Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hollywood Presbyterian Medical Center D/p Snf during CMS and state inspections, most recent first.
Expired medications, an expired syringe, and improperly labeled or stored drugs were found in multiple med carts. An LVN observed expired fiber supplements, an opened insulin lispro vial past its discard date, an expired 10 ml syringe, an opened eye drop without an open-date label, expired prochlorperazine, fenofibrate without an expiration label, and an unopened Novolog insulin vial not stored in cold storage. The DON stated medications must be checked for expiration before administration and that expired or improperly stored insulin should not be kept for use.
Kitchen staff were not competent in sanitizer testing or IDDSI Level 5 food preparation. A FSW did not know the correct sanitizer test strip or follow the manufacturer’s testing steps, and the facility’s training was presentation-only with no competency checklist. In addition, two cooks did not follow the standardized recipe for minced and moist turkey chili, which was processed to a puree-like consistency instead of the required minced texture, and they could not properly demonstrate the IDDSI fork test.
Unsafe food storage and meal transport practices were observed in the kitchen and during tray delivery. Expired cookies and blue cheese were stored in the walk-in refrigerator, raw chicken was thawing without a thaw date, and an open bag of frozen mango was exposed in the freezer. Resident meal trays were then transported in an unsecured cart across a public street, and fruit cups spilled onto trays during service.
Failure to notify a resident’s representative of a change in condition: a resident with chronic respiratory failure, COPD, basal cell carcinoma, and Alzheimer’s disease developed a new scratch on the left back of the neck, but the representative was not informed and there was no documentation of family notification. TX1 stated she forgot to call the representative, and the DON confirmed that licensed staff are expected to notify the physician and responsible representative of all changes in condition, including new skin issues.
A resident admitted with major depressive disorder, dementia, and anxiety had an MDS that did not trigger anxiety under Section I - Active Diagnosis. The MDS Nurse confirmed the resident had anxiety and was prescribed Ativan for anxiety, and the DON stated the diagnosis should have been documented to support the medication and related care planning for side effects and behavior monitoring.
Care planning was not kept current for two residents. One resident with chronic respiratory failure, ventilator dependence, hemiplegia, and severe cognitive impairment was observed with a right hand mitten, but the care plan had not been updated to reflect the restraint order. Another resident with chronic respiratory failure and pleural effusion had an order for side rails x2 as an enabler, but the side rails were not included in the care plan despite repeated observations of side rails in use. Staff stated the care plans should have reflected these interventions.
Staff failed to follow restraint-related orders for three residents. One resident with severe cognitive impairment and dependence for all ADLs had a right hand mitten that was not released as scheduled for circulation and skin checks. Two residents with seizure diagnoses had side rails in use, but staff were confused about the correct rail settings and physician orders did not match the rail use observed, despite care plans calling for padded side rails for seizure precautions.
Failure to provide oral care to a dependent resident with severe cognitive impairment, chronic respiratory failure, COPD, and ventilator dependence. The resident was observed with a dry, cracked mouth and white secretions covering the teeth, and staff noted that the LPN provides oral care. The care plan required daily oral care and total assistance with ADLs, and the facility ADL policy states oral care is intended to keep the mouth moist, cleanse it, and prevent oral infection.
A facility failed to manage a resident’s change in condition after a scratch was noted on the neck, with no documentation that the MD was notified, the care plan was updated, or the resident was monitored every shift for 72 hours. The facility also failed to follow a GT medication order for another resident by giving docusate sodium despite repeated loose stools, even though the order said to hold the stool softener when loose stools were present.
Urinary Catheter Dignity Bag Contacted the Floor: A resident with an indwelling urinary catheter, who was comatose and dependent for all ADLs, had a dignity bag observed touching the floor. A CNA, an LVN, and the DON all confirmed the bag should remain below the resident but off the floor, and the DON stated floor contact can contaminate the catheter and potentially lead to UTI.
Failure to monitor and report significant weight loss in a GT-fed resident: A comatose resident with chronic respiratory failure, anoxic brain injury, and a GT had weights decline from 166 lbs. to 147 lbs. over a short period, but staff did not document a COC assessment, notify the RP, or timely inform the MD and RD of the continued significant weight loss. The IDT documentation did not show a follow-up care conference after the weight loss was identified, and the care plan was delayed, backdated, and incomplete. The physician’s ordered weight check was also delayed.
A resident with chronic respiratory failure, COPD, and Alzheimer’s disease was observed in bed with both side rails raised, but the record contained no bed rail entrapment risk assessment, no documentation of alternatives, and no informed consent from the resident or representative. Staff stated side rails were used by standing order and that assessments were only done for alert residents, while an RN confirmed no risk assessment or consent had been obtained and noted the resident had impaired upper extremities.
Food service oversight was deficient because the DM served as the Director of Food Services while also overseeing patient transport, EVS, and overhead operations, and was not always in the kitchen. The DM stated that Chef1 and the retail manager helped with daily kitchen operations despite not having dietary manager credentials. Record review showed the DM had a certified dietary manager credential but had not completed the required 6 hours of CA Title 22 in-service training before assuming full-time DSS duties.
A resident with chronic respiratory failure, tracheostomy, ventilator dependence, DM, stroke, muscle weakness, gastrostomy, and severe cognitive impairment did not have a functional call light available in the bathroom and bathing area, and staff observed that no call light system was in place. TX 2 stated there should have been a call light attached to the system, while the record showed an order for a call light within reach every shift and the care plan directed use of a bell for assistance. RN 4 and the DON both stated that residents need access to a call light for safety, and the facility policy required it to remain within reach at all times.
A resident with quadriplegia and chronic respiratory failure, who was unable to use their arms, was not provided with an adaptive call light system as required by facility policy. Instead, the resident had a standard call light remote they could not access and had to rely on making clicking sounds to call for help, which sometimes went unheard by staff. Facility staff confirmed that adaptive call light devices were available but had not been provided to the resident.
Two residents with severe cognitive and physical impairments did not receive physician-ordered hand rolls for contracture management, as evidenced by missing documentation and direct observation. Staff and nursing leadership confirmed the absence of hand rolls and incomplete records, despite care plans and facility policy requiring their use to maintain joint mobility.
A facility failed to provide and utilize proper PPE during patient showering, leading to infection control deficiencies. Staff used standard gurneys instead of appropriate shower gurneys, which had been broken for months. A resident with complex medical needs was showered without water-resistant PPE, increasing infection risks. The facility's policies on PPE and infection prevention were not followed, contributing to the deficiency.
The facility failed to ensure patient safety by using standard gurneys instead of shower gurneys designed for wet environments. This was observed during a showering session where a patient with severe medical conditions was at risk of falling due to inadequate gurney features. The facility's decision to use standard gurneys, despite broken shower gurneys, led to a deficiency in patient safety.
The facility failed to have a licensed administrator, with the CNO of GACH 1 acting as the administrator without the required license. Staff interviews revealed the CNO rarely visited, and there was no dedicated administrator since the previous one resigned. This potentially impacted the timely addressing of resident and family concerns.
