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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbor Post Acute Care Center during CMS and state inspections, most recent first.
A resident with depression, anxiety, dementia, and moderate cognitive impairment, who was dependent on staff for several ADLs, reported that a CNA pinched her cheek, roughly handled her, pulled her hair, and placed a pillow over her face during care, causing her to feel afraid. The CNA admitted pinching her cheek as an unprofessional gesture of endearment and acknowledged he might have pulled her hair and caused a pillow to fall on her face without explaining his actions. Despite the facility’s abuse policy requiring protection and separation of the resident from the alleged perpetrator during an investigation, leadership arranged a face-to-face meeting between the resident and the CNA, with the HR representative and DSD present and the resident’s responsible party listening by phone, during which the CNA apologized and described the incident as a misunderstanding.
A resident with depression, anxiety, dementia, and moderate cognitive impairment, who was dependent on staff for several ADLs, reported to her responsible party that a CNA had roughly handled her, pinched her cheek, pulled her hair, and placed a pillow over her face during care, causing her to be afraid of the CNA. The responsible party relayed these allegations to the Administrator, and the CNA later acknowledged pinching the resident’s cheek as a gesture of endearment and possibly pulling her hair and causing a pillow to fall on her face while providing care. Despite the facility’s abuse policy requiring the abuse coordinator to report all abuse allegations to CDPH, law enforcement, and the Ombudsman, and the DON’s and DSD’s understanding that all such allegations must be immediately reported, the Administrator, acting as abuse coordinator, did not report the allegation to any external agencies, concluding on her own that abuse had not occurred.
Failure to Honor Resident Preference for CNA Assignment: A resident with anxiety disorder and insomnia, who had decision-making capacity and needed substantial to maximum assistance with ADLs, told staff she did not want a specific CNA assigned to her. Although the request was documented in a COC and a different CNA was initially assigned, the preference was not entered into the communication book, and the CNA was later assigned again without staff awareness of the resident’s request.
A resident with multiple chronic conditions and severe cognitive impairment experienced an elevated uric acid level and finger swelling. Although the physician was notified and further tests were ordered, staff did not initiate a required change in condition (COC) to ensure proper monitoring and communication, as confirmed by interviews and facility policy review.
A resident with multiple complex medical conditions experienced both swelling and pain in a finger and a significant 50-pound weight loss after readmission. Despite these issues being documented, staff did not develop or implement care plans to address either the swollen finger or the weight loss, contrary to facility policy. Nursing leadership confirmed that no separate care plans were created for these conditions.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely follow-up for dental services, including tooth extractions and dentures, due to lack of tracking and verification by the Social Services Director. Additionally, the same resident missed a scheduled urology follow-up for a UTI, with no documentation or explanation for the missed appointment, and staff failed to ensure transportation and proper recordkeeping.
Surveyors found that several food items, including nutritional supplements, ice cream, roll dough, and liquid eggs, were stored in the kitchen without required labels or dates. Dietary staff and supervisors confirmed that facility policy mandates labeling with delivery, open, and use by dates, but these procedures were not followed.
The facility lacked a comprehensive water management program, with incomplete documentation and no interdisciplinary team or system to identify Legionella risks. Infection Prevention and Control Program policies were outdated, particularly regarding staff COVID-19 vaccination requirements, and were not updated to reflect current regulations or practices. Additionally, a nurse failed to wear gloves while disinfecting a bedside table and preparing wound care supplies for a resident with complex medical needs, contrary to facility policy.
The facility did not accurately complete SNF ABN forms for two residents, omitting required information about specific services received and the daily cost of care after Medicare Part A coverage ended. Both residents, one with cognitive impairment and one with intact cognition, had forms that failed to specify care areas and costs, as confirmed by the admissions coordinator.
Two residents had their MDS assessments completed inaccurately when their use of anti-convulsant medications (Depakote and Neurontin) was not properly coded in the medication section, despite physician orders and administration during the assessment period. The MDS nurse confirmed these omissions during interviews and record reviews, resulting in incorrect data being submitted to CMS.
A resident with an indwelling catheter and multiple health conditions was not monitored for UTI symptoms as required by their care plan. Although the care plan specified monitoring for signs such as urine sediment and other symptoms, there was no documentation by nursing staff in the TAR or clinical records. Observation revealed sediment in the catheter tubing, and both a nurse and the DON confirmed that monitoring and documentation had not been performed.
A nurse left four prescribed medications at the bedside of a resident with end stage renal disease and dementia, despite the resident's fluctuating decision-making capacity and need for moderate assistance. Staff interviews confirmed that facility policy requires nurses to remain with residents until medications are taken, and that the resident was not safe to self-administer medications.
A resident with significant neurological and physical conditions was not provided with activities consistent with their care plan, which included TV, music, and sensory stimulation. Observations showed the resident was not engaged in these activities, and staff interviews confirmed a lack of consistent implementation of planned interventions.
A resident at risk for skin breakdown was found lying on a low air loss mattress that was incorrectly set to 320 lbs and left in static mode, contrary to care plan requirements and manufacturer instructions. Staff interviews confirmed the settings did not match the resident's weight and were not providing appropriate pressure relief, as required for pressure ulcer prevention.
Two residents did not have their respiratory care equipment labeled or replaced according to facility protocol. One resident's oxygen nasal cannula and humidifier were not properly dated or changed weekly, and another resident's nebulizer tubing was not replaced every seven days as required, despite regular use. Staff confirmed these lapses during interviews and observations.
A resident with chronic pain did not receive a follow-up pain assessment after being given tramadol for severe pain. The nurse administered the medication but did not return to evaluate its effectiveness, despite the care plan and facility policy requiring post-administration assessment. The resident continued to experience moderate pain and reported that no reassessment occurred.
A resident receiving hemodialysis, who had a history of end stage renal disease and dementia, experienced an episode of confusion that was not communicated by nursing staff to the dialysis center. The required documentation in the Dialysis Communication Record was also not completed, despite facility policy and staff statements emphasizing the importance of timely communication for residents undergoing dialysis.
A resident with CHF and obesity, who was able to make decisions and communicate, was prescribed Furosemide oral solution to be given by mouth. Instead, an RN administered the medication via the resident's feeding tube, contrary to the physician's order and facility policy, as confirmed by record review and staff interview.
A resident with diabetes did not receive Hemoglobin A1C testing every three months as ordered by the physician, with a missed test resulting in inadequate monitoring of their diabetes. An LVN confirmed the lapse, and facility policy requiring prompt completion of diagnostic orders was not followed.
A resident with a history of lung transplant and diabetes experienced severe, unrecognized weight loss due to inaccurate monitoring and documentation of food and fluid intake. Staff failed to follow care plan interventions, did not notify the physician or RD of poor intake, and did not provide clear instructions for calculating food consumption. As a result, the resident's significant weight loss was not identified, leading to delayed care and hospitalization for severe malnutrition and related complications.
A resident with a lung transplant did not receive Tacrolimus as ordered after a family member requested the medication be held for a blood test. Nursing staff acted on the family member's request without obtaining a physician's order, resulting in the medication being withheld. The physician was not notified, and facility policy requiring medications to be given per prescriber orders was not followed.
