Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Inglewood Health Care Center during CMS and state inspections, most recent first.
Grievance Process Not Followed: A resident with DM, hemiplegia, and schizoaffective disorder had multiple grievances filed by family regarding medication administration, physician service, and care. The facility did not provide written results or actions taken, grievance reports were left incomplete and unsigned, and the family was not informed of the findings or resolutions.
Failure to care plan COVID-19 vaccine refusal: A resident with DM, hemiplegia, and schizoaffective disorder had family refusal of the COVID vaccine documented, but no comprehensive person-centered care plan was developed or implemented for the refusal. Staff noted follow-up with the resident and family, and the resident later tested positive for COVID during a facility outbreak; the IP stated there was no process in place to monitor the resident's infection risk.
A CNA reported a resident’s change in condition through the Stop and Watch process, noting increased drowsiness, a facial rash, and an open wound, but the LVN charge nurse refused to accept and complete the form, leaving it incomplete. The facility also had inaccurate nursing documentation in the resident’s chart when an LVN recorded two sacral wounds and later edited the note after discharge, contrary to the charting policy for addenda and corrections.
A resident with anemia, COPD, and a left knee contusion was given morning meds without the facility following its required two-identifier process. She was observed without an ID band, her EHR did not have a photo attached, and the LPN said he used a dietary slip and claimed a CNA witnessed the identification, but the CNA denied assisting. The LPN could not state which identifiers were required, and ranolazine 500 mg was administered despite the identification process not being completed as required.
A resident with ESRD, COPD, severe cognitive impairment, and dependence on hemodialysis had physician orders for dialysis three times weekly with a set transportation pick-up and return time. On one treatment day, the resident was not picked up at the scheduled time, and progress notes showed the resident received only a partial dialysis session. The contracted transportation company reported that no transport had been scheduled initially and that they were called later in the morning, leading to a delayed pick-up. The SSD, who managed transportation based on standing dialysis orders, stated she did not track the contracted number of pick-up days or remaining trips, which resulted in the missed scheduled transport and shortened dialysis treatment, contrary to facility policies on transporting residents and providing appropriate hemodialysis care.
Two residents did not receive medications in accordance with professional standards when scheduled doses were repeatedly administered late and one resident’s oral medications were left at the bedside without verification of ingestion. One resident with DM, acute kidney failure, and encephalopathy had multiple 9 a.m. and TID medications, including antihypertensives, antiplatelets, anxiolytics, anticonvulsants, and antipsychotics, documented as late over several days, and a nurse admitted leaving the 9 a.m. medications at the bedside, charting them as given on time even though they were taken hours later. Another resident with toxic encephalopathy, HTN, and a GT had aspirin and a stool softener ordered via GT at 9 a.m., but an LVN was observed administering these medications more than two hours late while acknowledging the delay. Facility policy required medications to be given accurately, safely, and timely, and to verify that medications were actually taken.
A resident with PVD, DM, obesity, and HTN, who was cognitively able to make decisions and required supervision or setup assistance for mobility and ADLs, did not have a discharge care plan developed. An MDS nurse reported she could not locate a discharge care plan and stated that Social Services was responsible for discharge planning. The SSD confirmed that no discharge care plan existed for this resident, despite department responsibility for creating such plans. Facility policy required a comprehensive care plan with goals, measurable objectives, and timetables to address medical, nursing, mental, and psychosocial needs, including potential community discharge, but this was not implemented for this resident.
The facility failed to timely report multiple resident-to-resident abuse incidents to CDPH as required by federal regulations, AFL 24-09, and its Abuse Prevention Program policy. One resident with pneumonia, a cardiac pacemaker, and a right hip fracture, who was cognitively able to communicate, reported being repeatedly hit with a purse and later scratched on the face by another resident, resulting in observable facial wounds. Another resident with schizophrenia, dementia, and hypertension was slapped on the shoulder in a hallway by a resident with vascular dementia, metabolic encephalopathy, and a UTI, who was also documented as hitting residents and staff on several occasions. These events were recorded in SBARs, progress notes, and interviews, but the RN and the administrator acknowledged that the facial scratch incident and all incidents involving the resident with dementia were not reported to CDPH within the required 2-hour or 24-hour timeframes, even though they were reported to the ombudsman and police, leading to delayed state investigation and the risk of further abuse and serious harm.
The facility failed to report an alleged verbal abuse incident to the State agency as required. A resident with morbid obesity, HTN, and intact decision-making capacity had a verbal altercation with the Social Services Director after the director instructed the resident’s family member to wear a mask and told the resident not to worry about an outbreak because the resident was leaving. The resident called the director a derogatory name, the director raised her voice in response, and an RN intervened. The resident later described the director’s behavior as threatening and unprofessional. An RN reported the incident to the ADM, but the ADM did not notify the State agency, despite facility policy and CMS requirements to report all abuse allegations within specified timeframes.
A resident with morbid obesity, HTN, and intact decision-making capacity had a documented verbal altercation with the SSD after the SSD instructed the resident’s family member to wear a mask and declined to disclose details about an outbreak. The resident became upset, yelled at the SSD, and called her a derogatory name; the SSD returned to the room and questioned the resident about the insult. The resident later reported feeling threatened, describing the SSD as yelling, waving her arms, and attempting to re-enter the room. Despite facility policies and federal requirements mandating investigation of all abuse allegations, the ADM acknowledged that no abuse investigation was conducted and that the matter was instead treated as a grievance, with no evidence of a formal investigation or required reporting.
A resident with morbid obesity, hypertension, and intact decision-making capacity became upset after the SSD entered the room to instruct a visiting family member to wear a mask during an Influenza A outbreak and then refused to disclose the type of outbreak, reportedly adding that the resident was leaving anyway. As the SSD exited, the resident called her a derogatory name, and the SSD turned back, re-entered or attempted to re-enter the room, raised her voice, and questioned the resident about the insult, requiring an RN to step between them. The resident later reported feeling threatened and afraid of the SSD, and another resident corroborated that the SSD returned and yelled at the first resident, leading surveyors to find that the SSD failed to meet professional standards of quality in her interaction.
A resident with cerebral infarction, DM, and dementia, who had decision-making capacity, had a documented care plan and widely known preference to refuse ADL care from male CNAs and be assisted only by female CNAs. Despite this, nursing assignments for a night shift placed a male CNA in charge of the resident’s ADL care, contrary to the resident’s expressed wishes and the facility’s dignity policy, which commits to honoring resident choices, preferences, values, and beliefs.
The facility failed to report an influenza A outbreak to the state health department within the required 24-hour timeframe after two residents, both documented as capable of making medical decisions (one cognitively intact and one with moderate cognitive impairment), had positive influenza antigen tests on the same day. The Infection Preventionist acknowledged that, under the county outbreak toolkit, two or more lab-confirmed influenza cases within 72 hours constitute an outbreak that must be reported, and the facility’s Unusual Occurrence Reporting policy and the IP job description required timely reporting of communicable disease outbreaks to appropriate agencies. The Administrator confirmed that the outbreak was not reported within 24 hours, resulting in delayed investigation by the state agency.
A resident with heart failure, stage four CKD, and COPD, who was cognitively intact and self-responsible, tested positive for Influenza A and exhibited fever, vomiting, and cough. An NP gave a verbal order for Tamiflu 75 mg twice daily for five days, but the receiving nurse failed to transcribe the order onto a telephone order form, did not enter it on the MAR, and did not notify the pharmacy, contrary to facility policy. As a result, the Tamiflu order was not reflected in the physician orders or MAR, and the resident missed two doses of the antiviral medication.
A resident with dementia, metabolic encephalopathy, and osteoporosis, who was dependent on staff for ADLs, was kicked in the right shin by a CNA while the CNA was in the room feeding the resident’s roommate. An RN overheard the CNA speaking to the resident, then directly observed the kick, removed the resident from the room, and the resident indicated she had been hit and was in pain. Documentation later that day noted discoloration to the resident’s right leg. This incident occurred despite a facility policy prohibiting abuse, neglect, and exploitation and guaranteeing residents the right to be free from mistreatment.
A resident with dementia, severe cognitive impairment, generalized weakness, and a history of multiple falls was assessed as high risk for elopement and wandering, with care plans calling for a wander guard, bed and wheelchair alarms, visible placement, checking whereabouts, and incremental monitoring. These interventions were described by nursing staff and the DON as vague, were not clearly defined, and were not consistently implemented or documented, including failure to place the resident in a visible area and to carry out incremental monitoring. While the receptionist was on break, an RN briefly assumed responsibility for monitoring the lobby and exit door but left the area to go to the medication room without assigning another staff member, leaving the lobby and exit unsupervised. Shortly thereafter, the wander guard alarm sounded; staff found the resident outside, falling on the sidewalk, with no wheelchair alarm heard, and the resident sustained a closed head injury, intracranial hemorrhage, and fractures of two fingers, which staff and the DON attributed to lack of supervision and failure to follow the fall and wandering care plan.
Failure to Maintain Staff COVID-19 Vaccination Status: The facility did not maintain documentation of COVID-19 vaccination status for 19 employees. During record review, the IPN found a staff vaccination binder showing 19 employees declined the COVID vaccine, but she could not show documentation identifying which staff were vaccinated. The facility policy states the infection preventionist maintains a tracking worksheet of staff vaccination status.
Dirty hallway air filter observed. The facility failed to maintain a safe, clean, and sanitary environment when a hallway air filter was found covered with dust and a gray, fuzzy substance. A resident with acute respiratory failure, another with asthma, a resident with acute respiratory disease, and a resident with heart failure and a pacemaker all stated that clean air and clean filters were important and that dirty filters could worsen breathing or make them sicker. The HS said filters should be changed twice monthly, but the Cleaning Air Purifier Log showed they were changed only monthly.
Laundry handling, chemical storage, air filter, and ice machine sanitation deficiencies: A Laundry Aide was observed letting sheets drag on the floor and then placing the contaminated sheet on top of clean linen, and he could not explain the error. The same aide poured bleach into an unlabeled, uncovered bucket in the laundry room. In addition, a hallway air filter was found covered with dust and gray buildup, and the kitchen ice machine had dusty particulate and a green slimy film, with the cleaning log showing a missed cleaning. Staff stated these conditions could affect resident safety and sanitation.
