Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Infinity Care Of East Los Angeles during CMS and state inspections, most recent first.
A resident with COPD, stiff person syndrome, and muscle weakness received PRN Tramadol for moderate pain even though the order was for severe pain only. The MAR showed the opioid was given for pain scores of 6/10 and 5/10, and the DON stated those levels were moderate pain, not severe pain, and that the nurse should have clarified the order with the MD. Facility policy required meds to be given as ordered and prescribers to be contacted if a dose was believed inappropriate or excessive.
Staff failed to follow the facility policy for suspicious persons and unauthorized entry when a neighbor reported an unknown male leaving the rooftop, but the RNS did not notify police, the Administrator, or the DON and did not check for unauthorized persons. Later that night, a rooftop fire occurred. The side metal door was observed unlocked, and staff stated the facility had no working surveillance cameras.
Call Lights Not Kept Within Reach or Functioning: Two residents had call lights out of reach, and one resident’s call light did not function when tested. One resident with a stage 4 pressure ulcer, diabetes, and dependence for transfers and toileting had his call light dangling near the floor and said it had not worked since admission; his breakfast tray was also out of reach. Another resident with CKD, cirrhosis, and anxiety had a call light cord hanging on the back of the bed and could not reach it. Staff confirmed the call lights should be accessible for residents to request help.
A facility failed to maintain a safe, sanitary, and homelike environment for three residents. One resident with dementia and weakness had a leaking bathroom sink and a ceiling light above the sink with no bulbs, another resident had brown spots on the ceiling above the bed, and a third resident with severe cognitive impairment had a bed motor tied to the frame with a plastic bag and cords, which staff described as unsafe and an electrical hazard.
A comprehensive, person-centered care plan was missing for one resident receiving RNA services and another resident with a behavior of removing clothes and preferring to be naked. The first resident had orders for AAROM to BUE and BLE, but the care plan did not include RNA services despite staff confirming it should have been added. The second resident was observed naked in bed, and staff confirmed the resident refused clothing and threw off diapers and blankets, yet no care plan addressed the behavior or included measurable goals and interventions.
A resident with hearing loss and glaucoma did not receive her delivered hearing aids, and the aids were found stored in a box rather than being issued to her. Staff interviews showed the resident communicated by writing and that the hearing aids were not included in the care plan. Another resident with dry eye syndrome and vision concerns missed an ophthalmology follow-up, but the chart did not show a reason for the missed visit or documentation that the MD was notified.
Failure to Monitor I&O for Dialysis Residents: Two residents with ESRD and hemodialysis had care plans directing intake and output monitoring every shift, but the MAR and medical records contained no documentation that I&O was monitored. One resident also had heart failure and risk for fluid deficit, while the other had CKD, CHF, and ESRD. Staff interviews confirmed dialysis residents should have I&O monitoring and that it should be documented in the MAR.
Failure to Follow Up on Pharmacist MRR Recommendations: The facility did not timely act on pharmacist MRR findings for two residents. One resident with schizophrenia and anxiety had an MRR recommendation to monitor a Depakote level, but no current monitoring order was in place. Another resident with depression, fibromyalgia, and dementia had an MRR note questioning whether routine Ativan was clinically indicated, but the MD/psychiatrist was not informed and there was no written response in the record. The DON confirmed the missing follow-up during record review.
Failure to monitor for hypoglycemia and hyperglycemia in two residents receiving insulin. Both residents had diabetes-related diagnoses, care plans that identified risk for blood sugar instability, and orders for insulin and other diabetes medications, but the MARs did not document monitoring for symptoms such as confusion, sweating, tremors, polyuria, polydipsia, or blurred vision. An LVN and the DON confirmed the missing monitoring and documentation.
An unopened eye drop was stored in the wrong location, an insulin pen lacked a complete pharmacy label, two boxes of apple juice were kept in the med refrigerator, and two medication cups with opened unidentified tablets were left in a med cart. The cart also contained expired medications, and the DON stated refrigerated meds should stay refrigerated, food should not be stored with meds, prepared meds should not remain in cups, and expired meds should be discarded.
Unsafe Food Handling and Wet Kitchen Floor: During tray line assembly, an employee was observed checking the temperature of pureed vegetables without gloves and without sanitizing the food thermometer first. In a separate kitchen observation, the floor near the sink and exit area was wet with a small leak present. The DSS stated the floor should be kept dry, and facility policy required clean, sanitized thermometers, glove use when handling food directly, and regular cleaning of housekeeping surfaces.
Infection control practices were not followed during resident care, linen handling, surveillance, and PPE use. A trash bag with soiled gauze and bowel movement wipes was placed on a resident’s bed during wound care, clean linens and gowns were stored improperly and exposed to contamination, infection surveillance was not completed, an RN touched her mask and hair then handled food containers without hand hygiene, and a CNA provided high-contact care to a resident on EBP without wearing a gown.
Failure to Document Vaccine Education and Offering for Multiple Residents: The facility did not document that a resident with GERD, malnutrition, dysphagia, and DM; a resident with PNA and chronic respiratory failure; a resident with ESRD and heart failure; and a resident with acute respiratory failure, pulmonary edema, and CKD were educated about or offered influenza and/or pneumococcal vaccines. Chart review showed missing immunization histories, missing refusal/consent documentation, and no evidence that the VIS or vaccine education was provided as required by facility policy.
A resident with a foley catheter and diagnoses including DM2 and bladder dysfunction was observed sitting in a wheelchair with the urinary bag uncovered and hanging on the side of the chair. CNA confirmed the bag should have been covered with a dignity bag for privacy and dignity, and the DSD stated covering urinary catheter bags is important to maintain privacy, independence, and dignity.
The facility failed to provide NOMNCs to three residents before their Medicare Part A skilled coverage ended. Interviews with two residents and the BOM confirmed that the residents were not notified in advance that their benefits were expiring, and the record review showed no evidence that a NOMNC or other notice was issued before coverage ended.
Delayed Scheduling of Ordered Ortho Appointment: A resident with left hip arthritis and worsening hip pain had a physician order for an ortho evaluation and possible hip replacement, but the appointment was not scheduled for an extended period. Staff from nursing, social services, and admissions stated they did not follow up on the authorization status until much later, and the resident had already been approved before the facility became aware of it. The DON stated staff should have followed up sooner to avoid the delay in ordered services.
LALM Set Incorrectly for a Resident With a Pressure Ulcer: A resident with an unstageable sacral pressure ulcer, DM2, and severe cognitive impairment had a LALM ordered at the resident’s current weight, but staff observed the mattress set at 180 lbs while the resident weighed 159 lbs. The resident said the bed felt uncomfortable, and an LVN confirmed the setting was incorrect and stated it could add more pressure to the wound. The DON reviewed the facility P&P and the manufacturer’s manual, which indicated the mattress should be set to the resident’s weight.
A resident with GERD, protein-calorie malnutrition, dysphagia, and type 2 DM had weekly weights ordered and a care plan requiring intake and fluid monitoring, but the chart did not show weekly weights or fluid intake documentation as required. The resident was cognitively impaired and dependent for multiple ADLs, and the LVN and DON confirmed the missing weights and intake records should have been completed.
Failure to Follow Budesonide Order During Medication Administration: An LVN administered Budesonide inhalation via nebulizer to a resident with COPD, emphysema, pneumonia, and respiratory disorders, but did not ensure the resident rinsed his mouth afterward as ordered. The resident's care plan and medication order both directed staff to rinse the mouth after use, and the LVN acknowledged the omission. The DON stated rinsing after Budesonide is needed to prevent oral thrush and other complications, and the facility policy required medications to be given in accordance with prescriber orders.
Failure to honor a resident’s food preferences. A resident with HF, cellulitis, neuralgia, and neuritis had documented meal preferences for salads and specific food restrictions, and was cognitively intact. At lunch, the tray contained broccoli, garlic bread, and tofu instead of the preferred chicken salad listed on the tray card and dietary profile. The DS and RD confirmed the resident should have received a salad in accordance with the documented preferences and policy.
A resident with dementia, COPD, adult failure to thrive, and a feeding tube was transferred to the hospital after a dislodged G-tube. The Notice of Proposed Transfer/Discharge was incomplete because it did not document the reason for the transfer/discharge, and the RN supervisor confirmed the form was not filled out completely.
Failure to Educate, Offer, and Document COVID-19 Vaccination: A resident with GERD, protein-calorie malnutrition, dysphagia, type 2 DM, and severely impaired cognitive skills was not documented as being educated about or offered the COVID-19 vaccine. Review of both the electronic and physical chart found no evidence of vaccine education, VIS provision, consent, or declination for the resident or RP, despite facility policy requiring these steps.
Leaking AC Near Nursing Station: The facility failed to keep an AC unit near the nursing station in safe operating condition. An LVN, the ADM, and the DSD observed water leaking onto the floor in a high-traffic area where residents walk by, and there was no wet floor sign near the puddle. The IMD reviewed the Maintenance Services policy, which requires equipment to be maintained in a safe and operable manner and free from hazards.
Surveyors found that the facility did not maintain a clean, sanitary, and homelike environment after a roof leak, resulting in multiple areas with visible water damage, peeling paint, and damaged surfaces. On the second floor, hallways and a dining/TV area had dark brown ceiling discoloration, dried water leak marks, cracked wood, and peeling paint. Several resident rooms had scratched walls, peeling paint, cracked baseboards, and deteriorated ceilings and walls, including bathroom ceilings. In one room, a framed painting appeared damp with green and black substances inside the frame, and dried dark brown water marks extended from the ceiling down the wall and baseboards; the MS confirmed this was from an earlier water leak that had not been reported by staff or residents. The HKS stated that staff are supposed to clean walls and floors daily and acknowledged that the water marks and dirty painting should not have remained, while the DON and ADM confirmed that staff are expected to report such conditions and that the facility’s homelike environment policy requiring a safe, clean, and comfortable setting was not followed.
A cognitively impaired resident with dementia and Alzheimer’s disease, dependent or needing assistance with most ADLs and unable to consent to sexual activity, was found in bed with an open brief while a roommate with dementia and severe cognitive impairment was on his knees at the bedside touching the resident’s genital area with both hands. A CNA observed this non-consensual sexual contact for several seconds before intervening. Another cognitively intact resident reported previously seeing the same perpetrating resident lower the victim’s brief and touch the victim’s buttocks and stated he informed an unidentified staff member. Despite an abuse prevention policy that guarantees freedom from sexual abuse and requires identification, assessment, and investigation of all possible incidents of abuse, the facility failed to prevent this sexual abuse and the victim was documented as having experienced unwanted touching behavior and being at risk for emotional/psychological distress.
A resident with dementia and severe cognitive impairment, dependent on staff for most ADLs, was allegedly subjected to non-consensual sexual touching by a cognitively impaired roommate, as witnessed by a CNA and documented in SBAR notes. Another cognitively intact resident later reported seeing the same roommate lower the victim’s brief and touch the buttock on a different occasion. Staff notified the physician, DON, ADM, local law enforcement, and the ombudsman, but the ADM directed that CDPH not be contacted, citing both residents’ dementia and a misinterpretation of AFL 24-09. Despite a written policy requiring all alleged abuse to be reported to the state agency and a federal requirement to report alleged sexual abuse within 2 hours and submit a 5-day investigation report, the facility did not report this allegation or the investigation findings to CDPH as required.
A resident with dementia and severe cognitive impairment, whose bed was on a seven-day hold during a hospital transfer, was not readmitted to their reserved bed upon discharge within the hold period. Instead, the ADM and facility marketer arranged for the resident to be sent to another SNF, while telling the hospital that the original building was under remodeling due to water damage. The GACH case manager and documentation showed the transfer request came from facility staff, not the resident or family. Later observation and interviews with maintenance staff showed no remodeling was occurring in the resident’s former room, and the DON confirmed the resident had the right to return to the same room and bed under the facility’s bed-hold policy but was not notified of the transfer to the other SNF.
Two residents with significant physical and cognitive needs were using bed alarms for fall prevention, but their care plans did not document this intervention as required by facility policy. Staff confirmed the alarms were in use and acknowledged the omission in the care plans, despite policy mandating interdisciplinary documentation for such safety measures.
Failure to provide timely wound treatment for a resident with impaired cognition, diabetes, and a stage 2 sacral PU. A skin assessment identified a sacral PU and left buttock skin tear, but the wound treatment order was not started until several days later; the DON, DSD, and TXN confirmed the wounds were not treated during the gap because no order was in place.
