Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Intercommunity Care Center during CMS and state inspections, most recent first.
A resident with dementia, schizoaffective disorder, bipolar disorder, abnormal gait, and severely impaired decision-making required supervision for mobility and used a FWW, as documented in the MDS and PT records. Despite these findings and facility policies requiring the IDT to create individualized care plans with specific fall-prevention and mobility interventions, no fall-risk or FWW-related care plan was developed or implemented for this resident. The resident, who had periods of confusion and could forget to use the walker, was observed ambulating in the hallway without the FWW, increased speed, and fell, later being found to have an acute left femur fracture that required hospital evaluation and hip surgery. Staff and the DON acknowledged that the fall-risk assessments did not accurately reflect the resident’s risk and that a fall-prevention care plan with interventions such as reminders to use the FWW and environmental safety measures had not been in place before the fall.
A resident with schizophrenia, glaucoma, hypertension, and severe cognitive impairment, who required supervision or touch assistance for transfers, was found by a CNA face down on the floor of his room, unresponsive, pulseless, not breathing, and bleeding from the nose. An LVN assessed the resident, paramedics arrived and took over CPR, and the resident was pronounced deceased. The DON was informed of the injury and death but did not report the unwitnessed incident—an injury of unknown origin with serious bodily injury and death—to CDPH, despite facility policy requiring prompt reporting of all alleged abuse, neglect, mistreatment, and injuries of unknown source to state authorities within specified time frames.
Multiple infection control deficiencies were identified, including staff not using Enhanced Barrier Precautions for residents with indwelling devices, lack of staff training and signage, failure to implement the water management plan, improper hand hygiene between resident care, and improper handling of clean and soiled linens. Additionally, contact isolation precautions were not fully implemented for a resident with scabies, and staff did not follow recommended protocols for assessing and managing contacts.
Two residents were not treated with dignity and respect when staff failed to provide eye-level assistance during feeding and did not ensure privacy by leaving a resident exposed during care. Both incidents involved residents with cognitive impairments and required staff to follow established policies for maintaining dignity and privacy.
The facility did not develop or implement person-centered care plans for five residents, including failing to provide required monitoring for a resident at high risk for elopement, omitting a care plan for PTSD for a resident with that diagnosis, and not establishing smoking care plans for three residents who participated in supervised smoke breaks. Staff interviews and record reviews confirmed that these omissions left care needs unaddressed and staff without necessary guidance.
Surveyors found that dietary staff failed to label an open bag of pancake mix with an open date, left containers of breadcrumbs, macaroni noodles, and egg noodles uncovered or partially covered, and did not clean a stationary can opener that had a black tarry substance on it. Staff acknowledged these lapses, and facility policy requires proper labeling, dating, and sanitation of food and equipment.
Two residents with severe cognitive impairment and multiple diagnoses did not have their pneumococcal vaccination status documented in their medical records. This omission was confirmed by both the IPN and DON, despite facility policy requiring complete and accurate documentation.
The facility did not ensure that all staff were educated on Enhanced Barrier Precautions (EBP), as evidenced by a resident with a G-tube being cared for without proper isolation signage or PPE availability. Interviews revealed that staff, including an LVN, were unaware of EBP requirements, and the Infection Prevention Nurse confirmed the need for staff education, despite facility policy mandating such training.
A resident with severe cognitive impairment and psychiatric diagnoses received psychotropic medication via g-tube without a fully completed informed consent, as the consent form lacked required dosage and frequency details. Nursing staff confirmed that this information is necessary for proper consent documentation.
A resident with dementia, mobility issues, and impaired cognition was found asleep in bed with the call light on the floor behind the dresser, out of reach. Staff interviews confirmed the call light should have been accessible, and the care plan and facility policy required it to be within reach at all times.
A resident with severe cognitive and physical impairments was placed in a Geri-chair with a lap tray as a restraint without evidence that less restrictive alternatives were attempted first. Staff and record reviews confirmed that no monitoring or ongoing assessment was conducted for the continued use of the restraint, and the care plan lacked interventions for restraint reduction. Facility policy required less restrictive measures and ongoing evaluation, but these steps were not followed.
A resident's MDS assessment was completed without including an active diagnosis of schizophrenia, despite this diagnosis being documented in the medical record, psychiatric notes, and physician orders, and the resident receiving Zyprexa for this condition. The DON confirmed the omission was an oversight and that the assessment did not accurately reflect the resident's status as required by facility policy.
A resident with schizophrenia and significant cognitive and functional impairments was admitted without a completed PASARR Level 1 screening. The required screening, which identifies serious mental illness and the need for further evaluation, was only performed after the resident had already been admitted and was found to be positive for serious mental illness, necessitating a Level 2 screening. Facility staff acknowledged that the PASARR Level 1 should have been completed before admission, as required by policy.
A resident with contractures and significant ROM limitations in the right hand, right wrist, and left ankle was not provided with appropriate restorative or therapy services to maintain or improve joint mobility, despite assessments and staff recognition of the need. The only intervention in place was a hand roll, and no ROM exercises were ordered or implemented, resulting in a failure to follow facility policy and physician recommendations.
A resident with dementia, a history of wandering, and a verbalized desire to leave was not included in hourly monitoring rounds, despite care plan interventions requiring constant supervision. Staff interviews and record reviews confirmed that the resident was not monitored as required, and no documentation of monitoring was found, resulting in a deficiency in accident prevention and supervision.
A resident with severe cognitive impairment and respiratory conditions was observed receiving oxygen via a nasal cannula that was not labeled with the date of first use. Staff interviews revealed uncertainty about the required frequency for changing the cannula, and the facility lacked a policy on dating or replacing nasal cannulas, as confirmed by the DON and a review of facility procedures.
A resident with PTSD, depression, diabetes, and dementia did not receive trauma-informed care as required by facility policy. Staff were unaware of the PTSD diagnosis and did not provide specific trauma-informed interventions, despite existing policies outlining such care for residents with a trauma history.
A medication error rate above 5% was identified when an LVN attempted to administer a multivitamin and vitamin D to a resident earlier than the physician-ordered time. The resident, who has a history of paranoid schizophrenia and fluctuating decision-making capacity, refused the early medications. The LVN later confirmed the error, noting that facility policy requires medications to be given within one hour of the scheduled time.
Surveyors found that two residents' Humulin R insulin vials were not managed according to manufacturer and facility requirements: one vial was open without a labeled date, and another was expired but not removed from the medication cart. An LVN confirmed these deficiencies during inspection.
The facility did not document that all employees, including physicians, consultants, and rehabilitation staff, were screened, educated, or offered the COVID-19 vaccine, nor did it record their vaccination status, as required by facility policy.
Staff were not provided with required in-service training on PTSD and trauma-informed care, despite a resident with PTSD and other mental health diagnoses requiring such specialized support. Review of facility records and staff interviews confirmed the absence of this training, in violation of facility policy.
Three rooms were found to house more than four residents each, with one room accommodating five and two rooms accommodating six, in violation of regulatory requirements. The Administrator acknowledged the situation and reported no complaints from staff or residents.
Multiple rooms in the facility, each accommodating three residents, were found to be only 210 sq. ft., falling short of the required 80 sq. ft. per resident. Documentation review and room observations confirmed the deficiency, though no immediate adverse effects on privacy, health, or safety were noted during the survey period.
A resident with severe cognitive impairment and a history of falls was inadequately supervised, leading to a fall and right hip fracture. Despite being a high fall risk, the resident was able to exit onto a patio unassisted, and staff failed to respond to alarms. The resident was found on the ground over 40 minutes later, highlighting a lack of effective monitoring and supervision protocols.
A resident with severe cognitive impairment and wandering behaviors experienced an unwitnessed fall resulting in a left hip fracture. The incident was not reported to the CDPH within the required timeframe, despite being reported internally to the Administrator and DON. The facility's policy mandates immediate reporting of such incidents, which was not followed.
A resident with severe cognitive impairments was slapped by another resident with behavioral issues in an LTC facility. The facility failed to notify a doctor, update care plans, or adequately monitor the residents involved, violating policies on abuse prevention and care planning.
The facility failed to ensure three staff members had active CNA certificates before providing direct care. CNA 3, CNA 4, and RNA 1 were scheduled to work without verified certification status in the database. The DSD and DON acknowledged the importance of maintaining active certification, but the Administrator allowed staff to work if renewal submissions were made.
The facility failed to provide consistent in-service training for night shift staff, potentially compromising resident safety. The DSD admitted that night shift staff were excluded from certain trainings, such as shower procedures and cell phone policy, despite occasionally performing these tasks. Interviews with staff and the DON highlighted the importance of consistent training across all shifts to ensure quality care.