The facility failed to honor a resident’s request to retrieve his vehicle when staff did not follow up on his request for an OOP escort, and failed to provide dignified, safe mealtime assistance when a CNA was observed standing over another resident while feeding him. The first resident had diagnoses including respiratory failure, OA, and HF, and the second resident had encephalopathy, pneumothorax, UTI, hyperlipidemia, and otalgia. Staff interviews confirmed that the resident’s request for transportation and escort was not resolved and that feeding should be done seated at eye level to support safety, dignity, and infection control.
Failure to Resolve Resident Grievance About Missing Cane: A resident with respiratory failure, OA, and HF reported that his walking cane was left on the gurney/ambulance at admission and told the SSD it was missing, but the issue was not documented or resolved and he was not asked to file a grievance. The SSD acknowledged awareness of the missing cane and said it was important for the resident to have it, while the MDS nurse stated the cane should have been located or replaced immediately.
Inaccurate MDS After Resident Readmission: A resident with COPD, respiratory failure, and HF had an MDS that was not updated after readmission and was not completed within 14 days. The MDS Nurse stated the assessment should have been updated and accurate when the resident returned, and acknowledged the MDS was not accurate.
PASRR Screening Not Completed for Resident With Psychosis: A resident admitted and readmitted with psychosis, hallucinations, disorganized thinking, and fluctuating decision-making capacity had orders for aripiprazole and a care plan for psychosis, but the PASRR screening was not completed upon admission. The MDS nurse stated she was responsible for the PASRR and that it is used to assess needed mental or behavioral services, while the RN supervisor stated it is used to identify needs and guide referral to the appropriate care team.
A resident with contractures, malnutrition, and impaired cognition was observed at breakfast with the tray out of reach and the food and drink containers unopened. The resident stated staff often do this, making it hard to eat, and CNA and RN interviews confirmed the tray should have been set up, positioned, and opened for the resident.
Residents Smoked Without Required Staff Supervision: Two residents who were assessed as needing supervision while smoking were observed smoking without staff present. One resident with acute respiratory failure, lupus, kidney issues, and moderate cognitive impairment was seen smoking alone on the smoking patio, and another resident with acute respiratory failure with hypoxia and a femur fracture was observed smoking alone with loose tobacco in hand. Staff interviews and the smoking policy confirmed that residents who smoke must be supervised to prevent burns and ensure safety.
Unlabeled oxygen tubing for a resident on continuous oxygen therapy. A resident with severe cognitive impairment, no decision-making capacity, and diagnoses including acute respiratory failure with hypoxia was observed on 2 L/min via nasal cannula, but the tubing was not labeled with the date it was last changed. An LVN and RNS stated the tubing should be labeled and changed weekly or as needed, and the facility policy required resident-specific masks and cannulas to be replaced within 7 days.
Pain Monitoring Not Documented for a Resident With Headaches: A resident with dx including headache, encephalopathy, and conversion disorder with motor deficit was on a pain mgmt regimen and had an order for pain monitoring every shift. The eMAR showed the night shift LPN did not monitor or document pain, and the MDS Nurse confirmed the monitoring was not recorded. The resident stated he had headaches and that pain meds did not always work.
Missing HD Emergency Kit at Bedside: A resident receiving HD did not have an emergency HD access kit at the bedside. The resident was alert and oriented, and both an LVN and an RNS confirmed the kit was absent. The facility policy required an Emergency Hemodialysis Access Site Kit for all residents receiving off-site HD, stored in the med cart and at the resident’s bedside.
Medication boxes and a medication bottle in a med cart were found without open-date labels for three residents. An IPN and an LVN stated open-date labeling is needed to track expiration, stability, and efficacy, and the facility P&P did not include a procedure for labeling newly opened meds.
Expired chocolate frosting, flour, and starch were found stored in the kitchen food storage area. A DA stated expired foods could be used in resident meals and could make residents severely sick, and the DS stated expired ingredients must be discarded to prevent staff from using them and to avoid food-borne illness. The facility policy required foods past expiration to be discarded.
Unsecured TV Cable Wire in Resident Room: A wall-mounted TV in a resident room had an uncovered cable wire hanging underneath it. The HS stated the exposed wire should not be exposed because it could be dangerous to residents. Record review showed the facility did not have individual logs for tracking TVs in resident rooms, and a maintenance log noted a complaint about a faulty TV wall cable and sparking lights from a naked area.
A resident with COPD, respiratory failure, and severe cognitive impairment had an oxygen concentrator left on at 2 L with a nasal cannula attached while the resident was not in the room. RN and CNA staff stated oxygen should be turned off when not in use because it is a fire hazard, and the DSD confirmed the protocol was to turn off oxygen when the resident was out of the room; the facility also had no P&P on oxygen safety or staff training on the topic.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with moderately impaired cognition, who preferred independent activities such as watching TV, was unable to watch television in her room due to one TV displaying static and another not being plugged in. Both the resident and her family reported issues with the TV, and staff confirmed the lack of a functioning television, contrary to facility policies supporting person-centered care.
A resident with severe cognitive impairment and a history of refusing care was subjected to a blood draw despite expressing refusal, resulting in pain and bruising. Staff did not follow physician orders or facility protocol to contact the family when the resident refused, and proceeded with the procedure against the resident's wishes.
A resident with moderate cognitive impairment and a history of intracerebral hemorrhage and respiratory failure requested partial dentures, but did not receive follow-up dental services or the requested dentures. Despite documentation of the request and facility policies assigning responsibility to social services for dental referrals and follow-up, no further action was taken after the initial dental evaluation.
A resident with severe cognitive impairment and total dependence on staff for care was not changed in a timely manner after episodes of incontinence, as required by their care plan. Family reported the resident was sometimes left wet for extended periods, and staff interviews confirmed the risks associated with such lapses, including skin breakdown and infection.
A resident with dementia, osteoarthritis, and moderate cognitive impairment experienced ongoing pain that was not adequately addressed, as staff failed to complete a pain management evaluation or administer as-needed pain medication despite repeated reports of pain and existing physician orders. Interviews confirmed that a referral to pain management was not completed, and the facility's policy for pain evaluation and referral was not followed.
A resident who was severely cognitively impaired and fully dependent on staff was found to have no soap dispenser in their bathroom, with an un-labeled cup of liquid left on the sink instead. Staff failed to report or address the missing dispenser, and maintenance was unaware of the issue, resulting in a lapse in infection prevention and control practices as required by facility policy.
A resident with recent digestive system surgery and a Jackson Pratt drain was unable to attend a scheduled follow-up appointment with a surgeon due to the facility's failure to arrange transportation, despite physician orders and internal notifications. Documentation showed no evidence of transportation arrangements, and the responsible staff member could not recall or provide proof of arranging the required service.
A facility failed to implement proper infection control practices during wound care for three residents. An LVN was observed not adhering to hand hygiene protocols, such as washing hands between glove changes and removing PPE before leaving the work area. These actions were contrary to the facility's policies, potentially leading to cross-contamination and infection.
A resident with severe cognitive impairment and a no CPR order had a low blood pressure reading, leading to the withholding of medication. The resident's baseline blood pressure was typically low after dialysis. A nurse admitted she could have rechecked the blood pressure and informed the physician. The DON emphasized the importance of monitoring low blood pressure and informing the physician if it remained low.
A resident with cognitive and physical impairments, identified as high risk for falls, was left unattended with a raised bed during wound care by an LVN and CNA. This action was against the facility's policy, which prioritizes resident safety and supervision to prevent accidents.
The facility failed to conduct annual competency assessments for a RN and four CNAs, as required by their policy. The DSD acknowledged the absence of these assessments, which are crucial for validating staff ability to meet resident health and safety needs. The Administrator emphasized the importance of these assessments for compliance with regulations.
The facility failed to meet the nutritional needs and preferences of its residents. A resident who was a vegetarian was served meals containing meat, and incorrect portion sizes were served to residents on mechanical soft and pureed diets. Staff did not adhere to the facility's policies on food preferences and portion control.
The facility failed to properly store and label food items, with unlabeled frozen water and undated opened food found in the refrigerator. An internal fan with black substances was blowing over uncovered produce, risking cross-contamination. Interviews with the DDS and RD confirmed these issues, which were against the facility's policies for food storage and maintenance.
The facility failed to update its Facility Assessment to reflect the accurate resident census, with a discrepancy between the recorded average daily census and the actual number of residents. The Administrator acknowledged the mismatch and the potential risk of not providing quality care due to incorrect documentation. CMS guidance requires regular updates to the Facility Assessment to ensure accurate evaluation of resident needs.
A facility failed to implement its antibiotic stewardship program by not monitoring a resident's antibiotic use for a UTI. The resident, with a history of UTI, sepsis, and diabetes, was readmitted with a prescription for Bactrim DS. The IPN did not complete the required surveillance form, and no lab specimens were drawn post-hospital discharge, contrary to facility policy. The DON noted this could lead to unnecessary antibiotic use and potential harm.
A resident's family filed a grievance about a CNA's loud and rude behavior, but the CNA continued to be assigned to the resident for three days. The resident, who was fully dependent on staff, experienced a lack of dignity and respect. Despite acknowledgment of the grievance, the intervention to remove the CNA was not implemented.
A resident with severe cognitive impairment was not informed when her missing EBT card was found by the Activities Director, causing prolonged distress. The card, valued at $190, was reported missing by a CNA, but the Activities Director did not notify staff or the resident upon finding it, delaying resolution.
Grievance Process Not Followed
Penalty
Summary
The facility failed to follow its grievance process for one resident by not providing written notification of grievance investigation results and actions taken, not ensuring grievance reports were signed, and not making the reports available to the resident or the resident’s representative. The resident had diagnoses including DM, hemiplegia, and schizoaffective disorder. The H&P dated 9/2/2025 indicated the resident had the capacity to understand or make decisions, and the MDS dated 5/20/2026 indicated cognition was moderately impaired and the resident required partial/moderate assistance with ADLs. During interview, the resident’s family member stated multiple grievances had been filed with facility administration regarding medication administration, physician service, and patient care, but the family was not informed of the findings of the investigations or any actions that would be taken to correct identified problems. Review of three Grievance/Complaint Reports for the resident showed blank fields for documentation of follow-up, resolution, and notification details, and the Grievance QA&A logs for April, May, and June 2026 had blank administrator signature fields and no yes/no response indicating whether grievances were resolved. The Administrator acknowledged the documents were incomplete and that families were not notified of actions taken and resolutions.