A facility's call light system was found to be inaudible in a resident's care area and hallways, leading to delayed assistance. A resident reported waiting 30 minutes for help during the night shift, using her phone to call for assistance. The Maintenance Director demonstrated that the system's volume could be adjusted to be audible, but it had been left low for a long time. The DON confirmed the importance of audible call lights for resident dignity and timely care.
A resident was not readmitted to the facility after hospitalization due to an outstanding debt, despite being cleared for return by the hospital. The facility failed to provide a bed hold or discharge notice, resulting in the resident remaining at the hospital for 22 days. The facility's policies requiring a 30-day advance notice for transfers or discharges were not followed.
A facility failed to report a resident-to-resident altercation to the CDPH and Ombudsman within the required timeframe. One resident, with a history of aggressive behavior, verbally threatened another resident, which was witnessed by staff and family members. Despite recognizing the incident as verbal abuse, the facility did not report it promptly, violating their policy and residents' rights.
The facility failed to investigate a resident-to-resident altercation involving a resident with a history of verbally aggressive behavior. The incident, witnessed by family members and staff, involved one resident blocking another's room and yelling and cursing. Despite the facility's policy requiring immediate reporting and investigation of abuse, no investigation was conducted, and the incident was not reported to relevant authorities.
A resident with hemiplegia and hemiparesis required substantial assistance for transfers as per their care plan, which specified two or more staff members for safe transfers. However, an RNA transferred the resident alone, contrary to the care plan. Interviews revealed the RNA believed he could manage alone, while the care plan's instructions applied to all staff to ensure safety. The DON confirmed the care plan's requirements were not dependent on staff size or gender.
The facility failed to store food properly, leading to potential contamination risks for 106 residents. Observations revealed improperly dated and sealed food items, inadequate hand hygiene, and improper glove use by dietary staff, as well as a cook wearing an uncovered wristwatch during meal preparation, all contrary to facility policies.
The facility failed to maintain the dignity and privacy of residents during care. Two residents were exposed due to undrawn privacy curtains, and another resident's urinary bag was not fully covered, leaving it visible to others. These actions were contrary to the facility's policy on maintaining resident dignity and privacy.
The facility staff failed to ensure call lights were within reach for two residents, potentially delaying necessary assistance. One resident with severe cognitive impairment and another requiring maximum assistance were both observed with call lights on the floor. Staff interviews confirmed that this could lead to frustration and affect residents' psychosocial wellbeing.
The facility failed to submit MDS assessments for two residents within the required 14-day timeframe, as confirmed by the MDS Coordinator and CMS Submission Report. This delay could impact quality measures and care plans.
The facility failed to provide necessary social services to three residents, leading to deficiencies in their care. One resident's advanced directive was not followed up on, another experienced delays in receiving dentures, and a third was not seen by a podiatrist for six months, resulting in pain. These oversights highlight significant lapses in meeting residents' needs.
Two residents' refrigerated medications were improperly stored in a medication cart instead of a refrigerator, potentially affecting their potency. A resident with diabetes had an unopened vial of Insulin Glargine not refrigerated, and another resident's insulin pen lacked an opened date and was also not refrigerated. The facility's policy requires refrigerated medications to be stored securely in a refrigerator.
The facility failed to implement proper infection control measures, including the use of PPE for two residents under Enhanced Barrier Precautions, improper glove handling during medication administration, and incorrect isolation signage for a resident with ESBL. These lapses were acknowledged by staff and highlighted the need for adherence to infection control protocols.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. One resident was prescribed antibiotics for cellulitis despite normal WBC levels, another received antibiotics for a respiratory infection without meeting criteria, and a third was on long-term antibiotics without improvement. The facility did not consistently conduct culture and sensitivity tests to guide therapy.
A resident with a history of gastroenteritis, colitis, and myocardial infarction called 911 multiple times due to abdominal pain and constipation, leading to hospitalization for fecal impaction and stercoral colitis. The facility failed to assess the resident for a change of condition (COC) and notify the physician, as required by policy. Interviews with nursing staff revealed a lack of documentation and communication regarding the resident's condition and refusal of medication.
A resident with chronic respiratory failure did not receive continuous oxygen therapy as prescribed, as staff failed to replace the nasal cannula after personal care. The oxygen concentrator was left on, posing a fire hazard, and the resident's call light was out of reach, preventing them from requesting assistance.
A resident was prescribed psychotropic drugs without documented necessity, as the facility failed to ensure the medication was required for a specific diagnosed condition. Despite the addition of mental health diagnoses, the resident's records showed no documented episodes of the behaviors the medications were meant to address. The lack of specific behavior monitoring and documentation led to the failure to attempt Gradual Dose Reduction, resulting in the use of unnecessary psychotropic drugs.
The facility exceeded the acceptable medication error rate with a 10.71% error rate involving three residents. A resident did not receive a Lidocaine patch on time, another received eye drops in both eyes instead of one, and a third was given Calcium Acetate tablets late and without a meal. The DON confirmed these as medication errors.
Three residents experienced medication administration errors in an LTC facility. A resident did not receive a prescribed lidocaine patch due to unavailability, another received eye drops in both eyes instead of just the right eye, and a third was given calcium acetate without a meal. The DON confirmed these were medication errors.
A resident in an LTC facility did not receive food items of their choice due to the facility's failure to document and communicate their food preferences. Despite the resident's capacity to make decisions and express preferences, the dietary profile lacked documentation of dislikes, and the dietician's intended changes were not implemented. This resulted in the resident receiving unwanted food items, contrary to the facility's policies.
A resident reported being left in a soiled diaper, but the facility failed to investigate the grievance as required by its policy. Despite the resident's cognitive capacity and dependency on staff for toileting, no documentation or investigation was conducted, and the Director of Nursing and Social Services Director could not recall the events. This lack of action indicates a failure to adhere to the facility's grievance policy.
Failure to Protect Resident From Alleged Abuse and to Separate From Alleged Perpetrator During Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to separate the resident from the alleged perpetrator during an abuse investigation. The resident had depression, anxiety, dementia, moderate cognitive impairment, and fluctuating capacity to understand and make medical decisions, and was dependent on staff for several ADLs. According to the facility’s incident investigation, the resident reported that a CNA was inappropriate during care, including rough handling, hair pulling, and other actions perceived as harmful. The resident’s responsible party later reported to the administrator that the resident said the CNA placed a pillow on her face, pinched her cheek, covered her nose and mouth with his hands, and that the resident was fearful of the CNA. In interviews, the CNA admitted pinching the resident’s cheek as a gesture of endearment on the resident’s birthday, acknowledged he did not act professionally, and stated that while providing care he may have accidentally pulled her hair and caused a pillow to fall on her face without explaining his actions to the resident. Despite these allegations and the resident’s expressed fear, the facility did not implement protective separation between the resident and the alleged perpetrator during the investigation, contrary to its Abuse Program Policy and Procedure, which required that residents be protected from harm during the investigation process and that the resident and alleged perpetrator be separated. Instead, the DSD, HR representative, and the CNA held a face-to-face meeting with the resident, during which the CNA apologized and characterized the incident as a misunderstanding, while the resident’s responsible party listened by phone. The responsible party reported hearing the CNA apologize and the resident sounding upset and stating that the CNA was lying before later accepting the apology. The DSD stated she believed it was important for the CNA to apologize and clear up what she viewed as a misunderstanding and did not consider the policy requirement to separate the resident and alleged perpetrator when arranging the meeting. The resident later stated that the CNA’s actions made her afraid and that she did not want the CNA to provide her care anymore.
