Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Jewish Home & Rehab Center D/p Snf during CMS and state inspections, most recent first.
Two residents received psychotropic meds without adequate monitoring or order limits. One resident with vascular dementia had Olanzapine ordered for psychotic symptoms, but the chart did not identify specific target behaviors and staff described the monitoring as general. Another resident on hospice had PRN Lorazepam orders without stop dates, and the MAR showed doses given for mild anxiety without documentation of any behavior being observed.
Failure to Notify Ombudsman of Emergency Transfers: Two residents were transferred to acute care after emergency events, including one with Foley catheter trauma and bleeding and another after an unwitnessed fall with hip pain and lip laceration. Although Notices of Transfer or Discharge stated the transfers were necessary for the residents' welfare, the facility did not document sending the required notices to the Ombudsman, despite policy requiring Social Services or designee to provide copies for emergency transfers.
A resident with multiple risk factors for skin breakdown developed new and worsening pressure injuries, including MASD, Stage II and III pressure ulcers, and open lesions, due to the facility's failure to accurately monitor wounds, revise treatment plans, and implement or update interventions. Staff did not consistently document wound assessments, involve interdisciplinary teams, or educate the resident and family, resulting in inadequate prevention and management of pressure injuries.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not submit the required results of abuse investigations to the state agency within five working days for multiple incidents, including staff-to-resident and resident-to-resident abuse allegations. Although initial reports were made, the mandated follow-up documentation was delayed beyond the required timeframe.
Three residents experienced neglect due to staffing shortages, leading to long waits for care and services. One resident expressed feelings of helplessness and suicidal thoughts after waiting hours for assistance, while another was in pain due to delayed bedtime care. A third resident faced cold meals and long waits for call light responses. Staff confirmed that CNA staffing was reduced, causing delays in care.
A resident with quadriplegia and other conditions, fully dependent on staff, reported neglect through multiple emails, citing delayed or missed care and insufficient food and water. Despite the facility's policy requiring immediate reporting of neglect, the facility failed to document or investigate these complaints, leading to unmet needs and hospitalizations.
A resident with quadriplegia and other conditions experienced a 41.67% reduction in direct caregiver hours, despite no change in care needs. This led to feelings of frustration, abandonment, and suicidal ideation. The facility misclassified Safety Monitors as direct caregivers, and the resident was left waiting for assistance with basic needs. Social Services documented the resident's distress and fear of abandonment, and the facility could not provide a rationale for the care reduction.
The facility's kitchen was found to be unsanitary, with rodent droppings, food build-up, and grime under equipment. A pest control technician confirmed the presence of a mouse, and the Infection Preventionist raised concerns about salmonella contamination. The Director of Dining Services was unaware of the lack of regular deep cleaning under equipment. Additional issues included grime in the ice machine, dirty utensils, expired food, and unclean floor drains, all contrary to facility policies and FDA guidelines.
The facility failed to implement its fall policy for three residents, resulting in deficiencies in post-fall management. One resident with dementia had no IDT meetings after falls, another lacked consent for video monitoring and IDT documentation post-fall, and a third resident did not receive a post-fall assessment or detailed IDT documentation after an assisted fall.
A facility failed to maintain a medication error rate below 5%, with errors observed in the administration of inhalers and eyedrops. An LVN did not shake an inhaler or instruct a resident to inhale properly, resulting in ineffective delivery. Eyedrop administration errors included contact with eyelashes and lack of glove use, compromising sterility and infection control.
The facility's QAPI program failed to prevent medication administration errors, as observed during a survey. Multiple errors occurred during the administration of eye drops, with staff failing to adhere to sterile techniques and infection control standards. Interviews with the Quality Committee revealed a lack of awareness and proactive measures to address these issues, contributing to a 15% medication error rate.
The facility failed to provide the SNF-ABN to two residents receiving Part A services. One resident was admitted with Chronic Inflammatory Demyelinating Polyneuritis and another with Ileus. Both residents were not given the SNF-ABN form, as the facility believed it was unnecessary. Interviews revealed a misunderstanding of when the form should be issued, despite the facility's policy indicating its necessity for Part A services.
