Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Intercommunity Care Center during CMS and state inspections, most recent first.
A resident with schizophrenia and severe cognitive impairment received Zyprexa for psychotic symptoms and Remeron for right hand tremors, but staff could not show that non-pharmacologic interventions were provided before the psychotropic medications were given. The LVN also stated there was no documentation that the resident’s hand tremors were being monitored, and the DON noted that behavior monitoring should be documented so the psychiatrist can review whether the medications should continue.
Late Quarterly MDS Assessments for Five Residents: The facility failed to complete quarterly MDS assessments on time for five residents. Residents with diagnoses including schizophrenia, bipolar disorder, dementia, DM, metabolic encephalopathy, and mobility impairment had assessments showing cognitive impairment and assistance needs, but the MDS nurse confirmed the quarterly reviews were overdue or not completed. The MDS nurse, DON, and ADMIN stated MDSs must be completed timely to reflect current status and support care planning.
A facility failed to develop and implement person-centered care plans for a resident with PTSD and another resident with skin-picking behavior, and it also missed required quarterly JMA for two residents with ROM limitations. The PTSD care plan did not identify specific triggers, while a resident with dementia and skin-picking disorder was observed scratching until bleeding with long, untrimmed fingernails despite a care plan to keep nails short. In addition, two residents with contractures and RNA ROM programs did not receive quarterly JMA as directed by their care plans, and one later showed worsened contractures on PT evaluation.
A facility failed to prevent multiple accident hazards and supervision lapses. A resident with gait impairment and hemiplegia was observed using a FWW incorrectly, another resident was pushed while seated on a rollator despite a warning not to move it while seated, an unsecured electrical panel was left accessible in a hallway, and a cognitively impaired resident was observed entering another resident’s room and restroom. Staff interviews confirmed the unsafe conditions and that the residents involved had cognitive or mobility limitations.
An RN order to monitor a resident’s pupil for fixed and dilated changes was not carried out, and an LVN did not know how to identify ordered diet textures using the facility’s color-coded tray system. In a separate event, a CNA spoke to a resident in a stern and disrespectful manner, and the resident said the interaction made him feel the CNA did not like him. Orientation records for the CNA were incomplete for Resident Rights and handling inappropriate behavior.
Medication Error Rate Exceeded 5%: The facility had 3 medication errors out of 31 opportunities, resulting in a 9.68% error rate. One resident with DM did not receive ordered metformin at the scheduled time, and another resident with Alzheimer's disease, a G-tube, and GERD had ordered midodrine and esomeprazole unavailable during the med pass. The DON stated medications should be given as prescribed, and facility policy required meds to be administered within the ordered time frame and refilled so they remain available.
Medication labeling and storage errors were identified during cart checks. An LPN found one resident’s opened insulin past the discard date, Acidophilus stored outside the refrigerator instead of per label instructions, one resident’s used Lantus Solostar without a date opened, and another resident’s unopened Lantus Solostar not refrigerated as directed. The DON stated proper labeling and storage were needed to maintain medication effectiveness.
Mechanical soft diet meals were not prepared according to the menu recipe when a Dietary Aide placed whole, uncut parsley on plates after calling out chopped during lunch prep. The DS stated the recipe should have been followed as written, the RD stated residents on a mechanical soft diet should not receive uncut parsley, and the DON stated not following the menu recipe can place residents at risk for aspiration.
Expired Food Storage and Dirty Ice Machine: The facility failed to dispose of a container of shredded coconut labeled with a use-by date and failed to keep the ice machine free of dirt. A DS observed the coconut in dry storage and stated the date should indicate the use-by date. DA 1 observed black and gray matter along the internal wall of the ice chute, and the DS stated the dirty ice machine increased the risk for contaminated ice and cross-contamination.
A CNA spoke sternly to a resident with paranoid schizophrenia, anxiety, insomnia, and impaired decision-making when directing him to his room and telling him to sit down. The resident later stated he felt the CNA did not like him and thought he had done something wrong. The CNA acknowledged she should have used a respectful tone, and the RNS and DON stated residents should be approached calmly and treated with dignity and respect.
A resident with schizophrenia, severe cognitive impairment, delusions, and functional dependence had incomplete psychotropic informed consent for Zyprexa because the manifested behavior for the indication was not documented. The facility also did not renew informed consent for Remeron every 6 months; the SSD stated the consent was outdated and the DON stated renewal is needed so the resident and/or representative remains informed of the medication’s indications, risks, and benefits.
A resident with paranoid schizophrenia, Type II DM, anemia, and moderate cognitive impairment told staff she no longer wanted fish every lunch and dinner, but fish continued to be served and the tray label still reflected the old preference. The RD and DS both acknowledged the resident’s request and that the preference was not updated in time, despite facility policy requiring assessment of food likes/dislikes and reasonable efforts to accommodate resident choices and preferences.
The facility did not complete a COC or notify the MD when one resident with severe cognitive impairment repeatedly refused and removed prescribed knee and ankle splints, and restorative records showed worsening ROM with PT later documenting increased ankle contractures and a new right knee contracture. The facility also did not notify the MD when another resident with hemiplegia and a fall history began using a FWW improperly by pulling it behind them, despite staff observing the unsafe gait pattern and the care plan identifying the resident as at risk for falls.
A resident entered a shared room and used the restroom in another resident’s room when her own restroom was out of order. The room belonged to residents with severe cognitive impairment, and staff stated residents were usually directed to an unoccupied room but none was available. The DON stated residents should be redirected and not allowed into other residents’ rooms because it invades privacy.
A facility failed to provide a safe, comfortable, and homelike environment when two residents were observed without pillows on their beds and a third resident’s restroom had peeling paint. One resident had severe cognitive impairment and needed extensive assistance with ADLs, while the other had moderate cognitive impairment and needed substantial assistance with care. Both residents stated they wanted pillows, and a CNA said they should have them. The DON also stated residents should feel comfortable in their own home, and staff noted the peeling paint looked bad.
Abdominal Binder Used Without Required Consent, Assessment, Care Plan, or Monitoring: A resident with Alzheimer's disease, dementia, a g-tube, and significant functional dependence was observed wearing an abdominal binder ordered to prevent tube pulling. Staff stated the binder could be a restraint and that informed consent, a restraint assessment, monitoring, and a care plan were required, but the facility had no record of consent, no restraint assessment, no abdominal binder care plan, and no monitoring documentation.