A resident at high risk for falls, using a self-release belt in a wheelchair, fell and sustained injuries due to the facility's failure to maintain the belt's functionality. The Velcro securing the belt was worn out, and the facility did not develop a care plan with specific interventions to prevent falls. Despite the resident's high fall risk, the facility did not follow its policy for managing falls, leading to the resident's fall and injuries.
The facility failed to assess, monitor, and document the use of physical restraints for three residents, leading to a deficiency in care. A resident with dementia was observed with a lap belt restraint, and the Restraint Monitoring Flow Sheet showed multiple instances of missing documentation for releasing the restraint, assessing it, and checking skin integrity. Similar documentation failures were noted for two other residents, highlighting the facility's non-compliance with its policy on restraint use.
The facility allowed six nurse aides to provide direct resident care without completing a required training and competency evaluation program. Despite policy requirements, these aides were assigned to care for residents independently, without supervision from certified nursing assistants (CNAs). Interviews revealed that the aides had not been certified or completed skills competencies, and the Director of Staff Development admitted to assigning them unsupervised duties, contrary to initial claims.
The facility failed to provide necessary in-service training for nurse aides, including sexual harassment, LGBTQ, and adequate dementia training. Additionally, three nurse aides did not receive abuse training upon hire. The Director of Staff Development did not prepare lesson plans for abuse or infection control training, and the Human Resources department did not provide required training during new hire orientation, posing a risk to resident safety.
A resident with dementia and other mental health conditions was involved in a physical altercation with another resident during a smoking break on the patio. The incident occurred due to inadequate supervision, as only one CNA was present instead of the required two staff members. This resulted in the resident sustaining a nasal fracture and requiring hospital treatment.
A physical altercation between two residents resulted in one sustaining a bloody nose and bruising. Despite immediate internal notification, the incident was reported to CDPH nearly 16 hours later, violating federal regulations requiring reporting within two hours. The delay was attributed to the DON attending to resident needs and the Administrator being unaware of the reporting lapse.
A resident with severe cognitive impairment was injured in a resident-to-resident altercation, which was not reported to the Department of Public Health within the required timeframe. The facility's QAA and QAPI committees failed to maintain oversight of the plan of correction for previous deficiencies related to abuse prevention and reporting. The incident was not promptly reported due to a lack of training and communication among staff, including the DON and Administrator.
A resident, dependent on staff for care, was injured during a transfer when a CNA failed to follow the care plan requiring a two-person assist. The CNA heard a popping sound but did not report it, leading to the resident sustaining a fracture and requiring hospitalization. Facility staff confirmed the need for a two-person assist, highlighting a breach in protocol.
A resident with dementia and Alzheimer's experienced swelling and pain after a transfer, but the facility delayed ordering and obtaining a STAT X-ray. The X-ray, ordered at 2 p.m., was not conducted promptly, and results indicating a serious fracture were delayed until 8:27 p.m. Staff interviews revealed a lack of follow-up and communication, leading to prolonged pain for the resident.
A resident in a LTC facility became unresponsive in the dining room, but staff delayed CPR by moving the resident to his room, resulting in an eight-minute delay. The resident, with a Full Code status, was not immediately given CPR or had 911 called, leading to his death. The staff's actions were influenced by concerns for privacy and preventing panic among other residents.
A resident with a history of attempted elopement successfully left the facility unsupervised by climbing over a patio fence. The facility failed to accurately assess the resident's elopement risk and did not implement preventive measures, despite the resident's known wandering behavior and high risk for elopement. Staff did not respond to an alarm when the patio door was opened, allowing the resident to elope.
The facility failed to provide evidence of a thorough investigation of a resident-to-resident altercation. A resident with dementia reported being physically assaulted by another resident with Alzheimer's disease. The Administrator stated that the investigation was only verbal, with no written documentation, and could not provide evidence that the required five-day summary report was submitted to CDPH.
The facility failed to follow proper kitchen hygiene and food storage practices, as an opened salmon fillet was found undated and improperly stored on top of a box of pork in the refrigerator. The Dietary Supervisor and a cook acknowledged the error, highlighting a lapse in adherence to protocols requiring opened food items to be dated, wrapped, and stored correctly to prevent contamination.
Three residents in an LTC facility were found with physical restraints without proper ongoing assessment or documentation. A resident had a lap belt restraint for fall prevention, but checks for circulatory issues and skin integrity were not documented. Another resident had a lap buddy restraint, with similar documentation lapses. A third resident's lap belt restraint also lacked monitoring records. Staff interviews confirmed the absence of documentation, contrary to facility policy requiring restraint-free care and documented alternative interventions.
The facility failed to conduct background checks on 1,005 new employees, as required by its 'Abuse Prevention Program' policy, placing 123 residents at risk. Interviews with HR, DSD, DON, and the Administrator confirmed that only reference checks were performed, contrary to the policy that mandates background checks to prevent employing individuals with a history of abuse, neglect, or exploitation.
A facility failed to obtain informed consent from the responsible party of a resident before administering Seroquel, a psychotropic medication, for agitation and dementia with psychotic behavior. The resident, who required substantial assistance with daily activities, was given the medication without a physician's signed consent, violating the facility's policy and the resident's rights.
A resident with cognitive impairments and multiple diagnoses, including mesothelioma and neuropathy, exhibited black discoloration and pain on the second toe of the right foot. Despite observations by a CNA and an LVN, the condition was not reported or assessed, potentially delaying treatment. The DON later identified the discoloration as a possible wound, highlighting the facility's failure to adhere to its policy of promptly addressing skin abnormalities.
A resident with severe cognitive impairment and mental health issues was not provided a psychiatric consult despite being on antipsychotic medications. The facility's policy requires a comprehensive assessment for such medications, but interviews with staff revealed a lack of action and documentation regarding the psychiatric evaluation process. The resident's family member also expressed concern over the absence of a psychiatric consult.
A facility failed to monitor the side effects of Xarelto for a resident with impaired cognitive skills and a history of heart disease and pneumonia. Despite a care plan indicating the risk of bleeding, there were no physician orders or documentation in the MAR for monitoring side effects. Interviews with staff confirmed the lack of monitoring, which could have placed the resident at risk for undetected side effects.
A facility failed to maintain infection control during a medication pass when an LVN did not practice hand hygiene between tasks. The LVN handled medications without washing hands, which was confirmed during an interview. The facility's policies require handwashing before and after resident care and emphasize infection control during medication administration.
The facility did not post daily staffing information in visible areas, such as nursing stations and the lobby, as required. Observations showed the information was only posted by the time clock, limiting visibility for residents and visitors. Interviews with the ADON and DON confirmed this practice, acknowledging the need for broader posting.
The facility did not meet the requirement of providing at least 80 square feet per resident in multiple resident rooms, as identified in a Client Accommodation Analysis form. Several rooms were found to be below the required size. The Administrator requested a continuance of a previously granted waiver for room size, and observations indicated no adverse effects on residents' privacy, health, and safety.
Failure to Develop and Implement Individualized Fall-Prevention Care Plan for Cognitively Impaired Walker User
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized, comprehensive fall-prevention care plan for a resident who used a front-wheeled walker (FWW) and had cognitive impairment. The resident was admitted and later readmitted with diagnoses including schizoaffective disorder, bipolar disorder, dementia, and abnormality of gait. An MDS assessment documented severely impaired cognitive function for daily decision-making and a need for supervision with self-care and mobility, including sitting, standing, and walking, with use of a walker. Physical therapy evaluations and treatment notes showed that the resident was being followed by PT for mobility, gait training, and education on safe FWW use, and that the resident used a FWW as an assistive device and required supervision for transfers and gait. Despite these identified needs and the resident’s use of a FWW, record review showed there was no fall risk or FWW-related care plan in place prior to the fall event. The facility’s fall risk assessments scored the resident as low risk (scores of 2 and later 5, with >10 indicating high risk), and the DON later stated these assessments did not accurately reflect the resident’s fall risk. The facility’s policies on Care Planning–Interdisciplinary Team, Safety and Supervision of Residents, and Resident Mobility and Range of Motion required the IDT to develop individualized care plans based on comprehensive assessments, identify fall and mobility risks, and include specific, measurable interventions, goals, and responsibilities. However, the IDT did not meet to develop a care plan addressing the resident’s fall risk or the need to consistently use the FWW for ambulation, and no such care plan was found in the medical record before the incident. On the night of the fall, nursing notes documented that staff observed the resident walking in the hallway without the FWW, then suddenly running and falling onto the left side. The resident reported not knowing what happened and initially described mild left hip pain, for which ibuprofen was administered. Staff notified the physician, who ordered a stat left hip x-ray and safety monitoring every 30 minutes for 72 hours. The MAR showed ibuprofen was later given for severe left hip pain. The x-ray revealed an acute fracture of the left femur, and the resident was transferred to a general acute care hospital, where ED and orthopedic records confirmed a left femur fracture due to a mechanical fall and documented subsequent left hip hemiarthroplasty. Interviews with nursing staff, the DON, and the resident indicated that the resident knew she needed the FWW but forgot to use it, had periods of confusion, and that staff who saw her ambulating without the FWW should have intervened. The DON and other staff acknowledged that a fall-prevention care plan with interventions such as reminders to use the FWW and environmental safety measures should have been in place and implemented before the fall occurred, but it was not.