Two residents did not receive prescribed passive range of motion (PROM) exercises and splint applications due to staffing issues, leading to missed treatments. The facility's policy required CNAs and charge nurses to carry out RNA programs in the absence of RNAs, but RNAs were often reassigned to CNA duties, preventing them from fulfilling their responsibilities.
The facility failed to provide sufficient nursing staff to ensure RNA program treatments were completed for two residents, resulting in missed PROM exercises and splint applications. The DON confirmed that staffing levels were inadequate, with RNAs often reassigned to CNA duties, leading to missed treatments on multiple occasions.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate due to late administration of medications. An LVN administered 14 medications to a resident via a G-tube, completing the task over two hours late. The DON confirmed that three medications were given more than one hour past the scheduled time, violating the facility's policy for non-time-critical medications.
A resident with chronic respiratory failure, DVT, and heart disease received three significant medications two hours late due to a timing error by an LVN. The medications, Eliquis, carvedilol, and famotidine, were crucial for managing the resident's conditions. The DON confirmed the potential adverse effects of this error.
A resident with multiple serious medical conditions was unable to reach the call light, leading to delayed assistance. Staff were observed passing by the room without responding to the activated call light. The facility's policy required prompt response to call lights, which was not adhered to in this case.
A facility failed to complete and submit the MDS upon discharge for a resident with severe medical conditions, including chronic respiratory failure and dependence on a respirator. The resident was discharged without a discharge MDS being completed, which was confirmed by the MDS Coordinator and the DON. This deficiency had the potential to negatively affect the resident's care.
A resident with multiple health issues, including a stage 4 pressure ulcer, was found to be on a Low Air Loss Mattress (LALM) set incorrectly for their weight. The LALM was set for 140 lbs, while the resident weighed 104.1 lbs. This error was confirmed by an LVN and the DON, who acknowledged that incorrect settings could compromise the mattress's effectiveness in preventing skin breakdown.
Two residents with epilepsy and anoxic brain damage were found to have only one padded side rail on their beds, despite physician orders and care plans requiring two for seizure precautions. LVNs confirmed the deficiency, and the facility's policy emphasized the need for padded side rails to ensure safety during seizures.
Two residents receiving enteral feeding in an LTC facility did not receive appropriate care. One resident's bed was not elevated as required during tube feeding, increasing the risk of aspiration. Another resident's gastrostomy tube dressing was not dated, risking infection. These deficiencies were confirmed by staff and contradicted the facility's policies.
The facility failed to conduct an annual competency assessment for a Sub Acute Registered Nurse (SARN), identified as RN 2, which is necessary to ensure nursing staff have the skills to provide quality care. The last assessment was conducted in March 2023, and no assessment was on file for 2024, as confirmed by the DON. This lapse in policy adherence could potentially affect resident care quality.
The facility failed to comply with its drug disposition policy, as it did not specify the process or designate responsible personnel for disposing of discontinued medications. A nurse stated that the process did not require a witness, and the facility pharmacist confirmed the policy incorrectly referenced a regulation section.
A facility failed to clarify a physician's order for Creon, a medication for pancreatic insufficiency, as recommended by the pharmacy consultant. The order did not specify administration before meals, which is crucial for effectiveness. Despite receiving the recommendation, the order was not updated, potentially reducing the medication's effectiveness and causing discomfort for a resident.
A resident with multiple health conditions, including candida auris, experienced a breach in infection control when their condom catheter drainage bag was not properly closed, leading to urine leakage on the floor. This incident, confirmed by a CNA, highlighted poor infection control practices and was acknowledged by the DON as a potential risk for contamination and infection.
A resident with severe hand weakness and multiple medical conditions was not provided with an adaptable call light, leading to potential delays in care. Despite being able to communicate, the resident had to make a clicking noise to call for assistance. Facility staff acknowledged the deficiency, which was contrary to the facility's policy requiring assessment and provision of appropriate call light devices.
A resident with chronic respiratory failure and a tracheostomy was placed on bilateral hand mitten restraints to prevent tube removal. The facility failed to renew restraint orders daily and did not conduct required assessments from late June, leading to redness and swelling at the resident's knuckles. The DON admitted the facility's practices did not align with their policy, resulting in inadequate care and oversight.
A resident developed a stage 2 pressure injury at the facility, and the family was not informed. Additionally, the facility performed a wound debridement procedure without explaining the risks and benefits or obtaining consent from the resident's family, violating the resident's rights.
A resident with multiple diagnoses developed a stage 2 pressure injury, but the facility failed to develop a care plan, leading to the injury worsening to stage 3. The DON confirmed that the absence of a care plan delayed care and exacerbated the wound, violating the facility's wound care policy.
A facility failed to report an allegation of physical abuse involving a resident and an LVN to the Department. Despite the resident's daughter reporting the incident and requesting a meeting with the DON, Administrator, and SW, the facility did not report the allegation, justifying their inaction by stating that the daughter did not explicitly label the incident as abuse. This failure violated the facility's policies and procedures on abuse reporting.
A facility failed to thoroughly investigate an abuse allegation when a resident's daughter reported that an LVN punched the resident during tracheostomy care. The DON did not interview the resident or the CNA who witnessed the incident, and the allegation was not reported because the daughter insisted it was not abuse.
Expired and Improperly Stored Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and disposal of expired medications and syringes in three medication carts, including Medication Cart 3, Medication Cart 7, and Medication Cart 9. During a concurrent observation and interview with an LVN at Medication Cart 3, expired multiple fiber supplements were found with expiration dates of 11/28/2023, 4/10/2024, and 6/30/2025, along with an opened insulin lispro vial that had been opened on 10/26/25 and was labeled to be discarded after 28 days. The LVN stated that fiber supplements and expired insulin must be disposed of because they are ineffective and can cause harm. At Medication Cart 9, an expired 10 ml syringe with an expiration date of 11/2025 was observed during a concurrent observation and interview, and the LVN stated it should be discarded. At Medication Cart 7, an opened Refresh eye drop lacked an open-date label, an expired prochlorperazine vial with an expiration date of 11/2025 was present, fenofibrate filled on 11/14/2025 did not have an expiration date label, and an unopened Novolog insulin vial was not stored in cold storage. The DON stated that medications must be checked for expiration before administration, expired medications should not be kept in the medication carts or administered, and insulin that is not stored properly should be replaced to ensure resident safety.