Failure to keep a resident’s fingernails trimmed and clean led to observed scratching with bleeding to the head, forehead, and ear. The resident had schizophrenia, bipolar disorder, skin-picking disorder, and dementia, and was severely cognitively impaired. Staff observed long, sharp, unclean nails with blood on the fingers, while CNA could not confirm when nail care was last done or provide documentation of grooming or refusal. The care plan called for keeping fingernails trimmed short to reduce injury, but staff did not implement that intervention.
Failure to Carry Out Ordered Eye Monitoring: A resident with glaucoma, Type II DM, and cognitive impairment was seen by an optometrist, who ordered RN monitoring of the right pupil for fixed or dilated changes and to notify the MD if present. Record review showed the order was not carried out, and the LVN and DON confirmed the monitoring was not completed.
A facility failed to provide ROM services and splinting oversight for two residents. One resident with schizophrenia, osteoarthritis, severe cognitive impairment, and lower-extremity ROM limits had PT identified contractures and needed ankle splints, but no further PT treatment was provided to establish a safe splint wear time, and the resident later refused the new ankle splints during RNA care. Another resident’s OT eval for left-hand ROM impairment did not objectively measure the deficits, OT did not document splint tolerance or wear-time trials, and the RNA order for the left-hand splint did not include wear-time parameters.
Failure to Identify PTSD Triggers and Provide Trauma-Informed Care: A resident with PTSD, depression, insomnia, and a history of war trauma was observed in a dark room with the door closed because bright lights and loud noises triggered nightmares. Staff stated they were unaware of his specific triggers, and the care plan contained only generic PTSD interventions rather than resident-specific approaches. The SSD was not aware of the triggers, and the DSD could not provide evidence of trauma-informed care in-service training.
Missing Annual CNA Performance Evaluations: The facility failed to ensure two of five CNAs had annual performance evaluations. The DSD reviewed the employee files and confirmed the evaluations were not completed, despite the facility P&P requiring evaluations at the end of the 90-day probationary period and at least annually thereafter. The DSD and DON stated the evaluations were used to assess staff knowledge and skills for resident care.
A resident with Alzheimer's disease, dementia, and a gastrostomy tube did not have prescribed midodrine available for scheduled administration after the last dose was given. During a med pass, an LVN stated the medication was unavailable and would need to be obtained through hospice. The DON stated medications must be available as ordered to avoid interruptions in care, and facility policy required timely ordering of refills before the last dose was used.
Failure to Notify Physician When Midodrine Was Unavailable: A resident with Alzheimer's disease, gastrostomy, and dependence for all ADLs had an order for midodrine via GT every 8 hours for hypotension. During a med pass, an LVN stated the medication was unavailable and planned to contact hospice, but the EMR had no COC documentation and the physician was not notified when the dose was missed. The MAR later showed low BP readings, and staff and the DON stated the physician should have been notified when the medication was unavailable and when the resident's BP dropped.
The facility failed to keep accurate and complete records for two residents. One resident with severe cognitive impairment and ROM limitations had two JMA forms left unsigned, and staff could not identify who completed them. Another resident with Alzheimer's disease and a G-tube had prescribed midodrine unavailable, yet the MAR still showed the medication as given even though an LPN documented that the refill had been requested and the dose was not on hand.
Improper Disinfection of Porous Bed Foam: A resident with impaired cognition and multiple care needs had padded side rails and bed frames wrapped in porous foam that were cleaned with diluted bleach by HK staff. The HK stated she used bleach on all equipment and did not know the product was not for porous surfaces, while the MS and IPN stated the bleach was intended only for hard, non-porous surfaces and that the foam material was not appropriate for that use.
Antibiotic stewardship was not implemented for a resident with schizophrenia, bipolar disorder, skin-picking disorder, and dementia. The resident was observed scratching the head with bleeding and severe itching, while the treatment record showed daily Clindamycin Phosphate 1% lotion had been used for self-inflicted excoriations on the face, scalp, and ears without a documented indication or end date. Staff, including the TXN, IPN, and FPC, were unaware of the antibiotic order details, and no Loeb's Minimum Criteria assessment was completed.
Unsafe Resident Care Equipment: Two residents had worn and damaged care equipment in use. A resident with a history of falls had a torn bedside floor mat that did not extend the full length of the bed, and staff confirmed it was ripped and unsafe. Another resident who used a WC had torn armrests with exposed foam and a ripped pommel cushion with duct tape and exposed foam; staff stated the damaged equipment could scratch the resident's skin and should not be used in that condition.
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.
Failure to Document Non-Pharmacologic Interventions and Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to provide non-pharmacologic interventions before administering psychotropic medications to one resident with schizophrenia and a resting tremor of the right upper extremity. The resident was admitted to the facility on 2/26/2021 and later readmitted with diagnoses including schizophrenia and resting tremor. The resident’s H&P dated 3/14/2026 indicated fluctuating ability to understand and make decisions, and the MDS dated 3/10/2026 indicated severe impairment in thinking or decision-making and delusions. The MDS also showed the resident needed staff supervision or assistance with multiple activities of daily living. During record review and interviews, the resident had an order for Zyprexa 10 mg daily for schizophrenia manifested by complaining of people stealing from him, and an order for Remeron 15 mg nightly for right hand tremors. The LVN stated the Remeron order for hand tremors needed clarification and that there was no documentation showing the resident’s hand tremors were being monitored. Another LVN stated there was no indication that nonpharmacological interventions were provided prior to administration of Zyprexa and/or Remeron. The DON stated non-pharmacological interventions should be documented in the MAR with behavior management tasks and that it was important to monitor and document the medication’s indicated manifested behavior so the psychiatrist can review the behaviors and decide whether to decrease or continue the medications.
