiatric evaluation. Within days of admission, while pacing the hallway before a smoke break, the resident suddenly struck another resident seated in a wheelchair on the upper back with an open-hand slap, as witnessed by multiple staff, and later stated not knowing why the act occurred.
A resident with bilateral blindness, respiratory failure, and diabetes, who was cognitively intact and required moderate assistance with ADLs, did not have a comprehensive, person-centered care plan addressing visual impairment. The resident reported relying on touch and temperature to identify food, and nursing staff stated that assistance was usually provided with meal set-up, transfers, and toileting due to blindness. However, record review with nursing staff and the MDS nurse confirmed that no care plan had been initiated for the resident’s blindness, contrary to facility policy requiring measurable objectives and timetables for each resident’s physical, psychosocial, and functional needs.
A resident with chronic respiratory failure and COPD receiving continuous oxygen via nasal cannula was found to have oxygen tubing that was not labeled with the date it was last changed and nebulizer tubing that had not been changed within the required 7-day interval. During observations and interviews, an LVN and an RN acknowledged that oxygen tubing must be dated and changed weekly and that nebulizer tubing should be changed every 7 days to prevent infection, but there was no documentation in the medical record of the date and time of oxygen set-up or respiratory therapy. Review of facility policies confirmed requirements to change oxygen cannula and tubing every 7 days and to document the date and time of these procedures, which were not followed for this resident.
Three residents who required assistance with ADLs and incontinence care experienced prolonged delays in staff response to call lights, contrary to facility policy requiring responses within minutes. One resident, who was bedbound with severe cognitive impairment and total incontinence, reported waiting about an hour in wet and soiled briefs after using the call light, and a family member corroborated long waits and frequent unanswered call bells. Another resident with moderately impaired cognition, frequent incontinence, and mobility limitations reported waiting one to two hours for adult brief changes, and was observed in a wheelchair while the call light was placed on the bed out of reach. A third resident with hemiplegia and intact cognition, on a toileting program and needing substantial assistance, stated he routinely waited at least an hour after activating the room or bathroom call light for toileting and cleaning, and was also observed with the call light out of reach. Staff, including an LVN and the DSD, acknowledged that call lights should be within reach and answered promptly, but this did not occur, placing residents at risk for infection, skin breakdown, and discomfort.
A resident with severe cognitive impairment, dental problems, and new facial swelling developed toothache pain, and the MD ordered PRN Orajel along with existing PRN acetaminophen and shift pain monitoring. For three days, the MAR showed no administration of Orajel or acetaminophen and documented that the resident denied pain, while family repeatedly reported mouth pain and difficulty eating and were told the medication had not arrived. The resident later described pain at 8/10 and needing to chew on the opposite side, and the DSD confirmed the Orajel was ordered but not given for three days and that no thorough pain assessments were documented, contrary to the facility’s pain protocol.
A resident with open facial wounds and a history of squamous cell carcinoma did not receive appropriate pain management during wound care. Staff failed to consistently assess and document pain before, during, and after treatments, and did not always offer or administer prescribed pain medications. The resident exhibited both verbal and non-verbal signs of pain, and refusals of care due to pain were not properly communicated to the physician, as required by facility policy.
A resident with advanced skin cancer, wounds, and dementia experienced a breakdown in communication and collaboration among the Attending Physician, Wound Care Specialist, Dermatologist, and Oncologist. Gaps in documentation, unclear physician responsibility, and inconsistent care planning led to confusion among nursing staff about who was managing the resident's wound and pain care.
A resident with dysphagia was assisted with an adaptive utensil by an OT who remained standing over him instead of being seated at eye level. Another resident with Parkinson’s disease and impaired cognition was spoon-fed by a CNA who stood next to the bed during breakfast. In the dining room, a resident with dementia coughed up phlegm that dripped onto his clothing, and staff did not promptly clean him or respond with attention to his comfort and dignity.
Insufficient CNA and TXN Staffing: The facility did not maintain staffing levels consistent with its Facility Assessment and staffing policy, with multiple shifts staffed below the required CNA levels and several shifts without TXN coverage. A resident with paraplegia and an ostomy, a resident with severe cognitive impairment and incontinence, and a resident with severe cognitive impairment and a facial wound all had high ADL and nursing care needs. Interviews described delayed call-light response, heavy CNA workloads, and missed wound treatment documentation when no TXN was available.
Food storage and handling practices were not followed during a kitchen observation. In the dry storage area, multiple items including food thickener, barbecue sauce, corn oil, and soup base powder were found without required labels or expiration/use-by dates, and opened soup base cans on a prep shelf were also undated. An uncovered ice scoop was left on top of another scoop, and frozen tilapia filets were stored above frozen spinach in the freezer, contrary to facility policy and the DSS's statements about proper labeling, ice handling, and freezer storage.
Facility Assessment Missing CNA and TXN Staffing Details: The facility’s current Facility Assessment did not include the specific CNA staffing needs for each shift or the number of TXNs needed for the facility. During review, the ADM, DSD, and DON confirmed that the 12/10/2025 assessment was the current one in use, but it did not list CNA or TXN direct nursing care coverage by shift or unit, even though the earlier assessment had included those staffing details.
Failure to Assess, Consent, and Administer Pneumococcal Vaccine: Three residents did not receive PCV20 as required by facility policy. One resident with emphysema and DM was not consented for the vaccine after admission, while two other residents with HTN, schizophrenia, dementia, and kidney failure were consented but the vaccine was not administered. The IP stated she was newly hired and had to start a new immunization tracking log after not receiving proper endorsement from the prior IP.
A resident who consented to the COVID-19 vaccine was not administered the vaccine, despite having diagnoses including dementia and kidney failure. The facility also lacked an updated staff COVID-19 immunization record list because the newly hired IP was not endorsed the prior tracking information, and the facility policy states the IP oversees COVID-19 vaccine education, documentation, and reporting.
Two residents were involved in a physical altercation resulting in injury, but staff and the Administrator failed to report the incident to authorities, did not document the event in clinical records, and did not update care plans as required by facility policy. Both residents had cognitive impairments, and the lack of action left them unprotected and the incident uninvestigated.
Two residents with severe cognitive impairment were involved in an altercation resulting in one sustaining a visible injury. Despite staff awareness and documentation of the incident, the administrator instructed staff not to report the event, leading to a failure to notify authorities, responsible parties, or document the incident in the medical record, in violation of facility policy and state regulations.
Failure to Control Bedside Medications for a Resident Not Approved for Self-Administration: A resident with intact cognition and multiple diagnoses, including depression, HTN, atrial fibrillation, and obesity, was not approved to self-administer meds per the facility's own assessment, physician orders, or care plan. Despite this, staff observed 3 medication bottles and an unlabeled cup with white powder on the bedside table, and an LPN confirmed the bottles were diphenhydramine, acetaminophen, and oxymetazoline. The DON stated residents must be evaluated before self-administration and that self-administered meds must be monitored and stored securely.
Incomplete ADA documentation was found for a resident with ESRD, atherosclerotic heart disease, HTN, and moderately impaired cognition and memory. The ADA form lacked initials for multiple statements about treatment rights and advance directives, and the choice to decline or execute an AD was left blank. The SSD acknowledged the form in the record was incomplete and stated she and her designee were responsible for explaining and assisting residents with ADs.
Failure to complete a PASRR Level II evaluation after a PASRR Level I screening identified a resident with SMI. The resident had diagnoses including Parkinson's disease, psychosis, and bipolar disorder. The PASRR notice stated the Level II evaluation was not scheduled because facility staff were unresponsive to repeated communication attempts, and the DON confirmed the PASRR II report was not in the clinical file.
Musculoskeletal Care Plan Not Updated After Medication Discontinued: A resident with metabolic encephalopathy, epilepsy, low back pain, and moderately impaired cognition had a musculoskeletal care plan that still listed tizanidine HCl as an intervention even though the medication was no longer on the physician’s orders. The pain assessment showed frequent pain that disrupted sleep and sometimes limited daily activities, and an LPN stated the care plan had not been updated after the medication was discontinued. The DON stated care plans are used to guide care and track which interventions work, and must be updated when care changes or medications are discontinued.
Overlapping PRN Pain Medication Orders: A resident with metabolic encephalopathy, epilepsy, low back pain, and moderately impaired cognition had PRN pain orders for acetaminophen and hydrocodone-acetaminophen that overlapped at the higher pain range. An LN stated the orders could confuse staff because either medication could be given for pain rated 8/10 or higher, and the DON stated the orders were not specific and should be clarified.
A resident with Alzheimer’s disease, dysphagia, failure to thrive, and severe cognitive impairment was fully dependent on staff for turning and other care. Staff observed her repeatedly in the same right-side position despite a care plan for repositioning at least every 2 hours, and an LPN stated she was not turned to the left side during the shift. The resident’s g-tube site was also found without a dressing while tube feeding was infusing, and staff stated the dressing should have been assessed and changed to help prevent infection. After readmission from the hospital, nurses also failed to reconcile an abdominal binder order that had previously been used to protect the g-tube.
A resident with a Foley catheter and diagnoses including sepsis, DM, candidal cystitis, and urethritis did not have intake and output documented, urine output was not recorded in the Elimination section, and cloudy yellow urine was observed but not identified or reported as required by the care plan, physician order, and facility policy. Staff interviews confirmed uncertainty about who was responsible for documenting and monitoring the resident's urine output and appearance.
A resident with DM, dysphagia, and malnutrition had a documented dislike of green vegetables, but the meal tray served contained broccoli and cilantro. The DSD initially cleared the tray, then confirmed it was incorrect after reinspection, while the DS, KS, and KC described communication and preparation errors that led to the resident’s food preference not being honored.
Inaccurate documentation of wound care treatments: A resident with severe cognitive impairment and total dependence on staff had orders for a low air loss mattress and heel protector. The TAR showed these treatments were charted on day shift, but the audit report showed they were actually documented in the evening. TXN and DON interviews confirmed treatments should be documented after administration and on the correct shift, but the charting did not reflect the actual time care was provided.
A resident with Alzheimer’s disease, dysphagia, and severe cognitive impairment had a g-tube site observed without a dressing while an abdominal binder rubbed directly on the stoma and tube feeding was infusing. The care plan and OSR called for daily stoma care and a dressing, but an LN said she did not know the dressing was off, the TXN said the assigned LN should assess and change the dressing if no TXN was available, and the DON stated LNs were expected to visually inspect the site every shift.
Excessive Occupancy in Resident Bedrooms: Surveyors found five resident rooms with six beds each, and several rooms were occupied by five or six residents. The facility’s waiver and accommodation analysis confirmed the rooms did not meet the federal limit for multiple-resident rooms, while staff and residents reported there was enough space for care, equipment, and personal belongings. The facility’s Bedrooms P&P stated rooms should meet federal and state requirements and accommodate no more than two residents at a time.
Five resident rooms did not meet the required square footage per resident. Survey review showed Rooms 31 through 35 each had six beds and were below the required space standard, although residents, an ADM, an LPN, and a CNA reported that there was enough room for wheelchairs, walkers, and other equipment, and no complaints had been made about the room size.
Failure to care plan dysphagia and pureed diet needs: A resident with dysphagia, severe cognitive impairment, and dependence for multiple ADLs had ST notes indicating a pureed diet and swallow precautions, along with orders for a pureed diet and crushed meds. However, the care plan did not address the swallowing problem or the resident’s need for pureed foods and crushed medications, and RN confirmed the omission.
A resident with multiple pressure injuries and significant care needs did not receive the required weekly wound assessments and documentation by the wound doctor or treatment nurse, as outlined in the care plan. Facility staff failed to inform the wound doctor and did not document initial or ongoing wound evaluations, despite facility policies mandating regular assessment and documentation for pressure injury management.