Kitchen Staff Competency and IDDSI Texture Preparation Deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff were trained and evaluated for competency in food and nutrition services. During an observation in the cold food preparation area, Food Service Worker 2 was asked to test the sanitizer solution in a red bucket but did not know which test strip to use and relied on another staff member for assistance. The worker immersed the wrong end of the strip and stated there was no color change, and also stated that the sanitizer effectiveness was not personally tested. The Dietary Manager and Chef 1 stated staff had recently received an in-service on sanitizer testing, but the training was presentation style and there was no competency evaluation checklist after the training. The facility’s manufacturer instructions for the sanitizer required dipping the test strip for 5 seconds, shaking off excess solution, waiting 10 seconds, and comparing the color to the canister chart to determine concentration. The facility’s SAFE training agenda and roster dated 7/17/2025 showed staff participation in the training, and the Food Service Worker job description stated the worker was to adhere to sanitation procedures and maintain a clean work area to ensure food safety. The observation and interview findings showed the staff member did not demonstrate the required testing process as described by the manufacturer. The facility also failed to ensure cooks followed the standardized recipe and demonstrated the correct IDDSI Level 5 minced and moist texture. During tray line service, the minced and moist turkey chili appeared very loose and puree-like, and it was poured into bowls with a smooth consistency. Cook 2 stated the chili was processed in a food processor, and Cook 1 stated it was pulsed about 3 times, but later acknowledged it may have been pulsed too long and was more like a puree. Chef 1 stated the chili was already a minced product and should not have been processed for a long time, while the facility recipe instructed staff to pulse the regular turkey chili only once or twice to achieve the minced texture. When asked to demonstrate the IDDSI test, Cook 1 described the fork test but did not demonstrate the food meeting the required minced and moist standard.
Unsafe Food Storage and Meal Transport Practices
Penalty
Summary
Safe and sanitary food storage and distribution practices were not maintained in the kitchen and during meal delivery. During observation, five trays of uncooked cookies were found in the walk-in refrigerator with a use-by date of 11/25/2025, and four large bags of crumbled blue cheese were found in the walk-in refrigerator with a use-by date of 11/26/2025. The Dietary Manager and Executive Chef stated the cookies and cheese were old and should have been discarded, and the Executive Chef stated food beyond the use-by date could be bad quality or have gone bad. Two large boxes of raw chicken were observed thawing in the walk-in refrigerator with no thaw date marked on them. The Executive Chef stated the chicken had been delivered that morning and that food should be labeled and dated for safe storage. In the walk-in freezer, one bag of frozen mango was observed open and exposed to the freezer environment. The Executive Chef stated food had to be covered tightly to prevent cross contamination and removed the mango to discard it. Resident meal trays were also observed being transported from the main kitchen in Building A to the facility across the street by pushing a food cart through traffic and the public street. The cart was not covered, and its doors were closed but not locked, with gaps between the door and frame. During lunch service, fruit cups on resident trays were observed opened and tipped over, spilling fruit onto the trays, and an RN stated she was going to leave the fruit as it was. The Dietary Manager stated the food had been delivered this way for many years and acknowledged concern with cross contamination.
Failure to Notify Representative of Change in Condition
Penalty
Summary
The facility failed to ensure that Resident 60’s representative was notified of a change in condition involving a new skin scratch on the left back of the neck identified on 11/14/2025 at 19:42. Resident 60 was admitted with chronic respiratory failure, basal cell carcinoma of the skin, COPD, and Alzheimer’s disease, and the MDS dated 11/07/25 indicated impaired cognition and dependence for oral hygiene, toileting hygiene, showering, upper and lower body dressing, and personal hygiene. A review of the electronic medical record showed the change of condition note documented the scratch and recommended wound care as ordered, but there was no documentation that the family had been notified. During interview, TX1 stated Resident 60’s representative was not notified of the new skin scratch and said she forgot to contact the representative because she was not assigned to Resident 60 and was assisting nursing staff. The DON stated that licensed staff are expected to notify the resident’s physician and responsible representative of all changes in condition, including new skin issues, and confirmed that the notification was not completed. The facility policy titled Change of Condition, Notification stated to notify the resident’s family/caregiver of unexpected changes in condition and document such communication in the medical record.
MDS Did Not Accurately Capture Anxiety Diagnosis
Penalty
Summary
The facility failed to accurately document Resident 2’s active diagnoses in the MDS section I. Resident 2 was admitted on 1/8/2025 with diagnoses of major depressive disorder, dementia, and anxiety. In the MDS dated [DATE], the resident was documented as oriented to time but challenged with recall, yet anxiety was not triggered under Section I - Active Diagnosis. During a concurrent interview and record review on 12/4/2025, the MDS Nurse reviewed the admission record, the MDS, and the physician’s order dated 11/24/2025 and confirmed the resident had a diagnosis of anxiety and was prescribed Ativan for anxiety. The MDS Nurse stated the resident should have been triggered for anxiety because the resident was prescribed an antianxiety medication. The DON stated medications were required to have a diagnosis, the MDS should have been triggered first, and the resident would be at risk for not having a care plan to monitor for side effects of anxiety medications and for a lack of behavior monitoring.
Care Plans Not Updated for Restraint Use and Side Rail Order
Penalty
Summary
The facility failed to ensure care planning was completed and kept current for two residents. Resident 20 was admitted with chronic respiratory failure, dependence on a ventilator, and hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage. The MDS dated 10/10/2025 indicated severe impairment in cognitive skills for daily decisions and total dependence on staff for all ADLs. On 12/1/2025, Resident 20 was observed lying in bed with a right hand mitten on. During interview and record review, the DON and MDS nurse stated the mitten was a restraint and that the care plan should have been updated when the new order was in place, but the care plan reviewed on 12/3/2025 showed the goals and interventions for the right hand mitten had last been revised on 10/10/2025 and were not updated as expected. Resident 80 was admitted with chronic respiratory failure, dependence on a respirator, and pleural effusion. The H&P dated 12/2/2025 described the resident as awake, not following commands, with no movements, no agitation, no confusion, and no anxiety. The admit/readmit screener dated 11/29/2025 described the resident as alert, non-verbal, unresponsive, and totally dependent for bed mobility, transfer, dressing, and personal hygiene. On 12/1/2025 and 12/2/2025, the resident was observed in bed with 4 side rails up, and on 12/3/2025 side rails x2 were observed. The physician order allowed side rails x2 for positioning and ease of mobility as an enabler, but the RNS stated the side rails were not included in the care plan and that a care plan was needed to identify goals, interventions, and evaluation and reporting needs.
Failure to follow restraint orders and mitten release schedule
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for three residents. One deficiency involved Resident 20, who had diagnoses including chronic respiratory failure, dependence on a ventilator, and hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage. The MDS indicated the resident’s cognitive skills for daily decisions were severely impaired and that the resident was dependent on staff for all ADLs. During observation, Resident 20 was lying in bed with a right hand mitten on. During interview, an LVN stated the order required the mitten to be released every 2 hours for 15 minutes to check circulation and skin integrity, and that the assigned nurse was responsible for doing so. The LVN stated the mitten had last been released at 12:35 p.m. and was supposed to be released again at 2:30 p.m. A restraint assessment reviewed with an RN showed the restraint release documentation, and the facility policy stated all residents would be released for repositioning and checked for application, circulation, and pressure a minimum of every 2 hours, with documentation on the restraint assessment. The other deficiency involved Resident 35 and Resident 24, both of whom had seizure-related diagnoses and were dependent on staff for self-care needs. Resident 24’s care plan included padded side rails up times four for seizure precautions, and Resident 35’s care plan included padded side rails up times two for seizure precautions. Observations showed Resident 35 had side rails up times four and Resident 24 had side rails up times two. Review of the physician orders showed orders for padded side rails up times two for seizure precautions for both residents, but staff interviews indicated confusion about whether side rails up times four were appropriate and that there was no physician order for side rails up times four. The facility policy stated all restraints required a physician order and restraint use would be reflected in the resident’s plan of care.