Late Quarterly MDS Assessments for Five Residents
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed and transmitted within the required OBRA time frame for five sampled residents. For Residents 21, 34, and 123, the quarterly MDS assessments were not completed within the mandated 92-day schedule. For Residents 12 and 88, the quarterly MDS assessments were also late and were still in process when reviewed by the MDS nurse. Resident 21 was admitted with diagnoses including paranoid schizophrenia, DM, and extrapyramidal disorder. The H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed severely impaired cognitive skills for daily decision making and need for assistance with eating, hygiene, showering, dressing, bed mobility, and transfers. During interview and record review, the MDS nurse stated the resident’s last MDS was completed and transmitted on 2/12/2026 and no MDS had been completed after that; the quarterly assessment due 5/4/2026 was not completed. Resident 34 was admitted with bipolar disorder, schizophrenia, and blindness of the left eye. The H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed moderately impaired cognitive skills for daily decision making and need for assistance with eating, hygiene, dressing, showering, bed mobility, and transfers. The MDS nurse stated the last MDS was completed and transmitted on 2/10/2026 and no MDS had been completed after that; the quarterly assessment due 4/30/2026 was not completed. Resident 123 was admitted with dementia, DM, and schizophrenia. The H&P stated the resident could make needs known but could not make medical decisions. The MDS showed severely impaired cognitive skills for daily decision making and need for assistance with showering, personal hygiene, eating, oral hygiene, toileting hygiene, dressing, bed mobility, and transfers. The MDS nurse stated the last MDS was completed and transmitted on 2/12/2026 and no MDS had been completed after that. Resident 12 had diagnoses including metabolic encephalopathy and muscle wasting and atrophy, and the MDS showed severe cognitive impairment with assistance needs for eating, transfers, bathing, dressing, oral hygiene, and bed mobility. The MDS nurse stated the last MDS was completed on 2/2/2026 and the quarterly MDS due 5/2/2026 was late. Resident 88 had diagnoses including difficulty walking and paranoid schizophrenia, and the MDS showed moderately impaired cognitive skills with assistance needs for eating, oral hygiene, dressing, and transfers. The MDS nurse stated the last MDS was completed on 2/12/2026 and the quarterly MDS due 5/14/2026 was late. The MDS nurse stated MDS assessments were required on admission, quarterly, annually, and with significant change in condition, and that timely completion was necessary so the information accurately reflected the resident’s current status. The administrator and DON stated MDS assessments should be completed timely because resident care and treatment are based on the resident’s current health status and the assessments support care planning. Facility policy stated OBRA-required assessments, including quarterly assessments, must be performed for all Medicare and/or Medicaid certified nursing home residents, and the resident assessment coordinator is responsible for ensuring timely assessments.
Incomplete person-centered care plans and missed joint mobility assessments
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for residents with PTSD, skin excoriation from scratching, and joint mobility needs. For one resident with PTSD, the care plan addressed risk for ineffective coping and instructed staff to monitor early signs of PTSD symptoms and encourage the resident to identify and avoid known triggers, but the Minimum Data Set Nurse stated the plan did not identify the resident’s specific triggers and the interventions were not resident-specific. During observation, the resident stated he wanted his door closed and the lights off because he was sensitive to bright lights and loud noises, and he reported that exposure to those stimuli caused nightmares about war. The resident also stated he was taking a sleeping pill due to insomnia. For another resident with schizophrenia, bipolar disorder, skin-picking disorder, and dementia, staff observed the resident scratching her head while bright red blood was present on her head, forehead, and left ear. Her fingernails were long, sharp, jagged, unmanicured, and unclean, with dried and fresh blood on her fingers and nails. The resident stated her head, forehead, and ears were extremely itchy and that she could not stop scratching constantly. Her care plan identified a pattern of picking at skin, scalp, and ears and included keeping fingernails trimmed short to reduce the risk of injury, but the MDS Nurse stated staff failed to implement that intervention. The facility also failed to complete quarterly joint mobility assessments for two residents whose care plans required them. One resident with schizophrenia and osteoarthritis had an RNA program for PROM to both lower extremities and splints to the left knee and both ankles, and the care plan called for quarterly JMA. The only JMA in the record was from the prior year, and a PT evaluation later found increased ankle contractures and a new right knee contracture. Another resident with unsteadiness on feet and left hand contracture had an RNA program for BUE AAROM and left finger PROM, and the care plan also required quarterly JMA. The only JMA in the record was from the prior year, and staff stated quarterly assessments had not been completed as required by the care plan.
Unsafe resident supervision and environmental hazards
Penalty
Summary
The facility failed to ensure Resident 122 was reevaluated by PT after the resident began pulling the front wheel walker behind them instead of pushing it in front while walking. Resident 122 had diagnoses including history of falling, abnormalities of gait and mobility, and left-sided hemiplegia, and the record also indicated cognitive impairment and need for staff assistance with multiple activities of daily living. The care plan identified that the resident was using the front wheel walker improperly and included supervision and education interventions, but PT 1 stated the resident would have benefitted from a PT evaluation to address the walker use. Staff observed the resident walking in the hallway with the walker behind them, and CNA 1 stated this was how the resident always walked with it. The facility also failed to ensure an electrical panel in the hallway across from the smoking patio was secured and not easily accessible. During observation, the panel was unsecured, had no lock, and could be opened so the circuit breakers were accessible. The maintenance supervisor stated a resident could open it and switch off breakers for lighting, air conditioner units, and water heaters. The DON stated there was a safety risk if lights abruptly shut off because residents could fall if visibility was reduced. The facility further failed to ensure safe use of mobility equipment when a CNA pushed Resident 112 while the resident was seated on a rollator walker. Resident 112 had schizophrenia, dementia, depression, severe cognitive impairment, and used a walker for ambulation. The CNA stated the resident had just finished a shower and was pushed back to the room while sitting on the rollator seat. The rollator had a warning label stating not to move it while seated, and PT 1 stated residents were not to be seated on a rollator walker while it was being pushed. The facility also failed to identify and control resident safety concerns when Resident 144 was observed entering another resident's room, including the restroom, and then exiting through that room. Resident 144 had schizophrenia and moderate cognitive impairment and was able to walk with supervision or touching assistance. Family Member 1 stated other residents frequently entered Resident 61's room and used the restroom. The DON stated residents were to be redirected and not allowed into other residents' rooms, and that entering another resident's room posed a safety risk.
