Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ivy Creek Healthcare & Wellness Centre during CMS and state inspections, most recent first.
Failure to Address Residents by Preferred Names During Care: Two residents with severely impaired cognitive skills were observed during care interactions in which a CNA addressed one resident as "[NAME]" and another as "Mama" instead of using the residents’ preferred or proper names. The CNA and LVN later acknowledged that staff should not use those labels and should address residents by their first or last name or preferred name, consistent with the facility’s resident rights policy.
Homelike Environment Not Maintained in Multiple Resident Rooms: Surveyors observed peeled wallpaper, missing paint, white patches, and/or broken drawers in 34 of 47 resident rooms. A CNA, an LVN, the MS, and the Administrator all stated these conditions were not homelike and that residents should have rooms that feel comfortable and look nice. The facility policy stated residents will be provided a safe, clean, comfortable, and homelike environment.
Inaccurate MDS Antipsychotic Assessment: A resident with dementia, schizophrenia, and bipolar disorder received Risperdal 0.5 mg via GT twice daily for visual hallucinations, and the MAR and psychotropic utilization record showed ongoing AP use with a prior GDR attempt. However, the MDS incorrectly indicated the resident did not receive antipsychotics, and the MDS coordinator confirmed the assessment was not accurate and should have reflected routine AP use.
Inaccurate PASARR screening was completed for a resident with anxiety and dementia. Facility staff documented that the resident did not have a serious mental illness and did not need a Level 2 PASARR evaluation, even though the resident’s record showed an anxiety diagnosis at admission and the ADON later acknowledged the screening should have reflected a serious mental disorder. The MDS nurse stated the screening was inaccurate and that a Level 2 evaluation would have been initiated for assessment of specialized mental health services.
No care plan was developed to address a resident's anxiety. The resident had dementia, anxiety, and anemia, with severely impaired cognitive skills and dependence for multiple ADLs. During record review, the chart did not show an active anxiety care plan, and the ADON, MDSN, and DON all acknowledged that a care plan should have been in place to guide staff on the resident's anxiety behaviors, interventions, and person-centered care.
Failure to provide ADL care for nail hygiene and oral care: two residents with significant cognitive and physical impairments were observed with dirty fingernails and dry, crusted, discolored lips. One resident with DM, Alzheimer's disease, and dementia had dirty fingernails with brown discoloration on both hands, while another resident with dementia, hemiplegia, hemiparesis, and dysphagia was observed with crusted, dry, peeling, and discolored lips despite needing staff assistance with oral hygiene.
Two residents receiving insulin were not properly monitored for signs and symptoms of hypoglycemia and hyperglycemia. One resident with DM, Alzheimer’s disease, and dementia had a care plan directing staff to monitor and document blood sugar-related symptoms, but the MDS nurse found no documented evidence that this monitoring occurred, even though blood sugars were in the 200s to 300s. Another resident with DM, CKD, UTI, TIA, and cerebral infarction had insulin orders and a diabetes care plan that lacked specific symptom-monitoring interventions; the MDS nurse stated the plan was incomplete and the DON stated insulin recipients should be monitored and documented each shift.
Two residents with feeding tubes were involved in infection control lapses. One resident's TF machine and IV pole had visible beige, brown, and grime-like stains, and the IPN stated they were dirty and should have been cleaned before each TF administration. In another instance, an LPN touched a resident's clothing and towel, then handled the G-tube, aspirated GRV, flushed the tube, and gave meds without changing gloves after the contact.
Broken Resident Call Light: A resident with COPD, GERD, SIRS, and severe cognitive impairment had a call light that did not activate the wall indicator or the light above the door during multiple observations. The DON confirmed the call light was broken, and the MTD stated it had last been checked weeks earlier and was not rechecked after the resident’s room was painted and items were returned.
A resident with a history of severe mental health conditions exhibited multiple episodes of aggressive behavior, including physically striking another resident, while on Depakote. Despite care plan and physician orders to monitor and report behavioral fluctuations, staff did not consistently notify the physician or document the effectiveness of non-pharmacological interventions. Facility policies requiring monitoring, documentation, and interdisciplinary collaboration were not followed, resulting in unaddressed behavioral escalation and resident-to-resident aggression.
Two residents on dialysis with physician-ordered fluid restrictions consistently received fluids in excess of their prescribed limits. Staff did not consistently educate the residents, notify the physician, or convene the IDT as required by facility policy, and intake and output records showed repeated noncompliance with care plans.
Three residents did not receive their scheduled medications within the facility's required one-hour administration window. An LPN administered muscle relaxants, blood pressure medications, and other critical drugs late to residents with complex medical histories and cognitive impairments, contrary to facility policy and procedures.
Surveyors identified a medication error rate of over 30% when multiple medications were administered late to three residents with complex medical conditions. Despite facility policy requiring medications to be given within a one-hour window of the scheduled time, staff administered several medications outside this timeframe, resulting in a deficiency.
Three dumpsters outside the facility were found overflowing with empty boxes and kitchen trash, as confirmed by the Dietary Service Supervisor and Director of Nursing. Facility policy requires food waste to be placed in covered garbage cans, but observations and staff interviews revealed that dumpsters were not closed or managed properly, increasing the risk of contamination and pest attraction.
Staff did not consistently monitor or ensure that washing machines reached the required high temperatures for disinfecting soiled linens, with water temperatures recorded well below policy standards and broken equipment left unaddressed. This resulted in multiple loads of laundry being washed at insufficient temperatures, contrary to facility infection control policy.
A resident who was bed-confined and severely cognitively impaired was observed having their briefs changed by a CNA without the privacy curtain or door being closed. Interviews with staff and review of facility policy confirmed that privacy should have been provided during personal care to maintain dignity and respect.
Two residents did not have comprehensive, individualized care plans developed or implemented as required, despite having significant medical needs such as anticoagulant therapy for PVD and total assistance required for ADLs and bowel incontinence. Staff and nursing leadership confirmed that care plans addressing these needs were missing, which could impact the delivery of appropriate care.
A resident with significant physical and cognitive impairments, who was dependent on staff for oral hygiene and had no natural teeth, received a repaired upper denture, but the care plan was not updated to reflect this change. Staff confirmed the resident wore both upper and lower dentures daily, yet the care plan continued to reference the broken denture, contrary to facility policy requiring care plan updates after assessments and changes in condition.
A resident with a history of skin tears and cognitive impairment was not wearing Geri sleeves as ordered by the physician, despite a care plan and facility policy requiring their use to prevent further injury. During observation, the LVN could not locate the sleeves, and both the LVN and DON confirmed the order should have been followed.
A resident with end stage renal disease and an AV shunt in the left arm had multiple blood pressure checks incorrectly documented as being performed on the left arm by an LVN, despite orders prohibiting this due to the shunt. The resident confirmed blood pressure was only taken on the right arm, and the DON highlighted the need for accurate documentation to prevent misinterpretation by staff.
A resident with cognitive impairment and multiple medical conditions was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. Staff and the DON confirmed the call light should have been within reach to allow the resident to request assistance.
A resident with severe cognitive impairment and bed confinement was found in a room where the linen bin was overflowing with used linen, unlined with plastic, and left open. Both the DON and RN Supervisor confirmed this was against facility policy and infection control standards, resulting in an unsanitary environment.
