Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hyde Park Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, paranoid schizophrenia, and severe cognitive impairment had trust funds withdrawn after discharge to a board and care facility. The BOM kept $5,744 cash and two SS checks in her purse instead of returning the money to the resident’s trust account after the resident was transferred to a GACH and later readmitted, and the Asst Admin confirmed the funds should have been deposited back into trust.
A facility failed to timely report an allegation of misappropriation of a resident’s funds to CDPH within the required 2 hours. A resident with dementia, paranoid schizophrenia, and severe cognitive impairment had $5,744 cash and two SS checks retained by the BOM in her purse instead of being returned to the resident’s trust account, and the Asst Admin delayed reporting the missing funds while waiting for the money to be returned.
Failure to Timely Report Alleged Abuse: A resident with dementia, psychosis, and schizoaffective disorder, who needed substantial to maximal help with ADLs and could not make medical decisions, was transferred for behavioral concerns and later alleged to a GACH coordinator that facility staff abused her and did not feed her. An LVN documented the allegation and notified the RN supervisor and DON, but the DON did not report the allegation to the State Agency within the required timeframe under the facility’s abuse reporting policy.
Failure to Investigate Allegation of Abuse: A resident with dementia, psychosis, and schizoaffective disorder alleged that facility staff abused her and did not feed her, and a GACH staff member reported the allegation to the facility. An LVN notified the RN supervisor and DON, but the DON later stated he did not investigate because he was not aware of the allegation, and the AADM also stated he was unaware of it. The facility policy required an investigation within 24 hours of suspected or alleged abuse.
A resident identified as a high fall risk with confusion, balance problems, severe cognitive impairment, and a need for CGA while walking fell in the hallway after exiting the shower room. CNA staff assisted the resident out of the shower room but then left her walking with her wheelchair while cleaning the shower, and RN staff reported no one was close to the resident when she fell backward into a linen cart. PT notes and the DON confirmed the resident required close supervision during ambulation.
A facility failed to update care plans after a resident-to-resident altercation when two residents refused room changes, despite care plan interventions calling for separation, 1:1 supervision, and redirection. The DON stated there was no care plan addressing the room-change refusal. The facility also failed to create a care plan after a resident’s actual fall, even though the resident was found on the floor with pain and an x-ray order, and RN stated a post-fall care plan should include fall-prevention interventions, monitoring frequency, and supervision level.
Failure to complete ordered x-rays after a resident fall. A resident with parkinsonism, Alzheimer's disease, and HTN was found on the floor after an apparent fall with right elbow pain and skin discoloration on the right arm. The physician ordered x-rays of the right hip and right elbow, and the care plan included the same intervention, but the order was not entered and no x-ray results were found in the record. The DON stated the x-rays were never completed, and an LVN said the nurse was responsible for entering and faxing the radiology order.
A resident with DM, epilepsy, HTN, and moderate cognitive impairment had several ordered meds administered outside the facility’s 60-minute window. MAR review showed late doses of Coreg, Keppra, Metformin, Depakote, and Hydralazine, and staff confirmed the meds were given past the scheduled time despite the facility’s medication administration policy.
A resident with schizophrenia, bipolar disorder, and anxiety became acutely agitated, threw a phone toward staff, and tossed meal items, but staff did not document a change-of-condition assessment, notify the physician, revise the care plan, or implement enhanced monitoring or one-to-one supervision as required by existing behavior and abuse-prevention care plans and facility policies. Despite care plan directives to assess triggers, remove the resident from overstimulating environments, and transfer to a GACH for further evaluation when agitation escalated, these interventions were not carried out or documented. Later that day, the same resident pushed another cognitively impaired resident with dementia, depression, and psychosis in the hallway, causing the second resident to strike his face on a handrail and sustain a right eyebrow laceration requiring sutures at a GACH. The deficiency centers on the facility’s failure to follow its own care plans and change-of-condition and abuse-prevention policies, leading to resident-to-resident physical abuse and injury.
A resident with cerebral palsy, schizoaffective disorder, dysphagia, severe cognitive impairment, and documented swallowing difficulties experienced an aspiration episode while eating, after which the physician ordered a downgrade to a minced and moist (IDDSI Level 5) diet and an SLP evaluation confirmed swallowing deficits and recommended the same texture. However, the resident’s care plan remained outdated, continuing to direct CNAs, LPNs, and RNs to provide a regular easy-to-chew (IDDSI Level 7) diet instead of the newly ordered texture, contrary to facility policy requiring care plan review and revision with changes in condition and treatment.
A resident with encephalopathy, dementia, and schizophrenia had severe cognitive impairment and a care plan requiring staff to obtain and monitor labs as ordered and report results to the MD. A CBC ordered by the physician in one month was not drawn, with no documentation in progress notes that it was completed, attempted, refused, or that the MD was notified. After the resident later developed cough and chest congestion, another CBC was ordered to be drawn within three days, but records again showed no evidence that the test was done, attempted, refused, or communicated to the MD. An LVN and the DON confirmed that the CBC orders were not carried out and that appropriate follow-up with the lab vendor and physician did not occur.
A resident with severe cognitive impairment, multiple comorbidities, and documented fall risk experienced four falls, including unwitnessed events and falls resulting in lacerations, skin tears, bleeding from the mouth, and transfers to the hospital. The care plans in place focused on general assistance with ambulation and transfers, neuro checks, and broad directives to determine and address causative factors, but did not include specific, individualized fall-prevention interventions. After each fall, the facility did not hold IDT meetings with the attending physician or consult the pharmacist, despite policies requiring IDT-driven, person-centered care planning and medication review for fall risk. The DON acknowledged that the existing and revised interventions were insufficient to prevent further falls.
A resident with severe cognitive impairment and physical disabilities, who was conserved and dependent on staff for mobility and lower body dressing, was sexually assaulted by another resident with a documented history of sexually inappropriate behavior and wandering. Hospital records prior to admission had identified this behavior and led to precautions, and the admitting RN received a report noting the sexually inappropriate behavior. However, the behavior was not included in the admission summary, no behavior-focused care plan or monitoring was developed, and there was no documentation that staff beyond the admitting RN and RD were aware of the risk. The resident with sexually inappropriate behavior was observed entering the victim’s room multiple times and making flirtatious gestures before the incident. On the day of the event, a roommate summoned staff, and a CNA found the male resident on top of the cognitively impaired resident behind a drawn curtain, with both engaged in intercourse and the victim’s garments pulled down. The victim was nonverbal, assumed a fetal position, and later had genital ecchymosis documented on a sexual assault exam, while the male resident stated he had intercourse because the other resident did not object. These events demonstrate the facility’s failure to follow its abuse prevention, resident safety, and comprehensive care plan policies by not assessing, care planning, and monitoring a resident with known sexually inappropriate behavior.
A resident with COPD and type 2 DM reported that a tall male staff member of African descent with dark skin and an accent exposed his genitals and had unprotected sexual intercourse with her during nighttime hours before a hospitalization. She stated she reported the allegation to the ADON upon her return. The ADON and other leaders attempted to identify the alleged perpetrator primarily from memory and concluded no staff matched the description, without systematically using staffing records or fully considering the reported date and time. The AADM, responsible for the investigation, interviewed the resident and one CNA he believed matched the description but did not ensure interviews were conducted with all potentially involved male staff working the relevant shifts, and he submitted a conclusion letter to the SA with an incorrect incident date and unsupported statements that interviews with current and former male staff had been completed. Staffing records showed multiple male staff on duty during the relevant nights, yet there was no documentation of interviews, no evidence that any staff were suspended or placed on investigative leave, and no thorough, timely, and documented investigation as required by the facility’s abuse and protection policies.
A resident with COPD and other respiratory disorders, who had cognitive impairment and required substantial assistance with ADLs, had a physician order for O2 at 3 L/min every shift that did not specify whether it was to be given continuously or PRN. Nursing staff did not clarify the frequency with the physician and did not ensure that an O2 concentrator or tubing was available in the resident’s room, despite the resident reporting no access to O2 since readmission. An RN and the DON acknowledged the lack of clarification and the absence of immediately available O2, which was inconsistent with facility policies requiring complete respiratory orders and provision of O2 support when indicated.
Staff entered telephone and other medical orders under the attending physician’s name instead of the actual prescriber, including MDs and NPs covering for the attending. One physician reported that when her medical team phoned in orders, staff consistently used her name because the EMR did not list other team members as selectable ordering providers. Another physician confirmed that the EMR only allowed orders to be entered under the attending MD, making it difficult to determine which covering MD actually issued an order. Facility policy required medication telephone orders to be countersigned by the prescriber, but the documentation process did not accurately reflect the true ordering provider.
The facility failed to report an allegation of resident-on-resident physical abuse to CDPH as required. A resident with diabetes, hypertension, and documented need for extensive assistance reported to an LVN and the assistant administrator that another resident had been hitting her in the stomach since admission. Despite this allegation, there was no Change of Condition entry or progress note documenting the report for either resident, and no report was made to CDPH. The assistant administrator later acknowledged receiving the allegation from the LVN and not reporting it, even though facility policy and federal requirements direct that all abuse allegations be immediately reported to CDPH, the Ombudsman, and law enforcement using the SOC 341 form.
A resident with DM and HTN, who required supervision to maximal assistance with ADLs, was admitted without obtaining admission consent from the court-appointed conservator, despite facility policy requiring consent from the resident or responsible party and presentation of surrogate documentation at or before admission. The conservator later reported she had not been informed of the transfer and had not authorized the admission, and the Admission Coordinator acknowledged that the facility’s admission policy was not followed.
A resident with seizure-related diagnoses and documented decision-making capacity was transferred multiple times to an acute care hospital while on bed-hold status, but the facility failed to provide the required written bed-hold notifications at each transfer as mandated by its Bed-Hold policy. Staff interviews and record review showed only one bed-hold agreement signed at admission, despite census records indicating additional bed-hold periods, and nursing and administrative staff acknowledged that written information about the bed-hold option should have been provided and filed for each transfer.
Two residents with seizure disorders did not receive anticonvulsant medications as ordered, and required monitoring was not completed. One resident with a seizure history and conversion disorder missed scheduled doses of Keppra, with documentation showing a dose was not given due to waiting for pharmacy delivery and no record of follow-up, and another dose not given after return from hospital without explanation. PRN Ativan ordered for seizures was not documented as administered during a seizure event, and there were no orders or documentation of Keppra blood levels despite facility policy. A second resident with epilepsy missed two morning doses of Depakote because the medication was not available in the cart, with no documented physician notification or explanation in the progress notes. These actions and omissions did not follow the facility’s policies for medication administration and seizure disorder management.