Failure to Care Plan COVID-19 Vaccine Refusal
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who refused the COVID-19 vaccine. The resident was initially admitted and later readmitted to the facility and had diagnoses including DM, hemiplegia, and schizoaffective disorder. The resident's H&P dated 9/2/2025 indicated the resident had the capacity to understand and make decisions. A Preventative Health Care note dated 9/4/2025 documented that the resident's family refused the COVID-19 vaccine based on a conscientious objection. A progress note dated 12/4/2025 stated that staff spoke with the resident and family regarding the COVID vaccine and would follow up again when family members came into the facility. Later, the resident tested positive for COVID on 5/18/2026. During review of the resident's plan of care with the Infection Preventionist, there was no care plan developed or implemented for the resident's refusal of the COVID-19 vaccine. The Infection Preventionist stated that a plan of care should have been developed and implemented and that without it there was no process in place to monitor the resident's risk for infection, including during the facility-wide COVID-19 outbreak.
Failure to Respond to Change in Condition Report and Maintain Accurate Documentation
Penalty
Summary
The facility failed to respond to a CNA’s written Stop and Watch report of a change in condition for a resident with diabetes mellitus, hemiplegia, and schizoaffective disorder. The CNA documented that the resident was more drowsy than usual, had a rash on the face, and had an open wound on the bottom, and stated she attempted to give the form to the LVN charge nurse, who refused to take it because it was after 2:00 p.m. The facility’s Stop and Watch form for the resident was left incomplete, with the sections for reported to, nurse’s name, date, and time blank. The DSD stated the form should have been completed by the charge nurse and that refusing to accept or complete it was against policy and could have placed the resident at risk for delayed needed care. The facility also failed to maintain accurate nursing documentation when an LVN entered a progress note stating the resident had two sacral wounds and low O2 saturation with drowsiness, then later edited that note to reflect skin excoriation caused by friction on the sacrum and a scattered small red spot on the face. The LVN stated the documentation was changed after the resident had already been discharged, and the DON stated the charting policy for corrections should be followed to prevent errors and ensure the medical record is accurate. The facility’s charting policy required changes or additions to be made by addendum with the current date and time and a clarification referencing the amended entry.
Failure to Use Required Resident Identifiers Before Medication Administration
Penalty
Summary
The facility failed to follow its Medication Administration General Guidelines policy requiring residents to be identified with at least two identifiers before medications are given. Resident 1 was admitted with anemia, COPD, and a contusion of the left knee. Her MDS indicated she had clear speech, could express ideas and wants, could understand others, and required partial/moderate assistance with toileting hygiene, showering/bathing, and lower body dressing. During observation, Resident 1 was found without an identification band, and she stated she had asked staff for one because she thought she was going to have surgery, but staff did not provide it. During medication administration review, the LVN stated he gave Resident 1 her morning medications and said he verified her identity by the dietary slip and that a CNA witnessed the identification. However, Resident 1's electronic MAR did not have her picture attached, and the LVN could not state what identifiers should be checked to verify identity. The CNA stated she did not assist with verifying Resident 1's identification before the medications were given. The MAR showed the LVN administered ranolazine 500 mg to Resident 1 during the morning shift. The facility's Resident Identification System policy required an identification bracelet and resident picture on the electronic health record, and the Medication Administration General Guidelines policy stated residents are to be identified using at least two resident identifiers, including an identification band, photograph, and/or verification with other nursing care center personnel.
Failure to Arrange Timely Transportation Resulting in Incomplete Dialysis Treatment
Penalty
Summary
The facility failed to ensure timely transportation for a resident with ESRD who required hemodialysis three times weekly, resulting in the resident arriving late and receiving only a partial dialysis treatment. The resident had diagnoses including COPD, ESRD, and dependence on renal dialysis, and had fluctuating capacity to understand and make decisions, with an MDS indicating severely impaired cognitive skills and a need for substantial/maximal assistance with activities of daily living. Physician orders specified dialysis on Tuesdays, Thursdays, and Saturdays with a scheduled transportation pick-up time of 7:15 a.m. and return at 12 p.m., and nursing staff confirmed there had been no changes to these transportation orders. On the date of the incident, progress notes documented that the resident was not picked up at the scheduled standing pick-up time for dialysis and subsequently received an incomplete dialysis cycle of only two and a half hours. The contracted transportation company reported that no transportation had initially been scheduled for that day and that they only received a call from the facility later that morning, resulting in a delayed pick-up at 10 a.m. The transportation company also stated that the resident’s transportation services had been reactivated to start on a later date. The Social Services Director, who was responsible for managing residents’ transportation based on standing dialysis orders provided by licensed nurses, acknowledged that she did not track the contracted number of pick-up days or remaining trips, which led to the resident not being transported on time and receiving only partial dialysis treatment. Facility policies stated that transportation to appointments would be facilitated by Nursing or Social Services and that the facility would provide safe, accurate, appropriate hemodialysis-related care and coordination.
Failure to Administer and Monitor Medications per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in a timely manner and in accordance with physician orders, and that oral medications were not left at the bedside without verification of ingestion. For one resident with type 2 DM, acute kidney failure, and encephalopathy, the admission record showed she had clear speech, could express ideas and wants, and required partial/moderate assistance with toileting, bathing, and personal hygiene. A disciplinary action record dated 4/20/2026 documented that a charge nurse left this resident’s 9 a.m. medications at the bedside without confirming or observing that they were taken; the medications were later found by a family member. The disciplinary notice stated that leaving medications at the bedside threatened the resident’s safety, enabled hoarding of medications, and was viewed as negligence and failure to follow standards of care. Review of this resident’s Medication Administration History for April 2026 showed multiple instances of late administration of scheduled medications. Amlodipine 10 mg scheduled at 9 a.m. was charted late on several dates, as were aspirin 81 mg at 9 a.m., buspirone 5 mg at 9 a.m. and 5 p.m., gabapentin 100 mg three times daily at 9 a.m., 1 p.m., and 5 p.m., and quetiapine 25 mg three times daily at 9 a.m., 1 p.m., and 5 p.m. During an interview, the charge nurse stated that on 4/20/2026 at 9 a.m. he left the resident’s medications at the bedside at her request, documented them as given on time, but acknowledged the medications were actually taken later, between 11 a.m. and 12 noon. He stated that leaving medications at the bedside and failing to administer and observe the resident swallowing them could result in another resident taking the medications, the medications being lost, and adverse reactions. For a second resident with toxic encephalopathy, hypertension, and gastrostomy status, the MDS indicated clear speech with some difficulty communicating but able if prompted, and that the resident required setup or clean-up assistance with toileting, personal hygiene, and eating. The physician order report directed that aspirin 81 mg and docusate sodium 100 mg be administered via GT once daily at 9 a.m., with medications to be crushed as needed. On observation and concurrent interview at the bedside, an LVN was seen administering the resident’s 9 a.m. aspirin and docusate via GT at 11:40 a.m. and stated the medications were late because he was assisting other residents. The Medication Administration History confirmed that on that date both the aspirin and docusate scheduled for 9 a.m. were charted late. The facility’s undated policy on oral medication administration stated that oral medications should be administered in an accurate, safe, and timely manner and that staff should verify that medications were actually taken.
Failure to Develop Discharge Care Plan for A Resident
Penalty
Summary
Surveyors identified a failure to develop a discharge care plan for one of three sampled residents. The resident was admitted with diagnoses including peripheral vascular disease, diabetes mellitus, obesity, and hypertension. A History and Physical dated 7/31/2025 documented that the resident had the capacity to understand and make decisions. A Minimum Data Set (MDS) assessment dated 2/4/2026 showed the resident was able to understand and be understood by others and required supervision or touching assistance for walking, and setup or clean-up assistance for showering/bathing, sit-to-stand, and transfers. Despite these identified needs and the resident’s potential for community discharge, there was no discharge care plan developed for this resident. During an interview and concurrent record review on 4/13/2026, the MDS nurse reported she could not locate a discharge care plan for the resident and stated that Social Services was responsible for creating discharge plans. She explained that care plans serve as a guide for safe resident discharge, including interventions such as education for safe medication administration at home and follow-up with home health and physician appointments, and that they help ensure a continuum of care. In a subsequent interview and record review on 4/14/2026, the Social Services Director confirmed there was no discharge care plan for the resident and acknowledged that the Social Services Department was responsible for creating discharge care plans for all residents. The facility’s undated Comprehensive Plan of Care policy indicated that each resident would have a comprehensive care plan with goals, measurable objectives, and timetables to meet medical, nursing, mental, and psychosocial needs, including potential community discharge, which was not followed in this case.
Failure to Timely Report Resident-to-Resident Abuse Incidents to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to timely report multiple resident-to-resident abuse incidents to the California Department of Public Health (CDPH) as required by federal regulations, state guidance (AFL 24-09), and the facility’s Abuse Prevention Program policy. Surveyors identified that three sampled residents were involved in several abuse incidents that were documented in clinical records but not reported to CDPH within the mandated timeframes. The facility’s own policy stated that administration would report any allegations of abuse within timeframes required by federal requirements, and AFL 24-09 required written notice to the appropriate state agency for incidents resulting in physical harm, but these requirements were not followed. Resident 1, who had diagnoses including pneumonia, presence of a cardiac pacemaker, and a displaced intertrochanteric fracture of the right femur, was cognitively able to express ideas and understand according to the MDS dated 2/17/2026. Record review showed multiple incidents involving Resident 1 and other residents. On 3/14/2026, an SBAR documented that Resident 1 reported being hit by Resident 3 swinging a purse at her. On 3/25/2026, another SBAR indicated Resident 1 was hit by Resident 3, and an interview record documented Resident 1 stating that Resident 3 hit her on the back with a purse while she was in her wheelchair. On 3/31/2026, an SBAR documented that Resident 2 scratched Resident 1’s face while entering or exiting a room, resulting in a wound on the chin measuring 1 x 0.2 (unit not indicated) and an upper lip wound measuring 0.2 (unit not indicated) with minimal blood noted. An interview record and subsequent observation confirmed Resident 1’s report that another resident with long fingernails scratched her face, and a red scratch on the chin was observed. Resident 2, with diagnoses including schizophrenia, unspecified dementia, and hypertension, was also documented as cognitively able to express ideas and understand per the MDS. On 3/10/2026, an SBAR and progress notes documented that Resident 3, in a wheelchair, passed by Resident 2 while she was sitting in a chair in the hallway and slapped her on the right shoulder. On 3/31/2026, an SBAR documented that Resident 2 exhibited aggressive behavior and scratched another resident while exiting the activity room. Resident 3, who had vascular dementia, metabolic encephalopathy, and a UTI, was documented in multiple SBARs as hitting residents and staff on 3/10/2026, swinging a purse at Resident 1 on 3/14/2026, and hitting Resident 1 on 3/25/2026, with staff witnessing at least one of these events. Despite these documented incidents of resident-to-resident physical contact and injury, interviews with the RN and the Administrator confirmed that the incident on 3/31/2026 involving Resident 1’s facial scratch and all of Resident 3’s incidents on 3/10/2026, 3/14/2026, and 3/25/2026 were not reported to CDPH within the required two-hour or 24-hour timeframes. During interviews, RN 1 acknowledged that the 3/31/2026 incident in which Resident 2 scratched Resident 1’s face and caused an injury was not reported to CDPH and stated it should have been reported within two hours. The Administrator stated that the 3/31/2026 incident was reported to the Ombudsman and police but not to CDPH within two hours, and further stated that none of Resident 3’s incidents were reported to CDPH because Resident 3 had dementia and the facility believed AFL 24-09 only required reporting to the Ombudsman and police in such cases. Review of AFL 24-09, however, showed that for incidents resulting in physical harm, facilities are required to notify local law enforcement immediately but not later than two hours and to provide written notice of the incident to the appropriate state agency. Review of the State Operations Manual, Appendix PP, F600 and F609, confirmed that facilities must protect residents from abuse and must ensure that all alleged violations involving abuse are reported immediately, but not later than two hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not result in serious bodily injury, to the administrator and to the State Survey Agency. The facility’s failure to report these incidents to CDPH as required delayed CDPH’s investigation and, as stated in the report, placed residents at risk for further abuse causing humiliation and severe injuries, including hospitalizations.