Failure to Report Allegation of Abuse to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the California Department of Public Health (CDPH) and other required agencies after being notified of the allegation. Resident 1, who had depression, anxiety, dementia, moderate cognitive impairment, and fluctuating capacity to understand and make medical decisions, was dependent on staff for several ADLs. An incident investigation document indicated that on 3/22/2026 Resident 1 reported that a CNA was inappropriate during care, possibly rough handling her, pulling her hair, and engaging in other actions perceived as harmful. On 3/23/2026, Resident 1’s responsible party (RP) telephoned the Administrator (ADM) and reported that Resident 1 said the CNA placed a pillow on her face, pinched her cheek, covered her nose and mouth with his hands, and handled her roughly, causing Resident 1 to be fearful of the CNA. The RP later listened by phone to a meeting between Resident 1, the CNA, and a Human Resources representative, during which the CNA apologized for pinching Resident 1’s cheek and pulling her hair, and Resident 1 initially disputed his account before ultimately accepting the apology. During interviews, the ADM confirmed that the RP had reported these allegations to her on 3/23/2026 and stated she did not report the allegations to law enforcement, the Ombudsman, or CDPH because she concluded abuse had not occurred, believed the incident was a misunderstanding, and believed there was no harm to Resident 1. The Director of Staff Development (DSD) stated she did not report the incident because the ADM was the abuse coordinator, and the Director of Nursing (DON) stated the ADM, as abuse coordinator, was responsible for immediately reporting any allegations of abuse to the appropriate agencies and that all allegations should be reported to the Ombudsman, CDPH, and law enforcement. The facility’s Abuse Program Policy and Procedure indicated that the abuse coordinator shall report such incidents to the required agencies. Despite this policy and the staff’s understanding that all allegations of abuse must be reported, the allegation involving Resident 1 and the CNA was not reported to the required authorities.
Failure to Honor Resident Preference for CNA Assignment
Penalty
Summary
The facility failed to honor a resident’s request not to receive care from a specific CNA. The resident was admitted with diagnoses including unspecified anxiety disorder and insomnia, and the MDS dated 10/31/2025 indicated the resident had the capacity to understand and make decisions. The resident also required substantial to maximum assistance with toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. During interview, the resident stated that on 10/30/2025 CNA 1 was assigned during the 3-11 p.m. shift and refused to provide a shower, and that she told LVN 1 she did not want CNA 1 assigned to her. The resident’s request was documented in the Change of Condition Evaluation dated 10/30/2025, which stated she asked not to be assigned to CNA 1 and requested a different CNA; CNA 2 was then assigned. However, CNA 1 later stated she was assigned to the resident on 11/1/2025 and was not aware she was not to be assigned to her. LVN 1 stated the preference should be communicated to all nursing staff and documented in the communication book, but it was not documented there, and he was unaware of the preference at the time of assignment. RNA 1 stated he made the CNA assignment on 11/1/2025 without knowing the resident’s preference. The DON stated she was aware of the resident not wanting CNA 1 to provide care and that honoring such preferences relates to resident rights and dignity.
Failure to Initiate Change in Condition for Abnormal Lab Result
Penalty
Summary
The facility failed to complete a required change in condition (COC) for a resident who exhibited a sudden and clinically significant deviation from baseline health status. The resident, who had a history of cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia, was found to have an elevated uric acid level of 10.3 mg/dl, which was above the normal range. Additionally, the resident presented with swelling, tenderness, and pain in the left third finger. Although the physician was notified and further diagnostic tests were ordered, the facility did not initiate a COC as required by their policy. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed that a COC should have been completed to ensure appropriate monitoring and communication among staff regarding the resident's abnormal lab result and change in condition. Review of facility policy indicated that prompt notification and documentation of changes in a resident's medical or mental condition are required, but this process was not followed in this instance.
Failure to Develop Comprehensive Care Plans for Swelling and Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was readmitted with multiple diagnoses, including cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia. Upon review, it was found that the resident had a severely impaired cognition and was dependent on staff for activities of daily living. Despite documentation of swelling and pain in the resident's left third finger and a significant weight loss of 50 pounds upon readmission, no care plans were created to address these issues. The absence of care plans was confirmed by both the Registered Nurse Supervisor and the Director of Nursing during interviews, with the latter stating that the weight loss was considered under an existing tube feeding care plan rather than a separate plan. Facility policies required that comprehensive, person-centered care plans be developed to address all identified problems and conditions, including undesirable or unintended weight loss. The policies also specified that individualized care plans should include causes, goals, benchmarks, and time frames for monitoring and reassessment. However, the facility did not follow these procedures for the resident's swollen finger or significant weight loss, as evidenced by the lack of corresponding care plans in the resident's records.
Failure to Provide Timely Follow-Up for Dental and Urology Services
Penalty
Summary
The facility failed to ensure timely follow-up and coordination of medically-related social services for a resident with multiple complex diagnoses, including cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia. The resident was severely cognitively impaired and fully dependent on staff for activities of daily living. Despite recommendations for dental services, including tooth extractions and dentures, the Social Services Director did not follow up on the necessary authorizations for several months. The dental company scheduled appointments, but the Social Services Director did not verify whether the services were completed, resulting in a significant delay and the need to obtain a new authorization. Additionally, the facility did not ensure that the same resident attended a scheduled urology follow-up appointment, which was necessary to confirm the resolution of a urinary tract infection. The Licensed Vocational Nurse entered the appointment order into the facility's system and provided it to Social Services, who were responsible for arranging transportation. However, there was no documentation explaining why the resident missed the appointment, and neither the Social Services Designee nor the Social Services Assistant could provide records or notes verifying communication with the transportation provider. The absence of documentation and lack of follow-up led to the missed appointment. Interviews with staff, including the Director of Nursing, confirmed that there was no explanation or documentation for the missed urology appointment and that the Social Services team did not track or verify completion of outside appointments. The facility's policies required prompt referral and follow-up for medically-related social services, but these were not followed in the resident's case, resulting in delays in necessary care and services.
Failure to Label and Date Food Items in Kitchen Storage
Penalty
Summary
Surveyors observed multiple instances of improper food storage and preparation practices in the facility's kitchen. Specifically, a box of Boost nutritional drink supplement with 19 remaining packs was found in the dry storage area without a date or label. In freezer #1, a box of chocolate fat free ice cream with 26 cups and a box of honey wheat roll dough were both stored without any date or label. Additionally, in refrigerator #1, a box of liquid whole eggs pasteurized with 11 remaining packs was also found without a date or label. Dietary staff interviewed during these observations confirmed that all food items should be labeled with the delivery date, the date opened, and the best buy date, in accordance with facility policy. The Dietary Service Supervisor acknowledged that the lack of labeling and dating made it impossible to track when food items were opened or when they should be discarded. The facility's policy and procedure on labeling and dating of foods requires that all food items be labeled with the received date upon delivery, the open date once opened, and a use by date. These deficiencies were identified during concurrent observations and interviews, and the practices observed were not in compliance with the facility's stated standards.