A resident reported verbal abuse by nursing staff and a PT to a social worker, but the allegation was not reported to the facility administrator or necessary agencies as required by policy. The resident, who had undergone joint replacement surgery and had intact cognition, felt threatened with discharge and experienced a change in PT, which they perceived as retaliatory. The failure to report the incident left the resident at risk for continued exposure to abuse.
A resident with intact cognitive abilities reported verbal abuse by nursing staff and a PT, but the facility failed to investigate the allegations. Despite the resident's report to a social worker, no investigation or report was made to authorities, as confirmed by the administrator.
A resident's hearing needs were inaccurately assessed when the MDS recorded that they did not use hearing aids, despite the resident using them upon admission. The resident's care plan noted a hearing deficit requiring bilateral hearing aids, but staff were unaware of the resident using only one due to a broken aid. This discrepancy was acknowledged by the MDS nurse, highlighting a failure in accurate assessment and documentation.
A resident with dementia and a history of UTI and falls did not have a comprehensive care plan addressing these issues. Despite being at high risk for falls, interventions like 2-hour rounding and video monitoring were not documented or implemented, as confirmed by nursing staff.
The facility failed to update care plans for three residents after falls, potentially compromising their care. A resident with dementia experienced multiple falls without updates to her fall care plan. Another resident with dementia and anxiety disorder also had multiple falls without care plan revisions. A third resident with diabetes and lung cancer suffered a hip fracture, but her pain care plan was not updated post-surgery. These oversights indicate a failure to adhere to the facility's policy for revising care plans after significant health events.
A resident's right-sided hearing aid was broken for multiple days without staff awareness, despite the resident's intact cognitive status. The care plan required bilateral hearing aids for communication, but staff interviews revealed a lack of awareness about the resident's hearing aid status. The facility's policy required daily checks of hearing aid function, which were not performed.
A resident with a history of falls and cognitive impairment fell from a wheelchair while being transported by an untrained volunteer, resulting in multiple injuries. The facility failed to provide adequate supervision and did not ensure the use of footrests, contrary to its fall prevention policy.
The facility failed to maintain infection control practices and equipment maintenance. A CNA did not perform hand hygiene between assisting two residents, contrary to the facility's hand hygiene policy. Additionally, the facility did not maintain its washing machines as per the manufacturer's recommendations, with the last maintenance check occurring months after the contract had expired.
The facility failed to maintain reach-in refrigerator #7 in safe operating condition, resulting in condensation dripping onto food. This posed a potential contamination risk to 332 medically compromised residents. The Director of Dining Services noted that the refrigerator's door hinge needed realignment to prevent condensation, as observed by a surveyor.
A facility failed to implement a pressure ulcer care plan for a resident with multiple diagnoses, including dementia and a pressure ulcer. The care plan required repositioning every two hours, but a CNA only repositioned the resident once due to being busy. The CNA did not follow the care plan or inquire about the resident's last position change during shift endorsement, potentially delaying the healing of the pressure ulcer.
A CNA in an LTC facility was found to lack competency in caring for a resident, as she was unaware of the resident's dementia and UTI, which required enhanced barrier precautions. The CNA incorrectly believed the resident had C-diff and admitted to forgetting the resident's conditions, despite facility policies requiring nursing staff competency.