POLST Form Not Accurately Completed: A resident with impaired decision-making and dependence for several ADLs had a POLST that was not accurately completed. The SSD met with the resident's wife and nephew without using the facility's language access program, and the nephew translated CPR information in Spanish even though the SSD was unsure it was translated correctly. The wife stated she signed an English POLST she did not understand, and the provider signature line was left blank.
Care Plan Not Developed for Scratching and Dressing-Picking Behavior: A resident with cellulitis, PVD, and dermatitis had severe cognitive impairment and needed extensive assistance with ADLs, but staff observed frequent scratching of the legs, ears, arms, and body, along with picking at the dressing. The DON stated the resident did not have a care plan to address these behaviors, and that the right leg wounds could have been exposed when dressings came off because no specific care plan intervention was in place.
A resident with severe cognitive impairment and multiple medical conditions was overcharged for their share of cost, with financial records showing a charge exceeding the documented obligation. The facility's finance manager confirmed the overcharge and the absence of documentation explaining it, despite facility policies requiring accurate billing and advance notification of changes.
A resident with Parkinson's Disease, dementia, and a history of falls did not receive an accurate fall risk assessment, and their care plan and MDS did not reflect their true needs for ADL assistance. After a fall, the facility failed to thoroughly investigate the incident by not interviewing the roommate who witnessed it, and did not provide consistent monitoring or documentation across multiple shifts. These actions resulted in inadequate supervision and failure to prevent accident hazards.
A resident was not allowed to share a room with their spouse or roommate of choice, and did not receive written notice before a change in room assignment was made, violating resident rights.
The facility did not submit required PBJ staffing data for a reporting quarter on time due to errors in the staffing report and the closure of its previous payroll processing company. The Payroll Coordinator did not notify facility leadership about the issue, resulting in delayed submission of staffing and census information to CMS.
Multiple deficiencies were identified, including a resident using a plastic bag as a closet handle, another with a worn-out bed sheet, two residents sharing a restroom without a towel rack and with peeling ceiling paint, a resident's room wall with scratches and discoloration, a chipped rollator walker seat cushion, and a resident using a wheelchair in poor condition. These issues were confirmed by staff and residents, and facility policies requiring a safe, clean, and homelike environment were not followed.
Two residents with cognitive impairments were placed in Geri chairs, which limited their movement, without required assessments or physician's orders. Staff confirmed the use of these chairs as restraints to prevent unassisted rising, and facility policy was not followed regarding restraint assessment and authorization.
Two residents with severe cognitive impairment were involved in a verbal and physical altercation that was witnessed by staff, but the incident was not reported to CDPH, the ombudsman, or law enforcement within the required two-hour timeframe. The event was only documented as a room change, and facility leadership became aware of the incident several days later, acknowledging the failure to follow mandated reporting procedures.
Two residents at high risk for pressure ulcers did not receive required heel offloading as ordered by their physicians and outlined in their care plans. Despite clear documentation and staff awareness of the orders, observations showed that heel protectors or pillows were not used, and staff interviews confirmed the interventions were not consistently implemented.
Two residents did not receive their scheduled medications within the required time frame, as an LVN administered all prescribed morning medications more than one hour after the scheduled time. The delay was attributed to the LVN being occupied with another resident, and staff interviews confirmed that this constituted a medication error according to facility policy and physician orders.
A nurse administered scheduled medications late to two residents, resulting in a medication error rate of 32%, which exceeds the regulatory limit of 5%. The late administration was due to the nurse being occupied with another resident and not seeking help, leading to medications being given outside the required one-hour window. Staff interviews and facility policy confirmed that this timing constitutes a medication error.
Surveyors found that kitchen staff failed to label multiple food items in the refrigerator and freezer with required open or use-by dates, and did not discard expired food, as required by facility policy. The Dietary Supervisor and Administrator confirmed these lapses during interviews, and facility policy mandates proper labeling and timely discarding of expired foods.
Staff did not consistently follow infection prevention protocols for two residents on Enhanced Barrier Precautions, including improper use of PPE and lack of required signage and supplies. Additionally, clean linen was stored in a dirty area of the laundry room next to a clogged sink, and there was no signage to separate clean and dirty areas, contrary to facility policy.
The facility did not ensure that CNAs received the required annual in-service dementia management training, with one CNA not receiving such training since employment and another lacking recent training. The DSD confirmed there was no tracking system or updated records to monitor in-service hours, leading to noncompliance with federal training requirements.
A CNA assisted a resident with dementia and pressure ulcers during mealtime by standing above the resident's eye level instead of sitting, contrary to facility policy and expectations for promoting dignity. Nursing staff confirmed that maintaining eye level is required to show respect, and facility policies specify that staff should not stand over residents while feeding them.
Two residents with severe cognitive impairment and anxiety received PRN Lorazepam orders that were not discontinued after 14 days as required. The orders were written with 'indefinite' stop dates, and there was no physician documentation to justify extending the orders. Both the RN Supervisor and DON confirmed the orders should have been limited to 14 days, in accordance with facility policy.
A resident with a G-tube and multiple medical conditions did not receive proper care when a nurse failed to disinfect the tube and check gastric residual volume or tube patency before administering enteral feeding, contrary to physician orders and facility policy.
A resident with respiratory failure, COPD, and dementia who was dependent on staff and receiving oxygen therapy was found with the head of bed positioned almost flat, contrary to facility policy requiring elevation of at least 30 degrees during oxygen administration. Staff confirmed the resident was left in this position, and the nurse acknowledged the improper elevation, resulting in a failure to follow established respiratory care protocols.
A resident with end stage renal disease and a right femoral central venous catheter for dialysis did not receive proper assessment and documentation of their dialysis access site. Staff inaccurately recorded findings such as bruits and thrills, which are not applicable to this type of access, and documented the wrong access site location. These actions were not in accordance with facility policy or physician orders.
The facility did not have an RN on duty for at least eight consecutive hours on a day when scheduled RNs were absent and no replacement was provided. This left the facility without appropriate RN supervision to oversee resident care and staff, as required by federal regulations and the facility's own staffing plan.
Unnecessary Administration of PRN Tramadol
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary drugs when Tramadol Hydrochloride was administered outside of the physician’s order. The resident was admitted with diagnoses including COPD, stiff person syndrome, and muscle weakness, and the MDS indicated intact cognitive skills for daily decision making and dependence for several activities of daily living. The physician’s order dated 6/17/2026 directed Tramadol HCl 50 mg by mouth every eight hours as needed for severe pain, with instructions to hold for sedation or if the respiratory rate was less than 12. The MAR showed the resident received Tramadol 50 mg on 6/20/2026 for pain rated 6/10 and on 6/21/2026 for pain rated 5/10. During interview and record review, the DON stated Tramadol had been ordered for severe pain, that pain levels of 4 to 6 are moderate rather than severe, and that the medication should not have been given for those pain scores. The DON stated the nurse should have contacted the physician to clarify the order and request medication for moderate pain. Facility policies stated medications are to be administered in accordance with prescriber orders and that staff should contact the prescriber if a dosage is believed to be inappropriate or excessive.
Failure to Report Suspicious Rooftop Activity and Unauthorized Entry
Penalty
Summary
The facility failed to follow its policy for suspicious persons and unauthorized entry when a neighbor from an apartment building across the street reported to staff that an unknown male had been seen exiting the facility rooftop through the side stairwell/gate. The Registered Nurse Supervisor who received the information did not notify the police department, the Administrator, or the DON, and did not check the third floor for unauthorized persons. The DON later stated she had not been made aware of the neighbor’s report, and the RNS stated he was not aware of any policies and procedures regarding unauthorized people on the facility premises. Later that night, a fire occurred on the rooftop and was reported to the RNS and 911. During observation the next day, the side metal door serving as an entry and exit to the street was found unlocked, and the Maintenance Supervisor stated it remained unlocked all day and all night. The rooftop was observed to have a cement surface with air-conditioning units and tarps, and debris remained from a burnt shed that stored activity supplies. The facility also had two mounted cameras at the side entrance, but the DSD stated there were no working surveillance cameras.
Call Lights Not Kept Within Reach or Functioning
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not ensuring their call lights were within reach and functioning. Resident 12 was admitted with diagnoses including absence of the right leg above the knee, a stage 4 sacral pressure ulcer, and type 2 diabetes mellitus. His MDS indicated intact cognitive skills for daily decision making and dependence with toileting hygiene, lower body dressing, and chair/bed-to-chair transfer. During observation, he was lying in bed with the call light wrapped around the right-hand side rail and dangling close to the floor, and his breakfast tray was placed out of reach. He stated he could not reach the tray or the call light and said the call light had not worked since admission. CNA 2 observed the same condition and pressed the call light, but the light outside the room did not turn on. Resident 92 was admitted with diagnoses including CKD, cirrhosis of the liver, and anxiety. Her care plan included maintaining a call light within easy reach, and her MDS indicated intact cognitive skills for daily decision making, with substantial/maximal assistance needed for toileting hygiene and bathing and supervision or touching assistance for eating and oral hygiene. During observation, her call light cord was hanging on the back of the bed and out of reach, and she stated she could not reach it. LVN 1 stated the call light should always be accessible so the resident could contact staff for help with needs including food and bathroom assistance. The facility policy stated residents are provided with a means to call staff directly for assistance and that the resident call system will always remain functional.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for three sampled residents by leaving environmental and equipment issues unresolved in resident areas. The deficiency was identified through observation, interview, and record review in the environment task, and involved a leaking bathroom sink and nonfunctioning ceiling light for one resident, dirt on a ceiling above another resident’s bed, and an unsafe bed motor arrangement for a third resident. For one resident with diagnoses including encephalopathy, dementia, and muscle weakness, the record showed moderate impairment in daily decision making and need for assistance with multiple activities of daily living. During observation of the resident’s room, the bathroom sink had a white linen underneath it with yellow water marks and water stains indicating leakage, and there were no light bulbs in the ceiling light above the sink. The resident stated staff and the supervisor had been told about the leak and the missing light, but nothing had been fixed, and the resident continued using the sink because it was the only one available. The IPN stated the linen was not supposed to be left under the sink to absorb leaking water and that the ceiling light needed bulbs. The IMD stated the sink should have been repaired and that the room was not homelike. For another resident with CKD, cirrhosis of the liver, and anxiety, the MDS showed intact cognitive skills and substantial to maximal assistance with toileting hygiene, bathing, eating, and oral hygiene. Observation at the bedside showed brown spots splattered on the ceiling above the resident’s bed. The HS observed the same condition and stated the spots should not be there, was unsure whether they were food or stool, and said the resident’s environment should be clean and not dirty. For the third resident with epilepsy, cerebral infarction, a right femur fracture, and type 2 DM, the MDS showed severely impaired cognitive skills and dependence for oral care, toileting, personal hygiene, eating, dressing, and transfers. Observation showed a powered black box with multiple cords under the bed, wrapped in a white plastic bag and tied to the bed frame. The LVN stated the box was the bed control motor, that it should not have been tied to the frame, and that it created an electrical hazard. The IMD and MA stated the motor should not have been tied to the bed, was unsafe, and had a broken part that should have been replaced instead of tied.
Incomplete Care Plans for RNA Services and Clothing-Removal Behavior
Penalty
Summary
A comprehensive, resident-centered care plan was not developed for Resident 3 to address restorative nursing assistant (RNA) services. Resident 3 was admitted with diagnoses including an unspecified fracture of the left calcaneus, acute osteomyelitis of the left ankle and foot, and heart failure. The MDS dated 4/13/2026 indicated the resident’s cognitive skills for daily decision making were intact and that the resident was dependent for toileting hygiene, lower body dressing, lying to sitting on the side of the bed, and sitting to standing. A physician order dated 4/20/2026 directed RNA to provide active assisted range of motion to both upper extremities and both lower extremities five times a week or as tolerated. Review of the care plan dated 4/20/2026 to 6/11/2026 showed no care plan entry for RNA services. During interview and record review, LVN 1 stated Resident 3 did not have a care plan for RNA services and should have had one because the resident was receiving those services. The MDS nurse stated that once RNA services were started, the licensed nurse should have updated the care plan to include them. The DON stated Resident 3 should have RNA services included in the care plan because the services were performed to maintain functionality and prevent decline in range of motion. A comprehensive care plan was also not developed for Resident 74 to address the behavior of removing and throwing off clothes and preferring to be naked. Resident 74 was admitted with diagnoses including COPD, cirrhosis, and bipolar disorder. The MDS dated [DATE] indicated intact cognitive ability and dependence for toileting hygiene, showering, lower body dressing, putting on and taking off footwear, and personal hygiene, with maximal assistance needed for eating, oral hygiene, and upper body dressing. On 6/8/2026, Resident 74 was observed sleeping naked and without a blanket. LVN 3 stated the resident refused to wear clothes and threw off the diaper and blankets. Review of the care plan history dated 4/9/2026 to 6/8/2026 showed no care plan for this behavior, and LVN 3 stated the resident should have had a care plan because without one, interventions are not monitored and the behavior may worsen. The DON stated the facility’s care plan policy required measurable objectives and goals to address resident needs and behaviors, including behaviors such as not wearing clothes.