Failure to Timely Report Alleged Verbal Abuse Incident to State Agency
Penalty
Summary
The facility failed to report to the California Department of Public Health (CDPH) an alleged verbal abuse incident involving the Social Services Director (SSD) and Resident 1, as required by federal and facility policy. Resident 1, who had morbid obesity and hypertension and was assessed as having decision-making capacity and the ability to understand and be understood, was partially dependent on staff for various ADLs. On 2/3/2026, Resident 1’s family member entered the facility without a facemask and went into Resident 1’s room. The SSD saw the family member and requested that a mask be worn. When Resident 1 asked the SSD what the outbreak was, the SSD responded that Resident 1 should not worry because she was leaving the facility. Resident 1 did not like this response and called the SSD a “bitch” as the SSD was stepping out of the room. The SSD then raised her voice and asked Resident 1 why she had to be called that name, and RN 1 intervened by getting between them to calm the situation. Following the incident, Resident 1 reported that the SSD’s behavior was threatening and unprofessional and that the SSD should not be in her room. RN 2 stated she reported the 2/3/2026 verbal altercation to the Administrator (ADM) but did not know if the ADM reported it to CDPH. The ADM later stated that no one, including Resident 1, reported feelings of fear or threat or said they were scared for their life, and that if there had been such a report, she would have reported the incident to CDPH. Facility policies on abuse prevention and prohibition required reporting all abuse allegations to the State agency within required timeframes, and CMS Appendix PP required that all alleged violations involving abuse or mistreatment be reported to the State Survey Agency immediately, but not later than 2 hours after the allegation, with investigation results reported within 5 working days. Despite these requirements, the allegation that the SSD’s behavior was threatening and unprofessional toward Resident 1 was not reported to CDPH, resulting in a failure to timely report suspected abuse and the results of the investigation to the proper authorities.
Failure to Investigate Alleged Verbal Altercation Between SSD and Resident
Penalty
Summary
The deficiency involves the facility’s failure to investigate an alleged verbal altercation between the Social Services Director (SSD) and a resident, as required by the facility’s abuse investigation and reporting policies and federal regulations. The resident was admitted with diagnoses including morbid obesity and hypertension and had documented capacity to understand and make decisions. An MDS assessment showed the resident was cognitively able to understand and be understood, required varying levels of assistance with ADLs, and was dependent for some transfers and ambulation distances. On the date of the incident, a progress note documented that the SSD asked the resident’s family member to put on a face mask upon entering the resident’s room. The resident asked if there was an outbreak, and the SSD responded that she could not disclose other residents’ information. The note indicated the resident became very upset and started yelling at the SSD for not disclosing the information. As the SSD exited the room, she overheard the resident call her a “bitch,” then returned to the room and asked the resident why she had used that term. There was no documentation in the clinical record that any investigation was initiated or conducted regarding this verbal altercation. In subsequent interviews, the resident reported being afraid of the SSD and described the SSD as trying to fight with her at the beginning of the month when the incident occurred. The resident stated the SSD told her not to worry about the outbreak because she was going to leave anyway and that the SSD should not have entered her room due to multiple prior incidents. The resident further stated that during the altercation the SSD was waving her arms, yelling, asking why she was called a “bitch,” and attempting to re-enter the room, which made the resident feel threatened. The Administrator acknowledged that no investigation was conducted into the incident and stated it had been handled as a grievance instead. Facility policies on abuse prevention and prohibition require investigation of any allegations of abuse, and federal guidance in Appendix PP requires that all alleged violations be thoroughly investigated and reported to the State Survey Agency within five working days, which did not occur in this case.
Unprofessional Social Services Interaction During Outbreak Masking Dispute
Penalty
Summary
The deficiency involves the facility’s failure to ensure the Social Services Director (SSD) acted in accordance with professional standards when interacting with a resident during an infectious disease outbreak. Resident 1, who had morbid obesity and hypertension and was assessed as having decision-making capacity and the ability to understand and be understood, required varying levels of assistance with ADLs but was cognitively able to communicate needs and preferences. On the date of the incident, the SSD entered Resident 1’s room after a family member (FM1) entered without a mask during an Influenza A outbreak, and the SSD instructed FM1 to wear a mask. According to progress notes and interviews, when Resident 1 asked the SSD what type of outbreak was occurring, the SSD responded that she could not disclose that information, and per Resident 1 and RN 1, also stated that Resident 1 should not worry because she was going to leave the facility. Resident 1 became upset and, as the SSD was exiting the room, called the SSD a “bitch.” The SSD then turned back, re-entered or attempted to re-enter the room, raised her voice, and questioned Resident 1 about why she had called her that name. RN 1 reported stepping between the SSD and Resident 1 to calm the situation, and Resident 1 later stated she felt threatened by the SSD’s behavior, describing the SSD as waving her arms, yelling, and seeming like she wanted to fight. Resident 1 reported being afraid of the SSD and stated that the SSD was not supposed to enter her room due to prior unspecified incidents and that the SSD’s behavior was unprofessional and disrespectful toward someone who was bedridden. Resident 2 corroborated that Resident 1 had called the SSD a “bitch” as the SSD was leaving and that the SSD then walked back and yelled at Resident 1, asking why she had to be called that. In her own interview, the SSD acknowledged returning to the room after hearing the insult, asking Resident 1 why she had to be called a “bitch,” and later stated she probably should not have gone back into the room and should have allowed RN 1 to deescalate the situation. The surveyors concluded that the SSD’s conduct did not meet professional standards of quality and had the potential to affect Resident 1’s psychosocial well-being, leading to emotional harm.
Failure to Honor Resident Preference for Female CNA During ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly documented preference not to receive ADL care from male CNAs. The resident, who had diagnoses including cerebral infarction, DM, and dementia, was determined in a recent H&P to have the capacity to understand and make decisions. Her care plan, titled “Resident Refuses Male CNA Care,” specified that she would receive required care while maintaining dignity, comfort, and emotional well-being, and directed staff to assign a female CNA for personal care, document refusals of care, and respect her preference for female CNAs. The resident’s MDS showed she required varying levels of assistance with personal hygiene, dressing, bathing, toileting hygiene, footwear, oral hygiene, and eating, indicating she depended on staff for multiple ADLs. Despite this, review of the nursing assignment sheet for a specific night shift showed that a male CNA was assigned to provide ADL care to this resident. Staff interviews confirmed that the resident’s preference to refuse care from male CNAs was widely known among facility staff. The DON acknowledged that the resident’s preference for female CNA care was in the care plan and stated that this preference should have been honored, regardless of staffing changes due to multiple staff calling out sick. The facility’s undated “Quality of Life – Dignity” policy stated that residents will always be treated with dignity and respect and that the facility is committed to honoring resident choices, preferences, values, and beliefs throughout their stay. The assignment of a male CNA in contradiction to the resident’s expressed and care-planned preference constituted the cited deficiency and was noted as having the potential to affect the resident’s psychosocial well-being.
Failure to Timely Report Influenza Outbreak to State Health Department
Penalty
Summary
The facility failed to report an influenza A outbreak to the California Department of Public Health (CDPH) within 24 hours as required by its Unusual Occurrence Reporting policy and the Los Angeles County Department of Public Health (LAC DPH) Influenza and other Respiratory Virus Diseases Outbreak Toolkit. Resident 1, who had diagnoses including heart failure, stage four chronic kidney disease, and COPD, was cognitively intact, self-responsible, and had capacity to make medical decisions per the admission record, history and physical, and MDS. Resident 1 had a positive influenza antigen test result documented on 2/2/2026 at 12:00 p.m. Resident 8, with diagnoses including diabetes mellitus, hypertensive heart disease, and pleural effusion, was documented as capable of understanding and making decisions, with the MDS indicating moderate cognitive impairment, and also had a positive influenza antigen test result on 2/2/2026 at 12:00 p.m. During interview and record review with the Infection Preventionist (IP), it was confirmed that the LAC DPH toolkit defined an outbreak as two or more laboratory-confirmed influenza cases identified within 72 hours of each other and required such outbreaks, as well as sudden increases in acute respiratory illness cases, to be reported. The facility’s Unusual Occurrence Reporting policy required epidemic outbreaks or prevalence of communicable disease to be reported via telephone to appropriate agencies within 24 hours, and the IP job description required reporting all reportable diseases to the state health department. Despite having two confirmed influenza cases that met the outbreak definition on 2/2/2026, the facility did not report the outbreak to CDPH within 24 hours, as acknowledged by both the IP and the Administrator, resulting in delayed investigation by CDPH.