A resident with multiple health conditions, including delusional disorder and severe visual impairment, was found with several bottles of vitamin supplements at bedside and reported self-administering them. Staff interviews and record review revealed that the IDT had not assessed the resident's ability to safely self-administer medications, nor was there a physician's order or documentation as required by facility policy. Nursing staff were unaware of the supplements, and no evaluation or oversight was in place for the resident's self-administration of medications.
A resident with severe visual impairment and delusional disorder did not receive a comprehensive assessment within the required 14 days after admission, resulting in the absence of a care plan for her blindness. The resident expressed frustration with her care, and staff were uncertain how to address her needs due to the delayed MDS assessment.
A resident admitted with MASD and identified as high risk for pressure injury did not receive required weekly skin assessments as outlined in facility policy. Despite care plan interventions and the need for ongoing monitoring, staff confirmed that weekly assessments were missed, and documentation was lacking.
A resident with a history of major depressive disorder, anxiety, and schizophrenia exhibited escalating behavioral symptoms, including agitation, repeated requests for hospital transfer, and self-harm behaviors. Facility staff did not implement 1:1 supervision, failed to notify the physician of the resident's complaints and behavioral changes, and did not provide additional interventions or adequate monitoring. The situation escalated to the resident breaking a window and threatening self-harm, resulting in emergency transfer to a hospital.
A resident with cognitive impairment and a history of schizoaffective disorder physically and verbally abused another resident following a dispute. Although staff initially separated the two, the aggressor was able to return to the shared room due to inadequate supervision and communication, resulting in further threats and distress for the victim. The incident was not fully documented, and the facility's abuse prevention policy was not effectively implemented.
A resident with multiple chronic conditions was transferred to a GACH for psychiatric evaluation, and although a 7-day bed hold was ordered, neither the resident nor their responsible party received written information about the facility's bed hold policy at the time of transfer or within 24 hours, as required by facility policy. Interviews and record review confirmed the lack of notification and documentation.
A resident with diagnoses of bipolar disorder, depression, hemiplegia, and seizures did not have a person-centered care plan addressing their behavioral health needs or the use of medications such as Lexapro and Risperidone. The DON confirmed that care plans did not include interventions for these conditions, despite facility policy requiring comprehensive, updated care plans based on assessment findings.
A facility failed to implement its abuse prevention and reporting policies after a resident had a verbal altercation with an LVN. The incident was not investigated, and the LVN was not suspended, allowing further contact with the resident. The resident, who had intact cognition and required moderate assistance, called the police, but the facility did not document any investigation or interviews with the resident or witnesses. This failure placed residents at risk for potential abuse.
A resident in an LTC facility alleged verbal abuse by an LVN, prompting a police visit. Despite the facility's policy requiring immediate reporting of abuse allegations, staff failed to notify the State Survey Agency within the required timeframe. The resident, with intact cognition and a history of behavioral symptoms, accused the LVN of making threats. Interviews revealed that the DON and ADM were not informed, and staff did not adhere to mandated reporting duties.
The facility failed to implement its smoking policy, leading to unsupervised smoking and storage of smoking materials by residents, creating accident hazards. Residents were not adequately supervised, and some were allowed to smoke during nonscheduled times, posing risks of burns and fire hazards.
The facility failed to include POLST forms in the clinical records of three residents, potentially hindering access to their healthcare preferences during emergencies. Additionally, a resident's POLST and Advance Directive acknowledgment forms were missing, leading to uncertainty about their healthcare decisions. The facility's policies require these documents to be signed and filed appropriately, but this was not followed.
A resident with paraplegia and osteoarthritis refused podiatric care for long, infected toenails, but the facility failed to develop a care plan or conduct an interdisciplinary team meeting to address the refusal. The staff did not assess the reason for refusal or explain the risks, contrary to facility policy.
The facility failed to provide sufficient staffing to supervise residents during smoking times and monitor those at risk of elopement. Observations showed residents smoking without supervision, and staff interviews confirmed that short staffing prevented adequate monitoring. The DON acknowledged the staffing issues, which contradicted the facility's policy on providing sufficient nursing staff.
The facility failed to properly store medications for several residents, including Insulin Glargine and Lorazepam, leading to potential issues with medication integrity and security. Insulin pens were found in a refrigerator with water dripping from a melting freezer, and Lorazepam was stored at incorrect temperatures and not locked separately as required. These deficiencies could affect medication efficacy and security.
The facility failed to maintain proper sanitation and temperature logs in the kitchen, with missing entries in the sanitization sink solution, cold storage temperature, and sanitizer solution logs. This lack of documentation indicates non-compliance with the facility's policies, potentially risking food safety.
Failure to Protect Residents from Sexual Abuse by a Wandering Resident
Penalty
Summary
The facility failed to protect three residents from sexual abuse by another resident who had a documented history of inappropriate behavior, pacing, wandering, verbal aggression, and threats toward roommates and staff. The resident’s record showed diagnoses including anxiety, psychosis, and major depressive disorder, along with moderate cognitive impairment and a care plan that required close supervision, 24-hour hourly monitoring, hourly location monitoring, and hourly behavior logs because of prior inappropriate behavior toward female staff and attempts to touch residents. After a change in condition on 4/28/26, the resident was documented as threatening roommates and staff, using foul language, and being a danger to others, but the progress notes did not contain licensed nurse monitoring documentation for multiple shifts after that event. The resident’s behavior continued to escalate. A later change in condition documented pacing, insomnia, and angry outbursts, and the care plan called for frequent check-ins and gentle reminders to return to his room or a safe area. Progress notes again lacked licensed nurse monitoring documentation for multiple shifts after that change in condition. On 5/19/26, the resident was reported by police officers to have allegedly performed oral sex with other residents, and the facility documented that he was pacing the halls, entering other residents’ rooms without permission, touching his own private parts in another resident’s room, making sexual remarks to female staff, and attempting to touch another resident’s foot. He was then placed on 1:1 monitoring and recommended for transfer for psychiatric evaluation. Interviews with residents and staff described repeated inappropriate conduct that had not been prevented. One bedbound resident reported that the resident repeatedly entered her room, stood at the foot of her bed, and stared at her, making her feel very uncomfortable. Another bedbound resident stated the resident kissed his feet, stared at him while touching his own genitals, and threatened him when told to leave, leaving him feeling disgusted, helpless, and unsafe. A third resident reported that the resident entered his room, stared at him while rubbing his genitals, and made him feel unsafe. Staff interviews confirmed that the resident wandered the facility, stood by residents’ doors, and made sexual comments to staff, while the DON stated she had not been aware of the inappropriate behavior and that the facility’s monitoring documentation was incomplete.
Failure to Report Resident Verbal Abuse and Threats
Penalty
Summary
The facility failed to report resident-to-resident verbal abuse to CDPH, local police, and the local ombudsman as required by its Abuse Investigation and Reporting policy after a resident made verbal threats to physically beat his roommate and was described as threatening roommates and staff, using foul language, and being a danger to other residents and staff. The resident’s Change in Condition Evaluation dated 4/28/26 documented that he was going into roommates’ personal belongings and taking them, threatening roommates and staff, and stating, “I will beat your ass I am a gangster I don't care about going to jail,” while getting in staff’s face. The evaluation also described verbal aggression, dangerous behavior, and aggressive behavior, and it was completed and signed by an LVN. The resident had diagnoses including anxiety, psychosis, and major depressive disorder, and his MDS indicated moderate cognitive impairment and need for moderate assistance with most cares. During interviews, the DON stated she was not aware of the CIC because the LVN did not report the incident to her, and she stated that if she had known, she would have pushed for an immediate psychiatric consult and medical and psychological evaluation in a GACH. The DON and another LVN stated the resident’s verbal threats should have been reported to CDPH, local PD, and the local ombudsman, but the record reviewed did not contain documentation of those reports. The LVN who completed the CIC stated she only notified the physician and did not recall notifying CDPH, PD, the ombudsman, or the DON.
Failure to Supervise Resident With Aggressive and Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to properly supervise a resident with a history of anxiety, psychosis, major depressive disorder, moderate cognitive impairment, verbal aggression, pacing, wandering, and prior inappropriate behavior toward female staff and residents. The resident’s care plan called for close supervision, 24-hour hourly monitoring, hourly location monitoring, and hourly behavior logs, but the record showed multiple gaps in monitoring documentation after behavioral incidents, including after he threatened roommates and staff, stole roommates’ belongings, paced in the hallways, and had angry outbursts. The DON stated the resident was known to pace at night and attempt to touch female staff, and the facility’s internal behavioral monitoring binder was incomplete. The resident was observed and reported entering other residents’ rooms and engaging in inappropriate conduct. One bedbound resident reported that the resident repeatedly came into her room, stood at the foot of her bed, and stared at her, which made her feel very uncomfortable. Another resident reported that the resident entered his room, kissed his feet, played with his own genitals, and threatened him when asked to leave, leaving him feeling disgusted, helpless, and unsafe. A third resident reported that the resident entered his room, stared at him while rubbing his genitals, and made him feel very uncomfortable and unsafe. These residents were dependent on staff for care, and two were bedbound or unable to move independently. The record also showed that the resident’s behavioral issues were not consistently monitored or documented as required. After a change in condition for verbal threats and stealing, licensed nurse progress notes did not include monitoring documentation for several shifts. After a later change in condition for pacing and angry outbursts, progress notes again lacked documentation for additional shifts. Staff interviews confirmed that the resident’s behavior monitoring did not begin until after the initial behavioral incident and that the facility was not aware of some of the resident’s inappropriate conduct because it had not been reported or documented. The DON stated that if she had known about the threatening behavior, she would have pushed for immediate psychiatric evaluation and transfer for further medical and psychological assessment.
Failure to Develop and Implement G-Tube Care Plan for Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, resident-specific care plan for a resident with a gastrostomy tube (G-tube). The resident’s admission record showed readmission with unspecified protein-calorie malnutrition, unspecified dementia, and gastrostomy status. The resident’s MDS dated 3/3/2026 documented moderately impaired cognitive skills for daily decision-making and the presence of a feeding tube. The physician’s order summary dated 10/02/2025 included an enteral feeding order specifying Jevity 1.2 at 50 ml per hour for 20 hours via pump, with instructions to provide 1000 ml per 1200 calories in 24 hours, off at 8 AM and on at 12 PM or until dose limit. Despite these documented conditions and orders, review of the resident’s care plans revealed no care plan initiated that addressed the use of or care for the resident’s G-tube. During interviews, the DON stated that it was important to have a care plan for each resident to ensure goals are met and that care plans are revised as needed to meet resident-specific goals, and further stated that the care plan helps monitor resident care and guide staff in providing care. In the same interview, the QAN stated that the purpose of a care plan is to have specific goals and interventions so staff know how to care for the resident. The facility’s policy titled “Care Plans, Comprehensive Person-Centered,” dated 3/2022, required development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident within seven days of completion of the required MDS and no more than 21 days after admission, which was not followed for this resident’s G-tube care.