Four resident rooms were found to be below the required 80 square feet per resident in multiple occupancy rooms. Despite this, residents and staff reported no issues with space for mobility or care, and observations confirmed adequate maneuverability and care provision. The facility had submitted a waiver for these rooms, and the department recommended its approval.
A resident with pneumonia did not have two doses of IV antibiotics documented in the MAR, as required by the facility's policy. Two RNs administered the medication but failed to sign the MAR, which was confirmed by the DON. This lack of documentation could lead to medication errors.
The facility failed to provide appropriate communication boards for two residents with language barriers, leading to potential miscommunication and unmet needs. One resident had a board in the wrong language and out of reach, while another had no board at all. Staff confirmed these issues, which were contrary to the facility's policy on accommodating communication needs.
A resident with cognitive impairment accused a CNA of abuse, but the facility failed to report the allegation within the required two-hour timeframe. The incident involved a skin discoloration on the resident's hand, initially attributed to a blood draw. The LVN informed the DON, who misread the message, delaying the report to the CDPH. The facility's policy mandates prompt reporting to ensure resident safety.
The facility failed to provide a homelike environment for three residents. Two residents had rooms with peeling paint and unmaintained baseboards, while another resident's room had a staff member's beverage left on a hand sanitizer dispenser. The DON and Maintenance Assistant acknowledged these issues, which were not addressed in a timely manner.
The facility failed to ensure licensed nurses administered oxygen to two residents as per their care plans and physician orders, leading to potential risks in their respiratory care. CNAs were observed performing tasks that should have been handled by licensed nurses, contrary to facility policies.
The facility failed to ensure proper food storage and labeling, including unlabeled red fruit Jello, apple sauce cups, rice noodles, and garlic bags, as well as spoiled cilantro mixed with carrots and mislabeled chorizo containing bacon. These deficiencies were confirmed through observations and interviews with the Dietary Staff Supervisor and Dietary Aid.
The facility failed to maintain dignity and respect for two residents during feeding. Both residents, who have severe cognitive impairments and dysphagia, were fed by CNAs who were standing, causing discomfort and a lack of respect. Facility policies require staff to sit at eye level while feeding residents to ensure dignity.
The facility failed to ensure call lights were within reach for three residents, including those with severe cognitive impairments and vision issues, leading to potential delays in receiving necessary assistance.
The nursing staff failed to maintain the privacy and confidentiality of a resident's medical records by leaving the computer screen unattended multiple times, exposing sensitive information to passersby. The DON and Administrator confirmed that staff should log off and close computer screens before leaving the nursing station.
The facility failed to ensure that a Registered Nurse (RN) signed and certified the Minimum Data Set (MDS) and Care Area Assessment (CAA) for a resident with type 2 diabetes mellitus and moderate cognitive impairment. Instead, a Licensed Vocational Nurse (LVN) signed the MDS, which was against the facility's policy and CMS guidelines, potentially leading to an incomplete assessment and inaccurate care planning.
The facility failed to follow the care plan for a resident on oxygen therapy, who was observed lying flat despite needing the head of the bed elevated. This oversight, confirmed by an LVN and the DON, could lead to serious health issues for the resident, who has severe cognitive impairment and respiratory conditions.
A resident with severe cognitive impairment and dependency was found with white crust on the eyelids and brownish stains around the mouth, indicating a failure by the facility to provide necessary hygiene care. Staff acknowledged the deficiency, and facility policies on hygiene and resident rights were not followed.
The facility failed to ensure that a resident with Alzheimer's Disease had an abdominal binder to prevent g-tube dislodgement and did not reassess another resident's diabetic foot ulcer as per the care plan, leading to potential health risks.
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident receiving hospice services by not maintaining hospice nursing and visitation notes in the resident's medical record. The resident had severe cognitive impairment and was dependent on assistance for daily activities, with specific hospice visit frequencies ordered by a physician. The Director of Nursing confirmed the deficiency but was unsure who was responsible for ensuring complete documentation.
The facility failed to enforce infection control policies, including hand hygiene by CNAs, proper handling of nasal cannula tubing, and disinfecting laundry washers after each use. These lapses were observed during resident care and laundry handling, posing a risk of infection.
The facility failed to maintain kitchen equipment in safe operating condition when the kitchen burners did not ignite properly. The cook used a piece of paper to ignite the burner, which led to burns. The Dietary Staff Supervisor acknowledged the danger and mentioned that maintenance is scheduled monthly or as needed. The Maintenance Assistant was unaware of the issue, despite policies requiring safe and operable equipment.
The facility failed to ensure that four resident bedrooms met the federal regulation requirement of at least 80 square feet per resident in multiple resident bedrooms. Rooms 24, 26, 28, and 44 were found to be below the required space per resident, but the facility submitted a waiver request indicating adequate space for nursing care.
Failure to Address Residents by Preferred Names During Care
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not addressing them with their preferred names during care interactions. One resident, admitted and re-admitted with diagnoses including COPD, heart failure, and atrial fibrillation, had severely impaired cognitive skills for daily decision making and required assistance with multiple activities of daily living. During an observation in the resident’s room, a CNA addressed the resident as "[NAME]" while asking about breakfast and again while discussing changing the resident’s brief. The CNA later acknowledged using that label and stated staff should not use labels like "[NAME]" or "Mama" when addressing residents, and that staff should use the resident’s first or last name. A second resident, admitted and re-admitted with diagnoses including COPD, GERD, and SIRS, also had severely impaired cognitive skills for daily decision making and required dependent to substantial/maximal assistance with several ADLs. During a concurrent observation while an LVN assessed the resident and a CNA assisted with repositioning, the CNA addressed the resident as "Mama" while turning the resident and again after repositioning. In interviews, the CNA and LVN both stated that staff were not supposed to use "Mama" or "[NAME]" when addressing residents and that residents should be addressed by their first and last name or preferred name. The facility policy stated employees are to treat all residents with kindness, respect, and dignity and honor residents’ rights.
Homelike Environment Not Maintained in Multiple Resident Rooms
Penalty
Summary
The facility did not ensure a homelike environment for 34 of 47 resident rooms, including Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, and HH. During a concurrent observation of all 47 resident rooms, surveyors observed peeled wallpaper, missing paint on the walls, white patches on the walls, and/or broken drawers in those rooms. The Maintenance Supervisor stated the rooms were not homelike because of the missing paint, peeled wallpaper, and broken drawers, but that they should be. During interviews, CNA 4 stated a homelike environment should be provided and that missing paint or wallpaper should be fixed so residents are comfortable and feel safe. LVN 3 stated residents should feel like they are in their homes and that missing paint and white patches are not homelike because residents see it and no one would want their own homes to look like that. The Administrator stated the facility should provide a homelike, comfortable environment that looks nice, and that rooms with missing paint, peeled wallpaper, or broken drawers are not homelike. The facility policy titled Resident Rooms and Environment stated the facility will provide residents with a safe, clean, comfortable, and homelike environment and staff will provide residents with a pleasant environment.