Unnecessary Psychotropic Medication Use and Inadequate PRN Monitoring
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary psychotropic medications. For one resident with vascular dementia and psychotic disturbance, Olanzapine 5 mg at bedtime was ordered for psychotic symptoms, but the clinical record did not identify specific target behaviors to monitor for its use. The resident’s care plan noted a risk for altered thought processes and behavioral instability related to delusional thinking and directed staff to monitor for changes in thought content, hallucinations, and delusions, but the medication record only listed a general behavior monitoring entry for verbalization of delusional thinking. During interview, an LVN acknowledged the documentation was general and not specific, and a CNA stated she had not been told what behaviors to monitor and was not aware of the care plan. For another resident with dementia and agitation who was on hospice, the record showed multiple PRN Lorazepam orders for mild, moderate, and severe anxiety/seizures. The PRN orders did not have stop dates. The pharmacist stated PRN anxiolytics should be limited to 14 days and agreed the Lorazepam order should have had a stop date. An LVN confirmed the PRN Lorazepam orders had no end dates and stated the medication was being given indefinitely because the resident was on hospice. The record also showed Lorazepam 0.5 mg PRN for mild anxiety was administered on three occasions, but licensed nurse progress notes did not document behavior exhibited at the time of administration. A unit supervisor reviewed the MAR and notes and confirmed there was no behavior documented for those administrations, stating the medication should not be given unless a behavior was observed and that behavior monitoring is used to determine whether the medication is effective. The facility policy stated target behaviors should be resident specific and PRN anxiolytics or hypnotics are limited to 14 days unless the prescriber evaluates the resident and writes a new order with a specified end date.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility did not document notification to the Ombudsman when two residents were transferred out to acute care. One resident had diagnoses including urinary retention, benign prostatic hyperplasia, and infection and inflammatory reaction due to a urinary catheter. Nursing notes documented that the resident screamed for help, transferred from bed to chair unassisted with the Foley bag hanging by the bedside, pulled the catheter midway, and had bleeding with confusion and agitation. The physician was called and ordered transfer to the ED for active bleeding and further evaluation, and the resident was transported by 911. The facility's Notice of Transfer or Discharge stated the transfer was necessary for the resident's welfare and needs could not be met in the facility, but there was no documentation that the notice was sent to the Ombudsman. A second resident had diagnoses including fracture of the left femur, repeated falls, and dependence on renal dialysis. Nursing notes documented an unwitnessed fall in the resident's room while trying to eat by sitting on the side of the bed without assistance. The resident had left hip pain and an upper lip cut with bleeding, was alert and oriented x3, and was picked up by paramedics and transferred to acute care. The facility's Notice of Transfer or Discharge again stated the transfer was necessary for the resident's welfare and needs could not be met in the facility, but no Ombudsman notification was documented. During interview, the Director of Clinical Reimbursement stated that a notification should be sent to the Ombudsman's office for every resident transferred to acute care for emergency, and the facility policy required Social Services or designee to provide copies of notices for emergency transfers to the Ombudsman.
Failure to Provide Adequate Pressure Injury Services and Monitoring
Penalty
Summary
Facility staff failed to provide adequate pressure injury services for a resident, resulting in the development of new and worsening skin injuries. The staff did not accurately monitor or evaluate the resident's pressure injuries, nor did they revise treatment plans to promote healing. There was a lack of evaluation and monitoring of the impact of interventions intended to prevent new pressure injuries, and interventions were not implemented, monitored, or modified to address underlying risk factors. As a result, the resident developed new Moisture Associated Skin Damage (MASD) on the coccyx, a Stage II pressure injury on the coccyx, new open lesions on both rear thighs, and a Stage III pressure injury on the left heel, all of which developed while the resident was in the facility. The resident had multiple diagnoses that increased her risk for skin breakdown, including hemiplegia, hemiparesis, monoplegia, diabetes with peripheral angiopathy, muscle weakness, peripheral vascular disease, and incontinence. She was completely dependent on staff for mobility, hygiene, and dressing. Despite these risk factors, documentation showed that wound measurements were not consistently recorded, and there was a period when the facility lacked a designated wound nurse. During this time, floor nurses were responsible for wound care and weekly skin checks, but there was no routine schedule for physician or physician assistant review of wound care or treatment effectiveness. Communication and documentation regarding physician notification and reassessment of wounds were inconsistent or lacking. Interviews with staff revealed that interventions were not updated in response to new or worsening wounds, and care plans were not revised as required. Licensed nurses and CNAs reported that they were not involved in interdisciplinary team meetings, and there was no evidence that the resident or her family were included in care planning or educated about pressure injury prevention. Reports of the resident returning from outings with family in a wet condition did not result in changes to care interventions. Facility policy required interdisciplinary assessment and care plan updates for new pressure injuries, but these procedures were not followed. The lack of timely and appropriate interventions, monitoring, and care plan revisions directly contributed to the resident's skin injuries.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Timely Report Abuse Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of investigations into abuse allegations to the State Survey Agency (SSA) within five working days of the incidents for four residents. Specific incidents included allegations of rough handling by two CNAs during a bed change, verbal aggression and rudeness by a CNA, a nurse being harsh and hitting a resident, and a resident-to-resident altercation involving physical contact. In each case, while initial reports of the allegations were made to the appropriate authorities, the required follow-up documentation detailing the results of the investigations was not submitted to the SSA within the mandated five-day period. Record reviews showed that the follow-up reports were faxed to the California Department of Public Health (CDPH) several days after the five-day window had passed. The facility's policy requires that the results of abuse investigations be reported to government agencies within five working days, but this procedure was not followed in these instances. The administrator confirmed during an interview that the five-day reporting requirement was not met for these cases.