Failure to Provide Hearing Aids and Notify MD of Missed Ophthalmology Appointment
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices were provided to maintain residents’ vision and hearing abilities for two sampled residents. One resident had diagnoses including sensorineural hearing loss and glaucoma, and the record showed the facility received the resident’s right and left hearing aids on 3/24/2026. Despite this, the hearing aids were not given to the resident, and the resident stated she could not hear and had never been given a hearing aid since admission. Staff interviews confirmed the resident communicated by writing, using a notebook and marker, and several staff members stated they were unaware the resident had hearing aids or that the aids were stored in a box in the storage room. Record review and interviews also showed the resident’s care plan did not include the hearing aids or related interventions. The DSS, LVN, MDS nurse, and DON all stated the hearing aids should have been provided to the resident and included in the care plan so staff would know the resident had hearing aids and how to communicate effectively. The resident’s assessment documented hearing difficulty, and staff stated the resident was hard of hearing and needed hearing aids to communicate more effectively with staff and others. For the second resident, the record showed a diagnosis of dry eye syndrome and a care plan addressing risk for impaired visual acuity with ophthalmology and optometry examinations as needed. The resident had an ophthalmology follow-up appointment scheduled, but the appointment was missed. The resident stated she had trouble with her vision and needed the appointment, and the SSA stated the appointment was cancelled due to insurance pending approval. The medical chart did not show a reason for the missed appointment or documentation that the MD was notified, and RN staff confirmed there was no progress note or MD notification regarding the missed ophthalmology appointment.
Failure to Monitor Intake and Output for Dialysis Residents
Penalty
Summary
The facility failed to monitor intake and output for two residents receiving dialysis, despite care plans that directed monitoring every shift. One resident was admitted with end stage renal disease, heart failure, and dependence on renal dialysis. His care plan included monitoring intake and output every shift and monitoring the dialysis access site for redness, pain, signs and symptoms of infection, presence or absence of bruit, and bleeding. A separate care plan identified him as at risk for dehydration or potential fluid deficit related to weakness, laxative use, diabetes mellitus, and end stage renal disease, with interventions to monitor and document intake and output as per facility policy and to monitor vital signs as ordered or per protocol. Record review for this resident showed hemodialysis on Monday, Wednesday, and Friday, and the MDS indicated intact cognitive skills for daily decision making and dependence for toileting hygiene, lying to sitting on the side of the bed, and chair/bed transfers. Review of the MAR and medical records for May and June 2026 showed no documented evidence that intake and output were monitored. During interview, LVN 1 stated dialysis residents should be placed on intake and output monitoring when admitted, that this was done to prevent fluid overload, and that there was no order for intake and output monitoring. LVN 1 also stated the care plan indicated monitoring every shift, but there was no intake and output monitoring documented in the MAR. A second resident was admitted with type 2 diabetes mellitus with diabetic chronic kidney disease, acute on chronic diastolic congestive heart failure, end stage renal disease, and dependence on renal dialysis. His care plan directed intake and output monitoring every shift and monitoring the dialysis access area for redness, pain, signs and symptoms of infection, presence or absence of bruit, and bleeding. The MDS indicated intact cognitive skills for daily decision making and substantial/maximal assistance with toileting hygiene, upper and lower body dressing, lying to sitting on the side of the bed, and sitting to standing. The order summary showed hemodialysis on Monday, Wednesday, and Friday, but the MAR and medical records for May and June 2026 contained no documented evidence that intake and output were monitored. LVN 1 and the DON both stated dialysis residents should have intake and output monitoring, and the DON stated the monitoring should be documented on the MAR.
Failure to Follow Up on Pharmacist MRR Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up on medication regimen review (MRR) irregularities for two residents. For one resident with diagnoses including paranoid schizophrenia, unspecified anxiety disorder, and COPD, the MRR dated 5/11/2026 recommended monitoring the Depakote level in the blood stream. During record review and interviews with the DSD and DON, there was no current monitoring for the Depakote level, and the physician order for that monitoring had not been obtained. For another resident with diagnoses including major depressive disorder, dry eye syndrome, fibromyalgia, and dementia, the care plan for anxiety included pharmacist MRR review and follow-up with the MD. The consultant pharmacist’s MRR dated 4/12/2026 and 4/13/2026 stated to inform the MD and/or psychiatrist if routine Ativan was clinically indicated instead of renewing every 14 days if the resident was asking frequently. Review of the MARs showed lorazepam 0.5 mg was ordered as needed for anxiety and was administered during the reviewed period. During interview and record review with the DON, the resident’s physical and electronic medical records did not show that the physician and/or psychiatrist had been informed of the MRR report, and there was no written response indicating whether a routine lorazepam order was clinically indicated. The facility policy stated that the attending physician reviews and responds to the pharmacist’s recommendations and documents any actions taken, but the records reviewed did not show that this occurred for the two residents.
Failure to Monitor for Hypoglycemia and Hyperglycemia in Residents Receiving Insulin
Penalty
Summary
The facility failed to monitor the signs and symptoms of hypoglycemia and hyperglycemia for two residents who were receiving insulin. Resident 34 was admitted with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, acute on chronic diastolic congestive heart failure, and end stage renal disease. The care plan identified the resident as being at risk for hypoglycemia and hyperglycemia and directed staff to observe for symptoms such as polyuria, polydipsia, polyphagia, changes in level of consciousness, blurred vision, profuse sweating, irritability, and tremors, but the MAR for May and June 2026 did not show monitoring for these signs and symptoms while the resident was receiving Novolog FlexPen as sliding scale insulin. Resident 57 was admitted with diagnoses including type 2 diabetes mellitus with foot ulcer, COPD, neuralgia, and neuritis. The resident’s care plan and physician orders identified a risk for hypoglycemia and hyperglycemia and included monitoring for symptoms such as confusion, dizziness, shakiness, irritability, hunger, pale skin, sweating, trembling, weakness, anxiety, headache, poor coordination, coma, polyuria, polydipsia, blurred vision, profuse sweating, irritability, and tremors. The order summary also included Trulicity and Novlin R sliding scale insulin, and the MDS indicated the resident received insulin injections, but the MAR for May and June 2026 did not document monitoring for these signs and symptoms. During interviews, LVN 1 stated that residents receiving insulin should have monitoring for signs and symptoms of hypoglycemia and hyperglycemia and that this was not done for either resident. The DON stated that when residents had orders for insulin, monitoring for hypoglycemia and hyperglycemia should be done and documented on the MAR, and that both conditions could result in serious illness and/or death. The facility’s policies on insulin administration and diabetes clinical protocol also addressed monitoring and notification related to hypoglycemia and hyperglycemia.
Improper medication labeling and storage
Penalty
Summary
Medications were not stored and labeled in accordance with facility policy and procedure during observations of Medication Cart A, Medication Storage Room A, and Medication Cart B. An unopened Xalatan Solution 0.005% eye drop bottle was found inside a plastic zip lock bag labeled to refrigerate, but it was stored in the refrigerator rather than in Medication Cart A. An insulin pen was also observed in Medication Cart A with only the resident’s last name written on it in permanent marker, and the LVN stated it should have had a pharmacy label with the resident’s name, drug name, dose, and expiration date. In Medication Storage Room A, two boxes of apple juice were observed in the medication room refrigerator. The LVN stated the apple juice should have been kept in the break room refrigerator and not in the medication refrigerator. In Medication Cart B, two medication cups contained opened unidentified tablets, including one cup labeled Room A with 3 opened unidentified tablets and another cup labeled Room B with 3.5 medications. The LVN stated these prepared medications should not have remained in the cart if the residents refused them. Medication Cart B also contained expired medications, including Glucagon 1 mg with an expiration date of 3/2026, Elder Tonic Liquid Multivitamin/Mineral Supplement with an expiration date of 1/2026, and Iron Supplement Liquid with an expiration date of 5/2026. The DON stated insulin pens should include the resident’s name, medication name, dosage, and expiration date, refrigerated medications should remain refrigerated, apple juice should not be stored in the medication refrigerator, medications should not be left in medication cups with room numbers, and expired medications should be discarded. The facility policy stated medications and biologicals are to be stored in locked compartments under proper environmental controls, stored in their original packaging or dispensing systems, and labeled with required information including medication name, dose, strength, expiration date, resident’s name, route, and instructions.
Unsafe Food Handling and Wet Kitchen Floor
Penalty
Summary
The facility failed to follow its food handling policy and procedure during tray line assembly in the kitchen. During a concurrent observation and interview, [NAME] 1 was observed taking the temperature of pureed vegetables without wearing gloves and without sanitizing the food thermometer before use. [NAME] 1 stated that gloves should be worn and the thermometer should be sanitized before checking the temperature of cooked food on the tray line to prevent cross-contamination and the transfer of germs and pathogens from the skin to meals being served to residents. During another concurrent observation and interview in the kitchen, the floor near the sink area was observed to be wet and a small amount of water was leaking from the kitchen floor near the exit area. The Dietary Service Supervisor stated the kitchen floor should be kept dry to prevent slip-and-fall injuries and inhibit the growth of dangerous bacteria or mold. Review of the facility's Food Preparation and Service policy showed that food and nutrition services employees are to prepare, distribute, and serve food in a manner that complies with safe food handling practices, that thermometers used to verify food temperatures are to be clean, sanitized, and calibrated, and that gloves are to be worn when handling food directly and changed between tasks. Review of the Cleaning and Disinfection of Environmental Surfaces - Infection Control policy showed that housekeeping surfaces, including floors, are to be cleaned regularly, when spills occur, and when visibly soiled.
Infection Control Practices Not Followed During Resident Care, Linen Storage, Surveillance, and PPE Use
Penalty
Summary
Standard infection prevention and control practices were not followed during wound care for a resident with heart failure, type 2 DM, and an unstageable sacral pressure ulcer. During a dressing change, a trash bag containing soiled gauze with bodily fluids and wipes with the resident’s bowel movement was observed placed on top of the resident’s bed next to the resident’s left leg. The resident’s left leg was observed touching the trash bag. The resident was dependent for multiple activities of daily living and was receiving daily sacral wound care with Santyl ointment and a pressure-reducing device for the bed. Clean linens and resident gowns were not stored in a manner that maintained infection control. Folded white towels and bed linens were observed stored on top of a resident’s closet, and a used white towel was observed on top of the toilet in the bathroom of the room. In the laundry area outside the facility, a linen cart with folded resident gowns was observed uncovered and exposed to the environment. The Housekeeping Supervisor stated the gowns were clean and waiting to go into the facility, and stated they should have been covered and placed inside a bag to maintain infection control and prevent contamination from dust or dirt. The facility also did not complete infection surveillance from 2/1/2026 through 6/9/2026. The infection control binder did not contain completed surveillance documentation, and the Infection Prevention Nurse stated there were no surveillance logs, trackers, mapping, or reports. The IPN stated residents had received antibiotics from 3/2026 to 6/2026, and that surveillance was important to identify infection control issues and infection trends. In addition, RN 1 was observed touching her surgical mask and hair with bare hands while opening food container lids during lunch tray distribution without performing hand hygiene, and CNA 5 provided high-contact care to a resident on enhanced barrier precautions without wearing a gown. The resident had severe cognitive impairment and a G-tube, and the IPN stated the precautions required gowns and gloves during high-contact care.
