Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Guardian Care And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain documentation showing that an SSA received required orientation, competency validation, and job-specific training. Review of the SSA’s file showed no training records after hire, and the DSD and ADMN confirmed that only verbal training had been provided and that no formal training plan was in place. The SSA stated he had very limited knowledge of his job duties and responsibilities.
Failure to provide needed nail care occurred when a resident with dementia and severe cognitive impairment was observed with long, untrimmed fingernails and debris under the nails. The resident’s care plan identified an ADL self-care deficit and fragile skin, with instructions to keep fingernails short. Staff interviews indicated nail care was expected during showers and on Sundays, and the LN was responsible for checking grooming and hygiene, including fingernail care.
The facility failed to provide a safe, clean, and homelike environment when surveyors observed significant environmental deficiencies in a shower room, a main hallway, and a resident room. In a shower room, there was black discoloration on floor tiles and grout, white buildup on the shower head and handle, a mildewed and discolored call light string stuck to the wall, and a rusted soap holder; staff confirmed the room was used for resident bathing and that the conditions were dirty, with the DOM identifying mildew and hard water stains. In a hallway shared by two nursing stations and the kitchen, the baseboard was water damaged, pulling away from the wall, and packed with dust, debris, and cobwebs, a condition present for months and linked to a prior leak behind the wall. In a resident room, the protective wall covering and vinyl baseboard behind a bed were peeling away and collecting dust and debris. The IP stated that mildew in the shower and dust and debris in the hallway and room could make residents sick, and facility policies required a clean, sanitary, and well-maintained environment.
A resident with intellectual disabilities was started on a psychotropic medication for anxiety following evaluation by a mental health NP, but staff did not obtain informed consent from the resident’s responsible party (RP) before adding the drug to the MAR and administering multiple doses. Review of records showed no documented consent, and interviews with an LPN and the Director of Staff Development confirmed that facility policy requires resident/RP involvement and written informed consent for psychotropic medications. The LPN acknowledged that consent had not been obtained and reported that, when later contacted, the RP stated they did not want the resident to receive the medication.
A resident with enterocolitis due to C. diff was on contact precautions with orders requiring appropriate PPE and proper hand hygiene before and after contact with the resident or their environment. A CNA was observed exiting this resident’s room, removing PPE, and using only an alcohol-based hand gel before immediately entering another resident’s room. In interviews, the CNA confirmed using alcohol gel and believed this was appropriate, while the IP and DON stated that soap-and-water handwashing is required for C. diff, consistent with facility policy and CDC guidance that emphasize soap and water as the best method to prevent person-to-person spread of C. diff.
A resident with paraplegia and complete bowel and bladder incontinence did not receive timely incontinence care despite requesting to be cleaned and dressed late in the morning. Observation showed the resident’s brief was heavily saturated with urine. One CNA reported the resident had asked to delay care earlier in the morning and stated another CNA had provided care later, while the second CNA denied providing any care during the shift. Nursing leadership indicated residents are typically changed every 2 hours and that refusals should be addressed and communicated, and the resident’s care plan and the facility’s incontinence policy required regular checks, cleaning with each episode, and timely, individualized incontinence care.
A resident with paraplegia, chronic pain syndrome, major depressive disorder, and a history of polysubstance abuse, who was on chronic methadone, repeatedly tested positive for cocaine and cannabis over several months. Despite MD notes directing behavior monitoring and documenting ongoing drug use and behavior issues, the facility did not maintain a behavior monitoring log, did not revise the care plan after subsequent positive drug screens, and did not implement consistent supervision when the resident left the premises or received visitors. Staff acknowledged that residents with drug-seeking behavior should be monitored and that visitors and unsupervised outings could facilitate illicit drug use, yet no structured monitoring, psychological evaluation for substance use, or documented visitor controls were put in place, allowing continued access to illicit substances within and outside the facility.
A resident with multiple medical conditions, including dementia and a recent femur fracture, was found with a call light out of reach, hanging from the bed rail to the floor. The resident could not access the call light to request assistance, and both CNA and nursing staff confirmed the device was not properly placed, in violation of the care plan and facility policy.
A resident with multiple serious diagnoses, including dementia and Parkinson's disease, was found on the floor and later diagnosed with a subacute femoral neck fracture. The DON did not submit the required summary of investigation to the Department within the mandated timeframe, despite being aware of this requirement.
Surveyors found that kitchen staff failed to properly clean food-contact equipment, with four sheet pans stored as clean but visibly soiled with dark brown buildup, and also failed to label a pie in the freezer with a required use-by or expiration date. Dietary and nursing staff confirmed these lapses, which did not follow facility policy or FDA Food Code requirements.
Two residents with physician orders for oxygen therapy were observed receiving oxygen via concentrator without 'Oxygen in Use' signage posted on their doorways, as required by facility policy. Nursing staff and leadership confirmed the absence of signage and acknowledged it was their responsibility to ensure proper posting to maintain safety.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, failing to meet required safety standards.
The facility failed to maintain a comprehensive QAPI program when it did not follow its QAPI policy and had no documentation or evidence of ongoing QAPI activities. The ADM confirmed the program lacked appropriate monitoring, documentation, detailed follow-up, and clear implementation guidance, and the QAPI binder contained no evidence of detailed monitoring or corrective action review. Although the committee met quarterly, the facility was not following its QAPI policy.
Two residents did not receive care in accordance with their assessed needs: one resident with face and neck swelling did not have a care plan addressing the issue, and another resident with multiple sclerosis requiring two-person assistance for ADLs was turned by only one CNA, contrary to the care plan. These failures were confirmed by both staff and residents, and were not in line with facility policy.
A resident with diabetes and a foot ulcer reported severe foot and toe pain, and blackened areas were seen on both great toes, but the LNs did not promptly assess, document, or communicate the change in condition. Another resident had nine scabs on the forearm that were observed but not assessed or documented for over 48 hours. The report also described CNAs and nurses who could not speak English, with residents and leadership stating this created communication problems and unmet care needs.
A resident receiving palliative care reported being verbally and physically abused by a CNA. The facility's investigation was incomplete, as only the resident and the alleged CNA were interviewed, and the CNA's prior history of similar infractions was not reviewed, contrary to facility policy requiring a comprehensive investigation.
A resident with hypotension was ordered Midodrine BID with instructions to hold if SBP was over 120, but MAR review showed the medication was given outside those parameters on multiple occasions. An LPN stated she would give the medication for low BP, and the DON confirmed several administrations occurred when the resident’s BP readings were above the hold limit; the DON stated the medication should not have been given and could have caused hypertension.
A resident with a right upper extremity contracture and self-care deficit did not receive documented ROM exercises on multiple shifts, with staff recording "Not Applicable" instead of provided care or refusal. The ADON observed the resident’s contracted right hand had a strong odor, tightly curled fingers, and brown, crusty residue during hand hygiene; the ADON confirmed a hand roll should have been in place and that the resident was at risk for skin breakdown and infection if the care was not provided.
A resident with type 2 DM and paraplegia had a physician order for weekly weights, but staff did not complete or document the ordered monitoring. The record showed a 10-pound weight loss over one month, and the RNA, LPN, ADON, and DON all confirmed the weekly weights were not carried out.
A resident with a history of inappropriate diet and eating habits was observed keeping multiple meal trays, drinks, and food containers at the bedside and refused staff attempts to remove them. Staff documented the food-hoarding behavior and educated the resident about the risks, but no referral was made to a psychiatrist or psychologist even though the care plan included psychiatry evaluation as indicated.
Medication handling records were not consistently completed for pharmacy deliveries and medication destruction. In the Station 1 med room, packing slips for delivered controlled and non-controlled Rx meds were left unsigned by the receiving nurse, despite the form indicating the nurse was acknowledging receipt. In the Station 2 med room, records for destroyed non-controlled Rx meds lacked the required co-signature witness documentation, and the DON and consultant pharmacist confirmed that licensed staff witness signatures were expected per policy.
Failure to Reassess Long-Term PPI Use: Two residents remained on scheduled PPI therapy for GERD without documented recent stomach bleeding or ongoing GI complaints. The RN stated the meds had originally been started for prior bleeding or on admission, but there were no MD or nursing notes addressing continued need, and the CP confirmed no recommendation was made to reassess the long-term PPI use.
An unlabeled box of discontinued Kristalose was found stored with active meds in a med room, and an expired COSOPT eye drop bottle was found in an active med cart. An LPN acknowledged both findings, and the DON stated discontinued and expired meds should not remain in active storage areas.
A resident with hemiplegia/hemiparesis after an intracerebral hemorrhage and polyneuropathy missed a long-awaited neurology appointment because CNA prep was delayed. The resident and family were upset, stating the resident was not ready when the transport driver arrived, the mechanical lift was not nearby, and staff communication was poor. The CNA said the resident initially refused to get ready but did not document it or notify the CN, while the SSD confirmed the appointment had been scheduled for months and the delay could affect care.