A resident with multiple chronic conditions, including DM and hypertension, was admitted from a hospital with older discharge paperwork, and the admitting nurse did not obtain or clarify admission orders with a physician at the time of admission. Instead, an LVN later entered multiple medication orders based on the outdated hospital discharge list without contacting the attending MD or on-call coverage, and no evidence was found that any MD reviewed or authorized these admission orders. Facility policies required that residents be admitted only on written orders from the attending MD and that all medication orders be signed by a licensed prescriber, but this process was not followed, resulting in unverified admission orders for the resident.
A resident with multiple chronic conditions, including DM, HTN, GERD, hypothyroidism, hyperlipidemia, glaucoma, bipolar disorder, schizophrenia, and depression, was admitted and did not receive scheduled night medications or timely morning medications because admission orders were not properly entered or verified by an MD. Nursing staff reported that the admitting nurse failed to enter physician orders, that no follow-up call was made to the MD on night shift, and that they were instructed by an administrator to enter orders based on hospital discharge paperwork without contacting the MD. As a result, critical medications such as insulin, antihypertensives, psychotropics, and other chronic disease medications were either missed or administered several hours late.
A resident with cognitive impairment and psychiatric diagnoses was pushed to the floor by another resident with similar impairments, resulting in a head laceration that required hospital treatment. The incident was witnessed by staff, and records showed both residents had histories of agitation and required assistance with daily activities. Facility policy prohibits such abuse, but the event still occurred, leading to physical harm.
Licensed nurses did not follow up with the pharmacy to obtain a physician-ordered antipsychotic medication for a resident with a history of aggressive behavior, resulting in the resident missing the medication for eight days. During this period, the resident exhibited aggression and pushed another resident, causing a head injury that required hospital treatment. Documentation showed repeated notations of the medication being unavailable, and the pharmacy confirmed no request was received until after the incident.
A resident with severe cognitive impairment and multiple psychiatric diagnoses did not receive Seroquel 25 mg as ordered for eight consecutive days due to delays in medication procurement and administration. During this period, the resident was involved in an altercation that resulted in injury to another resident. The DON confirmed the medication was not obtained or administered as ordered, constituting a significant medication error.
Nursing staff failed to accurately document the administration of a psychotropic medication for a resident with severe cognitive impairment, recording doses as given or refused when the medication was not available in the facility. Pharmacy records confirmed the medication was not delivered for over a week after the order, and staff did not follow up to ensure timely access. This resulted in inaccurate medical records that did not reflect the actual care provided.
A resident with multiple psychiatric and cognitive diagnoses, including schizophrenia and suicidal ideation, was not properly assessed for elopement risk despite exhibiting unsafe behaviors and a change in condition. The facility failed to follow its own policies for reassessment and supervision, did not act on a physician's recommendation for immediate psychiatric intervention, and did not obtain a complete history of prior elopement. As a result, the resident eloped and was not found.
A staff member failed to use required personal protective equipment, specifically a gown, while providing ADL care to a resident with a stage 4 pressure ulcer who was under Enhanced Barrier Precautions due to an open wound. The resident was totally dependent on staff and had severe cognitive impairment. Facility policy and staff interviews confirmed that gown and glove use is required for such care to prevent the spread of multi-drug-resistant organisms.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
The facility did not limit PRN antipsychotic medication orders to 14 days for a resident with bipolar disorder and schizophrenia, and failed to monitor or document behaviors and adverse effects related to Ativan use for another resident with dementia and anxiety. The DON confirmed that required monitoring and documentation were not completed, and care plans addressing these issues were not developed.
The facility did not complete and resubmit PASARR Level I screenings or refer for Level II evaluations for two residents with mental health diagnoses, including anxiety disorder, schizophrenia, and major depressive disorder. In both cases, the residents' mental health conditions and use of psychotropic medications were not accurately reflected in the PASARR process, and the required notifications and referrals to the state mental health authority were not made, contrary to facility policy and regulatory requirements.
Two residents with significant mental health diagnoses did not have individualized care plans addressing their conditions or the use of psychotropic medications. One resident with anxiety and Ativan use lacked a care plan and monitoring for medication effects, while another with schizophrenia had no care plan for the diagnosis, contrary to facility policy. The DON confirmed these omissions and acknowledged the required processes were not followed.
A resident with severe cognitive impairment and ongoing tobacco use did not receive required quarterly smoking and safety assessments, as only the initial assessment was completed. Additionally, the fire extinguisher on the smoking patio was locked and not accessible to staff, with the key held by maintenance, leaving the area without immediate fire safety equipment.
The facility did not ensure that non-narcotic medication destruction logs in one medication room were properly completed, as required signatures and dates were missing from all reviewed records. The DON confirmed that nurses responsible for medication disposition failed to sign the logs, resulting in incomplete documentation.
Three medication administration errors were observed, resulting in an error rate above 5%. Two residents received incorrect medication doses and formulations, including a higher dose of calcium carbonate, a multivitamin with minerals instead of without, and a full tablet of Seroquel instead of a half-tablet. An LVN acknowledged not verifying medication labels against physician orders, leading to these errors.
Surveyors found that unopened latanoprost eye drops and two unopened Lantus insulin pens for three residents were stored at room temperature in medication carts instead of being refrigerated as required by manufacturer instructions. LVNs confirmed the improper storage and acknowledged the need for refrigeration prior to use, in accordance with facility policy.
A resident with multiple medical conditions was not included in care plan meetings despite being able to communicate and expressing a desire to participate. Staff interviews and record reviews confirmed that no care conference was held with the resident or her representative, and required documentation was incomplete.
A resident who was totally dependent on staff and had an indwelling catheter was observed with an exposed foley catheter drainage bag, as no privacy bag was applied. Both an RN and the DON confirmed that using a privacy bag is standard practice to maintain dignity, and facility policy requires care that respects resident privacy.
A resident with severe cognitive impairment and multiple chronic conditions did not have their Discharge MDS assessment transmitted to CMS within the required 14-day timeframe. The MDSN confirmed the delay, and facility policy requiring timely submission was not followed.
A resident admitted with schizophrenia, major depressive disorder, anxiety, and other mood disorders did not have a required Level 1 PASARR screening completed upon admission. The DON confirmed the omission and noted that facility policy requires such screenings for all potential residents, but the process was not followed in this instance.
A resident admitted with a history of stroke, dysphagia, and liver cirrhosis did not have a baseline care plan developed within 48 hours of admission, despite requiring moderate assistance with daily care. Facility staff confirmed that the interdisciplinary team did not complete the required interim care plan as outlined in facility policy.
A resident with a Stage 4 pressure ulcer and multiple medical conditions was observed lying on a regular mattress despite a physician's order for a low air loss mattress. The DON confirmed the absence of the required mattress and that no such mattresses had been ordered recently, contrary to facility policy for pressure injury care.
A resident with an indwelling catheter and a history of urinary tract infection was not referred to urology for evaluation as ordered upon hospital discharge. Despite documentation in the resident's records and facility policies requiring such referrals, the appointment was not scheduled by the nursing staff, resulting in a delay of necessary care.
A CNA's personnel file lacked both the initial and annual competency checklists as required by facility policy. The Director of Staff Development confirmed that these documents were missing and should have been completed to ensure staff competency.
A resident with bipolar disorder and schizophrenia received PRN Zyprexa for periods longer than 14 days after the facility failed to act on a consultant pharmacist's recommendation to limit the order duration. The DON confirmed that the facility did not follow policy requiring PRN antipsychotic orders to be limited to 14 days and did not document any response to the pharmacist's recommendation.
A nurse administered a full tablet of Seroquel instead of the prescribed half tablet to a resident with schizophrenia, after failing to reconcile a discrepancy between the physician's order and the pharmacy label. The medication packaging and label did not reflect the updated dose, and the nurse did not verify the correct dosage before administration.
A resident with epilepsy did not receive a physician-ordered Levetiracetam blood level every three months as required. The omission was confirmed by an LVN during record review, despite the care plan indicating the need for lab monitoring and reporting of abnormal results. The resident had multiple diagnoses, including epilepsy, and required moderate assistance with daily activities.
A resident with cognitive impairment and multiple diagnoses had a stat x-ray ordered for left leg and foot pain, but the x-ray results were not accessible or filed in the medical record. Nursing staff confirmed the records were incomplete, and there was no documentation of communication with the physician or follow-up with the x-ray provider. The DON stated the results were received and given to staff, but could not explain their absence from the record or provide evidence of physician notification.
A LVN failed to disinfect a shared blood pressure cuff before and after use during medication administration for two residents, despite facility policy requiring cleaning after each use. The LVN acknowledged not following the disinfection protocol during an interview.
Two residents with moderate cognitive impairment were involved in an altercation, with one alleging that the other tripped him, resulting in a fall. The facility did not report the incident to CDPH within the required two-hour timeframe, as staff were not made aware of the allegation until two days after the event. This delay led to a late investigation and increased risk for further abuse.
Resident Trust Funds Kept in BOM’s Personal Possession
Penalty
Summary
Protecting a resident from the wrongful use of belongings or money was not ensured when the Business Office Manager removed $7,744 from Resident 1’s trust fund after the resident was discharged to a board and care facility. Resident 1 had diagnoses including dementia, pneumonitis, paranoid schizophrenia, and type 2 DM. The History and Physical stated the resident did not have the capacity to make medical decisions but was able to make needs known, and the MDS indicated severe cognitive impairment and need for maximal assistance with activities of daily living. The Business Office Manager stated that $2,000 of the withdrawn funds was paid to the board and care facility and the remaining $5,744 was intended to be returned to the resident. When the resident was transferred to a GACH due to a change in condition and later readmitted to the facility, the funds were supposed to be deposited back into the trust account, but the Business Office Manager kept the $5,744 cash and two Social Security checks in her purse instead of returning them to the facility or trust account. The Assistant Administrator stated the funds should have been deposited back into the trust account and confirmed the Business Office Manager still had the resident’s cash after leaving employment.