Deficiencies in Water Management, Policy Updates, and Infection Control Practices
Penalty
Summary
The facility failed to maintain a comprehensive water management program as required by its own policies and procedures. The water management binder only contained results of random Legionella testing and daily water temperature checks in a limited number of locations, without documentation of procedures for out-of-range temperatures, diagrams of the water system, or identification of all areas where water may collect or flow. There was no interdisciplinary water management team meeting routinely, nor a system to identify situations that could lead to Legionella growth, such as biofilm or sediment buildup. Interviews with the Infection Prevention Nurse and Maintenance Supervisor confirmed these gaps and the absence of a complete water management plan as outlined in facility policy. The Infection Prevention and Control Program (IPCP) policies and procedures were not current or reflective of national standards. The policy on staff COVID-19 vaccination was outdated, still requiring vaccination, booster, and additional testing or masking for unvaccinated staff, despite current practice and regulations no longer mandating these measures. The administrator acknowledged that the policy had not been updated and that staff were not required to provide evidence for vaccine refusal, nor were they subject to additional testing or masking, contrary to the written policy. The facility's process for policy review was also found to be ineffective in ensuring policies remained current and aligned with regulatory requirements. Additionally, staff failed to follow infection control protocols during wound care preparation for a resident with multiple complex medical conditions, including an unstageable pressure ulcer, diabetes, dementia, and quadriplegia. A treatment nurse was observed disinfecting the resident's bedside table and preparing wound care supplies without wearing gloves, in direct violation of the facility's policy on glove use. The nurse acknowledged the lapse and the potential for transferring bacteria to the resident's wound, which could result in infection.
Incomplete Beneficiary Notices for Two Residents
Penalty
Summary
The facility failed to accurately complete Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms for two residents. For one resident with Alzheimer's disease, type 2 diabetes, dysphagia, and osteoarthritis, the SNF ABN form did not specify which services were being received or the cost per day for those services after Medicare Part A coverage ended. This resident required maximal assistance with activities of daily living and had moderately impaired cognitive skills. Similarly, another resident with anemia, type 2 diabetes, end stage renal disease, and congestive heart failure, who required partial assistance with activities of daily living and had intact cognitive skills, also had an incomplete SNF ABN form lacking details about specific services and daily costs. During an interview and record review, the admissions coordinator confirmed that the SNF ABN forms for both residents were incomplete, as they did not indicate the specific care areas or the cost per day for continued services. The facility's policy and procedure on beneficiary notice of non-coverage states that the SNF ABN is intended to inform residents about the services received and the potential out-of-pocket costs, allowing them to make informed decisions. The incomplete forms did not meet these requirements.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation of their medication regimens. For one resident with diagnoses including dementia, seizure disorder, and mood disorder, the MDS assessment did not reflect the use of Depakote, an anti-convulsant medication that had been ordered and administered during the assessment period. The MDS nurse confirmed that the resident began taking Depakote prior to the MDS completion date, but the medication was not coded as an anti-convulsant in the assessment. Similarly, another resident with neuropathy and paraplegia was prescribed Neurontin, a medication classified as an anti-convulsant, which was administered consistently during the MDS look-back period. However, the MDS assessment for this resident did not indicate the use of an anti-convulsant. The MDS nurse acknowledged that Neurontin should have been coded as an anti-convulsant in the MDS, as it was administered within the relevant assessment timeframe. Both instances were identified through interviews and record reviews, where the MDS nurse confirmed the inaccuracies in the MDS assessments. Facility policy requires that staff completing any portion of the MDS certify the accuracy of their entries, but in these cases, the medication information was not accurately documented, leading to the transmission of incorrect data to CMS.
Failure to Implement and Document UTI Monitoring for Catheterized Resident
Penalty
Summary
The facility failed to implement a care plan intervention to monitor for signs and symptoms of urinary tract infection (UTI) for a resident with an indwelling foley catheter. The resident had diagnoses including obstructive uropathy, malignant neoplasm of the bladder, and generalized muscle weakness, and required moderate assistance with daily activities. The care plan specifically included monitoring for UTI symptoms such as chills, fever, sediment build-up, blood clots, bladder distention, and changes in urine output, with the goal of preventing UTI development. Despite these interventions being outlined in the care plan, there was no documentation in the Treatment Administration Record or clinical nursing notes indicating that the resident was monitored for UTI symptoms. During observation, a nurse identified the presence of yellow/white sediments in the resident's catheter tubing, which is a sign of UTI, but confirmed that monitoring and documentation had not occurred. The Director of Nursing also verified the absence of required documentation and emphasized the importance of following care plan interventions to detect and treat UTIs early.
Medications Left Unattended at Bedside for Resident with Cognitive Impairment
Penalty
Summary
A licensed vocational nurse (LVN) left four prescribed medications at the bedside of a resident who had diagnoses including end stage renal disease, hemodialysis, and dementia. The resident had fluctuating capacity to understand and make decisions, as documented in the history and physical, and required moderate assistance with personal care tasks according to the Minimum Data Set. The resident reported that the nurse left the medications at his request during the morning medication pass, and the medications remained at the bedside for over two hours. Interviews with nursing staff, including the LVN, a registered nurse (RN), and the director of nursing (DON), confirmed that facility policy and standard practice require nurses to remain with residents until all medications are taken, and that medications should not be left unattended at the bedside. The DON and RN both stated that the resident was not considered safe to self-administer medications. Review of facility policies indicated that standards of practice are intended to ensure safe and effective care, and that quality of care is governed by regulations focused on resident well-being and safety.
Failure to Provide Resident-Centered Activities per Care Plan
Penalty
Summary
The facility failed to provide resident-centered activities consistent with the care plan for one resident. The resident, who had a history of cerebral infarction, cardiac arrest, anoxic brain damage, aphasia, and scoliosis, was admitted and re-admitted to the facility. The resident's care plan indicated preferences for watching TV, joining small groups, listening to music, and exercising, with specific interventions such as 1:1 socialization, providing an iPad for music, and sensory stimulation. Despite these documented preferences and interventions, observations revealed that the resident was not engaged in these activities as planned. During observations, the resident was found lying in bed, staring straight up, and not watching TV, even though a TV was present in the room. The Activity Director confirmed that the resident was not watching TV at the time and acknowledged that the resident would feel sad if unable to do so. Interviews with staff indicated that while resources and activities were offered, the responsibility for engaging residents in activities was primarily assigned to the Activity Director, with nursing staff only assisting as needed. This lack of engagement and failure to follow the care plan interventions led to the deficiency.
Incorrect Low Air Loss Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident at risk for skin breakdown had a low air loss mattress (LALM) set to the appropriate settings as required by their care plan and physician orders. The resident, who had multiple diagnoses including bladder cancer, limb absence, osteoarthritis, and intervertebral disc degeneration, was identified as having a potential for skin breakdown and required a pressure-redistribution mattress. Observations revealed that the LALM was set at 320 lbs, which did not correspond to the resident's actual weight, and was in static mode rather than alternating mode as recommended by the manufacturer. The resident was unaware of the purpose of the mattress, and the treatment nurse confirmed the settings were incorrect and could impact the effectiveness of pressure relief. Further review of the resident's records, including the care plan and Minimum Data Set (MDS), confirmed the need for a pressure-reducing device and moderate assistance with mobility. Interviews with staff, including the treatment nurse and the Director of Staff Development, acknowledged the importance of correct LALM settings based on resident weight to prevent pressure injuries. The facility's policy and the manufacturer's instructional video both emphasized the necessity of adjusting the mattress to the resident's weight and using the appropriate mode to provide effective pressure redistribution. The failure to follow these protocols constituted the deficiency.