Failure to Report Unwitnessed Injury of Unknown Origin and Resident Death to CDPH
Penalty
Summary
The facility failed to report an injury of unknown origin and subsequent death of a resident to the California Department of Public Health (CDPH) as required by regulation and facility policy. The resident had diagnoses including schizophrenia, glaucoma, and hypertension, and an MDS assessment showed severe cognitive impairment, with the resident sometimes able to understand and be understood, and requiring supervision or touch assistance for transfers between bed and chair or wheelchair. On the evening of the incident, a CNA walking past the resident’s room found the resident face down on the floor. An LVN assessed the resident and determined he was unresponsive, without a pulse, not breathing, and with blood coming from his nose. Paramedics arrived, took over resuscitation efforts, and pronounced the resident deceased shortly thereafter. The DON stated she was informed of the resident’s injury and death by an unidentified nurse but did not report the incident to CDPH because she did not consider it an unusual occurrence. She indicated that, based on her investigation, the resident may have become unresponsive in bed and fallen to the floor, injuring his nose, but acknowledged the incident was unwitnessed and the exact cause could not be determined. The facility’s Abuse Investigation and Reporting policy, revised 7/2017, required that all reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source be promptly reported to local, state, and federal agencies, including the state licensing/certification agency. The policy further required that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours, and other alleged violations within 24 hours. Despite these requirements, the facility did not report this unwitnessed injury of unknown origin and death to CDPH.
Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement multiple infection prevention and control measures as required by policy and regulatory guidance. Staff did not use Enhanced Barrier Precautions (EBP) for residents with indwelling devices such as gastrostomy tubes, as observed with several residents. In multiple instances, there was no EBP signage posted, no isolation carts available, and staff were unaware of EBP protocols. Interviews revealed that staff had not received in-service training on EBP, and the Infection Preventionist Nurse (IPN) confirmed that education and signage had not been provided. Additionally, staff were observed providing direct care to residents with G-tubes without donning appropriate personal protective equipment (PPE) such as gowns and gloves, contrary to facility policy and CDC guidance. The facility also failed to implement its water management plan, which is designed to prevent waterborne illnesses. The Maintenance Director stated that there were no logs or records indicating that water quality was being monitored as required, and the administrator confirmed that the water management program had not been implemented. This was in direct contradiction to the facility's own water management and Legionella prevention plan, which called for regular testing and documentation. Further deficiencies were observed in basic infection control practices, including hand hygiene and laundry handling. A certified nurse assistant was seen moving between residents without performing hand hygiene or properly disposing of gloves, and maintenance/laundry staff handled clean linens in a manner that allowed them to touch the floor and their clothing, did not use PPE when handling soiled laundry, and placed personal items near clean linens. Additionally, the facility failed to implement appropriate contact isolation precautions for a resident being treated for scabies, as only the affected resident was placed under isolation rather than the entire shared room, and there was no comprehensive assessment or prophylactic treatment for contacts as recommended by local guidelines.
Failure to Ensure Dignity and Privacy During Resident Care
Penalty
Summary
The facility failed to protect and promote resident rights for two residents by not ensuring dignified care and privacy during daily activities. In one instance, a certified nurse assistant (CNA) assisted a resident with eating while standing above the resident, rather than positioning at eye level as required by facility policy. The resident had moderate cognitive impairment and required moderate assistance with eating. The CNA confirmed not sitting next to the resident during the meal, and the director of nursing (DON) acknowledged the importance of eye-level positioning for a dignified experience. Facility policy specifically prohibits standing over residents while assisting with meals. In another instance, a CNA entered a resident's room and uncovered the resident without closing the privacy curtain or the door, resulting in the resident's left buttock being exposed. The resident had severe cognitive impairment, was dependent on staff for all activities of daily living, and was unable to communicate. The CNA admitted to not providing privacy during care, and both an LVN and the DON confirmed that privacy is essential to maintain resident dignity. Facility policy requires staff to promote, maintain, and protect resident privacy, including bodily privacy.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for five residents, resulting in unmet care needs and lack of guidance for staff. For one resident with dementia, alcohol dependence, and heart failure, who was assessed as high risk for elopement due to daily wandering and verbalizing a desire to leave, the care plan required constant monitoring. However, the resident was not included in hourly monitoring rounds, and there was no documentation of monitoring, despite staff acknowledging the necessity of these interventions. Another resident with diagnoses including depressive disorder, diabetes, vascular dementia, and PTSD did not have a care plan addressing PTSD, even though the resident's records and physician orders indicated the presence of this condition. Staff interviews confirmed that the absence of a PTSD care plan meant that staff were not informed about how to provide appropriate trauma-informed care or avoid known triggers, as required by facility policy. Additionally, three residents who smoked did not have baseline smoking care plans in place, despite their participation in supervised smoke breaks and documented cognitive impairments. Staff interviews and facility policy confirmed that all residents who smoke should have individualized care plans to ensure safety and appropriate supervision. The lack of these care plans meant that staff did not have clear instructions on how to manage the residents' smoking activities safely.
Improper Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices within the facility's kitchen. An open bag of buttermilk pancake mix was found on a shelf without an open date, and a large plastic container of breadcrumbs was left uncovered. Additionally, containers of macaroni noodles and egg noodles were found with their lids partially off. The dietary staff member present acknowledged that she had forgotten to close the containers due to being in a hurry and confirmed the importance of keeping food covered and labeled to prevent pest intrusion and moisture exposure. She also admitted to not dating the pancake mix when it was opened, which is necessary for tracking freshness and safety. Further inspection revealed a stationary can opener with a black tarry substance on it, which the dietary staff member identified as an infection control issue, stating it should be cleaned after each use. The Dietary Supervisor confirmed that all food items must be labeled and dated upon opening, and that lids should remain closed on all containers to prevent contamination. Review of facility policies supported these requirements, indicating that all food must be clearly dated and storage areas kept clean at all times.
Failure to Document Pneumococcal Vaccination Status in Medical Records
Penalty
Summary
The facility failed to document the pneumococcal vaccination status for two residents in their medical records. Both residents had significant cognitive impairments and required varying levels of assistance with daily activities, as indicated by their Minimum Data Set (MDS) assessments. A review of their face sheets and MDS confirmed their diagnoses, including dementia, diabetes, and hypertension, and outlined their dependence on staff for personal care. However, upon examination of their medical records, there was no documentation of their pneumococcal vaccination status. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that the vaccination status for these residents was not recorded in the medical records. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, but this standard was not met in these cases.
Failure to Educate Staff on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that all 160 staff members were educated on Enhanced Barrier Precautions (EBP), which involve the use of gowns and gloves during high-contact resident care activities. This deficiency was identified through observation, interviews, and record review. Specifically, a resident with a gastrostomy tube, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed without any isolation signage or a PPE cart at their room entrance. Interviews with facility staff revealed a lack of awareness and implementation of EBP. A Licensed Vocational Nurse stated he was unaware of EBP and that the facility did not place residents on EBP. The Infection Prevention Nurse confirmed that all staff needed education on EBP, and the Director of Nursing acknowledged the need to follow CDC guidance. Review of the facility's policy indicated that all staff should be trained on EBP, with annual refreshers and ongoing audits, but this had not been carried out.