Failure to Timely Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to follow its Abuse and Neglect Prohibition Policy when it did not report an allegation of misappropriation of a resident’s funds to the Licensing and Certification Program District Office within two hours. Resident 1 had diagnoses including dementia, pneumonitis, paranoid schizophrenia, and type 2 diabetes, and was documented as having severe cognitive impairment and needing maximal assistance with activities of daily living. The resident did not have capacity to make medical decisions but was able to make needs known. The Business Office Manager withdrew $7,744 from the resident’s trust fund after the resident was discharged to a board and care facility, paid $2,000 to that facility, and retained the remaining $5,744 to be returned to the resident. When the resident was later transferred to a GACH and then readmitted to the facility, the funds were not deposited back into the trust account. The Business Office Manager kept the resident’s $5,744 cash and two Social Security checks in her purse, stating she did not want to leave the cash in her office and did not have time to deposit the checks. After the Business Office Manager left employment, the Assistant Administrator learned she still had the resident’s money and checks, but the facility did not report the missing funds to CDPH until several days later, after waiting for the money to be returned.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to follow its Abuse and Neglect Prohibition Policy by not reporting an allegation of abuse to the Licensing and Certification Program District Office within two hours after a General Acute Care Hospital notified the facility that a resident alleged unidentified facility staff abused her and did not feed her. The resident had diagnoses including unspecified dementia, unspecified psychosis, and schizoaffective disorder. Her H&P stated she did not have the capacity to make medical decisions but could make needs known, and her MDS showed she required substantial to maximal assistance with ADLs such as personal hygiene, bed mobility, and upper body dressing. On 6/4/2026, the resident was transferred to the hospital for behavioral concerns and further medical and psychiatric evaluation. Later that day, an LVN received a call from the hospital coordinator stating the resident alleged abuse by facility staff and that she was not fed; the LVN documented the information and informed the RN supervisor, who then informed the DON. During interviews, the DON stated he was not aware of the allegation and did not report it to the State Agency, while the LVN and RN stated the allegation was communicated up the chain of command. The facility policy stated that upon receiving information concerning suspected or alleged abuse, the Administrator or designee would report the incident to the Licensing and Certification Program District Office immediately, but not later than two hours when abuse was alleged or serious injury resulted.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident after a GACH staff member reported on 6/4/2026 that the resident alleged she had been abused by facility staff and had not been fed. The resident’s record showed diagnoses including unspecified dementia, unspecified psychosis, and schizoaffective disorder. The resident’s H&P dated 1/24/2026 stated she did not have the capacity to make medical decisions but could make needs known, and the MDS dated 6/3/2026 showed she required substantial to maximal assistance with ADLs including personal hygiene, bed mobility, and upper body dressing. A progress note dated 6/4/2026 at 5:44 p.m. documented that an LVN received a phone call from GACH staff and was informed of the resident’s allegation of abuse by facility staff; the LVN immediately told the RN supervisor and the DON. During interviews on 6/23/2026, the DON stated he did not investigate the allegation because he was not aware of it, and the AADM stated he was not aware of any allegation involving the resident. The facility policy titled Abuse and Neglect Prohibition Policy stated that upon receiving information concerning suspected or alleged abuse, the Administrator or designee would initiate an investigation within 24 hours and report completed investigations in accordance with state law.
Failure to Supervise High-Fall-Risk Resident After Shower
Penalty
Summary
The facility failed to provide supervision for Resident 5, who was identified as a high fall risk and required contact guard assistance when walking. Resident 5’s records showed diagnoses of muscle weakness and muscle wasting/atrophy, intermittent confusion, balance problems, severe cognitive impairment, and a need for supervision or touching assistance for walking 10 feet. The care plan identified the resident as high risk for falls related to confusion, gait/balance problems, and psychoactive drug use, and PT notes stated the resident was confused, on fall risk precautions, and required contact guard assistance with transfers and gait. On 6/8/2026, Resident 5 fell in the hallway after exiting the shower room. The SBAR stated the resident lost balance and fell backward into a linen cart while ambulating and pushing her wheelchair. CNA 4 stated she assisted the resident out of the shower room and then cleaned the shower while the resident walked down the hallway with her wheelchair, and about 4 minutes later heard commotion because the resident had fallen. RN 2 stated there was no staff close to the resident when the fall occurred. The PT stated the resident required CGA while walking because she was impulsive with her gait and at risk for falls, and the DON stated staff should have supervised and monitored the resident after coming out of the shower for safety.
Failure to Update Care Plans After Resident-to-Resident Altercation and Fall
Penalty
Summary
The facility failed to develop resident-centered care plans that addressed a resident-to-resident altercation when two residents refused room changes after the incident. Resident 4 had diagnoses including schizophrenia, anxiety disorder, and depressive disorder, and the MDS dated 5/3/2026 indicated severe cognitive impairment with substantial to maximal assistance needed for multiple ADLs. On 5/20/2026, the COC documented that Resident 4 turned on Resident 5’s call light and walked into the hallway, where Resident 5 allegedly attacked Resident 4. Resident 4’s care plan for resident-to-resident interaction included offering room change/separation to reduce the risk for further altercation, but progress notes dated 5/22/2026 and 5/26/2026 stated Resident 4 did not want a room change. Resident 5’s record showed diagnoses including chronic kidney disease, muscle wasting and atrophy, and depressive disorder, and the MDS indicated moderate cognitive impairment with partial to moderate assistance needed for several ADLs. The 5/20/2026 COC documented that Resident 5 was observed bending over Resident 4 with clenched fists in an aggressive posture, after which the residents were separated and 1:1 supervision was initiated. The COC also indicated room change was initiated to reduce the risk for further altercations, but Resident 5 refused the room change. Resident 5’s care plan included maintaining 1:1 supervision, offering room change/separation, and redirecting the resident from confrontational situations, yet progress notes dated 5/22/2026 and 5/26/2026 stated Resident 5 did not want a room change. The facility also failed to develop a care plan after Resident 6 had an actual fall. The 5/14/2026 COC stated Resident 6 was found lying on her side in the hallway outside her bedroom door following an apparent fall, with pain in the right elbow and skin discoloration noted on the right arm. The physician ordered x-rays of the right hip and right elbow. During record review, no care plan for the actual fall was found in the clinical record, and RN 2 stated Resident 6 did not have a care plan for the fall and that staff should develop one after a resident falls, including interventions to prevent future falls, the frequency of monitoring, and the level of supervision required.
Failure to Complete Ordered X-Rays After Resident Fall
Penalty
Summary
The facility failed to meet professional standards of care when it did not carry out physician-ordered radiology testing for a resident who fell on 5/14/2026. Resident 6 had parkinsonism, Alzheimer's disease, and hypertension, lacked capacity to make medical decisions, and had severe cognitive impairment with substantial to maximal assistance needed for several activities of daily living. After the fall, the Change of Condition record documented that the resident was found lying on her side in the hallway outside her bedroom door, complained of pain in the right elbow, and had skin discoloration on the right arm. The physician ordered x-rays of the right hip and right elbow, and the care plan also included an intervention to order those x-rays. The physician's order record did not include the x-ray order for the right elbow and right hip, and the clinical record for 5/2026 did not contain x-ray results for either area. During interview, the DON stated the x-ray orders were never completed and the actual x-ray order was not placed. An LVN stated that when a resident had a COC and a physician's order, the nurse was responsible for entering the x-ray order, faxing it, and calling the radiology department. The facility policy on Change of Condition stated that physician's orders for treatment and medical intervention should be documented in the attending physician's order.
Late Medication Administration
Penalty
Summary
The facility failed to ensure that medications ordered by the physician for one resident were administered within 60 minutes of the scheduled time, as required by the facility’s Medication Administration - General Guidelines policy. The resident had diagnoses of DM, epilepsy, and HTN, and the MDS dated 4/19/2026 indicated moderate cognitive impairment and substantial to maximal assistance needed for ADLs such as dressing, toilet use, transfer, and mobility. A review of the physician’s orders and MAR for 5/2026 showed scheduled medications including Coreg 25 mg BID, Keppra 1000 mg BID, Metformin HCl 500 mg BID, Depakote DR 250 mg BID, and Hydralazine 50 mg two tablets TID. The MAR audit showed multiple late administrations, including Coreg given at 9:30 a.m. for an 8:00 a.m. dose, Depakote and Hydralazine given at 12:01 p.m. for 9:00 a.m. doses, and Keppra and Metformin given at 12:01 p.m. and 9:33 a.m. for 8:00 a.m. doses. Staff interviews confirmed the medications were administered past the scheduled time and that the facility’s practice was to give medications one hour before or one hour after the scheduled time.
Failure to Manage Escalating Behaviors Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to implement required assessments and interventions in response to escalating behaviors. On the morning of 4/5/2026 at 8:10 a.m., Resident 5, who had diagnoses including schizophrenia, bipolar disorder, and anxiety, became agitated at the nurse’s station, threw the facility phone toward a nurse’s head without provocation, then went to his room, removed a breakfast tray from the cart, and threw it onto the floor while stating, “I want to go to the hospital now.” Progress notes documented that Resident 5 was encouraged to self-regulate using deep breathing and that staff attempted to provide a safe environment with frequent safety checks, but there was no documentation of a Change of Condition (COC) assessment, no physician notification, and no new care plan or revision of the existing care plan after this behavioral outburst. The facility’s records did not show that Resident 5 was monitored for behavioral outbursts after 8:10 a.m. Resident 5 had an existing care plan titled “Risk for harm: self-directed or other-directed,” with a goal that the resident would not harm self or others and interventions including administering prescribed medications and notifying the provider if the resident posed a potential threat to injure others. Another care plan, “Resident does not harm self or others. New behavior potentially causing harm to self or others,” directed staff to monitor for signs and symptoms of agitation. A third care plan, “Increased Agitation manifested by throwing object at staff and yelling,” included interventions to assess for triggers, notify the physician of persistent or escalating behaviors, remove the resident from overstimulating environments when agitation began, and transfer the resident to a general acute care hospital (GACH) for further evaluation and treatment. Despite these written interventions, staff did not document that they assessed for triggers, notified the physician, removed Resident 5 from an overstimulating environment, initiated transfer to a GACH, or implemented one-to-one supervision after the 8:10 a.m. incident. Interviews with CNA 2, LVN 4, RN 1, the DON, and the Assistant Administrator confirmed that Resident 5 was agitated that morning, threw items including breakfast trays and a water pitcher, and that there was no additional documentation of continuous monitoring, physician notification, or care plan changes following the initial outburst. Later that same day, at approximately 11:45 a.m., Resident 3, who had diagnoses including unspecified dementia, depression, and unspecified psychosis and who had cognitive impairment requiring partial/moderate assistance with ADLs and supervision or touching assistance with transfers and bed mobility, was walking in the hallway when Resident 5 walked behind him and pushed him from behind. Resident 3’s right side of the face struck the hallway handrail, resulting in a cut to the right eyebrow with a small amount of blood. A COC dated 4/5/2026 at 11:45 a.m. documented that Resident 3 was walking in the corridor when Resident 5 pushed him, and that 911 was called and Resident 3 was transferred to a GACH for further evaluation and treatment, where he received six stitches in his right eyebrow. On 4/8/2026, observation showed Resident 3’s right eye was purple and swollen with steri-strips on the right eyebrow, and Resident 3 stated he did not know what happened to his eye. A separate COC for Resident 5 at 12:00 p.m. documented that Resident 5 stated Resident 3 was “evil” and “deserved it,” and that a 5150 transfer was recommended for behavioral issues. The facility’s Abuse and Neglect Prohibition Policy required the facility to identify, correct, and intervene in situations where abuse is more likely to occur by assessing, care planning, and monitoring residents with behaviors that may lead to conflict, including those with a history of aggressive behaviors. The failure to follow these policies and care plan interventions, and to promptly assess and respond to Resident 5’s escalating agitation, led to Resident 5 pushing Resident 3 to the floor and causing injury. The facility’s policies titled “Comprehensive Plan of Care” and “Change of Condition” required that care plans include interventions to manage risk factors and be revised as changes occur, and that the attending physician be promptly notified of changes in a resident’s mental condition, with use of the SBAR tool and development of a care plan for the change of condition. Nurse’s notes were to document changes in medical or mental condition. Interviews with RN 1 and the DON indicated that when Resident 5 became agitated, nurses should have assessed the situation, attempted to calm the resident, remained with him, notified the physician, obtained necessary medications, conducted frequent rounds (at least every 30 minutes), and considered one-to-one supervision. The Assistant Administrator stated he was not aware of the 8:10 a.m. incident but acknowledged that, based on the progress notes, Resident 5 had been agitated and should have been placed on one-to-one or sitter supervision for the safety of other residents. The lack of documented assessment, monitoring, physician notification, care plan revision, and implementation of the facility’s abuse prevention and change-of-condition policies after the initial behavioral incident constituted the actions and inactions that led to the physical abuse of Resident 3 by Resident 5.