Failure to Document Offering and Education for Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to educate and offer the influenza and pneumococcal vaccines to four sampled residents during admission and subsequent chart review. For Resident 48, the admission record showed diagnoses including GERD, protein-calorie malnutrition, dysphagia, and type 2 DM, and the MDS indicated severely impaired cognitive skills and dependence with oral care, toileting, personal hygiene, eating, dressing, and transfers. Review of both the electronic and physical medical charts showed no documented immunization history and no evidence that the resident or responsible party was educated about or offered the influenza or pneumococcal vaccines. For Resident 14, the admission record listed PNA, chronic respiratory failure, and MDD, and the MDS indicated severely impaired cognitive skills with dependence for toileting, bathing, and lower body dressing, plus assistance needs for oral hygiene and eating. The immunization history showed a most recent influenza vaccine on 10/11/2024, but there was no documented evidence of pneumococcal vaccination or refusal. Review of the electronic and physical charts showed no documentation that the resident or responsible party was educated about or offered the influenza and pneumococcal vaccines. For Resident 3, the admission record listed ESRD, heart failure, and type 2 DM, and the MDS indicated intact cognitive skills with dependence for toileting, bathing, and lower body dressing, and supervision or touching assistance with eating. The immunization history showed an influenza vaccine on 9/30/2023, with no documented history of pneumococcal vaccination administration or refusal. Review of the electronic and physical charts showed no documentation that the resident was educated about or offered the influenza and pneumococcal vaccines. For Resident 34, the admission record listed acute respiratory failure, chronic pulmonary edema, and CKD, and the MDS indicated intact cognitive skills with substantial/maximal assistance needed for oral care, toileting, personal hygiene, dressing, and set-up or clean-up assistance with eating. The immunization history showed influenza vaccine on 10/2/2024 and pneumococcal vaccine on 10/1/2024, but the electronic chart did not document that the resident was educated about or offered influenza vaccine, and the physical chart did not document education or offering of either vaccine.
Uncovered Foley Bag Observed on Resident in Wheelchair
Penalty
Summary
Facility staff failed to ensure Resident 96's foley bag was covered with a dignity bag. Resident 96 was admitted and readmitted to the facility with diagnoses including type 2 diabetes mellitus, neuromuscular dysfunction of the bladder, and presence of urogenital implants. The MDS dated 5/14/2026 indicated the resident had no cognitive impairment for daily decision making, required assistance with toileting hygiene, lower body dressing, and footwear, and used a foley catheter to drain the bladder and collect urine. During a concurrent observation and interview on 6/9/2026 at 4:16 PM, Resident 96 was seen sitting in a wheelchair with a urinary bag hanging on the left side of the wheelchair that was not covered with a dignity bag. CNA 4 stated the urinary bag was supposed to be covered with a dignity bag to provide privacy and dignity. The DSD later stated it is very important to cover the urinary bag with a dignity bag to maintain privacy, independence, and dignity. The facility's Dignity policy stated residents are to be treated with respect at all times and that staff are expected to help keep urinary catheter bags covered.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that three sampled residents, Residents 57, 72, and 103, who were discharged from Medicare Part A coverage within the last six months, received a Notice of Medicare Non-Coverage before their Medicare Part A benefits ended. Review of the Census and Rates reports showed each resident had a last covered day for Medicare Part A skilled services, but the records did not show that a NOMNC was issued before coverage expired. During interviews, Resident 57 stated the facility did not notify him that his Medicare Part A benefits were about to expire before the expiration date, and Resident 72 gave the same statement. In a concurrent interview and record review, the Business Office Manager confirmed that Residents 72, 103, and 57 had their Medicare Part A benefits expire and did not receive a NOMNC or any notification that their benefits would expire. The facility policy reviewed stated that a Medicare beneficiary is informed in advance and in writing when Medicare payment denial or change is likely, but the BOM stated there was no evidence that these residents were notified before their benefits expired.
Delayed Scheduling of Ordered Orthopedic Appointment
Penalty
Summary
The facility failed to ensure an ordered orthopedic appointment was scheduled for a resident with left hip arthritis and left hip pain. The resident was admitted with diagnoses that included left hip arthritis, pain in the left hip, and chronic kidney disease, and the physician’s order dated 4/1/2026 directed staff to make an appointment with Orthopedic Doctor 1 for left hip pain and arrange wheelchair transportation with return. A pain consultation physician’s note dated 4/13/2026 documented that the resident reported muscle stiffness, tenderness, and worsening pain in the left hip, and the plan was to send the resident to Orthopedic Doctor 1 for a possible left hip replacement. An urgent authorization request for the orthopedic appointment was submitted the same day. The resident’s MDS dated 5/2/2026 indicated intact cognitive skills and need for assistance with several activities of daily living. During interviews, the resident stated he had been told he would have an appointment for evaluation but the facility had not scheduled a follow-up or provided further information. Nursing, social services, and admissions staff stated they did not know the status of the appointment or had not followed up on the authorization request until 6/11/2026. The admissions coordinator stated the resident had been approved for the appointment since 5/15/2026, but the facility was unaware of the approval status, resulting in a delay in scheduling from 5/15/2026 to 6/11/2026. The DON stated staff should have followed up sooner to prevent delay of services. The facility policy stated social services would collaborate with nursing staff or other pertinent disciplines to arrange physician-ordered services.
LALM Set Incorrectly for Resident With Sacral Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one sampled resident with an unstageable sacral pressure ulcer. The resident was admitted with diagnoses including heart failure and type 2 DM, and the MDS indicated severely impaired cognitive ability and dependence for eating, oral hygiene, toileting hygiene, showering, dressing, footwear, personal hygiene, and rolling left and right. The resident’s treatment plan included a pressure reducing device for bed, and the physician’s order allowed use of a low air loss mattress (LALM) for wound management set at the resident’s current weight. On observation, the resident’s LALM was set at 180 lbs even though the resident’s recorded weight was 159 lbs. The resident stated the bed felt uncomfortable. An LVN confirmed the mattress was set at 180 lbs and stated it should have been set to 159 lbs, explaining that setting it higher adds more pressure and can make the resident’s pressure ulcer worse. The DON reviewed the facility’s Support Surface Guidelines and the manufacturer’s manual, which stated the mattress should be set to the patient’s weight, and agreed that if it is not set correctly it does not redistribute pressure but adds more pressure to a wound.
Missed weekly weights and fluid intake charting for a resident with nutritional risk
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was cited after the facility failed to obtain weekly weights from 2/17/2026 through 3/17/2026 and failed to record fluid intake every shift from 6/1/2026 through 6/11/2026 for one sampled resident. The resident was admitted with GERD, protein-calorie malnutrition, dysphagia, and type 2 DM, and the MDS showed severely impaired cognitive skills for daily decision making and dependence with oral care, toileting, personal hygiene, eating, dressing, and transfers. The resident's order summary showed weekly weights times four active on 2/17/2026, and the weight summary documented a weight of 154 pounds on 2/2/2025 with a 10 percent weight loss from 172 pounds on 8/6/2025, but it did not show completion of weekly weights from 2/17/2026 through 3/17/2026. The care plan for increased nutritional risk and weight loss directed staff to monitor and record intake at mealtimes and between meals and to monitor and record fluid intake every shift at meals and activities, but review of the paper chart, electronic chart, and CNA daily charting form did not show recorded fluid intake amounts for each meal and between meals during the reviewed period. LVN 1 and the DON both confirmed that the weekly weights and fluid intake monitoring should have been completed and recorded.
Failure to Follow Budesonide Order During Medication Administration
Penalty
Summary
The facility failed to follow the physician's order for one resident during medication administration by not ensuring the resident rinsed his mouth after receiving Budesonide Inhalation Suspension. The resident was admitted with diagnoses including COPD with acute exacerbation, pneumonia, emphysema, and respiratory disorders. His care plan identified him as at risk for shortness of breath, respiratory illness/distress, wheezing, dyspnea, and a history of acute respiratory failure with hypoxia, and it directed staff to administer Budesonide Suspension 0.5 mg/2 ml twice daily for shortness of breath and wheezing, rinse the mouth after use, and monitor and document side effects and effectiveness. The resident's MDS indicated his cognitive skills for daily decision making were intact and that he required supervision or touching assistance for several activities. During observation, an LVN administered Budesonide Inhalation Solution via nebulizer mask and later returned to the room without having the resident rinse his mouth. The LVN stated he should have had the resident rinse his mouth after administration and acknowledged that the order indicated to rinse the mouth. The DON stated the resident's mouth should be rinsed after Budesonide administration to prevent infection in the mouth such as oral thrush and other complications. The facility policy stated medications are administered in accordance with prescriber orders.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor one resident’s food preferences as requested. The resident was admitted with diagnoses including cellulitis of the right lower limb, heart failure, neuralgia, and neuritis, and had a physician’s order for a no added salt diet with regular texture, thin liquids, plus 16 ounces of fluids and a bowl of fruit with meals. The resident’s care plan directed staff to offer alternatives within dietary guidelines to accommodate tastes and preferences and to obtain and adhere to food preferences as able. The resident’s MDS indicated intact cognitive skills for daily decision making, and a nutrition note documented requests for no rice, no pasta, no juices except orange juice, and a preference for sandwiches and salads. During observation at lunch, the resident’s tray contained broccoli, garlic bread, and tofu, and the tray card listed preferred likes as salads with peas, corn, and chicken. The resident stated she did not want the lunch tray and should have received a chicken salad, explaining that she wanted to eat healthier because of her heart condition and requested salads at every lunch. The Dietary Supervisor reviewed the dietary profile and stated the facility had salads available for lunch and that the resident should have received a salad in accordance with her diet profile and preference. The Registered Dietitian and Dietary Supervisor also reviewed the facility policy on resident food preferences, which stated that food preferences should be placed on the profile card and identified on the tray card, and the RD stated those preferences should be honored by providing food in accordance with the resident’s preference.
Incomplete Transfer/Discharge Notice Documentation
Penalty
Summary
Resident 2 was readmitted to the facility with diagnoses including adult failure to thrive, COPD, dementia, and gastrostomy, and the discharge MDS indicated severely impaired cognitive skills, dependence for oral care, toileting, personal hygiene, bathing, and dressing, and the presence of a feeding tube. On 5/11/2026, Resident 2 had a dislodged gastrostomy tube, and the SBAR directed transfer to the hospital via 911 for further evaluation and management. The discharge summary documented that Resident 2 was discharged to a general acute care hospital for the dislodged tube. During record review, Resident 2's Notice of Proposed Transfer/Discharge dated 5/11/2026 was found to be incomplete because it did not indicate a reason for the transfer/discharge. In a concurrent interview, the RN supervisor stated the notice was not documented completely and that a transfer/discharge reason should have been indicated. The DON stated that all medical records must be complete and accurate, and the facility policy required documentation in the medical record to be objective, complete, and accurate.
Failure to Educate, Offer, and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to educate and offer the COVID-19 vaccine to one sampled resident, Resident 48, and failed to properly document the resident’s vaccination status. Resident 48 was admitted with diagnoses including GERD, protein-calorie malnutrition, dysphagia, and type 2 DM. The resident’s MDS dated 5/15/2026 indicated severely impaired cognitive skills for daily decision making and dependence with oral care, toileting, personal hygiene, eating, dressing, and transfers. During concurrent interview and record review, the resident’s electronic medical chart from 8/5/2025 through 6/9/2026 did not show that Resident 48 or the responsible party was educated about or offered the COVID-19 vaccine. The IPN stated there was no documentation that education was provided or that the vaccine was offered. A later review of the resident’s physical medical chart also failed to show education, offer, consent, or declination documentation. The IPN and DON stated that vaccine education, VIS provision, consent or refusal, and documentation are important and are addressed in the facility’s policies for COVID-19 vaccination of residents.
Leaking AC Near Nursing Station
Penalty
Summary
The facility failed to ensure the air conditioning unit near the nursing station was maintained in a safe operating condition in accordance with its Maintenance Service policy and procedure. During a concurrent observation and interview on 6/8/2026, the AC unit was observed leaking water onto the floor in front of the nursing station, in an area where residents walk by. LVN 1 stated the water was leaking from the AC and there was no wet floor sign on the puddle created by the leak. During the same observation, the Administrator and the Director of Staff Development both observed the leaking AC and stated that it was dripping water onto the floor and that there was no wet floor sign near the puddle. The DSD stated that wet floor signs alert residents to a wet floor so they will not trip. On 6/11/2026, the Interim Maintenance Director reviewed the facility policy titled Maintenance Services, which stated that maintenance services shall be provided to all areas of the building, grounds, and equipment, and that maintenance personnel are responsible for maintaining the building, ground, and equipment in a safe and operable manner at all times and keeping the building in good repair and free from hazards. The IMD stated he saw the water leaking on the floor from the AC and that it was a safety hazard because there was no wet floor sign and someone walking by would not be aware of it and could fall.