Failure to Label and Replace Respiratory Equipment per Protocol
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of respiratory care equipment for two residents. For one resident with end stage renal disease and anemia, an oxygen concentrator with a nasal cannula and humidifier was observed at the bedside. The nasal cannula was dated from the previous month, and the humidifier was not labeled with any date. The resident reported that the oxygen machine had not been used in the past two weeks. During an interview, a registered nurse confirmed that both the nasal cannula and humidifier should be labeled and changed at least weekly, and acknowledged that failure to do so could potentially cause infection. For another resident with chronic obstructive pulmonary disease and congestive heart failure, a review of records showed a physician's order for twice-daily Budesonide inhalation via nebulizer. The resident's care plan indicated a risk for infection, and medication administration records confirmed regular use of the nebulizer. During observation, the nebulizer tubing was found to be dated from eleven days prior, exceeding the facility's protocol of changing tubing every seven days. The mask attached to the tubing was dated more recently. A licensed vocational nurse stated that the tubing should have been changed according to the weekly schedule but was not. Facility policy and procedure for administering medications through a handheld nebulizer specified that equipment and tubing must be changed every seven days and stored in a plastic bag with the resident's name and date. The failure to follow these protocols for both residents resulted in deficiencies related to the safe and appropriate provision of respiratory care.
Failure to Reassess Pain After Medication Administration
Penalty
Summary
A deficiency occurred when a resident with chronic back pain, generalized osteoarthritis, and muscle weakness did not receive appropriate pain management. The resident was prescribed tramadol 50 mg every 12 hours as needed for moderate to severe pain, with care plan interventions specifying that medication should be administered as ordered and its effectiveness monitored. On the day in question, the resident received tramadol for severe pain, but there was no follow-up assessment of pain level after administration, as required by both the care plan and facility policy. The resident later reported ongoing moderate pain and stated that the nurse did not return to reassess his pain after giving the medication. The nurse confirmed that she did not reassess the resident's pain level after administering tramadol, acknowledging that she should have done so within 30 minutes to an hour to ensure the medication's effectiveness. The DON also stated the importance of assessing pain before and after medication administration to evaluate effectiveness and monitor for side effects. The facility's policy required pain management interventions to be consistent with the resident's goals and specifically documented, which was not followed in this instance.
Failure to Communicate Change of Condition to Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center regarding a resident who was receiving hemodialysis treatment. The resident, who had diagnoses including end stage renal disease, hemodialysis, and dementia, experienced an episode of confusion that was documented in the facility's records. However, the licensed nursing staff did not communicate this change of condition to the dialysis center staff, nor did they document it in the Dialysis Communication Record, which is intended to facilitate information sharing between facility and dialysis staff. Interviews with facility staff confirmed that changes in a resident's condition, such as the episode of confusion, should be communicated immediately to the dialysis center to ensure appropriate management and continuity of care. The facility's policy also emphasized the importance of structured communication and documentation of any changes in condition. Despite these requirements, the failure to communicate the resident's change of condition represented a lapse in following established protocols for residents receiving dialysis services.
Medication Administered by Incorrect Route
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure and obesity, who was capable of making decisions and communicating effectively, did not receive medication as ordered by the physician. The physician's order specified that Furosemide oral solution was to be administered by mouth once daily. However, during a medication pass, a registered nurse was observed administering the Furosemide through the resident's feeding tube instead of by mouth. Upon review of the resident's records, including the care plan and physician orders, it was confirmed that the medication was not given via the prescribed route. The facility's policy on medication administration requires that medications be given according to prescriber orders. The nurse acknowledged that administering medication by an incorrect route could have negative effects and that the medication should have been given by mouth as ordered.
Failure to Complete Ordered Diabetes Lab Monitoring
Penalty
Summary
The facility failed to ensure that a resident with diabetes mellitus received Hemoglobin A1C (HgA1C) testing every three months as ordered by the physician. The resident, who was dependent on staff for dressing and bathing and had a care plan indicating a risk for hypoglycemia or hyperglycemia, had a physician's order dated 2/27/2024 for quarterly HgA1C testing. However, a review of laboratory results showed that the test was completed on 8/16/2024 and 3/25/2025, but not on 6/25/2025 as required by the order. During an interview and record review, an LVN confirmed that the HgA1C test was not completed as ordered and acknowledged that the test was necessary to monitor the resident's diabetes status. The facility's policy required that diagnostic orders be promptly carried out as instructed by the physician, but this was not followed in this case, resulting in inadequate monitoring of the resident's diabetes.
Failure to Recognize and Respond to Severe Weight Loss Due to Inaccurate Food Intake Monitoring
Penalty
Summary
A resident with a history of lung transplant and diabetes mellitus experienced a severe, unrecognized weight loss of 19.25 lbs. in less than a month, dropping from 92 lbs. to 72.75 lbs. Facility staff failed to accurately monitor and document the resident's food and fluid intake, resulting in discrepancies between the Weekly Summary Nurse Progress Notes and the Documentation Survey Reports. The resident's care plan required monitoring for weight loss or gain of three pounds in a week and five pounds in a month, but this was not followed. Additionally, there was no documentation of the percentage of high protein nutrition (HPN) shakes consumed, and staff did not provide clear instructions on how to calculate or record food intake percentages. The facility did not notify the resident's physician or the registered dietitian (RD) of the resident's poor dietary intake and significant weight loss, as required by facility policy and the resident's care plan. Interviews with staff revealed that CNAs estimated food and fluid intake rather than measuring it accurately, and that intake below 50% was not consistently reported to licensed nurses. The DON and DSD confirmed that if a resident's intake was less than 50% for a week or two, or if three meals were missed, the physician and RD should have been notified, but this did not occur for this resident. As a result of these failures, the resident's severe weight loss went unrecognized by facility staff, leading to a delay in care and treatment. The resident was eventually transferred to a general acute care hospital, where she was diagnosed with failure to thrive, severe electrolyte abnormalities, severe protein-calorie malnutrition, cachexia, and dehydration, and required nasogastric tube feeding. The facility did not follow its own policies and procedures for nutritional screening, assessment, and weight change protocol, which required early identification and intervention for significant weight changes.
Failure to Administer Immunosuppressive Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral lung transplant and mild cognitive impairment did not receive Tacrolimus, an immunosuppressive medication, as ordered by the physician. The resident's care plan included the administration of Tacrolimus to prevent shortness of breath related to the lung transplant, and the physician's orders specified the medication should be given twice daily. However, the medication was placed on hold and not administered on a specific date, as documented in the Medication Administration Record. The sequence of events leading to this deficiency began when a family member requested that the medication be held due to an upcoming appointment and blood test. A registered nurse received this request and relayed it to a licensed vocational nurse but did not contact the physician to obtain an order to hold the medication. The physician later confirmed that he was not notified of the request and emphasized that Tacrolimus is necessary to prevent lung transplant rejection. The facility's policy required medications to be administered according to prescriber orders, which was not followed in this instance.
