Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Imperial Crest Health Care Center during CMS and state inspections, most recent first.
A sharps disposal container in a shower room was observed full, with two blue razors sticking out of the lid opening. A CNA said the housekeeper normally replaced the container when full, while Central Supplies staff said he and nursing staff were responsible for changing it and would wait until it was greater than 80% full. The facility policy required designated individuals to seal and replace sharps containers when they were 75% to 80% full.
A resident with acute pyelonephritis, overactive bladder, CVA, morbid obesity, and total urine and bowel incontinence did not receive documented incontinence care as outlined in the care plan on multiple shifts. The resident’s care plan called for toileting assistance and/or incontinence care, but several shifts had blank bowel and bladder intervention entries. In addition, a physician order required output to be monitored every shift and documented in mls, yet the MAR recorded urine episodes by count rather than measured output.
Improper Food Labeling and Cold Holding Temperatures: A container of Italian dressing was found in the kitchen refrigerator without an opened or use-by date, and the RD stated food items must be labeled to track safe storage time. During meal service, three-bean salad and vanilla mousse were observed above required cold-holding temperatures, including items measured at 50 F and 66 F, with ice not fully surrounding the mousse bowls.
A resident with DM2 and long-term insulin use received Humalog outside the ordered meal timing and without proper site rotation. An LPN administered fast-acting insulin when no meal or snack was available, despite the order to give it within 15 minutes before a meal or at the start of the meal, and MAR review showed repeated injections into the same abdominal site. The DON and consultant pharmacist confirmed the insulin should be given with meals and injection sites should be rotated.
A resident with epilepsy, HTN, dysphagia, and anxiety disorder was not provided an interpreter to understand medication instructions. An LVN told the resident to take BP medication, but the resident said no and pointed to the pills, then did not respond when addressed again. The LVN stated a Spanish-speaking translator would help explain the medication, side effects, benefits, and answer questions in the resident's native language.
Missing Comprehensive Care Plans for Multiple Resident Needs A facility failed to develop and implement comprehensive care plans for several residents with identified needs, including a resident with a PIV, a resident receiving heparin for DVT prophylaxis, a resident who refused the influenza vaccine and needed language/psychosocial support, and two residents who refused to wear ID bands. Records and staff interviews confirmed that the care plans were absent or not updated, despite diagnoses, assessments, and orders showing the residents’ needs and risks.
Care plans were not reviewed and revised quarterly for two residents. One resident had chronic respiratory failure, a trach, and a hx of pneumonia, and the Respiratory Care plan had not been updated for an extended period. Another resident had schizophrenia, dementia, and cognitive impairment, with care plans for behaviors and GT feeding that were also overdue for quarterly review. The RNS and MDS Coordinator stated care plans should be updated every 3 months, and the MDS Coordinator confirmed both residents’ plans were not updated quarterly.
Failure to provide effective language assistance for a resident with intact cognition and decision-making capacity. An LVN argued with the resident about BP meds while the resident, speaking Spanish, said he did not recognize the pills; the LVN initially could not understand him and only then contacted a Spanish-speaking staff member to interpret. The DON stated the facility had communication resources available, including a communication board, in-house interpreter, and phone app, and the facility policy required identifying communication needs and reflecting them in the care plan.
A resident with encephalopathy, DM, stroke history, thrombocytopenia, and dementia had a PIV in the right hand without a physician order to maintain or discontinue it, and the IV dressing was undated. Staff noted the need to monitor the site for infiltration and infection, and the DON stated an order should have been obtained to keep the PIV and monitor for signs of infection.
A resident with colon cancer, polyneuropathy, chronic pain syndrome, and sepsis had orders for Suboxone and Pregabalin for pain control, but multiple doses were missed when the medications were unavailable and the facility was waiting for pharmacy delivery. The eMAR and progress notes documented missed Pregabalin doses and a missed Suboxone dose, and an RN stated the emergency kit was not opened when the pain medication ran out.
Failure to complete monthly MRR for a resident with epilepsy, MDD, TIA, and psychosis. The RNS stated the resident's MRR was not done for several months for fluoxetine, trazodone, risperidone, and Risperdal, and noted the antipsychotic meds should have been reviewed for GDR, therapeutic dosing, and monitoring of behaviors and lab levels per facility policy.
Unlabeled humidifier bottles and oxygen tubing were observed in two residents’ room, and an RN supervisor stated the items were not dated and should be changed weekly. Another resident with a trach and G-tube was observed in a room with a housefly that landed on the resident’s face and hand; an RT stated houseflies can carry bacteria, viruses, and parasites and may cause infection in residents with trach and G-tubes.
A resident with dementia and other medical conditions reported sexual abuse to a hospital social worker, who then notified the facility's Social Service Director. The SSD confirmed the allegation with the resident but did not report it to the administrator or authorities within the required two-hour timeframe, as mandated by facility policy. This delay in reporting was acknowledged by both the SSD and the administrator during interviews.
Licensed staff did not notify the Medical Director after being unable to reach the primary physician for a resident with multiple serious conditions who experienced a significant change in condition, including hematuria and reduced urine output. Despite facility policy requiring escalation to the Medical Director, this step was missed, and staff ultimately called 911 for hospital transfer.
Surveyors found that expired and unlabeled medications, including vitamin B1 and Ipratropium with Albuterol Solution, were stored in a medication cart. An LPN confirmed that expired medications were present and that some opened medications lacked required labeling, making it impossible to determine if they were still safe or effective. Two residents with significant respiratory and medical needs were affected by these deficiencies, which were not in line with facility policy or manufacturer instructions.
Surveyors observed that the connectors for apple, grape, and pineapple juice dispensers had sticky residue and dust, which was confirmed by the Dietary Supervisor. This condition was not in accordance with the facility's policy requiring clean food storage areas and could result in cross contamination.
Three dumpsters were found with their lids off in the parking lot, contrary to facility policy requiring dumpsters to be kept closed and free of surrounding litter. Staff acknowledged that dumpsters should be closed to prevent contamination and animal attraction, especially when food waste is present.
A resident with quadriplegia and dementia was repeatedly found without access to a call light device, despite care plans and facility policy requiring it to be within easy reach. Staff confirmed the resident could not reach the device, leaving the individual unable to request assistance for daily care needs.
A resident with diagnoses including bipolar disorder and schizoaffective disorder was prescribed Risperdal, an anti-psychotic medication, but the MDS assessment did not reflect the use of this medication. The MDS Nurse confirmed the omission during review, noting the importance of accurate MDS documentation for CMS reporting and care planning.
A resident with multiple medical conditions, including diabetes and dysphagia, was not weighed weekly as ordered by the physician. Staff confirmed that only one weight was recorded during the required period, despite facility policy and physician orders specifying weekly monitoring.
A resident with multiple pressure ulcers and cellulitis was found lying on a low air loss mattress (LALM) set at 340 lbs, despite weighing 214 lbs. The care plan required the use of a LALM, and facility policy and the manufacturer's manual indicated the mattress should be set according to the resident's weight. The treatment nurse confirmed the setting was incorrect and could not explain the discrepancy.
A resident with a gastrostomy tube, who was cognitively impaired and fully dependent on staff, was observed receiving tube feeding in a Geri-chair with the head elevated only about 10 degrees, contrary to physician orders and facility policy requiring 30 to 45 degrees elevation. An LVN confirmed the improper positioning during the feeding.
A resident with multiple chronic conditions was not evaluated by a physician at the required intervals, as only Nurse Practitioner visits were documented for over a year. The resident reported not seeing a physician since admission, and the DON confirmed the lack of physician visits and documentation, contrary to facility policy.
A resident with multiple chronic conditions was not evaluated by a physician in over a year, contrary to facility policy requiring regular physician visits and documentation. Another resident, dependent on staff for daily activities, did not receive timely assistance from the Social Services Director to renew his driver's license, with no documented attempts to contact the DMV despite the resident's request. Both deficiencies reflect lapses in providing required medically-related social services and physician oversight.