Failure to Update Care Plan After Diet Texture Change Following Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s comprehensive care plan after a physician-ordered change in diet texture following an aspiration event. The resident had multiple diagnoses, including cerebral palsy, schizoaffective disorder, dysphagia, metabolic encephalopathy, seizures, protein-calorie malnutrition, hypothyroidism, schizophrenia, anxiety, and psychosis. The admission record and H&P documented that the resident was not self-responsible, could not make medical decisions, and had a conservator. The MDS showed severe cognitive impairment, short- and long-term memory problems, and a need for moderate assistance with eating, with documented issues of losing liquids/solids from the mouth and coughing or choking during meals or when swallowing medications. On a specified date, a Change of Condition (COC) documented that the resident experienced an episode of aspiration while eating, with coughing, difficulty clearing the throat after swallowing, and shortness of breath, and that this condition had not occurred previously. The COC indicated the primary physician recommended downgrading the resident’s diet. Physician orders dated the same day changed the diet to minced and moist/IDDSI Level 5 texture. The following day, an SLP evaluation and plan of treatment documented anterior-to-posterior transit delay, decreased bolus formation, and a tendency for the resident to overstuff her mouth, and recommended a minced and moist texture as tolerated, with any advanced diet texture trials to be provided only through the SLP. Despite these changes, the resident’s existing care plan, originally dated several months earlier, still directed CNAs, LPNs, and RNs to provide and serve a regular, easy-to-chew/IDDSI Level 7 diet. During interviews and concurrent record reviews, an LVN confirmed that the resident’s coughing and shortness of breath indicated a potential aspiration event and that the physician had ordered a diet change to prevent further choking and aspiration, stating that the care plan should have been updated to reflect the new orders. The SLP also stated that the resident’s care plan interventions were not updated to reflect the new physician-ordered diet texture. The facility’s policy on Comprehensive Plan of Care required that the comprehensive care plan address individual needs, include interventions to manage risk factors, and be reviewed and revised by the interdisciplinary team as changes in the resident’s care and treatment occur, including in response to changes in physical or functional status.
Failure to Complete and Communicate Ordered CBC Labs for a Resident
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that physician-ordered Complete Blood Count (CBC) laboratory tests were obtained for one resident. The resident was admitted with encephalopathy, dementia, and schizophrenia, and had severe cognitive impairment documented on the MDS, with limited ability to understand or be understood and no indication of rejecting care. The resident’s care plan for nutritional problems directed nursing and dietary staff to obtain and monitor laboratory work as ordered, report results to the physician, and follow up as indicated. A physician order dated 2/8/2026 directed that a CBC be drawn, but review of progress notes for February 2026 showed no indication that the CBC was completed, attempted, or refused, and no documentation that the physician was notified that the CBC was not done. On 3/5/2026, a change of condition was documented when the resident developed cough with chest congestion, and the physician again ordered a CBC. A subsequent physician order dated 3/6/2026 specified that the CBC was to be drawn one time within three days. Review of progress notes from 3/1/2026 through 3/11/2026 showed no indication that this CBC was completed, attempted, or refused, and no documentation that the physician was notified that the ordered CBC was not done. During interviews, an LVN confirmed that neither the February nor March CBC orders were carried out within the required time frames and that there was no documentation of attempts, refusals, or physician notification. The DON also confirmed that the CBC orders were not performed and that staff should have contacted the lab vendor and notified the physician. The facility’s policy on physician notification indicated that physicians must be notified when laboratory results fall outside clinical reference ranges.
Failure to Implement Effective Fall-Prevention Interventions and Post-Fall IDT Review
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate fall-prevention interventions and post-fall management for one resident identified as being at risk for falls. The resident had multiple diagnoses, including chronic pulmonary edema, cirrhosis of the liver, and morbid obesity, and was documented on the MDS as having short-term memory problems and severely impaired cognitive skills for daily decision-making. Functionally, the resident required substantial assistance with toileting, lower body dressing, transfers, and walking, and used a wheelchair with partial to moderate assistance for mobility. A Fall Risk Evaluation dated 10/17/2025 identified the resident as at risk for falls, and the care plan for risk of falls included general interventions such as assisting with ambulation and transfers, utilizing therapy recommendations, determining transfer ability, and initiating fall risk precautions if the resident was at risk. Despite these identified risks, the resident experienced four falls after admission: an unwitnessed fall on 12/27/2025 with a reported headache that led to an emergency room transfer; an unwitnessed fall on 1/23/2026 resulting in a laceration above the right eyebrow and a skin tear on the right forearm; a fall on 2/18/2026 where the resident was found lying on the floor on the right side; and another fall on 2/21/2026 where the resident was found on the floor between the bed and tray table with bleeding in the mouth and confusion, leading to transfer to a general acute care hospital. Care plans related to impaired physical mobility and actual injury from the first unwitnessed fall focused on neuro checks, physician notification, pain assessment, and hospital transfer, and later added a general directive to determine and address causative factors of the fall. After the fourth fall, additional broad interventions were documented, such as anticipating and meeting needs, ensuring call light within reach, appropriate footwear, following the fall protocol, reviewing past falls to determine causes, and educating the resident and IDT. The facility did not conduct post-fall IDT meetings with the primary physician or consult the pharmacist after any of the four falls, despite facility policies requiring IDT involvement and physician and pharmacist input in developing and revising comprehensive, person-centered care plans and fall-prevention interventions. The DON acknowledged awareness of the resident’s falls and stated that staff should have implemented new interventions such as rounding and assisting the resident as needed, and further stated that the interventions in the resident’s care plan would not prevent a fall and that the revised interventions would not prevent another fall. Facility policies on Person Centered Care Plan, Fall Prevention Program, and Comprehensive Plan of Care required identification of resident-specific risks and causes, development of realistic and specific goals and approaches, implementation of precautions according to the fall prevention program, and periodic review and revision of the care plan by the IDT, including the attending physician and consultant pharmacist. These policy requirements were not followed for this resident following the repeated fall incidents.
Failure to Assess, Care Plan, and Monitor Resident With Known Sexually Inappropriate Behavior Resulting in Sexual Assault of a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse and Neglect Prohibition Policy and related safety policies, resulting in a resident with severe cognitive impairment being sexually assaulted by another resident with known sexually inappropriate behaviors. The cognitively impaired resident had spastic quadriplegic cerebral palsy, depression, schizoaffective disorder, and was conserved, with an MDS showing severe cognitive impairment and need for staff assistance with mobility and lower body dressing. On the date of the incident, progress notes documented that this resident was found lying in bed with lower garments down and did not respond when asked if she was in pain or knew what had happened. A change of condition assessment noted that a CNA had informed the charge nurse that a male resident was in the room, but the assessment did not document what occurred prior to the residents being separated or specify the details of the vaginal exam performed. The male resident involved had a documented history of sexually inappropriate behavior prior to admission. Hospital records from a recent stay indicated he had confusion, frequent wandering, and a history of depression, bipolar disorder, and schizophrenia, and that he had displayed sexually inappropriate behavior, including masturbating while looking at a CNA, leading to placement on precautions for sexually inappropriate behavior. A facility document summarizing the nursing report at admission showed that the admitting RN was informed of this sexually inappropriate behavior. However, the admission summary completed by that RN did not include the sexually inappropriate behavior or any interventions to address it, and there was no care plan or behavior monitoring documented in the resident’s medical record to address this risk. Multiple observations and interviews described the events leading to and surrounding the assault. The cognitively intact roommate reported that the male resident had come into their room multiple times before the incident, made flirtatious faces at the cognitively impaired resident, and that she had yelled at him to leave. On the day of the incident, the roommate ran into the hallway and requested staff assistance. A CNA entered the room quietly, heard moaning, saw shoes and jeans at the foot of the bed, and upon pulling back the curtain observed the male resident on top of the cognitively impaired resident, with both facing each other and actively engaged in sexual intercourse; the male resident then jumped off and ran out. The cognitively impaired resident’s brief and pants were pulled down to her knees, and she curled into a fetal position and refused to talk. Subsequent hospital sexual assault examination records documented that staff and law enforcement reported the male resident was forcing penile-vaginal penetration, and the exam found brown ecchymosis on the left medial anterior labia minora, with a sexual assault kit collected and STI prophylaxis and emergency contraception provided. The male resident later told staff and hospital providers that he had intercourse because the other resident did not object and acknowledged she did not give consent. The facility’s own policies required assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or abuse, including wandering into others’ rooms and sexually aggressive behavior, and required the IDT to identify behavioral safety risks and develop resident-centered care plans. The dietician, who reviewed the admission paperwork and saw documentation of the male resident’s sexually inappropriate behavior, added this behavior as a problem in a nutrition care plan but did not notify other staff or develop behavior-related interventions, and the care plan interventions addressed only nutritional risks. The DON and ADON later acknowledged that the admitting RN knew of the sexually inappropriate behavior and that no care plan, behavior monitoring, or enhanced monitoring of the resident’s whereabouts was implemented, and that there was no documentation that staff beyond the admitting RN and RD were aware of the behavior. This lack of interdisciplinary communication, failure to incorporate known sexually inappropriate behavior into the comprehensive plan of care, and failure to monitor and manage the resident’s wandering and sexual behavior constituted noncompliance with the facility’s Abuse and Neglect Prohibition Policy, Protection of Resident policy, Resident Safety policy, and Comprehensive Plan of Care policy, and led to the sexual assault of the cognitively impaired resident.