Failure to Provide Oral Care
Penalty
Summary
The facility failed to provide oral care to one resident who was unable to perform activities of daily living independently. The resident was admitted with chronic respiratory failure, COPD, and dependence on a ventilator, and the history and physical indicated the resident did not have the capacity to understand and make decisions. The MDS showed severely impaired cognitive skills for daily decision making, functional impairment in both upper and lower extremities, and dependence on staff for oral hygiene. The care plan for self-care deficits stated the resident required total assistance with ADLs and included providing oral care daily and assisting as needed. During observations, the resident was seen with a dry mouth and caked white secretions, and later was observed sitting in bed at a 45-degree angle with a bubbling sound in the throat. The resident had dried and sticky white secretions between and covering the bottom teeth, and the mouth was dry and cracked. A CNA stated the licensed nurse does oral care, and an LVN observed the mouth and stated that cracked lips or secretions could allow aspiration and cause deterioration of teeth and decay. The facility's ADL program policy stated oral care is intended to keep the lips and oral tissues moist, cleanse and freshen the mouth, and prevent oral infection.
Failure to Follow Change-of-Condition and Medication Orders
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided according to orders and resident condition for two sampled residents. One resident, admitted with chronic respiratory failure, COPD, basal cell carcinoma, and Alzheimer’s disease, had impaired cognition and required extensive assistance with activities of daily living. On 11/14/2025, a change in condition was documented when the resident had a scratch on the left back of the neck with a recommendation to follow wound care as ordered, but there was no documentation that the physician was notified, no evidence that the care plan was updated, and no documentation that the resident was monitored every shift for 72 hours after the change in condition. During interview, the treatment nurse stated the resident experienced the change in condition at 7:43 p.m. and acknowledged that the physician was not notified. She stated she was assisting nursing staff at the time, that no documentation was entered because the required steps had not been completed, and that she forgot to initiate a care plan. The DON stated the facility expected physicians to be notified of changes in condition, family to be informed, care plans to be updated, and residents to be monitored every shift for adverse reactions. The DON also stated the resident was not monitored for 72 hours following the change in condition due to lack of documentation from staff. Another resident, admitted with chronic respiratory failure, type 2 DM, and anoxic brain damage, was rarely or never understood, dependent for all ADLs, and always bowel incontinent. The physician ordered docusate sodium oral liquid 100 mg/10 ml, 10 ml via GT daily for constipation and to hold the medication for loose stools. The bowel record showed multiple loose stools on several dates in November 2025, yet the MAR showed the resident still received docusate sodium on 11/18/2025, 11/22/2025, and 11/23/2025. RN 3 stated the order to hold docusate sodium when loose stool was noted had not been followed, and the DON stated staff must follow the physician’s order when a resident has loose stools.
Urinary Catheter Dignity Bag Contacted the Floor
Penalty
Summary
Appropriate care was not provided for a resident with an indwelling urinary catheter to prevent UTI. The resident was admitted with diagnoses including chronic respiratory failure, traumatic subdural hemorrhage, anoxic brain damage, UTI, and a GT in place. The MDS dated 11/06/2025 indicated the resident was comatose and dependent for all ADLs. During an observation on 12/01/2025 at 11:02 AM, the resident’s urinary catheter dignity bag was noted to be in contact with the floor. On 12/03/2025, a CNA observed the dignity bag touching the floor and stated that dignity bags must be positioned below the resident but must not touch the floor. An LVN also confirmed the bag was touching the floor and stated it should not touch the floor because it may contaminate the bag and increase the risk of UTI. The DON stated that dignity bags covering urinary catheter bags must remain off the floor and below the level of the resident, and explained that contact with the floor can contaminate the urinary catheter and potentially lead to UTI.
Failure to Monitor and Report Significant Weight Loss in a GT-Fed Resident
Penalty
Summary
The facility failed to ensure a resident receiving nutrition through a gastrostomy tube did not experience significant weight loss and did not receive timely change-of-condition monitoring, notification, and interdisciplinary review after the weight loss was identified. The resident was admitted with chronic respiratory failure, traumatic subdural hemorrhage, anoxic brain damage, a UTI, and a GT in place, and was comatose on the MDS. The resident’s weight was documented as 166 lbs. on admission and remained 166 lbs. on 11/5/2025, then dropped to 162 lbs. on 11/12/2025, 152 lbs. on 11/19/2025, and 147 lbs. on 11/26/2025. The record showed no COC assessment when the resident’s 14-lb. loss in 19 days was identified on 11/19/2025, and no COC assessment when the resident’s 19-lb. loss in 26 days was identified on 11/26/2025. The licensed nurses did not document notification of the resident’s RP regarding the significant weight loss. The record also did not show timely notification of the primary physician and RD regarding the continued 11.45% weight loss on 11/26/2025. The DON stated the resident’s family had not been notified of the significant weight loss. The interdisciplinary care conference documentation showed a meeting on 11/4/2025, with goals related to tube feeding tolerance, adequate nutrition, and mild weight loss toward the 150-lb. range or stable weight, but there was no other documented multidisciplinary care conference after that date. An untitled care plan was initiated on 11/21/2025 and included weekly weighing for four weeks and monthly thereafter, but the RD stated she noted the 8.43% weight loss on 11/21/2025 and addressed the 11.45% loss only on 12/1/2025 because she had been on vacation. The physician ordered a CBC, CMP, and one weight check on 11/22/2025, but the DON stated the weight check was delayed until 11/26/2025. The DON also stated the care plan initiation was delayed, was backdated, and was not complete, and that the resident’s continued weight loss had not been reported to the MD and IDT in time.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that Resident 60 was assessed for the risk of entrapment from bed rails before side rails were installed, and failed to review the risks and benefits with the resident’s representative or obtain informed consent before use. Resident 60 was admitted with chronic respiratory failure, basal cell carcinoma, COPD, and Alzheimer’s disease. The MDS dated 11/07/25 indicated impaired cognition and dependence for oral hygiene, toileting hygiene, showering, upper and lower body dressing, and personal hygiene. During observation on 12/2/2025, Resident 60 was lying in bed with both side rails raised, the bed in low position, and bilateral SCD boots in place with the machine on. Review of the medical record on 12/2/2025 found no documented bed rail entrapment risk assessment, no documentation of alternatives attempted, no informed consent from the resident or representative, and no care plan addressing bed rail use or potential entrapment. MDS Nurse 1 stated staff do not assess for entrapment risk prior to side rail use because all residents have standing orders for side rails as positioning and as an enabler, and that assessments are only done for residents who are alert. RN 4 stated there was no risk assessment or consent for Resident 60’s side rail use and noted the resident could not use the siderails due to impairment of both upper extremities.