Failure to Transcribe and Implement Verbal Tamiflu Order for Influenza-Positive Resident
Penalty
Summary
The facility failed to ensure that a nurse practitioner’s verbal order for Tamiflu was properly processed and implemented for a resident who tested positive for influenza. The resident, who had diagnoses including heart failure, stage four chronic kidney disease, and COPD, was cognitively intact and self-responsible, with documented capacity to make medical decisions. On 2/2/2026 around noon, the resident’s influenza antigen test was positive for Influenza A, and an SBAR documented fever of 103°F, vomiting, and coughing. The infection preventionist reported that the nurse practitioner was notified of the positive test and verbally ordered Tamiflu 75 mg twice daily for five days to treat the influenza. However, the infection preventionist stated she forgot to carry out the order and did not notify the pharmacy. Review of the resident’s physician orders and MAR for February 2026 showed no entry for Tamiflu, and nursing staff confirmed that there was no Tamiflu order documented. The nurse practitioner later confirmed that Tamiflu 75 mg had been ordered to treat Influenza A and that he was not notified that the resident did not receive the medication. The facility’s policy titled “Physician Orders” required that when receiving a telephone or verbal order, the licensed nurse must repeat the order to clarify, transcribe all components onto a telephone order form with time, date, and signature, transcribe the order onto the MAR, and notify the pharmacy of the new order. These required steps were not completed, resulting in the resident missing two doses of Tamiflu on the evening of 2/2/2026 and the morning of 2/3/2026.
Resident Kicked by CNA Resulting in Pain and Leg Discoloration
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA kicked the resident’s right shin while providing care. The resident, who had diagnoses including metabolic encephalopathy, osteoporosis, and dementia, had been assessed as lacking capacity to make decisions and having severely impaired cognitive skills for daily decision-making. The resident was dependent on staff for ADLs such as toileting and showering and required partial assistance for eating, oral hygiene, dressing, and positioning. While the CNA was in the room feeding the resident’s roommate, an RN overheard the CNA speaking to the resident and then directly observed the CNA kick the resident’s right leg. Following the observed kick, the RN immediately removed the resident from the room and the resident pointed to the right leg and stated she had been hit and was in pain. An SBAR form documented that the RN supervisor witnessed the CNA kick the resident and that the resident reported pain. A Resident Data Collection form completed later the same day documented discoloration to the resident’s right leg. The facility’s abuse, neglect, and exploitation prohibition policy stated that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property, but the observed conduct of the CNA and resulting pain and purplish discoloration to the resident’s right shin demonstrated that this policy was not followed in this instance.
Failure to Supervise High-Risk Wanderer Resulting in Elopement and Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and monitoring for a resident assessed as high risk for elopement and falls. The resident had dementia, Alzheimer’s disease, generalized muscle weakness, severe cognitive impairment, and a documented history of multiple prior falls. Assessments and care plans identified the resident as at risk for elopement and wandering without purpose, with exit-seeking and searching behaviors, and at high risk for falls due to poor decision making, incontinence, gait/balance problems, multiple medications, and multiple medical conditions. The care plans included interventions such as allowing safe movement in hallways, gently redirecting the resident back to supervised areas, checking the resident’s whereabouts, using a wander guard bracelet with function and placement checks every shift, providing bed and wheelchair alarms, placing the resident in visible areas after activities, providing individualized activities, encouraging the resident to ask for help, and implementing incremental monitoring for safety. Despite these identified risks and planned interventions, staff did not consistently implement or clearly define the required monitoring and supervision. The fall care plan intervention to “check resident’s whereabouts” and to provide “incremental monitoring” was described by nursing staff and the DON as vague and unclear, and there was no documentation or proof that incremental monitoring was carried out. The DON stated that the intervention for incremental monitoring was not documented and that a written log was not in place to verify implementation. The DON also acknowledged that the fall care plan intervention to place the resident in a visible area was not implemented. The RN and DON both indicated that the resident’s fall care plan interventions to prevent falls and injuries were not followed because the resident was outside the facility and unsupervised at the time of the incident. On the day of the event, the resident, who required supervision/touching assistance for transfers and ambulation and 24-hour staff assistance with mobility and daily care tasks, was able to move independently in a wheelchair around the unit. The receptionist asked an RN to observe the front door and lobby to ensure resident safety and prevent residents from leaving while the receptionist went on break. The RN reported that she did not see any residents in the lobby and left the lobby area to go to the medication room, from which the lobby and exit door could not be viewed. She did not assign another staff member to supervise the lobby and exit door. Shortly after entering the medication room, the RN heard the wander guard alarm activate at the front door. When she responded, she did not see any residents in the lobby or near the door, then ran outside and observed the resident falling on the sidewalk. Staff reported that they did not hear the resident’s wheelchair alarm prior to the fall, and the DON confirmed that the lobby and exit door were unsupervised when the wander guard alarm sounded. The resident sustained a closed head injury, left frontal scalp hematoma, intracranial hemorrhage, and fractures of the left hand fourth and fifth fingers as a result of the unwitnessed fall outside the facility after eloping without staff knowledge or supervision. Interviews with multiple staff members corroborated that the resident was not to leave the building without staff supervision and assistance, that the resident had unsteady gait and weakness, and that alarms such as wander guard and wheelchair alarms were in use but did not replace the need for active staff supervision. The Administrator acknowledged that a system-wide approach to prevent elopements and falls required active supervision of the lobby and exit door whenever the automatic-opening exit was unlocked. The facility’s own policies on Safety Supervision of Residents, Comprehensive Care Plan, and Fall Management required identification of individual risks, implementation of targeted interventions including adequate supervision, consistent implementation and evaluation of interventions, and updating care plans when falls recurred. However, the DON stated that these interventions were not correctly and consistently implemented for this resident, and that the resident’s fall and injuries were a major accident caused by lack of staff supervision and assistance when the resident exited the facility unsupervised.
Failure to Maintain Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to maintain the COVID-19 vaccination status for 19 employees. During a concurrent interview and record review, the Infection Prevention Nurse reviewed a binder titled Staff Vaccination 2025, which showed that 19 employees declined to receive a COVID vaccine. The Infection Prevention Nurse stated she could not show documentation of which staff were vaccinated and said she is supposed to offer the vaccine to all staff. She also stated it is important to know who is or is not vaccinated in the event of an outbreak, and that it would be easier to track where the outbreak may have started if unvaccinated staff were identified. Review of the facility policy titled COVID-19 Vaccination-Staff indicated the infection preventionist maintains a tracking worksheet of staff members and their vaccination status.
Dirty hallway air filter observed
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment when an air filter in the hallway was observed to be full of dust and a gray, fuzzy substance. The deficient practice was identified for four sampled residents: Resident 13, Resident 33, Resident 67, and Resident 99. The report states the condition had the potential to expose residents to an unclean environment and negatively impact comfort, safety, and quality of life. Resident 13 was admitted with diagnoses including acute respiratory failure with hypoxia, shortness of breath, heart failure, and sepsis. Records showed the resident was alert, cooperative, had normal affect and speech, and later MDS data indicated intact cognition. During observation and interview, Resident 13 pointed out the filthy air filter and stated it was full of dust. In a later interview, the resident said the hallway air quality was not good, that there could be different air pathogens in the air, and that the resident kept the door closed and asked staff to wear masks because of multiple prior lung problems. Resident 33 was admitted with asthma, acute respiratory failure with hypoxia, shortness of breath, and obesity, and records showed the resident was alert, oriented, and able to make own decisions, with later MDS data indicating intact cognition. Resident 67 was admitted with acute respiratory disease, hypertension, and acute kidney failure, and records showed the resident was alert, oriented, and able to make own decisions, with later MDS data indicating intact cognition. Resident 99 was admitted with heart failure, a pacemaker, and syncope, and records showed the resident was alert and oriented with fluctuating capacity to understand and make decisions, with later MDS data indicating intact cognition. During interviews, each resident stated that clean air filters and clean air were important and that dirty filters could worsen breathing or make them sicker. The Housekeeping Supervisor stated residents had the right to breathe clean air and have clean air filters, that filters needed to be changed twice monthly, and that the facility's Cleaning Air Purifier Log showed the filter was changed only once a month. Facility policies stated that items that collect dust or secretions may harbor microorganisms and that residents are to be provided a safe, clean, comfortable, and homelike environment.
Laundry handling, chemical storage, air filter, and ice machine sanitation deficiencies
Penalty
Summary
The facility failed to ensure linen was folded using proper technique to prevent recontamination. During observation in the laundry room, the Laundry Aide was seen folding sheets and allowing them to drag on the floor during folding, then placing the dirty sheet on top of the clean pile of linen after the surveyor pointed out the action. The Laundry Aide could not explain what was wrong or why it was harmful. The Housekeeping Supervisor stated laundry should not touch the floor while being folded because it contaminates the laundry and residents who come in contact with it can get sick. The facility policy on Laundry Handling Practices stated proper handling of linen reduces the likelihood of recontamination. The facility also failed to ensure a chemical was not poured into a new unlabeled, uncovered container in the laundry room. During observation, an uncovered white plastic bucket containing a yellowish liquid was seen on the floor in front of the washer, and the bucket was not labeled. The Laundry Aide stated the liquid was bleach and that he had poured it from the original container into the white plastic bucket. He could not explain why this practice was not safe. The Housekeeping Supervisor stated staff should never pour chemicals from one container into a new container because someone else would not know what it is. The MSDS for bleach indicated it should be stored in a closed container, and the Laundry Aide job description stated he was to take appropriate actions to secure laundry chemicals. The facility further failed to maintain a hallway air purifier filter and the kitchen ice machine in a clean condition. The air filter in the hallway was observed to have dust and fuzzy, gray buildup accumulation. The Infection Preventionist Nurse stated the dirty air filter could cause lung infections and other respiratory diseases such as pneumonia, COVID-19, flu, and asthma, potentially leading to hospitalizations. The ice machine lid had brown, gray dusty particulate and the top of the ice chest had a green slimy film, and the monthly cleaning log showed the ice machine was not cleaned on 11/6/2025. The Dietary Aid and Dietary Supervisor stated the ice machine needed to be cleaned to prevent bacterial buildup and to provide safe consumable ice for residents. The facility policy for cleaning and maintaining ice machines stated the ice storage compartment should be emptied and disinfected prior to quarterly maintenance.