Failure to Thoroughly Investigate Alleged Staff-to-Resident Sexual Misconduct
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of staff-to-resident sexual misconduct involving Resident 4. Resident 4, who had COPD and type 2 diabetes mellitus, was assessed on a recent MDS as having some difficulty with daily decision making in new situations but without inattention, disorganized thinking, or altered level of consciousness. Resident 4 reported that during nighttime hours, on the night before her most recent hospitalization, a tall male staff member of African descent with dark skin and an accent exposed his genitals, placed his penis on her hand, and then engaged in unprotected sexual intercourse with her in her bed. Resident 4 stated she reported this alleged encounter to staff upon her return from the hospital and identified the ADON as the first person she informed. The ADON acknowledged that Resident 4 reported the alleged sexual encounter and provided a description of the alleged perpetrator as tall, of African descent, with dark skin and an accent. The ADON stated she attempted to identify the alleged perpetrator by recalling male staff characteristics from memory and concluded that no one matched the description, without using staffing records or other objective data. The DSS similarly stated that Resident 4 described the alleged perpetrator as an African male and that there were no male staff who matched this description. The AADM, who was responsible for the investigation, reported that he interviewed Resident 4 and one CNA (CNA 3), whom he felt matched the description, but he did not take into account Resident 4’s report of the date and time of the incident to identify other potential staff. The DSD, who was supposed to conduct additional staff interviews, stated that as of several days after the allegation was reported, she had not interviewed any male staff matching the resident’s description who were working on or around the date of the alleged incident. The AADM submitted a conclusion letter to the State Agency indicating that the investigation was complete, that the alleged incident occurred on a date that did not correctly correspond to the resident’s hospitalization, and that no staff matched the resident’s description or had knowledge of the incident. The AADM later acknowledged that the incident date in the letter was incorrect and that he had assumed the alleged perpetrator had been terminated based solely on the resident’s statement that she had not seen the staff member since the incident, without confirming this through records. He also acknowledged that he did not verify that the DSD had completed staff interviews and that there were no documented interviews to demonstrate that an investigation had been conducted, despite the conclusion letter stating that interviews with current and former male staff had been done. Staffing assignments for the relevant night shifts showed multiple male staff, including those assigned to the resident’s care, but there was no documentation that these individuals were interviewed. Facility policies required prompt, thorough, and documented investigations of abuse allegations, including interviewing individuals who may have relevant information and suspending accused staff, but the investigation into Resident 4’s allegation was incomplete and not thoroughly documented as required. The facility’s own Follow-Up Investigation Report stated that a payroll report of all male staff was generated and that only one person fit the description, but the report did not specify what actions were taken regarding that staff member. The same report’s sections on interviews with alleged perpetrators and the conclusion stated that no one had any knowledge of the incident and that no one fit the description, despite the AADM’s admission that he had not confirmed that interviews were completed and could not provide documentation of such interviews. Additionally, the facility’s policies on Protection of Resident, Abuse – Reporting and Investigations, and Abuse and Neglect Prohibition Policy required that investigations be initiated within 24 hours, that they be thoroughly documented on the facility’s investigation form, and that involved or accused staff be placed on investigative leave or suspended until the investigation results were reviewed by the Administrator. These policy requirements were not met in the handling of Resident 4’s allegation, resulting in a deficient practice related to the facility’s response to alleged staff-to-resident sexual misconduct.
Failure to Clarify and Implement Oxygen Order for Resident With COPD
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care and services consistent with professional standards of practice for a resident with COPD and other respiratory disorders. During an observation in the resident’s room, the resident was seen sitting in a wheelchair without oxygen in use, and there was no oxygen concentrator or tubing present. The resident reported having COPD, sometimes experiencing shortness of breath, and stated that since being readmitted to the facility, no oxygen tank or tubing had been provided. Record review showed the resident had diagnoses including COPD, a respiratory disorder, and diabetes mellitus, and the MDS indicated cognitive impairment and a need for substantial/maximal assistance with ADLs. Review of the physician’s orders dated 1/9/2026 showed an order for oxygen at 3 L/min every shift related to COPD, but the order did not specify whether oxygen should be administered continuously or as needed. RN 1 acknowledged that the order lacked clarification on frequency and stated it was important to clarify the order with the physician and that an oxygen concentrator should have been available in the resident’s room for immediate use until clarification was obtained. The DON confirmed that the resident had a physician’s order for oxygen and that it was essential to follow physician orders, noting the resident could be at risk of respiratory distress if oxygen was not available for immediate use. Facility policies on oxygen administration and physician orders for respiratory modalities required provision of oxygen support when indicated and that all physician orders include modality, dosage, frequency, duration, and treatment diagnosis, which was not followed in this case.
Improper Documentation of Ordering Physician for Telephone and Medical Orders
Penalty
Summary
Facility staff entered telephone and other medical orders under the attending physician’s name rather than under the actual prescriber’s name, contrary to accepted standards and the facility’s own policy. During interview, one physician (MD1) reported that when telephone orders were given by members of her medical team (MDs, NPs), facility staff would document the orders using her name as the ordering physician. MD1 stated she had been informed that the facility’s electronic medical record system did not include the names of the other medical team members as options for the ordering provider. Another physician (MD2) confirmed that the computer program used for order entry only allowed selection of the attending physician’s name and did not allow the ordering MD to enter orders under their own name, making it difficult to identify which covering MD actually gave the order. Review of the facility’s Pharmaceutical Services Policy and Procedure Manual, dated 1/2025, showed that medication telephone orders were required to be countersigned by the prescriber. This practice resulted in difficulty identifying the ordering physician’s name in the medical record and had the potential to mislead the healthcare system and create potential for fraud, as documented by the surveyors.
Failure to Report Resident-on-Resident Abuse Allegation to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-on-resident physical abuse to the California Department of Public Health (CDPH). One resident (Resident 4), who was admitted with diabetes mellitus and hypertension, had documentation in a History and Physical dated 12/12/2025 indicating a lack of capacity to understand and make decisions, while a Minimum Data Set (MDS) dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with activities of daily living and mobility. Despite these documented needs and cognitive findings, there was no Change of Condition (COC) entry or progress note from 12/11/2025 to 12/16/2025 reflecting any allegation that another resident had been hitting this resident, nor any indication that such an allegation was reported to CDPH. During an interview on 12/16/2025 at 11:00 a.m. at nurse’s station 1, Resident 4 stated that another resident (Resident 5) had been hitting her in the stomach since her admission to the facility, and she repeated this allegation. Licensed Vocational Nurse (LVN 2) and the Assistant Administrator (AADM) were present during this interview, and LVN 2 reported Resident 4’s statement to the AADM at that time. However, the clinical record for Resident 4 did not contain documentation of this allegation as a COC or in progress notes, and there was no documentation that the allegation was reported to CDPH as required. Resident 5, who was also admitted with diabetes mellitus and hypertension and had an H&P dated 10/2/2025 indicating capacity to understand and make decisions, had an MDS showing that she was usually able to understand and be understood and required assistance with multiple activities of daily living and transfers. A review of Resident 5’s clinical records from 12/11/2025 to 12/16/2025 showed no COC or progress note documenting any allegation that she had hit Resident 4, and no indication that such an allegation was reported to CDPH. In a subsequent interview on 12/31/2025 at 1:00 p.m., the AADM stated that on 12/16/2025 at 11:30 a.m., LVN 2 had reported the allegation that Resident 5 had been hitting Resident 4 in the stomach since admission, and acknowledged that he did not report the incident to CDPH, despite facility policy and federal law requiring that all abuse allegations be reported to CDPH, the Ombudsman, and the police department. The facility’s policy titled “Reporting Guidance & Timelines for Abuse & injuries of Unknown Origin,” dated 6/2022, states that alleged violations related to abuse are to be reported immediately using the SOC 341 form.
Failure to Obtain Required Admission Consent From Resident’s Conservator
Penalty
Summary
The deficiency involves the facility’s failure to obtain admission consent in accordance with its policy and procedure titled “admission to the Facility.” One resident was admitted on a specified date with diagnoses including diabetes mellitus and hypertension. The resident’s History and Physical dated 12/12/2025 documented that the resident did not have the capacity to understand and make decisions, while the MDS dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with ADLs, including supervision, moderate assistance, and maximal assistance for mobility and self-care tasks. Despite the resident’s documented need for assistance and questions about decision-making capacity, the facility proceeded with admission without obtaining consent from the resident or the responsible party. During an interview, the resident’s family member stated she was the court-appointed conservator and reported that the prior facility did not inform her that the resident was being transferred and that she did not give the admitting facility permission to take the resident. In a concurrent interview and record review, the Admission Coordinator acknowledged that the facility’s policy was not followed when the conservator’s consent was not obtained prior to admission and stated that the conservator’s admission consent should have been obtained to ensure the resident’s and conservator’s wishes were respected. Review of the facility’s admission policy dated 1/2023 showed that residents are to be admitted only upon written order of the attending physician and with the consent of the resident or responsible party, and that identifying paperwork for any appointed surrogate or representative must be presented prior to or upon admission. These requirements were not met in this case.
Failure to Provide Required Bed-Hold Notices at Time of Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold notifications to a resident at the time of multiple transfers to an acute care hospital, as required by its own Bed-Hold policy and federal and state guidelines. The resident was originally admitted and later readmitted to the facility, with diagnoses including seizures and conversion disorder with seizures. A History and Physical dated 12/2/2025 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 12/4/2025 showed the resident required partial/moderate assistance with ADLs and certain mobility tasks. The facility’s Daily Census indicated the resident was on bed-hold on several dates when transferred out, and the Admission Coordinator stated the resident should have signed bed-hold notices for each of these transfers, in addition to the admission, with copies filed in the medical record. Record review and staff interviews confirmed that only one bed-hold agreement, signed on 12/1/2025, was present in the resident’s file, and there were no additional bed-hold notices for subsequent transfers. The facility’s Bed-Hold policy, dated 12/2016, required written notification of the bed-hold option upon admission and at the time of transfer to a hospital or therapeutic leave, specifying the duration of the bed-hold, sending a copy with the resident at transfer, and providing written notice to family or representative within 24 hours in case of emergency transfer. The LVN and Interim DON acknowledged that, according to this policy, residents who were transferred should receive written information about the option to exercise the bed-hold policy at each transfer, and that the absence of additional bed-hold notices in the resident’s file meant the facility did not follow its policy. The report states this failure had the potential for the resident not to exercise the option to use the facility’s bed-hold policy and lose their bed at the facility.