A resident with anemia, severe cognitive impairment, and total dependence on staff was prescribed 7.5 ml of ferrous sulfate daily via gastrostomy tube. During a med pass, an LVN administered only 5 ml, contrary to the physician's order. The LVN acknowledged the error, which was observed and confirmed through record review and interview.
A resident with multiple complex conditions, including diabetes and quadriplegia, did not receive physician-ordered CBC and Albumin lab tests intended to monitor a pressure ulcer. Review of records and staff interviews confirmed the tests were not completed, and no results were available, despite facility policy requiring staff to process and arrange for such tests.
A resident with a history of pressure ulcers and cellulitis had a foley catheter removed at her request, following a physician's order. The nurse who performed the removal did not document the procedure or the resident's response, contrary to facility policy, resulting in incomplete medical records and potential gaps in staff communication.
Staff, including the DON and an LVN, did not perform required hand hygiene before and after contact with a resident on enhanced barrier precautions, despite the resident's high risk for infection and facility policy mandating such practices.
Rooms with three beds each were found to be below the required 80 square feet per resident, with measurements ranging from 231.6 to 236.4 square feet per room. Despite the deficiency, no complaints were reported by residents, and staff indicated that care provision was not impacted.
A resident alleged that an RN hit her, but the facility failed to report the incident to CDPH within the required two-hour timeframe. The resident, who had muscle weakness and anxiety disorder, claimed the RN hit her while handling her g-tube. The RN did not report the incident immediately due to personal issues, and the Administrator was informed the following day, contrary to the facility's policy requiring immediate reporting.
A facility failed to provide adequate oral care and restorative services to residents. A resident with hemiplegia did not receive oral hygiene assistance for three days, and another resident did not receive prescribed restorative exercises and ankle-foot orthosis application. Documentation was incomplete, indicating services were not performed. Facility policies requiring necessary services for personal and oral hygiene and restorative programs were not followed.
A resident's tube feeding formula was improperly stored on a bedside table, contrary to facility policy requiring controlled conditions. An LVN noted the risk of other residents accessing the formula, which should be treated as medication and stored appropriately.
A resident was not readmitted to the facility after hospitalization, despite being medically cleared and beds being available. The facility cited the use of restraints as a reason for denial, although the resident was restraint-free at the time of attempted readmission. This action was contrary to the facility's policy, which prioritizes readmission for residents discharged to the hospital.
A facility failed to follow its policy for immediate reporting of suspected abuse to the Administrator and CDPH. An allegation that a respiratory therapist slapped a resident was not reported to the Administrator until several days later, delaying the investigation. The resident, admitted with respiratory failure, had the capacity for medical decision-making. This delay violated the facility's procedures and postponed the investigation by authorities.
A resident was allegedly slapped by a respiratory therapist, but the facility failed to document or investigate the incident as required by its policy. Despite staff awareness of the protocol to notify the administrator and conduct a thorough investigation, no such actions were recorded in the resident's progress notes.
A resident reported feeling terrified and upset after an LVN verbally threatened him by stating, 'No matter what, I still get paid, whether you take your medicine or not.' The facility's policies emphasize treating residents with respect and dignity, and the incident was confirmed by the Social Service Director, Director of Nursing, and Administrator.
The facility failed to ensure that undressed, cleaned wounds for two residents did not touch the bed's mattress after wound care. An LPN did not follow physician orders to clean wounds with normal saline before applying iodine and left wounds uncovered, allowing them to touch the mattress. Both residents had significant medical conditions and required substantial assistance with ADLs. The DON confirmed the importance of a clean environment during wound care.
The facility failed to properly clean and store laundry rubber gloves, posing an infection risk. Additionally, the facility lacked a comprehensive water management program to prevent Legionella and other waterborne pathogens, with no current measures or assessment plans in place.
The facility failed to formulate care plans for two residents and did not implement the care plan for a resident with a PICC line. This included missing care plans for diabetes and an Aspen collar, and lack of documentation for required measurements of a PICC line, as confirmed by interviews with staff.
The facility failed to obtain informed consent for the psychoactive medication Risperdal before administering it to a resident with major depressive disorder, schizophrenia, and anxiety disorder. The consent was obtained five days after the medication was started, violating the facility's policy and the resident's right to make an informed decision.
The facility failed to revise the care plan for a resident with contractures, including a contracted neck, despite observations and acknowledgments from staff that the care plan needed updating. The resident's care plan focused on upper and lower extremity contractures but did not address the neck contracture, contrary to the facility's policy for individualized nursing care plans.
The facility failed to complete a comprehensive assessment for a resident with a contracted neck, leading to an unsupported and abnormal neck position. Both the Physical Therapist and Infection Preventionist Nurse confirmed that the neck should have been included in the Joint Mobility Screening to develop a proper care plan.
The facility failed to groom a resident who was dependent on staff for personal hygiene. Despite multiple observations of the resident being ungroomed and no documentation of refusal, staff acknowledged the importance of grooming for the resident's well-being and appearance.
A facility failed to change a resident's PICC line dressing every 7 days and as needed, leading to a potential risk of infection. The dressing was found lifting at the edges and had not been changed within the required timeframe, despite the resident's care plan and facility policy specifying the need for timely changes.
A resident was found to be wearing an Aspen collar without a physician order, leading to improper fitting and lack of monitoring. The resident was not informed about the duration or proper use of the collar, and facility staff confirmed the absence of necessary physician orders.
A resident was given crushed enteric-coated aspirin, contrary to its prescribed form, due to the resident's pureed diet. The LVN and DON acknowledged that this practice could alter the medication's intended effect, violating the facility's medication administration policy.
The facility failed to follow up on a pharmacist's Medication Regimen Review (MRR) recommendations for a resident with type 2 diabetes, chronic obstructive pulmonary disease, and heart failure. Despite the MRR indicating the need for a follow-up with a Medical Doctor (MD) regarding blood glucose values, there was no documentation that the MD was notified. This lapse occurred despite the resident experiencing hypoglycemia in the previous month, highlighting the importance of adhering to MRR recommendations.
An expired and discontinued bottle of Pro-Stat was found in a medication cart during an inspection. The LVN acknowledged the issue, and the DON confirmed that medication carts should be inspected and expired medications properly disposed of, as per facility policy.
The facility failed to provide the required 80 square feet of living space per resident in a room with three occupied beds, potentially causing claustrophobia and storage issues.
Overflowing Sharps Container in Shower Room
Penalty
Summary
The facility failed to follow its Sharps Disposal policy in 1 of 2 shower rooms, where a sharps disposal container was observed to be full with two blue razors sticking out of the lid opening. During the observation, a CNA stated the housekeeper normally replaced the sharps disposal container when it was full. During a later interview, Central Supplies staff stated he and nursing staff were responsible for changing the sharps disposal containers and that he would wait until the container was full, greater than 80%, before replacing it. The facility policy dated 2012 stated contaminated sharps were to be discarded into designated containers and that designated individuals were responsible for sealing and replacing containers when they were 75% to 80% full.
Failure to Follow Incontinence Care Plan and Output Monitoring Orders
Penalty
Summary
Ensure services provided by the nursing facility met professional standards of quality was not maintained for one resident with diagnoses including acute pyelonephritis, overactive bladder, anxiety disorder, and a history of CVA and morbid obesity. The resident’s MDS indicated the resident was always incontinent of urine and bowel and required substantial assistance with toileting hygiene. The bowel and bladder program screener indicated the resident was immobile, forgetful, followed commands, was never aware of the need to toilet, and had stage 3 and stage 4 pressure ulcers. The resident’s care plan for incontinence included interventions to assist with toileting needs and/or provide incontinence care, monitor bladder incontinent episodes, assess for signs and symptoms of UTI, and notify the physician for a change in condition. However, the documentation survey report showed multiple shifts in May and June 2026 when the bowel and bladder elimination intervention/task was blank. The physician ordered output to be monitored every shift for 30 days and documented in mls, but the MAR documented urine episodes as counts of urination and did not show output measured in mls. During interview, the DSD stated the resident’s urine incontinence was documented in number of episodes, not in mls, and that failure to provide incontinence care could cause skin damage and infections.