Failure to Initiate Immediate CPR and Provide Adequate BLS and Oxygen Equipment for a Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide proper and effective Basic Life Support (BLS), including immediate CPR, to a resident who was documented as full code. The resident had multiple cardiac-related diagnoses, including diabetes mellitus, congestive heart failure, dementia, atrial fibrillation, and atherosclerotic heart disease, and a POLST indicating that resuscitation/CPR should be attempted with full treatment status. The resident’s care plan identified potential for cardiac distress and directed staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, edema, and to promptly contact the physician if symptoms occurred. On the day of the event, the resident had been stable earlier and ate 100% of dinner, but later became weak, had shallow breathing, stopped talking, and became unresponsive. When the change in condition occurred, CNAs observed the resident become unresponsive with eyes rolling back and immediately summoned nursing staff. RN 1 responded and found the resident sitting up at approximately a 70–90 degree angle, unresponsive, with shallow breathing and not verbally responsive, but making noises. RN 1 proceeded to obtain vital signs and reported normal blood pressure, heart rate, respiratory rate, and oxygen saturation initially at 98%, later dropping to 96% and then 89%. Instead of immediately initiating CPR or placing the resident supine on a firm, flat surface with a head-tilt, chin-lift to open the airway, RN 1 left the room to verify code status and retrieve the crash cart. RN 1 stated he did not initiate CPR because the resident made a noise in response to painful stimulation of the ear and he believed this indicated responsiveness. Staff did not initiate chest compressions while the resident remained unresponsive with shallow breathing, and no reassessment of oxygen saturation was documented after oxygen via simple mask was applied. Other licensed staff also failed to initiate BLS measures. LVN 1 reported that when called to the room, the resident was on oxygen via nasal cannula, breathing abnormally with two to three long breaths, and he recognized that 911 needed to be called, but he did not start CPR. LVN 2 stated that the resident was unresponsive and breathing slowly and acknowledged not being aware that ventilation could be provided when a resident is unresponsive and breathing slowly; vital signs she attempted to obtain were not documented. CNA 1 reported that no CPR was initiated by facility staff before EMS arrival. According to the EMS report and the responding Paramedic Captain, paramedics arrived to find the resident supine in bed, unresponsive, pulseless, apneic, and in asystole, with no CPR in progress and no measurable blood pressure, pulse, respirations, or oxygen saturation. The deficiency also included failure to ensure that emergency equipment and oxygen delivery systems were adequate and properly set up for resuscitation. The crash cart contained an oxygen regulator with a maximum output of only 8 L/min, which was insufficient to keep the BVM reservoir bag fully inflated and deliver 100% oxygen as required during resuscitation. The Paramedic Captain reported that the oxygen regulator connected to the resident’s oxygen tank was limited to 8 L/min, and another regulator found in the crash cart was also limited to 8 L/min, necessitating use of EMS’s own regulator to achieve 15 L/min, which delayed delivery of 100% oxygen. The Paramedic Captain also requested a backboard and was informed by RN 1 that the facility did not have one. Additionally, during surveyor observation and interview, RN 1 was unable to determine that the crash cart oxygen tank was empty and could not demonstrate proper connection of the suction tubing to the suction machine, stating he did not know how to determine whether the oxygen tank was empty or how to connect the suction machine. These failures occurred despite facility policies requiring immediate initiation of CPR for unresponsive residents without a DNR and the use of appropriate oxygen administration and emergency procedures. As a result of these findings, surveyors determined that the facility did not initiate immediate CPR for a full-code resident found unresponsive and did not perform continuous, uninterrupted CPR until EMS assumed care. The facility also failed to position the resident flat on a firm surface with airway opened, and failed to ensure availability and proper use of equipment capable of delivering 15 L/min oxygen for BVM use during resuscitation. EMS documentation indicated that no CPR was being performed upon their arrival, and the resident was found in cardiac arrest. The California Department of Public Health determined that the noncompliance constituted Immediate Jeopardy related to failure to ensure CPR was immediately performed on the resident.
Removal Plan
- RN 1 resigned from the facility.
- Staff involved (LVN 1, LVN 2) were removed by the DON from direct patient care until competency was validated.
- Immediate re-education was reinforced by the DON for direct care staff on immediate initiation of CPR, proper positioning on a firm/flat surface, continuous/uninterrupted CPR, crash cart utilization (including oxygen regulators capable of 15 L/min and backboards), and use of oxygen tanks (including how to determine if full or empty).
- Crash cart was checked by the DON and oxygen regulators were replaced to ensure 15 L/min capability; BVM bag and oxygen delivery systems were verified functional; oxygen tanks were ensured full.
- DON and DSD reviewed current certifications of all direct care staff and ensured only staff with validated CPR certification are assigned to residents' care.
- MRD identified residents designated as full code and ensured staff are aware where to find code status in paper medical records and the health record system.
- DON initiated in-service to licensed nurses (RNs/LVNs) and CNAs on the facility CPR emergency procedure policy with emphasis on calling code blue, locating code status, placing resident on firm/flat surface using backboard, head-tilt/chin-lift with oxygen via simple mask, using an oxygen regulator capable of 15 L/min for BVM, and performing continuous/uninterrupted CPR until EMS assumes care.
- Code Blue drills were initiated and will continue for skills check validation via return demonstration of licensed nurses and CNAs.
- A crash cart checklist was developed and implemented; crash cart and oxygen equipment checklist will be checked every shift by the lead licensed staff.
- Room changes will include updating residents' medical records to reflect new room assignment in both the electronic health record and physical medical record.
- A certified CPR instructor provided mandatory re-education and training for all licensed nurses and CNAs with return demonstration conducted.
- DSD/designee will validate that newly hired licensed nurses and CNAs have current valid CPR certification prior to scheduling for direct resident care; no direct care staff will work directly with residents without valid CPR certification.
- DON conducted a 1:1 in-service with LVN 1 and LVN 2 regarding medical emergency response (immediate CPR, proper positioning, continuous/uninterrupted CPR, crash cart utilization including 15 L/min regulators and backboards, and oxygen tank use/verification).
- DSD updated CPR certification status for all current direct care staff and will update monthly; DSD will audit and communicate with staff if CPR certification expires.
- DON/designee will provide a summary of findings for the monthly Quality Assurance Committee (QAC).
Failure to Ensure Competent Nursing Response During Resident Respiratory/Cardiac Emergency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff possessed and demonstrated the competencies required to provide emergency care consistent with facility policies and resident assessments. A resident with a POLST indicating full code and full treatment status was admitted for long-term care with diagnoses including diabetes mellitus, congestive heart failure, dementia, and atrial fibrillation. The resident’s MDS showed severe cognitive impairment and dependence on staff for all ADLs, and the care plan identified potential for cardiac distress related to cardiac conditions, directing staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, and to promptly notify the physician if symptoms occurred. Physician orders also included PRN oxygen 2–5 L via nasal cannula for shortness of breath or oxygen saturation below 92%. Surveyors found that nursing staff lacked critical emergency response skills and did not follow the facility’s CPR and oxygen administration policies when the resident became unresponsive with difficulty breathing. RN 1 was observed to be unable to determine that the oxygen tank on the crash cart was empty and could not demonstrate how to connect the suction tubing to the suction machine, and later stated not knowing how to check if the oxygen tank was empty or how to connect the suction machine. RN 1 also could not verbalize that a backboard was needed during CPR. Review of RN 1’s competency records showed no skills and competency evaluation for use of a suction machine, vital signs, or emergency response. The DON reported that RN 1 had a language barrier and that she paired RN 1 with experienced LVNs due to RN 1’s comprehension and communication needs. During the resident’s decline, LVN 2 reported that the resident had been stable earlier and had eaten 100% of dinner, but later was weak and breathing slowly. LVN 2 attempted to take vital signs but was unable to document the results and stated that paramedics initiated CPR upon arrival. The Paramedic Captain reported that, on arrival, facility staff were not performing CPR, a backboard was not in place, and the oxygen valve regulator connected to the oxygen tank delivered only up to 8 L/min. LVN 2 stated she was not aware that ventilation could be provided when a resident was unresponsive and breathing slowly and acknowledged inaccuracies in documentation times. Facility policies required assessment of symptoms such as shallow breathing and vital signs during oxygen therapy, immediate initiation of CPR by licensed staff certified in CPR when an individual is unresponsive and not breathing normally (unless a DNR is present), and accurate, time-specific documentation of procedures and treatments. The facility’s staffing policy required sufficient numbers of nursing staff with appropriate skills and competency, which was not met for the involved licensed nurses.
Failure to Assess and Monitor Psychiatric Resident Leads to Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, supervise, and provide necessary care for a newly admitted resident with significant psychiatric and behavioral issues, which resulted in that resident striking another resident. Prior to admission, a General Acute Care Hospital (GACH) psychiatric evaluation documented that the resident had a history of depression, anxiety, frustration, irritability, agitation, lack of motivation, dark thoughts, suicidal ideation with a plan to overdose, difficulty resisting urges to self-harm, unpredictability, impaired coping skills, and impaired insight, judgment, and impulse control. The GACH history and physical further indicated the resident had been admitted for increased agitation and anxiety. Upon admission to the facility, the resident’s diagnoses included paranoid schizophrenia, anxiety, and major depressive disorder. Despite this extensive psychiatric history, the facility’s social services and nursing staff did not adequately review or incorporate the hospital records into the resident’s initial assessments or care planning. The Social Service History and Initial Assessment completed the day after admission left multiple psychosocial adjustment factors blank, including distressed mood, history of depression, history of suicidal ideation/gestures, anxiety, insomnia, use of psychotropic medications, history of drug/alcohol abuse, disruptive behavior, difficulty controlling behavior, agitation/aggression, and resistance to care. The Social Service Director later acknowledged she had not reviewed the hospital records before completing the assessment and was unaware of the resident’s documented dark thoughts, suicidal ideation, and increased agitation. The Interdisciplinary Team (IDT) meeting held the same day did not document or discuss the resident’s past behaviors from the GACH records, even though the IDT noted the resident would be admitted to psych services and monitored daily. Nursing staff also failed to fully assess and plan for the resident’s behavioral risks upon admission. The admitting nurse reported receiving information from the GACH that the resident had increased aggressive behavior but did not ask for specifics, did not review the hospital records that accompanied the resident, and only initiated monitoring orders for anxiety, schizophrenia, and insomnia based on limited observations of repetitive anxious questions. Another nurse confirmed that the baseline care plan completed on admission noted psychotropic medication use but left mental health needs and behavioral concerns blank, and that there was no behavior management care plan in place before the incident. Psychiatric and psychological consults were not ordered until days after admission, and the resident had not been evaluated by a psychiatrist in the facility before the event. On the morning of the incident, multiple staff members observed the resident walking up and down the hallway while waiting for a smoke break. Payroll staff and central supply staff both witnessed the resident suddenly stop behind another resident seated in a wheelchair and strike that resident on the upper back with an open hand, describing the contact as a hard smack with an audible sound. A CNA confirmed that the resident had rushed through breakfast and was pacing the hallway before the smoke break when the incident occurred. Following the event, a change of condition evaluation documented that the resident had allegedly physically abused another resident by slapping them and that the resident stated he did not know why he did it. The facility’s own policies required thorough evaluation of behavioral symptoms, identification of underlying causes, assessment of severity and safety risk, and immediate implementation of safety strategies, as well as completion of a baseline care plan within 48 hours of admission to meet immediate needs; however, these processes were not effectively carried out for this resident prior to the incident.
Failure to Develop Comprehensive Care Plan for Visually Impaired Resident
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan addressing the needs of a legally blind resident. The resident’s admission record showed diagnoses including bilateral blindness, respiratory failure, and diabetes, and the history and physical documented that the resident had capacity to understand and make decisions. The MDS indicated the resident was cognitively intact and required moderate assistance with oral hygiene, toileting hygiene, dressing, and footwear. During interview, the resident reported being unable to visually identify meals and stated she used her hands to determine what she was eating by feeling the texture and temperature of the food. A nurse confirmed the resident was blind in both eyes and stated that assistance was usually provided for meal set-up, including identifying food items and their location on the tray, as well as for transfers and toileting due to the visual impairment. Record review with nursing staff revealed there was no care plan initiated to address the resident’s specific diagnosis of blindness. RN 2 acknowledged that a care plan should have been initiated and should have included measurable goals and interventions to address the resident’s behaviors and needs, including measures to decrease stress and anxiety. The MDS nurse also confirmed there was no care plan in place for the resident’s blindness. This was inconsistent with the facility’s written policy on comprehensive, person-centered care plans, which requires development and implementation of a care plan with measurable objectives and timetables for each resident, including after significant changes in status, and ongoing revision as resident conditions change.