Inaccurate MDS Antipsychotic Assessment
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident who was admitted with diagnoses including dementia, schizophrenia, and bipolar disorder. The resident had an order for Risperdal 0.5 mg via GT twice daily for unspecified schizophrenia manifested by visual hallucinations, and the MAR showed the medication was administered throughout February, March, and April 2026. A facility Psychotropic and Sedative/Hypnotic Utilization form also documented that the resident's last GDR for risperidone was on 1/28/2026. During review of the resident's MDS, the assessment indicated the resident's cognitive skills for daily decision making were severely impaired, but it also indicated the resident did not receive antipsychotics, which skipped the sections regarding the last GDR attempt and whether the physician documented the GDR as clinically contraindicated. The MDS Coordinator stated the resident was taking an antipsychotic medication that was not reflected on the Antipsychotic Medication Review, that the MDS was not accurate, and that the answer should have been documented as yes, antipsychotics were received on a routine basis only. The facility's RAI Process policy stated resident assessments must accurately depict resident-specific issues and meet state and federal guidelines and data submission requirements.
Inaccurate PASARR Screening for Resident With Anxiety
Penalty
Summary
PASARR Level 1 screening was completed inaccurately for one resident with diagnoses that included anxiety and dementia. The resident’s admission record and MDS documented anxiety, and the PASARR Level 1 screening completed by facility staff stated the resident did not have a serious mental illness and did not require a Level 2 PASARR evaluation. During record review and interview, the ADON acknowledged the resident had an anxiety diagnosis at the time the screening was completed and stated the PASARR should have reflected a serious mental disorder. The resident’s records also showed severely impaired cognitive skills for daily decision making and assistance needs with bathing, oral care, toileting, personal hygiene, and eating. The MDS nurse stated the PASARR screening was inaccurate because the resident had anxiety on admission and at the time of the screening, and that a Level 2 evaluation would have been initiated for assessment of specialized services for mental health disorders but was not. Facility policy stated all residents are to be screened for mental illness and ID or a related condition, and that the MDS Coordinator is responsible for ensuring PASARR updates are completed per MDS guidelines.
No Care Plan for Resident Anxiety
Penalty
Summary
Failure to develop a care plan to address a resident's anxiety was identified for Resident 43. The resident was readmitted to the facility with diagnoses that included dementia, anxiety, and anemia. The Minimum Data Set dated 3/18/2026 indicated the resident had severely impaired cognitive skills for daily decision making, required substantial/maximal assistance with showering and bathing, partial/moderate assistance with oral care, toileting, and personal hygiene, and setup or clean-up assistance with eating. The assessment also indicated the resident had anxiety. During a concurrent interview and record review on 5/20/2026, the resident's electronic medical chart from 5/20/2025 through 5/20/2026 was reviewed and did not show a developed care plan for anxiety. The ADON stated there was no active care plan for the resident's anxiety. The MDSN stated there should be a care plan to address the anxiety diagnosis so staff would know the resident's behaviors or manifestations of anxiety and how to manage them and provide person-centered care. The DON stated the resident should have a developed care plan for anxiety because it remained an active diagnosis and a care plan would help staff know what interventions were in place and allow monitoring of their effectiveness. The facility policy on Comprehensive Person-Centered Care Planning stated the facility will provide person-centered, comprehensive, interdisciplinary care and ensure a comprehensive person-centered care plan is developed for each resident.
Failure to Provide ADL Care for Nail Hygiene and Oral Care
Penalty
Summary
The facility failed to ensure ADL care was provided for two residents who were dependent or partially dependent on staff for personal care. Resident 4 had diagnoses including DM, Alzheimer's disease, and dementia, and the MDS indicated severely impaired cognitive skills and dependence for bathing, dressing, footwear, personal hygiene, and bed mobility. During observations on 5/18/2026 and 5/19/2026, Resident 4's fingernails on both hands were observed to be dirty with brown discoloration around the nail edges. During a concurrent observation and interview on 5/20/2026, the IPN stated the fingernails were dirty with brownish to blackish discoloration and that staff should clean them when providing care. The DSD also stated the resident's fingernails had debris around and under them and that nail care should be part of morning care. Resident 72 had diagnoses including dementia, hemiplegia, hemiparesis, and dysphagia, and the MDS indicated severely impaired cognitive skills, partial/moderate assistance with eating and oral/personal hygiene, and dependence for toileting hygiene and bathing. The H&P stated the resident did not have the capacity to understand and make decisions. The care plan identified the resident as at risk for oral/dental health problems and directed staff to provide mouth care and monitor for cracked or bleeding lips. During a concurrent observation and interview on 5/21/2026, Resident 72 was observed lying in bed with crusted skin on the bottom lip and inner upper lip and red/brown discolorations on the inner upper and lower lips. CNA 3 stated the lips looked dirty, dry, and scabbing, and that the resident needed total oral care assistance and could not provide oral care to himself. During the same observation, LVN 1 stated Resident 72 had dryness, lip peeling, and brown/red discolorations, and should receive oral care whenever staff notice the mouth and lips are dry. RN 2 stated oral care was important to maintain moisture and prevent further mouth sores and bacteria that can cause infections, and the DON stated dry lips occur when lips are not moist and chapping occurs when there is a cut and bleeding may occur. The facility policy on oral care stated all residents are to receive appropriate oral care daily, and the nursing department staff are responsible for ensuring good oral care for each resident.
Failure to Monitor Insulin-Related Blood Sugar Symptoms
Penalty
Summary
The facility failed to monitor two residents for signs and symptoms of hypoglycemia and hyperglycemia while they were receiving insulin. For one resident, the record showed diagnoses of diabetes mellitus, Alzheimer’s disease, and dementia, with severely impaired cognitive skills for daily decision making and dependence in multiple activities of daily living. The resident’s diabetes care plan directed staff to monitor, document, and report signs and symptoms of both hyperglycemia and hypoglycemia, and the physician orders included Lantus Solostar at bedtime and Novolin R before meals and at bedtime with sliding-scale dosing and blood sugar parameters. During review of the resident’s nurses’ progress notes, the MDS nurse stated there was no documented evidence that staff monitored the resident for signs and symptoms of hypoglycemia or hyperglycemia. The MDS nurse also reviewed the medication administration record and stated the resident’s blood sugars were ranging in the 200s to 300s, which was considered hyperglycemic, and that because there was no documentation of monitoring, the monitoring was not done. The MDS nurse further stated the care plan was not implemented because staff did not monitor for signs and symptoms of hyperglycemia and hypoglycemia. For the second resident, the record showed diagnoses of diabetes, chronic kidney disease, urinary tract infection, transient ischemic attack, and cerebral infarction without residual deficits, with moderately impaired cognitive skills for daily decision making and need for assistance with multiple ADLs. The physician orders included Lantus Solostar daily and Humulin R before meals and at bedtime with sliding-scale dosing and blood sugar parameters. However, the resident’s diabetes care plan only included general interventions such as giving diabetes medication as ordered, monitoring for side effects and effectiveness, dietary consultation, fasting serum blood sugar as ordered, consulting the doctor if infection was present, and offering substitutes for foods not eaten. The MDS nurse stated the care plan should have included interventions to monitor for signs and symptoms of hyperglycemia or hypoglycemia and that the care plan was incomplete and not person centered. The DON stated licensed staff should always monitor residents who received insulin for signs and symptoms of hypoglycemia and hyperglycemia and document in nurses’ progress notes every shift.