Food Service Oversight and Qualified Leadership Deficiency
Penalty
Summary
The facility failed to ensure adequate oversight of Food and Nutrition Services by qualified personnel. The Dietary Manager (DM) was serving as the Director of Food Services while also overseeing patient transport, environmental services, and overhead operations. During interview, the DM stated the role was full-time, that the DM stopped by the kitchen every day to make sure everything was okay, and that Chef1 and the retail manager assisted with daily kitchen operations even though neither had dietary manager credentials. The DM also stated the office was not located in the kitchen and that the DM's time was split among different departments and was not always in the kitchen. Record review showed the DM had a certification from an accredited certified dietary manager program effective through 8/31/2026, but did not receive at least six hours of in-service training on the specific California dietary service requirements contained in CCR title 22 before assuming full-time duties as a dietetic services supervisor. The Registered Dietitian stated the RD was the clinical Nutrition Manager and supervised three full-time dietitians and part-time dietitians, and also assisted with in-services for kitchen staff. The facility job description for Food Service Supervisor described responsibilities including supervising production, observing food preparation and cooking, and enforcing nutrition and sanitation standards.
Missing Functional Call Light for a Dependent Resident
Penalty
Summary
A functional call light was not available in the bathroom and bathing area for Resident 71, and during the initial tour the resident had no call light system in place. During a concurrent observation and interview, TX 2 stated there was no call light attached to the call system and said there should be a call light there but it may have been removed. Resident 71 was admitted with chronic respiratory failure with tracheostomy and ventilator dependence, diabetes, cerebral ischemic stroke, muscle weakness, and gastrostomy, and the MDS indicated severe cognitive impairment and maximum assistance needed for ADLs. The record review showed an order for an appropriate call light within reach every shift for safety, and the care plan included encouraging the resident to use a bell to call for assistance. RN 4 stated staff must keep the call light within the resident's reach, and the DON stated the importance of providing residents access to a call light for safety so they can request assistance when needed. The facility policy stated the call light must be within the resident's reach at all times and repositioned appropriately before leaving the bedside.
Failure to Provide Adaptive Call Light for Resident with Quadriplegia
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and chronic respiratory failure, who was dependent on staff for all activities of daily living and unable to move their arms, was not provided with an appropriate adaptive call light system. Despite the resident's cognitive abilities being intact and their ability to communicate needs, the standard call light remote was placed next to the resident's head, which the resident could not access due to paralysis. The resident reported having to make clicking sounds to call for help, which sometimes went unheard by staff, resulting in delays in receiving assistance. Interviews with facility staff revealed that an adaptive call light system, such as a tap or pad that could be activated by cheek movement, was available but had not been provided to the resident. The Director of Engineering confirmed the availability of such devices and the process for installing them upon request. The Director of Nursing acknowledged that the resident should have had an adaptive call light system based on their assessment and current condition. Facility policy required that call lights be within easy reach and that adaptive devices be provided for residents with limited mobility, but this was not followed in this case.
Failure to Provide Ordered Hand Rolls for Contracture Management
Penalty
Summary
The facility failed to ensure that two residents with significant medical conditions and physician orders for hand rolls received the appropriate services to prevent a decline in range of motion (ROM) and mobility. Both residents had orders for hand rolls to be donned at all times or as tolerated for contracture management, as documented in their care plans and physician orders. However, review of the Restorative Nursing Assistant Records (RNAR) for both residents showed multiple dates where there was no documentation that hand rolls were applied, and there was no indication in the progress notes that the residents could not tolerate the hand rolls. Resident 1 had a history of chronic respiratory failure, hemiplegia, hemiparesis, cerebral infarction, contractures in both hands, and was dependent on a ventilator and gastrostomy tube. Resident 2 had chronic respiratory failure, cerebral palsy, contracture of a joint, intellectual disabilities, and was dependent on supplemental oxygen. Both residents were assessed as having severely impaired cognitive skills and were dependent on staff for all activities of daily living. Despite these needs and the clear orders for hand roll use, observations confirmed that neither resident had the required hand rolls in place during the survey, and staff interviews confirmed that the absence of documentation meant the intervention was not provided. The facility's policy required the implementation of strategies to prevent further limitations in joint mobility, with the charge nurse responsible for ensuring RNA orders were carried out. Both the Restorative Nursing Aide and the Interim Director of Nursing confirmed that the hand rolls were not in place as ordered and that there was missing documentation for their application. The lack of adherence to physician orders and care plan interventions for ROM management constituted the deficiency identified during the survey.
Inadequate PPE Use During Patient Showering
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) was supplied and utilized by staff when showering a patient, leading to a deficiency in infection control protocols. During an observation, two certified nursing assistants (CNAs) were seen showering a patient on a standard gurney instead of an appropriate shower gurney, which had been broken for several months. The CNAs were standing in water, and one was not wearing shoe covers, resulting in wet clothing. The Director of Nursing Services (DNS) confirmed that the facility had been using standard gurneys due to the unavailability of shower gurneys, despite the safety concerns. Patient 1, who was being showered at the time of the observation, had a complex medical history, including neuromuscular disease, functional quadriplegia, severe scoliosis, and dependence on a mechanical ventilator. The use of a standard gurney posed a risk of cross-contamination and increased the likelihood of infection transmission due to the lack of appropriate PPE. Interviews with staff revealed that the broken shower gurneys had been out of service for four to five months, and the facility had not been able to secure replacements or rentals. The facility's policy on PPE and infection prevention emphasized the importance of using water-resistant PPE to prevent exposure to potentially infectious materials. However, the shoe covers provided were not water-resistant, and staff reported difficulties in safely transferring patients due to the wet conditions. The Clinical Educator and Infection Preventionist were unaware of the use of standard gurneys and confirmed the necessity of appropriate PPE to minimize infection risks. The facility's failure to adhere to its own policies and procedures contributed to the deficiency in infection control.