Failure to Administer and Monitor Anticonvulsant Therapy for Residents With Seizure Disorders
Penalty
Summary
The facility failed to ensure seizure medications were administered according to professional standards for two residents with seizure disorders. One resident with a history of seizures and conversion disorder was ordered Levetiracetam (Keppra) 1000 mg orally every 12 hours. The Medication Administration Record (MAR) for that month showed missed doses at 9 a.m. on one date and 9 p.m. on the following date. An order administration note documented that the 9 a.m. dose was not given because the facility was waiting for the medication to be delivered, and there was no documentation that staff followed up with the pharmacy to ensure timely delivery. Nursing progress notes showed the resident was sent to a general acute care hospital later that afternoon due to a seizure and was readmitted the next evening, yet there was no documentation explaining why the 9 p.m. dose of Keppra was not administered upon readmission. For the same resident, the MAR showed a PRN order for Lorazepam (Ativan) 2 mg/mL IM every five minutes as needed for seizures, up to three doses, but there was no indication that Ativan was administered when the resident experienced the seizure that led to transfer to the hospital. Review of active and discontinued orders for the month showed no orders for monitoring Keppra blood levels. Interviews with LVNs revealed that Keppra doses were not documented when given, one dose was charted on the wrong date, and there was no documented evidence of pharmacy follow-up when the medication was reportedly unavailable. The interim DON stated that Keppra levels should have been obtained on initial assessment and readmission per facility policy, but there was no record of any Keppra levels for this resident. A second resident with epilepsy, described as intractable without status epilepticus, was ordered Divalproex Sodium (Depakote) 750 mg twice daily. Review of the MAR for the same month showed that the 9 a.m. doses on two consecutive days were not administered. An LVN stated that these doses were not given because the Depakote was not available in the medication cart. Another LVN stated that staff should have called the physician for orders when Depakote was not available and that the resident should have received the missed doses to prevent seizures. Review of the resident’s progress notes for those dates did not show documentation explaining the missed doses. Facility policies on medication administration and care for residents with seizure disorders required timely administration, immediate documentation on the MAR, and assessment and documentation of anticonvulsant blood levels, which were not followed in these cases.
Failure to Obtain and Verify Physician Admission Orders for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and verify physician admission orders for a newly admitted resident as required by its admission and pharmaceutical services policies. The resident was admitted with diagnoses including diabetes mellitus and hypertension. The admission record showed the resident was admitted from a general acute care hospital with discharge paperwork dated several weeks prior to the admission date. Progress notes documented that the admitting physician’s orders were not entered at the time of admission because the orders needed clarification from the attending physician, and that the hospital’s updated discharge records for the actual admission date could not be located. Subsequent review of the resident’s record showed telephone orders entered the day after admission listing multiple medications and treatments, including allopurinol, aripiprazole, atorvastatin, carvedilol, famotidine, insulin glargine, regular insulin per sliding scale, latanoprost, levothyroxine, lisinopril, olanzapine, quetiapine, trazodone, and glucagon. An LVN reported that the admitting nurse did not enter physician orders at the time of admission and could not recall why, and that no follow-up call was made to the attending physician because physicians were perceived as not answering facility calls on night shift. The LVN stated that the medication list used for the physician orders entered was taken from the resident’s older hospital discharge paperwork and that these orders were not verified with the attending physician. Interviews with the attending physician and another physician indicated that neither had given admission orders for the resident on the admission date and that there was no record of admission orders being sent for verification. The attending physician described the usual process of photographing transfer orders and sending them to the physician for review and verbal acceptance or declination, but could not find any evidence this occurred for this resident. Both physicians stated it was important for physicians to review admission orders to prevent medication errors. Review of facility policies confirmed that residents were to be admitted only upon written order of the attending physician and that medication orders must be signed by a licensed physician authorized to prescribe medications. The facility’s failure to follow these procedures resulted in the resident’s admission orders not being verified by a physician.
Failure to Obtain Timely MD Verification and Administer Admission Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician verification and administration of admission medications for a newly admitted resident. The resident was admitted with diagnoses including DM, hypertension, gout, GERD, hypothyroidism, hyperlipidemia, glaucoma, bipolar disorder, schizophrenia, and depression. The resident’s H&P indicated a lack of capacity to understand and make decisions, while the MDS documented that the resident could understand and be understood and required varying levels of assistance from supervision to maximal assistance for ADLs and mobility. Telephone orders dated the early morning after admission listed multiple medications, including antihypertensives, insulin (both glargine and sliding scale regular insulin), psychotropic medications, and other chronic disease medications. Record review and staff interviews showed that the resident’s admission date and time were documented, but the resident did not receive night medications due on the evening of admission, including carvedilol, insulin glargine, and trazodone, because the medication orders were not verified by the prescribing physician. The LVN interviewed stated that the resident’s medication administration history showed that all 9 a.m. medications the following day were not given until 12:21 p.m., over three hours late. These medications included aripiprazole, famotidine, sliding scale insulin, lisinopril, olanzapine, quetiapine, and trazodone. The LVN explained that the delay and missed doses were related to the lack of physician verification of the admission orders. Further interviews revealed that the admitting nurse did not enter any physician orders at the time of admission and could not recall why the admission orders were not entered. Another LVN stated she did not make a follow-up call to the physician because physicians do not answer facility calls on night shift and that she had been told by an administrator to enter physician orders without calling the physician, as night shift nurses enter orders without contacting MDs. The medication list used for the physician orders was taken from the resident’s hospital discharge paperwork. The attending physician later stated she had not given admission orders for the resident on the date of admission and emphasized the importance of MD review of admission orders to prevent medication errors, duplicate drugs, or contraindicated medications.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident pushed another to the floor, resulting in a head injury that required hospital evaluation and treatment. The incident occurred when a resident with a history of major depressive disorder, type 2 diabetes mellitus, and paranoid schizophrenia was talking with another resident in the hallway. Another resident, who had diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease, approached and pushed the first resident to the floor without provocation. The injured resident sustained a 1.0-inch laceration to the back of the head, which required two staples at a general acute care hospital. Record reviews indicated that both residents involved had moderately impaired cognitive skills and required assistance with activities of daily living. The resident who was pushed had a documented history of agitation and aggressive behaviors, and was noted to lack the capacity to make reasonable decisions, requiring redirection. The resident who pushed also had a history of agitation and aggressive behaviors, lacked capacity for medical decisions, and required redirection. The incident was witnessed by staff, who observed the push and responded by providing immediate first aid and calling emergency services. The facility's policy prohibits abuse, mistreatment, and neglect, and specifies that residents who threaten or attack others should be removed from the situation. Despite these policies, the incident occurred, resulting in physical harm to a resident. The deficiency was identified through interviews, record reviews, and direct observation of the incident and its aftermath.
Failure to Obtain and Administer Ordered Antipsychotic Medication Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that licensed nurses followed up with the contracted pharmacy regarding a physician's order for Seroquel 25 mg three times daily for a resident with diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. The order was written to manage the resident's aggressive behavior, but the medication was not obtained or administered for eight days. Documentation in the Medication Administration Record (MAR) repeatedly indicated that the medication was not available, and progress notes showed ongoing delays attributed to awaiting pharmacy delivery. The pharmacy confirmed that no medication request was received for the order, and the medication was not delivered until eight days after the order was written. During this period, the resident did not receive the prescribed Seroquel, which was intended to manage symptoms of aggression and angry outbursts. On the eighth day without the medication, the resident exhibited aggressive behavior by pushing another resident, resulting in the second resident falling and sustaining a 1.0-inch laceration to the back of the head. The injured resident required evaluation and treatment at a general acute care hospital, where two staples were placed to close the wound. Interviews with staff and review of records confirmed that the medication omission was not promptly addressed, and the pharmacy was not contacted in a timely manner to resolve the issue. The facility's policy on medication errors defines omission of a vital medication as a medication error and requires assessment, documentation, and reporting to the physician and pharmacy. Despite this policy, the omission persisted for eight days, and the resident's care plan, which included administration of psychotropic medications as ordered, was not followed. The Director of Nursing acknowledged that staff failed to ensure the medication was obtained and administered as ordered, and that this failure could have contributed to the aggressive incident and resulting injury.
Failure to Administer Ordered Antipsychotic Medication Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that Seroquel 25 mg, an antipsychotic medication, was obtained, available, and administered as ordered for a resident with multiple psychiatric and neurological diagnoses, including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. Despite a physician's order for Seroquel 25 mg three times daily starting on 11/24/2025, the medication was not requested from the pharmacy until 12/1/2025 and was not received by the facility until 12/2/2025. As a result, the resident missed eight consecutive days of the prescribed medication. During this period without the ordered antipsychotic, the resident, who had severely impaired cognitive skills and required assistance with daily living activities, was involved in a resident-to-resident altercation that resulted in injury to another resident. The DON confirmed that nursing staff did not ensure timely procurement and administration of the medication, and acknowledged that the absence of Seroquel could have contributed to the escalation in the resident's behavior. Facility policy defined the omission of a prescribed medication as a medication error.
Falsification of Medication Administration Records for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that registered nurses (RNs) and licensed vocational nurses (LVNs) accurately documented the administration of a psychotropic medication, Seroquel, for a resident with multiple diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. The resident was assessed as having severely impaired cognitive skills and lacked capacity to make medical decisions. The physician ordered Seroquel to be administered three times daily for behavior management, and the care plan directed staff to administer the medication as ordered. Review of the Medication Administration Records (MARs) for November and December showed that staff documented Seroquel as administered or refused on multiple occasions when the medication was not actually available in the facility. Progress notes indicated that the medication was not administered at several scheduled times due to pending pharmacy delivery, yet the MARs reflected administration or refusal entries. Interviews with nursing staff confirmed that they documented administration or refusal despite the medication not being present, and did not follow up with the pharmacy to ensure timely delivery. Pharmacy records and interviews revealed that the pharmacy did not receive a request for Seroquel until several days after the order was written, and the medication was not delivered until more than a week later. The facility's policy required medication to be administered and documented in accordance with physician orders and good nursing practice, but this was not followed. As a result, the resident's medical records were inaccurate and did not reflect the actual care provided or the resident's clinical condition during the period in question.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Assessment and Supervision
Penalty
Summary
A facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent the elopement of a resident with significant psychiatric and cognitive impairments. The resident in question had diagnoses including schizophrenia, suicidal ideations, bipolar disorder, major depressive disorder, and diabetes mellitus. Despite these conditions, the facility's elopement risk assessment did not account for the resident's cognitive level or history of elopement, and the assessment inaccurately determined that the resident was not at risk for elopement. The resident had demonstrated poor judgment and unsafe behaviors, including an attempt to ingest hand sanitizer, which was documented as a change of condition requiring reassessment and increased supervision. Following the resident's attempt to ingest hand sanitizer and escalating agitation, the physician recommended a 5150 hold for immediate psychiatric evaluation and stabilization. However, the facility did not follow this recommendation in a timely manner, nor did it reassess the resident's risk for wandering and elopement after the change in condition. The care plan called for close monitoring and hourly documentation, but the resident was last observed walking in the hallway and was later found missing during staff rounds. The facility's policies required identification, assessment, and appropriate interventions for residents at risk of elopement, but these procedures were not followed. Interviews with facility staff and review of records confirmed that the elopement risk assessment was conducted incorrectly, and that the resident should have been placed on one-to-one supervision and transferred to a general acute care hospital as recommended. The facility also failed to obtain a complete history of the resident's prior elopement behavior from family or conservators, which contributed to the inaccurate risk assessment. As a result of these failures, the resident eloped from the facility and was not found as of the time of the report.
Removal Plan
- Elopement Code was activated (Code Green) to alert staff to immediately search for Resident 1 inside and outside the facility and its vicinity.
- Acute hospitals were contacted to check for Resident 1's presence.