Incomplete Psychotropic Medication Consent for Resident
Penalty
Summary
The facility failed to obtain a completed psychotropic medication consent for one of six sampled residents. Interviews with nursing staff confirmed that psychotropic medication consents are required to include the resident's name, medication, dosage, route, and frequency, and must be signed by the physician. Record review for a resident with diagnoses including schizoaffective disorder and major depressive disorder, who was severely cognitively impaired and dependent on staff for all activities of daily living, showed that the resident was receiving Zyprexa Zydis via gastrostomy tube as ordered by the physician. However, the Facility Verification of Resident Informed Consent form for this resident, dated prior to the medication administration, was missing the required dosage and frequency information for Zyprexa Zydis. The facility's policy and procedure on informed consent specifies that the nature of the procedure, including probable frequency and duration, should be presented to the resident prior to obtaining consent. This omission resulted in the resident receiving psychotropic medication without a fully completed and compliant informed consent.
Call Light Not Accessible to Resident
Penalty
Summary
A deficiency occurred when a resident's call light was found on the floor behind the dresser, out of the resident's reach, while the resident was asleep in bed. Multiple staff members, including an Activities Aide, LVN, CNA, and the DON, confirmed during interviews that the call light should have been within the resident's reach at all times. The facility's policy also requires that all residents, including those who are confused, have access to the call signal at all times and know how to use it. The resident involved had a history of dementia, difficulty walking, osteoarthritis, and a previous stroke, and was assessed as having severely impaired cognitive skills and requiring assistance with personal hygiene. The resident's care plan specifically indicated that the call light should be within easy reach. The failure to ensure the call light was accessible was directly observed and acknowledged by staff, in contradiction to both the care plan and facility policy.
Failure to Attempt Less Restrictive Alternatives and Monitor Physical Restraint Use
Penalty
Summary
The facility failed to implement less restrictive alternatives before using a Geri-chair with a lap tray as a physical restraint for a resident with severe cognitive impairment and significant physical care needs. The resident, who had diagnoses including dementia, anxiety, and convulsions, was dependent on staff for most activities of daily living and was unable to make decisions or understand the use of the restraint. The Geri-chair with lap tray was ordered and used to prevent the resident from falling, but there was no evidence that less restrictive interventions were attempted prior to its implementation. Record reviews and staff interviews confirmed that the Geri-chair with lap tray was considered a restraint, and that no monitoring or ongoing assessment was conducted for its continued use. The care plan referenced the use of the Geri-chair with lap tray and included goals to prevent complications, but did not document interventions for reducing or discontinuing the restraint. Staff acknowledged that monitoring was only performed for residents with non-self-release lap bands, not for those with lap trays, and that no care plan interventions were in place to address restraint reduction for this resident. The facility's policy required that restraints only be used after less restrictive alternatives had been tried unsuccessfully, and that ongoing re-evaluation and documentation were necessary. However, both the RN and DON confirmed that less restrictive interventions were not attempted before the lap tray was introduced, and that there was no documentation or monitoring for the continued need for the restraint. This failure to follow policy and regulatory requirements resulted in the deficient practice identified by surveyors.
Failure to Accurately Complete MDS Assessment for Active Diagnosis
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident by omitting an active diagnosis of schizophrenia in Section I of the assessment, despite clear documentation of this diagnosis in the resident's medical record. The resident's admission record, history and physical, psychiatric note, and order summary all indicated a diagnosis of schizophrenia, with associated behaviors such as confabulation and uncontrollable yelling, and a prescription for Zyprexa specifically for this condition. However, the MDS assessment did not reflect this diagnosis. During an interview, the DON acknowledged that the MDS assessment was inaccurate and attributed the omission to an oversight by the MDS coordinator. Facility policy requires that MDS assessments consistently reflect information found in progress notes, care plans, and resident observations. The failure to include the schizophrenia diagnosis in the MDS assessment meant that the resident's assessment did not accurately represent his current status as required by both facility policy and regulatory standards.
Failure to Complete PASARR Level 1 Screening Prior to Admission
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) Level 1 for one resident prior to or shortly after admission. The resident in question was admitted and later readmitted with diagnoses including schizophrenia, COPD, and hypertension. Medical records indicated the resident had confusion, was unable to make medical decisions, and was rarely or never understood. The resident required varying levels of assistance with daily activities and had a psychiatric diagnosis of schizophrenia, for which antipsychotic and antidepressant medications were prescribed. Despite these indicators, the PASARR Level 1 screening was not completed until the date of the record review, well after the resident's admission. The screening ultimately indicated the presence of a serious mental illness and the need for a Level 2 screening. Interviews with facility staff confirmed that the PASARR Level 1 should have been completed prior to admission, in accordance with facility policy and federal requirements, but this was not done for the resident.
Failure to Provide ROM Interventions for Resident with Contractures
Penalty
Summary
A resident with a history of muscle weakness, chronic fractures, osteomyelitis of the left leg, and contracture of the right wrist was admitted to the facility and identified as having significant range of motion (ROM) limitations in the right hand, right wrist, and left ankle. Assessments, including the Minimum Data Set (MDS) and Joint Mobility Assessment (JMA), documented moderate to severe ROM limitations and contractures, with the resident requiring varying levels of assistance for daily activities. A physician's order was in place for the application of a hand roll to the right hand, but there were no orders or interventions for ROM exercises for the affected limbs. Observations and interviews revealed that the resident's right hand was consistently positioned in a contracted state, with minimal movement possible in the right wrist and left ankle. The Restorative Nursing Aide (RNA) reported only assisting with hand hygiene and application of the hand roll, stating there were no orders for ROM exercises despite believing the resident would benefit from them. The RNA had previously communicated this need to the unit manager, but no action was taken to initiate ROM interventions. The unit manager confirmed that she had not been informed of the need for ROM exercises and agreed that such services were appropriate for the resident's condition. Further review by the MDS Coordinator and Director of Nursing confirmed that the resident was identified as having ROM limitations but was not receiving skilled therapy or restorative nursing services to address these deficits. Facility policy required that residents with limited ROM receive appropriate interventions to maintain or improve mobility, but this was not implemented for the resident in question. The lack of appropriate services and interventions to address the resident's ROM limitations constituted the deficiency.
Failure to Monitor High-Risk Resident for Elopement
Penalty
Summary
The facility failed to monitor and document hourly rounds for a resident identified as being at high risk for elopement. The resident, who had diagnoses including dementia, alcohol dependence, and heart failure, was assessed as lacking capacity to make decisions and exhibited daily wandering behavior, hallucinations, and a verbalized desire to leave the facility. Despite these risk factors, the resident was not included on the list for hourly rounds, and there was no documentation of monitoring from April to early May. The care plan for this resident specifically indicated the need for constant monitoring due to the risk of elopement, but this intervention was not implemented. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the care plan interventions were not followed as required. The facility's own policy required identification and monitoring of residents at risk for unsafe wandering or elopement, with care plans to include detailed monitoring plans. However, the lack of documentation and failure to include the resident in hourly rounds demonstrated that these procedures were not carried out, resulting in a deficiency related to accident prevention and supervision.
Failure to Date and Replace Nasal Cannula for Resident Receiving Oxygen
Penalty
Summary
A deficiency was identified when a resident receiving oxygen therapy via nasal cannula did not have the cannula labeled with the date it was put into use. During observation, the resident was seen using a nasal cannula for oxygen delivery, but there was no indication of when the cannula had last been changed. The resident had a history of acute respiratory failure and COPD, and was dependent or required significant assistance with most activities of daily living. The physician's order specified oxygen administration as needed, but there was no documentation or labeling to track the replacement of the nasal cannula. Interviews with staff revealed that the nurse on duty had not checked or dated the nasal cannula and was unsure of the required frequency for changing the tubing. The Director of Nursing confirmed the importance of dating nasal cannulas and stated that undated cannulas should be replaced to maintain infection control standards. The facility did not have a policy or procedure in place regarding the dating and replacement of nasal cannulas, as confirmed by a review of their respiratory care policies.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to one of three sampled residents diagnosed with post-traumatic stress disorder (PTSD). The resident, who also had diagnoses of depressive disorder, diabetes mellitus, and dementia, was moderately impaired in cognitive skills and required varying levels of assistance with daily activities. Despite documentation in the resident's records indicating a diagnosis of PTSD, staff interviews revealed that the registered nurse was unaware of the resident's PTSD diagnosis and that no specific trauma-informed care or services were provided for residents with PTSD. Further review of facility policies showed that there were procedures in place for the care of residents with PTSD and for trauma-informed care, which included assessing behavioral health history and ensuring person-centered care to avoid re-traumatization. However, these policies were not implemented for the resident in question, as evidenced by the lack of staff awareness and absence of trauma-informed interventions. This deficiency was identified through interviews and record reviews, highlighting a failure to follow established protocols for residents with a history of trauma.