Failure to Honor Resident Requests and Provide Safe Mealtime Assistance
Penalty
Summary
The facility failed to ensure Resident 98 was provided goods and services related to his request to retrieve his vehicle. Resident 98 was admitted with diagnoses including respiratory failure, osteoarthritis, and heart failure. His H&P stated he had the capacity to understand and make decisions, while the MDS indicated moderately impaired cognition and that he required partial/moderate assistance with several activities of daily living. Progress notes documented that he requested to go out on pass to retrieve his vehicle from the hospital parking lot, and during interview he stated the social worker had not followed up with him about retrieving it. The Social Services Director stated she was aware Resident 98 needed to go out on pass and needed an escort to leave the facility to run errands, but she had no documentation regarding his concerns and did not check or follow up with him to see whether he went out on pass. She stated that not following up could make him feel upset. A Registered Nurse also stated that when Resident 98 expressed he wanted to go out on pass, the facility could provide transportation with an escort, and that social services were to work with him no later than the following day to check whether the issue was resolved. The facility also failed to ensure Resident 78 was assisted with eating in a manner that supported dignity and safety. Resident 78 was admitted and readmitted with diagnoses including encephalopathy, pneumothorax, UTI, hyperlipidemia, and otalgia. His H&P stated he had the capacity to understand and make decisions, and the MDS indicated intact cognition and dependent assistance with eating and several other ADLs. During observation, a CNA was seen standing over Resident 78 while feeding him lunch. Staff interviews stated that sitting down while feeding a resident was important to ensure safety, prevent choking, avoid cross contamination, and engage the resident so he or she would not feel rushed. The facility policy on resident dining also addressed resident rights during meal service and training on proper food handling, infection control, and responding to choking or aspiration events.
Failure to Resolve Resident Grievance About Missing Cane
Penalty
Summary
The facility failed to ensure that one of five sampled residents, Resident 98, had his grievance about a missing walking cane promptly resolved. Resident 98 was admitted with diagnoses including respiratory failure, osteoarthritis, and heart failure. His H&P stated he had the capacity to understand and make decisions, while the MDS indicated moderately impaired cognition and that he required partial/moderate assistance with toileting hygiene, showering, and dressing, but could walk 50 feet and make two turns. Resident 98 stated his walking cane was left on the gurney when he was admitted and that he notified the SSD that it was missing, but he was not asked to file a grievance and the cane was not recovered. During interview, the SSD stated she was aware the cane had been left in the ambulance and that it was important for Resident 98 to have it because it was his preference, but she had not documented the issue in progress notes and Resident 98 had not filed a grievance. The SSD stated this could make the resident feel that staff did not care about his situation. The MDS Nurse stated missing items should be reported to social services, the resident can file a grievance, and Resident 98's cane should have been located or replaced immediately. The facility policy stated it was to support each resident's right to voice grievances and actively resolve the issue and communicate a resolution.
Inaccurate MDS After Resident Readmission
Penalty
Summary
The facility failed to ensure that Resident 10’s MDS was completed accurately. Resident 10 was admitted to the facility, later readmitted, and had diagnoses including COPD, respiratory failure, and heart failure. The H&P dated 7/4/2025 stated that Resident 10 could not make medical decisions but was able to make needs known. In contrast, the MDS dated [DATE] indicated that Resident 10 had the ability to understand others and required partial/moderate assistance from staff for toileting hygiene, showering, and dressing, and also required respiratory treatment with oxygen therapy. The record also showed that Resident 10 returned to the facility from the hospital on [DATE], and a later MDS indicated Resident 10 was readmitted to the facility on [DATE]. During a concurrent interview and record review on 12/4/2025 at 2:14 p.m., the MDS Nurse stated that Resident 10 was re-admitted on [DATE] and that the MDS was not updated and completed within 14 days after the readmission. The MDS Nurse stated the MDS should be updated and accurate when Resident 10 returned to the facility, and acknowledged that the MDS was not accurate and had the potential for Resident 10 to not receive proper care and have needs not met.
PASRR Screening Not Completed for Resident With Psychosis
Penalty
Summary
The facility failed to ensure a PASRR screening was completed for one resident upon admission and readmission. The resident’s face sheet showed admission on 8/13/2025 and readmission on [DATE] with diagnoses of psychosis due to substance or known physiological condition. The resident’s MDS dated 8/19/2025 indicated use of antipsychotic medication, and the H&P dated 9/12/2025 noted fluctuating capacity to understand and make decisions. Physician orders documented aripiprazole 5 mg daily for psychosis manifested by visual hallucinations and disorganized thinking, with orders entered on 8/13/2025, 9/17/2025, and 10/5/2025. The care plan also addressed mental illness/psychosis and included interventions for administering aripiprazole and monitoring for side effects. During interview and record review, the MDS nurse stated the PASRR was not completed upon admission and that she was responsible for completing and following up the screening. She stated PASRR is used to assess a resident for mental or behavioral services needed during the stay and that failure to complete it upon admission may prevent the resident from receiving needed mental or behavioral treatment and services. The RN supervisor stated the MDS was responsible for conducting PASRR on admission to identify needs based on admission diagnoses so the resident could be referred to a care team to better manage the mental or behavioral condition. The facility policy stated designated staff review the PASSR from the acute hospital and determine whether follow-up is required, and that Level I screening is submitted online by the hospital or facility if not admitted from the acute hospital.
Meal Tray Not Set Up for Resident With Contractures
Penalty
Summary
The facility failed to ensure Resident 4’s breakfast tray was properly set up so the food and drink containers were opened and within reach for the resident to eat. Resident 4’s record showed diagnoses including contractures, protein-calorie malnutrition, and adult failure to thrive. The H&P stated the resident lacked capacity to make medical decisions due to a CVA, and the MDS indicated moderately impaired cognition and dependence on staff for several activities, with supervision/touching assistance needed while eating once the meal was placed before the resident. During an observation in the resident’s room, the breakfast tray was not positioned for Resident 4 to reach and the food items were not opened. Resident 4 had right hand contracture and difficulty opening food items, and stated staff do this all the time, that sometimes he does not eat because it is too hard to open the containers, and that staff then takes the food away. CNA 1 stated she was supposed to set up the tray, position the resident upright, and open the food items. RN 3 stated the protocol was for food items to be opened and within reach of the resident. The facility policy on assisting the resident to eat stated to remove food covers and prepare and arrange the food for the resident.
Residents Smoked Without Required Staff Supervision
Penalty
Summary
The facility failed to ensure that residents who were identified as needing supervision while smoking were supervised by staff. During observation, Resident 52 was seen smoking on the smoking patio without staff present, and Resident 52 stated staff were supposed to be present when residents were outside smoking. Resident 52's records showed admission on 9/26/2025 with diagnoses including acute respiratory failure, systemic lupus erythematosus, obstructive and reflux uropathy, acute kidney failure, and benign prostatic hyperplasia. The H&P dated 9/27/2025 indicated Resident 52 had the capacity to understand and make decisions, while the MDS dated 10/27/2025 showed moderate cognitive impairment and need for supervision or touching assistance with multiple activities of daily living. Resident 52's Safe Smoking Assessment indicated the resident was a safe smoker and needed supervision while smoking. Staff interviews confirmed that residents who smoke must be supervised to ensure safety and prevent burns. The Activities Assistant, MDS Nurse, Activities Director, and RN Supervisor all stated that residents must be accompanied or supervised while smoking, and that lack of supervision could result in burns to the resident or others. The facility's smoking program schedule identified staff assigned for supervision during smoking times, and the smoking policy stated residents may only smoke under supervision until the smoking assessment is complete. Resident 18 was also observed smoking without supervision. During observation, Resident 18 was seated alone in a wheelchair outside the designated smoking patio with loose tobacco at hand, and stated he had been smoking without supervision and keeping tobacco in his room for about 2 to 3 months. Resident 18's records showed admission on 11/7/2024 with diagnoses including acute respiratory failure with hypoxia and left femur fracture. The H&P dated 11/8/2024 indicated the resident was alert, oriented, and able to make own decisions, and the MDS dated 11/16/2025 showed intact cognitive function. The Safe Smoking Assessment/Evaluation dated 11/24/2025 indicated the IDT determined Resident 18 needed supervision while smoking.
Unlabeled oxygen tubing for a resident on continuous oxygen therapy
Penalty
Summary
The facility failed to ensure that Resident 8’s oxygen tubing was labeled with the date it was last changed. Resident 8 was admitted on 9/22/2025 and later readmitted with diagnoses including metabolic encephalopathy, anemia, and acute respiratory failure with hypoxia. The resident’s H&P dated 10/28/2025 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 11/3/2025 indicated severe cognitive impairment, dependence for multiple activities of daily living, and the need for continuous oxygen therapy. During an observation on 12/2/2025 at 10:06 a.m., Resident 8 was in bed awake and on 2 L/min of oxygen via nasal cannula, and the nasal cannula was not labeled with the date it was last changed. During a concurrent observation and interview, the LVN stated the tubing should have been labeled and that oxygen tubing, along with the set-up bag and pre-filled humidifier, were changed weekly or as needed. The LVN and the RNS stated the label was needed to identify when the nasal cannula was last changed, and the facility policy titled Cleaning Respiratory Equipment stated masks and cannulas used by an individual resident were to be replaced within 7 days and when obviously contaminated.
Pain Monitoring Not Documented for Resident With Headaches
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met for one of five sampled residents, Resident 57. Resident 57’s record showed diagnoses of conversion disorder with motor deficit, headache, and encephalopathy. The H&P dated 5/27/2025 indicated Resident 57 did not have the capacity to understand and make decisions. The MDS dated 11/1/2025 indicated moderately impaired cognition, required set-up or clean-up assistance for oral hygiene, toileting hygiene, and showering, and was on a pain management regimen. The physician order report dated 2/20/2024 directed staff to monitor pain every shift, but the eMAR dated 11/19/2025 showed the night shift licensed nurse did not monitor Resident 57’s pain. During interview, Resident 57 stated he had headaches and received pain medication, but it did not always work and he still had a headache afterward. In a concurrent interview and record review, the MDS Nurse confirmed the pain monitoring was not recorded during the night shift and stated, “If it’s not documented then it was not done.” The facility’s Pain Management policy stated staff were to identify residents experiencing pain and monitor and document the resident’s response to pain management interventions.
Missing HD Emergency Kit at Bedside
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for one resident who required hemodialysis. Resident 108 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, dependence on renal dialysis, and myocardial infarction. The resident’s history and physical indicated she had the capacity to understand and make decisions. During a concurrent observation and interview in the resident’s room, there was no hemodialysis emergency kit at the bedside, and the resident stated she did not recall any emergency kits being placed there. During the same observation, an LVN and an RNS both confirmed that no HD emergency kit was at the resident’s bedside. The LVN stated the kit was important for emergency situations related to hemodialysis access malfunction, including excessive bleeding at the access site, and stated that without it the resident could bleed out. The RNS stated the kit should be readily available for emergencies related to the hemodialysis access site and stated that without it the resident could bleed excessively, placing the resident at risk for harm or even death. The facility policy stated that an Emergency Hemodialysis Access Site Kit must be maintained for all residents receiving off-site hemodialysis treatment and stored in medication carts and at the resident’s bedside.