Neglect Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that three residents were free from neglect, as they were dependent on staff for transfers and activities of daily living (ADL). The residents reported that their unit was short-staffed, leading to long waits for services. This resulted in Resident 1 experiencing feelings of helplessness, frustration, and discomfort due to waiting four hours in wet briefs, being left on the commode for 1.5 hours, and not being repositioned in a timely manner. Resident 1 expressed feelings of frustration, abandonment, and suicidal thoughts. Resident 2 reported being in pain at night after staff did not put her to bed in a timely manner. She expressed feelings of frustration and worry because staffing issues were communicated to the facility without any substantive changes. Resident 3 expressed feelings of anger, frustration, and neglect due to being served cold meals and waiting an hour for staff to answer his call light. All three residents were totally dependent on staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and showers. Interviews with staff, including charge nurses and certified nursing assistants (CNAs), confirmed that the unit was often short-staffed, with CNA staffing reduced from six to as low as four without a reduction in resident census or change in resident acuity. This staffing shortage led to residents having to wait for care, with some residents waiting up to an hour for assistance. The unit manager admitted that residents would have to wait when the unit was short-staffed, and safety monitors could not perform direct patient care tasks.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect for a resident who was admitted with multiple diagnoses, including quadriplegia, constipation, depression, muscle spasms, and limitations due to disability. The resident was entirely dependent on staff for daily activities such as bed mobility, transfers, dressing, toilet use, personal hygiene, and showers. Despite having a Brief Interview for Mental Status (BIM) score indicating no cognitive impairment, the resident sent multiple emails to the facility's grievance portal and staff, alleging neglect in care. These emails detailed issues such as delayed or missed care, insufficient food and water, and lack of assistance with toileting, which led to painful symptoms and hospital admissions due to internal infections. The facility's policy required immediate reporting of alleged neglect to appropriate authorities, but the facility did not document or investigate the resident's complaints as grievances or neglect allegations. The emails highlighted that the resident's care was inconsistent, particularly when regular CNAs were off duty, resulting in unmet needs and hospitalizations. The facility was unable to provide documentation showing that the resident's emails were treated as grievances or that any investigation or reporting of neglect occurred, as required by state regulations.
Reduction in Direct Care Hours Leads to Resident Distress
Penalty
Summary
The facility failed to provide the necessary care to maintain the highest practicable mental and psychosocial well-being for a resident who was totally dependent on staff for Activities of Daily Living (ADL) and other care needs. Starting in July 2024, the facility unilaterally reduced direct caregiver hours by 41.67% for this resident, despite no change in her care needs. This reduction in care led to the resident expressing feelings of frustration, abandonment, and suicidal ideation. The resident, who was admitted with multiple diagnoses including quadriplegia, depression, and muscle spasms, was entirely reliant on staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and showers. Observations and interviews revealed that the resident was left waiting for assistance with basic needs, such as repositioning and toileting, due to staff shortages. The facility had implemented Safety Monitors (SM) who were not allowed to perform direct patient care tasks, yet one SM was found to be providing such care, indicating a misclassification of staff roles. The facility's documentation showed discrepancies in the reported hours of care provided, with Safety Monitors being incorrectly counted as direct caregivers. Social Services notes documented the resident's ongoing distress and fear of abandonment, as well as her dependence on staffing levels to plan her daily activities. Despite requests, the facility was unable to provide clinical rationales for the reduction in direct care hours, highlighting a significant deficiency in meeting the resident's care needs.