Medication Error Rate Exceeds Acceptable Threshold Due to Early Administration Attempt
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a rate of 7.69%. This was identified through observation, interview, and record review, where two medication errors occurred out of 26 opportunities. Specifically, a Licensed Vocational Nurse (LVN) prepared and attempted to administer a multivitamin and vitamin D to a resident at 8:30 AM, despite the physician's order specifying administration at 12:00 PM. The resident refused the medications, stating they were not scheduled to be given until later. Review of the resident's records indicated a history of paranoid schizophrenia and fluctuating capacity to understand and make decisions. The LVN acknowledged the error, stating that medications should be administered within one hour of the prescribed time, as per facility policy and physician orders. The facility's policy requires medications to be given only as prescribed, and the deviation from this protocol led to the cited deficiency.
Failure to Properly Label and Remove Expired Insulin Vials
Penalty
Summary
Surveyors observed that one opened vial of Humulin R insulin for Resident 6 was stored in a medication cart without a labeled open date, contrary to manufacturer requirements that the medication be used or discarded within 31 days of opening. During the inspection, the Licensed Vocational Nurse (LVN 1) confirmed that the vial was open but not labeled, making it unclear when the medication would expire. This lack of labeling meant staff could not determine if the insulin was still safe and effective for use. Additionally, another opened vial of Humulin R insulin for Resident 104 was found in the same medication cart with an open date that indicated it had already expired, yet it had not been removed from storage. LVN 1 acknowledged that the expired insulin should have been removed and that its continued presence in the cart was not in accordance with facility policy or manufacturer guidelines. The facility's policy requires that all drugs be stored safely and that outdated medications be returned to the pharmacy or destroyed, which was not followed in these instances.
Lack of Documentation for COVID-19 Vaccination Status Among Staff
Penalty
Summary
The facility failed to provide documented evidence that all employees, including physicians, consultants, and rehabilitation staff, were screened, educated, and offered the COVID-19 vaccine, as well as to document their current vaccination status. During an interview with the Infection Prevention Nurse (IPN) and a review of employee records, it was found that the COVID-19 immunization status for these groups was unknown, and there was no documentation to show that they had been screened, educated, or offered the vaccine. The IPN confirmed that she did not obtain the COVID-19 immunization status for these staff members. The facility's policy indicated that the COVID-19 vaccination policy applies to all employees.
Failure to Provide Staff Training on PTSD and Trauma-Informed Care
Penalty
Summary
The facility failed to provide staff education and in-service training on post-traumatic stress disorder (PTSD) and trauma-informed care for residents diagnosed with PTSD. This deficiency was identified during a review of records and staff interviews, which revealed that no in-service training on PTSD or trauma-informed care had been conducted for staff in 2024 or 2025. The facility's in-service topics binder confirmed the absence of such training, and both a registered nurse and the Director of Nursing acknowledged that staff had not received education on how to care for residents with PTSD or trauma-informed care approaches. A resident with diagnoses including depressive disorder, diabetes mellitus, dementia, and PTSD was identified as requiring specialized care due to their mental health conditions. The resident was moderately impaired in cognitive skills and required varying levels of assistance with daily activities. Despite the resident's documented need for trauma-informed care, the facility's policies requiring annual training on trauma-informed care and staff competency development were not followed, as evidenced by the lack of relevant staff training and education.
Resident Room Overcrowding Exceeds Regulatory Limits
Penalty
Summary
The facility failed to comply with the requirement that no more than four residents occupy a single room. Observations conducted between 5/5/25 and 5/8/25 revealed that three rooms each housed more than four residents, with one room accommodating five residents and two rooms each accommodating six residents. During an interview, the Administrator confirmed awareness of the room occupancy but noted there were no complaints from staff or residents regarding the number of residents in these rooms.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to meet the regulatory requirement to provide at least 80 square feet per resident in multiple occupancy rooms. A review of the Client Accommodation Analysis form dated 5/5/2025 revealed that multiple rooms, each housing three residents, measured only 210 square feet, which is less than the required 240 square feet for three residents. This deficiency was identified through documentation review and was further confirmed during room observations conducted by surveyors. During interviews, the facility administrator acknowledged the deficiency and requested a continuance of a previously granted waiver for room size requirements. Despite the room size shortfall, observations conducted over several days did not reveal any adverse effects on residents' privacy, health, or safety that could be directly attributed to the room dimensions at the time of the survey.
Failure to Supervise High-Risk Resident Leads to Injury
Penalty
Summary
The facility failed to adequately monitor and supervise a resident who was assessed as a high fall risk, resulting in the resident sustaining a right hip fracture. The resident, who had severe cognitive impairment and dementia, had previously fallen and fractured his left hip. Despite these known risks, the facility did not ensure continuous supervision, particularly when the resident was outside on the facility's patio. On the day of the incident, the resident was able to exit the building onto the patio unassisted, and staff did not respond to the sensor alarm that was triggered when the resident opened the door. The resident was observed on video surveillance walking unassisted on the patio without his front wheel walker, which was against his care plan requirements. He attempted to sit in a chair but missed and fell to the ground, remaining there for over 40 minutes before staff arrived to assist him. This lack of timely intervention and supervision was a significant factor in the resident's fall and subsequent injury. Interviews with facility staff revealed a lack of consistent monitoring and supervision protocols for high-risk residents. Staff were not assigned dedicated monitoring responsibilities, and there was a failure to respond to alarms and ensure the resident's safety. The Director of Nursing acknowledged that the resident should have been monitored more frequently due to his high fall risk and previous fall history, but this was not documented or implemented effectively.
Removal Plan
- The social services department completed an audit of Fall Risk Assessments for all residents to validate the total number of residents at high risk for falls and determined it to be 53 out of 141 residents.
- The ADM updated the facility's Zoning Map and Monitoring Log to include all external walkways, patios, and interior hallways.
- New job responsibilities/descriptions were created for staff assigned to zone monitoring which included 15-minute safety rounds. Staff assigned to monitoring will only be assigned to monitoring.
- The facility reviewed, and updated care plans for the 53 identified residents at risk for falls. The care plans were updated to include individualized fall prevention interventions and reassessed those residents who required mobility aids for compliance and proper support.
- The Director of Staff Development conducted an in-service training on the Fall/Accident Prevention Program for all nursing staff. Topics included were Fall Prevention and Resident Supervision Policies, Timely Response to Alarms and Emergency Situations, Proper Use of Mobility Aids and Resident Transfers, and Accident Investigation and Documentation Procedures.
- The DON/designee will collect and review Zone Monitoring Logs daily, and the DON and ADM will review trends in resident fall incidents, response times, and staff compliance.
Failure to Report Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who experienced an unwitnessed fall resulting in a left hip fracture. The resident, who was severely cognitively impaired and exhibited wandering behaviors, was found on the floor in his restroom and was unable to move. Despite the immediate need for an X-ray and subsequent transfer to a General Acute Care Hospital for surgery, the incident was not reported to the California Department of Public Health (CDPH) in a timely manner. Interviews revealed that the Registered Nurse (RN) reported the incident to the Administrator and the Director of Nursing, but the Director of Nursing did not recall receiving the report. The Administrator was unaware of the incident and acknowledged that it should have been reported to him and the state agency within 24 hours. The facility's policy required that such incidents be reported immediately or within 24 hours if they did not involve abuse or result in serious bodily injury, which was not adhered to in this case.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an incident where one resident slapped another on the cheek. The affected resident, who has severe cognitive impairments due to dementia and other mental health conditions, was unable to verbalize the incident. The facility's records did not indicate that a doctor was notified of the incident, and there was no evidence of a care plan being updated or implemented for the resident who was slapped. The incident involved two residents, both with dementia and behavioral issues. The resident who committed the act of aggression had a history of physical and verbal behavioral symptoms, which were documented in their Minimum Data Set (MDS). Despite this, the facility did not adequately monitor or update the care plans for both residents involved in the incident. The facility's staff, including Licensed Vocational Nurses and the Director of Nursing, acknowledged that the monitoring and documentation were insufficient, and the necessary protocols were not followed. The facility's policies on abuse prevention, change in condition, and care planning were not adhered to in this case. The staff failed to conduct a thorough investigation, notify the physician, or update the care plans to address the incident and prevent future occurrences. The lack of proper documentation and monitoring put the residents at risk of further harm and did not ensure their safety and well-being.