Shared glucometers were not properly cleaned and disinfected between resident blood sugar checks. An LPN used two glucometers for multiple residents, performed finger sticks, then briefly wiped each device with only one germicidal wipe for less than 5 seconds before letting it dry. The LPN acknowledged she did not complete the second sanitizing step or keep the devices wet for the required contact time. The IP and DON stated staff were expected to follow the two-step cleaning and disinfection process for reusable glucometers.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A dumpster lid was found propped open with a stick, as confirmed by the DSS during an observation. Staff interviews, including with the DON, acknowledged that dumpster lids should always be closed to prevent pest and infection risks. Facility policies and the FDA Food Code require closed, tight-fitting lids on outside refuse containers, but this was not followed.
Staff did not follow a resident's care plan requiring a mechanical lift for transfers and instead manually lifted the resident from a shower chair to bed, resulting in a right leg fracture and skin breakdown. The resident had significant mobility limitations and a history of bone weakness, and staff acknowledged the transfer method used was unsafe and not in accordance with facility policy.
A resident with a history of diabetes and mental health issues refused medications, blood sugar tests, and physical therapy multiple times. The facility failed to notify the resident's physician and Responsible Party (RP) of these refusals, contrary to policy. The Director of Nursing acknowledged the lapses in communication and documentation, which left the RP uninformed and unable to participate in medical decisions.
A resident was discharged from the facility following a hospital admission for surgery, but the required documentation specifying the basis for discharge and the unmet needs was not included in the medical record. The DON and Social Services Director completed and served a discharge notice, but both the Administrator and DON confirmed that the medical record lacked details as required by facility policy.
A resident's responsible party and the LTC ombudsman were given a discharge notice that listed incorrect appeal information, directing them to the CDPH instead of the appropriate Office of Administrative Hearings and Appeals. The Social Services Director and DON confirmed they were unaware of the correct process, resulting in the responsible party not being properly informed of how to appeal the facility-initiated discharge.
A resident was not permitted to return to the facility after a hospital stay, even though their bed and personal belongings remained in place and the facility had available capacity. The facility cited the expiration of the bed-hold period and served discharge paperwork, but did not follow policy allowing return to the previous room or first available bed.
A facility failed to ensure LNs had the necessary skills to perform the milking technique for a resident's leg edema, despite multiple physician orders. The resident reported being denied treatment, and staff interviews revealed a lack of knowledge and experience in performing the procedure. Medical professionals confirmed the importance of following the orders, but the treatment was not consistently administered.
A resident with multiple medical conditions, including heart failure and atrial fibrillation, refused critical medications over two months. The facility failed to notify the medical doctor of these refusals, leading to the resident's hospitalization due to worsening symptoms. Interviews with staff revealed a lack of adherence to protocols for notifying medical professionals about ongoing medication refusals.
The facility failed to provide training and establish a policy for the use of continuous glucose monitoring (CGM) devices for nine residents. A licensed nurse admitted to not knowing how to change the CGM sensor, and the Director of Staff Development confirmed that no training was provided. The Consultant Pharmacist noted issues with sensor replacements and the absence of a policy, while the Director of Nursing acknowledged the lack of training and procedures for staff and residents.
The facility failed to ensure proper medication labeling and storage, including undated medications and improper storage of hazardous drugs. A resident's chemotherapy medication was not labeled or stored as hazardous, and inhalers and CGM Readers lacked proper identification, risking misuse and incorrect dosing.
A resident with lung cancer was not assessed for the ability to safely self-administer her prescribed inhaler, which was found at her bedside without proper labeling or instructions. The facility's process, requiring a physician's order, an assessment, and an IDT meeting, was not followed, leading to potential unsafe medication practices.
A resident's POLST form was found incomplete due to the absence of a physician's signature, despite being marked for a trial period of artificial nutrition. Facility staff, including the MDSC, LN, and DON, confirmed the missing signature, which is crucial for validating the document and ensuring the resident's medical wishes are honored. The facility's policy underscores the importance of a complete POLST form to record treatment wishes.
A facility failed to provide a complete SNFABN to a resident, omitting the estimated cost of services not covered by Medicare. The resident was informed that Medicare coverage would end, but the SNFABN lacked cost details, leaving the resident uninformed about potential financial liabilities. Staff interviews revealed that the BOM expected the form to include private pay rates, while the MDSC did not fill in the cost, directing inquiries to the business office instead.
A licensed nurse violated privacy protocols by using a personal smartphone to photograph a resident's medication labels, which included the resident's name and drug information, during a medication pass. This action breached the facility's confidentiality policy, as confirmed by the DON.
A resident reported a loss of $25, but the facility failed to investigate the incident. Staff did not follow proper procedures for reporting theft, as the Social Services Director was not informed. Interviews revealed inconsistencies in the reporting process, and a binder at the nurse's station lacked specific instructions for handling such incidents. The facility's policy requires prompt investigation of theft, which was not followed in this case.
A resident reported $200 missing from her purse, suspecting a CNA of theft. The LN informed the charge nurse and left a note for the social worker but did not follow up, resulting in a delay in reporting the incident to the Department. The SSD was unaware of the theft and stated she would have taken action if informed. The Administrator confirmed the incident should have been reported within 24 hours as per policy.
A resident with respiratory failure and quadriplegia refused to wear a smoking apron, but the facility failed to update the care plan or educate the resident on the risks. Despite the resident's ability to understand, staff did not revise the care plan or document the refusal, as confirmed by the Director of Nursing.
A facility failed to provide a resident with activities that met their needs and interests. The resident, with a history of stroke and failure to thrive, did not attend group activities and was infrequently offered in-room activities. Staff interviews revealed inaccuracies in activity documentation, with the resident participating in activities on only three days in June. The DON expected consistent activity offerings to prevent depression, but the facility's policy was not effectively implemented.
A resident with a Foley catheter for urinary retention had their catheter drainage bag improperly maintained, as it was found resting on the floor. This was confirmed by a CNA, who noted the risk of infection, and further supported by the IP, LN, and DON, who all emphasized the importance of keeping the bag off the floor to prevent infection and other complications.
A resident receiving enteral nutrition through a gastrostomy tube was not provided appropriate care when their feeding was not discontinued five hours past its expiration. The feeding bag was observed to be past its expiration time, and staff confirmed it should have been changed earlier. The DON stated that expired feeding could risk health infections and improper digestion.
A resident receiving oxygen therapy was at risk for infection due to the facility's failure to label and change the nasal cannula and humidifier bottle as required. The resident, with lung cancer and COPD, required continuous oxygen, but the equipment lacked date labels, contrary to professional standards. Staff confirmed the oversight and acknowledged the infection risk.
A facility failed to ensure safe use and accountability of controlled narcotic medications for a resident. Norco was removed from the Controlled Drug Record (CDR) without corresponding documentation in the Medication Administration Record (MAR) on multiple occasions. The Director of Nursing (DON) confirmed the discrepancies, and the nurse responsible was no longer employed at the facility. The facility's Consultant Pharmacist had conducted a random audit of narcotic use.
The facility failed to ensure safe use of psychotropic medications for two residents. One resident's bipolar disorder diagnosis was not properly documented, leading to inappropriate use of risperidone. Another resident's frequent use of PRN alprazolam was not reassessed, contrary to policy. These lapses could lead to adverse consequences and medication dependence.
The facility failed to ensure safe food storage for 92 residents, as several food items in the kitchen were not labeled with use-by dates, and thawing bacon trays lacked date and time labels. This oversight was confirmed by the Dietary Supervisor and Registered Dietitian, who emphasized the importance of labeling to prevent serving expired food and potential exposure to foodborne illnesses.
Missing Training Documentation for SSA
Penalty
Summary
The facility failed to develop, maintain, and implement an effective training program for an existing Social Services Designee/Assistant (SSA) because it was unable to provide documentation verifying that the SSA had completed the required competency validation or job-specific training. During concurrent interview and record review, the SSA’s employee file was reviewed and showed that the SSA was hired on 6/16/26, but there was no documentation of competency validation or job-specific training in the file. The Director of Staff Development stated that all staff were expected to receive appropriate orientation and training before performing job duties and that documentation of training and competency validation should be maintained in the personnel file. The DSD confirmed that the facility could not provide documentation of the SSA’s competency or job-specific training and stated she would attempt to locate the records by contacting the Administrator, who was the SSA’s direct supervisor and responsible for training. During interview and record review with the Administrator, the SSA’s file still contained no documentation of facility competency or job-specific training. The Administrator stated the facility was without a Social Services Director, that the SSA was the only staff member assigned to Social Services, and that she was providing oversight during the vacancy. The SSA stated he had very limited knowledge of his job duties and responsibilities and that he had not received proper training. The Administrator later stated the SSA had received only verbal training, that no documentation was maintained in the personnel file, and that the facility did not have a formal training plan for the SSA.