Infection Control Lapses During Tube Feeding and G-Tube Medication Administration
Penalty
Summary
Standard infection prevention and control practices were not followed for two residents receiving tube feeding. Resident 4 was admitted and re-admitted to the facility with diagnoses including DM, Alzheimer's disease, and dementia, and the MDS indicated severely impaired cognitive skills for daily decision making, dependence in multiple activities of daily living, and use of a feeding tube for nutrition. During observations on 5/18/2026 and 5/19/2026, Resident 4's TF machine was turned off and had beige-colored stains, and the IV pole where the TF machine was attached had brown and beige-colored stains. During a concurrent observation and interview on 5/20/2026, the IPN stated the IV pole had grime and beige-colored splatter stains from TF formula and that the TF machine and IV pole were dirty and should have been cleaned before each TF administration for infection control. In a separate observation involving Resident 10, who was admitted and re-admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction affecting the right side, functional quadriplegia, and dementia, the MDS indicated severely impaired cognitive skills for daily decision making and dependence or substantial assistance with multiple ADLs, including feeding tube use for nutrition. During the 5/20/2026 observation, LVN 2 changed gloves, then touched the resident's linen cover and clothing and removed the towel covering the G-tube. LVN 2 then connected the flush syringe, aspirated the gastric residual volume, flushed the G-tube, and began administering medications through the G-tube without changing gloves after touching the resident's clothing and towel. During interview, LVN 2 stated she should have changed her gloves after touching the resident's clothing and towel to maintain proper infection control before checking the G-tube residual and administering medications. Facility policies reviewed included Cleaning and Disinfection of Resident-Care Items and Equipment, General Guidelines for Medication Administration, and Medication-Administration, which addressed cleaning resident-care equipment, hand hygiene, and medication administration via enteral tubes.
Broken Resident Call Light
Penalty
Summary
A functional call system was not available in Resident 58’s room, including the bathroom and bathing area call system requirement referenced in the deficiency. Resident 58 was admitted and re-admitted to the facility with diagnoses including COPD, GERD, and SIRS. The MDS dated 3/26/2026 indicated the resident was severely impaired in cognitive skills for daily decision making and was dependent for toileting hygiene, shower/bathe self, lower body dressing, footwear, chair/bed-to-chair transfer, and tub/shower transfer, with substantial to maximal assistance needed for several other activities of daily living. During observations on 5/18/2026 and 5/19/2026, the surveyor activated Resident 58’s call light and the wall indicator light and the light above the door did not illuminate. When the DON tested the call light on 5/19/2026, the wall indicator light did not turn on until the cord was unplugged and plugged back in, and then it failed again when pressed a second time. The DON stated the call light was broken and needed to be replaced, and also stated that if it was not functioning properly, Resident 58 would not be able to call for help if assistance was needed. The MTD stated the facility checks residents’ call lights monthly and designated areas weekly, and that Resident 58’s call light was last checked on 4/3/2026. The MTD also stated that after Resident 58’s room was painted on 5/14/2026 and items were removed and returned, the call light was not rechecked to ensure it was functioning properly.
Failure to Address and Report Escalating Behavioral Disturbances
Penalty
Summary
The facility failed to adequately address and manage the recurrent behavioral fluctuations of a resident with a history of bipolar disorder, delusional disorder, psychosis, and dementia, who was prescribed Depakote for mood stabilization. Despite physician orders and care plan directives to monitor and document episodes of behavioral disturbances, including verbally aggressive outbursts and diminished interest in activities of daily living (ADLs), the facility did not consistently notify the physician of escalating behaviors or document the effectiveness of non-pharmacological interventions (NPI). The resident experienced 11 incidents of behavioral disturbances within a short period, yet there was no evidence that the physician was informed or that the care plan interventions were fully implemented and evaluated as required. On one occasion, the resident physically struck another resident, resulting in the latter being hit on the left leg. Staff interviews confirmed that the aggressive behaviors were observed and that there was an expectation to notify the physician and document interventions, but this was not done. The medication administration records (MAR) and behavior monitoring logs indicated gaps in documentation, particularly regarding the use and effectiveness of NPIs prior to administering medication. Additionally, staff acknowledged that the physician should have been notified of the resident's increasing aggression to consider possible changes in medication or further evaluation. Facility policies and procedures required monitoring and reporting of behavioral symptoms and side effects of psychotropic medications, as well as collaboration with the physician and interdisciplinary team when changes in behavior occurred. However, these protocols were not followed, as evidenced by the lack of timely physician notification, incomplete documentation of behavioral episodes, and insufficient evaluation of interventions. This failure to adhere to established care processes contributed to an incident of resident-to-resident aggression and placed residents at risk for harm.
Failure to Enforce Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring fluid restrictions as part of their treatment for end stage renal disease (ESRD). For one resident with severe cognitive impairment and multiple comorbidities, including ESRD and diabetes, physician orders and care plans specified a daily fluid restriction of 1200 ml. Despite these orders, intake and output records showed that this resident consistently received fluids in excess of the prescribed limit on the majority of days over two consecutive months. Staff interviews confirmed that the resident was given additional fluids upon request, and there was no evidence that staff consistently educated the resident about the fluid restriction or notified the physician of noncompliance, as required by the care plan and facility policy. Additionally, the resident's noncompliance was not addressed in a timely manner by the Interdisciplinary Team (IDT), and the last documented IDT discussion regarding this issue was several months prior to the survey. A second resident, who was cognitively intact and also dependent on dialysis, had a physician-ordered fluid restriction of 1000 ml per day. Intake and output records revealed that this resident also regularly received fluids exceeding the prescribed limit on most days during the review period. Staff interviews and care plan reviews indicated that nursing and dietary staff did not ensure the division and distribution of fluids according to the care plan, and the resident's intake was not adequately monitored or restricted as ordered. There was no documentation of staff providing education about the risks of noncompliance or notifying the physician when the resident exceeded fluid limits, as required by facility policy. Facility policies reviewed during the survey specified that noncompliance with fluid restrictions should be documented, the physician notified, and the IDT convened to address ongoing issues. However, these protocols were not followed for either resident. Observations confirmed that residents had access to fluids beyond their prescribed limits, and staff interviews revealed a lack of consistent communication and intervention regarding fluid restrictions. These failures resulted in the facility not adhering to physician orders and established care plans for residents on dialysis.