Unsanitary Kitchen Conditions in LTC Facility
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by multiple observations of unsanitary conditions. A rodent dropping was found under the cooking line, which also had a build-up of food, black grime, and trash. The presence of a rodent dropping was confirmed by a pest control technician, who suggested that an automatic exterior door might be allowing mice to enter the kitchen. The Infection Preventionist expressed concern about potential salmonella contamination from the rodent. Additionally, the Director of Dining Services acknowledged that the floors under the equipment should be clean and free of rodent droppings. Further observations revealed multiple areas in the kitchen with old food, trash, and black grime on the floors under various pieces of equipment, including the coffee cart, tilting skillet, flat top grill, and ovens. The Director of Dining Services was unaware that the contracted cleaning service did not include regular deep cleaning of the floors under the equipment. The facility's policy and the FDA Federal Food Code require that nonfood contact surfaces be kept free of debris to prevent the attraction of pests and the accumulation of pathogenic microorganisms. Additional deficiencies included a black grime build-up in the ice machine, utensils stored with old food grime, expired and undated food in the refrigerator, and floor drains with old food and grime. The Director of Dining Services acknowledged that these areas should be kept clean and free of debris. The facility's policies and the FDA Federal Food Code emphasize the importance of maintaining cleanliness to prevent contamination and ensure food safety.
Failure to Implement Fall Policy and Procedure
Penalty
Summary
The facility failed to adhere to its fall policy and procedure for three residents, leading to deficiencies in post-fall management. For Resident 187, who was admitted with dementia, hypertension, and atrial fibrillation, there was no evidence of an interdisciplinary team (IDT) meeting following falls on two separate occasions. Despite the resident being found on the floor twice, the necessary IDT meetings to discuss and document the falls were not conducted, as confirmed by a registered nurse during a record review. Resident 327, diagnosed with dementia, anxiety disorder, and a urinary tract infection, also experienced a lapse in post-fall protocol. The resident's care plan included video monitoring as a fall prevention measure, but there was no documented consent for this intervention. Additionally, after a witnessed fall, there was no IDT meeting note recorded, which was acknowledged by the Director of Nursing and a nurse manager, indicating a failure to follow the facility's policy requiring IDT meetings after each fall. For Resident 356, who had a history of falling and a displaced fracture of the right femur, the facility did not complete a post-fall assessment after an assisted fall during a physical therapy session. Although an IDT note was present, it lacked detailed documentation of the fall's cause, root cause analysis, and intervention recommendations, as required by the facility's fall prevention policy. This oversight was confirmed by a nurse manager during a review of the resident's electronic medical record.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 15% error rate during a medication pass. This was observed over two days, where four medication errors occurred out of twenty-six opportunities involving three residents. The errors included improper administration techniques and failure to adhere to established procedures for medication delivery. One significant error involved the administration of Flovent HFA 220 ug inhaler to a resident. The LVN did not shake the inhaler before use, which is crucial for proper medication mixing. Additionally, the resident was not instructed to inhale deeply and hold their breath, leading to most of the medication mist exiting the resident's mouth instead of being inhaled into the lungs. This improper technique resulted in the resident not receiving the full dose of the medication. Other errors were related to the administration of eyedrops. In multiple instances, the tip of the eyedropper bottle came into contact with residents' eyelashes, compromising sterility. One LVN did not wear gloves during the administration, further breaching infection control standards. These deviations from proper technique were acknowledged by the staff involved, indicating a lack of adherence to the facility's medication administration procedures.
Ineffective QAPI Program Leads to Medication Administration Errors
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) program was found to be ineffective in preventing medication administration errors, particularly during the administration of eye drops. During a survey, multiple medication errors were observed. A Licensed Vocational Nurse (LVN) administered Systane eye drops to a resident, allowing the dropper tip to touch the resident's eyelashes, which deviated from the sterile technique outlined in the facility's policy. Another LVN administered the same eye drops to a different resident without wearing gloves, and the dropper tip again touched the resident's eyelashes. A Registered Nurse (RN) also failed to maintain proper technique while administering Olopatadine eye drops, allowing the dropper tip to come into contact with a resident's eyelashes, causing the resident to blink excessively. Interviews with the facility's Quality Committee, including the Assistant Director of Nursing, the Director of Nursing, and the Administrator, revealed that they had not identified any issues related to medication pass observations. The committee members acknowledged the absence of ongoing performance improvement projects aimed at addressing medication errors, despite a reported medication error rate of 15%. This lack of proactive measures and oversight contributed to the deficiencies observed during the survey.