Failure to Provide Needed Nail Care
Penalty
Summary
Provide care and assistance with ADLs for a resident who was unable to perform them independently was deficient when Resident 1 was observed with untrimmed fingernails on both hands and a brown substance underneath the nails. Resident 1 was admitted with dementia with agitation and had a BIMS score of 7 out of 15, indicating severe cognitive impairment. The care plan identified an ADL self-care deficit related to dementia and stated the resident would be assisted by staff with ADLs that could not be met by the resident. The skin care plan also identified fragile skin and directed that fingernails be kept short. During interviews, a CNA stated residents' fingernails were trimmed and cleaned during shower days and on Sundays, and an LN stated she was responsible for checking residents for adequate grooming and hygiene, including trimmed and cleaned fingernails. During the observation, the resident stated, "I have long and dirty nails," and the IP confirmed the appearance of the fingernails and stated someone should take care of them. The DSD stated nail care should be provided to prevent infections and that untrimmed, unclean fingernails could affect dignity. The DON stated nails should have been trimmed and cleaned as scheduled, especially for residents with fragile skin or on anticoagulant medications, and the ADM stated the facility would implement a process to ensure residents' nail care would be provided regularly.
Environmental Cleanliness and Maintenance Deficiencies in Shower Room, Hallway, and Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for a census of 99 residents, as evidenced by multiple areas of uncleanliness and disrepair. In shower room [ROOM NUMBER], surveyors observed black discoloration on the floor tiles, grout, and in the cracks where the floor met the wall, as well as white discoloration on the shower head and handle, brown and pink discoloration on the emergency call light string that was stuck to the wall, and rust on the metal soap container. A CNA confirmed the shower room was used to bathe residents and agreed the room was dirty. The Director of Maintenance (DOM) scraped the black substance and stated it appeared to be mildew, identified the white stains as likely hard water deposits, confirmed the rust on the soap holder, and stated the call light string appeared mildewed and should be replaced. The Infection Preventionist (IP) stated the mildew in the shower room could get residents sick. In the hallway shared by station 1, station 2, and the kitchen, the baseboard was pulling away from the wall, appeared water damaged, and was compacted with dust, debris, and cobwebs. The Maintenance Assistant attributed the condition to a prior leak from the kitchen garbage disposal and stated the area was difficult to clean, while the DOM reported the wall and baseboard had been in that condition for approximately six months and acknowledged that breathing dust and debris was not good for residents. In room [ROOM NUMBER], behind bed B, the plastic protective wall covering and vinyl baseboard were peeling and pulling away from the wall, with gaps containing dust and debris; the DOM confirmed this accumulation and stated it was not good for the resident. The DOM reported that maintenance relied on repair books at each station, checked three times daily, and weekly room rounds to identify needed repairs, but suggested the area behind bed B may have been missed because the resident was in bed at the time. Facility policies on a homelike environment and maintenance services required a clean, sanitary, orderly environment and building maintenance in good repair and free from hazards.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident’s responsible party (RP) prior to initiating and administering a psychotropic medication. The resident, who had diagnoses including unspecified intellectual disabilities, was seen by a mental health nurse practitioner on 2/27/26, and an order was written to start buspirone twice daily for anxiety disorder. Nursing documentation indicated that the orders were noted and carried out, and the medication was added to and administered per the Medication Administration Record (MAR). Review of the electronic health record showed no documentation that informed consent for the psychotropic medication had been obtained from the resident’s RP before the medication was started. The MAR showed that buspirone was administered on multiple occasions, including doses on 2/28/26 and several dates in early March, totaling seven doses. During interviews, a licensed nurse confirmed that informed consent was required before administering buspirone due to the nature of the medication and its potential side effects, and acknowledged that consent had not been obtained from the RP prior to administration. The nurse further stated that when the facility did contact the RP, the RP stated they did not want the resident to receive the medication. The Director of Staff Development stated that facility practice required informed consent from the resident or RP before adding a psychotropic medication to the MAR, and facility policies on Resident Rights and Psychotropic Medication Use indicated that residents and their representatives must be informed of and participate in treatment decisions and that written informed consent must be obtained for psychotherapeutic drugs.
Failure to Use Soap-and-Water Hand Hygiene for C. diff Contact Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to care of a resident with Clostridioides difficile (C. diff). The resident was admitted in February 2026 with diagnoses including enterocolitis due to C. diff and a urinary tract infection, and had physician orders for contact precautions, including use of gown and gloves when entering the room and ensuring proper hand hygiene before and after contact with the resident or their environment. The facility’s own C. diff policy directed frequent handwashing with soap and water by staff and residents, and the Infection Preventionist (IP) and Director of Nursing (DON) both stated that proper hand hygiene for C. diff required soap and water because alcohol-based hand gel would not kill C. diff bacteria. During observation on Hall 400, a CNA was seen entering the C. diff resident’s room wearing appropriate PPE. Upon exiting the room, the CNA removed PPE and performed hand hygiene using an alcohol-based sanitizing gel located outside the room, then immediately proceeded down the hall and entered another resident’s room. In a subsequent interview, the CNA confirmed using alcohol-based gel and stated she believed she had done appropriate hand hygiene before moving to the next resident, despite the resident’s known C. diff infection. The IP and DON both indicated their expectation that staff wash hands with soap and water after caring for a C. diff resident, and the DON stated the risk was the spread of infection to other residents. CDC guidance cited in the record indicated that washing hands with soap and water is the best way to prevent the spread of C. diff from person to person.
Failure to Provide Timely Incontinence Care per Care Plan and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care in accordance with professional standards and the resident’s care plan for one resident with paraplegia and complete bowel and bladder incontinence. The resident reported around midday that she had not received care since 6:30 AM and had requested to be cleaned and dressed at 11 AM. During observation, her incontinence brief showed a blue line indicating wetness and appeared heavily saturated with urine. The resident stated she would be unable to go to the dining room for lunch because she had not been cleaned and expressed concern about her risk for urinary tract infection if she was not changed when needed. CNA 1 stated she attempted to provide care at 7 AM, but the resident asked her to return at 11 AM. CNA 1 did not provide care at 11 AM because she went to lunch and stated that CNA 2 had changed the resident instead. CNA 2 later stated he did not provide care to the resident at 11 AM or at any other time during the shift. LN 2 stated her expectation was that the resident would receive timely incontinence care or that CNAs would inform her if they were unable to provide care. The DON stated residents were usually changed every two hours, that refusals would be care planned, and that CNAs should continue to attempt care and notify the nurse if refusals continued. The resident’s care plan documented that she was always bowel and bladder incontinent, with goals to remain free from skin breakdown due to incontinence and interventions including cleaning the perineal area with each incontinence episode, checking every 2–3 hours and as required, and monitoring for signs and symptoms of UTI. The facility’s incontinence care policy required timely, appropriate, individualized care at routine intervals per the care plan and as requested by the resident.
Failure to Monitor and Control Illicit Drug Use for a Resident on Chronic Opioid Therapy
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain effective preventive measures and monitoring for a resident with known drug-seeking behavior and repeated positive urine drug screens for illicit substances. The resident, admitted in 2013 with paraplegia, chronic pain syndrome, and major depressive disorder, had a history of polysubstance abuse and was on chronic methadone therapy for pain. Urine drug screens showed a positive result for cocaine and cannabis on 7/18/25 and additional positive results for cannabis on 8/21/25, 9/25/25, and 12/6/25. Despite these findings and multiple office visit notes from the MD documenting polysubstance abuse, opiate dependence, behavior issues, and instructions to monitor behavior, the facility did not implement ongoing, structured behavior monitoring or revise the care plan in response to the repeated positive tests. The resident reported using marijuana for many years while residing at the facility and admitted to sniffing cocaine when stressed. He stated that he went alone to a nearby park, where a friend supplied him with cocaine and marijuana, and that he informed facility staff that a friend had given him cocaine. He also stated that he was never supervised by staff when leaving the premises and was allowed to go to the park by himself, and that after his positive drug test in July 2025 he stopped going to the park following a doctor’s order of no more day passes. The resident further reported that a visitor brought him marijuana brownies during visits in August, September, and December 2025, and that he brought a marijuana cartridge into the facility but was only told he could not smoke marijuana in the facility. He stated that no one at the facility had discussed substance use treatment services with him. Staff interviews and record reviews showed that, although a care plan for history of substance use disorder and drug-seeking behaviors was initiated on 7/23/25, it was not revised after subsequent positive cannabis tests. The DON stated that behavior monitoring was documented in progress notes for only 72 hours after the 7/18/25 positive test and that no daily behavior tracking was implemented for drug-seeking behavior or drug use. LNs 1, 2, 3, and 4 confirmed there was no ongoing behavior monitoring log for drug use, no psychological evaluations documented for drug use, and no regular drug behavior monitoring despite continued positive urine drug screens and documented behavior issues such as agitation and yelling at staff. CNA 2 acknowledged that residents with a history of drug-seeking behavior should be monitored regularly and that unsupervised residents could go outside and consume illicit substances or be influenced by visitors. The facility’s visitation policy allowed for supervised visitation or denial of access for individuals with a history of bringing illegal substances, but there was no documentation that such measures were applied in this case, even though the IDT investigations repeatedly documented the resident’s continued cannabis use and refusal to stop.