Failure to Follow Oxygen and Respiratory Therapy Infection Control Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its infection prevention and control program related to oxygen and respiratory therapy equipment for one resident. The resident was admitted with chronic respiratory failure, obstructive pulmonary disease, and a delusional disorder, and was cognitively intact with moderate assistance needs for ADLs. The resident had a physician’s order for continuous oxygen at 5 L/min via nasal cannula. During observation in the resident’s room, surveyors noted that the oxygen tubing in use was not labeled with a date or time to indicate when it was last changed, and the nebulizer tubing attached to the resident’s breathing treatment device was labeled with a date showing it had last been changed on 1/5/2026. In interviews conducted at the time of observation, an LVN stated that oxygen tubing must be dated so staff know when to change it, and an RN confirmed that the oxygen tubing was not labeled and should be labeled weekly to ensure it is changed to prevent infection. The RN also stated that the nebulizer tubing, dated 1/5/2026, should have been changed every seven days and therefore should have been changed by 1/19/2026. The RN further stated there was no way to know when the oxygen tubing was last changed due to the lack of labeling or documentation. Review of the facility’s policies showed that the Oxygen Administration policy required documentation of the date and time oxygen set-up was performed in the medical record, and the Respiratory Therapy policy required changing oxygen cannula and tubing every seven days and documenting the date and time respiratory therapy was performed. These policy requirements were not followed for this resident’s oxygen and nebulizer equipment.
Failure to Timely Respond to Call Lights and Provide ADL/Incontinence Assistance
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights in a timely manner and to provide needed assistance with activities of daily living (ADLs), specifically toileting and incontinence care, for three residents. Facility policy on the call system required that calls for assistance be answered as soon as possible and no later than five minutes, and the ADL policy required appropriate support and assistance with hygiene and elimination in accordance with the care plan. Interviews with staff, including the Director of Staff Development (DSD), Licensed Vocational Nurse (LVN) 1, and the Administrator, confirmed that call lights are to be within residents’ reach and answered promptly, with the DSD specifying no more than 15 minutes and stating that a resident should not wait one hour for assistance. Resident 1 was admitted with encephalopathy, epilepsy, and hypertension, was bedbound, had decreased tone and no movement on the right side, and had severely impaired cognitive skills. The MDS showed he required substantial assistance with toileting hygiene, showering, dressing, and transfers, and was always incontinent of urine and bowel. His care plan required monitoring and assisting with ADLs, keeping him clean and dry, changing adult briefs as needed, and ensuring the call light was within reach and answered promptly. Family Member 1 reported that on one occasion Resident 1 waited over an hour for his adult brief to be changed and that call bells were frequently sounding when she visited. During an interview, Resident 1 stated he used the call light to request assistance for brief changes and that it took about one hour for staff to respond, leaving him in wet and soiled briefs, which he described as uncomfortable. Resident 2 was admitted with benign prostatic hyperplasia, polyneuropathy, lumbar spondylosis, and bilateral knee osteoarthritis. His MDS indicated moderately impaired cognition, a need for supervision with toileting hygiene and other ADLs, and frequent urinary and bowel incontinence. His care plan documented an ADL deficit related to his osteoarthritis and polyneuropathy, with goals that his ADL needs be met daily and interventions to monitor and assist with ADLs, keep him clean and dry, change him as needed, and keep the call light within reach with prompt staff response. During observation and interview, Resident 2 was seated in a wheelchair next to his bed while the call light was on top of the bed, out of his immediate reach. He reported that he used a urinal for urination and an adult brief for bowel movements and that after pressing the call light for a brief change, he often had to wait one to two hours for staff to respond. Resident 3 was admitted and later readmitted with hemiplegia and hemiparesis following a stroke, osteoarthritis of both shoulders, and glaucoma. His history and physical indicated he had decision-making capacity, and his MDS showed intact cognition but a need for substantial assistance with toileting hygiene, repositioning, and transfers, with frequent urinary incontinence and occasional bowel incontinence. He was on a bowel toileting program. His care plans documented bowel and bladder interventions, including assistance with toileting as needed, keeping the call light within reach for assistance, and providing limited to extensive assistance by one staff member for personal hygiene and toileting, including an extensive-assistance toileting schedule. During observation, Resident 3 was in his wheelchair in front of his bed with the call light placed on top of the bed, not within his reach. He stated he used the call light to request help going to the bathroom and used the bathroom call light to request cleaning after bowel movements, which he described as very messy, and reported that he typically waited at least one hour before someone came to his room. Staff interviews confirmed that call lights are intended as the primary means for residents to request assistance with needs such as brief changes and toileting, and that they are expected to be within reach and answered timely, which did not occur for these residents. As a result of this deficient practice, the residents were placed at risk for infection, skin breakdown and discomfort.
Failure to Provide Ordered Oral Pain Medication and Adequate Pain Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain management for a resident with a toothache and facial swelling. The resident was admitted with encephalopathy, epilepsy, and hypertension, was bedbound with decreased tone and no movement on the right side, and had severely impaired cognitive skills per the MDS. The MDS also showed the resident required substantial assistance with ADLs and that the staff assessment for pain was left blank, with no pain management regimen documented and the resident denying pain at that time. The care plan, revised in November, identified dental health problems related to poor oral hygiene and missing teeth, with interventions to monitor, document, and report signs and symptoms of oral or dental pain. On 12/27/2025, a change of condition evaluation documented mild swelling of the lymph nodes and left cheek, and a pain level of 5/10 in the upper left jaw. A physician order dated 12/27/2025 directed that the resident receive Orajel 2X Toothache & Gum Mouth/Throat Gel 20-0.26%, one application by mouth every six hours as needed for toothache for seven days. There was also an existing PRN order for acetaminophen 325 mg, two tablets by mouth every four hours as needed for moderate pain (pain scale 4–7), and an order to monitor the resident’s pain level every shift using a pain scale. However, review of the December MAR showed no documented evidence that the resident received either acetaminophen or Orajel from 12/27/2025 to 12/29/2025, and the MAR entries for those dates indicated the resident denied pain. Family members reported that during the three days after the Orajel was ordered, they frequently informed nursing staff that the resident was having mouth pain and discomfort, and were repeatedly told the medication had not yet arrived from the pharmacy. One family member stated the Orajel was not delivered until 12/30/2025 and that nothing was done until that day, despite offering to pick up the medication. The resident later reported experiencing frequent pain at 8/10 severity in the upper left jaw during that period and difficulty eating, having to chew on the right side and eat slowly. The Director of Staff Development confirmed that the Orajel was ordered on 12/27/2025 but first administered on 12/30/2025, and that there was no documented evidence of Orajel or Tylenol administration or of a thorough pain assessment, including pain level, location, frequency, and description, from 12/27/2025 to 12/29/2025. The facility’s pain protocol required assessment at onset of new pain or worsening pain, identification of pain characteristics, and regular reassessment, which were not documented as having been carried out during this time. The deficiency is that the facility failed to provide the ordered Orajel for three days after the physician’s order for toothache pain and failed to document and perform thorough pain assessments despite reports of pain and an existing pain monitoring order. As a result, the resident reported consistent pain at 8/10 and difficulty eating during that period, which the report states could lead to weight loss and/or prevent participation in ADLs, affecting quality of life.
Failure to Provide Appropriate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with open wounds on the right and left temporal areas. Despite physician orders and care plan interventions requiring pain assessment and management before, during, and after wound treatments, there was no documented evidence that pain levels were monitored or that pain medications were offered or administered prior to wound care on multiple occasions. Treatment Administration Records (TARs) and Medication Administration Records (MARs) were frequently left blank for required pain assessments, and staff interviews confirmed that pain management protocols were not consistently followed. The resident was observed to exhibit both verbal and non-verbal signs of pain during activities of daily living and wound care, including screaming, guarding, and refusing care due to pain. The resident had a history of squamous cell carcinoma with open wounds on the face, which were described as tender, bleeding, and interfering with daily activities. The care plan identified both acute and chronic pain, with interventions to monitor pain characteristics and non-verbal indicators every shift and as needed. Orders were in place for both non-pharmacological and pharmacological pain management, including acetaminophen and hydrocodone-acetaminophen as needed for moderate to severe pain. However, documentation and staff interviews revealed that these interventions were not consistently implemented, and the resident was not always premedicated prior to painful treatments. Additionally, the facility failed to reevaluate the resident's pain management plan and notify the attending physician when the resident refused wound care due to pain, as required by facility policy. There was no evidence that probable causes of pain episodes were monitored or documented, nor that non-verbal pain indicators were consistently assessed. Staff, including nurses and CNAs, reported the resident's sensitivity and pain during care, but these observations were not systematically recorded or communicated to the physician. The lack of proper pain assessment and management resulted in the resident experiencing unnecessary pain and negatively impacted the resident's quality of life.
Breakdown in Physician Communication and Collaboration for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure continuous communication and collaboration among multiple physicians involved in the care of a resident with complex medical needs, including squamous cell carcinoma, open wounds, and dementia. The resident was under the care of an Attending Physician, a Wound Care Specialist, a Dermatologist, and an Oncologist at various times, but there was a breakdown in communication regarding who was responsible for the resident's overall medical management. Documentation and interviews revealed that the Wound Care Specialist discontinued involvement after learning the Dermatologist was managing the case, but this change was not clearly communicated to nursing staff or reflected in the resident's care orders. As a result, nursing staff assumed the Wound Care Specialist was still overseeing wound care, while the Attending Physician and DON believed the Oncologist was managing the resident's cancer and related wounds. The resident's medical records showed inconsistencies in wound documentation, pain assessments, and care planning. The Minimum Data Set (MDS) assessments did not consistently indicate the presence of open lesions or pain, despite clinical observations and physician notes describing significant wounds and cancerous lesions. Orders for wound care consults were present in the record, but there were gaps in actual wound care visits and unclear documentation regarding the discontinuation of wound care services. The lack of clear direction and coordination among the physicians led to confusion among nursing staff about who was responsible for wound care and pain management. Interviews with facility staff, including nurses and the DON, confirmed that there was a lack of awareness about changes in physician responsibility and ongoing confusion about the resident's care plan. The facility's Bioethics Committee was identified as the responsible party for the resident's care due to the absence of family, but this committee did not ensure effective communication and collaboration among the physicians. The facility's policy required the attending physician to participate in assessment and care planning, but this was not effectively implemented, resulting in a breakdown of communication and collaboration for the resident's overall medical management.
Dignity and Respect During Feeding and Resident Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained residents’ dignity and respect for three sampled residents during assistance with meals and personal care. Resident 32 was admitted and later readmitted with diagnoses including dysphagia and lack of coordination, and the record indicated severe cognitive impairment and substantial assistance needed with eating. During lunch in the activities room, OT 1 stood over Resident 32 while helping her grip an adaptive spoon and use it to scoop pureed food, rather than being seated at eye level during the feeding assistance. Resident 69’s record showed diagnoses including Parkinson’s disease, bipolar disorder, and schizophrenia, with impaired cognition and partial assistance needed with eating. During breakfast in the resident’s room, CNA 1 was observed standing next to the bed and spoon-feeding Resident 69 while the resident lay in bed with the meal tray in front of her. CNA 1 stated she knew she should have been sitting down while feeding Resident 69 but continued standing because there was no chair in the room. Resident 81’s record showed diagnoses including degenerative disease of the basal ganglia, diabetes mellitus, and dementia, with severely impaired cognition and partial/moderate assistance needed with eating. In the dining room, Resident 81 coughed for 2 to 3 seconds and phlegm came out of his mouth and dripped onto his chest and clothing while another CNA at the table did not respond. CNA 2 later approached Resident 81 and stated she should have checked him and noticed the phlegm and cleaned him, and the DSD stated staff in the same room were supposed to check the resident when they hear them cough and assist with cleaning before leaving.