Facility Uses Inappropriate Gurneys for Showering Patients
Penalty
Summary
The facility failed to ensure the safety of fourteen patients by using standard gurneys instead of shower gurneys designed with safety features for wet environments. This practice was observed during a showering session where a patient with neuromuscular disease, functional quadriplegia, severe scoliosis, and mechanical ventilator dependence was being showered on a standard gurney. The gurney's side rails had large gaps, and there were no barriers at the head and foot, creating a risk of the patient falling. The staff members were standing in water, and one was not wearing shoe covers, increasing the risk of slipping and infection control issues. The Director of Nursing confirmed that both shower gurneys had been broken for several months, leading to the use of standard gurneys for showering patients. Despite acknowledging the safety concerns, the facility decided to continue using standard gurneys after discussions with the facility administrator. The Director of Supply Chain Operations mentioned that there was a plan to repair the broken gurneys, but they were not found when the repair engineer arrived. Attempts to rent replacements were unsuccessful, and although new gurneys were ordered, there was no estimated delivery date. The facility's Environment of Care Safety Management Plan outlines the need to minimize safety risks, but the use of standard gurneys for showering patients contradicts this plan. The operation manual for the standard gurney used emphasizes that it should not be submerged or used inappropriately, and maintenance is required after every fifth washing. The facility's failure to address the broken shower gurneys and the decision to use inappropriate equipment led to a deficiency in ensuring patient safety during showering.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to ensure adequate administration services as the administrator did not possess an administrator's license and there was no designated administrator for the facility. The Chief Nursing Officer (CNO) of General Acute Care Hospital (GACH) 1 was acting as the facility's administrator without the required license. The CNO's job description indicated responsibilities related to nursing operations and quality patient care, but did not include holding an administrator's license. The organizational chart showed the CNO as the administrator, but there was no posted administrator license at the facility. Interviews with staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed that the CNO rarely visited the facility and there was no dedicated administrator present. The Medical Director confirmed the absence of a dedicated administrator since the previous administrator resigned, which potentially impacted the timely addressing of resident and family concerns. The facility did not provide a policy and procedure regarding administration when requested.
Failure to Provide Prescribed ROM Treatments
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion (ROM) for two residents, Resident 6 and Resident 72, as ordered by their physicians. Resident 6, who was admitted with anoxic brain injury and was dependent on a ventilator, did not receive the prescribed passive range of motion (PROM) exercises and splint applications on multiple occasions across October, November, and December 2024. The Director of Nursing (DON) confirmed that several treatments were missed, which were crucial to prevent decline in mobility and contractures. Resident 72, who was in a persistent vegetative state and also dependent on a ventilator, similarly did not receive the ordered PROM exercises and splint applications. The documentation showed that treatments were missed on several days in October, November, and December 2024. The DON confirmed these omissions and emphasized the importance of the RNA treatments in maintaining mobility and preventing contractures. The facility's policy indicated that in the absence of a Restorative Nursing Aide (RNA), Certified Nursing Assistants (CNAs) and charge nurses were responsible for carrying out the RNA program. However, RNA 1 reported that when CNAs were short-staffed, RNAs were often pulled to perform CNA duties, which prevented them from completing their RNA responsibilities. This staffing issue contributed to the failure in providing the necessary treatments to the residents.
Inadequate Staffing Leads to Missed RNA Treatments
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to ensure that the Restorative Nursing Aide (RNA) program treatments and services were completed for two residents, as indicated on the physician's orders. This deficiency was identified through interviews and record reviews, revealing that the residents did not receive the prescribed passive range of motion (PROM) exercises and splint applications on multiple occasions. The Director of Nursing (DON) confirmed that the RNA services were not provided on specific dates in October, November, and December 2024, due to insufficient staffing levels. Resident 6, who was admitted with diagnoses including anoxic brain injury and ventilator dependency, had physician's orders for RNA to perform PROM exercises and apply elbow and knee splints. However, documentation showed that these treatments were missed on several dates across three months. The DON acknowledged that the staffing levels were inadequate, with only one or two RNAs available, which was insufficient to meet the needs of the residents. The DON also noted that RNAs were often reassigned to perform Certified Nurse Assistant (CNA) duties when CNAs called off, further impacting the ability to provide RNA services. Similarly, Resident 72, who was in a persistent vegetative state and dependent on a ventilator, had orders for PROM exercises and splint applications. The resident's RNA documentation indicated missed treatments on multiple dates in October, November, and December 2024. The DON confirmed the staffing shortages and the practice of pulling RNAs to cover CNA duties, which contributed to the missed RNA treatments. The facility's policy on staffing projections indicated that the DON and Administrator were responsible for adjusting nursing hours to meet resident needs, but the current staffing levels were insufficient to ensure the delivery of RNA services.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate due to three errors out of 25 opportunities. The errors were related to the administration of medications at the wrong time. During an observation, an LVN was seen preparing and administering 14 medications to a resident via a gastrostomy tube. The medications were due at 9 AM, but the administration was completed at 11:25 AM, indicating a significant delay. The Director of Nursing acknowledged that the administration of three specific medications—Eliquis, carvedilol, and famotidine—occurred more than one hour past the scheduled time, which was against the facility's policy for non-time-critical medications. The facility's policy stated that medications with a dosing schedule more frequent than once daily should be administered within one hour before or after the scheduled time. The delay in administration was attributed to the workload of the LVN, who was responsible for preparing and administering medications to an average of 10 residents, taking approximately 5 hours to complete the task.
Significant Medication Timing Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for a resident during medication administration observations. Specifically, a licensed vocational nurse administered 14 medications to a resident at 11:25 AM, which were scheduled for 9 AM. Among these, three medications were identified as significant: Eliquis, carvedilol, and famotidine. The Director of Nursing confirmed that these medications were administered two hours late, which constituted a significant wrong time error. The resident involved had a complex medical history, including chronic respiratory failure with hypoxia, acute embolism, deep vein thrombosis, hypertension, and atherosclerotic heart disease. The physician's orders specified that Eliquis and carvedilol were to be administered twice daily via a gastrostomy tube, and famotidine was prescribed for gastrointestinal bleeding. The Director of Nursing acknowledged that the irregular administration of these medications had the potential to adversely affect the resident's health condition.
Failure to Ensure Timely Response to Call Light
Penalty
Summary
The facility failed to ensure that the call light device was within reach and answered in a timely manner for Resident 65, who was admitted with multiple serious medical conditions including chronic respiratory failure, polyneuropathy, and neuromuscular dysfunction of the bladder. The resident was observed with the call light placed on the bedside table, out of reach, and reported that staff did not always respond when she called for help. The resident expressed difficulty in pressing the call light due to a lack of strength and resorted to yelling for assistance, which was not always effective. During observations, staff members were seen passing by the resident's room without responding to the activated call light. A CNA acknowledged the call light was not within reach and suggested that the resident would benefit from an adaptable call light. The facility's policy required call lights to be answered promptly, within five minutes, and emphasized the importance of ensuring call lights are accessible to residents at all times. The Director of Nursing confirmed that staff should not pass by a room with an active call light and that the facility had alternative methods for residents unable to use standard call lights.
Failure to Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) upon discharge for a resident, identified as Resident 62. This resident was admitted with serious medical conditions including chronic respiratory failure, cachexia, a tracheostomy, gastrostomy, dependence on a respirator, and dysphagia. The resident had severely impaired cognitive skills and was dependent on assistance for various daily activities. The last MDS assessment for Resident 62 was completed on 7/18/2024, and the resident was discharged on 9/25/2024 without a discharge MDS being completed or submitted. During a review of the resident's electronic health record, it was confirmed by the MDS Coordinator that the discharge MDS was missed and should have been completed and submitted within 14 days of discharge. The Director of Nurses also confirmed that the MDS assessment should have been completed within one week of discharge and submitted to CMS within 14 days. The failure to complete and submit the MDS in a timely manner was identified as a deficiency, with the potential to negatively affect the provision of necessary care and services for the resident.