Call Light Not Accessible to Resident
Penalty
Summary
A deficiency occurred when a resident's call light was not within reach, as observed during a survey. The call light was found hanging from the left side of the bed rail down to the floor, making it inaccessible to the resident. The resident reported being unable to find the call light and expressed concern that staff would not be able to respond promptly if assistance was needed. Both a CNA and a licensed nurse confirmed the call light was not in the proper place and acknowledged that the resident would not be able to get help right away, which created a safety risk. The Director of Nursing also confirmed that call lights should always be within reach and that failure to do so placed the resident at risk for a fall. The resident involved had multiple diagnoses, including senile degeneration of the brain, Parkinson's disease with dyskinesia, unspecified dementia, chronic obstructive pulmonary disease, palliative care, depressive disorder, and a recent fracture of the right femur. The resident's care plan specifically included interventions to keep the call light within reach, particularly due to a history of an unwitnessed fall and the femur fracture. Facility policy also required that call lights be accessible to residents when in bed, but this was not followed in this instance.
Failure to Timely Submit Investigation Summary After Resident Fracture
Penalty
Summary
The facility failed to submit a summary of investigation of an alleged unusual incident/injury report to the Department within five working days, as required, following a fracture incident involving a resident. The resident, who was admitted under hospice care with multiple diagnoses including senile degeneration of the brain, Parkinson's disease with dyskinesia, unspecified dementia, COPD, depressive disorder, and a right femur fracture, was found sitting on the floor with no visible injury noted upon assessment. Subsequently, the resident complained of right hip pain and an X-ray revealed a subacute fracture of the right femoral neck. Despite being aware of the requirement, the DON acknowledged during interviews that she forgot to submit the summary of investigation for the incident. The facility's policy requires prompt initiation and documentation of investigations for accidents or incidents, but this was not followed in this case. The lack of timely submission of the investigation summary meant that the Department was not informed within the mandated timeframe following the incident.
Deficient Food Storage and Equipment Sanitation in Dietary Services
Penalty
Summary
The facility failed to ensure proper food storage and maintenance of kitchen equipment in accordance with professional standards for food safety, affecting all 93 residents who consumed facility-prepared meals. During an initial kitchen tour, surveyors observed four large sheet pans stored on the clean rack with dark brown buildup on their raised rims. The Dietary Supervisor confirmed the pans were not properly cleaned and acknowledged that this was unacceptable, as it could expose residents to foodborne illness. Dietary staff interviews further confirmed that improper cleaning of pans could result in old food particles contaminating meals, and that the dishwashing process was intended to remove all food residue, but expectations were not met in this instance. Additionally, a food item (pie) was found in the freezer with an open date but missing a use-by or expiration date. The Dietary Supervisor confirmed the pie was leftover from a recent event and acknowledged it should have been labeled with a use-by date. Staff interviews indicated that all food items were required to be labeled with open, preparation, use-by, and expiration dates to ensure safety, but this procedure was not followed for the pie. The Assistant Director of Nursing also confirmed that improper labeling of food items could result in foodborne illness. Review of the facility's policies and procedures revealed requirements for all utensils, counters, shelves, and equipment to be kept clean and maintained in good repair, and for all food items in storage to be labeled and dated. These policies were not followed, as evidenced by the unclean sheet pans and the improperly labeled pie. The FDA Food Code was also referenced, which requires food-contact surfaces to be clean to sight and touch and free of encrusted grease deposits and other soil accumulations.
Failure to Post Oxygen in Use Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure that supplemental oxygen was administered in accordance with professional standards of practice for two residents who were receiving oxygen therapy. Both residents had active physician orders for oxygen to be administered via nasal cannula as needed for shortness of breath or comfort, and both were observed receiving oxygen through concentrators in their rooms. However, during multiple observations, there was no 'Oxygen in Use' signage posted on the doorways of either resident's room, as required by facility policy and procedure. Interviews with nursing staff, including licensed nurses and certified nurse assistants, confirmed that the residents were receiving oxygen therapy and that the required signage was not posted. Staff members acknowledged the importance of posting 'Oxygen in Use' signs to alert staff, residents, and visitors to the presence of oxygen and to prevent fire hazards. The staff also confirmed that it was their responsibility to ensure the signage was in place whenever a resident was receiving oxygen therapy. A review of the facility's policy and procedure for oxygen administration, as well as interviews with the Director of Staff Development and the Assistant Director of Nursing, further confirmed that the expectation was for nursing staff to post the appropriate signage immediately upon initiation of oxygen therapy. The Assistant Director of Nursing acknowledged that the facility's policy was not followed in these instances, as the required signage was not posted for either resident while they were receiving oxygen.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Incomplete QAPI Program and Lack of Documentation
Penalty
Summary
The facility failed to implement and maintain a comprehensive QAPI program and plan when it did not adhere to its QAPI policy and did not provide documentation or evidence of ongoing QAPI activities. During interview and record review, the Administrator reviewed the QAPI program and confirmed that the facility did not have an appropriate monitoring and documentation portion of the QAPI program. Review of the QAPI binder showed no evidence of detailed monitoring, follow-up, or documentation of QAPI activities. The Administrator acknowledged that documentation of the QAPI program should have been completed and confirmed the program lacked sufficient details and follow-through. The Administrator also acknowledged that the QAPI policy was not comprehensive, required revision, and lacked clear guidelines for implementation. Although the committee had been meeting on a quarterly basis, the facility was not following its QAPI policy.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unmet care needs. One resident, admitted with chronic and abdominal pain, experienced face and neck swelling. Despite reporting the swelling and requesting interventions such as ice application, there was no care plan addressing this issue, and progress notes only documented the complaint and a general ongoing plan of care. The Director of Nursing confirmed the absence of a care plan for the swelling, acknowledging its importance for proper treatment. Another resident with multiple sclerosis, requiring two-person assistance for activities of daily living (ADLs), was turned in bed by a single CNA, contrary to the care plan's specified intervention. Both the resident and the CNA confirmed that care was provided by only one staff member. The Director of Staff Development verified this deviation from the care plan and emphasized the necessity of following prescribed interventions to ensure proper care. Facility policy also required staff to check care plans for specific positioning needs and the number of staff required.
Delayed assessment of wounds and pain, plus staff communication barriers
Penalty
Summary
Resident 83, who was admitted with diagnoses including type 2 diabetes and a foot ulcer, reported bilateral foot and toe pain after his toenails had been trimmed. During observation, two blackened nickel-sized areas were seen on each great toe, and the resident stated his toes and the bottoms of his feet really hurt. The day shift LN was informed of the pain and blackened areas, but later stated she had not written a progress note and had not looked at the resident’s toes. The resident later stated the nurse never came to ask about the pain, and he described constant pain rated 7 out of 10 that was keeping him awake at night. The record also showed a podiatry note from 8/19/25 that included a plan to check feet daily, but staff stated they should have known about the consult and entered that order and had not. The day shift nurse did not inform the oncoming shift of the new onset foot pain, and another nurse later assessed the resident’s feet and noted the blackened areas looked like diabetic ulcers. The DON stated that when a resident has pain, the nurse is responsible for assessing the resident and notifying the physician if it is a new onset of pain, and that the resident’s pain and blackened great toes had not been assessed and reported, resulting in a delay in care. Resident 10, who was admitted with a diagnosis including depression, was observed with nine dime-sized scabs on the right forearm. The record review showed no documented assessment of the scabs, no progress notes, no change in condition documentation, and no care plan related to the areas. Two days later, the scabs were still present with red raised areas around them, and the resident stated they were a little painful and had been present for about 2 months. Two LNs stated they had seen the scabs but had not asked the resident about them, and the DON confirmed the areas and stated the expectation was for nurses to document, complete a change in condition, care plan the issue, and notify the physician and resident representative. The report also described concerns involving staff communication. Residents stated that some CNAs and nurses did not speak English and that residents could not understand them. One resident said non-English speaking staff did not understand his needs, and another stated staff did not understand requests for a nebulizer. A CNA stated, through a translator, that she worked night shift because she did not speak English, and the DSD confirmed she spoke only basic English and needed interpretation for orientation and training. The DON stated it was her expectation that all staff would be able to communicate with residents and speak English, and the facility’s CNA job description required staff to read, write, speak, and understand English.