Unlabeled Open Medications in Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles because three sampled residents had medications in medication cart 3 without an opened date label. During a concurrent observation and interview on 12/3/2025 at 3:20 p.m. with the Infection Preventions Nurse, medication cart 3 in station 2 contained Lidocaine Patch and Albuterol Sulfate Inhalation for Resident 48 and Lovenox injections for Resident 111, all without opened date labels. During a concurrent observation and interview on 12/4/2025 at 12:25 p.m. with LVN 3, medication cart 3 in station 2 contained a Levetiracetam bottle for Resident 7 without an opened date label. The IPN stated it was important to have open date labels to know when medications expire, and LVN 3 stated opened medications must be labeled with the open date to track expiration, stability, and efficacy. Review of the facility policy and procedure titled Medication Storage, Storage of Medication, undated, did not indicate procedures for placing open date labels on newly opened medications.
Expired Ingredients Found in Kitchen Storage
Penalty
Summary
The facility failed to ensure chocolate frosting, flour, and starch stored in the kitchen were not expired. During an observation in the kitchen food storage room, chocolate frosting in a plastic tub was observed with an expiration date of 11/19/2025, and starch and flour stored in grey circular bins with lids each had expiration dates of 11/24/2025. During interview, a Dietary Aid stated the expired foods should be thrown away because they may be used in foods served to residents and could make residents severely sick. The Dietary Supervisor stated expired food must be discarded as soon as it expires to prevent staff from using expired ingredients and stated foods made with expired ingredients could cause signs and symptoms of food-borne illnesses that may lead to more complicated health issues. The facility policy titled Food Storage Principles stated foods that have exceeded their expiration date are to be discarded.
Unsecured TV Cable Wire in Resident Room
Penalty
Summary
Keep all essential equipment working safely. The facility failed to maintain a wall-mounted television in room [ROOM NUMBER]B in safe and operating condition when an uncovered and unsecured cable electrical wire was observed hanging underneath the television. During observation and interview, the Housekeeping Supervisor stated the television cable wire was exposed and should not be exposed because the wires could be dangerous to residents. Record review showed the facility's Preventative Maintenance Monthly Checklist for 2025 did not include logs for tracking televisions individually in resident rooms. A maintenance log dated 5/17/25 documented a complaint about a TV wall cable being faulty and sparking lights from a naked area. The facility's Preventative Maintenance Program policy stated that a basic preventative maintenance program results in cleaner, safer, and more efficient operation with fewer deficiencies and emergency repairs, and that it is a company-wide system to communicate issues or items needing attention, repair, or replacement.
Oxygen Left On When Resident Was Out of Room
Penalty
Summary
The facility failed to ensure that oxygen was turned off when Resident 23 was not in the room and not in use. Resident 23’s record showed diagnoses of COPD, respiratory failure, and dementia, and the H&P stated the resident had limited capacity to understand and make decisions. The MDS indicated the resident’s cognition was severely impaired, the resident required substantial to maximal assistance with toileting hygiene, showering, and dressing, and the resident received oxygen therapy. During observation, Resident 23’s oxygen concentrator was on and set at two liters with a nasal cannula attached while the resident was not in the room. This was observed again during a concurrent observation and interview with RN 1, who stated the oxygen concentrator should be off when the resident was not in the room and that leaving it on was a fire hazard. CNA 3 stated that when the resident was no longer in the room, staff were to report to the licensed nurse to turn off the oxygen because it was dangerous to leave it unattended. The DSD stated the protocol was to turn off the oxygen when the resident was no longer in the room, that oxygen was a medication, and that licensed staff were to turn it off when Resident 23 was not in the room. The DSD also stated there was no P&P regarding oxygen safety and no staff training regarding oxygen safety, and the facility’s P&P review found no policy on oxygen safety regarding turning off oxygen while residents were not in their rooms.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Resident Unable to Access Functioning Television for Preferred Activities
Penalty
Summary
A deficiency was identified when a resident, who enjoyed watching TV as part of her preferred activities, did not have access to a functioning television in her room. The resident's care plan and activity assessment documented her interest in independent activities such as watching TV, and her medical records indicated she had moderately impaired cognition but was able to make her own decisions. During interviews and observations, it was found that the TV mounted on the wall in her room displayed static and unclear channels, making it difficult to watch. Additionally, a second TV on the nightstand was not plugged in, further limiting her ability to watch TV. The resident's family member reported that the TV was always fuzzy and unclear, and the resident herself confirmed that the TV was sometimes very unclear and difficult to watch. Staff, including an LVN, verified that both TVs in the room were either not functioning or not set up for use. Facility policies reviewed indicated an expectation for person-centered care and activities tailored to residents' interests, but these were not met in this instance, resulting in the resident being unable to enjoy watching TV as she preferred.
Failure to Honor Resident's Right to Refuse Blood Draw
Penalty
Summary
The facility failed to honor a resident's right to refuse treatment when staff attempted to draw blood from a resident who had previously indicated refusal. The resident, who had diagnoses including dementia, anxiety, and osteoarthritis, was assessed as having severely impaired cognition and was dependent on staff for daily activities. Despite physician orders and signage above the resident's bed instructing staff to call the family if the resident refused a blood draw, staff proceeded with the procedure after the resident expressed refusal. Observations and interviews revealed that the resident verbally told staff to stop during the blood draw, but staff continued and completed the procedure. The resident reported that staff held her down and did not listen to her refusal, resulting in pain and bruising on both wrists. Documentation showed that the resident had a history of refusing care, and the care plan included interventions to encourage the resident to verbalize feelings and offer understanding and empathy. Staff interviews confirmed that the protocol was to call the family if the resident refused a blood draw, and that residents should not be forced to accept care. However, the staff involved were either unaware of the signage or did not follow the established protocol. Facility policies reviewed indicated that residents have the right to refuse treatment and should not be compelled by force, but these policies were not followed in this instance.
Failure to Provide Follow-Up Dental Services for Resident Requesting Partial Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who requested partial dentures. The resident, who had a history of intracerebral hemorrhage and respiratory failure, was observed to have a large gap in the upper row of teeth and expressed feeling embarrassed and self-conscious due to missing teeth. Documentation showed that the resident had moderate cognitive impairment and required assistance with eating and oral hygiene. The physician had referred the resident for annual and as-needed dental consultations, and dental notes indicated the resident requested partial dentures. However, social services notes from the same date stated no recommendations were given, and there was no evidence of follow-up or provision of dentures after the resident's request. Interviews with the Social Services Director and the DON confirmed that the social services department was responsible for following up on dental evaluations and resident needs, but no follow-up dental services or dentures were provided after the initial request. The facility's policies required social services staff to make referrals, secure dental care, and document interactions, but these steps were not completed for this resident. The DON acknowledged that the lack of dentures could potentially result in weight loss and swallowing issues for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease and severe cognitive impairment, who was fully dependent on staff for all activities of daily living and always incontinent of bowel and bladder, was not provided timely incontinence care. The resident's care plan required staff to clean and dry the resident after each incontinent episode and to observe for skin irritation and redness. However, according to a family member, the resident was sometimes only changed once per shift instead of the expected twice, and on one occasion was found wet with urine in both the incontinence brief and gown, indicating the brief had not been changed since the morning. Interviews with staff confirmed that leaving a resident in a wet brief can result in rashes, skin breakdown, and urinary tract infections. The Director of Nursing acknowledged that residents are to be changed at the beginning of the shift and as needed, and that failure to do so puts residents at risk. The facility's policy on bladder and bowel incontinence emphasized the importance of preventive measures for infection control, but the observed and reported practices did not align with these standards.
Failure to Provide Pain Management Evaluation
Penalty
Summary
The facility failed to provide a pain management evaluation for a resident with multiple diagnoses, including unspecified dementia, anxiety, primary osteoarthritis of both knees, and hypertension. The resident was noted to have moderate cognitive impairment and was dependent on staff for most activities of daily living. Physician orders included scheduled and as-needed pain medications, and the care plan directed staff to acknowledge pain, use non-pharmacological interventions, administer pain medication as ordered, and notify the provider if pain was not adequately controlled. Despite these orders, pain monitoring records showed the resident repeatedly reported moderate pain levels in the knees, with no documented administration of as-needed acetaminophen during the month reviewed. Progress notes indicated a referral to pain management was planned, but interviews with staff revealed that the referral was not completed and the resident had not been evaluated by a pain specialist. The DON confirmed that the resident should have been seen for pain management but was unsure why this had not occurred. The facility's policy required pain screening, evaluation, and referral to other disciplines as needed, but this process was not followed for the resident, resulting in unaddressed and unmanaged pain.
Failure to Provide Soap Dispenser in Resident Bathroom Creates Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident's bathroom was found to be lacking a soap dispenser, with an un-labeled plastic cup containing yellow liquid placed on the sink instead. The resident in question was admitted with Alzheimer's disease and anxiety, was severely cognitively impaired, and fully dependent on staff for all activities of daily living, including hygiene and toileting. The resident was also always incontinent and at risk for developing pressure ulcers. The absence of a soap dispenser was confirmed during an observation and interview, with the resident's family member stating that there had never been soap available in the restroom. Staff interviews revealed that the Certified Nurse Aide (CNA) did not report the missing soap dispenser to the charge nurse as required, and the maintenance team was unaware of the issue, as there was no entry in the maintenance log regarding the missing dispenser. The Infection Preventionist Nurse and Director of Nursing both acknowledged that the lack of a soap dispenser and the use of a cup for soap constituted an infection control problem and a safety issue. Facility policies required regular inspection of resident rooms and bathrooms to ensure all dispensers were functioning, but this was not followed in this instance.