Failure to Ensure Active CNA Certification for Staff
Penalty
Summary
The facility failed to ensure that three out of 31 staff members had an active Certified Nursing Assistant (CNA) certificate before providing direct resident care. This deficiency was identified during a review of the December 2024 CNA monthly staff schedule and the Certificate Verification database. The database search indicated that there were no data found for the certification status of CNA 3, CNA 4, and RNA 1, all of whom were scheduled to provide direct resident care. Interviews with the Director of Staff Development (DSD) and the staff members involved revealed that CNA 3 was hired with a certificate expiration date of 11/7/2024, but the certificate was not renewed in the database. CNA 4's certificate also did not show renewal on the certificate status website. RNA 1, who must have a CNA certificate to work as a Restorative Nursing Assistant, had an initial certificate expiration of 12/11/2023 and had resubmitted his renewal form in July 2024, but the database did not reflect an active certificate. The DSD acknowledged that the staff should not work without an active certificate, as it poses a danger and indicates they may not be qualified to perform their duties. The facility's self-assessment and policies require CNAs to be certified, and the DSD is responsible for tracking licenses and certificates. Despite this, the Administrator allowed staff to work as long as renewal submissions were made. The Director of Nursing emphasized the importance of keeping track of certificates and ensuring staff are informed of upcoming expirations. The facility's policies indicate that CNAs must function within the standards of practice as accorded by their certification, highlighting the importance of maintaining active certification for staff providing direct care.
Inadequate In-Service Training for Night Shift Staff
Penalty
Summary
The facility failed to ensure that night shift staff received the same in-service training as the day and evening shifts, potentially jeopardizing resident safety due to inadequate staff education. The Director of Staff Development (DSD) admitted that in-services were conducted at different times to cover all shifts, but night shift staff were not included in certain trainings, such as those on shower procedures and cell phone policy, because they were not deemed necessary for their shift. However, the DSD acknowledged that any staff member could benefit from in-service training, and the lack of training could compromise the quality of care provided to residents. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that night shift staff occasionally performed tasks like showering residents, which they had not been trained for. The DON emphasized the importance of consistent in-service training across all shifts to ensure staff are reminded of essential care practices, such as hand hygiene and fall prevention. The facility's policies indicated that the Staff Developer was responsible for identifying staff learning needs and implementing training programs, but the inconsistency in training delivery highlighted a deficiency in this process.
Failure to Maintain Functional Self-Release Belt Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safety of a resident who was assessed as high risk for falls and was using a self-release belt while in a wheelchair. The Velcro used to secure the self-release belt was worn out and not in functional condition, which led to the resident falling out of the wheelchair and sustaining injuries. The resident, who had a history of falling, dementia, and kyphosis, was unable to understand and make decisions, making the proper functioning of the self-release belt crucial for their safety. The facility did not develop a care plan for the resident's use of the self-release belt with specific interventions to ensure safety and prevent falls. Despite the resident's high fall risk score, the care plan only included general interventions such as providing a safe environment and ensuring the self-release belt was properly secured. However, the facility did not follow its policy and procedure for managing falls and fall risks, which required staff to identify specific interventions related to the resident's risks and causes to prevent falls. The resident experienced multiple falls, including one where they fell face forward from the wheelchair, resulting in a nose fracture and head contusion. Interviews with staff revealed that the Velcro on the self-release belt was worn out and did not stick properly, leading to the resident's fall. Staff members acknowledged that the fall could have been avoided if the self-release belt was in good condition and securely fastened. The facility's failure to ensure the self-release belt was functional and to develop a comprehensive care plan contributed to the resident's fall and subsequent injuries.
Failure to Document and Monitor Restraint Use
Penalty
Summary
The facility failed to properly assess, monitor, and document the use of physical restraints for three residents, leading to a deficiency in care. Resident 1, who was diagnosed with dementia and Alzheimer's disease, was observed with a lap belt restraint while in a wheelchair. The Restraint Monitoring Flow Sheet for Resident 1 showed multiple instances where there was no documentation of releasing the restraint, assessing the restraint, or checking skin integrity over several days. Licensed Vocational Nurse (LVN) 1 confirmed that the documentation was incomplete and stated that staff should have monitored and documented the restraints every two hours. Resident 2, also diagnosed with dementia, required partial assistance for transfers and was subject to similar documentation failures. The Restraint Monitoring Flow Sheet for Resident 2 indicated numerous occasions where there was no record of releasing the restraint, assessing the restraint, or checking skin integrity. LVN 1 acknowledged the importance of monitoring restraints to prevent injuries and entrapment but noted the lack of documentation. Resident 3, with a history of dementia and a hip fracture, was similarly affected by the facility's failure to document restraint use properly. The Restraint Monitoring Flow Sheet for Resident 3 showed several instances of missing documentation for releasing the restraint, assessing the restraint, and checking skin integrity. The Director of Nursing (DON) emphasized that if care is not documented, it is considered not done, highlighting the critical nature of thorough documentation. The facility's policy on restraint use required regular observation and documentation, which was not adhered to in these cases.
Nurse Aides Working Without Required Training and Supervision
Penalty
Summary
The facility failed to ensure that six nurse aides completed a nurse aide training and competency evaluation program before allowing them to provide direct resident care without supervision. This deficiency was identified through observation, interviews, and record reviews. The nurse aides were assigned to various rooms and were responsible for providing care to residents independently, despite not having completed the necessary training and competency evaluations. Interviews with the nurse aides revealed that they were working independently without having been certified or having completed skills competencies. One nurse aide mentioned that she had been working by herself for a while, and another stated that she had started taking care of residents independently shortly after beginning her employment. The Director of Staff Development (DSD) initially claimed that nurse aides were paired with experienced CNAs, but later admitted that the aides were given their own assignments and were not supervised as required. The facility's policy and procedure on nurse aide qualification and training requirements, in accordance with the Omnibus Budget Reconciliation Act of 1987 (OBRA), mandates that nurse aides must undergo a state-approved training program and cannot be employed for more than four months without completing the necessary training and competency evaluations. However, the facility did not adhere to these requirements, leading to the potential risk of residents not receiving appropriate care due to the lack of training and supervision of the nurse aides.
Inadequate Staff Training and Lack of Lesson Plans
Penalty
Summary
The facility failed to ensure that nurse aides received the necessary in-service training upon hire and annually, as per the facility's Policy and Procedure titled Competency of Nursing Staff dated May 2019. Specifically, the facility did not provide sexual harassment or LGBTQ training to nurse aides, and only provided two hours of dementia training instead of the required five hours annually. Additionally, three nurse aides did not receive abuse training upon hire. The Director of Staff Development (DSD) acknowledged the lack of training and the absence of lesson plans for abuse or infection control in-service training, which are essential for guiding and assessing staff education. Interviews with the Director of Staff Development, Human Resources, the Director of Nurses, and the Administrator revealed that the facility's training program was not adequately implemented. The DSD admitted to not conducting the required training and not preparing lesson plans, which are crucial for ensuring comprehensive staff education. The Human Resources department also failed to provide necessary training during new hire orientation. The lack of proper training and lesson plans posed a risk to resident safety, as staff members were not adequately prepared to prevent abuse, neglect, and provide appropriate dementia care.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision during a smoking break on the patio, leading to a physical altercation between two residents. Resident 1, who has a history of dementia, bipolar disorder, and schizophrenia, was involved in the incident. The Minimum Data Set indicated that Resident 1's cognition was severely impaired, and she experienced hallucinations and delusions. During the altercation, Resident 1 elbowed Resident 2, who then retaliated by elbowing Resident 1 in the nose, resulting in a fracture. The incident occurred on the facility's patio, where only one staff member, CNA 1, was present to monitor the residents. CNA 1 was positioned at the top of the stairs, which limited her ability to intervene in the altercation. The facility's policy required two staff members to be present during smoking hours due to the large area and hidden spots on the patio. However, at the time of the incident, the second staff member had not yet arrived, leaving CNA 1 unable to prevent the altercation. Following the altercation, Resident 1 was transferred to a General Acute Care Hospital for evaluation and treatment of her injuries. The hospital's CT report confirmed a fracture and deformities in Resident 1's nasal bones, requiring a reduction procedure to realign the bones. The Director of Nursing acknowledged that the altercation could have been prevented if the residents had been redirected to sit further apart and if the appropriate number of staff had been present to monitor the patio during smoking hours.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report a physical altercation between two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. On the morning of August 18, 2024, a Certified Nurse Assistant (CNA) witnessed Resident 2 elbow Resident 1 in the nose, causing a bloody nose, bruising, and nasal deviation. Despite the immediate notification of the Director of Nursing (DON) and the Administrator, the incident was not reported to CDPH until nearly 16 hours later, at 11:55 p.m. This delay in reporting violated federal regulations and the facility's policy, which mandates that such incidents be reported immediately, but no later than two hours after the occurrence. Resident 1, who was involved in the altercation, had a medical history including dementia, bipolar disorder, and schizophrenia, with severely impaired cognition as indicated in her Minimum Data Set (MDS). The incident was documented in Resident 1's Situation Background Assessment Recommendation (SBAR) and Nurse Progress notes, which detailed the injuries and subsequent transfer to a general acute care hospital (GACH) for further evaluation. Interviews with facility staff, including the CNA and Registered Nurse (RN) who responded to the incident, confirmed the sequence of events and the failure to report the incident in a timely manner. The DON admitted to not reporting the incident immediately due to being occupied with the residents' needs, and the Administrator was unaware of the delay until later that night.