Failure to Provide SNF-ABN to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to two residents, Resident 177 and Resident 248, who were receiving Part A services. Resident 177 was admitted with a diagnosis of Chronic Inflammatory Demyelinating Polyneuritis and was placed on Part A for daily skilled physical, occupational, and speech therapy. The SNF Beneficiary Protection Notification Review indicated that the last covered day of Part A service was 5/1/24, and the Notice of Medicare Non-Coverage (NOMNC) was given on 4/28/24. However, the SNF-ABN form was not provided to Resident 177, as the facility believed it was not needed. Resident 177 remains in the facility for custodial care. Similarly, Resident 248 was admitted with a diagnosis of Ileus and was placed on Part A for skilled rehabilitation. The SNF Beneficiary Protection Notification Review showed that the last covered day of Part A service was 4/23/24, and the NOMNC was given on 4/9/24. The SNF-ABN form was also not provided to Resident 248, as the facility deemed it unnecessary. Resident 248 continues to reside in the facility for custodial care. Interviews with the Utilization Manager and MDS RN revealed a misunderstanding of when the SNF-ABN form should be issued, as they believed it was only necessary for non-covered services or when Medicare B was involved. The facility's policy indicated that the SNF-ABN should be used for Part A items and services when they may not be covered, but this was not followed in these cases.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to recognize and report an allegation of verbal abuse involving a resident who had undergone joint replacement surgery and had an intact cognitive status. The resident reported to a social worker that they were verbally abused by a nurse and a physical therapist. The resident felt that the change in their physical therapist was retaliatory and reported feeling threatened with discharge due to lack of progress. Despite the resident's report to the social worker, the allegation was not communicated to the facility administrator or other necessary agencies as required by the facility's policy. The facility's policy mandates that any allegations of abuse be reported immediately to the administrator, state agencies, police, and ombudsman. However, the social worker who received the report from the resident did not follow through with these procedures. Interviews with the Director of Social Services and the social worker confirmed that the incident was not reported, and the facility administrator was unaware of any investigation into the alleged abuse. This oversight potentially left the resident and others at risk for continued exposure to abuse.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to recognize and investigate an allegation of verbal abuse involving a resident who reported being verbally abused by nursing staff and a physical therapist. The resident, who had intact cognitive abilities as indicated by a perfect score on the Brief Interview for Mental Status, reported to a social worker that she was yelled at by nursing staff for ordering something online and felt retaliated against by being switched to a different physical therapist. The resident alleged that the physical therapist made disparaging remarks about her condition, suggesting she should be thankful for having one good leg. Despite the resident's report to the social worker, the facility did not conduct a thorough investigation into the allegations. Interviews with the Director of Social Services and the social worker revealed that the allegations were not reported to the necessary authorities, including the police, state agencies, and the ombudsman, as required by the facility's policy. The administrator confirmed the absence of any report or investigation into the alleged abuse, highlighting a significant oversight in addressing and documenting the resident's complaint.
Inaccurate Assessment of Resident's Hearing Needs
Penalty
Summary
The facility failed to accurately assess the hearing needs of a resident, identified as Resident 356, who was admitted with a diagnosis of a displaced fracture of the medial condyle of the right femur. Upon admission, the resident was noted to use hearing aids, yet the Minimum Data Set (MDS) assessment inaccurately recorded that the resident did not use hearing aids. This discrepancy was highlighted during a review of the resident's care plan, which indicated a communication problem related to a hearing deficit, with interventions including the application of bilateral hearing aids while awake. Observations and interviews revealed that the resident had been using only one hearing aid due to the right-sided hearing aid being broken, an issue that had persisted for about ten days. The resident communicated this problem by pointing to her left ear and explaining the situation to staff. However, RN 3, during an interview, was unaware of the resident's use of only one hearing aid. MDS Nurse 1 acknowledged the inaccuracy in the MDS assessment, admitting that it should have reflected the resident's use of hearing aids, thus indicating a failure in accurately assessing and documenting the resident's hearing needs.