Failure to Thoroughly Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was admitted with palliative care needs. The resident reported that a staff member used foul language and physically slapped her. Documentation in the resident's progress notes confirmed that the allegation was reported, and monitoring for distress was initiated. However, the investigation into the incident was limited in scope. The Social Services Director (SSD) only interviewed the resident and the alleged perpetrator, CNA 8, without interviewing other staff or residents who may have had relevant information. The SSD also did not review the employee file of CNA 8, which contained prior incidents of poor communication and inappropriate behavior. The Director of Nursing (DON) confirmed that a more comprehensive investigation should have included interviews with other staff and residents and a review of the employee's history. Facility policy required a thorough investigation, including interviews with all relevant parties and review of all events leading up to the incident, which was not followed in this case.
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for one resident with hypotension who was ordered Midodrine by mouth twice daily, with instructions to hold the medication if systolic blood pressure was greater than 120. The resident’s care plan identified hypotension and directed that medications be given as ordered. Review of the August 2025 MAR showed Midodrine was administered outside the ordered parameters on 16 of 53 opportunities during the month. During interview and record review, a licensed nurse stated she would administer Midodrine for low blood pressure and that the parameters were in the physician’s order. The DON reviewed the MAR and confirmed multiple administrations occurred when the resident’s blood pressures were above the hold parameter, including readings such as 122/60, 126/78, 124/76, 128/77, 134/89, and others. The DON stated the medication should not have been given for those blood pressures and explained it could have caused hypertension. The facility policy required checking vital signs before medication administration and holding medications for blood pressure results that met hold criteria.
Failure to Provide ROM and Hand Hygiene for Resident with Right Hand Contracture
Penalty
Summary
The facility failed to ensure appropriate care and services were provided to maintain a resident’s highest practicable level of function when staff did not provide range of motion (ROM) exercises to Resident 80’s extremities and did not provide hand hygiene to his contracted right hand. Resident 80 was admitted in early 2024 and had a care plan identifying a self-care deficit, requiring 1-2 person extensive total assistance with activities of daily living and noting a right upper extremity contracture. The care plan included interventions to incorporate ROM exercises during care and to monitor, document, and report signs and symptoms of immobility, including contractures forming or worsening and skin breakdown. The resident’s MDS indicated a functional limitation in ROM of the upper extremity with impairment on one side. However, the facility’s documentation for ROM exercises during August 2025 repeatedly recorded “Not Applicable” for multiple AM and PM shifts. During interview, a CNA stated she documented the number of minutes ROM was provided, documented “Resident Refused” if the resident refused, and used “Not Applicable” if she did not perform ROM or if the resident was asleep. During observation, the ADON confirmed the resident’s contracted right hand had a strong odor, his fingers were curled tightly into the palm, and hand hygiene produced a brown, crusty residue on the washcloth. The ADON also confirmed the resident should have had a clean right hand and a hand roll in place to prevent his fingers from digging into his palm, and stated the resident was at risk for skin breakdown and infection if the care was not provided.
Failure to Complete Ordered Weekly Weights
Penalty
Summary
The facility failed to ensure that a physician-ordered weekly weight monitoring order was carried out for Resident 43. Resident 43 was admitted with diagnoses including type 2 diabetes mellitus with other specified complication and paraplegia. The clinical record showed a physician order dated 7/1/25 for weekly weights beginning 7/7/25, and the care plan included weekly weights x 4 weeks. During interview and record review on 8/28/25, the Restorative Nurse Assistant, Licensed Nurse, Assistant Director of Nursing, and Director of Nursing all confirmed that staff did not follow the order to monitor and document the resident's weight every week. The record showed Resident 43's weight decreased from 132 pounds on July 3, 2025, to 122 pounds on August 3, 2025, and there was no documentation that the weekly weights were completed by staff.
Failure to Refer Resident With Food Hoarding Behavior for Behavioral Health Evaluation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident who had a documented behavior of storing and hoarding food items at the bedside. The resident was admitted with a diagnosis that included inappropriate diet and eating habits, and during observation was seen with multiple food trays, drinks, and food containers kept in and around the bed. The resident stated he saved the food trays so he could eat small amounts over time and said he could not eat a lot at once. Staff reported that he became angry when they tried to remove old food trays and that he would not allow staff to touch them. Facility staff acknowledged that the resident had long-standing food hoarding behavior and that he had been educated about the risks of keeping food at the bedside. The care plan identified storing and hoarding food items at bedside and included an intervention for a psychiatry evaluation as indicated, but the resident was not referred to a psychiatrist or psychologist. The DON stated the resident was not referred to either discipline and that staff did not speak to the medical doctor about the behavior. The SSD confirmed that a psychiatric consult referral was not sent.
Medication Receipt and Destruction Records Not Properly Signed
Penalty
Summary
The facility failed to ensure safe medication handling practices when medication delivery documents from the provider pharmacy were not consistently signed and documented upon receipt. During observation and interview in the Station 1 medication room, the white binder contained packing slips listing the names and quantities of medications delivered, including controlled medications and non-controlled prescription medications, but the delivery sheets were unsigned. The licensed nurse acknowledged that the delivery records were not consistently signed and stated that two sheets were used, one for the driver and one for the binder. The packing slip itself indicated that by signing, the nurse acknowledged receipt of the items listed. The DON stated that medication delivery documents should be signed by licensed staff receiving the medications, and the consultant pharmacist stated the receiving nurse should verify the accuracy and accountability of the prescription drug delivery. The facility also failed to consistently document destruction and disposition of non-controlled prescription medications with co-signature witness by two licensed staff. During review of the Station 2 medication room records, the destruction record listed discontinued prescription medications and included a signature space for co-signers, but there was no co-signature by licensed staff for the non-narcotic medication disposition documentation. The licensed nurse acknowledged the missing witness signatures. The consultant pharmacist stated that two licensed nurses were needed as witnesses for destruction of prescription medication, and the DON stated that non-controlled drug destructions were done by night shift nurses or charge nurses and should be co-signed per facility policy. The facility policy required medication disposition records to include the resident name, date, quantity, method of destruction, and signatures of witnesses.
Failure to Reassess Long-Term PPI Use
Penalty
Summary
The facility failed to assess and review the long-term use of proton pump inhibitor medications for two residents, both of whom were receiving scheduled PPI therapy for GERD without documented recent or current stomach bleeding or related complaints. Resident 7’s record showed pantoprazole 40 mg daily had been active since 5/8/24, and Resident 36’s record showed omeprazole 20 mg daily had been active since 1/29/25, with both medications reportedly started earlier when the residents were admitted to the facility. During record review and interview, the licensed nurse stated that Resident 7’s pantoprazole had actually been started in 2021 for a history of stomach bleeding, but there had been no notes or concerns about GERD, upset stomach, or bleeding in the medical doctor or nursing notes since admission. For Resident 36, the licensed nurse stated omeprazole had been started in 2022 upon admission, and there had likewise been no notes or concerns regarding GERD, upset stomach, or bleeding in the medical doctor or nursing notes. The nurse also stated the medical doctor saw the residents on 8/28/25, but there were no notes or orders related to the PPI therapy or GERD diagnosis. The consultant pharmacist stated he began assisting the facility in July 2025 and was aware of FDA warnings and side effects of long-term PPI use, including pneumonia, C. diff, and low magnesium, but confirmed no recommendation had been provided to the facility or the medical doctor to reassess the long-term use of PPI therapy for either resident. The DON stated the long-term use of PPI should have been reassessed because there was no complaint about stomach issues and she relied on the pharmacy and doctors to address it.
Unlabeled discontinued medication and expired eye drops found in active storage
Penalty
Summary
Safe medication storage practices were not maintained in one medication room at Nurse Station 1 when an unlabeled box of discontinued prescription Kristalose (lactulose) packets was found stored with active OTC medications. During the observation, LN 15 acknowledged the box and stated that prescribed medications should be destroyed when residents no longer needed them, but she did not know who the medication had belonged to. The DON later stated that discontinued non-controlled medications were to be destroyed by night shift nurses and/or the desk nurse and should not be stored with active medications in the medication storage areas. Safe medication storage practices were also not maintained in one medication storage cart at Nurse Station 1 when COSOPT eye drops were found expired with an expiration date of 8/17/25 and still stored in the active medication cart. LN 15 acknowledged the expired medication and stated it should be removed from the active cart and not used for any resident. LN 11 stated expired and outdated medications should be removed from active medication storage carts and disposed of in the pharmaceutical waste container, and the DON stated expired and outdated medications should be removed from active carts as soon as possible per facility policy.
Missed Neurology Appointment Due to Delayed Transport Preparation
Penalty
Summary
The facility failed to have 1 of 32 sampled residents, Resident 48, ready in time for a neurology appointment. Resident 48 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage and polyneuropathy. On 8/28/25, Resident 48 and his family member were visibly upset after he missed his first appointment with a neurologist, which he had been waiting over 4 months to attend. Resident 48 stated he was over 20 minutes late because CNA 6 did not get him ready on time, and he reported frustration with the lack of communication between staff and the mechanical lift not being nearby when needed. The transportation driver stated he was outside the resident’s room at the scheduled 1:30 PM pick-up time, but the resident was not ready. CNA 6 confirmed she was assigned to Resident 48 and stated it usually took about 45 minutes to transfer him because of his preferred leg positioning with the mechanical lift. CNA 6 stated Resident 48 initially refused to get ready when asked just after noon, but she did not document the refusal, inform the charge nurse, or ask for assistance. CNA 6 also confirmed she had to ask CNA 9 to find a mechanical lift. Resident 48 and his family member stated the family member arrived early so the resident could receive pain medication before transfer, and both said he never refused to get ready for the appointment. The Social Services Director confirmed the appointment had been scheduled since April 2025 and stated the missed appointment could delay the resident’s care. The Transportation Sign In/Out Log showed the driver arrived at 1:30 PM and the resident left the facility at 2:20 PM.