Failure to Maintain Clean, Sanitary, and Homelike Environment After Water Damage
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not addressing visible water damage, peeling paint, and damaged surfaces in multiple resident care areas. On the second floor, surveyors observed a ceiling panel near a window across from the second dining/TV room with dark brown discoloration and adjacent wall areas with cracked wood and peeling paint. Along the second-floor resident hallway, ceilings showed scattered dark brown discoloration and dried brown water leak marks on the walls. In Room A, there were multiple scratches on the wall, peeling paint, and a cracked baseboard protruding from the wall. In Rooms C, D, and E, surveyors observed cracked and peeling paint on walls and ceilings, including the bathroom ceiling in Room D, despite the Maintenance Supervisor stating these areas had been repainted after a roof leak in early January. In Room B, surveyors and the Maintenance Supervisor observed a framed painting on the wall that appeared damp inside the frame, with an unidentified green substance on the top left corner and a black substance on the bottom middle area extending to the right corner. A dried dark brown water mark extended from the ceiling to the wall above the painting, continued beneath it, and ran down to the baseboards; the Maintenance Supervisor confirmed this was from a water leak after heavy rains in early January and stated no staff or residents had reported it. The Housekeeping Supervisor stated that rooms, hallways, and other areas are cleaned daily and that housekeeping staff should clean walls and floors, but she did not know why the dried water leak marks and the dirty painting with greenish and blackish substances in Room B had not been addressed, and acknowledged that the painting looked very dirty and that whatever substance was in it could potentially make residents sick. The DON stated staff are expected to report dirty rooms, cracked walls, and peeling paint to maintenance so issues can be addressed immediately, and the Administrator confirmed that the facility’s “Homelike Environment” policy, which requires a safe, clean, comfortable, and homelike setting, was not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by a roommate. One resident with dementia and Alzheimer’s disease, documented as severely impaired in cognitive skills for daily decision-making and dependent or needing assistance with most ADLs, was lying in bed when another resident entered his space. The cognitively impaired resident required assistance with transfers, dressing, personal hygiene, and eating, and was not able to provide meaningful information during post-incident interviews, only being able to state his name. The Director of Nursing later stated that this resident did not have the ability to consent to sexual activity. A second resident, also diagnosed with dementia and polyneuropathies and severely impaired in cognitive skills for daily decision-making, was identified as the perpetrator of the sexual contact. This resident required varying levels of assistance with transfers, dressing, personal hygiene, and eating, and was unable to recall the incident when interviewed. On the date of the incident, a CNA entered the shared room while passing dinner trays and observed the second resident on his knees at the side of the first resident’s bed, with the first resident’s diaper open, and using both hands to touch the first resident’s private parts. The CNA estimated that the touching continued for approximately 10 seconds from the time she first observed it until she intervened. Another cognitively intact resident reported having previously witnessed the same perpetrating resident lowering the first resident’s diaper and touching his buttocks in the shared room. This witness stated he reported what he saw to an unidentified staff member, but the facility was unable to identify who received that report and was unable to substantiate that earlier allegation. The facility’s abuse prevention policy states that residents have the right to be free from abuse, including sexual abuse, and that the administration will protect residents from abuse by anyone, identify and assess all possible incidents of abuse, and investigate and report any allegations of abuse within required timeframes. Despite these policies, the observed non-consensual sexual contact occurred between the two residents, constituting a failure to protect the first resident’s right to be free from sexual abuse. The facility’s documentation following the incident reflected that the first resident experienced unwanted touching behavior and was at risk for emotional/psychological distress due to possible unwanted touching behavior by another resident. The second resident’s documentation reflected possible unwanted touching behavior as well. The survey findings concluded that the facility failed to protect the first resident from sexual abuse by the second resident when the second resident was observed playing with the first resident’s private part, and that this failure resulted in sexual abuse and had the potential to result in negative psychosocial effects based on the reasonable person concept, given the first resident’s severely impaired cognitive status.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to the state survey agency (CDPH) within the required federal time frame and to submit the results of the investigation within five working days. One resident with dementia and Alzheimer’s disease, who was assessed as severely cognitively impaired and dependent or needing assistance with most ADLs, was the alleged victim. According to the SBAR documentation, a CNA observed the cognitively impaired roommate kneeling by the resident’s bed and touching the resident’s genital area while the resident was lying in bed. The CNA intervened, separated the residents, and reported the incident to an RN, who then notified the physician, DON, and Administrator. The roommate alleged to have committed the touching also had dementia and polyneuropathies and was documented as severely cognitively impaired, requiring assistance with transfers, dressing, hygiene, and other ADLs. SBAR documentation for this resident indicated that when interviewed by the RN after the incident, the resident did not remember what had occurred. Another cognitively intact resident later reported that, on a separate occasion, he had witnessed the same roommate lowering the alleged victim’s brief and touching the victim’s buttock in their shared room and that he had reported this to an unidentified staff member. The report does not identify any injuries but characterizes the incident as inappropriate sexual touching of a resident who lacked capacity to consent. Interviews with facility leadership and staff showed that the incident was reported to local law enforcement and the ombudsman, but not to CDPH. The DON stated she was informed of the incident and confirmed that it was reported to the police and ombudsman only. The RN reported that the Administrator instructed her not to call CDPH because both residents had dementia. The Administrator stated that, based on his interpretation of AFL 24-09 and the absence of injury, he believed the incident did not need to be reported to CDPH. Review of the facility’s Abuse Investigation and Reporting policy showed it required reporting all alleged violations of abuse to the state licensing/certification agency and also referenced AFL 24-09 for resident-on-resident abuse involving residents with dementia. Both the Administrator and DON later acknowledged, after reviewing the CMS SOM, that the allegation of sexual abuse involving a resident without capacity to consent should have been reported to CDPH within two hours and that a five-day written investigation report was also required, but this did not occur.
Failure to Honor Bed-Hold Rights and Readmit Resident to Reserved Bed
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to return to their reserved bed following a hospitalization within the state-defined bed-hold period. The resident, who had dementia with severe cognitive impairment and polyneuropathy, required assistance with transfers, dressing, hygiene, and bed mobility. The resident had been initially admitted and later readmitted to the facility and was residing in a specific room and bed (Bed AA), which was placed on a seven-day bed hold when the resident was transferred to a general acute care hospital (GACH) for escalating dementia. The DON confirmed that the resident’s discharge date from GACH fell within this seven-day bed-hold period and that it was the resident’s right to return to the same room and bed. Instead of readmitting the resident to the facility, the Administrator requested that the resident be placed at another SNF (SNF 2), citing an isolated incident of sexual abuse involving the resident and stating that SNF 2 was more appropriate to care for the resident. The Admissions Director at SNF 2 reported that the referral came from the facility’s marketer (MK) and that no reason for the transfer was provided other than a request to take the resident “for now.” The GACH case manager stated that the transfer request to SNF 2 did not come from the resident or the resident’s family representative, but from the facility’s MK, who reported that the building was undergoing remodeling due to water damage and that the resident’s room needed remodeling, necessitating a temporary transfer. GACH documentation reflected that, according to the facility, there was a problem at the facility and that the resident would be sent temporarily to a sister facility due to building construction from rain damage, with the family allegedly made aware. Subsequent observations and interviews did not support the stated reason of remodeling for denying the resident’s return. Surveyors observed no remodeling or maintenance in the resident’s former room, and the Maintenance Supervisor confirmed that only other specified rooms were undergoing drywall replacement due to leaks, with no work needed in the resident’s room. The DON stated that the resident was on a seven-day bed hold and had the right to return to the facility and to the same room and bed, and that she was not notified on the day the resident was transferred to SNF 2, so she could not verify bed availability. The DON also stated she was unaware that SNF 2 was not a locked facility and that SNF 2 should have been informed of the resident’s behavior before accepting the transfer. The facility’s bed-hold policy stated that residents returning within the bed-hold period are allowed to return to their previous room if available and that post-hospitalization evaluations should be based on the resident’s current condition. Despite this, the resident was not readmitted to the reserved bed and was instead discharged from GACH to another SNF within the bed-hold period.
Failure to Document Bed Alarm Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans for two residents who were using bed alarms as fall prevention interventions, as required by facility policy. For one resident with diagnoses including generalized muscle weakness, anxiety disorder, and urinary tract infection, the care plan did not include the use of a bed alarm, despite the resident being observed with one in use and staff confirming its purpose for fall prevention. The resident's care plan only addressed other safety measures such as adequate lighting, bed positioning, and call light accessibility, omitting the bed alarm intervention. Similarly, another resident with depression, hypothyroidism, and generalized muscle weakness was observed with a bed alarm in place, and staff confirmed its use for fall prevention. However, this intervention was not documented in the resident's care plan. Facility staff, including a CNA, LVN, and RN, acknowledged that the care plans should have reflected the use of bed alarms, in accordance with the facility's policy, which requires interdisciplinary team involvement and documentation of such interventions in the care plan for residents at risk for falls.
Failure to Provide Timely Wound Treatment for Sacral Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident who was readmitted with diagnoses including type II diabetes mellitus, metabolic encephalopathy, and cerebral infarction. The resident's MDS dated 11/12/2025 indicated impaired cognitive skills, dependence on staff for toileting hygiene, oral hygiene, and turning, and one stage 2 pressure ulcer present upon admission/entry or reentry. A skin re-assessment check dated 11/7/2025 identified a skin tear on the left buttock and a pressure ulcer on the sacrum. The resident's care plan for skin integrity, initiated on 11/10/2025, directed treatment of the left buttock and sacral wounds with cleansing, Medi-honey, and foam dressing every shift for 21 days. However, the TAR showed wound treatment for the left buttock and sacrum did not begin until 11/11/2025 at 3:00 PM, and the DON stated the facility staff should have placed a wound treatment order after the skin assessment on 11/7/2025 but did not. The DON, DSD, and TXN 1 all stated the left buttock and sacral wounds were not treated from 11/8/2025 to 11/10/2025, and the DSD stated there was no order for those wound treatments during that period.
POLST Form Not Accurately Completed
Penalty
Summary
The facility failed to ensure the POLST form for one resident was accurately completed. The resident was readmitted with diagnoses including type II diabetes mellitus, metabolic encephalopathy, and cerebral infarction, and the MDS indicated impaired cognitive skills in decision making and dependence on staff for toileting hygiene, oral hygiene, and rolling side to side. During interview and record review, the Social Service Director stated she met with the resident's wife and nephew to complete the POLST form, but did not use the facility's Language Access Program to assist with the wife's limited English proficiency. The SSD stated the nephew explained CPR in Spanish to the wife and she was not sure whether he correctly translated the medical terminology, resulting in the resident's and wife's wishes and needs not being accurately communicated and the POLST not being accurately completed. The POLST form reviewed showed the wife's signature, but the signature line for the physician, nurse practitioner, or physician assistant was left blank. The resident's wife stated she signed a POLST form that had been filled out before the meeting and that it was written in English and she did not understand it.
Care Plan Not Developed for Scratching and Dressing-Picking Behavior
Penalty
Summary
The facility failed to ensure a resident-specific care plan was developed and implemented for one of two sampled residents. The resident was admitted and later readmitted with diagnoses including cellulitis of the right lower leg, peripheral vascular disease, and dermatitis. The Minimum Data Set dated 7/31/2025 indicated the resident had severe impairment in cognitive skills for daily decision making and required substantial to maximal assistance with personal and toileting hygiene, showering, upper and lower body dressing, and putting on and taking off footwear, as well as partial to moderate assistance with oral hygiene and supervision with eating. During interviews, a CNA stated she had seen the resident scratch her legs, ears, and almost her entire body, and an LVN stated the resident had a behavior of scratching her arms and legs and picking on her dressing. During a concurrent record review and interview, the DON stated the resident did not have, and should have had, a care plan to address the scratching behavior and picking at the dressing. The DON also stated the resident's right leg wounds could have been prevented from being exposed when the dressings came off if the facility had a specific care plan intervention for the resident's behavior. The facility policy stated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and is developed and implemented for each resident.