Failure to Implement Comprehensive Care Plans for UTI and Fall Risk
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, identified as Resident 327, who had a urinary tract infection (UTI) and was at high risk for falls. Despite being diagnosed with a UTI and receiving antibiotic treatment, there was no care plan developed to address this condition. Interviews with nursing staff confirmed the absence of a care plan for the UTI, which was acknowledged as necessary by the staff. Additionally, the resident's clinical records indicated a history of falls, yet the interventions outlined in the fall care plan, such as 2-hour rounding and video monitoring, were not documented or implemented. The resident, who had dementia and was rarely understood, was admitted with multiple diagnoses, including anxiety disorder and UTI. The resident's fall risk was assessed as high, with a score of 14, but the care plan interventions to mitigate this risk were not followed. The facility's policy required appropriate interventions for fall prevention, but there was no evidence of documentation for the prescribed interventions. Interviews with nursing staff confirmed the lack of documentation and implementation of the fall care plan interventions, which were necessary to address the resident's high fall risk.
Failure to Update Care Plans for Residents After Falls
Penalty
Summary
The facility failed to update care plans for three residents, which could potentially compromise their care. Resident 187, who has dementia, hypertension, and atrial fibrillation, experienced multiple falls on three separate occasions. Despite these incidents, her fall care plan was not updated to reflect these events, as confirmed by a registered nurse during a record review. The lack of an updated care plan after each fall indicates a failure to address the resident's changing needs and risks. Similarly, Resident 327, diagnosed with dementia, anxiety disorder, and a urinary tract infection, also experienced multiple falls. The resident's fall care plan was not updated following falls on two specific dates, as verified by both a registered nurse and a licensed vocational nurse. The facility's policy requires that care plans be revised after a fall, yet this was not adhered to, leaving the resident without potentially necessary interventions to prevent further falls. Resident 264, who has diabetes, lung cancer, and osteoporosis, suffered a fall resulting in a hip fracture. Although the fall care plan was updated, the pain care plan was not revised to address the new pain management needs following the fall and subsequent surgery. Interviews with staff confirmed that the pain care plan was not due for an update, despite the significant change in the resident's condition. This oversight suggests a gap in the facility's process for ensuring comprehensive care planning in response to significant health events.
Failure to Maintain Resident's Hearing Aid Function
Penalty
Summary
The facility failed to ensure that a resident's assistive hearing device was functioning properly, which affected one of the two sampled residents. Resident 356 reported that their right-sided hearing aid had been broken for multiple days, and the clinical staff were not aware of this issue. The resident indicated that the problem occurred about ten days prior when someone accidentally jammed a battery while changing it. Despite the resident's intact cognitive status, as indicated by a BIMS score of 13 out of 15, the issue was not addressed in a timely manner. The care plan for Resident 356, dated prior to the incident, highlighted a communication problem related to a hearing deficit, with interventions including the application of bilateral hearing aids while awake. However, interviews with staff revealed a lack of awareness regarding the resident's hearing aid status. A CNA believed the resident had a hearing aid in only one ear, while an RN was unaware that the resident had been wearing only one hearing aid. The Nurse Manager later acknowledged the expectation for nursing staff to check the function of hearing aids daily, as per the facility's policy, which was not adhered to in this case.
Resident Falls from Wheelchair Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident 250, leading to fall-related injuries. Resident 250, who had a history of repeated falls and multiple fractures, was being transported by a volunteer in a wheelchair without footrests. The resident, who had moderate cognitive impairment and balance deficits, was sleepy and leaning forward, which resulted in him falling out of the wheelchair and sustaining a laceration on the forehead, a fracture of the second cervical spinal bone, and a fracture on a finger of the left hand. The incident occurred in the hallway, and the volunteer involved was not trained to handle such situations. Interviews with staff revealed that there was a lack of proper supervision and training for volunteers transporting residents in wheelchairs. The care plan for Resident 250 did not address safety during transport, and the volunteer was unaware of the necessary precautions to prevent falls. The facility's policy on fall prevention emphasized maintaining a safe environment and providing adequate supervision, but these measures were not effectively implemented in this case, leading to the resident's injuries.