- The elopement involving Resident 1 was reported to Los Angeles Police Department (LAPD), California Department of Public Health (CDPH), and the local Long-Term Care (LTC) Ombudsman.
- The DON and/or DSD initiated an in-service for facility nursing staff and Interdisciplinary Team (IDT) every shift on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement.
- The IDT which included Social Worker (SW), DON and Activities Director (AD) conducted record review and reassessed 65 out of 65 residents for wandering and elopement.
- A total of 4 residents were identified as high risk for elopement. The IDT updated the plan of care for all 4 residents.
- The facility's DON and Director of Staff Development (DSD) provided Licensed Vocational Nurse (LVN), door monitor Certified Nursing Assistant (CNA) and CNA assigned to Resident 1 one on one education on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement.
- The DON and/or DSD provided staff in-service on regular rounding for patient safety and daily safety huddles.
- The facility's DSD observed CNAs during their shift when caring for 4 of 4 residents who were at high risk for wandering and with inappropriate behavior. Residents observed receiving adequate supervision accordingly.
- IDT initiated review of records and reassessment of 4 of 4 residents who were at high risk for elopement and wandering and plan of care updated.
- The Maintenance Director installed door chimes to notify staff of entry or exit in addition to the door monitor CNA, which was stationed at the entrance/exit 24 hours per day, 7 days per week.
- The Director of Medical Records/Designee conducted an audit of residents' behavior, elopement and wandering episode to identify residents who had changes in condition, need monitoring and transfer to General Acute Care Hospital (GACH) for behavior management, through record review of assessments and physician's order.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a stage 4 pressure ulcer. The resident, who had diagnoses including hepatic encephalopathy, COPD, and dementia, was totally dependent on staff for activities of daily living (ADLs) such as eating, oral hygiene, and toileting. The resident's medical records indicated severely impaired cognitive skills and an inability to make medical decisions. During an observation, a Certified Nurse Assistant (CNA) was seen providing ADL care to the resident without wearing a gown, despite the resident being on EBP due to the presence of an open wound. Interviews with the CNA, Director of Staff Development (DSD), and Director of Nursing (DON) confirmed that EBP protocols require staff to wear gloves, mask, and gown when providing care to residents with wounds or medical devices to prevent the spread of multi-drug-resistant organisms (MDROs). The CNA acknowledged forgetting to use a gown during care. Review of the facility's policy confirmed that gown and glove use is required for high-contact care activities under EBP, such as dressing, bathing, and toileting.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Limit PRN Antipsychotic Orders and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN (as needed) orders for antipsychotic medications were limited to a 14-day duration for one resident. Specifically, a resident with a diagnosis of bipolar disorder and schizophrenia had active PRN orders for Zyprexa that exceeded the 14-day limit on two occasions, with one order lasting 24 days and another lasting 16 days. The Director of Nursing (DON) confirmed that the facility did not adhere to the policy requiring PRN antipsychotic orders to be limited to 14 days, as the rationale for use may change within that period. Additionally, the facility did not monitor or document the target behavior or adverse effects related to the use of Ativan for another resident diagnosed with dementia and anxiety. The resident was prescribed Ativan for anxiety manifested by an inability to relax, but there was no documentation in the Medication Administration Record (MAR) to record or quantify the behavior or monitor for adverse effects. There were also no physician orders or care plans addressing the monitoring of the behavior or adverse effects related to Ativan use for this resident. The facility's policy on psychoactive medication management requires that PRN antipsychotic orders be limited to 14 days and that nursing staff document behaviors and adverse reactions in the MAR. The policy also specifies that behaviors and possible adverse drug reactions should be monitored every shift. The facility did not follow these requirements for the two residents involved, as confirmed by the DON during interviews.
Failure to Complete and Resubmit PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete and resubmit the Preadmission Screening and Resident Review (PASARR) Level I screening and refer for a Level II evaluation when indicated for two residents. For one resident, the admission record showed diagnoses including metabolic encephalopathy, dysphagia, and dementia, with a psychiatric evaluation confirming an anxiety disorder. The resident was prescribed Lorazepam, a psychotropic medication, for anxiety. Despite these findings, the PASARR Level I completed by the transferring hospital did not reflect the mental health diagnosis or psychotropic medication use, and the facility did not resubmit a new PASARR Level I to indicate the updated diagnosis or refer for a Level II evaluation as required. Another resident was admitted with diagnoses of schizophrenia and major depressive disorder. The PASARR Level I application for this resident incorrectly indicated that there was no mental health disorder, and therefore, a Level II PASARR was not initiated. The DON acknowledged that the PASARR should have been resubmitted to reflect the accurate diagnoses, but this was not done. The DON also noted that PASARRs are to be completed before or within 24 hours of admission, but she had not been given access to process them. Facility policy and the PASRR reference manual require prompt notification and re-evaluation by the state mental health authority if there is a significant change in a resident's mental condition or if a mental illness is identified. In both cases, the facility did not comply with these requirements, resulting in the failure to ensure appropriate assessment and referral for specialized mental health services for the affected residents.
Failure to Develop Comprehensive Care Plans for Residents with Mental Health Diagnoses and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with specific mental health diagnoses and medication needs. For one resident with a diagnosis of anxiety and behaviors of inability to relax, the facility did not create a care plan addressing these issues or the use of Ativan, an anti-anxiety medication. There was no documentation or monitoring of the resident's behaviors or potential adverse effects related to Ativan use in the Medication Administration Record (MAR), and no physician orders were in place to monitor for these concerns. The Director of Nursing (DON) confirmed that the lack of a care plan and monitoring prevented the care team from properly evaluating the ongoing need for the medication. Additionally, another resident with a diagnosis of schizophrenia did not have a care plan developed to address this condition, despite facility policy requiring individualized care plans for residents with behavioral and psychoactive medication needs. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for partial assistance with activities of daily living. The DON acknowledged that care plans should be initiated upon admission or change of condition and that the absence of a care plan for schizophrenia could result in improper care.
Failure to Complete Smoking Assessments and Ensure Accessible Fire Safety Equipment
Penalty
Summary
A review of a resident's records revealed that the facility failed to complete required quarterly smoking and safety assessments for a resident with severe cognitive impairment, dementia, and ongoing tobacco use. The resident's Minimum Data Set indicated a need for supervision with daily activities and current tobacco use, yet only an initial smoking and safety assessment was completed, with no follow-up assessments performed as required by facility policy. The MDS nurse confirmed responsibility for these assessments and acknowledged the omission, which is necessary to ensure appropriate interventions and care planning for residents who smoke. Additionally, during an observation on the smoking patio, the fire extinguisher was found locked in a box, and the staff present did not have access to the key. The activity assistant stated that in the event of a fire, the extinguisher would not be accessible, and she would have to leave the area to retrieve another extinguisher from the kitchen. This lack of immediate access to fire safety equipment on the smoking patio was confirmed by staff and is contrary to facility policy requiring accessible fire safety measures in smoking areas.
Incomplete Non-Narcotic Medication Destruction Logs
Penalty
Summary
The facility failed to maintain complete records for the destruction of non-narcotic medications in the Station 1 Medication Room. During an observation, it was found that the non-narcotic medication destruction logs, kept in a three-ring binder, did not contain signatures from licensed staff or witnesses, nor did they indicate who was responsible for completing the medication destruction. A review of the Facility Medication Destruction Form records from early March to late June revealed that none of the available records had the required signatures or dates, making it impossible to determine which nurses completed the disposition of medications. An interview with the DON confirmed that the destruction logs for non-narcotic medications were incomplete, as the nurses responsible for performing the disposition on the overnight shift failed to sign off on any of the available logs after completing the destructions. The facility's policy, revised in July 2022, requires that a non-controlled medication disposition log be used for documentation, including the date of disposition and signatures of the required witnesses, but these requirements were not met.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Errors
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required. During medication administration observations, three errors were identified out of 26 opportunities, resulting in an error rate of 11.54%. These errors involved two residents who were administered medications that did not match their physician's orders. Specifically, one resident received an incorrect dose of calcium carbonate, and another received both the wrong formulation of a multivitamin and an incorrect dose of Seroquel. For the first resident, the nurse administered a 750 mg tablet of calcium carbonate instead of the prescribed 500 mg dose. The resident had a history of paranoid schizophrenia and was capable of making her own medical decisions. The error was observed during the medication pass, and the nurse later acknowledged administering the incorrect dose. The second resident, who also had a diagnosis of schizophrenia and was capable of medical decision-making, was given a multivitamin with minerals instead of the prescribed formulation without minerals. Additionally, the nurse administered a full 50 mg tablet of Seroquel instead of the ordered half-tablet dose. The nurse stated that she did not verify the medication label against the physician's order and failed to notice a discrepancy between the pharmacy label and the current order, which contributed to the administration of the incorrect dose and formulation.
Failure to Store Medications per Manufacturer Instructions
Penalty
Summary
Surveyors observed that the facility failed to store certain medications according to manufacturer instructions. Specifically, one unopened vial of latanoprost eye drops intended for a resident was found stored at room temperature in a medication cart, rather than in the refrigerator as required by the product labeling. During an interview, the LVN confirmed that unopened latanoprost should be refrigerated and acknowledged that improper storage could affect the medication's effectiveness. Additionally, two unopened Lantus insulin pens for two other residents were found stored at room temperature in a medication cart, instead of being refrigerated as specified by the manufacturer. The LVN responsible for these medications confirmed that unopened insulin pens are supposed to be refrigerated until use and that improper storage or labeling could compromise their effectiveness. A review of the facility's medication storage policy indicated that medications and biologicals must be stored safely and properly, following manufacturer recommendations, including refrigeration when required.
Resident Not Included in Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident participated in the development and implementation of her person-centered plan of care. The resident, who had diagnoses including cerebral infarction, dysphagia, and liver cirrhosis, was admitted to the facility and was assessed as having the ability to express ideas and understand others. Documentation indicated that the resident required moderate assistance with daily activities and expressed a desire to participate in assessment and goal setting. However, there was no evidence that the resident or her representative attended any care plan meetings, and the Multidisciplinary Care Conference Note was incomplete with no documentation of attendance. Interviews with the resident confirmed that she had never met with facility staff to discuss her condition or medications. Staff interviews, including those with the Social Service Director, MDS Nurse, and Director of Nursing, acknowledged the importance of involving the resident or her representative in care planning and confirmed that this did not occur. Review of facility policies showed that care conferences should be held with residents or their representatives and documented accordingly, but this was not followed in this case.
Failure to Provide Foley Catheter Privacy Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with a history of benign prostatic hyperplasia, bladder disease, and metabolic encephalopathy, who was totally dependent on staff for personal care and had an indwelling catheter, was observed without a privacy drainage bag covering the foley catheter. During an observation in the resident's room, the foley catheter drainage bag containing urine was exposed and not concealed with a privacy bag, contrary to the facility's standard practice and policy. Registered Nurse 1 confirmed that it is standard practice to use a privacy bag for all residents with a foley catheter to maintain dignity and prevent potential damage to the drainage bag. The Director of Nursing also stated that licensed nursing staff are responsible for applying privacy bags to promote resident dignity. The facility's policy on Resident Dignity and Personal Privacy requires care to be provided in a manner that respects and enhances each resident's dignity and right to personal privacy.