Uncarried Physician Order, Diet Tray Competency Gap, and Disrespectful CNA Interaction
Penalty
Summary
Nursing staff failed to carry out a new physician order for a resident with glaucoma, type II DM, and frontotemporal neurocognitive disorder. The resident’s record showed that an optometrist/MD issued an order for an RN to monitor the right pupil daily for one week for fixed and dilated changes and to call the MD if those changes occurred. Review of the licensed personnel weekly progress notes did not show that the monitoring was done, and during interview and record review, LVN 7 stated the order was not carried out. LVN 7 stated the nurse who took the order should have endorsed it to an RN, completed a change of condition, and started a monitoring task, but that was not done. The DON also stated the order was not carried out and that physician orders are important because they ensure the proper treatments are being done. Nursing staff also failed to demonstrate competency in checking resident meal trays using the facility’s color-coded diet system. During lunch service preparation, dietary staff were observed placing whole uncut parsley on plates while calling out chopped. LVN 7 stated there was no way to know the physician-ordered diet texture unless the order was checked in the chart. The DS explained that black labels indicated pureed food, orange labels indicated chopped foods, and blue labels indicated regular texture food. The RD stated nursing checks trays before distribution and should be able to identify the ordered food texture based on the color-coded system. The in-service training attendance sheet for the dining room diet color code showed only CNAs were in-serviced, and LVN staff were not included. A CNA also spoke to a resident in a disrespectful and stern manner. A resident with paranoid schizophrenia, anxiety disorder, and insomnia, whose H&P stated he did not have the capacity to understand information and make decisions, was observed interacting with another resident in the hallway when CNA 4 approached and sternly told him to go to his room and sit down. The resident later stated that CNA 4 did not like him because of the way she spoke to him and that he thought he had done something wrong that made her mad at him. CNA 4 stated she should have used a respectful tone of voice. The DSD reviewed CNA 4’s orientation record and found no initials for Resident Rights or Handling Residents with Inappropriate Behavior, and no trainer signature or date of evaluation, and stated the orientation was not completed.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5%, with 3 medication errors out of 31 total opportunities for an overall error rate of 9.68%. The errors affected two residents observed during medication administration: one resident did not receive prescribed metformin at the scheduled time, and another resident had two ordered medications unavailable for administration. One resident was admitted with diagnoses including hypertension, paranoid schizophrenia, and diabetes mellitus, and records showed impaired decision-making and need for varying levels of assistance with activities of daily living. During a medication pass observation, the resident refused medications including metformin. The physician order report showed metformin 850 mg was ordered twice daily with food at 7:00 a.m. and 5:00 p.m., and the LVN stated the medication should be given with food within the two-hour window or timed with breakfast to reduce stomach upset. A second resident was admitted with diagnoses including Alzheimer's disease, gastrostomy, and GERD, and records showed the resident was unable to make needs known and was dependent on staff for all ADLs. During a medication pass observation, the LVN stated the resident's midodrine and esomeprazole were unavailable. The medication orders included midodrine 5 mg via gastrostomy tube every eight hours for hypotension and esomeprazole daily for GERD. The DON stated medications should be administered as prescribed to treat symptoms, illnesses, or disease, and the facility policies required medications to be administered according to prescriber orders and refilled in time to remain available.
Medication Labeling and Storage Errors
Penalty
Summary
The facility failed to ensure that Resident 50’s Humulin R insulin with an open date of 4/30/2026 was discarded after the required time period. During a concurrent observation and interview on 6/9/2026, LVN 2 observed the medication cart and stated the insulin should have been discarded on 5/28/2026 and replaced with a new vial. Resident 50’s record showed diagnoses including diabetes mellitus, dementia, and bipolar disorder, and the resident was receiving insulin. The facility also failed to store Acidophilus according to the manufacturer’s instructions. During the same observation, LVN 3 found Acidophilus that had been opened on 6/4/2026 and was being stored in the medication cart instead of the refrigerator. LVN 3 stated the supplement should have been refrigerated as directed on the label, and that failure to do so would affect its effectiveness. In addition, Resident 64’s used Lantus Solostar was not labeled with the date opened, and Resident 7’s unused Lantus Solostar was not refrigerated as indicated on the pharmacy label. Resident 64’s record showed diabetes mellitus and severe impairment in decision-making, and Resident 7’s record showed diabetes mellitus and fluctuating capacity to understand and make decisions. During the observation, LVN 3 stated the opened insulin needed a date written on the label to track the 28-day discard period, and the unopened insulin should have been stored in the refrigerator because it had not been opened and used.
Mechanical Soft Diet Menu Not Followed
Penalty
Summary
The facility failed to follow its diet menu instructions when preparing meals for 31 of 141 residents on a mechanical soft diet. During lunch service preparation in the kitchen, a Dietary Aide called out chopped, and another Dietary Aide placed whole, uncut parsley on the plate for a resident. A similar observation occurred again shortly afterward when chopped was called out and whole, uncut parsley was placed on the plate for another resident. During record review, the menu recipe dated 6/9/2026 indicated no parsley for the mechanical soft diet, and the Dietary Supervisor stated staff should have followed the recipe as written. The Registered Dietician stated a mechanical soft diet consists of soft foods that are easy to chew and swallow, and that residents on this diet should not receive uncut parsley because it placed them at increased risk of aspiration. The DON also stated that not following the menu recipe can place residents at risk for aspiration. The facility policy on meal preparation stated staff should pay attention to therapeutic diet preparation and appropriate seasoning and garnishing.
Expired Food Storage and Dirty Ice Machine
Penalty
Summary
The facility failed to ensure that one container of shredded coconut labeled 2/2/2025 was disposed of. During a concurrent observation and interview on 6/8/2026 at 8:09 a.m. with the Dietary Supervisor (DS), the container was observed in the kitchen dry storage, and the DS stated the date should indicate the use by date. The facility's policy and procedure titled Food Receiving and Storage, dated July 2014, stated that dry foods stored in bins will be removed from original packaging, labeled, and dated with the use by date. The facility also failed to keep the ice machine free of dirt. During a concurrent observation and interview on 6/9/2026 at 12:51 p.m. with Dietary Aid (DA) 1, black and gray colored matter was observed along the internal wall of the ice machine's ice chute. During interview, the DS stated the ice machine should not look like that and that when the ice machine is dirty, it increases the risk for contaminated ice and cross contamination. The facility's Ice Machine Maintenance Manual, Section 4 Maintenance, dated February 2020, stated the facility was responsible for maintaining the ice machine in accordance with the instructions in the manual, and that an extremely dirty ice machine must be taken apart for descaling and sanitizing.