Improper Food Labeling and Cold Holding Temperatures
Penalty
Summary
Food safety and sanitary food storage and preparation practices were not maintained in the kitchen. During observation and interview, one container of Italian dressing was found stored in the kitchen refrigerator without an opened date or use-by date. The Registered Dietitian stated that food items should be labeled with the date opened and use-by date so staff can determine when the item was opened and when it is no longer safe for consumption. The facility's Food Receiving and Storage policy stated refrigerator foods must be labeled, dated, and monitored to ensure use by their use-by date. During lunch service, three-bean salad and vanilla mousse were observed at temperatures above the facility's required cold-holding standards. One pre-plated cup of three-bean salad measured 50 F, and another cup held in an ice-holding bin measured 66 F. Bowls of vanilla mousse were also observed in an ice-holding bin with ice that did not fully surround the bowls, and three randomly selected bowls measured 50 F. The RD stated the three-bean salad and vanilla mousse were not maintained at 41 F or below, and the facility's Menu Service policy stated salads and desserts must be served at 40 F or below.
Humalog Given Outside Meal Timing and Without Site Rotation
Penalty
Summary
The facility failed to ensure that one resident with Type II diabetes mellitus and long-term insulin use received Humalog in accordance with the physician’s order and manufacturer instructions. The resident’s order directed Humalog sliding-scale insulin to be given before meals and at bedtime, no more than 15 minutes before a meal or at the beginning of the meal, and to rotate the injection site. The resident’s care plan identified diabetes-related risks for hypoglycemia and hyperglycemia, and the resident’s cognitive skills for daily decision making were intact. During observation and record review, a licensed nurse checked the resident’s blood sugar at 10:34 AM and stated it was 200, requiring 4 units of Humalog. The nurse administered the insulin at 10:41 AM, and no meal or snack was observed available or offered at that time. The resident’s lunch was scheduled for 12:15 PM, and the nurse later stated the resident normally receives Humalog around 10:30 AM. The DON stated the insulin should have been given with meals and acknowledged that the documented administration times for the resident’s 11:30 AM Humalog doses occurred before lunch on multiple dates. The facility also failed to ensure the insulin injection site was rotated. Review of the MAR and location of administration report showed Humalog was given at the same abdominal site for multiple doses, including two doses in the RUQ on the same day and three doses in the LLQ on another day. The nurse acknowledged she should not have injected the insulin into the same site as the previous dose and should have rotated the site. The DON stated the injection sites must be rotated to avoid infection, redness, or swelling, and the consultant pharmacist stated that alternating sites is necessary to prevent lumps or scar tissue that may delay or decrease absorption.
Failure to Provide Interpreter for Medication Communication
Penalty
Summary
The facility failed to ensure that Resident 22 was provided an interpreter so the language used could be understood. Resident 22 was admitted with diagnoses including epilepsy, HTN, dysphagia, and anxiety disorder. The admission record and H&P indicated the resident had the capacity to make medical decisions, and the MDS indicated the resident was able to understand and be understood by others, had intact cognition, and used a walker and wheelchair with moderate assistance for ADLs and mobility. During a concurrent observation and interview, an LVN told Resident 22 to take blood pressure medication. Resident 22 was observed saying no while pointing to the two pills, and when the LVN called the resident again, the resident did not respond. The LVN stated she would contact a staff member to interpret and explain the medication to Resident 22, and stated that having a translator who speaks Spanish can help explain the type of medications, side effects, benefits, and answer questions in the resident's native language.
Missing Comprehensive Care Plans for IV Therapy, Heparin, Vaccine Refusal, Communication Needs, and ID Band Refusal
Penalty
Summary
Comprehensive care plans were not developed and implemented for five sampled residents with identified needs involving IV therapy, anticoagulant medication, vaccine refusal, communication needs, and refusal to wear identification bands. The facility’s care plan report and related records showed missing or incomplete care planning for each of these issues, and staff interviews confirmed the gaps in documentation and implementation. Resident 59 had diagnoses including encephalopathy, diabetes mellitus, history of infectious and parasitic diseases, cerebral infarction, thrombocytopenia, and dementia. The MDS showed severely impaired cognitive skills and dependence on staff for multiple ADLs. Although Resident 59 had a peripheral IV catheter, the care plan report did not include any care plan for the PIV. The order summary and admission orders also did not include an order to maintain or discontinue the PIV, and there was no order for IV hydration or PIV care, use, or monitoring. An RN supervisor stated there was no care plan for the PIV upon admission to ensure the site was monitored for infection, swelling, or pain. Resident 1 had diagnoses including chronic respiratory failure, dysphagia, pneumonia, and encephalopathy. The MDS indicated severely impaired cognition and dependence on staff for ADLs, and the H&P stated the resident did not have capacity to understand and make decisions. Physician orders included heparin 5000 units subcutaneously twice daily for DVT prophylaxis, but there was no care plan for the heparin medication. An RN stated she did not see a care plan for the heparin and that the absence of a care plan could affect monitoring for complications and medication protocol compliance. Resident 22 had diagnoses including epilepsy, anxiety, and hypertension. The H&P stated the resident had capacity to make medical decisions, and the MDS showed intact cognition and independence with ADLs. The DSD stated the resident spoke Spanish and did not have a care plan addressing language and psychosocial needs. The resident also did not receive the annual influenza vaccine for the 2025-2026 season, and the immunization record reflected refusal. The IP stated there was no care plan for influenza vaccine refusal and that an individualized care plan should have been developed to guide education, monitoring of continued refusal, and infection prevention measures. Residents 50 and 92 were observed without ID bands, and the AD stated both residents had refused to wear wrist ID bands but nursing staff and Social Services were not informed. Resident 50 had diagnoses including epilepsy, major depressive disorder, transient ischemic attack, and psychosis, with intact cognition and capacity to make medical decisions. Resident 92 had diagnoses including encephalopathy, emphysema, hypertension, anemia, and schizoaffective disorder; the H&P stated the resident did not have capacity to understand and make decisions. RNS 1 stated there was no documentation by Social Services, the MDS coordinator, or nursing about the refusal, and the MDS coordinator stated the care plans were not updated at the time of the refusal. The facility policy required comprehensive person-centered care plans with measurable objectives and timetables, including the right to refuse treatment.
Care Plans Not Updated Quarterly for Two Residents
Penalty
Summary
The facility failed to ensure care plans for two residents were reviewed and updated quarterly as required by its policy and procedures titled, Comprehensive Person-Centered Care Plans. One resident had chronic respiratory failure, a history of pneumonia, and a tracheostomy, and was documented as lacking capacity to understand and make decisions. That resident’s Respiratory Care care plan, initiated on 10/11/2022, was last revised on 7/1/2024 and had a target date of 6/24/2026. The second resident was admitted with schizophrenia and dementia and was documented as lacking capacity for medical decision making due to mild cognitive impairment; the MDS also indicated moderate cognitive impairment and dependence on staff for eating, hygiene, dressing, and rolling in bed. That resident had a Behaviors care plan, initiated on 6/12/2024 and last revised on 4/3/2025, and a GT Feeding care plan, initiated on 4/3/2025 and last revised on 1/20/2026; both had target dates of 6/14/2026. The RNS and MDS Coordinator stated care plans should be updated every three months, and the MDS Coordinator stated the two residents’ care plans were not updated quarterly.