Failure to Timely Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit a resident's Discharge Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion, as required. Review of the resident's records showed that the discharge MDS assessment, dated 3/9/2025, was not transmitted in a timely manner. The Minimum Data Set Nurse (MDSN) confirmed during interview and record review that the assessment had not been submitted to CMS, and acknowledged that all MDS assessments should be transmitted within 14 days from the Assessment Reference Date (ARD) or discharge date. The resident involved had a history of metabolic encephalopathy, epilepsy, and chronic obstructive pulmonary disease (COPD), and was noted to have severely impaired cognitive skills and total dependence on staff for several activities of daily living. The facility's policy required timely transmission of MDS assessments according to electronic medical record and RAI guidelines, but this process was not followed for the resident in question.
Failure to Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to submit a Pre-admission Screening and Resident Review (PASARR) for one of four sampled residents. The resident in question was admitted with diagnoses including schizophrenia, major depressive disorder, anxiety, and other persistent mood disorders. Review of the resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills and a need for maximal assistance with activities of daily living. Despite these significant mental health diagnoses, there was no evidence that a Level 1 PASARR was completed upon admission as required. During an interview and record review, the DON confirmed that PASARR screenings are to be completed before or within 24 hours of admission, but acknowledged that the process was not followed for this resident. The DON also stated she had the capability to process PASARRs but had not been given access to do so. The facility's policy, dated December 2022, requires PASARR Level 1 screening for all potential skilled nursing facility residents, but this protocol was not adhered to in this case.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one of its residents within the required timeframe following admission. Specifically, a resident admitted with diagnoses including cerebral infarction, dysphagia, and liver cirrhosis did not have a baseline care plan created within 48 hours of admission, as required by facility policy. The resident's Minimum Data Assessment indicated a need for moderate assistance with oral hygiene, toileting hygiene, and personal hygiene, and the resident was able to express ideas and understand others. Interviews with facility staff, including the Social Service Director, MDS Nurse, and Director of Nursing, confirmed that the interdisciplinary team did not create the required baseline care plan for this resident. The facility's policy states that an interim plan of care should be developed within 48 hours of admission to address the resident's initial needs, using information from various sources such as referring facilities, physician orders, and assessments. The absence of this plan was acknowledged by staff during the survey.
Failure to Provide Ordered Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
A resident with a history of a Stage 4 pressure ulcer, major depressive disorder, bradycardia, and sepsis was readmitted to the facility and had a physician's order for a low air loss mattress to address their pressure ulcer. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for partial assistance with activities of daily living. Despite the physician's order, the resident was observed lying on a regular mattress during a facility visit. The Director of Nursing confirmed that the resident did not have the ordered low air loss mattress and acknowledged that no such mattresses had been ordered for any resident in the past two months. Facility policy required the use of specialty mattresses for residents with pressure injuries or those at risk. The failure to provide the prescribed low air loss mattress constituted a deficiency in pressure ulcer care for this resident.
Failure to Complete Urology Referral for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a urology referral and appointment were completed for a resident who had been discharged from a general acute care hospital with orders for a urology evaluation, including urodynamics and cystogram, due to a history of urinary tract infection. The resident's admission record indicated diagnoses of benign prostatic hyperplasia, other specified diseases of the bladder, and metabolic encephalopathy. The Minimum Data Set assessment showed the resident was totally dependent on staff for oral hygiene, toileting, and personal hygiene, and had an indwelling catheter in place. Despite documentation in both the hospital discharge orders and facility progress notes indicating the need for a urology referral, the appointment was not scheduled. During interviews, the MDS nurse confirmed that the responsibility for scheduling the appointment rested with the licensed nursing staff and acknowledged that the referral should have been made but was not. The facility's policies required referrals to outside agencies to meet residents' needs and outlined interventions to prevent catheter-related urinary tract infections, but these were not followed in this case.
Failure to Complete Required Competency Checklists for CNA
Penalty
Summary
The facility failed to ensure that initial and annual competency checklists were completed for one of four sampled employees, specifically a Certified Nurse Assistant (CNA). A review of the CNA's personnel file revealed that there was no documentation of an initial competency checklist upon hire and no annual competency checklist for the following year, as required by facility policy. During an interview, the Director of Staff Development confirmed that these competency checklists were missing and acknowledged that they should have been completed according to the facility's procedures. The facility's policy states that nursing staff competency must be reviewed upon hire and annually during performance evaluations.
Failure to Limit PRN Antipsychotic Order and Respond to Pharmacist Recommendation
Penalty
Summary
The facility failed to respond to a consultant pharmacist's recommendation to limit a resident's PRN (as needed) order for Zyprexa, an antipsychotic medication, to a 14-day duration. The pharmacist made this recommendation on 3/23/25 after reviewing the resident's medication regimen, but the facility did not document any response or action taken regarding this recommendation. Review of the resident's Medication Administration Records (MAR) showed that the resident had active PRN orders for Zyprexa for periods exceeding 14 days, specifically from 3/6/25 to 3/30/25 (24 days) and from 3/31/25 to 4/16/25 (16 days). The resident had a history of bipolar disorder and schizophrenia and was assessed as having the capacity for medical decision-making. During an interview, the DON acknowledged that the facility did not limit the PRN Zyprexa order to 14 days as required and failed to respond to the pharmacist's recommendation. Facility policy requires that PRN antipsychotic orders be limited to 14 days and that any pharmacist recommendations be communicated to the physician with documentation of the rationale for medication changes. The facility's failure to follow these procedures resulted in the resident receiving PRN antipsychotic medication for longer than the policy allows, without documented physician evaluation or justification.
Incorrect Seroquel Dose Administered Due to Order and Label Discrepancy
Penalty
Summary
A Licensed Vocational Nurse (LVN) administered an incorrect dose of Seroquel to a resident diagnosed with schizophrenia. The resident was prescribed Seroquel 50 mg, with instructions to take one-half tablet by mouth every morning and at bedtime. However, during a medication administration observation, the LVN prepared and administered a full 50 mg tablet instead of the prescribed half tablet. The medication was provided in a bubble-pack containing only full tablets, and the pharmacy label instructed to give one full tablet twice daily, which did not match the physician's order. The LVN acknowledged the error, stating she failed to compare the medication label with the resident's current order and did not notice the discrepancy between the pharmacy label and the physician's order. The LVN also confirmed that the pharmacy had not received the updated order reflecting the decreased dose, resulting in the incorrect instructions on the medication packaging. The facility's policy requires staff to compare the medication and dosage on the Medication Administration Record (MAR) with the medication label and to verify with the physician's order if there are discrepancies, which was not followed in this instance.
Failure to Complete Ordered Levetiracetam Level for Resident with Epilepsy
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of epilepsy received timely laboratory monitoring as ordered by the physician. Specifically, the physician had ordered a Levetiracetam blood level to be completed on the next lab day and every three months thereafter. Review of the resident's records showed that this test was not completed as ordered. The care plan for the resident indicated that laboratory results were to be monitored and any subtherapeutic or toxic results reported to the physician, but there was no evidence that the required Levetiracetam level was obtained. During an interview and record review with an LVN, it was confirmed that the Levetiracetam blood test had not been performed. The LVN acknowledged the importance of the test in ensuring the medication dosage was appropriate and stated that the physician relied on these results to determine if adjustments were needed. The resident's medical history included hypertension, diabetes mellitus, and epilepsy, and the resident was assessed as needing moderate assistance with activities of daily living.
Incomplete Medical Record Documentation and Missing X-ray Results
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and that the x-ray results were accessible and properly filed. Specifically, a physician ordered a stat x-ray of the resident's left leg and foot to evaluate pain and swelling, but the results were not available in the resident's medical record. There was no documentation of communication with the physician regarding the x-ray results, nor any evidence of follow-up with the x-ray provider. During a review, a nurse confirmed that the medical records were incomplete and that if documentation was missing, it was considered not to have occurred. The Director of Nursing stated that she had received the x-ray results and given them to a licensed nurse, but could not explain why the results were not accessible in the medical record and could not provide documentation that the results were reported to the physician. The facility's policies require that records be complete, accessible, and filed in a manner that allows for easy retrieval, and that staff document and report results of diagnostic tests to the physician. The failure to maintain complete and accessible records was observed during interviews and record reviews.
Failure to Disinfect Shared Blood Pressure Cuff Between Uses
Penalty
Summary
Staff failed to disinfect a shared blood pressure cuff before and after use during medication administration for two residents. During medication administration, a Licensed Vocational Nurse (LVN) was observed taking the blood pressure of one resident using an automatic blood pressure machine with a Velcro-style cuff without disinfecting it prior to use. After use, the LVN placed the machine and cuff back into its case and returned it to the medication cart without cleaning or disinfecting it. Shortly after, the same LVN used the same blood pressure machine and cuff to take another resident's blood pressure, again without disinfecting the cuff before or after use. The LVN acknowledged during an interview that she did not clean or disinfect the blood pressure cuff before or after taking blood pressures for both residents, despite being required to do so by facility policy. The facility's policy, revised in August 2017, states that all resident-contact surfaces, including blood pressure cuffs and tubing, must be cleaned and disinfected after each use.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the California Department of Public Health (CDPH) within the required timeframe for two of three sampled residents. Resident 118, who had a history of bipolar disorder, anxiety, polyosteoarthritis, and myalgia, was found on the floor in his room and stated that his roommate had tripped him. Resident 59, who had diagnoses including abnormalities of gait and mobility, psychosis, muscle wasting, and lack of coordination, denied the allegation. Both residents were assessed as having moderately impaired cognitive skills and required partial assistance with activities of daily living. The incident occurred on 6/8/2025, but the facility did not report the allegation to CDPH until 6/10/2025. Interviews with the Director of Nursing (DON) and Assistant Administrator revealed that they were not informed of the incident on the day it occurred. The DON and Assistant Administrator both acknowledged that the facility's policy required reporting allegations of abuse within two hours, especially if the incident involved abuse or resulted in serious bodily injury. The delay in reporting resulted in a delay in CDPH's investigation and placed other residents at risk for further abuse.
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Illustrative
What surveyors actually found near you
We read the 7,369 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Lotus Care Center | 0.4 mi | ★★★★★ | 14 | 0 |
| Primrose Post-acute | 0.8 mi | ★★★★★ | 7 | 0 |
| Century Villa, Inc | 0.9 mi | ★★★★★ | 12 | 0 |
| Inglewood Health Care Center | 1.3 mi | ★★★★★ | 32 | 0 |
| View Park Convalescent Center | 1.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.