Shared Glucometers Not Properly Cleaned Between Resident Uses
Penalty
Summary
The facility failed to ensure safe infection prevention and control practices for five residents when shared glucometers were not cleaned and sanitized between resident uses. During a medication administration observation, a nurse used glucometer 1 for Resident 45, then placed the device on the medication cart and wiped the outer surface for less than 5 seconds with one Super Sani-Cloth wipe before leaving it to dry. The same nurse used glucometer 2 for Resident 67 and again wiped the device briefly with one wipe for less than 5 seconds before allowing it to dry. The nurse then alternated between the two glucometers for Resident 39, Resident 102, and Resident 49, repeating the same process after each blood sugar check. For each resident, the nurse used gloved hands to perform the finger stick, obtained the blood glucose reading, placed the glucometer on the cart outside the room, and cleaned only the outer surface quickly with one wipe. The nurse later stated she used two glucometers while each was drying and acknowledged that she cleaned both devices quickly with one wipe and did not use a second wipe or keep the surfaces wet for 2 minutes as recommended. The Infection Preventionist stated there was a two-step process for cleaning and sanitizing a glucometer and that staff should use two wipes and keep the device wet per the wipe instructions. The DON stated she expected nursing staff to follow best practices and manufacturer specifications for cleaning and sanitizing shared glucometers. The manufacturer instructions and facility procedure both indicated that reusable blood glucose meters must be cleaned and disinfected between resident uses, including use of two disposable wipes and following the required wet contact time.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Dumpster Lid Left Open, Violating Infection Control and Sanitation Policies
Penalty
Summary
A deficiency was identified when one of two outside dumpster lids was observed to be propped open with a stick, rather than being properly closed. This observation was made during a walkthrough of the facility's dumpster area with the Dietary Services Supervisor (DSS), who confirmed the lid was intentionally left open. Multiple staff interviews, including with the DSS and the Director of Nursing (DON), confirmed that dumpster lids are required to be closed at all times to prevent exposure to pests and to maintain infection control standards. Staff acknowledged that leaving the dumpster open could allow animals and pests to access the garbage and potentially spread disease. A review of facility policies indicated that garbage and trashcans must be inspected daily to ensure lids are closed and the surrounding area is free of debris. The facility's infection prevention and control policy also requires maintaining a safe and sanitary environment. Additionally, the FDA Food Code 2022 specifies that outside receptacles for refuse containing food residue must have tight-fitting lids. The failure to keep the dumpster lid closed was contrary to both facility policy and federal guidelines.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
Staff failed to use safe and appropriate transfer methods for a resident with significant physical limitations and a history of muscle weakness and bone density disorders. The resident's care plan specified the use of a mechanical lift for all transfers due to his inability to stand and the presence of bilateral plantar flexion contractures. Despite this, staff transferred the resident from a shower chair to his bed manually, with three to four staff members lifting him instead of using the mechanical lift as required by his care plan and facility policy. During the transfer, the resident reported hearing a crack and experienced pain in his right leg. Subsequent assessments by nursing staff documented discoloration, pain, and later, the development of blisters and cellulitis on the right lower leg. An x-ray confirmed a minimally displaced fracture of the right proximal tibia. Interviews with staff, including the ADON and CNAs involved, confirmed that the mechanical lift was not used because the resident often refused it, and staff attempted a manual transfer instead, which was acknowledged by staff as unsafe. The facility's policy on safe lifting and movement of residents required the use of appropriate devices and techniques to ensure safety, and manual lifting was to be eliminated when feasible. Both the Director of Staff Development and the physical therapist stated that more than two staff members should not perform a manual transfer and that the mechanical lift was always the safest option for this resident. The failure to follow the care plan and facility policy directly preceded the resident's injury.
Failure to Notify Physician and Responsible Party of Resident's Treatment Refusals
Penalty
Summary
The facility failed to report a change in condition and medical treatment to the physician and the Responsible Party (RP) for a resident who refused medications, fingerstick blood sugar monitoring (FSBS) tests, and physical therapy treatments on multiple occasions. The resident, who had a history of intertrochanteric fracture, diabetes mellitus, and delusional disorders, was noncompliant with her treatment plan. Despite the refusals, the facility did not consistently notify the resident's physician or RP, which resulted in the RP being uninformed of the resident's change in condition and unable to participate in medical decisions. Interviews and record reviews revealed that the resident refused numerous doses of various medications, including those for diabetes, cholesterol, and blood pressure, over a period of three months. Licensed nurses documented the refusals in the progress notes but failed to notify the RP or the physician consistently. The Director of Nursing (DON) acknowledged that the facility's policy was not followed, as the refusals should have been documented in a Change in Condition (CIC) form and communicated to the RP and physician. Additionally, the resident refused FSBS tests and physical therapy sessions multiple times. The facility's policy required notification of the physician and RP after two consecutive refusals of treatment or medications, but this was not adhered to. The Physical Therapist and Director of Nursing confirmed that the resident's refusals were not communicated to the RP, and there was no specific policy for handling physical therapy refusals. The lack of communication and documentation led to the resident's physician and RP being unaware of the extent of the refusals, potentially impacting the resident's health management.
Failure to Document Basis for Facility-Initiated Discharge
Penalty
Summary
The facility failed to properly document the required information prior to discharging a resident. The resident had been at the facility since the spring of 2024 and left for a scheduled medical appointment, after which they were admitted directly to the hospital for surgery. Subsequently, the hospital sent a request for the resident's re-admission to the facility. The facility then completed a NOTICE OF TRANSFER OR DISCHARGE, stating that the resident's needs could not be met in the facility, and served this notice to the resident's responsible party while the resident was still hospitalized. Upon review, it was found that there was no documentation in the resident's medical record specifying the basis for the discharge or detailing the needs that could not be met by the facility. The facility's own policy requires that the specific resident needs that cannot be met, as well as the facility's attempts to meet those needs, be documented in the medical record when a facility-initiated transfer or discharge occurs. Both the Administrator and the DON confirmed the absence of this required documentation.
Failure to Provide Correct Appeal Information in Discharge Notice
Penalty
Summary
The facility failed to provide the required information regarding appeal rights in the discharge notice given to a resident's responsible party and the long-term care ombudsman prior to a facility-initiated discharge. The discharge notice, completed by the Social Services Director (SSD) and the Director of Nursing (DON), included the contact information for the California Department of Public Health (CDPH) as the entity to which appeals should be sent. However, this was incorrect, as appeals should be directed to the Office of Administrative Hearings and Appeals (OAHA), as specified by the Department of Health Care Services (DHCS). During interviews, the SSD confirmed that the facility had been using the CDPH contact information on all discharge and transfer paperwork and was unaware that this was not the correct entity for appeals. The facility's policy required that residents be provided with accurate information on how to appeal a transfer or discharge, including the correct entity's contact details and instructions for obtaining and submitting an appeal form. As a result of this error, the resident's responsible party was not properly informed of how to appeal the facility's decision to discharge the resident.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to ensure a resident's right to return after hospitalization was protected. The resident, who had been living at the facility since Spring 2024, was sent to the hospital for a scheduled appointment and subsequently admitted for surgery. Upon the hospital's request for re-admission, the facility did not allow the resident to return, citing that the seven-day bed hold had expired. Despite this, the resident's bed and personal belongings remained in place, and the facility had available capacity, with the resident's previous room and bed still unoccupied. The facility completed and served a Notice of Transfer or Discharge to the resident's responsible party, stating the reason for discharge was the facility's inability to meet the resident's needs. However, the Administrator indicated that the paperwork was served only as a formality due to the expired bed hold. Observations confirmed that the resident's personal items were still present in the assigned room, and staff verified that the bed remained available. Facility policy indicated that residents should be allowed to return to their previous room if available or to the first available bed after the bed-hold period, but this was not followed in this case.