Failure in Abuse Reporting and Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to maintain oversight of the plan of correction (POC) for deficiencies identified in a previous survey related to abuse prevention and reporting. This oversight failure led to a resident-to-resident altercation resulting in physical injury to a resident, which was not reported to the Department of Public Health within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment and mental health diagnoses, who was injured during an altercation with another resident. The incident occurred when a Certified Nurse Assistant (CNA) observed two residents sitting close together on a bench. One resident, who had severe cognitive impairment and mental health issues, told the other to move away and then elbowed them. The second resident retaliated by elbowing the first resident in the nose, causing significant injury. The CNA, who was responsible for monitoring the area, reported the incident to a Registered Nurse (RN), who assessed the injured resident but was unfamiliar with the reporting process and had not received recent training on abuse reporting. The Director of Nursing (DON) and the facility Administrator were both unaware of the incident's reporting requirements and the facility's POC related to abuse prevention and reporting. The Administrator admitted that the QAPI meeting did not include discussions on abuse prevention, and the new abuse policy was not presented to the DON. This lack of communication and oversight resulted in the facility's failure to report the incident promptly, violating federal regulations and the facility's policy.
Failure to Provide Adequate Assistance During Transfer
Penalty
Summary
The facility failed to ensure that a resident, who was totally dependent on staff for care and required a two-person physical assist for activities of daily living, did not sustain an injury during a transfer. The incident involved a Certified Nurse Assistant (CNA) who transferred the resident from a Geri-chair to a bed by himself, contrary to the resident's care plan and Minimum Data Set (MDS) requirements. The CNA heard a popping sound during the transfer but did not report it to a licensed nurse, which was against the facility's policy and procedure. The resident, who had diagnoses including dementia, Alzheimer's disease, and anxiety, required dependent assistance from two or more staff for transfers and other activities. Despite this, the CNA proceeded with the transfer alone, believing that the two-person assist requirement was more applicable to female CNAs. The CNA noticed the resident became more agitated than usual during the transfer but did not consider it significant enough to report. The resident later sustained an acute comminuted displaced oblique fracture of the distal right femoral shaft, requiring surgical intervention at a General Acute Care Hospital. Interviews with facility staff, including the Unit Manager, Licensed Vocational Nurse, Physical Therapist, Director of Staff Development, and Director of Nursing, confirmed that the resident required a two-person assist for safety during transfers. The facility's policies emphasized the need for staff to seek assistance when necessary and to report any changes in a resident's condition. The failure to adhere to these protocols resulted in the resident's injury and subsequent hospitalization.
Delay in STAT X-ray for Resident with Fracture
Penalty
Summary
The facility failed to ensure a STAT X-ray was ordered and conducted immediately for a resident who experienced swelling and pain following a transfer from a Geri-chair to a bed. The resident, who had a history of dementia, Alzheimer's disease, and anxiety, was admitted to hospice care. On the day of the incident, the resident was found with swelling above the right knee and posterior thigh, accompanied by facial grimaces and moaning during repositioning. Despite these symptoms, there was a delay in ordering and obtaining the X-ray. The STAT X-ray was ordered at 2 p.m., but the X-ray technician did not arrive promptly, and there was no follow-up to ensure the technician's timely arrival. The Unit Manager and Licensed Vocational Nurse (LVN) involved did not document the X-ray order as STAT, and there was a lack of communication and follow-up with the hospice physician. The X-ray results, which indicated a serious fracture, were not received until 8:27 p.m., over six hours after the order was placed, and there was no documentation of when the facility staff received the results. Interviews with family members and staff revealed concerns about the delay in obtaining the X-ray results and the resident's prolonged pain. The Director of Nurses acknowledged that the results of a STAT X-ray should be received within four hours, but this was not achieved. The facility's policy indicated that diagnostic services should be promptly carried out as instructed by the physician's order, which was not adhered to in this case.
Delayed CPR Response for Unresponsive Resident
Penalty
Summary
The facility failed to ensure that nursing staff immediately initiated basic life support, including CPR, for a resident who became unresponsive in the dining room. The resident, who had a Full Code status, was found unresponsive, not breathing, and without a pulse. Instead of starting CPR immediately, the staff delayed the process by moving the resident from the dining room to his room, which resulted in an eight-minute delay before CPR was initiated. The incident involved a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) who did not follow the appropriate emergency response protocol. The CNA initially performed the Heimlich maneuver, suspecting the resident was choking, but the resident remained unresponsive. The LVN assessed the airway and found no obstruction but did not initiate CPR or call 911 immediately. The decision to move the resident to his room for privacy and to avoid alarming other residents further delayed the initiation of life-saving measures. The resident, who had a history of severe cognitive impairment, blindness, hypertension, seizure disorder, and dementia with psychosis, was pronounced dead after the delay in CPR. The failure to act promptly and follow established emergency procedures placed other residents with Full Code status at risk of not receiving timely life-saving measures.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was under conservatorship and assessed as high risk for elopement. The resident, who had a history of attempted elopement, successfully climbed over the patio fence and left the facility unsupervised. This incident occurred despite a previous attempt by the same resident to elope by climbing the fence, which should have prompted the facility to implement preventive measures. The facility did not accurately assess the resident for wandering and elopement risk, as evidenced by the lack of elopement risk assessments on two occasions. Additionally, the resident's care plan did not include interventions to prevent elopement, even after a previous attempt. The staff failed to supervise the resident adequately, particularly when the resident was on the patio, and did not respond to the alarm when the patio door was opened, allowing the resident to elope. Interviews with staff revealed that the resident was known to wander and was considered a high risk for elopement, yet was not placed on 1:1 monitoring. The facility's policy on elopement prevention was not followed, as there was no documentation of an interdisciplinary team meeting or investigation following the resident's previous elopement attempt. The lack of supervision and failure to implement appropriate interventions contributed to the resident's successful elopement.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide evidence of a thorough investigation of a resident-to-resident altercation between two residents. Resident 1, who has unspecified dementia and mild cognitive impairment, reported that Resident 2, who has Alzheimer's disease and dementia with behavioral disturbances, physically assaulted her. Resident 1 had multiple superficial scratches on her face and expressed feeling unsafe as long as Resident 2 was in the facility. Resident 2 denied any recollection of the incident and did not provide any information about it. The facility's Administrator stated that an investigation was conducted, but it was only verbal, and no written documentation was available. Additionally, the Administrator could not provide evidence that the five-day summary report was submitted to the California Department of Public Health (CDPH), as required by the facility's policy and procedure on abuse investigation. The facility's policy mandates that all reports of resident abuse be promptly and thoroughly investigated, with interviews conducted with the person reporting the incident, any witnesses, and staff members who had contact with the resident during the period of the alleged incident. The investigation should be concluded within five working days, and a copy of the completed Resident Abuse Investigation Report Form should be provided to the administrator within this timeframe. The failure to document the investigation and submit the required five-day summary report to CDPH resulted in the allegation of abuse not being thoroughly investigated and the conclusion of the facility's investigation not being known by CDPH.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to proper kitchen hygiene and food storage practices, as observed during a survey. An opened salmon fillet was found undated and improperly stored on top of a box of pork in the refrigerator. This practice was contrary to the facility's policy, which requires all opened food items to be dated, wrapped, and stored correctly to prevent contamination. The Dietary Supervisor acknowledged the error, stating that the salmon should have been wrapped, dated, and placed at the bottom of the refrigerator to avoid potential contamination from drips. Interviews with the Dietary Supervisor and a cook revealed a lack of adherence to established protocols for food storage and dating. The Dietary Supervisor admitted to not knowing how the salmon ended up in the incorrect position and emphasized the importance of proper storage to prevent contamination. The cook confirmed the requirement to date opened items and store raw fish at the bottom of the refrigerator, indicating a lapse in following these procedures. The facility's policy clearly outlines the need for proper labeling and storage of food items to ensure safety and prevent foodborne illnesses.