Failure to Prevent Overcharge of Resident Personal Funds
Penalty
Summary
The facility failed to follow its policy and procedure regarding the management of a resident's personal funds, resulting in an overcharge. A review of the resident's financial records showed that the resident, who had diagnoses including dementia, glaucoma, and bilateral hearing loss, was severely cognitively impaired and dependent on staff for daily activities. The resident's eligibility response indicated a share of cost of $1,133.00, but the facility ledger showed the resident was charged $1,867.00 for one month, resulting in an overcharge of $734.00. There was no documentation explaining the reason for this overcharge. Further review of the facility's policies revealed that any overcharge to a resident's funds should be returned to the resident or their representative. Additionally, the facility's policy required residents to be informed in advance of any changes to their bills. The finance manager confirmed the overcharge and the lack of documentation to support it during interviews and record reviews.
Failure to Accurately Assess, Investigate, and Monitor Resident After Fall
Penalty
Summary
A resident with a history of Parkinson's Disease, muscle weakness, dementia, and previous falls was not provided with adequate care and services to prevent accidents. The resident's fall risk assessment was found to be incomplete and inaccurate, as it only marked the age category and failed to account for significant risk factors such as vision impairment, cognitive deficits, use of antihypertensive medication, unsteady gait, and altered awareness. The Director of Nursing (DON) acknowledged that these omissions placed the resident at a high risk for falls. Additionally, the resident's Minimum Data Set (MDS) did not accurately reflect the level of assistance required for activities of daily living (ADLs), as therapy certifications indicated the need for moderate to contact guard assistance, while the MDS documented independence in these activities. The facility also failed to conduct a thorough investigation following the resident's fall. The investigation did not include an interview with the resident's roommate, who had witnessed the fall and could provide critical details about the incident. The DON admitted to forgetting to interview the roommate, which was contrary to facility policy requiring clarification of fall circumstances and evaluation of events leading up to the fall. Furthermore, the resident's care plan was not resident-centered and lacked specific, individualized interventions to address the resident's risk for decline in ADLs and falls, as required by facility policy. There were additional lapses in monitoring and documentation after the suspected fall. The responsible party reported the fall to both the LVN and the DON, but the LVN did not initiate further assessment or monitoring because the resident denied the fall. Progress notes revealed gaps in monitoring and documentation across several shifts following the incident, despite facility policies mandating ongoing monitoring and documentation of residents after a fall. These deficiencies in assessment, investigation, care planning, and post-fall monitoring contributed to the failure to ensure a safe environment and adequate supervision to prevent accidents.
Failure to Honor Resident's Roommate Choice and Provide Written Notice
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to share a room with their spouse or roommate of choice. Additionally, the resident did not receive written notice prior to a change being made to their room assignment. This action was not in accordance with the resident's rights as outlined in regulatory requirements.
Failure to Timely Submit PBJ Staffing Data Due to Payroll Processing Issues
Penalty
Summary
The facility failed to submit complete and accurate Payroll Based Journal (PBJ) staffing data for the first quarter of 2025 within the required timeframe. According to the CMS PBJ Staffing Data Report, the facility did not submit staffing data for the period from January 1, 2025, to March 31, 2025, by the designated deadline. The Payroll Coordinator reported that there were three errors in the staffing data report for this quarter. Additionally, the Payroll Coordinator stated that the facility's previous payroll processing company had closed for an unknown reason, and a new payroll company was not engaged until the end of May 2025. As a result, the required staffing data was not submitted on time and was only accepted by CMS after the deadline. The facility's policy and procedure required that staffing and census information be reported electronically to CMS through the PBJ system no later than 45 days after the end of each reporting quarter. The policy also specified that the Payroll Coordinator was responsible for preparing, verifying, and submitting the quarterly PBJ. The Administrator, who began working at the facility in June 2025, was not aware of the failure to submit the staffing data report for the first quarter and indicated that the Payroll Coordinator should have informed the previous Administrator about the payroll company closure to prevent the delay.
Plan Of Correction
Immediate Corrective Action: On 6/16/25, the Payroll Coordinator sought help with the new payroll software in familiarizing themselves with the system in preparation for future submissions. Corrective Action for Others Affected: On 6/16/25, the Payroll Coordinator reviewed all reports from the quarterly Payroll Base Journal reports for the past year and did not find any other quarter affected by the deficient practice. Measures Taken to Prevent Recurrence: The Administrator in-serviced the Payroll Coordinator on 06/16/25 regarding the significance of regularly and promptly submitting the quarterly Payroll Base Journal, as it affects reporting of the facility’s direct care staffing compliance. Performance Monitoring to Ensure that Solutions are Sustained: Starting 7/01/25, the administrator will review with the Payroll Coordinator the preparation of the monthly labor reports that will comprise the quarterly Payroll Base Journal submission. Starting 7/01/25, the administrator will review with the Payroll Coordinator on a quarterly basis the submission of the Payroll Base Survey to ensure prompt submission. Starting 7/01/25, the administrator will discuss during the QAPI meeting issues encountered during the monthly and quarterly Payroll Base Journal reviews for the next 3 months. Starting 7/01/25, all findings will be presented by the administrator during the monthly QAPI Meeting for the next 3 months.
Failure to Maintain Safe, Clean, and Homelike Environment for Multiple Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for seven residents, as evidenced by multiple observations and interviews. One resident's closet handle was found to be replaced with a plastic trash bag loop, which the resident used to make it easier to open the door. The Director of Staff Development acknowledged that this posed a safety risk, as residents could get caught in the loop and injure themselves. Another resident's bed sheet was observed to be worn out, thin, discolored, and old, with confirmation from a Licensed Vocational Nurse that the sheet needed replacement. In a shared restroom used by two residents, towels were found hanging on various fixtures such as the soap dispenser, toilet paper holder, and shower hose, rather than on a proper towel rack. The ceiling paint in the restroom was also peeling. One resident expressed concern about the lack of a towel rack and the unsanitary conditions, while the other resident noted the safety risk of reaching for towels in unsafe locations. The Director of Staff Development agreed that the situation was unsafe, unsanitary, and not homelike. Another resident's room wall near the head of the bed was observed to have discolorations and multiple scratches, which the resident found unpleasant. The Maintenance Director stated that the damage was likely caused by the bed hitting the wall and agreed that it did not create a homelike environment. Additional deficiencies included a rollator walker with a chipped seat cushion exposing foam for one resident, and a wheelchair in poor condition for another resident, with a cracked armrest held together by tape, a sagging and cracked backrest, and missing vinyl. The affected resident reported discomfort and had previously requested a new wheelchair. The Maintenance Supervisor and DON confirmed the importance of maintaining assistive devices in good repair and acknowledged the poor condition of the wheelchair. Facility policies reviewed indicated requirements for maintaining a clean, safe, and homelike environment, as well as regular maintenance of equipment, which were not met in these instances.
Plan Of Correction
b. The Housekeeping Supervisor replaced the worn-out bedsheet of resident 55 on 6/9/25. c. The Maintenance Supervisor installed a towel rack on 6/17/25 in the shared restroom for Residents 37 and 57. On 6/17/25, the Maintenance Supervisor patched the ceiling of the restroom for Residents 37 and 57. d. On 6/18/25, the Maintenance Supervisor painted the wall for resident 64, near to the head of the resident bed. e. The Maintenance Supervisor replaced on 6/9/25 Resident 7's rollator with a newer one. f. The Maintenance Supervisor replaced on 6/9/25 Resident 66's wheelchair with a newer one. Corrective Action for Others Affected a. On 6/16/25, the Maintenance Supervisor began daily rounds and found no other residents affected by the deficient practice related to paint and wheelchairs and rollators. Measures Taken to Prevent Reoccurrence a. The Administrator in-serviced the Housekeeping Director on 6/16/2025 regarding quality control in the distribution of linens. b. The DSD in-serviced the CNA staff on 6/16/2025 regarding safe, clean, comfortable home-like environment. c. The Administrator in-serviced the Maintenance Supervisor on 6/17/25 regarding proper maintenance of wheelchairs, walkers, and rollators. Performance Monitoring to Ensure that Solutions are Sustained a. Beginning 6/16/25, the DSD shall make random rounds monthly, for the next 3 months, and check 5 random rooms to make sure that residents are using good quality linens. b. Beginning 7/01/25, the Maintenance Supervisor will report monthly to the Administrator on the status of painting and patching for the next 3 months.
Failure to Assess and Obtain Orders for Use of Physical Restraints
Penalty
Summary
Two residents were found to be placed in Geri chairs, which are considered physical restraints, without the required assessments or physician's orders. Both residents had significant cognitive impairments and required varying levels of assistance with daily activities. Observations confirmed that each resident was seated in a Geri chair in the hallway or their room, and staff interviews revealed that the chairs were used to prevent the residents from getting up unassisted, as it was more difficult for them to rise from a Geri chair compared to a wheelchair. Record reviews for both residents showed no documentation of a restraint assessment prior to the use of the Geri chair, nor was there a physician's order authorizing its use. Staff, including a CNA and Registered Nurse Supervisors, acknowledged that the Geri chair limited the residents' movement and that proper procedures, such as assessment and obtaining a physician's order, had not been followed. The facility's own policy also identified Geri chairs as potential restraints and required a pre-restraining assessment and a written physician's order before use. The failure to conduct assessments and obtain physician's orders for the use of Geri chairs resulted in the use of physical restraints without proper justification or documentation. This practice limited the residents' mobility and did not comply with regulatory requirements or the facility's policy regarding the use of restraints.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice; DON added on EHR Restraint-Physical assessment and attained consents and orders for residents 81, 86, 85, 77. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; Admission assessment will include 19. Physical Restraint Initial/Quarterly/Annual. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; DON and or designee will add to her Chart Review to include Restraint Physical assessment which is done initially and Quarterly, annually with IDT members. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy for two residents by not reporting an allegation of abuse to the appropriate authorities within the required timeframe. An incident occurred involving a verbal altercation between two residents, one of whom attempted to hit the other with a pillow. The altercation was witnessed by a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who intervened by moving one resident to a new room. However, the incident was not reported to the California Department of Public Health (CDPH), the state ombudsman, or local law enforcement within two hours as required by federal and facility policy. Resident 15, who was involved in the incident, had a history of severe cognitive impairment and required substantial assistance with daily activities. The resident's care plan was updated to reflect the risk for emotional and psychosocial distress following the altercation. Resident 241, the other party in the incident, also had severe cognitive impairment and a history of encephalopathy and psychosis. Documentation showed that the altercation was only recorded as a room change in the communication book, and no formal incident report was made at the time. Interviews with facility staff, including the DON, LVN, CNA, and Administrator, confirmed that the incident was not reported as required. The DON and Administrator both acknowledged that the event should have been reported within two hours, but the delay occurred because the incident was not brought to their attention until several days later during a meeting. The facility's policy clearly states that all allegations of abuse must be reported immediately, but this procedure was not followed in this case.
Plan Of Correction
Immediate Corrective Action a. The new administrator faxed over the SOC-341 to the CDPH and Long-Term Care (LTC) Ombudsman, and reported to the local police district on 6/5/25, after being informed by the MDS Coordinator about the alleged altercation between residents 15 and 241. b. The final investigation report was faxed over to the ombudsman on 6/11/25 within 15 days from submitting the SOC-341. On 6/11/25, within 5 working days from submitting the Corrective Action for Others Affected, the progress notes for the residents contained in the residents' files were reviewed by the MAS, Coordinator, and analyzed. No other residents were found to be affected by the incident. Preventive Measures to Recurrence a. The previous DON resigned on 6/2/25 with immediate effect. b. LVN 3 was in-serviced over the phone by the new administrator in 2025 regarding the incident and documentation of allegations of abuse. c. The administrator in-serviced all staff on 6/6/25 regarding the prevention of abuse. Performance Monitoring and Solutions a. The MDS Coordinator will review, twice a month for the next 3 months starting 6/6/2025, 5 random progress notes of residents to verify documentation and allegations of abuse. The MDS Coordinator will report findings during the monthly QAPI meeting. b. The RN/DS Coordinator will report during the resident stand-up meeting at around 9:50 a.m., with progress notes of date achieved.