Failure to Perform Milking Technique for Resident's Edema
Penalty
Summary
The facility failed to ensure that Licensed Nurses (LNs) possessed the necessary competencies and skills to provide appropriate treatment for a resident, specifically in performing the milking technique for lymphatic drainage on the resident's right leg. This deficiency was identified through observations, interviews, and record reviews, revealing that the milking was not consistently performed by the licensed staff, despite multiple physician orders indicating its necessity. The resident, who was admitted with conditions requiring such treatment, reported being denied the milking treatment multiple times without explanation. The resident's medical records showed several physician orders for milking the right leg, alongside the use of compression stockings, ice, and elevation, which were not consistently followed. Interviews with the facility staff, including LNs and a physical therapist, highlighted a lack of knowledge and experience in performing the milking technique. The physical therapist noted that while milking was part of their training, it was not routine, and the responsibility lay with the nursing staff. Despite the orders, the staff expressed discomfort and lack of experience in performing the procedure, leading to its omission. Further interviews with medical professionals, including a nurse practitioner and a medical doctor, confirmed the importance of following the physician's orders for the resident's edema management. The medical doctor emphasized that the order was reasonable and should have been accommodated, while the nurse practitioner noted that the facility staff had requested the discontinuation of the milking order, which was not approved. The Director of Nursing confirmed that the order for milking was only added to the treatment administration record shortly before the resident's discharge, indicating a delay in addressing the resident's needs.
Failure to Communicate Medication Refusals
Penalty
Summary
The facility failed to ensure that ongoing medication refusals by Resident 16 were communicated to the medical doctor in a timely manner. Resident 16, who had multiple medical diagnoses including heart failure, atrial fibrillation, hypothyroidism, and depression, was documented to have refused several critical medications over June and July 2024. These medications included Furosemide, Paroxetine, Apixaban, and Levothyroxine, which are essential for managing her heart conditions, depression, and thyroid function. Despite these refusals, there was no documentation indicating that the medical doctor was notified of the refusals during this period. Interviews with facility staff, including Licensed Nurse 14 and the Director of Nursing, revealed that the workflow for handling medication refusals involved offering the medication three times before documenting the refusal in the Medication Administration Record (MAR). However, the staff acknowledged that the medical doctor should have been informed of refusals, especially for critical medications. The Director of Nursing confirmed that Resident 16 was sent to the hospital due to excessive swelling in her lower extremities, which was attributed to her refusal to take Lasix, a medication critical for managing her heart failure. The facility's Consultant Pharmacist and Medical Doctor also confirmed that they were not informed of the ongoing medication refusals. The Consultant Pharmacist noted that the refusal of medications could have contributed to the resident's worsening condition, including the need to increase the dosage of Levothyroxine due to low thyroid hormone levels. The facility's policy on administering medications did not address the need to notify the medical doctor of ongoing refusals of high-risk medications, contributing to the deficiency in care for Resident 16.
Lack of Training and Policy for CGM Devices
Penalty
Summary
The facility failed to ensure that licensed staff received appropriate training and that a written policy and procedure were in place for the use of continuous glucose monitoring (CGM) devices for nine residents. During an observation and interview, a licensed nurse admitted to not knowing how to change the CGM sensor and confirmed that no training or reading materials had been provided by the facility. The Director of Staff Development (DSD) acknowledged that although diabetes training was conducted, it did not cover the use of CGMs. The DSD also expressed concerns about the lack of training, which could lead to incorrect blood sugar readings. The Consultant Pharmacist (CP) revealed that the facility began using CGMs in March 2024, but was unaware that no written policy and procedure were in place. The CP noted issues with sensor replacements occurring more frequently than intended, leading to potential improper glucose assessments. The Director of Nursing (DON) confirmed the absence of training for both staff and residents on CGM use and acknowledged the lack of a policy and procedure to guide staff in the proper use of the devices.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication labeling and storage practices, affecting the safety and efficacy of medication administration. During an inspection, it was observed that the medication refrigerator contained undated lorazepam, a controlled medication, and improperly stored Gvoke HypoPen, which should not be refrigerated. Additionally, the Emergency Kit contained contaminated bottles of SPS Suspension, and the medication cart had undated test strips and control solutions, which should have been dated upon opening. Resident 27's chemotherapy medication, capecitabine, was not labeled or stored as a hazardous drug, posing a risk to staff handling it without proper precautions. The medication was stored with non-hazardous drugs, and staff were unaware of the necessary safety measures, such as wearing gloves during administration. Furthermore, Resident 27's inhaler was not labeled with her name or instructions, increasing the risk of misuse by other residents. Residents 5 and 14's continuous glucose monitoring (CGM) Readers were not labeled with their names, leading to potential confusion and incorrect insulin dosing. The CGM Readers were left unsecured in their rooms, and staff confirmed the lack of identifiers, which could result in serious health issues if the devices were used by the wrong resident.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess Resident 27 for the ability to independently use her prescribed inhaler, which is necessary for safe self-administration of medication. Resident 27, who was admitted with a diagnosis including lung cancer, had an order for Budesonide-Formoterol Fumarate Inhalation Aerosol to be used twice daily. During an observation, the inhaler was found on her bedside table without any labeling, and Resident 27 confirmed she used it on her own without informing the nurse. Licensed Nurse 12 acknowledged the inhaler was at the bedside per physician's order but lacked proper labeling and instructions. The Director of Nurses (DON) and Licensed Nurse 1 explained the facility's process for allowing medications at the bedside, which includes obtaining a physician's order, conducting an assessment for self-administration capability, and holding an Inter-Disciplinary Team (IDT) meeting to discuss the resident's capacity. However, these steps were not completed for Resident 27, as confirmed by the DON. The facility's policy requires an IDT assessment to ensure it is clinically appropriate and safe for residents to self-administer medications, but this was not adhered to, leading to the potential for unsafe medication practices.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) was completed accurately for one resident, identified as Resident 27. The POLST form, which is a legal document that communicates a resident's medical wishes for end-of-life care, was not signed by the physician or their representative. This omission was discovered during a review of Resident 27's Order Summary Report, which indicated that the resident was admitted with a diagnosis of cancer. The POLST form, dated 7/4/24, was marked for a trial period of artificial nutrition, including feeding tubes, but lacked the necessary physician's signature, rendering it incomplete and invalid. Interviews with facility staff, including the Minimum Data Set Coordinator (MDSC), Licensed Nurse (LN) 7, and the Director of Nurses (DON), confirmed the absence of the physician's signature on the POLST form. The MDSC and LN 7 emphasized the importance of the physician's signature to validate the document and ensure that the resident's wishes are honored. The DON stated that without the physician's signature, the facility could not implement the resident's or their representative's wishes regarding medical care and emergency treatment. The facility's policy on Advanced Directives also indicated that the POLST form is designed to record patients' treatment wishes, highlighting the significance of having a complete and signed document.
Failure to Provide Complete SNFABN to Resident
Penalty
Summary
The facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) to one of its residents, identified as Resident 20. The SNFABN, which is meant to inform residents of potential financial liabilities for services not covered by Medicare, was missing the estimated cost of services that Resident 20 might be responsible for. This omission was discovered during a review of Resident 20's records, which showed that she was readmitted to the facility in 2023 and was informed that her Medicare coverage for nursing services would end on January 2, 2024. The SNFABN issued on December 29, 2023, indicated that Medicare would not cover certain skilled nursing services starting January 3, 2024, but failed to provide an estimated cost for these services. Interviews with facility staff revealed a lack of adherence to proper procedures for completing the SNFABN. The Business Office Manager (BOM) acknowledged that the form should have included the estimated cost of services, typically the private pay room and board rate, to inform the resident or their representative of potential financial responsibilities. The Minimum Data Set Coordinator (MDSC) admitted to not filling in the estimated cost on the SNFABN and instead directed residents or their representatives to contact the business office for this information. This practice was contrary to the facility's procedure, which required the SNFABN to include an estimated cost to help beneficiaries make informed decisions about their care and financial responsibilities.
Unauthorized Photography of Resident's Medical Information
Penalty
Summary
The facility failed to protect the privacy of a resident's medical information during a medication pass. A licensed nurse used a personal smartphone to take a picture of medication labels, which included the resident's name and drug information, to review later. This action was observed during a medication administration session in the hallway of Unit 1. The nurse intended to delete the pictures afterward, but this use of a personal phone for photographing protected medical information violated the facility's policy on confidentiality and personal privacy. The Director of Nursing confirmed that staff were not permitted to use personal phones for such purposes.
Failure to Investigate Resident's Reported Loss of Property
Penalty
Summary
The facility failed to protect the rights of a resident, identified as Resident 45, by not investigating a reported loss of $25. Resident 45, who was admitted to the facility in 2018, reported the missing money during rounds at 5 AM. The staff searched the resident's room but did not find the money and planned to endorse the issue to the next shift nurse for follow-up with Social Services. However, the Social Services Director (SSD) was not informed of the missing item, as the staff did not follow the proper procedure for reporting such incidents. Interviews with various staff members revealed inconsistencies in the reporting process for theft and loss. Licensed Nurse (LN) 1 confirmed that the missing money was not documented on the shift-to-shift endorsement form. LN 2, who documented the complaint in the progress notes, did not recall any training on reporting theft and loss. The Director of Staff Development (DSD) and LN 3 mentioned a binder at the nurse's station with procedures, but it lacked specific instructions for reporting theft and loss. The Director of Nurses (DON) emphasized the importance of reporting missing items to maintain residents' dignity and rights. The facility's policy, revised in April 2021, mandates prompt investigation of theft or misappropriation of resident property, but this was not adhered to in this case.