Incorrect LALM Settings for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to maintain the correct settings on a Low Air Loss Mattress (LALM) for a resident, identified as Resident 10, who was at risk for pressure ulcers. Resident 10 was admitted with multiple diagnoses, including anoxic brain damage, neuromuscular dysfunction, epilepsy, and a stage 4 pressure ulcer in the sacral region. The resident's care plan included the use of a LALM to aid in wound management and prevent further skin breakdown. However, during an observation, it was found that the LALM was set incorrectly for a weight of 140 lbs, while Resident 10 weighed 104.1 lbs. This discrepancy was confirmed by LVN 5, who acknowledged that the LALM should have been set at a level appropriate for 105 lbs. The Director of Nursing (DON) confirmed that the LALM settings were determined by the resident's weight and that incorrect settings could render the mattress ineffective in preventing skin breakdown. The manual for the LALM indicated that settings should be adjusted based on the patient's height and weight to ensure comfort and effectiveness. The failure to adjust the LALM settings according to Resident 10's actual weight had the potential to compromise the resident's skin integrity and exacerbate existing pressure ulcers.
Failure to Implement Seizure Precautions for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents diagnosed with epilepsy and anoxic brain damage. Both residents were required to have two padded side rails on their beds as a precaution against injury during seizures, as per their physician's orders and care plans. However, observations revealed that each resident only had one padded side rail, contrary to the prescribed seizure precautions. Licensed Vocational Nurses confirmed the deficiency during interviews, acknowledging the importance of having two padded side rails to prevent injuries during seizures. The facility's policy on seizure management and precautions emphasized the necessity of padded side rails to ensure resident safety during seizure activity. Despite this policy, the facility did not comply with the prescribed safety measures for the two residents, leaving them at risk of injury. The Director of Nursing also confirmed the importance of padded side rails for residents with a history of seizures, highlighting the oversight in implementing the necessary precautions as outlined in the residents' care plans and physician's orders.
Deficiencies in Enteral Feeding Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services for two residents who were fed by enteral means. For one resident receiving nutrition via a gastrostomy tube (GT), the head of the bed was not elevated more than 30 degrees while the tube feeding was on, contrary to the physician's order and care plan which required the head of the bed to be elevated between 30 to 45 degrees. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the risk of aspiration if the head of the bed was not properly elevated. Another resident's gastrostomy tube dressing was not dated, which is a deviation from the facility's policy requiring dressings to be dated and initialed by the nurse. This practice is crucial to ensure that dressing changes are not skipped, which could lead to complications such as infections. During an observation and interview, an LVN confirmed the absence of a date and initials on the dressing, acknowledging the potential for missed dressing changes. The Director of Nursing (DON) confirmed the importance of maintaining the head of the bed elevation to prevent aspiration and the necessity of dating and initialing dressing changes to prevent infections. The facility's policy and procedure documents also emphasize these practices to reduce risks associated with enteral feeding tubes, highlighting the facility's failure to adhere to its own guidelines.
Failure to Conduct Annual Competency Assessment for RN
Penalty
Summary
The facility failed to complete an annual competency assessment for a Sub Acute Registered Nurse (SARN), identified as RN 2, which is required to ensure that nursing staff have the necessary skills and knowledge to provide quality care to residents. During a review of RN 2's employee file, it was discovered that the last competency assessment was conducted on 3/21/2023, and no assessment was on file for 2024. This oversight was confirmed by both the Human Resources representative and the Director of Nursing (DON), who acknowledged that the competency assessments are supposed to be conducted annually. The facility's policy mandates that all nursing staff undergo an annual competency assessment to validate their ability to perform nursing tasks effectively. The DON stated that these assessments are crucial for ensuring that staff can perform essential nursing skills, such as medication administration and suctioning, which are critical for resident care. The absence of a current competency assessment for RN 2 indicates a lapse in the facility's adherence to its own policies and procedures, potentially affecting the quality of care provided to residents.
Deficiency in Drug Disposition Policy Compliance
Penalty
Summary
The facility failed to ensure compliance with their policy on drug disposition, specifically regarding the process of returning or destroying unused medications. During an interview, a registered nurse stated that a nurse performs the disposition of discontinued medications that are not controlled substances, and this process did not require a witness. A review of the facility's policy, last revised in August 2019, indicated that discontinued medications should be disposed of in compliance with state and federal laws, but the policy did not specify the process or designate the person responsible for performing the drug disposition. Additionally, the facility pharmacist confirmed that the policy incorrectly referenced a California Code of Regulations section for drug disposition, which should have been section 72371 instead of 73369.
Failure to Clarify Creon Administration Timing
Penalty
Summary
The facility failed to clarify the physician's orders for Creon, a medication used to treat pancreatic insufficiency, as recommended by the facility's pharmacy consultant during the monthly medication regimen review. This deficiency involved a resident who was taking Creon for pancreatic insufficiency, a condition where the pancreas does not produce enough digestive enzymes. The physician's order for Creon did not specify that it should be administered before meals, which is crucial for its effectiveness. The resident, who was readmitted to the facility with multiple diagnoses including chronic respiratory failure, type 2 diabetes, and morbid obesity, was receiving Creon three times a day. However, the medication administration record did not indicate whether Creon was given before meals, as recommended by the pharmacy consultant. The Director of Nursing confirmed that the physician's order had not been updated to include this important detail, despite the recommendation being received on 11/14/2024. The facility's policy requires that recommendations from the pharmacy consultant be acted upon within two weeks, but this was not done in this case. The Director of Pharmacy stated that the recommendation should have been fulfilled promptly to ensure the medication's effectiveness. The failure to clarify the order as recommended had the potential to reduce the effectiveness of Creon and cause stomach discomfort for the resident.
Infection Control Breach Due to Improper Catheter Management
Penalty
Summary
The facility failed to observe proper infection control measures for a resident using a condom catheter, resulting in a deficiency. The resident, who had been admitted with multiple diagnoses including chronic respiratory failure, muscular dystrophy, quadriplegia, dysphagia, and a tracheostomy, was on contact isolation precautions due to candida auris. The physician's orders required condom catheter care every shift, and the care plan included checking the tubing for kinks. However, during an observation, it was found that the resident's catheter drainage bag was not properly closed, leading to urine leakage onto the floor. The incident was confirmed by a CNA who noted that the leakage was a poor infection control practice. The Director of Nursing emphasized the importance of securing urinary collection bags to prevent contamination and potential infection risks. The resident's quarterly Minimum Data Set indicated intact cognition and extensive assistance needs, highlighting the importance of diligent care. The failure to secure the catheter drainage bag properly resulted in a breach of infection control protocols, posing a risk to the resident and others in the environment.