Failure to Administer Medications Within Prescribed Time Frames
Penalty
Summary
The facility failed to administer medications within the prescribed time frames as indicated by facility policy for three of four sampled residents. For one resident with a history of osteoarthritis, GERD, and thoracic spine fusion, cyclobenzaprine was scheduled for 8 AM but was administered at 9:28 AM, outside the allowed one-hour window. This resident was noted to have moderately impaired cognitive skills and required significant assistance with daily activities. Another resident, admitted with obstructive and reflux uropathy, hypertensive heart disease, and dementia, had multiple medications scheduled for administration at 8 AM and 9 AM, including bethanechol, metoprolol, verquvo, eliquis, and entresto. All these medications were administered at 10:26 AM, exceeding the facility's policy of a one-hour window before or after the scheduled time. This resident also had moderately impaired cognitive skills and required varying levels of assistance with daily living activities. A third resident with chronic kidney disease, atherosclerotic heart disease, and hypertension had orders for amlodipine and clopidogrel to be given at 9 AM, but both were administered at 10:52 AM. This resident required moderate to maximal assistance with daily care. Interviews with nursing staff and the DON confirmed the facility's policy of a one-hour administration window and the importance of timely medication administration. Review of the facility's policy and procedure corroborated these requirements.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with eight medication errors identified out of 26 observed opportunities, resulting in a 30.77% error rate. The errors involved the late administration of prescribed medications to three residents during observed medication passes. The facility's policy and staff interviews confirmed that medications are to be administered within a one-hour window before or after the scheduled time, but this protocol was not followed in multiple instances. For one resident with osteoarthritis, GERD, and a thoracic spine fusion, cyclobenzaprine was scheduled for 8 AM but was administered at 9:28 AM, outside the permitted window. Another resident with obstructive and reflux uropathy, hypertensive heart disease, and dementia was scheduled to receive five different medications between 8 AM and 9 AM, but all were administered at 10:26 AM, well past the allowed timeframe. A third resident with chronic kidney disease, atherosclerotic heart disease, and hypertension was scheduled to receive amlodipine and clopidogrel at 9 AM, but both were given at 10:52 AM. Staff interviews confirmed awareness of the facility's medication administration policy, which requires adherence to the scheduled times for medication administration to ensure consistency and accurate monitoring. Despite this, the observed medication passes did not comply with the policy, resulting in multiple late administrations and a medication error rate significantly above the acceptable threshold.
Improper Disposal and Overflowing Dumpsters
Penalty
Summary
Three dumpsters located on the west side of the facility, near the entrance and parking area, were observed to be overflowing with empty boxes and clear plastic bags containing kitchen trash. This was noted during an observation, and the Dietary Service Supervisor (DSS) confirmed that the dumpsters were overflowing with both empty boxes and kitchen trash. The DSS also stated that all kitchen trash was disposed of in these dumpsters and acknowledged that the dumpsters were not supposed to be overflowing and should be closed properly. Further interviews with the DSS and the Director of Nursing (DON) confirmed that the dumpsters should be fully closed and not overflowing to prevent attracting rodents, flies, and insects, and to reduce the risk of cross-contamination. A review of the facility's Waste Management Policy and Procedure indicated that food waste should be placed in covered garbage and trash cans to reduce the risk of contamination from regulated waste and to ensure proper handling and disposal of all waste.
Failure to Ensure Proper Water Temperature for Laundry Disinfection
Penalty
Summary
Facility staff failed to obtain accurate water temperature readings and did not ensure that the water used to wash soiled linens in both washing machines met the required temperature according to facility policy. During observations and interviews, it was revealed that the laundry staff did not check the thermometer for the water temperature, and the maintenance supervisor confirmed that the thermometer was broken and the water heater was turned off, resulting in water temperatures between 70-80 degrees Fahrenheit. The maintenance supervisor also stated that the water temperature should have been set at 140 degrees Fahrenheit to properly disinfect the linens, but the actual temperature was only between 72-74 degrees Fahrenheit during the washing of two loads of white linens. Further interviews indicated inconsistent practices, as another laundry staff member reported a thermometer reading of 130 degrees Fahrenheit and mentioned checking but not logging a temperature of 146 degrees Fahrenheit earlier that day. The administrator and infection prevention nurse both confirmed that the washing machines should operate at high temperatures to effectively kill bacteria and pathogens on the laundry. Review of the facility's policy confirmed that the hottest available water should be used for washing linens, but this was not consistently followed, as evidenced by the low water temperatures and lack of proper monitoring.
Failure to Provide Privacy During Personal Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed changing the briefs of a resident without providing adequate privacy, as both the privacy curtain and the door to the resident's room were left open during the procedure. The resident involved had a history of falling, adult failure to thrive, was bed-confined, and was severely cognitively impaired, requiring total assistance for personal and toilet hygiene. The lack of privacy was directly observed by surveyors in the hallway outside the resident's room. Interviews with the CNA involved, another CNA, and the Director of Nursing (DON) confirmed that facility policy and standard practice require staff to provide full privacy by closing both the curtain and the door when performing personal care tasks. The facility's policy on resident rights and quality of life also specifies the importance of promoting and maintaining resident privacy, dignity, and respect during care. The failure to provide privacy during the brief change was contrary to these established policies and procedures.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, as required by its own policies and federal regulations. For one resident with a diagnosis of peripheral vascular disease (PVD) and a physician's order for Eliquis 2.5 mg twice daily, there was no care plan addressing the use of this anticoagulant medication. The resident's medical record indicated moderate cognitive impairment and a need for assistance with personal hygiene and toileting, yet the care plan did not reflect interventions or monitoring related to the medication. Both the Director of Nursing and Infection Preventionist Nurse confirmed during interviews that a care plan should have been initiated upon receipt of the medication order to guide staff in providing appropriate care and monitoring for potential side effects. Another resident, admitted with osteoarthritis, GERD, and a thoracic spine fusion, was assessed as being dependent or requiring significant assistance with activities of daily living (ADLs) such as bathing, dressing, toileting, and was always incontinent of bowel. Despite these findings on the Minimum Data Set (MDS) and baseline care plan, there was no comprehensive care plan addressing the resident's ADL functional abilities or bowel incontinence. Staff interviews confirmed the resident's high level of dependency and need for total assistance with hygiene and incontinence care, but the absence of a care plan meant that interventions such as monitoring for skin breakdown and repositioning were not formally documented or communicated to staff. The facility's policy required that a comprehensive care plan be developed within seven days of completing the MDS assessment, incorporating all goals and interventions from the baseline care plan and updating as needed based on the resident's assessed needs. In both cases, the lack of a comprehensive care plan was acknowledged by nursing leadership and staff, who stated that this omission could hinder staff's ability to provide appropriate and individualized care.
Failure to Revise Dental Care Plan After Change in Resident's Dental Status
Penalty
Summary
The facility failed to review and revise the dental care plan for one resident after the completion of the Minimum Data Set (MDS) assessment and following a change in the resident's dental status. The resident, who had diagnoses including hemiplegia, hemiparesis, dysphagia following a stroke, and major depressive disorder, was dependent on staff for oral hygiene and had no natural teeth. The care plan, dated several months prior, indicated the resident had a broken upper denture and included an intervention for the resident to refrain from using the upper denture until it was fixed. Subsequent documentation showed that the resident's upper denture was repaired and delivered, and later evaluations confirmed the resident had both upper and lower dental appliances. Interviews with staff confirmed that the resident wore both dentures daily and that staff assisted with their care. However, a review of the medical chart with the Director of Nursing revealed that the care plan had not been updated to reflect the repaired denture and the resident's current dental status, despite facility policy requiring care plan revisions after assessments and changes in condition.
Failure to Apply Geri Sleeves as Ordered
Penalty
Summary
A deficiency occurred when staff failed to apply Geri sleeves to a resident as ordered by the physician. The resident, who had diagnoses including acute respiratory failure, muscle weakness, and dementia, was assessed as having moderately impaired cognitive skills and required assistance with daily activities. The resident had a history of scratching his forearms, resulting in skin tears, and had a physician's order for the application of bilateral upper extremity Geri sleeves at all times, except during hygiene care. The care plan also specified measures to prevent further skin tears and instructed staff to follow the physician's order. During an observation, the resident was found in bed without Geri sleeves on either forearm, and the assigned LVN was unable to locate the sleeves in the resident's room. The LVN confirmed that the resident should have been wearing the sleeves per the physician's order. The DON also confirmed the order and stated that it should be followed, noting the resident's fragile skin and tendency to scratch. The facility's policy required treatments to be administered as prescribed, but the Geri sleeves were not applied as ordered at the time of the surveyor's observation.