Insufficient CNA and TXN Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and failed to have a licensed nurse in charge on each shift as reflected in the staffing records and interviews. The facility’s Staffing policy stated that staffing levels are based on resident needs, the plan of care, the resident assessment, and the Facility Assessment. The Facility Assessment revised 9/8/2025 indicated staffing needs of 1 TXN, 11 CNAs for the 7:00 AM to 3:00 PM shift, 9 CNAs for the 3:00 PM to 11:00 PM shift, and 6 CNAs for the 11:00 PM to 7:00 AM shift. Record review and staff interviews showed multiple shifts in September, October, and December 2025 when CNA coverage was below the facility’s stated staffing needs, including shifts where fewer CNAs worked than were scheduled and shifts where assignments were split among fewer staff. The DSD stated there was no TXN coverage on 9/6/2025 for all three shifts, and no TXN coverage on 10/28/2025 and 10/29/2025 for all three shifts. The DSD also stated that the current Facility Assessment dated 12/10/2025 did not indicate CNA or TXN direct nursing care per shift or per unit, and that this was missed. The DSD further stated there was no contingency plan in place for the short staffing on the dates identified. The affected residents had significant care needs. Resident 80 was admitted with paraplegia and osteomyelitis and was dependent for toileting and bathing, with substantial assistance needed for transfers and moderate assistance for repositioning; the resident also had an ostomy bag. Resident 69 had Parkinson’s disease with dyskinesia and heart failure, severe cognitive impairment, and dependence for toileting, showering, dressing, transfers, and repositioning, with urine and stool incontinence. Resident 34 had an open wound of the right cheek and temporomandibular area and squamous cell carcinoma of the face, severe cognitive impairment, dependence for toileting, showering, dressing, transfers, and repositioning, and urine and stool incontinence. Resident and family interviews described delayed responses to call lights and care needs. Resident 80 stated staff sometimes took almost 45 minutes to respond to a call light. Family of Resident 69 stated the resident developed a rash that broke down her skin because CNAs took too long to respond to call lights and change adult briefs. CNA interviews also described heavy workloads, extra assignments, and staying past the end of shift to complete tasks. For Resident 34, the TAR showed no documented wound care treatment on 10/28/2025 and 10/29/2025, and the DSD stated this occurred because there was no TXN coverage and the LNs did not document that the treatment was administered.
Food Storage, Labeling, and Ice Handling Deficiencies
Penalty
Summary
The facility failed to follow its food storage, freezer storage, and ice handling policies during a kitchen observation and interview with the Dietary Service Supervisor (DSS). In the dry storage room, a bulk container of food thickener had no open-date or use-by date, a one-gallon bottle of barbecue sauce had no expiration date, a one-gallon bottle of yellow liquid had no product name or expiration date, an unopened box and four loose cans of soup base powder had no expiration date, and two opened cans of soup base powder on a shelf over the food preparation counter had no use-by date or expiration date. The DSS identified the yellow liquid as corn oil and stated it should have been clearly labeled to prevent confusion. The DSS also stated that dry stored and frozen foods without labels or dates were unsafe for resident consumption and that kitchen staff were required to label and date foods when storing them. During the same observation, an ice scoop was left uncovered on top of a smaller container near the juice and coffee machine, and another ice scoop with an attached lid and broken handle was found underneath the larger scoop. In the freezer, a bag containing five tilapia filets was stored on top of four packages of frozen spinach. The DSS stated that ice should be handled as food and kept in a covered plastic or stainless steel container, and that storing fish over vegetables in the freezer was inappropriate and unsafe practice according to Food Code. The facility policy stated that dry bulk foods should be stored in labeled, covered, and dated containers, opened dry food items should be tightly closed, labeled, and dated, and raw meat must be stored below ready-to-eat foods such as vegetables to prevent cross-contamination.
Facility Assessment Missing CNA and TXN Staffing Details
Penalty
Summary
The facility failed to ensure its Facility Assessment, dated 12/10/2025, was updated to include the specific staffing needs for Certified Nurse Assistants (CNAs) and the Treatment Nurse (TXN) for each resident unit and each shift. The assessment listed RN/desk nurse coverage for the 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shifts, but it did not identify the number of CNAs needed for those shifts or the number of TXNs for the facility. During record review and interviews on 12/12/2025, the Administrator stated that the Facility Assessment provided on entrance, dated 9/8/2025, was out of date and that the 12/10/2025 assessment was the most current and comprehensive assessment in use. The DSD reviewed both assessments and stated that the earlier assessment identified one TXN and specific CNA staffing numbers for each shift, while the 12/10/2025 assessment did not indicate the number of CNAs per shift or the number of TXNs. The DON also reviewed the 12/10/2025 assessment and stated that it was the current assessment the facility was following, but it did not indicate CNA or TXN direct nursing care per shift or per unit, and that this was missed.
Failure to Assess, Consent, and Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide pneumococcal vaccination as required and appropriate for three sampled residents. Resident 68 was admitted with diagnoses including emphysema and diabetes mellitus, but the record showed no consent for PCV20 five days after admission and the CAIR2 record showed the vaccine had not been administered. Resident 42 was admitted with diagnoses including hypertension and schizophrenia, had a Vaccine Consent Form dated 12/5/2025 indicating consent for PCV20, but the CAIR2 record showed the vaccine had not been administered. Resident 66 was admitted with diagnoses including dementia and kidney failure, had a Vaccine Consent Form dated 12/5/2025 indicating consent for PCV20, but the CAIR2 record showed the vaccine had not been administered. The Infection Preventionist stated she was newly hired and did not receive proper endorsement of immunization surveillance and tracking from the previous IP, so she had to start a new tracking log. She stated residents admitted to the facility should be assessed for vaccine eligibility, consented, and administered the vaccine per facility policy, and that proper tracking was important because residents who did not receive vaccines were at risk of developing illnesses such as pneumonia and could be hospitalized. The facility's Pneumococcal Vaccine policy dated October 2019 stated residents would be assessed for eligibility prior to or upon admission and, when indicated, offered the vaccine series within 30 days of admission unless medically contraindicated or already vaccinated, with vaccination status assessed within five working days of admission if not done prior to admission.
COVID-19 Vaccine Not Given to Consenting Resident; Staff Immunization Records Not Maintained
Penalty
Summary
The facility failed to provide the COVID-19 vaccine to a resident who had consented to receive it. Resident 66 was admitted with diagnoses including dementia and kidney failure. The resident’s Vaccine Consent Form dated 12/5/2025 indicated consent for the COVID-19 vaccine, but the CAIR2 record showed the vaccine had not been administered for the 2025-2026 season. The facility also failed to maintain documentation of staff COVID-19 vaccination status. The newly hired Infection Preventionist stated she did not receive an endorsed list of staff members who had consented to or received the COVID-19 vaccine from the prior Infection Preventionist, so she had to start a new tracking log. She further stated she did not have a list of staff vaccination records for 2025-2026 because no updated list had been handed off from the previous Infection Preventionist. The facility policy stated that COVID-19 vaccine education, documentation, and reporting are overseen by the Infection Preventionist and that each resident is to be offered the vaccine unless medically contraindicated or already immunized.
Failure to Report, Investigate, and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention, reporting, and investigation policies following a physical altercation between two residents. On the morning of the incident, staff heard a commotion and discovered that one resident had sustained a visible mark on the forehead, allegedly caused by another resident. Staff members separated the residents and reported the incident to the Administrator, who instructed them not to report the event further. No documentation of the incident was made in either resident's clinical records, and no notifications were sent to responsible parties or physicians. Despite the facility's policies requiring immediate reporting and investigation of abuse allegations, the incident was not reported to the Department of Public Health, local law enforcement, the Ombudsman, or Adult Protective Services. The Administrator, who was also the designated Abuse Prevention Coordinator, did not initiate or document an investigation, nor did he interview involved staff or witnesses. Staff members did not complete required forms or document the injury and failed to develop or update care plans for either resident involved in the altercation. Both residents had significant cognitive impairments and behavioral symptoms documented in their medical histories, with one resident unable to make decisions and the other requiring moderate assistance with mobility. The lack of documentation, reporting, and care planning following the incident meant that the facility did not take steps to protect the residents from further harm or address the underlying behavioral issues. The facility's failure to follow its own policies placed the residents and others at risk for further abuse and neglect.
Failure to Timely Report Resident-to-Resident Altercation and Injury
Penalty
Summary
The facility failed to report an alleged resident-to-resident altercation within the required 24-hour timeframe to the California Department of Public Health (CDPH), as mandated by its own Abuse Reporting and Investigation Policy and Procedure. Two residents, both with severe cognitive impairments and significant behavioral and communication challenges, were involved in an incident where one resident sustained a visible red mark on the forehead. Despite the presence of physical evidence and staff awareness of the altercation, there was no documentation of the incident in either resident's clinical records, nor was there evidence of notification to responsible parties or physicians. Multiple staff members, including a staff coordinator and two licensed nurses, witnessed or were informed of the incident and observed the injury. The staff coordinator documented the injury with a photograph, and both nurses confirmed that the administrator was notified of the event. However, the administrator instructed staff that he would handle the situation and directed them not to report the incident further. As a result, the incident was not reported to law enforcement, the Ombudsman, or CDPH as required by facility policy and state regulations. Interviews with staff and review of facility records revealed that no Change in Condition Evaluations were completed for either resident following the altercation, and no follow-up investigation or interviews were conducted. The administrator later acknowledged the lack of documentation and reporting, and could not provide an explanation for the failure to follow required procedures. The facility's policy clearly states that all allegations of abuse, including injuries of unknown source, must be reported to appropriate agencies within specified timeframes, which was not done in this case.
Failure to Control Bedside Medications for a Resident Not Approved for Self-Administration
Penalty
Summary
The facility failed to ensure that one resident sampled for self-administration of medications was determined to safely self-administer medications. Resident 64 was admitted with diagnoses including depression, hypertension, atrial fibrillation, and obesity. The resident's H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated intact cognition, but the resident also required substantial and moderate assistance with multiple activities of daily living. Resident 64's self-administration assessment dated 11/13/2025 stated the resident was not capable of self-administering eye and ear drops, required assistance to store medications in a secure location, open and close medication containers, and self-administer oral medications, and was not approved for self-administration of medications. The assessment also stated the resident may not keep medications at bedside. The resident's current physician orders did not include permission to self-administer medications, and the care plans from admission through 12/12/2025 did not include a care plan for self-administration of medications. During a concurrent observation and interview, Resident 64's bedside table was observed with 3 bottles of medications and one unlabeled medication cup containing white powder. The resident identified the bottles as medications for pain, sleep, and allergies, and stated the white powder had been given by the nurse the night before, but did not know what it was. The LN confirmed the bedside medications were diphenhydramine HCl 50 mg, acetaminophen 500 mg, and oxymetazoline HCl 0.05% nasal spray, and stated residents are not allowed to keep medications at the bedside. The DON stated residents are evaluated before being permitted to self-administer medications and that self-administered medications must be monitored and stored securely.