Inaudible Call Light System in Resident Care Area
Penalty
Summary
The facility failed to ensure that the call light system was functioning efficiently, as the volume was not turned up to an audible level. On a specific date, it was observed that the call light system in one of the two nursing stations was not audible in a resident's care area and the facility's hallways. This deficiency was highlighted during an interview with a resident who reported that although the call light illuminated when pressed, she was uncertain if the staff could hear it. The resident recounted an incident where she had to wait 30 minutes for assistance during the night shift, eventually resorting to using her personal phone to call for help. Further observations and interviews revealed that the call light system's volume was adjustable, and when turned up by the Maintenance Director, it became loud and audible. The Registered Nurse Supervisor acknowledged that the system had been inaudible for a long time, relying on staff to visually notice the lights above resident rooms. The Director of Nursing confirmed that the call lights should be both seen and heard to ensure residents' needs are met promptly, as per the facility's policy on resident rights, which emphasizes maintaining residents' dignity and quality of life.
Failure to Readmit Resident After Hospitalization Due to Outstanding Debt
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite the resident being cleared for return by the General Acute Care Hospital (GACH). The resident, who had been initially admitted to the facility with diagnoses of heart failure and chronic respiratory failure, was transferred to the GACH due to shortness of breath. The facility did not provide a bed hold or a notice of transfer discharge, which resulted in the resident remaining at the GACH for 22 days beyond the date they were cleared to return. The facility's administrator refused to readmit the resident due to an outstanding debt of over $14,500 owed by the resident. This decision was made without providing the resident or their responsible party with a bed hold or discharge notice, as required by the facility's policies. The resident's responsible party was informed of the potential eviction on the day of the hospital transfer, causing concern about the resident's potential homelessness. Interviews with the Director of Nursing Services and the Administrator confirmed the lack of proper documentation and communication regarding the resident's transfer and discharge. The facility's policies require a 30-day advance written notice for transfers or discharges, which was not adhered to in this case. The Director of Nursing Services acknowledged that the resident should have been readmitted to ensure continuity of care and to prevent feelings of abandonment.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to immediately report a resident-to-resident altercation to the California Department of Public Health (CDPH) and the State Long Term Care Ombudsman within the required two-hour timeframe. This deficiency involved two residents, both of whom were involved in an incident where one resident exhibited verbally aggressive and threatening behavior towards the other. The failure to report this incident in a timely manner hindered the CDPH's ability to investigate the allegations of abuse promptly and posed a risk of other abuse allegations going unreported. Resident 1, who was admitted with multiple diagnoses including nontraumatic intracerebral hemorrhage and hemiplegia, exhibited verbally aggressive behavior on several occasions as documented in their Medication Administration Record (MAR). On the day of the incident, Resident 1 blocked the door to Resident 2's room and began yelling and cursing at Resident 2 and the staff. This behavior was witnessed by family members of Resident 2 and staff, including a Licensed Vocational Nurse (LVN), who intervened before any physical harm occurred. Despite the aggressive behavior being recognized as verbal abuse, there was no investigation summary report for this incident. The facility's policy and procedure on abuse require that any incident constituting abuse be reported immediately or no later than 24 hours after identification. However, the facility did not adhere to this policy, as evidenced by the lack of a timely report to the appropriate authorities. Interviews with the Administrator and Director of Nursing confirmed that the incident was considered abuse and should have been reported. The facility's failure to report the incident promptly is a clear violation of the residents' rights to be free from abuse, as outlined in their policy and procedure.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not investigating a resident-to-resident altercation involving two residents. Resident 1, who had a history of verbally aggressive and threatening behavior, was involved in an incident where they blocked the door to Resident 2's room and began yelling and cursing at Resident 2 and the staff. This incident was witnessed by family members of Resident 2, who reported feeling scared for Resident 2's safety. Despite this, the facility did not conduct an investigation into the incident or document it in their incident investigation summary reports. Resident 1 had been admitted to the facility with several diagnoses, including nontraumatic intracerebral hemorrhage, hemiplegia, and hemiparesis, and was noted to have intact cognitive skills but required maximal assistance for activities of daily living. Resident 2, on the other hand, had moderate cognitive impairment and required moderate assistance for mobility and personal hygiene. The altercation between the two residents was not reported to the Department of Public Health, the ombudsman, or the police, as required by the facility's policy. Interviews with staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that the incident was considered verbal abuse and should have been reported and investigated. The facility's policy mandates that any incident of abuse be reported immediately and investigated, with corrective measures implemented to prevent further occurrences. However, in this case, the facility did not adhere to its policy, resulting in a failure to protect residents from potential abuse.
Failure to Follow Care Plan for Resident Transfers
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required substantial assistance during transfers due to hemiplegia and hemiparesis following a cerebral infarction. The resident's care plan specified the need for two or more staff members to assist with transfers to prevent falls or injuries. However, during an observation, a Restorative Nursing Assistant (RNA) transferred the resident from a wheelchair to a bed without assistance from another staff member, contrary to the care plan's requirements. Interviews with the resident, RNA, and other staff members revealed that the RNA believed he could perform the transfer alone, while the care plan clearly indicated the necessity of two or more staff members for safe transfers. The Director of Nursing confirmed that the care plan's instructions apply to all staff members, regardless of their size or gender, to ensure resident safety. The facility's policy on comprehensive care plans emphasized that interventions are designed after careful consideration of the resident's needs, yet this protocol was not followed in this instance.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of microorganisms and potential foodborne illnesses for 106 out of 108 residents. During an observation, it was noted that various food items in the dry storage room were not properly dated, labeled, or sealed. Items such as vanilla pudding mix, lemon gelatin mix, and various types of pasta were found without proper 'used by' dates, and some containers were not tightly sealed. The Dietary Supervisor acknowledged the responsibility of all dietary staff to ensure food items are labeled, dated, and stored correctly to prevent contamination. Additionally, during a tray line observation, a Dietary Aid failed to perform proper hand hygiene and glove changes between tasks, which could lead to cross-contamination. The Dietary Aid was observed handling various items, including refrigerator doorknobs and ice scoops, without changing gloves or washing hands. This was contrary to the facility's policies on handwashing and glove use, which emphasize the importance of changing gloves and washing hands between different tasks to prevent foodborne illnesses. Furthermore, a cook was observed wearing a wristwatch that was not fully covered by gloves while assisting in checking food temperatures during meal preparation. This was against the facility's dress code policy, which requires jewelry and wristwatches to be covered with gloves during food handling to prevent the spread of germs. The Registered Dietitian confirmed that proper hand hygiene and PPE use are essential to prevent cross-contamination during meal preparation.