Infection Control and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific deficiencies. Firstly, a Certified Nursing Assistant (CNA) did not perform hand hygiene between assisting two residents in the dining room. This was observed when the CNA assisted one resident, cleaned the table, and then proceeded to assist another resident without washing hands. The CNA acknowledged the lapse in hand hygiene when questioned, and both the Nurse Manager and the Infection Preventionist confirmed that hand hygiene should be performed between assisting different residents. The facility's policy on hand hygiene, revised in May 2024, emphasizes the importance of hand hygiene in preventing the spread of infections, particularly after contact with a resident's skin and before and after handling food or assisting with meals. Secondly, the facility failed to maintain its washing machines according to the manufacturer's recommendations. The machines were supposed to be maintained quarterly by the company from which they were purchased. However, the last maintenance check was conducted in February 2024, and the contract for maintenance had expired. The Environmental Services Manager confirmed that the company was responsible for scheduling maintenance visits, but the contract had terminated, leaving the machines without the required maintenance. The facility's policy on laundry services specifies that laundry equipment should be maintained according to the manufacturer's instructions to prevent microbial contamination.
Refrigerator Condensation Risk in Kitchen
Penalty
Summary
The facility failed to maintain equipment in safe operating condition when condensation was observed inside reach-in refrigerator #7, located on the dairy side of the kitchen. This condensation was dripping onto food, posing a potential risk of food contamination and food-borne illness to 332 out of 338 medically compromised residents who receive food from the kitchen. During an initial tour and interview with the Director of Dining Services (DDS), it was noted that the refrigerator's door hinge needed realignment to prevent the condensation. The DDS acknowledged that the issue was previously observed by a surveyor. The facility's policy on Safety and Equipment Maintenance, dated January 2024, assigns the responsibility of maintaining the physical plant and equipment to the Director in cooperation with the Maintenance department. Additionally, the FDA Federal Food Code, dated 2022, mandates that equipment must be maintained in a state of repair and condition to ensure proper operation. Failure to maintain equipment, such as refrigeration units, could lead to violations that risk consumer health by failing to properly cool or hold time/temperature control for safety foods.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to implement a pressure ulcer care plan for a resident, identified as Resident 1, who was admitted with multiple diagnoses including nephritis, renal and perinephric abscess, dementia, and a pressure ulcer. The care plan required repositioning every two hours to aid in the healing of the pressure ulcer. However, on a specific day, a Certified Nursing Assistant (CNA) did not reposition Resident 1 every two hours as required. The CNA admitted to repositioning the resident only once at 9 AM, despite the care plan and bedside schedule indicating the need for repositioning at 8 AM, 10 AM, and 12 noon. The CNA cited being busy as the reason for not adhering to the schedule and did not inquire about the resident's last position change during the shift endorsement. The Nurse Manager confirmed that the care plan, which was initiated months earlier, required repositioning every two hours and as needed. The facility's policy on wound and skin management also mandated repositioning every two hours, which was not followed in this instance, potentially delaying the healing of the resident's pressure ulcer.
CNA Lacks Competency in Resident Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was competent in caring for a resident, as evidenced by the CNA's lack of awareness of the resident's medical conditions. The CNA did not know that the resident had dementia and a urinary tract infection (UTI), which required enhanced barrier precautions due to the presence of extended spectrum beta-lactamase (ESBL) producing bacteria. This lack of knowledge was revealed during an observation and interview, where the CNA incorrectly stated that the resident had Clostridium difficile (C-diff) and was unaware of the resident's dementia diagnosis. The resident in question was admitted with multiple diagnoses, including nephritis, renal and perinephric abscess, dementia, and a pressure ulcer. The CNA, who was floating and not regularly assigned to the resident, admitted to forgetting the resident's conditions and did not take notes during shift endorsements. The facility's policy requires nursing staff to be competent in their roles, but the CNA's actions demonstrated a failure to adhere to this policy, potentially impacting the resident's care.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Francisco Post Acute | 1.7 mi | ★★★★★ | 0 | 0 |
| Laguna Honda Hospital & Rehabilitation Ctr D/p Snf | 2.1 mi | ★★★★★ | 5 | 0 |
| Zuckerberg San Francisco General Hosp & Trauma Snf | 2.2 mi | ★★★★★ | 1 | 0 |
| Lawton Skilled Nursing & Rehabilitation Center | 2.7 mi | ★★★★★ | 9 | 0 |
| California Pacific Medical Ctr- Davies Campus Hosp | 2.8 mi | ★★★★★ | 11 | 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.