Incomplete Advance Directive Acknowledgment Documentation
Penalty
Summary
The facility failed to ensure completion of the Advance Directive Acknowledgment (ADA) and documentation of the resident’s exercise of rights regarding advance directives for one sampled resident. Resident 77 was admitted with diagnoses including ESRD, atherosclerotic heart disease, and hypertension. The MDS dated 11/28/2025 indicated the resident had moderately impaired cognition and memory and required partial/moderate assistance with eating, oral hygiene, and walking 10 feet. The ADA form dated 11/22/2025 was incomplete. The sections requiring initials from the resident or Responsible Party were not completed for statements about receiving written material and information on the right to accept or refuse medical treatment, being informed of the right to formulate advance directives, not being required to have an advance directive to receive medical treatment at the facility, and understanding that executed advance directives would be followed to the extent permitted by law. The section asking whether the resident or Responsible Party declined to execute an advance directive or wished to execute one was also left blank. During interview and record review, the SSD stated she and her designee were responsible for explaining and assisting residents with advance directives and acknowledged the form in the record was incomplete.
Failure to Complete PASRR Level II Evaluation After SMI Screening
Penalty
Summary
The facility failed to complete a PASRR Level II follow-up assessment for one sampled resident after the initial PASRR Level I screening identified the resident as requiring a serious mental illness (SMI) level II mental health evaluation. The resident was admitted with diagnoses including Parkinson's disease, psychosis, and bipolar disorder. The facility's PASRR Completion Policy stated that the facility would coordinate Level II recommendations with assessment, care planning, and transition of care, and that if the Level II evaluation was not available within five days of admission, the admission coordinator or designee would follow up on the status of the evaluation. The resident's PASRR Level I screening results indicated the need for a Level II evaluation, and a subsequent notice stated that the Level II evaluation was not scheduled because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. During interview, the DON reviewed the resident's PASRR documents and stated that she did not see an SMI or PASRR II evaluation report in the clinical file. The DON stated the resident should have received a PASRR II shortly after admission and could not explain the reason listed in the notice of attempted evaluation.
Musculoskeletal Care Plan Not Updated After Medication Discontinued
Penalty
Summary
The facility failed to ensure that Resident 8’s musculoskeletal care plan was updated to reflect current nursing interventions. Resident 8 was admitted and later readmitted with diagnoses including metabolic encephalopathy, epilepsy, and low back pain. The H&P dated 11/13/2025 did not indicate whether the resident had the capacity to understand and make decisions, and the MDS dated 10/2/2025 indicated moderately impaired cognition. A pain assessment note dated 10/2/2025 documented that the resident had received pain medication in the prior 5 days, experienced pain frequently, had pain that frequently disrupted sleep, occasionally had pain that limited day-to-day activities, and that pain was alleviated by medications. The care plan for risk for musculoskeletal system, initiated on 2/20/2025 and revised on 3/1/2025, identified altered musculoskeletal status related to pain, decreased strength, and left-sided weakness. It included a goal for pain to be resolved within 1 hour of interventions and listed tizanidine HCl 2 mg every 6 hours as needed for spasms as an intervention. However, the physician’s orders for 12/2025 did not include tizanidine HCl. During interview and record review, LN 4 stated the musculoskeletal care plan had not been updated because the resident no longer had an order for tizanidine HCl, and that the care plan should have been updated when the medication was discontinued. The DON stated that care plans are used as a guide for resident care and to monitor which interventions work, and that care plans must be updated when care changes or medications are discontinued.
Overlapping PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure that one resident’s PRN analgesic physician orders were clear, specific, and non-conflicting. Resident 8 was admitted and readmitted with diagnoses including metabolic encephalopathy, epilepsy, and low back pain. The resident’s H&P did not indicate whether the resident had the capacity to understand and make decisions, and the MDS dated 10/2/2025 indicated moderately impaired cognition and no pain during the assessment reference period. However, a pain assessment note from the same date documented that the resident had received pain medication in the prior 5 days, experienced pain frequently, had sleep disrupted by pain, had occasional limitation in day-to-day activities, and that pain was alleviated by medications. The physician orders for 12/2025 included acetaminophen 325 mg, 2 tablets every 6 hours PRN for moderate to severe pain (4-10), and hydrocodone-acetaminophen 10-325 mg, 1 tablet every 6 hours PRN for severe pain (8-10), both ordered on 11/13/2025. During interview and record review, an LN stated the orders overlapped because both medications could be given when the resident reported pain of 8 out of 10 or greater, creating confusion about which medication to administer. The DON stated the pain medication orders should be clarified and changed because they were not specific, and that unclear orders could mismanage the resident’s pain. The facility policy on adverse consequences and medication errors stated that the interdisciplinary team monitors medication usage to prevent and detect medication-related problems and that staff strive to minimize adverse consequences by defining appropriate indications for medication use.
Failure to Reposition, Maintain G-Tube Dressing, and Reconcile Abdominal Binder Order
Penalty
Summary
Resident 54, who had diagnoses including Alzheimer’s disease, dysphagia, and failure to thrive, was assessed as having severely impaired cognition and being fully dependent on staff for all cares, including turning in bed. Her care plan for risk of skin breakdown directed staff to reposition her at least every two hours, but during multiple observations on 12/9/2025 she was seen lying in bed in the same right-side position with a pillow underneath her left side. CNA 4 stated that Resident 54 preferred to be positioned on her right side and that she did not position her on her left side at all during the shift. The care plan did not indicate a right-side positioning preference. Resident 54 also had a g-tube feeding care plan and physician order for g-tube stoma site care, including cleansing with normal saline, patting dry, applying vitamin A and D ointment and gauze around the tubing below the bumper, then a T-drain sponge every day shift. During observation, her g-tube site was found without a dressing, and the abdominal binder was rubbing directly onto the stoma site while feed tubing remained connected and infusing. LN 1 stated she was not aware the g-tube site did not have a dressing and had not assessed the site during her shift. LN 1 also stated the treatment nurse was responsible for changing g-tube dressings, although no treatment nurse was available during the day. TXN 2 stated that if no treatment nurse was available, the assigned LN was responsible for assessing and changing the g-tube dressing, and that a dressing was important to prevent infection. After Resident 54 was readmitted from the hospital following g-tube reinsertion, licensed nurses failed to reconcile an abdominal binder order. The order summary did not show an abdominal binder order, although LN 4 stated the resident previously had one because she had pulled out her g-tube and the primary physician ordered the binder to protect the tube from being pulled out again. LN 4 stated the order was not reconciled when the resident returned from the hospital. The DON stated LNs were expected to visually inspect the g-tube site every shift, that the site should be covered with a dressing to prevent infection with an MDRO, and that the admitting licensed nurse was responsible for ensuring physician orders were effective and carried out appropriately on readmission.
Failure to Monitor and Document Foley Catheter Output and Urine Appearance
Penalty
Summary
Appropriate care for a resident with an indwelling Foley catheter was not provided because staff failed to document intake and output, record urine output in the Elimination section, and identify or report cloudy urine as required by the physician's order, the care plan, and facility policy. The resident was admitted with diagnoses including sepsis, diabetes mellitus, candidal cystitis, and urethritis, and the care plan identified the Foley catheter as being in place due to a pressure ulcer with a goal of showing no signs or symptoms of urinary infection. The physician ordered staff to monitor every shift for signs and symptoms of infection and document findings such as dysuria, fever, gross hematuria, functional decline, and purulent drainage around the catheter site. Record review showed no documented intake and output from 12/1/2025 through 12/12/2025, and no documented urinary output in the Elimination records for that same period. During observation, the Foley catheter drainage was noted to contain cloudy yellow urine, and this was seen again later the same day. A CNA acknowledged the cloudy urine and stated she would document output if instructed, while a TXN stated the charge nurse should be responsible for assessing the resident and being aware of urine color. A LN stated she could not find documentation of urinary output and was unsure whether intake and output had been recorded, and the DON stated that without an intake and output record, staff could not determine whether the catheter was unobstructed or whether the bladder was retaining urine.
Meal Tray Included Disliked Green Vegetables
Penalty
Summary
The facility failed to ensure that Resident 74’s meal tray reflected the resident’s documented food dislikes. Resident 74 had diagnoses including dysphagia, DM, and malnutrition, and the record showed intact cognition, capacity to make decisions, and a therapeutic diet order for CCHO, regular texture, regular/thin consistency, with a documented dislike of green vegetables. The nutritional screening note also listed dislikes of green vegetables, fish, and shellfish, and the care plan included interventions to honor the resident’s food and drink preferences. During meal tray inspection, the DSD initially stated the trays in meal cart A had the correct diet orders, but when Resident 74’s tray was rechecked it was found to contain broccoli and cilantro. The DSD confirmed the tray needed to be sent back because the resident’s preference was not honored. The DS stated the tray should not have contained green vegetables, and staff interviews showed the tray was prepared and communicated incorrectly: KS 1 said she forgot to tell KC 1 about the resident’s food preference, and KC 1 stated he prepared trays based on what KS 1 told him. Resident 74 stated that green vegetables cause gagging and loss of appetite, and the DON stated that meal preferences such as likes and dislikes must be honored.
Inaccurate Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate medical records for Resident 54, who was admitted with diagnoses including Alzheimer's disease, dysphagia, and failure to thrive. The resident's MDS dated 12/5/2025 indicated severely impaired cognition and full dependence on staff for all cares such as personal hygiene, toileting hygiene, and dressing. The resident's OSR dated 12/11/2025 included orders for a low air loss mattress for skin/wound management and a heel protector, both to be monitored every shift. A review of the December 2025 TAR and medication admin audit report showed Treatment Nurse 1 documented the low air loss mattress and heel protector as provided on day shift on 12/8/2025 and 12/9/2025, but the audit report showed the administration times were 7:42 PM and 8:39 PM, respectively. During interviews, TXN 2 stated treatments should be documented after they are done and should reflect the accurate time administered. TXN 1 stated he worked evening shift and documented day shift treatments because he was covering for day shift and documenting treatments that were not done during day shift. The DON stated treatments should be documented on the same shift after administration and that TXN 1 should have documented the treatments for the evening shift to reflect the actual time they were administered.
G-tube Site Left Without Dressing and Not Assessed
Penalty
Summary
The facility failed to inspect and ensure that a dressing was in place on a resident’s g-tube site. The resident was admitted with diagnoses including Alzheimer’s disease, dysphagia, and failure to thrive, and the MDS indicated severely impaired cognition and full dependence on staff for all cares. The care plan for g-tube feeding included a goal for the insertion site to remain free of signs and symptoms of infection and directed staff to cleanse the stoma site with NS, pat dry, and apply a T-drain sponge. The OSR also included an order for daily g-tube stoma site care with NS, vitamin A and D ointment, gauze around the tubing below the bumper, and a T-drain sponge, along with EBP for the g-tube and wounds. During observation, the resident’s abdomen was covered with an abdominal binder, but the g-tube site was observed without a dressing and the binder was rubbing directly onto the stoma site while the feeding tubing remained connected and infusing. An LN stated the TXN was responsible for changing g-tube dressings but there was no treatment nurse available during the day, and she was not aware the dressing was off because she had not assessed the g-tube during her shift. The TXN stated that if no TXN was available, the assigned LN was responsible for assessing and changing the g-tube dressing, and the DON stated LNs were expected to visually inspect the g-tube site every shift as part of the daily assessment. The facility policy for gastrostomy/jejunostomy site care directed staff to assess the stoma site for redness, pain, soreness, or drainage and to protect the site from irritation, breakdown, and infection.