Failure to Provide Adaptable Call Light for Resident
Penalty
Summary
The facility failed to provide an adaptable call light for a resident, identified as Resident 55, who was unable to use the standard call light due to severe weakness in both hands. This deficiency was observed during a survey where Resident 55, who had intact cognition and was able to communicate, reported that he had to make a clicking noise with his mouth to call for assistance. The resident's medical history included chronic respiratory failure, COPD, Guillain-Barre syndrome, tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder, all of which necessitated extensive assistance with daily activities. Interviews with facility staff, including an LVN and the DON, revealed that the facility's policy required an assessment of residents' needs for appropriate call light devices upon admission and as needed. However, Resident 55 had not been provided with a tap call light, which was the alternative for residents who could not use a push call light. The lack of an appropriate call light device posed a risk of delayed care for the resident, as acknowledged by the staff.
Failure to Manage Restraint Use and Monitoring
Penalty
Summary
The facility failed to properly manage the use of physical restraints on a resident, identified as Resident 1, who was admitted with chronic respiratory failure, hypoxia, a tracheostomy, and a gastrostomy. The resident was placed on bilateral hand mitten restraints to prevent the removal of the tracheostomy and G-tubes. However, the facility did not renew the restraint orders daily as required by their policy, from May 3, 2024, to June 30, 2024. The Director of Nursing (DON) acknowledged that the facility's practice did not align with their policy, which mandates that restraint orders be renewed every 24 hours following a physician's examination. Additionally, the facility failed to conduct regular restraint assessments for Resident 1. The last documented assessment was on June 24, 2024, and no further assessments were recorded until June 30, 2024. This lack of monitoring was contrary to the facility's policy, which requires assessments every two hours to check for circulation, skin integrity, and any signs of redness or swelling. A Licensed Vocational Nurse (LVN) confirmed that such assessments were necessary to prevent injuries from restraints. As a result of these deficiencies, Resident 1 experienced redness and swelling at the knuckles, along with mild pain, which was discovered on June 30, 2024. The facility's failure to adhere to its own policies regarding restraint management and monitoring led to this adverse outcome for the resident, highlighting a significant lapse in care and oversight.
Failure to Inform Family and Obtain Consent for Pressure Injury Treatment
Penalty
Summary
The facility failed to inform the family of a resident about the development of a stage 2 pressure injury in the sacral area. The resident, who had a history of stroke, ventilator-dependent respiratory failure, dysphagia, diabetes mellitus type II, and hypertension, was admitted to the facility without any pressure injuries as indicated in the Minimum Data Set (MDS) dated 12/22/2023. However, a wound photo dated 1/9/2024 showed a stage 2 sacral wound, and the Director of Nursing (DON) confirmed that the pressure injury was acquired at the facility. The DON acknowledged that this change in condition should have been communicated to the resident's family, but there was no documentation to support that the family was notified. Additionally, the facility did not explain the risks and benefits or obtain consent from the resident's family before performing a wound debridement procedure for the stage 2 pressure injury. The wound care specialist performed an excisional debridement through subcutaneous tissue, which is considered an invasive procedure. The DON confirmed that the wound care specialist needed to obtain informed consent from the resident's family prior to the procedure, but there was no documentation of such consent in the physician's progress notes. This failure to obtain informed consent was a violation of the resident's rights as per the facility's policy and procedure on Resident's Rights and Responsibilities.
Failure to Develop Comprehensive Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure its nursing staff developed a comprehensive care plan to address a pressure injury for a resident. The resident, who was admitted with multiple diagnoses including stroke, ventilator-dependent respiratory failure, dysphagia, diabetes mellitus type II, and hypertension, developed a stage 2 pressure injury on the sacral area. Despite the presence of this injury, no care plan was developed when the injury was discovered, as confirmed by the Director of Nursing (DON) during an interview. The lack of a care plan led to inadequate intervention and care, resulting in the pressure injury worsening to a stage 3 injury within a few days. The facility's policy and procedure on wound care, which mandates that a care plan should be individualized and initiated within 12 hours of admission for patients at risk for or with existing open or pressure wounds, was not followed. The DON acknowledged that the absence of a care plan could delay care and exacerbate the wound. This deficiency was identified during a review of the resident's history and physical records, Minimum Data Set, and wound photo assessments, which documented the progression of the pressure injury from stage 2 to stage 3.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident and an LVN to the Department. The resident, who was admitted with chronic respiratory failure, anxiety disorder, blindness, and diabetes mellitus, reported to their daughter that the LVN punched them on the face during tracheostomy care. Despite the resident's daughter reporting this incident to the Interdisciplinary Team (IDT) and requesting a meeting with the Director of Nursing (DON), Administrator, and Social Worker (SW), the facility did not report the allegation to the proper authorities. The DON and Director of Therapy Services (DTS) justified their inaction by stating that the resident's daughter did not explicitly label the incident as abuse and insisted not to call the authorities. The facility's policy and procedure on abuse or neglect clearly state that all suspected cases should be reported to the proper authorities. However, the facility did not adhere to this policy. The DON acknowledged that abuse should be reported within 24 hours but did not report the incident because the resident's daughter did not explicitly state it was abuse. The DTS also confirmed that the incident should have been reported immediately, and the employee should have been suspended pending investigation. The failure to report the allegation of abuse was a clear violation of the facility's policies and procedures, potentially placing the resident and others at risk for further abuse.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was thoroughly investigated for a resident when the facility did not obtain a statement or interview from the resident or the CNA who reportedly witnessed the incident. The resident, who was admitted with chronic respiratory failure, tracheostomy, anxiety disorder, blindness, and diabetes mellitus, had complained to their daughter that a night LVN punched them on the face during tracheostomy care. The Interdisciplinary Team (IDT) attempted to explain to the resident's daughter that the resident might have misinterpreted the procedure due to anxiety. However, the facility did not follow through with a thorough investigation as required by their policy and procedure on abuse or neglect, which mandates obtaining statements from witnesses and involved parties. The Director of Nursing (DON) did not interview the resident about the incident, citing the presence of family members during the assessment as a reason. Additionally, the CNA who was present during the tracheostomy care was not interviewed as part of the internal investigation. The DON also did not report the allegation because the resident's daughter insisted it was not abuse, despite the serious nature of the complaint. This failure to conduct a thorough investigation and obtain necessary statements from all involved parties is a significant deficiency in the facility's handling of the abuse allegation.
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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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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Virgil Rehabilitation & Skilled Nursing Center | 0.4 mi | ★★★★★ | 30 | 1 |
| The Meadows On Sunset Post Acute | 0.6 mi | ★★★★★ | 49 | 1 |
| Alexandria Care Center | 0.6 mi | ★★★★★ | 14 | 0 |
| Garden Crest Rehabilitation Center | 1 mi | ★★★★★ | 20 | 0 |
| Fountain View Subacute And Nursing Center | 1.1 mi | ★★★★★ | 10 | 0 |
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