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of four residents during care, as observed by surveyors. For two residents, the privacy curtain was not drawn while personal care was being provided, resulting in exposure of the residents' bodies to passersby in the hallway. Resident 26 was observed with an exposed left breast, and Resident 27 was seen with their back exposed while wearing an incontinent brief. Both residents required assistance for all activities of daily living and had no cognitive impairments, emphasizing the importance of maintaining their dignity and privacy during care. Additionally, the facility did not ensure that Resident 213's indwelling urinary bag was fully covered with a privacy bag, leaving the urine visible to visitors and other residents. Resident 213 had the capacity to understand and make decisions and required substantial assistance with personal care. The failure to cover the urinary bag was acknowledged by a CNA, the Infection Preventionist Nurse, and the Director of Nursing, all of whom stated that the privacy bag was necessary to maintain the resident's dignity. The facility's policy on Quality of Life-Dignity emphasizes the importance of treating residents with dignity and respect, including maintaining bodily privacy during personal care. The policy explicitly prohibits demeaning practices and requires staff to assist residents in keeping urinary catheter bags covered. The observations and interviews conducted during the survey highlight the facility's failure to adhere to these policies, resulting in a deficiency in maintaining resident dignity and privacy.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility staff failed to ensure that the call lights were within reach for two residents, Resident 12 and Resident 16, which could prevent them from receiving necessary assistance. Resident 16, who was admitted with severe cognitive impairment and required assistance for all activities of daily living, was observed on two occasions with the call light on the floor and not within reach. The care plan for Resident 16 included an intervention to keep the call light available and answer it promptly, but this was not adhered to during the observations. Similarly, Resident 12, who had no cognitive impairment but required maximum assistance for activities of daily living, was also observed with the call light on the floor and not within reach. The care plan for Resident 12 also included the intervention to keep the call light available and answer it promptly. Interviews with the Director of Staff Development, a Certified Nursing Assistant, and a Registered Nurse confirmed that the unavailability of the call light could lead to frustration and affect the psychosocial wellbeing of the residents, as well as delay the care needed.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents were transmitted within the required 14-day timeframe after completion. Specifically, the assessments for Resident 69 and Resident 83 were submitted late, as indicated by the MDS submission forms dated 05/16/2024 and 06/24/2024, respectively. This delay was confirmed during an interview with the MDS Coordinator, who acknowledged that the discharge assessments from the hospital for these residents were not submitted on time. The MDS Coordinator admitted that the late submission could impact the quality measures, the plan of care, and the accuracy of the assessments. A review of the Centers for Medicare and Medicaid Services (CMS) Submission Report dated 08/07/2024 further confirmed that the final validation reports for both residents' assessments were completed more than 14 days after the required timeframe. The facility's policy and procedure on MDS Completion and Submission Timeframes, although undated, stated that assessments should be conducted and submitted in accordance with federal and state submission timeframes.
Deficiencies in Social Services and Ancillary Care
Penalty
Summary
The facility failed to provide necessary social services to three residents, leading to deficiencies in their care. For Resident 37, the facility did not follow up on the advanced directive, which is crucial for ensuring that the resident's healthcare decisions are respected. Despite having the capacity to understand and make decisions, Resident 37's California Power of Attorney form was incomplete, lacking dates and signatures. The Social Service Director acknowledged the absence of an advance directive since the resident's admission in 2015, which could lead to conflicts regarding healthcare decisions. Resident 93 experienced a lack of follow-up regarding dentures, which affected his comfort and well-being. Although the resident had undergone dental procedures, there was no documentation or follow-up on the need for dentures, despite the resident expressing his frustration and the facility being aware of the issue since February 2024. The Social Service Director admitted to knowing about the denture issue but failed to document any follow-up actions, leading to a delay in addressing the resident's needs. Resident 94 was not seen by a podiatrist for six months, resulting in untrimmed toenails and pain in her right toe. Despite the facility's policy of podiatrist visits every two months, a pending authorization from the resident's health insurance delayed the visit. The Registered Nurse Supervisor and Director of Nursing acknowledged the oversight, emphasizing the importance of timely podiatric care, especially for residents with diabetes. The facility's failure to ensure timely podiatric care for Resident 94 highlights a significant lapse in meeting the residents' ancillary service needs.
Improper Storage of Refrigerated Medications
Penalty
Summary
The facility failed to appropriately store medications that required refrigeration for two residents, leading to a potential loss of medication potency. Resident 80, who has Type 2 diabetes mellitus with diabetic neuropathy and anemia, was found to have an unopened vial of Insulin Glargine that was not stored in the refrigerator as required. The medication instructions specified that it should be refrigerated before use and discarded 28 days after opening. However, the insulin was found in the medication cart instead of being refrigerated, which could affect its effectiveness. Similarly, Resident 5, who has Type 2 diabetes mellitus, hyperlipidemia, and peripheral vascular disease, had an insulin pen that was also not stored in the refrigerator. The insulin pen lacked an opened date, and the Licensed Vocational Nurse (LVN) acknowledged that the insulin should have been refrigerated and disposed of properly. The facility's policy on medication storage mandates that medications requiring refrigeration must be stored in a refrigerator located in a secure location, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Usage and Isolation Protocols
Penalty
Summary
The facility failed to implement proper infection control measures for two residents, Resident 4 and Resident 213, who were under Enhanced Barrier Precautions (EBP) due to their medical conditions. Certified Nursing Assistant (CNA) 1 did not wear a gown while assisting Resident 4 with activities of daily living and changing bed linen, despite the requirement to do so in an EBP room. Similarly, CNA 7 failed to wear a gown while handling Resident 213's urinary catheter bag. Both CNAs acknowledged their lapses, attributing them to forgetfulness, and recognized the importance of wearing PPE to prevent infection. Another deficiency was observed during the medication administration for Resident 25. Licensed Vocational Nurse (LVN) 4 was seen removing gloves from her pocket instead of the dispensing box, which is against the facility's policy. LVN 4 admitted that this practice could lead to contamination and expose residents to infection. The facility's policy clearly states that gloves should be removed from the dispensing box to maintain hygiene standards. The facility also failed to place correct isolation signage for Resident 62, who was supposed to be under contact isolation for ESBL in urine. Instead, the signage indicated red cohort isolation, which required different PPE. LVN 3 entered the room without the appropriate PPE, as the signage was misleading. The Infection Preventionist Nurse confirmed the error in signage and emphasized the importance of correct isolation protocols to prevent ineffective infection control.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for three residents. Resident 12 was prescribed Clindamycin for left foot cellulitis despite having a normal white blood cell count, and the antibiotic was later changed to Keflex without clear justification. The Infection Preventionist Nurse (IPN) acknowledged that the resident's WBC was within the normal range and that the decision to prescribe antibiotics was based on McGeer's Criteria, which may not have been fully met. Resident 78 was treated with Levaquin for a respiratory tract infection based on a chest x-ray showing lower left lobe infiltrate, despite not having a cough or fever and only one of the required respiratory subcriteria being met. The IPN admitted that the McGeer's Criteria was incorrectly documented and that the resident did not have a confirmed diagnosis of pneumonia. Additionally, Resident 78 was later prescribed Clindamycin for right arm cellulitis without a significant change in clinical status or WBC count. Resident 100 was on long-term antibiotics, including Clindamycin and Rifampin, for cellulitis and recurrent wound infections. Despite ongoing treatment, the resident reported that the condition had not improved, and the wound size remained unchanged over several assessments. The facility's policy indicated that antibiotics should be prescribed under the guidance of the Antibiotic Stewardship Program, but there was no evidence of culture and sensitivity tests being conducted to guide antibiotic therapy. The IPN and RNS acknowledged the importance of reassessing the need for antibiotics and conducting cultures, but these steps were not consistently followed.