Excessive Occupancy in Resident Bedrooms
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents, as five rooms in the facility (Rooms 31, 32, 33, 34, and 35) each contained six beds. A review of the facility’s request for an additional room waiver dated 12/9/2025 and the Client Accommodation Analysis form dated 12/9/2025 showed that these rooms did not meet the federal requirement of no more than four beds per multiple-resident room. The waiver stated the rooms had been occupied by more than four residents in the past few years and were designed for adequate nursing care and resident comfort and privacy. During observations from 12/9/2025 through 12/12/2025, surveyors found the rooms occupied by five or six residents, with six beds present in each room. During a concurrent observation and interview, residents stated they liked their rooms and had enough space for their belongings and equipment. Staff also stated there was enough space to perform their work and use resident equipment such as wheelchairs, front wheel walkers, and Hoyer lifts. The facility’s P&P titled Bedrooms, dated May 2017, stated that bedrooms should meet federal and state requirements and accommodate no more than two residents at a time.
Bedroom Space Requirement Not Met in Five Multi-Resident Rooms
Penalty
Summary
The facility failed to ensure that five resident bedrooms, Rooms 31, 32, 33, 34, and 35, met the required 80 square feet per resident. A review of the facility’s room waiver dated 12/9/2025 showed these rooms were approximately 4378.56 sq. ft., and the Client Accommodation Analysis form submitted the same day identified that each of the five rooms did not meet the required space standard. The form listed the rooms as having six beds each, with five or six occupied beds, and stated the required total square footage for Rooms 31 through 35 was 480 sq. ft. During survey observations from 12/9/2025 through 12/12/2025, residents in Rooms 31 through 35 were seen with adequate room for wheelchairs, walkers, and canes, and staff were observed providing care without difficulty. The Administrator stated there had been no complaints from residents, families, or staff about the room size. Residents interviewed said they liked their rooms and had enough space for their belongings and mobility equipment. A nurse and a CNA stated there was enough space for residents and equipment, including wheelchairs, front wheel walkers, and a Hoyer lift, and the facility’s policy stated bedrooms should meet federal and state requirements and accommodate no more than two residents at a time.
Failure to Care Plan Dysphagia and Pureed Diet Needs
Penalty
Summary
The facility failed to initiate a person-centered care plan for one resident with dysphagia. The resident was admitted with diagnoses including epilepsy, malnutrition, encephalopathy, narcolepsy, muscle weakness, and dysphagia. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition, substantial assistance with multiple ADLs, supervision for eating and oral hygiene, and a mechanically altered diet. Speech therapy notes indicated the resident required a pureed diet and swallow precautions. Physician orders for the month included a NAS diet with pureed texture and regular/thin consistency, and an order allowing staff to crush medications unless contraindicated. However, the resident’s care plans did not include any plan for dysphagia or the need for a pureed diet. During interviews, the family member, the resident, and nursing staff stated the resident required pureed foods and crushed medications due to difficulty swallowing, and RN 1 confirmed the care plans did not address the resident’s dysphagia.
Failure to Implement and Document Weekly Wound Assessments for Pressure Injuries
Penalty
Summary
A resident with a history of metabolic encephalopathy, hemiplegia, hemiparesis, and diabetes mellitus was admitted with a Stage 3 pressure injury on the sacrum and suspected deep tissue pressure injuries (SDTPI) on both heels. The care plan for these wounds required weekly assessments and documentation by the wound doctor (WMD) and treatment nurse (TN), including measurements of each wound and reporting of any changes to the medical doctor. The resident was identified as bedfast with limited mobility and a moderate risk for pressure sores, requiring significant assistance with daily activities. Despite these documented needs and care plan interventions, there was no evidence in the facility's records of weekly wound assessments or documentation by either the WMD or TN for the resident's pressure injuries. The TN admitted to forgetting to inform the WMD, resulting in missed weekly assessments on two occasions. The Director of Nursing (DON) confirmed that there was no documentation of initial or weekly wound assessments as required by the care plan. Facility policies required regular risk assessments, ongoing evaluation of skin conditions, and documentation of interventions and their effectiveness. However, these protocols were not followed, as the resident did not receive the required weekly wound evaluations and documentation, nor were the wounds reported to the WMD for evaluation and management as outlined in the care plan.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to evaluate and assess a resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate. The resident, who had diagnoses including delusional disorder, diabetes, severe visual impairment, and anemia, was observed with five bottles of vitamin supplements at her bedside. The resident stated she had been taking the vitamins herself for years and was aware of their presence at her bedside. During interviews, staff members, including an LVN and the DON, confirmed there was no assessment or evaluation by the IDT or physician to determine if the resident was appropriate to self-administer supplements, nor was there a physician's order for self-administration. Record review showed that the resident required varying levels of assistance with activities of daily living and had episodes of incontinence. The facility's policy required an IDT assessment and documentation for residents to self-administer medications, as well as ongoing review by nursing staff. However, there was no documentation of any assessment or evaluation for this resident regarding self-administration of medications, and nursing staff were unaware of the supplements at the bedside. The facility's failure to follow its own policy and procedures resulted in the resident self-administering supplements without proper evaluation or oversight.
Failure to Complete Timely Comprehensive Assessment and Care Plan
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, and preferences within the required 14-day timeframe after admission, as mandated by both facility policy and federal regulations. The Minimum Data Set (MDS) for the resident, who was admitted with diagnoses including delusional disorders and severe bilateral visual impairment (category 3 blindness), was due by 8/21/2025 but was not completed until 8/25/2025, four days late. The incomplete and delayed assessment resulted in the absence of a care plan addressing the resident's significant visual impairment. During the period before the assessment was completed, the resident expressed frustration with her care, stating that staff did not know how to address her needs. Staff interviews revealed uncertainty in managing the resident's care, particularly regarding her refusal of incontinence care, and the DON acknowledged that the lack of a timely and thorough assessment contributed to the failure to address all of the resident's needs. Review of facility policies confirmed the requirement for timely MDS completion and comprehensive assessment to inform care planning.
Failure to Complete Weekly Skin Assessments for Resident with MASD
Penalty
Summary
A resident was admitted to the facility with Moisture-Associated Skin Damage (MASD) to the buttocks extending to the groin area, along with diagnoses of diabetes and anemia. The resident was identified as being at high risk for pressure injury, required partial to moderate assistance with toileting and personal hygiene, and was frequently incontinent of urine with occasional bowel incontinence. The care plan for the resident included monitoring and documenting the location, size, and treatment of the skin injury, as well as reporting abnormalities, failure to heal, and signs of infection to the physician. Facility policy required weekly skin assessments for residents at risk of pressure injuries. Despite these requirements, the resident did not receive a weekly skin assessment for the MASD from admission through the review period. Both the Director of Nursing (DON) and the Treatment Nurse (TN) confirmed that the weekly assessment was missed, and the electronic health record showed no documentation of such assessments. The facility's policy and procedure on prevention of pressure injuries specifically called for weekly risk assessments and ongoing evaluation of interventions, which was not followed in this case.
Failure to Provide Adequate Behavioral Health Interventions and Supervision
Penalty
Summary
A resident with diagnoses of major depressive disorder, anxiety, and schizophrenia was readmitted to the facility following a recent hospital stay. Upon readmission, the resident exhibited escalating behavioral symptoms, including agitation, repeated requests to go to the hospital, verbalization of pain and chest pain, and multiple incidents of moving herself to the floor. Despite these behaviors, staff did not implement a 1:1 sitter intervention, did not adequately monitor or supervise the resident, and failed to document or assess the resident's complaints and behaviors as required by facility policy. Throughout the evening and night, the resident's behavior continued to escalate, with repeated reports from CNAs to LVNs about the resident's agitation, yelling, and requests for hospital transfer. The LVNs did not follow up with the physician for new orders after initial communication, nor did they notify the physician of the resident's ongoing pain complaints, chest pain, or behavioral escalation. There was no evidence of additional interventions or individualized care planning to address the resident's mental health needs or to ensure safety, despite clear indications that the resident's behavior was not being managed and posed a risk to herself and others. The situation culminated in the resident breaking a window, obtaining a large shard of glass, and brandishing it toward her neck while demanding to be sent to the hospital. Emergency services were called, and the resident was transferred to an acute care hospital for a suicide attempt. Interviews and record reviews confirmed that staff did not follow facility policies on behavioral assessment, intervention, monitoring, or change in condition, and failed to provide the necessary treatment and services to attain the highest practicable mental and psychosocial well-being for the resident.
Failure to Prevent Resident-to-Resident Abuse and Ensure Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by not adequately separating and supervising two residents after a physical altercation. One resident, who had a history of schizoaffective disorder, cognitive impairment, and lacked decision-making capacity, struck another resident during a disagreement about a curtain. Staff responded by separating the residents and moving the aggressor to another room, but did not ensure continuous supervision. Despite being moved, the aggressor was able to return to the original room, where further verbal threats were made toward the other resident. Staff interviews revealed lapses in communication and supervision, as well as a lack of immediate follow-up documentation regarding the second incident. The aggressor was not properly monitored, allowing for a second encounter that resulted in additional verbal abuse and threats. The resident who was the victim of the altercation reported feeling unsafe due to the repeated access of the aggressor to the shared room. Staff acknowledged that the residents should have been completely separated and that the second incident was not properly documented or communicated to the physician. The facility's policy prohibits all forms of abuse, but the actions taken were insufficient to prevent further abuse and ensure resident safety.
Failure to Provide Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding bed hold policies to a resident and their responsible party upon the resident's transfer to a General Acute Care Hospital (GACH). The resident, who had diagnoses including Type 2 Diabetes, COPD, and schizoaffective disorder, was transferred for psychiatric evaluation due to medication refusal, hostile behavior, and increased delusions. Documentation showed a physician's order for a seven-day bed hold, but there was no evidence that the resident or their responsible party received written notification about the bed hold policy at the time of transfer or within 24 hours, as required by facility policy. Interviews with the resident, the responsible party, and facility staff confirmed that neither the resident nor the responsible party was informed or provided with written information about the bed hold policy during or after the transfer. The Director of Nursing acknowledged that the facility's policy requires written notification upon admission and at the time of transfer, or within 24 hours in the case of an emergency, but there was no documentation that this occurred. The facility's policy and procedure for bed holds and returns, revised in 2022, was not followed in this instance.