Failure to Follow Heel Offloading Orders for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers by not following physician orders for heel offloading for two residents. Both residents had documented orders and care plans requiring their heels to be offloaded, either with heel protectors or pillows, to prevent skin breakdown due to their high risk for pressure injuries. Despite these orders, multiple observations over several days showed that neither resident had their heels offloaded as required. For one resident with a history of cerebral infarction, contractures, and high risk for pressure injury, the care plan and physician order specified bilateral heel offloading every shift. Observations revealed the resident lying in bed without heel protectors or pillows under the heels, and the resident confirmed that staff had not been applying the heel protectors or using pillows. Interviews with CNAs and the Restorative Nursing Assistant indicated a lack of awareness of the order and inconsistent application of the intervention, with staff stating that heel offloading had not been performed during their shifts. The second resident, who had a diagnosis including an unstageable pressure ulcer on the right heel and diabetes, also had a physician order and care plan intervention for continuous right heel offloading. Observations found the resident's right foot wrapped but not offloaded, with no heel protector or pillow in use. Staff interviews confirmed that the required offloading was not being performed, and the importance of following the order to prevent further injury was acknowledged by nursing staff. Facility policy required structured assessment and intervention for residents at risk of pressure injuries, but these were not implemented as ordered for these residents.
Plan Of Correction
Immediate Corrective Actions for resident affected by this deficient practice. On 6/12/25, DON and DSD immediately placed bilateral heel protectors for both residents 42 and 54. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; All other Residents with orders for Off-Loading heels were checked and verified by Treatment Nurse and DON on 6/12/25 and found no other deficient practices. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur. On 07/02/25, DSD and DON in-serviced all licensed Nurses regarding proper implementation of heel protectors as ordered by the physician. Starting 7/01/25, Medical Records Director will Audit daily EHR orders for heel protectors and report to the DON any deficient practice. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: DON or Designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance starting 7/01/25. Monthly QA discussion will occur for 3 months.
Late Administration of Scheduled Medications
Penalty
Summary
Surveyors identified a deficiency in the administration of medications for two residents, as medications were not given within the required time frame according to facility policy and physician orders. During a medication pass observation, a Licensed Vocational Nurse (LVN) administered scheduled 9 AM medications to two residents after the permitted 60-minute window. The LVN confirmed that the delay occurred because they became occupied with another resident, resulting in late administration of all prescribed medications for both individuals. The first resident involved had diagnoses including neuralgia and right knee osteoarthritis, and required varying levels of assistance with daily activities. This resident was prescribed gabapentin, a multivitamin with minerals, and acetaminophen, all of which were administered late during the observed medication pass. The second resident had a medical history of hypertension, dementia, anemia, and encephalopathy, and was prescribed multiple medications including aspirin, ferrous sulfate, carvedilol, lactulose, lisinopril, and Plavix. All of these medications were also administered outside the required time frame. Interviews with facility staff, including another LVN, the Registered Nurse Supervisor, and the Director of Nursing, confirmed that medications are to be administered within one hour before or after the scheduled time, and that deviations from this protocol constitute a medication error. The Director of Nursing further stated that the LVN should have requested assistance if unable to complete the medication pass on time. Review of the facility's policy corroborated that medications must be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: Resident 55 and Resident 84 were reassessed by the DON on 06/11/25 and the DON also called MD for a one-time late med pass order. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON found two residents affected by the same deficient practice. Physician was notified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: 1:1 in-service with LVN 4 on 6/16/2025 with DON and Pharmacy Consultant with importance of timely Medication Pass emphasis to ask for assistance by another licensed nurse and call Physicians for an order to pass medications late to reduce complications. All licensed Nurses are in-serviced on 6/16/25 regarding 60 minutes Pharmaceutical/Facility Policy and Physician orders to include, "Medications must be administered within 60 minutes of scheduled time". Pharmacy Consultant to continue random twice monthly med pass observation / Medication Cart Audit per Regulation and provide DON results. Any discrepancies will be addressed immediately. See Med pass Observation form. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.
Medication Error Rate Exceeds Regulatory Limit Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required by federal regulations. During a survey, it was observed that a Licensed Vocational Nurse (LVN 4) administered medications late to two residents, resulting in eight medication errors out of 25 opportunities, yielding a 32% medication error rate. The late administration occurred because LVN 4 became busy with another resident and did not administer the 9 AM medications within the required one-hour window. Resident 84, who had diagnoses including neuralgia and right knee osteoarthritis, was prescribed gabapentin, a multivitamin with minerals, and acetaminophen, all scheduled for administration at 9 AM. During observation, these medications were given at 10:18 AM, outside the permitted time frame. Resident 55, with a history of hypertension, dementia, anemia, and encephalopathy, was prescribed multiple medications including aspirin, ferrous sulfate, carvedilol, lactulose, lisinopril, and Plavix, also scheduled for 9 AM. These medications were administered at 10:30 AM, again exceeding the one-hour window. Interviews with nursing staff and the Director of Nursing confirmed that medications must be administered within one hour of the scheduled time, and that failure to do so constitutes a medication error. The facility's policy also requires medications to be given in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. The deficiency was attributed to the nurse not seeking assistance when unable to complete medication administration on time.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice; DON Followed as a 1:1 Medication Pass with LVN 4 and gave instruction with return Demonstration. See 6/12/2025 at 6 pm form. 1:1 in-service 6/12/2025 with DON Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; Laminated Medication Pass reminders and given to all Medication Pass Nurses. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; DON will do Competency Medication Pass with LVN 4 every Month times 3 months to ensure efficiency and any discrepancies will be addressed immediately by DON. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.
Failure to Label and Discard Food Items According to Policy
Penalty
Summary
Surveyors observed multiple instances where food items stored in the facility's kitchen refrigerator and freezer were not labeled with required open or use-by dates. Items such as cooked chicken, sliced ham, turkey, ground beef, chicken salad, diced pears, cut honey dew, salsa sauce, peeled garlic, tomato sauce, and margarine were found in the walk-in refrigerator without use-by dates. Additionally, three bags of corn tortillas were found with a use-by date that had already passed. In the freezer, several packages of frozen fish, chicken thighs, chicken strips, mixed vegetables, and peas were missing open or use-by dates, or only had delivery dates. These observations were made during a walkthrough with the Dietary Supervisor, who confirmed that facility policy requires all food removed from original packaging to be labeled with open and use-by dates, and that expired food should be discarded. Interviews with the Dietary Supervisor and the Administrator confirmed the importance of proper food labeling and discarding expired foods to prevent foodborne illness. A review of the facility's policy and procedure on food receiving and storage indicated that all food stored in the refrigerator or freezer must be covered, labeled, and dated with a use-by date. The failure to follow these procedures was directly observed and acknowledged by facility staff during the survey.
Plan Of Correction
Immediate Corrective Action Undated food items were immediately discarded by Kitchen Supervisor 06/09/25. Corrective Actions for Others Affected On 6/09/25, the kitchen supervisor conducted a thorough inspection and all food items were labeled properly and found no other residents affected by the deficient practice. Measures Taken to Prevent Reoccurrence On 7/01/25, the Dietary Supervisor implemented a strict policy requiring all food items to be clearly labeled with a use-by date. Starting 7/01/25, the Dietary Supervisor will conduct regular audits of food inventory to ensure compliance with labeling requirements. Dietician Consultant conducted an in-service on food storage practices on 06/18/25 with all kitchen staff to reiterate the importance of checking use-by dates when restocking the storages; notify all staff the importance of labeling and checking food for spoilages. Beginning 7/01/25, the Dietary Supervisor implemented a log for regularly checking and updating use-by dates. Performance Monitoring to Sustain Solutions 1. Beginning 7/01/25, the Dietary Supervisor will conduct random spot checks weekly to ensure standards are maintained continuously (to be submitted and documented for monthly QAPI meetings) for 3 months. F 812
Failure to Implement Infection Control Protocols for Residents on Enhanced Barrier Precautions and in Laundry Area
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for two residents on Enhanced Barrier Precautions (EBP) and in the facility's laundry area. For one resident with dementia and multiple pressure ulcers, a certified nurse assistant provided care while only wearing gloves and removed her isolation gown before completing all care activities, despite an active EBP order. Interviews with nursing staff confirmed that the EBP protocol required the use of both gown and gloves for all high-contact care activities, and that the gown should not have been removed until care was finished and before leaving the room. For another resident with end stage renal disease and a central venous catheter, there was no EBP signage or PPE cart outside the room, despite an active EBP order. A nurse confirmed that staff should have access to and use appropriate PPE, including gown, gloves, and mask, during direct care for this resident. Facility policy required that EBP signage and PPE be readily available and that staff, residents, and visitors be educated on EBP requirements. In the laundry area, a cart of clean linen was placed in the dirty area next to a sink clogged with dark brown water, and there was no signage to distinguish clean and dirty areas. The housekeeping supervisor and infection preventionist nurse both stated that clean linen should be stored in the clean area to prevent cross-contamination, and that the sink should remain unclogged to prevent the spread of bacteria. Facility policy required that soiled and clean linens not be stored together and that laundry equipment problems be reported and addressed promptly.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/13/25, DSD applied Enhance Barrier Precautions signage and isolation cart to outside of room 119. On 6/13/25, Housekeeping Supervisor placed signs to indicate clean and dirty areas in Laundry Room. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD with DON rounded and found no other resident affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/13/25, CNA 5 was given 1:1 by DSD in-service to render care with Enhanced Barrier Precautions (gown and gloves) to prevent cross contamination of infections. In-service was done by DSD to all licensed Nurses and Certified Nurses Assistants on 06/15/25 that includes to wear gown and gloves when rendering care with Residents who have indwelling catheters, open skin areas, gastronomy tubes, hemodialysis shunt sites, etc., to prevent the spread of infection. DON gave a 1:1 in-service on 06/13/25 with Infection Preventionist regarding prevention and infection control. On 6/13/25, the DON gave the Infection Preventionist an Infection Control Clinical Rounds daily check-off list and will do rounds. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD with DON rounded and found no other resident affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/13/25, CNA 5 was given 1:1 by DSD in-service to render care with Enhanced Barrier Precautions (gown and gloves) to prevent cross contamination of infections. In-service was done by DSD to all licensed Nurses and Certified Nurses Assistants on 06/15/25 that includes to wear gown and gloves when rendering care with Residents who have indwelling catheters, open skin areas, gastronomy tubes, hemodialysis shunt sites, etc., to prevent the spread of infection. DON gave a 1:1 in-service on 06/13/25 with Infection Preventionist regarding prevention and infection control. On 6/13/25, the DON gave the Infection Preventionist an Infection Control Clinical Rounds daily check-off list and will do rounds.
Failure to Provide Required In-Service Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that nurse aides received the required in-service training, specifically dementia management training, as mandated by federal regulations. A review of employee records for two certified nursing assistants (CNAs) revealed that one CNA had not received dementia management training since 2022, and the other since 2024. Additionally, one CNA reported never receiving dementia management training from the facility, only from her school. The Director of Staff Development (DSD) confirmed there was no tracking system in place to ensure CNAs completed at least 12 hours of in-service education per year, nor was there an updated in-service calendar or timely updates to employee files. The DSD acknowledged the lack of upcoming dementia management training and was unable to provide documentation of recent training for CNAs and other staff. The facility's policy and procedure for the DSD role outlined responsibilities for planning, developing, and coordinating the nursing assistant training program, including maintaining appropriate records and ensuring compliance with federal and state guidelines. However, these duties were not fulfilled, resulting in the deficiency related to insufficient in-service training for nurse aides.
Plan Of Correction
Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. DSD rounded on 6/12/25 and found no other resident affected by the deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: Starting 6/12/25, DSD will maintain a calendar of what in-services will be given every month to include Dementia Management. DSD initiated a log on 6/19/2025. Continue Education to oversee CNAs have enough CEUs that include Dementia Management with Competency to ensure residents are properly cared for. DSD on 06/17/25 and 06/19/25 conducted required in-service training with CNAs and Licensed Nurses with emphasis given on Dementia Management that all Nurse Aides to be in-serviced quarterly and for at least 2 hours. Dementia-specific Training as part of facility orientation program. Administrator conducted 1:1 in-service training with the DSD on Dementia on 6/19/2025. Performance Monitoring: Starting 7/01/25, the DON will review the DSD's training calendar to ensure inclusion of Dementia Training and the DON will report in the monthly QAPI meeting for discussion and review. Monthly discussion and review will occur for 3 months. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: DSD will report any deficient practices, review Performance, and report to Administrator and report to QAPI monthly meetings for compliance.