Failure to Provide Effective Language Assistance
Penalty
Summary
The facility failed to ensure effective communication services and language assistance were provided to one of five sampled residents, Resident 22. Resident 22 was admitted with diagnoses including epilepsy, HTN, dysphagia, and anxiety disorder. The H&P indicated the resident had capacity to make medical decisions, and the MDS indicated the resident was able to understand and be understood by others, had intact cognition, used a walker and wheelchair, and required moderate assistance with ADLs and mobility. During a concurrent observation and interview, an LVN was arguing with Resident 22 about taking blood pressure medication while the resident pointed to the two pills and said no. The LVN stated she understood Spanish and that Resident 22 understood English, but Resident 22 stated in Spanish that he did not recognize the two pills. The LVN then stated she did not understand what the resident said and contacted a Spanish-speaking staff member to interpret. The interpreter explained the medications to Resident 22. The DON stated she was not aware the LVN was not using the facility's resources to communicate with Spanish-speaking residents and stated the facility had a communication board, an in-house interpreter, and a phone application available for interpretation. The facility policy stated it was committed to identifying communication needs and developing care plans to reflect current communication needs.
Undated PIV Dressing and No Order to Maintain IV Line
Penalty
Summary
The facility failed to provide for the safe, appropriate administration of IV fluids for one resident with a PIV line. Resident 59 had diagnoses including encephalopathy, DM, history of infectious and parasitic diseases, cerebral infarction, thrombocytopenia, and dementia, and the MDS indicated severely impaired cognitive skills for daily decision making. The resident was dependent on staff for eating, oral and toileting hygiene, bathing, upper and lower body dressing, and personal hygiene. A review of the order summary did not show an order to maintain or discontinue the resident’s PIV, and the resident did not have a physician’s order for IV infusions. During observation, the resident was seen with a PIV in the right hand and an undated IV dressing. LVN 1 stated the dressing was not dated and that licensed staff should monitor the PIV site for signs of infiltration and skin discoloration due to the risk of infection. RNS 1 stated it was important to know when the IV dressing was changed to prevent infection. The MAR showed the Dextrose with Sodium Chloride IV solution order had been completed, and checking the IV site every shift was discontinued. The DON stated staff should have obtained a physician’s order to keep the PIV, assess it, and monitor for signs of infection.
Missed Pain Medication Doses Due to Unavailable Refills
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. Resident 11 was admitted and readmitted with diagnoses including colon cancer, polyneuropathy, chronic pain syndrome, and sepsis. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident was cognitively intact and required substantial assistance with ADLs. Physician orders included Suboxone 8-2 mg sublingually twice daily for chronic pain syndrome and Pregabalin 25 mg three times daily for chronic neuropathic pain. Review of the eMAR showed missed doses of pain medication: Pregabalin was not given on 4/16/2026 and 4/25/2026 at 10:00 a.m. and 2:00 p.m., and the 2:00 p.m. dose was also missed on 5/1/2026. Progress notes stated Pregabalin was unavailable and the facility was waiting for pharmacy delivery. The eMAR also showed Suboxone was not given at 6:00 p.m. on 5/11/2026, and progress notes dated 5/18/2026 stated Suboxone was unavailable and the facility was waiting for pharmacy delivery. RN 1 stated that if a resident ran out of pain medication and was in pain, the licensed nurse should call the pharmacy to obtain a code to open the emergency kit, and that pain medications should have been refilled a week before running out. The facility policy stated refills must be reordered from the issuing pharmacy not less than three days before the last dose is administered.
Failure to Complete Monthly Medication Regimen Review
Penalty
Summary
The facility failed to conduct the monthly Medication Regimen Review for one sampled resident, Resident 50, whose record showed admission diagnoses including epilepsy, major depressive disorder, transient ischemic attack, and psychosis. The resident's H&P dated 8/12/2025 indicated the resident had the capacity to understand and make medical decisions, and the MDS dated 2/27/2026 indicated the resident was able to understand and be understood by others, had intact cognition, and required substantial assistance with activities of daily living and mobility. During a concurrent interview and record review on 5/21/26 at 9:28 a.m., the Registered Nurse Supervisor stated Resident 50's Medication Regimen Review was not conducted in January 2026, February 2026, March 2026, and April 2026 for fluoxetine 30 mg, trazodone 50 mg, risperidone 1 mg, and Risperdal 0.5 mg. The RNS stated the resident's antipsychotic medications should have been reviewed by the Pharmacy Consultant to ensure gradual dosage reduction was discussed, the dosage was therapeutic, and behaviors and laboratory levels were monitored for medication efficacy. The facility policy stated the consultant pharmacist reviews the MRR of each resident at least monthly and that recommendations are acted upon and documented by facility staff and/or the prescriber.
Unlabeled oxygen equipment and flies in resident room
Penalty
Summary
The facility failed to provide a safe and sanitary environment for three sampled residents by not ensuring that humidifier bottles and oxygen tubing were dated when changed. During an observation in the room shared by two residents, the Registered Nurse Supervisor stated the humidifier bottles and tubing were not dated and explained that if they are not dated, staff would not know when to change them. The supervisor also stated the humidifier bottles and tubing should be changed weekly, and that if they are not changed, organisms could grow and the resident could be at risk for infection. One resident had diagnoses including sleep apnea, diaphragmatic hernia, and epilepsy, and was documented as having the capacity to understand and make decisions. The other resident had chronic respiratory failure, a history of pneumonia, and a tracheostomy, and was documented as lacking decision-making capacity and being severely cognitively impaired and dependent on staff for multiple ADLs. The facility also failed to keep the room of another resident free of flies. That resident had chronic respiratory failure, a tracheostomy tube, a gastrostomy tube, type 2 DM, and was documented as lacking decision-making capacity, being severely cognitively impaired, non-verbal, and bedbound. During observation, a housefly was seen in the room and landed on the resident's right hand and left cheek near the mouth while the resident had the mouth wide open. During a later interview, the Respiratory Therapist stated houseflies are known to carry bacteria, viruses, and potential parasites and could cause infections to residents with tracheostomy and gastrostomy tubes by laying eggs and causing maggots to form in the openings. The facility's infection control policy required a safe, sanitary, and comfortable environment, and the pest control policy required an ongoing pest control program to keep the building free of insects and rodents.
Failure to Timely Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure that an accusation of sexual abuse involving one resident was reported within the required two-hour timeframe. The incident began when a hospital social worker notified the facility's Social Service Director (SSD) that a resident had reported being sexually assaulted at the facility. Upon the resident's return, the SSD confirmed with the resident that she had been sexually abused. Despite recognizing that such an accusation constitutes abuse and that she is a mandated reporter, the SSD did not notify the facility administrator or initiate the required reporting process within two hours of receiving the allegation. The resident involved had diagnoses including dementia, depressive disorder, and a history of transient cerebral ischemic attack, and was dependent on staff for activities of daily living. Facility records indicated the resident lacked capacity to make decisions. The facility's policy required immediate reporting of abuse allegations, defined as within two hours, to the administrator and appropriate authorities. Both the SSD and the administrator acknowledged during interviews that the reporting process was not followed as required, and the delay in reporting could have caused the resident to feel dismissed and experience psychological harm.
Failure to Notify Medical Director After Unresponsive Primary Physician During Resident Change of Condition
Penalty
Summary
Facility licensed staff failed to notify the Medical Director after being unable to reach the primary physician for a resident who experienced a significant change in condition. The resident, who had chronic respiratory failure, obstructive uropathy, anemia, and was dependent on staff for care, exhibited no significant urine output and later developed hematuria with reduced urinary output. Despite attempts to transfer the resident to a general acute care hospital, no beds were available, and the primary physician did not respond to calls from staff. The facility's policy required that if the primary physician and alternate could not be reached, the Medical Director should be contacted, but this step was not taken. The Director of Nursing confirmed that the Medical Director was not called during the period when the resident's condition was deteriorating and the primary physician was unresponsive. The Medical Director also stated that staff should have contacted him if the primary physician did not return their call, regardless of the time. As a result of the lack of physician response and failure to escalate to the Medical Director, staff ultimately called 911 to transport the resident to the hospital.