Failure to Monitor and Document Restraint Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary physical restraints, as required by regulations. Resident 8 was observed with a lap belt restraint in a wheelchair, which was intended to prevent falls due to poor safety awareness. However, there was no ongoing assessment or documentation of the restraint's necessity or effectiveness. The care plan for Resident 8 included monitoring for circulatory problems and skin integrity, but these checks were not documented consistently. Similarly, Resident 58 was found with a lap buddy restraint in a wheelchair to prevent unassisted standing due to mobility issues and a history of falls. The care plan required regular monitoring and assessment of the restraint, but documentation was lacking. Interviews with staff revealed that assessments were not consistently recorded, and the facility had only recently begun documenting restraint checks. Resident 69 also had a lap belt restraint while in a wheelchair to prevent unassisted standing. Despite the requirement for regular monitoring and assessment, there was no documentation of these activities in the resident's chart. Staff interviews confirmed the absence of documentation and highlighted the potential risks of not monitoring restraints, such as impaired circulation and skin breakdown. The facility's policy emphasized the right of residents to be free from restraints and required alternative interventions to be attempted and documented before using restraints, which was not adhered to in these cases.
Failure to Conduct Employee Background Checks
Penalty
Summary
The facility failed to protect the health, welfare, rights, and safety of all 123 residents by not conducting background checks on potential employees. This deficiency was identified during a review of the employee roster and personnel files, which revealed that since the last recertification in 2021, 1,005 new employees were hired without documented evidence of background screening. Interviews with the human resources department, the Director of Staff Development, the Director of Nursing, and the Administrator confirmed that the facility only conducted reference checks and did not perform background checks on prospective employees. The facility's policy and procedure titled 'Abuse Prevention Program,' revised in December 2016, explicitly stated that employee background checks should be conducted as part of the resident abuse prevention strategy. The policy also indicated that the facility should not knowingly employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment. The failure to adhere to this policy placed residents at risk for abuse and neglect, as the facility did not ensure that employees did not have a criminal background.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the responsible party of Resident 73 was informed in advance about the risks and benefits of psychotropic medication, specifically Seroquel, which was prescribed for agitation and dementia with psychotic behavior. The resident was admitted with diagnoses including anxiety, dementia, and mood disturbances, and required substantial assistance with daily activities. The physician's order for Seroquel was not accompanied by a signed informed consent from the physician, which is a requirement according to the facility's policy. The medication was administered on several occasions without this consent. Interviews with the Director of Nursing and RN Supervisor confirmed that informed consent is crucial due to the potential side effects of psychotropic medications, such as extrapyramidal symptoms, palpitations, and lethargy, which could lead to falls. The facility's policy mandates that informed consent must be obtained and signed by the physician before administering such medications. The lack of a physician's signature on the informed consent form for Seroquel indicates a violation of the resident's right to make an informed decision regarding their treatment.
Failure to Assess and Report Toe Discoloration
Penalty
Summary
The facility failed to identify and assess a resident who exhibited black discoloration and pain on the second toe of the right foot. The resident, who was admitted with diagnoses including mesothelioma, idiopathic neuropathy, and cirrhosis of the liver, had moderately impaired cognitive skills and required assistance with daily activities. Despite the presence of black discoloration and pain, the condition was not reported or assessed by the staff. A Certified Nursing Assistant (CNA) observed the discoloration during a shower but did not notify the charge nurse, as the resident was not in pain at that time. A Licensed Vocational Nurse (LVN) also failed to notice the discoloration when applying ointment to the resident's great toe. The Director of Nursing (DON) later identified the discoloration as potentially indicative of a wound and emphasized the importance of reporting such abnormalities to a physician. The facility's policy and procedure on Quality of Care mandates the identification and provision of needed care and services, including the immediate reporting of skin abnormalities. The failure to assess and report the resident's condition could have led to a delay in treatment and care, as the facility did not adhere to its policy of reducing wait and harmful delays in care.
Failure to Provide Psychiatric Consult for Resident on Antipsychotic Medications
Penalty
Summary
The facility failed to provide a psychiatric consult for a resident who was receiving antipsychotic medications. The resident, identified as having severe cognitive impairment and a history of mental health issues including unspecified dementia, alcohol dependence, and bipolar disorder, was admitted to the facility with these diagnoses. Despite being on medications such as olanzapine, Haldol, trazodone, and Namenda, there was no evidence of a psychiatric evaluation being conducted since the resident's admission. This lack of evaluation was confirmed through interviews with the resident's family member, who expressed concern over the absence of a psychiatric consult, and facility staff who were unable to provide documentation of any such request. The facility's policy on psychotropic medication use requires a comprehensive assessment by a physician or prescriber to ensure the necessity of such medications. However, interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed a lack of clarity and action regarding the process for obtaining psychiatric evaluations for residents on psychotropic medications. The DON acknowledged the importance of psychiatric evaluations but cited a change in the resident's primary doctor due to medical insurance as a reason for the delay. Despite this, there was no documented evidence of any request made for a psychiatric consult, highlighting a deficiency in the facility's adherence to its own policies and procedures.
Failure to Monitor Xarelto Side Effects
Penalty
Summary
The facility failed to monitor the side effects of Xarelto, a medication used to prevent blood clots, for one of its residents. This resident, identified as Resident 315, was admitted with diagnoses including atherosclerotic heart disease and lobar pneumonia. The resident's records indicated impaired cognitive skills and a need for assistance with daily activities. Despite having a care plan that highlighted the potential for bleeding due to Xarelto and aspirin, there was no physician order or documentation in the Medication Administration Record (MAR) to monitor for side effects such as bleeding gums, bruises, or black tarry stool. Interviews with facility staff, including a Licensed Vocational Nurse (LVN 2), a Registered Nurse Supervisor (RNS1), and the Director of Nursing (DON), confirmed the absence of monitoring orders and documentation for Xarelto's side effects. The facility's policy on unnecessary medications emphasized the need for adequate monitoring, which was not adhered to in this case. This oversight had the potential to place Resident 315 at risk for undetected and potentially life-threatening side effects of Xarelto.
Inadequate Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to observe proper infection control measures during a medication pass, as observed on May 9, 2024. A Licensed Vocational Nurse (LVN 4) did not practice hand hygiene between tasks while preparing medications. Specifically, LVN 4 entered the medication storage room, accessed the refrigerator, and handled containers of medicines on the medication cart without washing her hands. This action was confirmed during an interview with LVN 4, who acknowledged the lapse in hand hygiene and its potential to spread infection and contaminate other medicines. The Infection Preventionist Nurse (IPN) emphasized the necessity of hand hygiene during medication administration to prevent the transfer of germs to residents. A review of the facility's policies and procedures revealed that handwashing is required before and after resident care and after handling contaminated articles. Additionally, the facility's medication administration policy underscores the importance of infection control during medication passes.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a visible and prominent place daily, as required. During observations on May 7, 2024, and May 10, 2024, no visible staffing information was found at the nursing stations or in the lobby of the facility. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the staffing information was only posted by the time clock, which is not easily accessible to residents and visitors. The DON acknowledged that the information should be posted in other areas such as the nursing stations and the lobby to ensure visibility for family and visitors.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to meet the requirement of providing at least 80 square feet per resident in multiple resident bedrooms. This deficiency was identified during a review of the facility's Client Accommodation Analysis form, which was provided by the Administrator on May 7, 2024. The form indicated that several rooms, specifically room numbers 5, 6, 7, 8, 9, 10, 16, 17, 18, 19, 20, 36, 37, 38, 51, 52, 53, 54, 55, 56, 57, 58, 62, 63, 49, 40, and 61, did not meet the required space per resident. During an interview with the Administrator, a request was made to continue the previously granted waiver/variance for room size for the year 2024. Observations and interviews with residents conducted from May 7 to May 10, 2024, revealed no adverse effects on residents' privacy, health, and safety due to the room sizes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Long Beach Care Center, Inc | 0 mi | ★★★★★ | 47 | 0 |
| Ocean Ridge Post Acute | 1.1 mi | ★★★★★ | 23 | 0 |
| Coral Cove Post Acute | 1.1 mi | ★★★★★ | 45 | 0 |
| Courtyard Care Center | 1.5 mi | ★★★★★ | 28 | 0 |
| Marlora Post Acute Rehab Hosp | 1.5 mi | ★★★★★ | 31 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.