Failure to Timely Report Alleged Theft
Penalty
Summary
The facility failed to report an allegation of stolen property involving a resident within the required 24-hour timeframe. Resident 22 reported to a Licensed Nurse (LN) that she suspected a Certified Nursing Assistant (CNA) of stealing $200 from her purse during the first week of July. Despite notifying the charge nurse and leaving a note for the social worker, LN 10 did not follow up, and the social worker was not informed of the incident. Consequently, the facility did not report the incident to the Department until 7/19/24, well beyond the mandated reporting period. This delay in reporting resulted in Resident 22 feeling upset and distressed over the loss of her money, which she liked to have for personal purchases. The Social Services Director (SSD) was unaware of the incident and stated that had she been informed, she would have filed a police report and monitored the resident for psychosocial distress. The Administrator confirmed that the missing money was considered abuse and should have been reported to the police, the Department, and the ombudsman within 24 hours, as per the facility's policy on abuse prohibition and prevention.
Failure to Update Resident's Care Plan for Smoking Safety
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was resident-centered and updated in a timely manner. The resident, who was admitted with multiple diagnoses including respiratory failure and quadriplegia, had a care plan that included the use of a smoking apron to prevent burns while smoking. Despite the resident's ability to understand and communicate effectively, as indicated by a BIMS score of 15, the care plan was not revised when the resident refused to wear the smoking apron. Interviews and observations revealed that the resident was not wearing a smoking apron and had not been asked to wear one by the facility staff. The Director of Staff Development was unable to provide evidence that the care plan was updated or that the resident was educated about the risks of not wearing the apron. The Director of Nursing acknowledged that the care plan should have been revised following the resident's refusal. The facility's policy on care plans emphasizes documenting refusals in the resident's clinical record, which was not adhered to in this case.
Deficiency in Meeting Resident's Activity Needs
Penalty
Summary
The facility failed to ensure that a resident received activities that met their interests and needs. The resident, who was admitted with diagnoses including nontraumatic intracerebral hemorrhage and adult failure to thrive, did not attend group activities and was infrequently offered in-room activities. Interviews with staff revealed that the resident did not get out of bed to attend activities, and the activity participation documentation was inaccurate, indicating activities were provided on days when they were not. The Activities Director confirmed that the resident only participated in activities on three days in June 2024, with no documentation of refusals. The Director of Nurses expressed the expectation that activities should consistently be offered to residents unable to leave their rooms, as participation could help prevent feelings of depression. The facility's policy on activity evaluation emphasized the importance of developing an activities plan that reflects the resident's choices and interests to promote their well-being. However, the lack of consistent activity offerings and accurate documentation for the resident highlighted a deficiency in meeting the psychosocial needs of the resident.
Improper Maintenance of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag was properly maintained, leading to potential complications. Resident 38, who was admitted with a diagnosis of urinary retention requiring a Foley catheter, was observed with their urinary catheter drainage bag resting on the floor. This was confirmed by a Certified Nurse Assistant (CNA) who acknowledged that the bag should not be on the floor due to the risk of infection. The CNA also noted that the bag was full and needed to be emptied. Interviews with the Infection Preventionist (IP), a Licensed Nurse (LN), and the Director of Nurses (DON) further confirmed that the urinary catheter bag should be hung off a non-movable part of the bed to prevent infection and other issues such as dislodgement. The IP and LN both emphasized the infection risk associated with the bag touching the floor, while the DON stated that it was expected for catheter bags to be kept off the floor to avoid such risks.
Failure to Timely Change Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate care to a resident who was receiving enteral nutrition through a gastrostomy tube. The resident's enteral feeding liquid nourishment was not discontinued approximately five hours past its expiration time, which increased the potential for complications such as nausea, vomiting, diarrhea, and stomach cramping. The resident was observed in their room receiving enteral feeding through a pump, with the feeding bag labeled with a date and time indicating it should have been changed earlier that morning. Licensed Nurse 3 confirmed that the enteral feeding bag was past its expiration and should have been changed at 4 a.m. The nurse acknowledged that the feeding and pump supplies needed to be replaced to prevent the formula from becoming spoiled. The Director of Nurses stated that enteral feedings, including formula, flush water, and tubing, should be labeled with the resident's name, date, time, and flow rate, and confirmed that expired enteral feeding could put the resident at risk for health infections and improper digestion.
Failure to Label and Change Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 27, who was receiving oxygen therapy. The resident's nasal cannula and oxygen humidifier bottle were not labeled with the date they were last changed, which is a requirement according to professional standards. Resident 27 was admitted with diagnoses including lung cancer and chronic obstructive pulmonary disease, necessitating continuous oxygen therapy at a flow rate of 2-5 liters per minute. The facility's order summary indicated that the nasal cannula and humidifier should be changed every seven days or as needed, but during an observation, it was found that neither the nasal cannula nor the humidifier bottle had a date label. Interviews with facility staff, including a licensed nurse, the infection preventionist, and the director of nurses, confirmed the lack of labeling and acknowledged the risk of infection due to this oversight. The staff members stated that the expectation was for the nasal cannula and humidifier to be labeled with the date of use and changed weekly. The absence of proper labeling and timely changes of the respiratory equipment placed Resident 27 at risk for infection, as confirmed by the staff during the interviews.
Failure in Controlled Narcotic Medication Accountability
Penalty
Summary
The facility failed to ensure the safe use and accountability of controlled narcotic medications, specifically Norco, for a resident. The Controlled Drug Record (CDR) indicated the removal of Norco for PRN use on several occasions, but there was no corresponding documentation in the Medication Administration Record (MAR) for these instances. Specifically, on four occasions, there were discrepancies between the CDR and MAR, with three instances lacking MAR documentation and one instance lacking CDR removal documentation. During the investigation, the Director of Nursing (DON) acknowledged the missing documentation and noted that the nurse responsible for the removal of Norco was no longer employed at the facility and could not be contacted for clarification. The facility's Consultant Pharmacist had conducted a random audit of narcotic use and provided a report to the facility. The facility's policy on controlled substances, which was undated, indicated compliance with laws and regulations related to handling and documentation of controlled medications.
Failure in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure the safe use of psychotropic medications for two residents. For Resident 45, there was a discrepancy in the medical records regarding the diagnosis of bipolar disorder, which was used to justify the administration of risperidone. The diagnosis was not reflected in the medical doctor's progress notes and assessments, and there was no physician cosignatory on the nurse practitioner's order. The MDS Coordinator confirmed that the diagnosis was entered based on a nurse's input, which should have been reviewed by the medical doctor and the Interdisciplinary Team. For Resident 92, the facility did not properly evaluate and reassess the use of PRN alprazolam, an anti-anxiety medication, despite its frequent use. The medication was administered nearly daily without a stop date or reevaluation after two weeks, as required by the facility's policy. The Licensed Nurse and the Director of Nursing acknowledged that the PRN order should have been reassessed, and the Consultant Pharmacist noted that the pharmacy provider should have questioned the order during the initial dispensing review. These failures in medication management could contribute to unsafe use of psychotropic medications, potentially putting Resident 45 at risk for adverse consequences and Resident 92 at risk for dependence. The facility's policy on psychotropic medication use was not followed, as medications were not clinically indicated or reassessed as required.
Failure to Ensure Safe Food Storage Practices
Penalty
Summary
The facility failed to ensure safe food storage practices for 92 residents receiving food service from the kitchen. During an inspection, it was observed that several food items in the walk-in refrigerator and freezer were not labeled with use-by dates. Specifically, an opened bottle of minced garlic, a gallon of barbeque sauce, a bag of veggie patties, a box of precut green beans, a spice bottle of rubbed sage, and a bottle of vanilla extract were all found without use-by dates. The Dietary Supervisor confirmed these findings and acknowledged that these items should have been labeled appropriately. Additionally, trays of thawing bacon in the walk-in refrigerator were not labeled with the date or time when the thawing process began. The Registered Dietitian confirmed that all food products should be labeled with use-by dates to prevent serving expired food, which could expose residents to foodborne illnesses. The facility's policies on labeling and dating foods, as well as thawing meats, were reviewed and indicated that all food items should be labeled and dated, but these procedures were not followed.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Manteca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harvest Crossing Post Acute | 1.3 mi | ★★★★★ | 3 | 0 |
| Bethany Home Society San Joaquin County | 7.3 mi | ★★★★★ | 5 | 0 |
| Lincoln Square Post Acute Care | 10.9 mi | ★★★★★ | 24 | 0 |
| Good Samaritan Rehab And Care Center | 11.2 mi | ★★★★★ | 1 | 0 |
| Hampton Post Acute | 11.5 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.