Expired and Unlabeled Medications Found in Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of medications in medication cart 1. During observation and interview, an opened bottle of vitamin B1 was found in the cart with an expiration date that had already passed. The bottle was labeled with an opened date, but the expiration date printed on the bottle had lapsed. The nurse present acknowledged that it was the responsibility of licensed nursing staff to check expiration dates and stated that administering expired medication could cause adverse effects. Additionally, an opened foil pack of Ipratropium with Albuterol Solution for a resident with respiratory failure, dysphagia, and a gastrostomy tube was found in the medication cart without a label indicating the date it was opened. The pharmacy fill date was several months prior, and the nurse could not determine when the pack was opened. The manufacturer's instructions require that opened foil packs be used or discarded within two weeks of opening, and the lack of labeling made it impossible to ensure compliance with this requirement. A similar issue was found for another resident with COPD, hypertension, obstructive sleep apnea, and muscle weakness. An opened and expired foil pack of Ipratropium with Albuterol Solution was found in the medication cart, with the nurse confirming it had been opened beyond the recommended period. Facility policies reviewed by surveyors required all medications to be properly labeled and expired or deteriorated drugs to be returned or destroyed, but these procedures were not followed in these instances.
Unsanitary Juice Connectors Observed in Kitchen
Penalty
Summary
During an observation in the facility's kitchen, surveyors noted that the connectors for apple, grape, and pineapple juice dispensers had a sticky residue and dust present. The Dietary Supervisor confirmed the presence of the sticky substance and acknowledged that it could cause cross contamination, potentially leading to infection. A review of the facility's policy and procedure on food receiving and storage indicated that food service staff are required to maintain clean food storage areas and keep non-refrigerated foods clean. The failure to keep the juice connectors clean was directly observed and confirmed by staff during the survey.
Dumpsters Not Kept Closed as Required
Penalty
Summary
Three dumpsters were observed in the facility's parking lot with their lids off during a concurrent observation and interview. Facility staff confirmed that the dumpsters should be kept closed to prevent possible contamination, especially if food waste is present, as this could attract animals. A review of the facility's policy and procedure on food-related garbage and refuse disposal indicated that dumpsters are required to be kept closed and free of surrounding litter. The deficiency was identified due to the dumpsters not being kept covered as required when not in continuous use.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A resident with functional quadriplegia and unspecified dementia was readmitted to the facility and had documented limitations in the range of motion in both upper extremities. The resident's care plan specified that the call light device should be within easy reach to allow the resident to request assistance for activities of daily living and hygienic needs. However, during multiple observations, the call light device was found to be inaccessible: once it had fallen between the bed mattress and the upper left side rail, and another time it was pinned to the upper right side of the resident's pillow, still out of the resident's reach. Interviews with staff, including the DON and LVNs, confirmed that the resident could not access the call light device and would be unable to contact staff for help when needed. The facility's policy required that the call light be accessible to residents when in bed or wheelchair, but this was not followed in the resident's case. The deficiency was identified through direct observation, staff interviews, and review of the resident's care plan and facility policy.
Failure to Accurately Document Anti-Psychotic Medication Use in MDS
Penalty
Summary
The facility failed to ensure that the use of an anti-psychotic medication was accurately documented in the Minimum Data Set (MDS) for one resident. Review of the resident's records showed that the resident had diagnoses including bipolar disorder, schizoaffective disorder, and heart failure, and was prescribed Risperdal, an anti-psychotic medication, for schizoaffective disorder. However, the MDS assessment did not indicate that the resident was taking any anti-psychotic medication. During an interview and record review with the MDS Nurse, it was confirmed that the MDS did not reflect the resident's use of Risperdal. The MDS Nurse acknowledged that Risperdal is an anti-psychotic and stated the importance of accurate MDS documentation, as this information is submitted to CMS and is used to guide the resident's plan of care and quality of care.
Failure to Obtain Weekly Weights as Ordered for a Resident
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered for one resident. Specifically, a resident with diagnoses including dysphagia, type 2 diabetes, schizophrenia, and hyperlipidemia was admitted and had a physician order to be weighed every Saturday until a specified date. Record review and staff interviews confirmed that the resident was only weighed once during the required period, missing subsequent weekly weights as ordered by the physician. Certified Nurse Assistant 2 and Registered Nurse 2 both acknowledged during interviews that the resident was not weighed weekly according to the physician's order. The facility's policy indicated that residents should be weighed at intervals established by the interdisciplinary team, but this was not followed in the case of this resident. The failure to obtain weekly weights as ordered constituted a deficiency in meeting professional standards of quality.
Failure to Set Pressure-Relieving Mattress According to Resident Weight
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM), prescribed for a resident with multiple pressure ulcers and cellulitis, was set according to the manufacturer's recommendations and the resident's actual weight. The resident, who was cognitively intact and dependent on staff for activities of daily living, was observed lying on a LALM set at 340 pounds, despite weighing 214 pounds. The care plan specifically required the use of a LALM to enhance wound healing, and facility policy indicated that support surfaces should be adjusted to individual needs. During observation and interview, the treatment nurse confirmed that the LALM should be set to match the resident's weight for optimal pressure relief and was unable to explain why the setting was incorrect. Review of the manufacturer's manual supported the need to adjust the mattress based on the resident's weight. This discrepancy between the resident's actual weight and the LALM setting constituted a failure to follow both manufacturer guidelines and facility policy for pressure ulcer management.
Failure to Maintain Proper Head Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (GT) was observed receiving continuous tube feeding while lying in a Geri-chair with the head of the chair elevated to only about 10 degrees. Facility policy and the resident's physician order required the head of the bed or chair to be elevated 30 to 45 degrees during GT feedings to observe aspiration precautions. The Licensed Vocational Nurse present confirmed that the resident was not in the correct position and acknowledged that the head of the Geri-chair should have been elevated as per the order and policy. The resident involved had multiple diagnoses, including anemia, GT placement, and chronic obstructive pulmonary disease (COPD), and was assessed as having severely impaired cognitive skills, being totally dependent on staff for care. The failure to maintain the required elevation during tube feeding was directly observed by surveyors and confirmed by staff, representing a lack of adherence to professional standards of practice and the facility's own policy for enteral feeding safety.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including liver cirrhosis, hypertension, and anemia, was not evaluated by a physician at the required intervals. Review of the resident's clinical records and interviews revealed that the resident had not been seen by a physician in the facility for over a year, despite regular visits from a Nurse Practitioner. The resident reported not having met or seen his physician since admission and expressed a desire to discuss his medical conditions with the physician. The facility's policy and procedure required that the attending physician visit each patient at least once every 30 days for the first 90 days after admission, and at least every 60 days thereafter. Documentation confirmed that only Nurse Practitioner visits were recorded, with no evidence of physician visits as required. The Director of Nursing acknowledged the absence of physician visits and documentation in the resident's progress notes, which did not comply with the facility's policy or regulatory requirements.
Failure to Ensure Timely Physician Visits and Social Services for Residents
Penalty
Summary
The facility failed to ensure that a resident was evaluated by a physician every 60 days and that these visits were documented in the clinical records. Specifically, one resident with diagnoses including liver cirrhosis, hypertension, and anemia had not been seen by a physician in the facility for over a year, as confirmed by both the resident and the Director of Nursing (DON). Although the resident was seen by a Nurse Practitioner on multiple occasions, there was no documentation of a physician visit as required by facility policy, which mandates physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. The resident expressed that he had not met his physician since admission and wished to do so to discuss his medical conditions. Additionally, the facility failed to provide timely medically-related social services to another resident who required assistance renewing his driver's license for identification purposes at medical appointments. The resident, who is dependent on staff for activities of daily living and has a history of spinal stenosis, quadriplegia, cervicalgia, and major depressive disorder, reported informing the Social Services Director (SSD) of his need for license renewal two weeks prior, but the SSD had not documented any attempts to contact the Department of Motor Vehicles. The facility's social worker job description requires assisting residents in obtaining outside services, including processing forms and applications, but this was not done in a timely manner for the resident.