Failure to Arrange Transportation for Post-Surgical Follow-Up
Penalty
Summary
The facility failed to arrange transportation for a resident who required a follow-up appointment with a surgeon regarding a Jackson Pratt drain. The resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, left bundle branch block, and acute on chronic systolic heart failure. The resident's Minimum Data Set indicated the ability to communicate needs and required partial to moderate assistance with personal care. A physician's order and progress notes documented the need for a follow-up appointment, and the surgeon's office communicated the appointment date to the facility. The Social Service Designee was notified to arrange transportation. However, a review of the Social Service Designee's calendar showed no documentation of transportation arrangements for the resident's appointment. On the scheduled date, the resident was unable to attend the appointment due to transportation difficulties, and the appointment was subsequently rescheduled. During an interview, the Social Service Assistant, responsible for arranging transportation, could not recall making the arrangements and was unable to provide documentation to support that transportation had been arranged. The facility's policy indicated that the Social Service Assistant is responsible for assisting with residents' transportation needs.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during wound care for three residents. During an observation, a Licensed Vocational Nurse (LVN) was seen performing wound care on Resident 2 without adhering to proper hand hygiene protocols. The LVN cleaned the bedside table, applied a plastic cover, and changed gloves multiple times without washing hands in between. Additionally, the LVN applied ointment and dressed the wound without ensuring the cleanliness of the heel protector boots, which had dried flaky skin particles inside. In another instance, the same LVN was observed conducting wound care for Resident 3. The LVN prepared the wound care supplies and donned personal protective equipment (PPE) but failed to remove the PPE before leaving the room to retrieve additional supplies. This action was contrary to the facility's policy, which requires the removal of PPE before exiting the work area. The LVN continued the wound care procedure without washing hands after changing gloves, which could lead to cross-contamination and infection. Similarly, during wound care for Resident 4, the LVN did not follow proper hand hygiene practices. The LVN left the room wearing PPE to get more supplies, which is against the facility's guidelines. The Director of Nursing confirmed that the LVN should have washed hands every time gloves were changed to prevent contamination. The facility's policy mandates handwashing after glove removal and before applying new gloves, which was not adhered to during these observations.
Failure to Recheck Low Blood Pressure in Resident
Penalty
Summary
The facility failed to recheck the blood pressure of a resident who had a physician's order of no Cardiopulmonary Resuscitation and a low blood pressure reading. The resident, who had severe cognitive impairment and was on palliative care, had a history of low blood pressure after dialysis. On a specific date, the resident's blood pressure was recorded at 93/55 mmHg with a heart rate of 53 beats per minute, leading to the withholding of blood pressure medication. During interviews, a Licensed Vocational Nurse acknowledged that the resident's baseline blood pressure was typically low after dialysis and admitted that she could have rechecked the blood pressure after 15 minutes and informed the physician. The Director of Nursing emphasized the importance of monitoring residents with low blood pressure and stated that even if the baseline was low, the blood pressure should have been rechecked and the physician informed if it remained low.
Failure to Provide Safe Environment During Wound Care
Penalty
Summary
The facility failed to provide a safe environment for a resident during wound care, which had the potential to result in a fall and injury. The resident, who was admitted with a diagnosis of a pressure ulcer in the sacral region, was identified as having cognitive impairment and one-sided impairment in both upper and lower extremities. The resident was also dependent on assistance for movement and was assessed as being at high risk for falls. During an observation, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) raised the resident's bed to provide wound care. However, both staff members left the resident unattended with the bed raised, which was against the facility's policy for residents at high risk for falls. Interviews with the LVN and CNA confirmed that they were aware that residents should not be left alone with the bed raised, especially those at high risk for falls. The Director of Nursing (DON) also reviewed the resident's fall risk assessment and acknowledged that the resident should not have been left unattended during care. The facility's policy emphasized the importance of resident safety and supervision to prevent accidents, highlighting a failure in adhering to these guidelines in this instance.
Failure to Conduct Annual Competency Assessments
Penalty
Summary
The facility failed to ensure that a competency assessment skills check was performed upon hire and annually for two out of five randomly selected staff members. During an interview and record review, it was found that the Director of Staff Development (DSD) did not have an annual skills competency assessment check on file for a Registered Nurse (RN 1) and four Certified Nurse Assistants (CNA 1, CNA 2, CNA 3, and CNA 4). The DSD acknowledged that these assessments were necessary to validate the ability of the nursing staff and CNAs to meet the health and safety needs of the residents. The Administrator confirmed the importance of performing annual competency assessments to ensure compliance with state and federal regulations. The facility's policy and procedure indicated that competency skills evaluations should be completed upon orientation and annually thereafter. Additionally, the Facility Assessment stated that the DSD would provide ongoing training and assess competencies upon hire, annually, as needed, and on demand. The lack of these assessments had the potential to impact the facility's ability to provide nursing services while ensuring resident safety and well-being.
Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of its residents, as evidenced by several deficiencies in meal preparation and service. Resident 33, who identified as a vegetarian, was served meals containing meat, contrary to her dietary preferences. Despite being aware of Resident 33's vegetarian preference, the facility's staff, including the Certified Nursing Assistant and the Director of Dietary Services, did not ensure that her meals were appropriately adjusted. The facility's policy required food preferences to be reviewed quarterly, but this was not adhered to, leading to the resident receiving non-preferred food. Additionally, the facility did not follow standardized recipes and portion sizes for residents on mechanical soft and pureed diets. Observations revealed that 25 residents on mechanical soft diets and 20 residents on pureed diets were served incorrect portion sizes of ground meat and squash. The Registered Dietician confirmed that the portions were incorrect, which could potentially affect the residents' nutritional intake. The facility's policy on portion control was not followed, as the staff used incorrect scoop sizes due to damaged equipment, leading to improper serving sizes.
Improper Food Storage and Sanitation in Facility
Penalty
Summary
The facility failed to ensure the safe and proper storage of food items in the refrigerator, as observed during a survey. Specifically, a frozen bottled water was found unlabeled in the freezer, and several opened food items, including a bag of white sliced bread, oatmeal, grits, hot sauce, cornstarch, pickle relish, and mayonnaise, were found without open or use-by dates. Additionally, the internal fan in one of the refrigerators, which was blowing air over uncovered fresh produce, had black substances on its blades, indicating improper sanitation. Interviews with the Director of Dietary Services (DDS) and the Registered Dietician (RD) confirmed the presence of dirt on the fan and the uncovered fresh produce, which could potentially lead to cross-contamination and food poisoning. The facility's policies and procedures for food storage and maintenance were reviewed, revealing requirements for labeling food with expiration dates and maintaining clean and efficient cold storage areas. However, these policies were not adhered to, as evidenced by the observations and interviews conducted during the survey.
Inaccurate Facility Assessment and Resident Census
Penalty
Summary
The facility failed to revise and provide an updated and accurate resident census in its Facility Assessment, which is a process for evaluating the resident population and identifying the resources needed to provide care and services. During a review of the facility census on October 15, 2024, it was found that 94 residents were residing in the facility. However, during a concurrent interview and record review on October 18, 2024, with the Administrator, it was revealed that the Facility's Assessment was last updated on September 7, 2024, and indicated an average daily census of 88 to 91 residents. This discrepancy between the recorded census and the actual number of residents was acknowledged by the Administrator, who admitted that the Facility Assessment did not match the current census and that some residents were not accounted for in the assessment. The Administrator stated that she was responsible for updating the Facility Assessment, which serves as an overview of the services provided by the facility to the resident population. The incorrect documentation on the Facility Assessment could potentially result in not providing quality and standard care to residents. The Centers for Medicare and Medicaid Services (CMS) guidance, referenced as QSO-24-13-NH, requires that the facility assessment include an evaluation of the resident population's diseases, conditions, and limitations, and be updated as necessary and at least annually. The failure to maintain an accurate and updated Facility Assessment could place residents at risk for delays in care and treatment services.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not monitoring and addressing antibiotic use for a resident who was on antibiotics for a urinary tract infection (UTI). The resident, who had a history of UTI, sepsis, and diabetes mellitus, was readmitted to the facility from a hospital with a prescription for Bactrim DS to treat the UTI. Despite the facility's policy requiring infection surveillance within three days of admission, the Infection Preventionist Nurse (IPN) did not complete the surveillance form for the resident, and no laboratory specimens were drawn at the facility after the resident's discharge from the hospital. The Director of Nursing (DON) acknowledged that the lack of surveillance could lead to unnecessary antibiotic use, potentially causing harm such as antibiotic resistance or adverse reactions. The facility's policy on the Antibiotic Stewardship Program outlined specific steps for infection surveillance, including monitoring the type of antibiotic ordered, the route of administration, and whether a culture was obtained before ordering the antibiotic. However, these steps were not followed for the resident, leading to the deficiency identified in the report.
Failure to Reassign CNA After Grievance
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 5) was not assigned to a resident (Resident 195) after a grievance was filed by the resident's family member regarding the CNA's loud and rude behavior. Resident 195, who was admitted with multiple fractures and was fully dependent on staff for daily activities, experienced a lack of dignity and respect from CNA 5, as reported by the resident and confirmed by the family member's grievance. Despite the grievance, CNA 5 continued to be assigned to Resident 195 for three days after the grievance was filed. Interviews with the Social Services Director, Registered Nurse Supervisor, Director of Staff Development, and Human Resources Staffing Coordinator revealed that the grievance was acknowledged, and it was agreed that CNA 5 should have been removed from providing care to Resident 195. However, the intervention to remove CNA 5 was not implemented, leading to continued interaction between CNA 5 and Resident 195. The facility's policy on dignity, which requires staff to speak respectfully to residents, was not adhered to in this case.
Failure to Notify Resident of Found EBT Card
Penalty
Summary
The facility failed to notify a resident, her doctor, and a family member when her missing Electronic Benefit Transfer (EBT) card was found. The resident, who was admitted with diagnoses including metabolic encephalopathy, chronic kidney disease, and dementia, had a severely impaired cognitive ability and required substantial assistance from staff. The EBT card, valued at $190, was reported missing by a Certified Nursing Assistant (CNA) to the resident's responsible party, who was informed during a visit. The resident expressed worry about the missing card, and the CNA reported the issue to the registered nurse supervisor. The Activities Director later found the EBT card in the activity room but failed to notify the staff or the resident, which prolonged the resident's distress. The registered nurse stated that the lack of communication among staff delayed the resolution of the issue and increased the resident's distress. The facility's policy on residents and personal property requires reports of misappropriation or mistreatment of resident property to be investigated and documented, but this process was not followed in this instance.
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.
Illustrative
What surveyors actually found near you
We read the 7,348 citations issued within 25 miles in the last 12 months — including the 34 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Inglewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Century Villa, Inc | 0.5 mi | ★★★★★ | 12 | 0 |
| Primrose Post-acute | 0.7 mi | ★★★★★ | 7 | 0 |
| Centinela Skilled Nursing & Wellness Centre West | 0.8 mi | ★★★★★ | 18 | 0 |
| Osage Healthcare & Wellness Centre | 0.8 mi | ★★★★★ | 25 | 0 |
| Hyde Park Healthcare Center | 1.3 mi | ★★★★★ | 33 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Inglewood Health Care Center.
100% money-back within 48 hours.
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.