Failure to Speak Respectfully to a Resident
Penalty
Summary
The facility failed to ensure CNA 4 spoke to Resident 119 in a respectful manner. Resident 119 was admitted with diagnoses including paranoid schizophrenia, anxiety disorder, and insomnia, and the H&P stated the resident did not have the capacity to understand information and make decisions. The MDS indicated the resident's cognitive skills for daily decision making were moderately impaired and that the resident required assistance or supervision with multiple activities of daily living. During an observation, Resident 119 was seen gently stroking another resident's hair and face while seated in the hallway, then stood and asked the other resident to shake hands. CNA 4 approached and sternly told the resident, "Go to your room, now!" After the resident entered the room, CNA 4 sternly stated, "Sit down," then walked away and told the resident to stay in the room. In a concurrent interview, Resident 119 stated CNA 4 did not like him because of the way she spoke to him and that he thought he had done something wrong that made her mad at him. CNA 4 stated she should have used a respectful tone of voice when directing the resident. RNS 1 stated staff should approach Resident 119 in a calm manner and speak nicely, and the DON stated all staff should be trained to care for residents with dignity and respect.
Incomplete and overdue psychotropic informed consent
Penalty
Summary
The facility failed to ensure that Resident 130’s informed consent for Zyprexa included the manifested behavior for the medication indication. Resident 130 was admitted with diagnoses including schizophrenia and resting tremor of the right upper extremity. The history and physical noted fluctuating ability to understand and make decisions, and the MDS indicated severe impairment in the ability to think or make decisions, delusions, and need for staff assistance with multiple activities of daily living. During record review, the informed consent dated 12/31/2025 showed the legal empowered representative consented to Zyprexa for schizophrenia, but the consent did not identify the manifested behavior associated with that indication. The facility also failed to renew informed consent for Remeron every six months. During review, the most recent informed consent for Remeron was dated 7/28/2024 and indicated consent for use of Remeron to treat the resident’s right hand tremor on 7/28/2025. The SSD stated this was the most recent consent and that the facility had not gotten to this resident’s station for consents yet, and also stated psychotropic informed consent should have been renewed every six months. The DON stated that renewing informed consents every six months is important so the resident and/or representative is informed of the indications, risks, and benefits of the medication and has the opportunity to agree or refuse treatment.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to reasonably accommodate a resident’s food preferences by continuing to serve fish at lunch and dinner after the resident stated she no longer wanted fish every day. Resident 106 was readmitted with diagnoses including paranoid schizophrenia, Type II DM, and anemia. Her H&P noted fluctuating capacity to understand and make decisions, and her MDS indicated moderate cognitive impairment with varying levels of assistance and supervision needed for daily care. On 6/7/2026, the resident told staff she no longer wanted fish every lunch and dinner and wanted fish only when everyone else was eating fish. Despite that request, the resident was observed on 6/8/2026 with fried fish on her lunch tray, and the tray cart label still indicated, “Requests fish daily at lunch and dinner unless pizza, hot dogs or hamburgers.” The resident again stated on 6/9/2026 that she had told staff she did not want fish anymore. The RD stated the resident had informed her on 6/2/2026 that she did not want fish daily, but the RD did not check whether the preference was updated. The DS stated she was informed on 6/2/2026 that the resident did not want fish anymore for lunch and dinner, and acknowledged the resident still received fish for lunch on 6/8/2026 and 6/29/2026. Facility policies stated resident food preferences should be assessed, residents should be interviewed when possible, and reasonable efforts should be made to accommodate resident choices and preferences.
Failure to Notify Physician of Resident Declines and Unsafe Mobility Changes
Penalty
Summary
The facility failed to complete a change of condition and notify the physician when a resident with schizophrenia, osteoarthritis, severe cognitive impairment, and longstanding lower-extremity ROM limitations repeatedly refused to wear splints and repeatedly removed them early. The resident had orders for daily PROM to both lower extremities, a left knee splint, and both ankle splints. Restorative documentation in February, March, April, May, and June 2026 showed repeated splint refusals and repeated removal of splints, while the flowsheets also showed progressively limited wear time and no documentation for how long the ankle splints were worn. The resident’s records showed a prior JMA with limitations in the hips, knees, and ankles, and care plans identified risk for further joint limitation and the need to notify the physician of changes in mobility status. In April 2026, restorative summaries documented multiple refusals and removals of splints, and staff interviews confirmed that RNA staff reported the resident’s refusal and removal behavior to nursing. However, the record review and interviews with the RNS showed no change of condition assessment was completed in response to the repeated refusals and removals, and the physician was not notified of the decline in ROM or the repeated inability to maintain the splint program. By June 2026, observation and therapy assessment showed the resident’s knees and ankles were more contracted, the ankle splints no longer fit, and PT documented increased contracture in both ankles and a new contracture in the right knee compared with the prior PT evaluation. Staff interviews stated that earlier notification could have led to therapy reassessment and other interventions, but the facility records did not show that the physician had been informed when the repeated refusals and splint removal began. The facility policy required prompt notification of the resident, physician, and representative for changes in condition, and staff interviews acknowledged that the repeated refusals and removal of splints constituted a change of condition. The facility also failed to notify the physician when another resident began using a front wheel walker improperly by pulling it behind them instead of pushing it in front. The resident had diagnoses including history of falls, gait and mobility abnormalities, and left-sided hemiplegia, and the care plan identified the resident as at risk for falls or injuries related to improper walker use. Staff observed the resident walking with the walker behind them, and a CNA stated the resident always walked that way and resisted redirection. A LVN review found no documentation that the physician had been notified of the improper walker use, despite the facility policy requiring physician notification for significant changes in condition or refusal patterns.