Failure to Assess Change of Condition and Notify Physician
Penalty
Summary
The facility failed to assess a resident for a change of condition (COC) and notify the physician when the resident called 911 due to abdominal pain and constipation. The resident, who had a history of gastroenteritis, colitis, and myocardial infarction, was dependent on nursing staff for various activities and had the capacity to understand and make decisions. Despite the resident's complaints of abdominal pain and constipation, there was no documentation of a COC assessment or physician notification, leading to the resident calling 911 multiple times and being hospitalized for abdominal pain, fecal impaction, and stercoral colitis. Interviews with the nursing staff, including an LVN and the Registered Nurse Supervisor (RNS), revealed that the resident had requested pain medication, which was not administered as scheduled, and subsequently called 911. The LVN acknowledged the lack of COC documentation and physician notification, while the RNS confirmed that the resident was hospitalized after calling 911 due to feeling hot, nauseated, and unable to have a bowel movement. The RNS also noted that the resident had refused medication for constipation, but this refusal was not documented or communicated to the physician. The Director of Nursing (DON) admitted that the nursing staff did not have time to assess the resident for a COC before the paramedics arrived. The facility's policy and procedure required prompt notification of the physician and documentation of any changes in the resident's condition, which was not followed in this case. The resident's medical records from the general acute care hospital indicated diagnoses of abdominal pain, fecal impaction, and stercoral colitis, highlighting the severity of the situation and the facility's failure to provide appropriate care and communication.
Failure to Ensure Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received continuous oxygen therapy as prescribed. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, heart failure, and schizoaffective disorder, required assistance for all activities of daily living and had no cognitive impairment. The care plan for the resident included administering oxygen for shortness of breath due to chronic respiratory failure and monitoring its effectiveness. However, during observations on multiple occasions, the resident's nasal cannula was found on top of the bed, not in the resident's nostrils, while the oxygen concentrator was on. Interviews revealed that staff sometimes forgot to replace the nasal cannula after providing personal care, and the resident was unable to call for assistance as the call light was on the floor. The Director of Staff Development and a Licensed Vocational Nurse confirmed that the oxygen concentrator should be turned off when not in use to prevent fire hazards and ensure safety. The facility's policy on oxygen administration emphasized the importance of removing flammable items from the area and ensuring the call light is within easy reach of the resident.
Failure to Ensure Necessary Use of Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for a resident, identified as Resident 24, by not confirming that the medication was necessary to treat a diagnosed specific condition documented in the clinical record. Resident 24 was admitted with diagnoses including dementia and cerebral infarction, and later schizoaffective disorder, major depressive disorder, and anxiety disorder were added. Despite these diagnoses, the Minimum Data Set (MDS) indicated that Resident 24 had no hallucinations, delusions, or behavioral symptoms, yet was prescribed antipsychotic, antianxiety, and opioid medications. The facility's records showed that there were no documented episodes of the behaviors that the medications were intended to address, such as mood swings, anger outbursts, or paranoid ideation, from June to July 2024. The Registered Nurse Supervisor acknowledged that the behaviors being monitored were not specific and that the lack of documentation could lead to improper Gradual Dose Reduction (GDR) practices. The Psychiatry Physician's Assistant admitted that the decision not to attempt GDR was based on staff reports of behavior issues, which were not documented, leading to potential unnecessary medication use. The Director of Nursing confirmed that the facility should have attempted GDR based on the resident's behavioral episodes and that psychotropic medication use should be minimized. The facility's policies required monitoring for effectiveness and side effects of psychotropic medications, with specific behaviors documented in the resident's health record. However, the lack of specific behavior monitoring and documentation led to the failure to provide the minimum effective dose for Resident 24, resulting in the use of unnecessary psychotropic drugs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.71 percent. This was identified through four medication errors out of 28 opportunities involving three residents. For Resident 90, a Lidocaine patch prescribed for left shoulder pain was unavailable, leading to a delay in administration. The LVN acknowledged the absence of the patch and informed the resident and the nurse practitioner about the delay, which could potentially increase the resident's shoulder pain. Resident 310 experienced a medication error when the LVN administered an eye drop intended only for the right eye into both eyes. The LVN admitted to the mistake during an interview. For Resident 81, the LVN administered Calcium Acetate tablets late and without a meal, contrary to the prescribed order. The Director of Nursing confirmed that not following the doctor's order constitutes a medication error and emphasized the importance of timely medication administration as per the facility's policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors. Resident 90 did not receive a prescribed lidocaine patch for left shoulder pain because it was unavailable. The Licensed Vocational Nurse (LVN) acknowledged the absence of the patch and informed the resident, the nurse practitioner, and the pharmacy about the delay. This oversight had the potential to increase Resident 90's shoulder pain and limit arm movement. Resident 310 received an incorrect administration of eye drops. The LVN administered brimonidine tartrate eye drops in both eyes, although the medication was prescribed only for the right eye to treat glaucoma. Additionally, Resident 81 was given calcium acetate tablets without a meal, contrary to the prescription that required administration with meals to lower phosphorus levels. The Director of Nursing confirmed that not following the doctor's orders constitutes a medication error and emphasized the importance of timely medication administration as per the facility's policy.
Failure to Honor and Document Resident's Food Preferences
Penalty
Summary
The facility failed to honor and document the food preferences of a resident, leading to the resident not receiving food items of their choice. The resident, who had the capacity to understand and make decisions, was on a regular renal diet and expressed dissatisfaction with the food provided, specifically mentioning a dislike for mocha mix and a preference for regular milk. Despite the resident's requests for meal substitutes, these preferences were not communicated to the kitchen staff, resulting in the resident receiving unwanted food items. The dietary profile and nutritional review screening for the resident lacked documentation of food dislikes and specific preferences. The dietary supervisor acknowledged that food preferences should be documented upon admission and updated as needed, but this was not done for the resident. The registered dietician confirmed that the resident's diet was supposed to be changed to regular milk upon admission, but this change was not implemented. The facility's policies required food preferences to be identified and documented within a specific timeframe, but these procedures were not followed, contributing to the deficiency.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to implement its grievance policy and procedure, which requires that all grievances be investigated promptly after being filed. This deficiency was identified in the case of a resident who had been admitted with a diagnosis of traumatic hemorrhage of the left cerebrum and was cognitively intact. The resident was dependent on staff for toileting hygiene and was always incontinent. Despite these needs, the resident reported being left in a soiled diaper, and a family member allegedly took pictures of the incident. However, the facility did not document any investigation into this grievance, and no progress notes or interdisciplinary team meetings were conducted to address the concern. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) revealed that neither could recall the events related to the grievance, and no documentation was found to indicate that an investigation had been conducted. The facility's policy requires that grievances be initiated as soon as practicably possible and that residents be kept informed of the resolution process. The lack of documentation and investigation into the resident's grievance indicates a failure to adhere to this policy, potentially affecting the resident's quality of life.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Torrance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Rehabilitation Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Vermont Healthcare Center | 0.4 mi | ★★★★★ | 29 | 1 |
| Sunnyside Nursing Center | 0.8 mi | ★★★★★ | 28 | 1 |
| Lomita Post-acute Care Center | 2.6 mi | ★★★★★ | 29 | 0 |
| Beachside Post Acute | 2.9 mi | ★★★★★ | 10 | 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 July 2026) and official state health department websites.