Inaccurate Documentation of Blood Pressure Site for Resident with AV Shunt
Penalty
Summary
The facility failed to accurately document the site of blood pressure measurement for one resident with end stage renal disease who required hemodialysis via an arteriovenous (AV) shunt in the left arm. Review of the resident's medical records showed that a licensed vocational nurse (LVN) documented blood pressure checks as being performed on the left arm on multiple occasions, despite the resident's order summary indicating that no blood pressure checks or blood draws should be performed on the left arm due to the presence of the AV shunt. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for varying levels of assistance with daily activities. During interviews, the LVN acknowledged making documentation errors regarding the site of blood pressure measurement and stated that she should have reviewed her documentation for accuracy. The resident confirmed that blood pressure was only taken on the right arm, never on the left. The Director of Nursing emphasized the importance of accurate and complete documentation to ensure proper monitoring and avoid assumptions. The facility's policy required that medical record entries be complete, legible, descriptive, and accurate, and outlined the procedure for correcting errors.
Call Light Not Within Reach for Resident Requiring Assistance
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a call light was within reach for a resident as required by the care plan and facility policy. The resident, who had diagnoses including metabolic encephalopathy, COPD, and cerebral infarction, was assessed as having moderately impaired cognitive skills and required supervision or assistance for activities such as toileting, bathing, personal hygiene, and transfers. The care plan specifically indicated that the call light should be within reach due to the resident's risk for falls related to impulsive behavior and poor safety judgment. During an observation, the call light was found on the floor, out of the resident's reach, while the resident was lying in bed. Staff confirmed that the call light should have been placed on the bed next to the resident. The DON also stated that call lights should be within reach to ensure residents can call for assistance. Facility policy required call cords to be placed within the resident's reach, but this was not followed in this instance.
Failure to Maintain Sanitary Linen Management in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and sanitary environment for one of three sampled residents by not ensuring that the linen bin in a resident's room was properly managed. Specifically, the linen bin in Room A was observed to be overflowing with used white linen and was not lined with plastic, as required. The bin was also left open, contrary to facility policy and infection control standards. Both the Director of Nursing and the Registered Nurse Supervisor confirmed during interviews that the linen bin should have been lined with plastic, kept closed, and not allowed to overflow to maintain cleanliness and prevent the spread of bacteria. The resident involved had a history of falling, adult failure to thrive, was bed-confined, and had severely impaired cognitive skills, making them particularly vulnerable. The facility's policy and procedure on resident room environment emphasized the importance of providing a safe, clean, and homelike atmosphere, with attention to cleanliness and order. The failure to properly manage the linen bin in the resident's room resulted in an unsanitary environment, as directly observed and confirmed by staff.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that four of its resident bedrooms (rooms 24, 26, 28, and 44) met the minimum required size of 80 square feet per resident in multiple occupancy rooms. Measurements showed that each of these rooms, which housed three residents each, was below the required square footage per resident. The deficiency was identified through observation, interviews, and record review, including a review of the facility's room waiver, which acknowledged the rooms did not meet the regulatory size requirement. Despite the deficiency, observations indicated that residents in these rooms were able to maneuver their wheelchairs and ambulate without difficulty, and nursing staff reported having sufficient space to provide care, maintain privacy, and uphold residents' dignity. Interviews with residents revealed no concerns about room size, and staff confirmed that care could be provided effectively. The facility had submitted a room waiver, and the department recommended approval of this waiver based on the findings.
Failure to Document IV Antibiotic Administration
Penalty
Summary
The facility failed to document the administration of two doses of intravenous antibiotics for a resident, as required by the Medication Administration policy. The resident, who was admitted with pneumonia, had a physician's order for cefepime HCL to be administered twice daily. However, the Medication Administration Record (MAR) lacked signatures for the 9 PM doses on two consecutive days. This omission was confirmed during interviews with two registered nurses who administered the medication but did not document it in the MAR. The Director of Nursing confirmed that the facility's policy requires licensed nurses to document the administration of medications to ensure accurate tracking. The policy mandates that nurses chart the drug, time administered, and initial their name with each medication administration. The failure to document the administration of the IV antibiotics could potentially lead to medication errors, such as double dosing, as there was no proof of administration recorded in the MAR.
Failure to Provide Appropriate Communication Boards
Penalty
Summary
The facility failed to provide appropriate communication boards for two residents, which were necessary for effective communication due to their language barriers. Resident 1, who was moderately impaired cognitively and required assistance with various activities of daily living, had a communication board that was not in her primary language and was not within her reach. This was confirmed through observations and interviews with staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, who acknowledged the communication board's incorrect language and its inaccessibility. Resident 2, who had severe cognitive impairment and required substantial assistance with daily activities, did not have a communication board available in her room. Observations and interviews with staff revealed that communication with Resident 2 was attempted through hand gestures and pointing, but the absence of a communication board hindered effective communication. The Director of Staff Development confirmed that the purpose of the communication board was to facilitate communication for residents who do not speak English, and its absence could delay care. The facility's policy on accommodating residents' communication needs, which includes providing adaptive devices like communication boards, was not adhered to in these cases. The policy mandates that such accommodations be reflected in the residents' care plans, but this was not implemented for Residents 1 and 2, leading to potential miscommunication and unmet needs.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe to the State Survey Agency, the state ombudsman, and local law enforcement. This incident involved a resident who was moderately impaired with cognitive skills and required assistance with daily activities. The resident had a skin discoloration on the back of their right hand, which was initially attributed to a blood draw. However, the resident later accused a Certified Nursing Assistant (CNA) of causing harm. On the morning of the incident, a Licensed Vocational Nurse (LVN) observed the discoloration and was informed by the resident of the alleged abuse. The LVN communicated this to the Director of Nursing (DON) via text message, but the DON misread the message and did not report the allegation immediately. The DON later acknowledged the oversight and reported the incident to the California Department of Public Health (CDPH) later that day. Interviews with staff revealed that the facility's policy required abuse allegations to be reported within two hours to ensure timely investigation and resident safety. The delay in reporting the incident potentially compromised the resident's protection and emotional wellbeing. The facility's policy and procedure on abuse prevention and management emphasized the importance of prompt reporting and thorough investigation of such allegations.
Failure to Provide a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for three residents, as observed during a survey. Resident 19's room had peeling paint and baseboards that were peeling off the wall. Resident 19 was admitted with severe cognitive impairments and required substantial assistance with daily activities. The Director of Nursing (DON) acknowledged that the room conditions were not homelike and that the Maintenance Department was responsible for repairs, but it was unclear if these issues had been addressed during rounds. Resident 81's room also had peeling paint and white patches on the wall next to the bed and around the electrical outlet. Resident 81, who was severely impaired with cognitive skills due to dementia, required various levels of assistance with daily activities. The DON confirmed that the room conditions were not homelike and that the Maintenance Department should have addressed these issues. The Maintenance Assistant (MA 1) stated that the Maintenance Supervisor was responsible for identifying and fixing such issues but was unsure how long the problems had existed. In Resident 20's room, a plastic cup of frozen beverage belonging to staff was left on top of the resident's hand sanitizer dispenser. Resident 20, who had moderate cognitive impairments and required substantial assistance with daily activities, was affected by this unsanitary practice. The DON confirmed that staff should not leave their belongings in residents' rooms as it is not homelike and violates the residents' private space. The facility's policies emphasized the importance of maintaining a safe, clean, and homelike environment for residents, which was not upheld in these instances.