Incorrect Dosage of Medication Administered
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer the correct dosage of ferrous sulfate to a resident with anemia, gastrostomy, and chronic obstructive pulmonary disease. The resident, who was totally dependent on staff for care and had severely impaired cognitive skills, had a physician's order for 7.5 ml (330 mg) of ferrous sulfate to be given daily via gastrostomy tube. During a medication pass observation, the LVN administered only 5 ml (220 mg) instead of the prescribed 7.5 ml. The LVN acknowledged during an interview that she did not follow the physician's order and attributed the error to an oversight. The facility's policy and procedure for administering medication requires that medications be given in accordance with prescriber orders. This failure to administer the correct dosage was directly observed and confirmed through interview and record review.
Failure to Complete Physician-Ordered Lab Tests for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement physician-ordered laboratory tests for one resident, specifically a Complete Blood Count (CBC) and Albumin test, which were ordered due to the presence of a pressure ulcer. Review of the resident's records showed that the orders for these tests, dated 12/11/2024, were not carried out, and there were no corresponding laboratory results available. During an interview, a registered nurse confirmed that the tests had not been performed and acknowledged that without these results, the facility would not have information necessary to understand the cause of the resident's pressure ulcers. The resident involved had significant medical conditions, including diabetes, dysphagia, and quadriplegia, and was dependent on staff for activities of daily living such as toileting, bathing, and dressing. The resident also lacked the capacity to make decisions. Facility policy required staff to process test requisitions and arrange for laboratory tests, but this was not followed in this instance, resulting in inadequate monitoring of the resident's health status.
Failure to Document Foley Catheter Removal
Penalty
Summary
The facility failed to document the removal of a foley catheter for a resident, as required by its own policies and procedures. The resident, who had a history of pressure ulcers and cellulitis and was cognitively intact but dependent on staff for activities of daily living, requested removal of the foley catheter. A physician's order was obtained for the removal, and the treatment nurse performed the procedure. However, there was no documentation in the resident's medical record indicating when the catheter was removed, details of the removal process, or how the resident tolerated the procedure. During interviews, the treatment nurse confirmed that she removed the catheter but did not document the event, believing it was unnecessary since nothing unusual occurred. The facility's policies require that all treatments and procedures, including the date, time, assessment data, and resident response, be documented in the medical record. The lack of documentation resulted in incomplete communication among staff regarding the resident's care.
Failure to Follow Hand Hygiene Protocols for Resident on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices for a resident on enhanced barrier precautions (EBP), an intervention designed to reduce the transmission of multidrug-resistant organisms. During an observation, both the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) entered the resident's room without performing hand hygiene before entry, before touching the resident's linen, after assisting the resident, and before leaving the room. Interviews with both the DON and the LVN confirmed that staff are expected to perform hand hygiene before resident contact and between residents, especially when EBP is in place, and that failure to do so can lead to infection transmission. A review of the resident's care plan indicated the individual was at high risk for infection due to a medical history of previous infections, with interventions including hand hygiene during care to reduce infection risk. The facility's policy on hand hygiene, dated April 2023, required the use of alcohol-based hand rub before and after direct contact with residents and after contact with objects in the resident's immediate vicinity. These protocols were not followed during the observed care of the resident.
Resident Room Size Below Regulatory Minimum
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms, as observed in rooms 109, 111, and 117. Each of these rooms contained three resident beds but measured only 231.6 to 236.4 square feet, which is less than the required space per resident. This deficiency was identified through a review of the facility's Request for Waiver Variation Letter and confirmed by direct measurement during multiple observations. The administrator acknowledged that the rooms did not meet the square footage requirement but stated that there had been no complaints from residents and that staff were still able to provide care. No evidence was found that the room sizes adversely affected residents' health or safety during the survey period.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved a resident who alleged that a Registered Nurse (RN) hit her on the right side of the face. The resident, who had been admitted to the facility with diagnoses including muscle weakness and anxiety disorder, was reported to have a puffy face and peri-orbital area. During a visit by a family member, the resident claimed that the RN hit her while handling her g-tube. The RN, however, did not report the incident immediately due to personal issues and only informed the Administrator the following day. The delay in reporting the alleged abuse was compounded by the RN's failure to adhere to the facility's policy, which mandates reporting any suspicion or allegation of abuse within two hours. The Administrator confirmed that the facility was supposed to report such allegations promptly to ensure a timely investigation and safeguard resident safety. The policy review indicated that all reports of abuse, neglect, or misappropriation should be reported to the appropriate authorities immediately, defined as within two hours of the allegation.
Deficiencies in Oral Care and Restorative Services
Penalty
Summary
The facility failed to provide adequate oral care and restorative services to residents, as observed in the cases of Resident 3 and Resident 2. Resident 3, who was admitted with diagnoses including hemiplegia and adult failure to thrive, required moderate assistance with oral hygiene. However, during an observation, Resident 3's mouth was found to be dirty, and the resident reported not having received oral care for about three days. RNA 1 confirmed that the personal hygiene section of the documentation was left blank, indicating that the care was not provided. Additionally, Resident 3's care plan required restorative exercises and the application of an ankle-foot orthosis (AFO) to prevent foot drop. However, Resident 3 reported not receiving these services for months, and RNA 1 admitted to not being familiar with Resident 3 and not having applied the AFO for about a week. The documentation for RNA services was incomplete, and RNA 1 acknowledged that the lack of documentation meant the services were not performed. Resident 2, diagnosed with cerebral infarction and muscle weakness, was supposed to receive passive range of motion exercises five times a week. However, Resident 2 reported only receiving these services about three times a week. The facility's policies required the provision of necessary services to maintain residents' personal and oral hygiene and ensure appropriate restorative programs, but these were not adhered to, as evidenced by the deficiencies in care provided to Residents 2 and 3.
Improper Storage of Tube Feeding Formula
Penalty
Summary
The facility failed to ensure the safe storage of tube feeding formula for a resident, which was observed during a survey. The resident, who was admitted with diagnoses including hemiplegia and adult failure to thrive, required enteral feeding through a gastric tube. During an observation, two bottles of Jevity, a tube feeding formula, were found on the resident's bedside table. This was contrary to the facility's policy, which required such formulas to be stored in temperature and light-controlled conditions. A Licensed Vocational Nurse (LVN) acknowledged that the tube feeding bottles should not have been left at the bedside, as they could be accessed by other residents, potentially causing adverse reactions. The LVN stated that tube feedings are prescribed by a physician and should be treated as medication, requiring proper storage. The facility's policy on enteral feedings, dated November 2018, also indicated that unopened liquid enteral formulas should be stored away from direct sunlight and in a cool environment.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite the resident being medically cleared to return. The resident, who had been admitted to the facility with chronic obstructive pulmonary disease, encephalopathy, and heart failure, was transferred to a general acute care hospital due to altered mental status. The resident was initially restrained at the hospital but was later cleared to return to the facility without restraints. However, the facility did not readmit the resident, citing the use of restraints as a reason for denial. The facility's census records indicated that there were available male beds during the period when the resident was ready for readmission. Despite this, the facility's Admission Coordinator, Administrator, and Director of Nursing all acknowledged the availability of beds but did not facilitate the resident's return. The facility's policy stated that residents discharged to the hospital should be given priority for readmission, yet this was not adhered to in this case. Interviews with the facility's staff and the hospital's Clinical Social Worker revealed a lack of communication and follow-up regarding the resident's readmission. The facility's policy on bed-holds and returns was not followed, as the resident was not allowed to return to their previous room or the first available bed, despite being restraint-free for the required period. This oversight resulted in the resident not being readmitted to the facility, contrary to the facility's stated policies.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting and investigating abuse, neglect, exploitation, or misappropriation. The policy required immediate reporting of suspected abuse to the Administrator and the State licensing/certification agency, the California Department of Public Health (CDPH). An incident occurred where a family member of a resident alleged that a respiratory therapist slapped the resident on the face. This allegation was reportedly communicated to another respiratory therapist, who claimed to have informed the Administrator on the same day. However, there was no documentation to support that the Administrator was notified immediately. The Administrator later confirmed that they were not informed of the abuse allegation until several days after the incident. Consequently, the facility did not report the allegation to CDPH in a timely manner, delaying the investigation. The resident involved had been admitted with serious medical conditions, including respiratory failure, and had the capacity for medical decision-making. The lack of timely reporting and documentation of the incident violated the facility's established procedures and delayed the necessary investigation by the appropriate authorities.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting and investigating allegations of abuse, neglect, exploitation, or misappropriation of resident property. This deficiency was identified in the case of a resident who was allegedly slapped by a respiratory therapist. Despite the family member notifying a respiratory therapist about the incident, there was no documentation to confirm that the administrator was informed, nor was there evidence of an investigation or interventions being conducted as per the facility's policy. Interviews with various staff members, including a licensed vocational nurse, the director of nursing, and a registered nurse supervisor, revealed that the facility's protocol requires immediate notification of the administrator and a thorough investigation of any abuse allegations. However, the progress notes for the resident did not reflect any investigation or actions taken following the reported incident. The facility's policy, reviewed with the administrator, clearly states that the administrator is responsible for initiating and documenting the investigation and keeping the resident and their representative informed, which was not adhered to in this case.