Failure to Protect Resident Privacy When Room and Restroom Were Used by Another Resident
Penalty
Summary
The facility failed to ensure privacy and confidentiality for residents when a resident entered another resident’s room and used the restroom without permission. During observation on 6/8/2026 at 10:11 a.m., Resident 144 was seen entering a room that was not hers. The room was shared by Resident 150, Resident 160, and Resident 170. Resident 144 went into the restroom and then walked back through the room before exiting. Resident 150’s record showed admission diagnoses including CKD, heart failure, and urinary retention, and the MDS dated 3/19/2026 indicated severe cognitive impairment with rare or no decision-making. Resident 160’s record showed admission diagnoses including depression and schizophrenia, and the MDS indicated severe cognitive impairment with rare or no decision-making. Resident 170’s record showed admission diagnoses including schizoaffective disorder, diabetes mellitus, and constipation, and the MDS indicated severe cognitive impairment. During interviews, LVN 1 stated Resident 144’s restroom was out of order and she needed to use another restroom, and that the residents usually used an unoccupied room but none was available at the time. The maintenance supervisor stated the restroom in Resident 144’s room was out of order and residents were to use another resident’s restroom if theirs was out of order. FM1 stated that while visiting Resident 61, other residents frequently walked into Resident 61’s room and used the restroom. The DON stated residents were to be redirected and not allowed into other residents’ rooms, and that entering another resident’s room invaded privacy and should not happen.
Missing pillows and peeling paint affected resident comfort and homelike environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment when Resident 12 and Resident 88 did not have pillows on their beds. Resident 12 was initially admitted on 12/2/2021 and readmitted later with diagnoses including metabolic encephalopathy and muscle wasting and atrophy. The MDS dated 2/2/2026 indicated severe cognitive impairment and that Resident 12 required assistance with eating, transfers, bathing, dressing, and oral hygiene. During observations on 6/8/2026 and 6/9/2026, Resident 12 was seen in bed without a pillow, with the head resting on the mattress, and stated he would like a pillow. During a concurrent observation and interview, CNA 5 stated Resident 12 should have a pillow to rest and sleep on, and Resident 12 again asked for one. Resident 88 was initially admitted and later readmitted with diagnoses including difficulty walking and paranoid schizophrenia. The MDS dated [DATE] indicated moderate cognitive impairment and that Resident 88 required supervision with eating and substantial assistance with oral hygiene, dressing, sit-to-stand, and bed-to-chair transfers. During observations on 6/8/2026 and 6/9/2026, Resident 88 was seen in bed and later in a wheelchair, and no pillow was observed on the bed. During a concurrent observation and interview, CNA 5 stated Resident 88 should have a pillow, and Resident 88 stated he would like one. The report also identified Resident 100’s restroom as having peeling paint under the toilet paper dispenser; the maintenance supervisor stated it looked bad and the DON stated the facility should not have peeling paint and should look nice and homelike. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Abdominal Binder Used Without Required Consent, Assessment, Care Plan, or Monitoring
Penalty
Summary
The facility failed to ensure that Resident 146 had the required informed consent, restraint assessment, care plan, and monitoring documentation before and during use of an abdominal binder. Resident 146 was admitted with diagnoses including Alzheimer's disease, gastrostomy, and dementia. The MDS dated 4/2/2026 indicated the resident was moderately cognitively impaired, dependent for all ADLs, and had impairments on one side of both the upper and lower extremities. The H&P dated 6/9/2026 stated the resident was unable to make his needs known. The medication and treatment order dated 6/2/2026 directed staff to apply an abdominal binder to prevent the resident from pulling the g-tube. During observation on 6/9/2026, the resident was seen wearing the abdominal binder. During interview and record review, LVN 3 stated abdominal binders can be considered a restraint and that a physician's order and informed consent were required before use. LVN 3 also stated a restraint assessment should be completed, the resident should be monitored every two hours for skin redness and intact skin, and the binder should be removed for 20 minutes before being reapplied. LVN 3 stated the facility did not have any record of monitoring the resident for the abdominal binder and there were no care plans for it. The DON stated restraints needed to be monitored for proper positioning and skin integrity, informed consents were obtained so the resident and/or RP were agreeable to treatment, the abdominal binder care plan ensured proper care was given, and the restraint assessment was used to determine appropriate use and whether less restrictive measures had been implemented. The facility's policies stated that physical restraints require a pre-restraint assessment, written physician order, consent from the resident and/or representative, documentation of observation and range of motion/repositioning, and care plans that address restraint use and efforts to reduce or eliminate it. The record review and staff interviews showed these items were not present for Resident 146's abdominal binder use.
Failure to Keep Fingernails Trimmed and Clean
Penalty
Summary
The facility failed to ensure a resident’s fingernails were kept trimmed and clean to prevent skin excoriation caused by scratching. Resident 115 was admitted with diagnoses including schizophrenia, bipolar disorder, skin-picking disorder, and dementia, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident required varying levels of assistance with dressing, hygiene, showering, toileting hygiene, oral hygiene, bed mobility, transfer, and eating. During a concurrent observation and interview, Resident 115 was seen seated in a wheelchair scratching her head, with bleeding noted on the top of the head, forehead, and left ear. RNA 1 stopped the resident from scratching. The resident’s fingernails were observed to be long, sharp, unmanicured, jagged, and unclean, and the fingernails and fingers were covered with dried blood mixed with fresh blood. The resident stated that her head, forehead, and ears were extremely itchy and that she could not stop herself from scratching constantly. CNA 12 stated she was assigned to the resident’s grooming but could not recall when the fingernails were last trimmed or cut and could not provide documentation that nail trimming had been completed. CNA 12 stated the resident refused fingernail trimming, but there was no documentation to support refusal. The resident’s care plan for potential further infection related to picking at the skin, scalp, and ears included keeping fingernails trimmed short to reduce the risk of injury, and RNS 1 stated staff failed to implement that intervention. The DON stated residents’ fingernails should be kept clean and trimmed to prevent skin injury and infection, and that there should be a system for tracking grooming status and documentation.