Failure to Develop Comprehensive Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan to address a resident's behaviors related to bipolar disorder and depression. Despite the resident having documented diagnoses of hemiplegia, seizures, mood disorder, and depression, and being prescribed medications such as Lexapro and Risperidone for these conditions, the care plans did not include specific interventions or monitoring related to these behavioral health needs. The resident's Minimum Data Set and psychiatric examination confirmed the presence of depression and mood disorder, yet these were not reflected in the active care plans. During interviews and record reviews, the DON acknowledged that the care plans lacked specific focus on the resident's depression, bipolar disorder, and the use of related medications. The facility's own policy and procedure required care plans to incorporate all problem areas identified through comprehensive assessment and to be revised as the resident's condition changed. The absence of these care plan elements meant that the facility could not effectively track or manage the resident's behavioral health conditions.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policy and procedure for abuse prevention and reporting following a verbal altercation between a resident and an LVN. The incident occurred on 2/11/2025, when the resident had a verbal argument with the LVN, which was not investigated by the facility. The facility did not suspend the LVN pending the investigation, as required by their policy, nor did they prevent further contact between the LVN and the resident. The resident involved in the incident was admitted with diagnoses including lack of coordination, muscle wasting, and depression. The resident had intact cognition and required moderate assistance for self-care and mobility. On the day of the incident, the resident called the police to report the altercation, but there was no documented evidence that the facility staff interviewed the resident or investigated the allegation of abuse. Additionally, the resident's roommate, who witnessed the argument, was not interviewed by the facility staff. Interviews with facility staff revealed that the incident was not reported to the DON or ADM, and the LVN continued to have contact with the resident after the altercation. The facility's policies require that all allegations of abuse be reported and investigated, and that any employee accused of abuse be placed on leave with no resident contact until the investigation is complete. The failure to follow these procedures placed the resident and other residents at risk for potential abuse.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to notify the State Survey Agency (SA) within the required two-hour timeframe following an allegation of verbal abuse made by a resident against a Licensed Vocational Nurse (LVN). The incident occurred when the resident called the police, who arrived at the facility to investigate the complaint. Despite the police visit and the resident's allegation, the facility staff, including the Registered Nurse (RN) and the LVN involved, did not report the incident to the facility's Abuse Coordinator or the SA as mandated by the facility's policy. The resident involved in the incident was admitted with diagnoses including lack of coordination, muscle wasting, and depression, and was assessed to have intact cognition and the capacity to make decisions. The resident's behavioral symptoms care plan noted a history of yelling, screaming, and cursing, but did not include taking the resident to the patio as an intervention. The incident involved a verbal altercation between the resident and the LVN, during which the resident accused the LVN of making threatening remarks. Despite the seriousness of the allegation, the staff failed to document interviews with the resident or report the incident to the appropriate authorities. Interviews with facility staff revealed a lack of communication and adherence to reporting protocols. The Director of Nursing (DON) and the Administrator (ADM) were not informed of the police visit or the resident's allegations. The facility's policy requires immediate reporting of abuse allegations, defined as within two hours, to the administrator and relevant authorities. However, the staff, including the RN, LVN, and Certified Nursing Assistant (CNA), did not fulfill their mandated reporting duties, resulting in a failure to address the resident's complaints and protect them from potential further abuse.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to implement its smoking policy and procedure, leading to an environment with significant accident hazards for eight residents who were smokers. These residents, identified as unsafe smokers, were not provided with the necessary supervision while smoking. Additionally, one resident's smoking assessment was not completed, and another resident was found storing cigarettes and lighters in their drawer, contrary to the facility's policy. The facility did not ensure that residents who were assessed as unable to light tobacco safely did not share cigarettes or use lighters unsupervised. There were instances where a receptionist provided lit cigarettes to residents, allowing them to smoke unsupervised during nonscheduled smoking times. Furthermore, several residents were not identified as noncompliant with the smoking policy despite smoking during nonscheduled times, and they were allowed to keep smoking materials in their possession. The facility lacked a designated staff member to supervise the smoking patio area during both scheduled and nonscheduled smoking times. This lack of supervision and failure to secure smoking materials posed a risk of accidental burns and fire hazards, potentially affecting the health and safety of residents, staff, and visitors. The California Department of Public Health identified an Immediate Jeopardy situation due to these deficiencies.
Removal Plan
- Residents 3, 56 and 67's two packs of cigarettes and lighter were taken from Residents 3, 56 and 67's bedside drawers by the DON and kept in the locked drawer in the receptionist desk.
- Resident 67 was provided education by the Social Service Director (SSD), and the DON regarding facility staff keeping the smoking materials and Resident 67 would not smoke without any supervision by the facility staff. Resident 67 agreed to comply with the facility staff after discussion with Resident 67. The facility's receptionist would be the keeper of the smoking items and smoking materials. Only staff would have access to the keys of the smoking items.
- Resident 3 was educated by the SSD on the facility's smoking P&P including surrendering cigarettes and smoking materials to facility staff.
- Residents 3 and 56's Care Plans (CPs) for smoking were updated by the licensed nurses indicating the interventions for Resident 3 and 56 to safety smoke, and the DON initiated additional CPs for Resident 3 and 56's non-compliance with smoking per P&P.
- Resident 136 was transferred to the General Acute Hospital (GACH) and would be re-educated by the SSD or designee regarding the facility's smoking P&P including not giving and not receiving cigarettes from other residents.
- The smoking attendants were provided education by the DON/Designee on the facility's smoking P&P regarding the importance of supervision and being on the designated smoking area during smoking schedule. No smoking attendant would be assigned as a smoking attendant without being educated on the importance of being at smoking area during smoking schedule.
- The facility implemented dedicated smoking attendants to monitor smokers 24 hours a day during scheduled and nonscheduled smoking times. The Activities Director (AD)/designee was responsible to schedule the smoking attendants weekly or as needed. The dedicated smoking attendant would log the behavior of the identified non-compliant residents and would intervene accordingly if residents found to not following the facility's P&P such as smoking on nonscheduled times or having in possession smoking paraphernalia when inside or outside the facility.
- Residents 2, 9, 14, and 18's CPs were updated to reflect smoking non-compliance.
- Resident 9 was re-educated regarding the facility's P&P for smoking including lighting cigarettes in the smoking area by the delegated smoking supervisor.
- Residents 3 and 56 were provided education by the SSD about safety on smoking and not to smoke without any supervision by staff.
- Resident 14 was re-educated by the SSD regarding the facility's smoking P&P including not giving and not receiving cigarettes from other residents.
- REC 1 was provided a 1:1 in-service by the DON regarding the facility's new smoking P&P including supervision of smokers.
- The SSD and Interdisciplinary Team (IDT) members initiated a discussion with all residents who smoke (not limited to Residents 3 and 56) regarding the facility's P&P on smoking and importance of adhering to the policy for safety. Residents 3 and 56 agreed on complying per IDT discussion.
- The quality Assessment and Assurance Committee (QAA) members with the medical director and administrator updated the smoking policy with the policy not limited to addressing supervision of smokers and indicating potential outcomes for the non-compliant smokers.
- The DSD/designee initiated an in-service to licensed, non-licensed staff and smoking attendants on the importance of ensuring supervision of smokers In-service to all staff would be continued until all smoking attendants that would be scheduled were provided education on supervision.
Deficiencies in POLST and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) were included in the clinical records of three residents. Resident 66, who was admitted with anxiety disorder and dementia, had a POLST that was not in the paper chart but was instead kept in a hospice chart under the nurse's station desk. This practice could hinder quick access to the POLST during emergencies. Similarly, Resident 69's POLST was not in the paper chart but in a binder under the desk, awaiting a physician's signature since August 2024. The absence of the POLST in the resident's chart could lead to confusion about the resident's wishes during medical emergencies. Resident 77's POLST was also missing from the paper chart, and the staff was unaware of the resident's wishes for emergency medical treatment. The facility also failed to ensure that the POLST and Advance Directive (AD) acknowledgment forms were present in the clinical records of Resident 14. This resident, who had been diagnosed with bipolar disorder, schizoaffective disorder, and nicotine dependence, was under conservatorship due to being gravely disabled. Despite being cognitively intact according to a recent assessment, there was no documented evidence that a POLST or AD acknowledgment form was completed or offered to Resident 14. The absence of these documents in the clinical records could lead to uncertainty about the resident's healthcare preferences in emergencies. The facility's policies and procedures require that POLST forms be signed by both the resident and the physician and filed in the resident's clinical records. The Advance Directives policy mandates that residents be provided with information about their rights to formulate an advance directive and that staff document any assistance offered or decisions made by the resident. The failure to adhere to these policies resulted in the potential for conflict with the residents' healthcare decisions during emergencies.
Failure to Address Resident's Refusal of Podiatric Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who refused treatment for long nails with a fungal infection and podiatric care. The resident, who was admitted with diagnoses including paraplegia and primary osteoarthritis, had a physician order for podiatry care every 60-90 days. Despite having the capacity to understand and make decisions, the resident refused podiatric evaluation and treatment on a specified date, which was not addressed in the care plan. The facility's staff did not assess the reason for the resident's refusal or explain the risks and benefits of refusing treatment. There was no care plan or interdisciplinary team meeting conducted to address the refusal, as confirmed by the Social Service Director and the Director of Nurses. The facility's policy requires that if a resident refuses care, an appropriate member of the interdisciplinary team should meet with the resident to discuss concerns and document the refusal in the medical record, which was not done in this case.
Insufficient Staffing for Resident Supervision
Penalty
Summary
The facility failed to ensure sufficient staffing to monitor and supervise residents during both scheduled and nonscheduled smoking times, as well as to monitor residents at risk of elopement. On a specific day, observations revealed that several residents were smoking in the designated area without staff supervision. Interviews with staff members, including activity staff and a licensed vocational nurse, confirmed that due to short staffing, they were unable to adequately supervise the smoking area and monitor residents at risk of elopement simultaneously. This lack of supervision was attributed to the facility's ongoing staffing issues. The Director of Nurses acknowledged that each designated area for smoking and elopement should have been assigned to one activity staff member per area, but due to insufficient staffing, this was not possible. The facility's policy and procedure on staffing indicated that sufficient numbers of nursing staff with appropriate skills and competency should be provided to meet resident needs, but this was not adhered to, leading to the deficiency in supervision during smoking times and monitoring of residents at risk of elopement.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications for four of five sampled residents, leading to potential issues with medication integrity and security. Insulin Glargine pens for Residents 3, 69, and 76 were not stored correctly, as they were found in a refrigerator with water dripping from the freezer compartment, potentially compromising the medication. Additionally, Lorazepam oral concentrate for Resident 66 was stored in a refrigerator that was not maintained at the required temperature range, which could affect the medication's efficacy. The facility also failed to maintain a sanitary environment for medication storage. During an observation, a mini refrigerator in the medication room was found with water pooling from a melting freezer compartment, affecting the storage of Insulin Glargine pens and Lorazepam oral concentrate. The Licensed Vocational Nurse (LVN) was unaware of the issue until informed by the surveyor, and the Maintenance Supervisor noted that the refrigerator's temperature setting was incorrect, leading to the melting ice. The Director of Nursing (DON) confirmed that the refrigerator's temperature was out of range, which could render the Lorazepam ineffective. Furthermore, the facility did not ensure that controlled medications were stored in separately locked, permanently affixed compartments. Resident 66's Lorazepam oral concentrate was found in an unlocked refrigerator, contrary to the facility's policy. This oversight could lead to undetected diversion or loss of controlled medication. The facility's policy, dated April 2019, requires all drugs and biologicals to be stored securely and under proper conditions, which was not adhered to in these instances.
Deficient Sanitation and Temperature Logging in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed under sanitary conditions, as evidenced by missing documentation in several critical logs. During an initial kitchen tour, it was observed that the sanitization sink solution was not consistently logged, with missing entries for several days in October. The Dietary Supervisor Assistant (DSA) confirmed that the sanitization sink solution log was incomplete, which meant it was unknown if the sanitization solution was within the appropriate range of 200-400 ppm. This lack of documentation indicates that the facility did not adhere to its policy and procedure for manual dishwashing, which requires testing and recording the concentration of the sanitizing solution. Additionally, the facility failed to maintain accurate records of cold storage temperatures, with missing entries noted for the PM shift on a specific date in October. The DSA acknowledged that the temperature logs were incomplete, which is crucial for ensuring that food is stored at safe temperatures to prevent spoilage. Furthermore, the Sanitizer Solution Log for the quaternary sanitizing solution used in the kitchen was also incomplete, with no records indicating that the solution was tested for concentration over an extended period. The Dietary Supervisor (DS) confirmed the missing entries and emphasized the importance of maintaining these logs to ensure the kitchen's sanitation practices were in line with the facility's policies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 5,958 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Burbank Healthcare & Rehab | 0 mi | ★★★★★ | 75 | 1 |
| Alameda Care Center | 0.1 mi | ★★★★★ | 15 | 0 |
| Dreier's Nursing Care Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Broadway Manor Care Center | 2.5 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 2.5 mi | ★★★★★ | 35 | 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.