Verbal Threat by LVN Violates Resident's Dignity
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect. Specifically, a Licensed Vocational Nurse (LVN 1) verbally threatened a resident (Resident 1) by stating, 'No matter what, I still get paid, whether you take your medicine or not.' This incident was reported by Resident 1, who felt terrified and upset by the comment. Resident 1 had been admitted to the facility with diagnoses including nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus, and epilepsy, and required total assistance in toileting hygiene and dressing. The resident had the capacity to understand and make decisions, as indicated in his medical records and assessments. Interviews with the Social Service Director (SSD), Director of Nursing (DON), and the Administrator (ADM) confirmed that LVN 1's behavior was unprofessional and violated the resident's dignity. The facility's policies on dignity and residents' rights emphasize treating each resident with respect and full recognition of their dignity and individuality. The Administrator confirmed that LVN 1 admitted to making the unprofessional comment, which was against the facility's policy to treat all residents with respect and dignity.
Failure to Maintain Clean Environment During Wound Care
Penalty
Summary
The facility failed to ensure that undressed, cleaned wounds for two residents did not touch the bed's mattress after wound care was performed. For Resident 1, who was admitted with diagnoses including muscle weakness, type 2 diabetes mellitus, and acute osteomyelitis, the Licensed Vocational Nurse (LVN) did not follow the physician's order to clean the wound with normal saline before applying iodine. Additionally, after applying the treatment, the LVN left the wound uncovered, allowing it to touch the mattress. Resident 1 was noted to be awake but not alert, unresponsive, and nonverbal, requiring dependent assistance with activities of daily living (ADLs). The LVN acknowledged forgetting to clean the wound first and admitted that the wound touching the mattress could cause infection. For Resident 2, who had similar diagnoses and required substantial assistance with ADLs, the LVN placed the resident's socks near the surgical wound and left the wound uncovered after cleaning it, allowing it to touch the mattress. Resident 2 was awake, alert, and verbal. The LVN admitted that it was important to keep the environment clean during wound care to prevent infections and acknowledged the mistake. The Director of Nursing (DON) confirmed that all wound care should be done in a clean environment and suggested using disposable linen to pad the mattress. The facility's policy indicated the use of paper towels or disposable liners to ensure a clean field during treatment.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to ensure that laundry rubber gloves were properly cleaned and stored after use. During an observation, blue rubber gloves were found placed on the sink where staff wash their hands. The Maintenance Supervisor and Laundry Aide confirmed that the gloves should be cleaned with bleach wipes and hung on hooks after use, as per the facility's policy. The improper storage of gloves on the sink posed a risk for the spread of infection among residents. Additionally, the facility did not have a comprehensive water management program in place to prevent Legionella and other waterborne pathogens. The Infection Prevention Nurse and Administrator admitted that they lacked policies, procedures, and testing for Legionella. Although they were in the process of contracting an outside company for water testing and mapping the facility's water system, no current measures or assessment plans were in place. The facility's policy indicated the need for a water management program, but essential components such as a detailed water system diagram and measures to control Legionella were missing.
Failure to Formulate and Implement Care Plans
Penalty
Summary
The facility failed to ensure a care plan was formulated for two residents, Resident 54 and Resident 81. Resident 54, who had severe cognitive impairment and required dependent assistance for activities of daily living, did not have a care plan for diabetes. This was confirmed during interviews with the LVN, RN, and DON, who all acknowledged the importance of having a care plan to monitor the resident's condition and interventions. Similarly, Resident 81, who was admitted with an Aspen collar, did not have a care plan for the collar, which was necessary to guide the nurses on the interventions required for its use. This was confirmed by the DON and MDS Coordinator during their interviews, who both stated that a care plan should have been developed for the Aspen collar to set goals and interventions for the resident's care. The facility also failed to implement the care plan for Resident 86, who had a PICC line for intravenous therapy. The care plan required measuring the external catheter length and arm circumference upon admission and with each dressing change. However, there was no documentation of these measurements in the resident's medical record. This was confirmed during interviews with RN 7 and RN 6, who both emphasized the importance of these measurements to identify potential complications such as infection or a dislodged catheter. The DON also confirmed the necessity of these measurements to monitor the resident's condition and take immediate action if significant changes were observed. The facility's policy and procedure for resident care plans indicated that a care plan should be implemented for each resident on admission and developed throughout the assessment process. It was the responsibility of the licensed nurse to ensure that the plan of care was initiated and evaluated. However, the facility failed to adhere to this policy, resulting in the lack of care plans for specific diagnoses and the failure to document required measurements for a resident with a PICC line. This deficiency had the potential to affect the quality of care provided to the residents and the staff's ability to monitor and address their medical needs effectively.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that Resident 25 and/or their responsible party (RP) was informed in advance about the risks and benefits of the psychoactive medication Risperdal. Resident 25, who has diagnoses including major depressive disorder, schizophrenia, and anxiety disorder, was started on Risperdal 1mg on 3/23/2024. However, the informed consent for this medication was not obtained until 3/28/2024, five days after the medication had already been administered. This lapse in procedure was confirmed during interviews with Licensed Vocational Nurse (LVN) 8 and Registered Nurse (RN) 7, who both acknowledged that informed consent should be obtained before administering the medication. The Director of Nursing (DON) also confirmed that informed consent is required prior to starting psychotropic medications to ensure residents' rights to make informed decisions about their treatment are upheld. The facility's policy and procedure on psychotropic medication use, dated July 2022, clearly states that informed consent must be obtained from the physician before administering such drugs. Despite this policy, the staff failed to document or obtain the necessary consent before starting the medication. This oversight was identified during a review of Resident 25's records and through staff interviews, highlighting a significant deficiency in the facility's adherence to its own policies and procedures regarding informed consent for psychoactive medications.
Failure to Revise Care Plan for Resident with Contracted Neck
Penalty
Summary
The facility failed to revise the care plan for Resident 11, who was admitted with diagnoses including contractures, chronic obstructive pulmonary disease (COPD), and encephalopathy. The Minimum Data Set (MDS) indicated that Resident 11 had severely impaired cognition and was dependent on assistance for toileting hygiene and showering. During an observation, Resident 11 was found lying in bed with a contracted neck leaning to the left side, unsupported by any interventions. The care plan, dated 3/13/2024, focused on contractures of the upper and lower extremities but did not include specific interventions for the neck contracture. Both the Infection Preventionist (IP) and the MDS Coordinator acknowledged that the care plan needed to be revised to address the neck contracture to ensure Resident 11's comfort and proper care. The facility's policy and procedure for resident care plans indicated that individualized nursing care plans should promote continuity of care and include long and short-term goals for restorative and rehabilitative nursing care. The policy also stated that it is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated. Despite this, the care plan for Resident 11 was not updated to include interventions for the neck contracture, which was a significant oversight in providing comprehensive care for the resident's condition.