Failure to Carry Out Ordered Eye Monitoring
Penalty
Summary
The facility failed to monitor one resident’s right eye as ordered by the physician. The resident was admitted with glaucoma, Type II DM, and frontotemporal neurocognitive disorder, and the MDS indicated mild cognitive impairment with partial assistance needed for bathing and personal hygiene and supervision for other ADLs. The H&P stated the resident did not have the capacity to understand and make decisions. After the resident was seen by the optometrist, the physician ordered RN monitoring of the right pupil daily for the next week to check whether it became fixed and dilated and to call the physician if it did. The record review did not show that facility staff carried out the order. LVN 7 stated the nurse who took the order should have endorsed it to an RN, completed a COC, and started a monitoring task, but this was not done. The DON stated the order was not carried out, and the physician stated the monitoring was ordered so nurses could evaluate for a serious medical problem such as a ruptured aneurysm if cranial nerve 3 palsy was present.
Failure to Assess ROM and Splint Wear Time
Penalty
Summary
The facility failed to provide services and treatments to maintain or prevent further decline in ROM for two residents. One resident had diagnoses including schizophrenia and unspecified osteoarthritis, was severely cognitively impaired, used a wheelchair, and required substantial to dependent assistance with multiple ADLs. That resident’s records showed ROM limitations in the lower extremities and a PT evaluation on 12/18/2024 identified contractures in the left knee and both ankles, with splints needed for both ankles. After that PT evaluation, no further PT treatment was provided. The same resident had physician orders for an RNA program for PROM to both lower extremities and later had new ankle splints used during RNA treatment. The report states PT did not provide treatments to assess and establish a safe wear time for the new ankle splints. As a result, the resident had lack of tolerance and refusals to wear the new ankle splints during RNA treatment. A second resident had an OT evaluation for left hand ROM impairments, but the evaluation did not objectively measure the impairments or identify which joints were affected or how severe the impairments were. OT records also did not document splinting trials or a wear time for the new left hand splint, and the RNA order for left hand splinting did not include wear-time parameters. RNA staff reported they had been applying the splint for about four to six hours and were unsure of the correct wear time because it was not specified in the order.
Failure to Identify PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to identify and intervene on events related to one resident’s history of trauma and triggers that could cause re-traumatization. The resident was admitted with diagnoses including PTSD, depression, insomnia, and left eye blindness, and the H&P documented that he had the capacity to understand and make decisions. The MDS showed he required assistance with several activities of daily living, including oral hygiene, showering, dressing, toileting hygiene, bed mobility, transfers, and eating. During observation and interview, the resident was found in a dark room with the door closed and curtains drawn. He stated he wanted the room dark and the door closed because he was sensitive to bright lights and loud noises, and that exposure to those stimuli caused nightmares about the war. He also stated he was a veteran and suffered from traumatic war experiences, and that he took a sleeping pill due to insomnia. A restorative nursing assistant stated the resident preferred his room to remain dark and the door closed most of the time, but she did not know about his PTSD triggers. Record review showed the care plan for ineffective coping due to PTSD included a goal for the resident to remain free of PTSD symptoms and general approaches to monitor for early signs of PTSD symptoms and encourage him to identify and avoid known triggers, but the RN supervisor stated the plan did not identify the resident’s specific triggers and was generic rather than resident-specific. The social service director stated she was not aware of the resident’s PTSD triggers such as bright lights and loud noises because he did not mention them, and the director of staff development could not provide evidence that trauma-informed care in-service training had been completed. The DON stated that when a resident with PTSD is admitted, the SSD should assess the resident for triggers and past history to prevent re-traumatization, and stated that re-traumatization would harm the resident’s psychosocial well-being.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that two of five CNAs had annual performance evaluations. During a concurrent interview and record review on 6/11/2026 at 9:12 a.m. with the DSD, CNA 9 and CNA 10's employee files were reviewed, and the DSD stated that both CNAs did not have annual performance evaluations. The facility's P&P titled Performance Evaluations, dated 2001, stated that a performance evaluation will be completed on each employee at the conclusion of the 90-day probationary period and at least annually thereafter. During interviews on 6/12/2026, the DSD stated that annual performance evaluations were important to ensure staff were evaluated on their knowledge and skills to care for the facility's resident population, and that without them the facility would be unable to determine whether staff were competent and had the knowledge regarding resident care. The DON also stated that annual performance evaluations were needed to assess staff knowledge and skills and to re-educate staff regarding the skills needed to care for the facility's resident population, and that failure to conduct them could result in staff providing lesser quality of care.
Midodrine Not Available for Scheduled Administration
Penalty
Summary
The facility failed to ensure that one of four sampled residents, Resident 146, had prescribed midodrine available for administration after the last dose was given on 6/7/2026. Resident 146 was admitted with diagnoses including Alzheimer's disease, gastrostomy, and dementia, and the record indicated he was unable to make his needs known and was dependent on staff for all activities of daily living. The MDS also showed moderate impairment in thinking or decision-making and dependence on staff for all aspects of ADLs, with impairments on one side of both the upper and lower extremities. Resident 146 had a physician order for midodrine hydrochloride 5 mg via gastrostomy tube every 8 hours for hypotension. During a medication pass observation, the LVN stated the midodrine was unavailable and said she would inform the hospice agency to obtain the medication. The LVN stated the medication needed to be available so the resident could receive it and maintain blood pressure. The DON stated medications needed to be available as ordered to prevent interruptions in care and delays in treatment. The facility policy required medications to be requested, received, and administered in a timely manner, and required refills to be reordered at least three days before the last dose was administered.
Failure to Notify Physician When Midodrine Was Unavailable
Penalty
Summary
Resident 146 was admitted with diagnoses including Alzheimer's disease and gastrostomy, and the admission record and H&P indicated the resident was unable to make needs known and was dependent on all ADLs. The MDS dated 4/2/2026 indicated moderate impairment in thinking or decision-making, dependence on staff for all aspects of ADLs, and impairments on one side of both the upper and lower extremities. The physician ordered midodrine hydrochloride 5 mg via gastrostomy tube every 8 hours for hypotension. During a medication pass observation, LVN 3 stated the resident's midodrine was unavailable and that she would inform the hospice agency to obtain the medication. During record review, LVN 1 stated the MAR showed the last dose was given on 6/7/2026 and that there was no COC documentation in the EMR; she stated the physician should have been notified when the medication was unavailable for administration. The MAR also showed blood pressure readings of 100/60 mm Hg on 6/7/2026 at 4:00 p.m. and 90/60 mm Hg on 6/8/2026 at 4:00 p.m. LVN 1 stated the physician should have been notified when the midodrine did not arrive, and the DON stated the importance of notifying the physician when a medication was not available was to ensure the resident was being monitored for side effects of low blood pressure. The facility policies reviewed stated changes in condition and adverse reactions to medication are to be documented and that the physician is to be notified for such changes.