Failure to Follow Oxygen Administration Policy
Penalty
Summary
The facility failed to follow its policy to ensure licensed nurses administer oxygen to two residents, leading to potential risks in their respiratory care. Resident 143, who has dementia and chronic kidney disease, was observed having their nasal cannula tubing picked up from the floor and connected to the oxygen concentrator by a CNA, who admitted not knowing the correct oxygen dosage. This task should have been performed by a licensed nurse as per the resident's care plan and physician orders, which specified oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 92% for chronic respiratory failure with hypoxia. Similarly, Resident 85, diagnosed with COPD and dependent on supplemental oxygen, was observed having their nasal cannula tubing placed and oxygen concentrator regulated by another CNA. The CNA acknowledged that this responsibility should have been handled by a licensed nurse. The resident's care plan and physician orders indicated oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath or to keep oxygen saturation above 91%. Interviews with the Director of Staff Development, Infection Preventionist Nurse, and Director of Nursing confirmed that it is the responsibility of licensed nurses, not CNAs, to administer and regulate oxygen therapy. The facility's policies on oxygen therapy and oxygen safety and handling also stipulated that licensed nursing staff should administer oxygen as prescribed, ensuring safe and sanitary conditions to meet residents' needs.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the storage, preparation, and distribution of food were done under sanitary conditions. Specifically, a red fruit Jello container, apple sauce tray cups, rice noodles, and a garlic bag were not labeled with use by or expiration dates. Additionally, an expired cilantro bag was found mixed with carrots in the same container, and a container labeled as chorizo actually contained bacon. These deficiencies were confirmed through observations and interviews with the Dietary Staff Supervisor (DSS) and Dietary Aid (DA). The DSS acknowledged that the red fruit Jello was not labeled and should have been discarded the previous day. Similarly, the DSS confirmed the spoiled cilantro mixed with carrots and the mislabeled chorizo container containing bacon. The facility's policies and procedures, which were reviewed and revised, indicated that food items should be stored, thawed, and prepared in accordance with good sanitary practices, with all items correctly labeled and dated. However, these policies were not followed, as evidenced by the observations and interviews conducted. The DSS admitted that the cilantro should have been discarded the previous day and that the labeling errors were likely due to oversight by the cook. These practices have the potential to expose residents to pathogens and increase the risk of foodborne illnesses.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced dignity and respect for two residents. Resident 11, who has dementia and dysphagia, was observed being fed by a CNA who was standing, causing the resident to extend his neck to look up. The CNA acknowledged the mistake and stated that she should have sat down to be at the resident's eye level. The Director of Nursing confirmed that staff should sit while feeding residents to maintain dignity. Facility policies also support this practice to promote quality of life and respect for residents. Similarly, Resident 37, who has severe cognitive impairment and dysphagia, was also fed by a CNA who was standing. The CNA admitted that it was not appropriate and that sitting at the resident's eye level is important for maintaining dignity and respect. The Director of Staff Development reiterated that feeding residents while standing is not acceptable as it can make residents feel rushed and disrespected. Facility policies emphasize treating residents with kindness, respect, and dignity, and maintaining eye level during feeding is part of these guidelines.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs of three residents by not ensuring their call lights were within reach. Resident 37, who was severely cognitively impaired and dependent on assistance for daily activities, had their call light placed out of reach. This was confirmed during an observation and interview with a CNA, who acknowledged the issue. The Director of Staff Development also confirmed that the call light should always be within reach to ensure residents can call for assistance in emergencies. Resident 73, who had dementia and impaired vision, was found without their call light within reach. During an observation, the resident stated they did not know where the call light was, and a CNA later found it behind the bed. The resident's care plan indicated the need for the call light to be within reach due to their risk of falls and need for prompt assistance. Resident 3, who had Alzheimer's disease and was severely impaired in cognitive skills, was found with their call light on the floor and out of reach. An Infection Control Nurse confirmed that the call light should be next to the resident. Interviews with a CNA and the Director of Nursing highlighted the importance of having the call light within reach to prevent falls and ensure timely assistance. The facility's policy also stated that call cords should be placed within the resident's reach.
Failure to Maintain Privacy and Confidentiality of Resident Medical Records
Penalty
Summary
The nursing staff failed to provide privacy and confidentiality of Resident 11's medical records by leaving the computer screen unattended multiple times. Resident 11, who has dementia and lacks the capacity to make decisions, had their care plan information left visible on the computer screen at the nursing station. This occurred on several occasions, with the responsible nurse walking away from the station without closing the screen, leaving the resident's sensitive information exposed to passersby. The Director of Nursing (DON) acknowledged that this practice was not compliant with HIPAA regulations and emphasized the importance of closing the screen to protect patient information. Additionally, during a record review, the responsible nurse logged into the computer and left it open for another staff member to use without logging out. This second staff member also left the computer screen open with wound care and medical orders information visible. Multiple staff members walked by the nursing station while the screen was left open, further compromising the confidentiality of the resident's medical records. Both the Administrator and the DON confirmed that staff should log off and close computer screens before leaving the nursing station to ensure compliance with privacy policies.
Failure to Ensure RN Certification of MDS and CAA
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) signed and certified the Minimum Data Set (MDS) and Care Area Assessment (CAA) for Resident 84, as required by the facility's policy. Resident 84, who was admitted with a diagnosis of type 2 diabetes mellitus, had moderate cognitive impairment and required varying levels of assistance with daily activities. The MDS, dated 11/16/23, was signed by a Licensed Vocational Nurse (LVN) instead of an RN, which was confirmed by the Clinical Consultant during an interview and record review on 4/12/24. The facility's policy and the CMS RAI version 3.0 Manual both mandate that an RN must sign and certify the completion of the MDS and CAA sections. The Clinical Consultant verified that the LVN's signature on the MDS assessment was not in compliance with the facility's policy, which requires an RN to validate the completion of these assessments. This deficiency had the potential to result in an incomplete assessment and an inaccurate depiction of resident-specific issues, which could affect the development of an individualized care plan for Resident 84. The facility's policy, dated October 4, 2016, and the CMS RAI version 3.0 Manual, dated October 2023, both emphasize the necessity of an RN's certification for the accuracy and completeness of resident assessments and care planning.