Failure to Complete Comprehensive Assessment for Resident with Contracted Neck
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed for Resident 11, who had a contracted neck. Resident 11 was initially admitted with diagnoses including contractures, chronic obstructive pulmonary disease (COPD), and encephalopathy. The Minimum Data Set (MDS) indicated that Resident 11 had severely impaired cognition and was dependent on others for toileting hygiene and showering. During an observation, Resident 11 was found lying in bed with an unsupported neck leaning to the left side, indicating a contracture that was not properly addressed in the resident's care plan. During a review of Resident 11's Joint Mobility Screening, it was found that the screening did not address the resident's neck. Both the Physical Therapist (PT) and the Infection Preventionist Nurse (IPN) confirmed that the neck should have been included in the screening. The PT stated that the neck is considered a joint and should have been part of the body screening to develop a proper plan of care. The IPN also noted that the abnormal position of Resident 11's neck should have been assessed to determine if the condition was improving or declining. The facility's policy on accommodating residents' needs emphasized maintaining residents' dignity and well-being, which was not adhered to in this case.
Failure to Groom Resident
Penalty
Summary
The facility failed to groom one out of five residents, specifically Resident 139, who was dependent on staff for personal hygiene. Resident 139, who had diagnoses including aphasia, chronic kidney disease, and metabolic encephalopathy, was observed multiple times over several days without being groomed. The Minimum Data Set (MDS) indicated that Resident 139 was not able to cognitively recall information and was dependent on staff for personal hygiene tasks such as combing hair and shaving. Despite these needs, Resident 139 was observed lying in bed and seated in a wheelchair without being groomed on multiple occasions. Interviews with staff, including the Social Worker (SS), Director of Nursing (DON), and MDS Coordinator, revealed that there was no documentation of Resident 139 refusing to be shaved. The staff acknowledged the importance of grooming for the resident's well-being and appearance. The facility's policy on Activities of Daily Living (ADLs) indicated that residents should be provided with care to maintain or improve their ability to carry out ADLs, and any refusal of care should be documented. However, this documentation was not present for Resident 139, leading to the deficiency in care.
Failure to Change PICC Line Dressing as Required
Penalty
Summary
The facility did not ensure that a PICC line dressing was changed every 7 days and as needed for Resident 86, who was admitted with diagnoses including discitis and acute respiratory failure. The resident's care plan specified that the PICC line dressing should be changed every 7 days and as needed if the dressing was soiled or lifting at the edges. However, during an observation, the dressing was found to be lifting at the edges and was dated either 3/26/24 or 3/28/24, indicating it had not been changed within the required timeframe. Registered Nurse 6 confirmed that the dressing was lifting due to perspiration and acknowledged that it should have been changed more frequently if it was dirty, coming off, or damaged. The Director of Nursing also stated that the PICC line dressing should be changed every 7 days and more frequently if it was lifting, dirty, or had blood or water in it. The facility's policy and procedure corroborated this requirement, emphasizing the importance of changing the dressing to prevent infection.
Lack of Physician Order for Aspen Collar
Penalty
Summary
The facility failed to ensure there was a physician order for a resident (Resident 81) to wear an Aspen collar, a device used to support the neck and aid in healing. Resident 81 was admitted with diagnoses including spinal stenosis, hydrocephalus, and ataxia, and had the capacity for medical decision-making. Observations revealed that the Aspen collar was loose around Resident 81's neck, and the resident was not informed about the duration or proper use of the collar. Interviews with the Director of Nursing (DON) and the MDS Coordinator confirmed that there was no physician order for the Aspen collar, which is necessary for monitoring and proper fitting of the device. The deficiency was further highlighted during multiple observations and interviews, where it was noted that the Aspen collar was not fitted correctly, potentially preventing proper healing. The facility's policy and procedure require physician orders for any treatment or medication, but this protocol was not followed in Resident 81's case. The lack of a physician order and proper fitting of the Aspen collar placed Resident 81 at risk for inadequate monitoring and care.
Improper Administration of Enteric-Coated Medication
Penalty
Summary
The facility did not ensure that an enteric-coated medication was not crushed for one of the residents. Resident 57, who was readmitted with diagnoses including cerebral infarction and atrial fibrillation, was prescribed Aspirin Enteric Coated Tablet Delayed Release 81 mg to be taken once daily by mouth. During an observation, LVN 6 was preparing Resident 57's morning medications and stated that the medications needed to be crushed and placed in applesauce due to the resident's pureed diet. However, the LVN acknowledged that crushing the enteric-coated aspirin would alter its intended effect in the body. The Director of Nursing confirmed that crushing enteric-coated aspirin would defeat its purpose, as the coating prevents it from dissolving in the stomach to avoid acidity and stomach ulcers. The facility's policy on administering medications indicated that medications should be administered safely and in accordance with prescriber orders. The failure to adhere to this policy resulted in the potential for Resident 57 to experience adverse drug reactions due to the improper administration of the medication.
Failure to Follow Up on Pharmacist's Medication Regimen Review
Penalty
Summary
The facility failed to follow up with the Pharmacist's Medication Regimen Review (MRR) recommendations for one resident, identified as Resident 8. The MRR, dated March 2024, indicated that Resident 8 required a follow-up with a Medical Doctor (MD) regarding the pattern of recorded blood glucose values with Insulin Lispro sliding scale. Despite this recommendation, there was no documentation that the MD was notified. Registered Nurse (RN) 8 confirmed that the process involves notifying the MD and documenting any changes in the nursing progress notes, but no such documentation was found. RN 8 also noted that Resident 8 had experienced hypoglycemia in February 2024, highlighting the importance of following up with the MD to prevent further adverse effects. RN 5, who claimed to have informed the MD, was also unable to locate any documentation to support this claim. The pharmacist, Rx 1, confirmed that no one had contacted him for clarification of his recommendation and emphasized the importance of reviewing the MRR to prevent adverse effects for residents. Resident 8's medical history includes type 2 diabetes mellitus, chronic obstructive pulmonary disease, and heart failure. The resident was initially admitted to the facility on an unspecified date and readmitted on another unspecified date. The Minimum Data Set (MDS) dated January 5, 2024, indicated that Resident 8 was cognitively oriented and required moderate assistance with activities of daily living (ADLs) such as toileting hygiene and showering. The facility's policy and procedure (P&P) for Medication Regimen Reviews, dated May 2019, and the Registered Nurse Job Description, dated August 2011, both emphasize the importance of timely notification and documentation of physician orders to ensure quality care. However, the facility failed to adhere to these guidelines, resulting in a deficiency in the care provided to Resident 8.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility did not ensure an expired and discontinued bottle of Pro-Stat (Concentrated Liquid Protein Medical Food) was discarded from medication cart #3. During an observation and interview with an LVN, an expired bottle of Nutricia Pro-Stat was found in the medication cart, with an expiration date clearly indicated. The LVN acknowledged that having expired medication in the cart is not acceptable as it may not have the appropriate effect if administered to a resident. The Director of Nursing confirmed that medication carts should be inspected by the LVN on their shift, and any expired or discontinued medications should be properly disposed of. The facility's policy and procedure on the storage of medications also indicated that discontinued, outdated, or deteriorated drugs should be returned to the dispensing pharmacy or destroyed.
Insufficient Living Space for Residents
Penalty
Summary
The facility failed to ensure each resident had 80 square feet of living space. During an observation in a resident room, there were three occupied beds noted in a room measuring 236.4 square feet, which does not meet the required space per resident. An interview with the administrator revealed that residents might feel claustrophobic due to the smaller room size, especially depending on the number of personal belongings each resident has. The Client Accommodations Analysis confirmed the room's measurements and its capacity for three residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hawthorne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawthorne Healthcare & Wellness Centre, Lp | 0.6 mi | ★★★★★ | 17 | 0 |
| Osage Healthcare & Wellness Centre | 1.8 mi | ★★★★★ | 25 | 0 |
| Centinela Skilled Nursing & Wellness Centre West | 1.8 mi | ★★★★★ | 18 | 0 |
| Camino Healthcare | 2.3 mi | ★★★★★ | 21 | 0 |
| Lawndale Healthcare & Wellness Centre Llc | 2.5 mi | ★★★★★ | 33 | 0 |
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