Failure to Promote Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a certified nurse assistant (CNA) assisted a resident with dementia, sacral pressure ulcer, and heel pressure ulcers during mealtime while standing above the resident's eye level. The resident was dependent on staff for all activities of daily living, including eating, and had moderately impaired cognitive skills, requiring cues and supervision. The care plan for the resident specified that staff should assist at mealtime and with all food and fluid offerings. During the observed incident, the CNA stood on the right side of the bed and fed the resident from above, rather than sitting at eye level. This action was confirmed by a licensed vocational nurse (LVN) who verified that the CNA and the resident were not at the same eye level. The CNA explained that she did not sit because she was short and found it difficult to reach the resident from a seated position. Interviews with other nursing staff, including an LVN and a registered nurse (RN), confirmed that staff are expected to maintain eye level with residents during feeding to establish rapport and show respect. A review of the facility's policies indicated that residents should be cared for in a manner that promotes their sense of well-being, self-worth, and dignity, and that staff should not stand over residents while assisting them with meals. The observed practice did not align with these policies, resulting in a failure to promote dignity and respect for the resident during mealtime.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/12/25, Administrator ordered 4 Height Adjustable Stools to provide to Staff to better assist them with providing meals to the residents in a dignified manner. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: On 6/13/25, DON did rounds with DSD and found 9 other residents who are assisted with meals by CNAs, all were observed sitting down at eye level and exchanging rapport and socializing in a dignified manner. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/14/25, DSD in-serviced all CNAs regarding the importance of maintaining resident dignity while providing care. On 6/14/25, the DSD gave a 1:1 in-service to CNA 5 regarding the importance of sitting at eye level for Residents well being and dignity. Performance Monitoring: Starting 7/01/25, the DON or Designee will review check off form and findings will be reported to Administrator during our QAPI Monthly Meeting to ensure compliance is achieved. Monthly QAPI discussion will occur for 3 months. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/14/25, DSD in-serviced all CNAs regarding the importance of maintaining resident dignity while providing care. On 6/14/25, the DSD gave a 1:1 in-service to CNA 5 regarding the importance of sitting at eye level for Residents well being and dignity. Performance Monitoring: Starting 7/01/25, the DON or Designee will review check off form and findings will be reported to Administrator during our QAPI Monthly Meeting to ensure compliance is achieved. Monthly QAPI discussion will occur for 3 months. F 550 Immediate Corrective Action: a. The plastic bag tying resident 33's closet was removed by the Maintenance Supervisor on 6/9/25.
Failure to Discontinue PRN Psychotropic Medication Orders After 14 Days
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic drug use, specifically regarding PRN Lorazepam orders that were not discontinued after 14 days as required by federal regulations and the facility's own policy. For one resident, the Lorazepam PRN order was initiated for anxiety and restlessness, with the order specifying an 'indefinite' stop date. Upon review, the Registered Nurse Supervisor confirmed that the order should have been discontinued after 14 days, but it remained active beyond this period without appropriate physician documentation or review. Another resident had a similar issue, with a PRN Lorazepam order for anxiety that also had an 'indefinite' stop date. The order was not discontinued after 14 days and was only changed months later when the frequency was increased, but the new order again lacked a stop date. The Registered Nurse Supervisor and the Director of Nursing both verified that the PRN Lorazepam order should have been limited to 14 days, and there was no written documentation from the physician to justify extending the order beyond this period. Both residents had significant cognitive impairments and required extensive assistance with activities of daily living. Their medical records indicated diagnoses such as dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder. The facility's policy on psychotropic medication use, revised in February 2025, clearly stated that PRN orders for psychotropic medications are limited to 14 days, yet this policy was not followed in these cases.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: Resident 85 Hospice Physician was alerted and new order placed for Lorazepam 2mg/ml q 4 hrs as needed for anxiety on 6/12/2025 to include a 14 day stop date. See Written Education with Compliance Cue to support 1:1 with DON. Immediate Corrective Action for resident affected by this deficient practice: Resident 86 Lorazepam was discontinued on 2/17/2025. Renewed on 6/24/2025 by Hospice Physician. Give Lorazepam 1 mg q 2 hours PRN x 14 days for anxiety. See Written Education with Compliance Cue to support 1:1 with DON. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: Resident 86 Hospice N/P and Resident 85 Hospice Physician have received a 1:1 in-service by DON on 7/4/2025 regarding Compliance Cue (New Regulation) to provide written documentation extending a PRN psychotropic drug if deemed necessary or need to limit to 14 days. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: DON added new Template Program labeled: Order Listing Report, to monitor PRN Psychotropic drug to include active PRN Psychotropic drug and DON and/or designee will run daily. Included instructions to audit PRN psychotropic drugs. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings to ensure total compliance is achieved. Monthly QA discussion will occur for 3 months. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: DON added new Template Program labeled: Order Listing Report, to monitor PRN Psychotropic drug to include active PRN Psychotropic drug and DON and/or designee will run daily. Included instructions to audit PRN psychotropic drugs. Facility Plan to Monitor Corrective action(s) and Sustain Compliance: Beginning 7/01/25, DON or designee will review performance and report to the Administrator and report to QAPI monthly meetings to ensure total compliance is achieved. Monthly QA discussion will occur for 3 months.
Failure to Follow G-Tube Protocols for Enteral Nutrition
Penalty
Summary
A deficiency was identified when staff failed to follow proper procedures for the care and management of a gastrostomy tube (G-tube) for a resident with significant medical needs, including dysphagia, type 2 diabetes mellitus, and heart failure. The resident was totally dependent on staff for daily care and was receiving nutrition via a feeding tube. Physician orders and the resident's care plan required staff to check tube placement and patency every shift, as well as to check gastric residual volume (GRV) before administering feedings. During an observation, a Licensed Vocational Nurse (LVN) was seen preparing to administer a tube feeding to the resident. The LVN did not disinfect the tip of the G-tube or the extension feeding port prior to connecting the feeding, and also failed to check the GRV or the patency of the tube before starting the feeding. The LVN acknowledged that not performing these checks could result in feeding being administered incorrectly, potentially leading to complications for the resident. Interviews with nursing staff confirmed the importance of disinfecting the G-tube and checking placement and GRV for infection control and to prevent complications. Review of the facility's policy on enteral nutrition also indicated that staff should confirm tube placement and check GRV as part of standard care. The failure to follow these procedures constituted a deficiency in the care and treatment of the resident's G-tube.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/11/25, LVN 4 disinfected the G-Tube tubing tip. DSD checked resident 28 was checked for residual prior to connecting the G-Tube Feeding on 06/11/25. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DSD rounded on 06/11/25 for all other gastric tube residual and found no other resident affected by same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: Starting 7/01/25, LVN 4 will be observed q monthly by Pharmacy Consultant and random medication pass with medication review and cart check twice a month per regulation. On 6/16/25, LVN 4 was given a 1:1 in-service to properly disinfect extension tubing at enteral feeding port also showed proficiency with checking Gastric Volume Residual with DON and Pharmacy Nurse Consultant. Medication Administration Clinical Competency Skills check for all licensed nurses done by DON from 6/19/25 to 7/04/25 and found no other residents affected by same deficient practice. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, the DON will immediately correct any issues reported by Pharmacy Consultant and all findings will be reviewed by Administrator and reported to QAPI monthly meetings for compliance for 3 months. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, the DON will immediately correct any issues reported by Pharmacy Consultant and all findings will be reviewed by Administrator and reported to QAPI monthly meetings for compliance for 3 months.
Failure to Maintain Proper Head of Bed Elevation During Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a history of respiratory failure, COPD, and dementia, who was dependent on staff for all activities of daily living and receiving oxygen therapy, was found with the head of bed positioned almost flat. The resident's medical orders included oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During observation, the resident was noted to be on oxygen with the bed nearly flat, contrary to the facility's policy requiring the head of bed to be elevated to at least 30 degrees when oxygen is applied. Staff interviews confirmed that the resident had been left in this position by a CNA, and a nurse acknowledged the head of bed was only at 15-20 degrees, which was not appropriate for a resident with shortness of breath. The facility's policy and procedure for oxygen therapy specifically stated that the head of bed should be elevated 30 degrees or higher for residents receiving oxygen. The failure to maintain the required bed elevation was directly observed and confirmed by staff, constituting a failure to follow established protocols for respiratory care.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: Resident 34 head of bed was immediately raised to 30 degrees by CN on 6/12/2025. DON and DSD rounded and found two other residents on continuous low dose oxygen with head of bed at 30 degrees or greater without discomfort. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON rounded and found no other residents were affected by deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: All licensed nurses in-serviced on 06/14/25 and 06/15/25 regarding head of bed to be greater than 30 degrees while on oxygen for comfort. Licensed nurses' daily check list and duties as soon as you step in, to include number 4: head of bed greater than 30-45 degrees. DON added to batch order set on electronic health template details to include "While on oxygen, keep head of bed at least 30 degrees or greater." Facility plan to monitor corrective action(s) and sustain compliance: Starting 7/01/25, DON or designee will review performance and report to the administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.
Failure to Accurately Assess and Document Dialysis Access Site
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis was provided appropriate dialysis care and services in accordance with facility policy and physician orders. Specifically, staff did not properly assess the resident's right femoral dialysis access site on multiple occasions, as required. Documentation and assessments were inaccurate, with staff incorrectly recording findings such as bruits and thrills, which are not applicable to a femoral central venous catheter but rather to an arteriovenous fistula. Additionally, the assessment forms indicated the wrong access site location, listing a right thigh access instead of the correct right femoral site. The resident involved had a history of end stage renal disease and a right femoral central venous catheter for dialysis. The care plan and physician orders required regular monitoring of the access site for signs of infection or leakage, as well as pre- and post-dialysis assessments. However, record reviews and staff interviews confirmed that these assessments were not performed accurately or consistently, leading to incomplete and potentially misleading documentation regarding the resident's dialysis access care.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice. DON re-assessed the right femoral hemodialysis site and found the site intact and covered. 06/13/25 Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken. No other residents were affected by the same deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: 1. 1:1 in-serviced to 5 CN for proper placement of Hemo Dialysis catheter. On 05/24/25, 05/25/25, 05/27/25, 05/29/25, 05/31/25, 06/03/25. 2. Medical Records to Audit this form daily and any deficient practices will be brought to DON to adhere to standards of practice. 3. Hemo dialysis Nursing pre and post communication record will also accompany new form "Dialysis Alert" to double down on precise location and description of access to receive proper care. 4. All licensed nurses were in-serviced on 6/13/2025 on accurate dialysis site assessment pre and post hemodialysis. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Beginning 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours on a specific day, as required by federal regulations. Review of the Nursing Staffing Assignment and Sign-In Sheet for that day showed that no RN Supervisor was present for either the morning or evening shifts. The Director of Staff Development confirmed that the RNs scheduled for those shifts did not report to work—one did not show up and the other called in sick. The Director of Nursing was not scheduled and was also not present, and no replacement RN was arranged for either shift. The facility's own Facility Assessment and staffing plan indicated that an RN Supervisor is needed every day of the week. The RN Supervisor job description outlined responsibilities such as supervising nursing staff, handling personnel issues, reporting to the DON or medical staff, and monitoring incident reports. The absence of an RN on the specified day meant that there was no qualified individual to oversee resident care, supervise staff, or respond to clinical needs as required by the facility's policies and federal regulations.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/03/25, DSD reviewed the rest of the R.N. schedule for June 2025 and found 8 hrs consecutively 7 days a week were covered. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: On 7/01/25, DSD reviewed the schedule for June 2025, and no other deficient practice was identified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 7/10/25, an RN Supervisor was hired 7:00am-3:30pm Monday through Friday. Starting 6/02/25, DSD and/or DON will utilize Contracted Agency for RN as needed. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance for 3 months.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 7,482 citations issued within 25 miles in the last 12 months — including the 30 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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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) |
|---|---|---|---|---|
| Hollenbeck Palms | 0.6 mi | ★★★★★ | 23 | 0 |
| White Memorial Medical Ctr Dp | 0.8 mi | ★★★★★ | 0 | 0 |
| Los Angeles Comm Hospital | 2 mi | ★★★★★ | 15 | 1 |
| Kei-ai Los Angeles Healthcare Center | 2 mi | ★★★★★ | 34 | 0 |
| East Los Angeles Doctors Hosp | 2.1 mi | ★★★★★ | 7 | 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.