Failure to Implement Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to implement the care plan for Resident 18, who was on oxygen therapy due to respiratory failure, COVID-19, and pneumonia. Despite the care plan specifying that the head of the bed (HOB) should be elevated to facilitate ventilation, Resident 18 was observed lying flat on her back with the HOB in a flat position. This observation was confirmed by Licensed Vocational Nurse 3 (LVN 3), who acknowledged that the HOB should be elevated to allow the lungs to expand and take in more air. LVN 3 also noted that failing to elevate the HOB could lead to shortness of breath, decreased oxygen levels, and tachycardia, potentially resulting in hospitalization for Resident 18. The Director of Nursing (DON) reiterated the importance of following the care plan to prevent respiratory distress and hospitalization, emphasizing that the care plan interventions are assessed and evaluated to meet Resident 18's specific needs. Resident 18's medical history indicated severe cognitive impairment due to dementia, making her dependent on staff for daily activities and decision-making. The facility's policies on oxygen therapy and comprehensive person-centered care planning were reviewed, both of which stress the importance of administering oxygen as prescribed and following individualized care plans. Despite these policies, the facility did not adhere to the care plan for Resident 18, leading to a deficiency that could have serious health implications for the resident.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that Resident 17, who was unable to perform activities of daily living (ADL) due to severe cognitive impairment and dependency, received the necessary services to maintain good personal hygiene. Resident 17, diagnosed with dementia and receiving palliative care, was observed with white crust on the eyelids and brownish stains around the mouth. The resident's care plan indicated a dependency on staff for personal hygiene and oral care, yet these needs were not adequately met, as evidenced by the physical condition observed during the survey. Certified Nursing Assistant (CNA) 9 acknowledged that it was not acceptable for the resident to be in such a state and that staff should ensure proper hygiene. The Director of Staff Development (DSD) also confirmed that the resident should have been cleaned immediately and any changes in the resident's condition should be reported to the charge nurse. The facility's policies on bed baths and resident rights emphasize the importance of maintaining residents' hygiene and treating them with dignity and respect, which were not adhered to in this case.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate treatment and care according to the physician's order and care plan. Resident 3, who has Alzheimer's Disease and severe cognitive impairment, was observed without an abdominal binder, which is crucial for preventing the dislodgement of her gastrostomy tube (g-tube). The binder was being washed, and no replacement was available. Staff, including the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS), acknowledged the importance of the binder and the potential risks of not having it on, but no immediate action was taken to provide a replacement binder for Resident 3. The facility also failed to reassess and monitor Resident 30's right big toe as indicated in the care plan. Resident 30, who has type 2 diabetes mellitus and moderate cognitive impairment, was observed with redness on the right big toe, which was not documented or treated. The Treatment Nurse (TN) confirmed the redness and stated that daily skin checks by Certified Nursing Assistants (CNAs) were essential for early detection and treatment of skin abnormalities. However, the redness was not reported or addressed in a timely manner, as confirmed by interviews with the CNA and LVN. Both deficiencies highlight a failure to follow physician orders and care plans, which are critical for the residents' health and well-being. The lack of adherence to these protocols had the potential to result in significant health complications for both residents, including the risk of g-tube dislodgement for Resident 3 and the worsening of a diabetic foot ulcer for Resident 30.
Failure to Maintain Hospice Documentation
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident receiving hospice services. Specifically, the facility did not maintain hospice nursing and visitation notes in the resident's medical record as required by the hospice policy. This deficiency was identified during an interview and record review, where it was found that the last Licensed Vocational Nurse (LVN) note in the hospice binder was from 2/13/24, and the last Certified Home Health Aide (CHHA) note was from 3/8/24. The Director of Nursing (DON) confirmed that all hospice notes should be in the resident's hospice binder to communicate the type of care provided, but was unsure who was responsible for ensuring this documentation was complete. The resident involved, identified as Resident 79, was admitted to the facility with diagnoses including Alzheimer's disease, iron deficiency anemia, and chronic kidney disease. The resident was severely impaired with cognitive skills for daily decision-making and was dependent on assistance for various activities of daily living. The resident had a physician order to be admitted to hospice care with specific visit frequencies for different hospice staff. However, the facility's failure to maintain up-to-date hospice notes in the resident's medical record could result in a delay or lack of coordination in the delivery of hospice care and services to the resident.
Infection Control Deficiencies
Penalty
Summary
The facility failed to enforce its infection control policies and procedures, leading to several deficiencies. Certified Nursing Assistant (CNA) 6 did not perform hand hygiene after removing dirty gloves and before putting on clean gloves during resident care. This lapse was observed during peri-care for a resident who was severely impaired with cognitive skills and dependent on assistance for daily activities. CNA 6 acknowledged the failure to perform hand hygiene, which is crucial to prevent the spread of germs and bacteria. Another deficiency involved CNA 7, who picked up a resident's nasal cannula tubing from the floor and connected it to the oxygen concentrator without replacing it. The resident, who had dementia and chronic kidney disease, required oxygen therapy to maintain adequate oxygen saturation levels. Both the Director of Staff Development (DSD) and the Infection Preventionist Nurse (IPN) confirmed that the tubing should have been changed to prevent infection. Additionally, the facility failed to disinfect laundry washers after each use. Laundry Staff (LS) 1 was observed loading dirty linen into a washer and then proceeding to the dirty linen area without performing hand hygiene after removing gloves. LS 1 also did not disinfect the washer after use, which could lead to contamination. The IPN confirmed that hand hygiene and disinfecting the washers after each use are necessary to prevent the spread of infection. These practices were not followed, as per the facility's policies on hand hygiene and infection control.
Failure to Maintain Kitchen Equipment in Safe Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition when the kitchen burners did not ignite properly. During an initial tour, it was observed that the cook used a piece of paper to ignite the burner, stating that this method made the flame bigger. The cook admitted to having burned himself before while using this method and mentioned that the igniter was often borrowed by staff and not returned. The Dietary Staff Supervisor (DSS) acknowledged the danger of using paper to ignite the burners and stated that the cook should use an igniter, which was currently misplaced. The DSS also mentioned that maintenance is scheduled monthly or as needed to repair or replace kitchen equipment, and she would contact the maintenance supervisor immediately to address the issue. The Maintenance Assistant (MA) was interviewed the following day and stated that he was not aware of the issue with the kitchen burners. A review of the facility's policies and procedures indicated that the maintenance department is responsible for ensuring that all equipment is maintained in a safe and operable manner. The policies also outlined that the Director of Maintenance is responsible for developing a maintenance schedule to ensure safety. Despite these policies, the failure to maintain the kitchen burners in safe working condition was evident, posing a risk to staff safety.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that four of its resident bedrooms met the federal regulation requirement of at least 80 square feet per resident in multiple resident bedrooms. Specifically, Rooms 24, 26, 28, and 44 were found to be below the required space per resident. Room 24 measured 230.84 square feet and housed three residents, Room 26 measured 221.56 square feet and housed three residents, Room 28 measured 217.74 square feet and housed three residents, and Room 44 measured 237.6 square feet and housed three residents. These measurements were confirmed during a general observation of the facility and through a review of the Client Accommodation Analysis record by the Administrator, who acknowledged that these rooms did not meet the 80 square feet per resident requirement. Despite the space constraints, the facility had submitted a room waiver request, indicating that there was adequate space for nursing care and that the health and safety of the residents were not in jeopardy. The waiver request, dated 4/9/24, sought re-authorization for the four resident rooms with floor areas ranging from 215 to 235 square feet. The Department recommended the room waiver for Rooms 24, 26, 28, and 44 as requested by the facility.
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What surveyors actually found near you
We read the 7,113 citations issued within 25 miles in the last 12 months — including the 35 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 San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Gabriel Valley Medical Ctr D/p Snf | 0 mi | ★★★★★ | 17 | 0 |
| Live Oak Rehab Center | 0.2 mi | ★★★★★ | 38 | 1 |
| Royal Vista Care Center | 0.5 mi | ★★★★★ | 31 | 0 |
| Broadway Healthcare Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.