Incomplete assessments and inaccurate MAR documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with schizoaffective disorder, bipolar type, vascular dementia, severe cognitive impairment, and functional ROM limitations, the facility did not sign two Joint Mobility Assessments dated 9/25/2025 and 12/22/2025. During record review, the Registered Nurse Supervisor stated both assessments had been completed, but the signatures were missing, so staff could not identify who completed the documents. The DON stated staff need to sign medical records to show they completed the assessment, and if a document is not signed, staff cannot know who completed it. For another resident with Alzheimer's disease, a gastrostomy tube, inability to make needs known, and dependence for all ADLs, the facility did not accurately document administration of prescribed midodrine hydrochloride 5 mg every 8 hours for hypotension. The hospice nurse stated the facility called the hospice provider on 6/7/2026 to request a refill because the medication was not available, and the refill had not yet been processed. An LVN stated she wrote notes indicating she called the hospice provider for the refill and informed the incoming nurse, and another LVN stated she later called again when the medication still had not arrived. Despite the medication being unavailable, the MAR showed the midodrine as given on 6/7/2026 and 6/8/2026. One LVN stated she signed and recorded the medication on the MAR even though she did not write on the back of the MAR that the medicine was not there. The DON stated initials on the MAR indicate the medication was administered, and if a medication is not given, the nurse should circle the initials and explain the reason on the back of the MAR. The DON also stated inaccurate MAR documentation meant the facility would not know whether the resident received the prescribed medication.
Improper Disinfection of Porous Bed Foam
Penalty
Summary
The facility failed to implement infection control measures for one sampled resident when the padded side rails and bed frames wrapped with porous foam were not properly disinfected. During observation, the housekeeper cleaned the foam-covered side rails and bed frames in the resident’s room by spraying diluted bleach solution onto a towel and wiping the surfaces. The housekeeper stated she cleaned all equipment, including the side-rail and bed-frame foam, with diluted bleach and did not realize the manufacturer’s guidelines indicated bleach should not be used on porous surfaces. The resident had diagnoses including schizophrenia, anxiety disorder, and bradycardia, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident’s cognitive skills for daily decision making were moderately impaired and that the resident required varying levels of assistance with toileting, hygiene, dressing, transfers, bed mobility, and eating. The maintenance supervisor stated bleach should not be used on the porous foam because it could not penetrate the material, could degrade the foam, and could leave moisture and residue that may encourage mold and bacteria growth. The infection preventionist nurse stated the manufacturer’s guideline for the bleach indicated it was to be used only on hard, non-porous surfaces, and that the porous foam around the side rails and bed frames was not appropriate because it could prevent proper cleaning and cause the foam to break down.
Antibiotic Stewardship Not Implemented for Topical Clindamycin Order
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one sampled resident by not identifying the indication and duration of a prescribed topical antibiotic and by not completing a Loeb's Minimum Criteria assessment. Resident 115 was admitted with diagnoses including schizophrenia, bipolar disorder, skin-picking disorder, and dementia. The resident's H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decision making and need for assistance with multiple activities of daily living. During observation, Resident 115 was seen scratching the head while seated in a wheelchair, with bright red blood noted on the top of the head, forehead, and left ear. The resident stated the head, forehead, and ears were extremely itchy and that the resident could not stop scratching constantly. The resident's fingernails were long, sharp, unmanicured, jagged, and unclean, and both the fingers and nails had dark red dried substance and bright red liquid substance appearing to be blood. Record review showed Clindamycin Phosphate 1% lotion, a topical antibiotic, had been ordered for daily application to the face, scalp, and both ears and had been in place since 1/16/2025 without an end date. The treatment record showed it was administered daily for self-inflicted excoriation on the face, scalp, and both ears. Staff interviews indicated the treatment nurse was unaware the lotion was an antibiotic and was unsure of the indication, the infection preventionist had not completed Loeb's Minimum Criteria and was not aware of the order, and the pharmacy consultant was also not aware of the skin culture result or the ongoing lotion order. The physician order report did not specify an indication, and the facility's antibiotic stewardship policy required complete antibiotic orders including drug name, dose, frequency, duration, route, and indication.
Unsafe Resident Care Equipment
Penalty
Summary
The facility failed to provide safe resident care equipment for two sampled residents. Resident 12, who had severe cognitive impairment, muscle wasting and atrophy, and a history of falls with injury, had an order for floor mats at bedside for fall precaution. During observation, Resident 12 was sitting at the edge of the bed with a torn floor mat next to the bed that extended only from the foot of the bed to about half to three quarters of the bed length. Staff interviews confirmed the mat was ripped and did not cover the full length of the bed, and the DON stated the mat should not be torn and should be the length of the resident's bed. Resident 80, who had schizophrenia, unspecified osteoarthritis, severe cognitive impairment, and used a wheelchair, had an order for a pommel cushion when up in the wheelchair for proper body alignment and to prevent forward sliding. During observation, Resident 80's wheelchair had both armrests torn with the underlying foam exposed, and the pommel cushion cover was ripped open with foam exposed and black tape around the middle portion. Restorative nursing staff stated the wheelchair and cushion were old, the cushion had duct tape around the middle, and the torn material could scratch Resident 80's skin and cause skin issues. Additional interviews with the RN supervisor and DON confirmed that wheelchair cushions should be intact and not ripped, and that worn or defective equipment should not be used in this condition. The facility policy stated assistive devices and equipment are to be maintained according to manufacturer instructions, and defective or worn devices are to be discarded or repaired.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 6,567 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 43 | 0 |
| Ocean Ridge Post Acute | 1.1 mi | ★★★★★ | 23 | 0 |
| Coral Cove Post Acute | 1.1 mi | ★★★★★ | 8 | 0 |
| Courtyard Care Center | 1.5 mi | ★★★★★ | 28 | 0 |
| Marlora Post Acute Rehab Hosp | 1.5 mi | ★★★★★ | 29 | 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 August 2026) and official state health department websites.