Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Jurupa Hills Post Acute during CMS and state inspections, most recent first.
A resident and three other residents were observed smoking in the parking area in front of the facility, which was not the designated smoking area. The ADM stated smoking was only allowed in the back patio area and that residents were to be supervised there. One resident involved stated he usually did not smoke but joined the others, and he acknowledged that smoking was only permitted in the designated area. The resident's record showed diabetes mellitus and that he had the capacity to understand and make decisions.
A resident with morbid obesity and intact cognition reported that a CNA threw wipes at her groin, made degrading comments about her weight, and later called her a "fat bitch" in the hallway while other CNAs laughed. The grievance record noted the resident complained the CNA had an attitude and left her during care because the brief did not fit, but the investigation documentation did not show a further inquiry by the Administrator or designee.
Failure to Thoroughly Investigate Alleged Verbal Abuse: A cognitively intact resident with morbid obesity reported that a CNA made derogatory comments during care, threw wipes at her groin, and later mocked her in the hallway by calling her a fat bitch. The grievance was handled as a communication issue, but the record did not show a thorough abuse investigation, and interviews confirmed staff understood the comments could constitute verbal abuse and should have been investigated.
A resident with HTN and fibromyalgia had a propranolol order to hold if SBP was below 110 or HR was below 60, but the MAR showed the medication was held repeatedly and also given on several occasions when SBP was below 110. The resident stated she rarely takes propranolol because she has low BP, and the ADON said the MD should be notified when the medication is held multiple times so the need for the medication can be evaluated.
A resident with Afib on Eliquis underwent a suprapubic catheter procedure, with physician orders to hold Eliquis before and immediately after the procedure and then resume it on a specified morning. The MAR showed Eliquis was held for several days and not given at the ordered morning time, but instead administered later that morning after the resident, who was cognitively intact, reminded the LN. Nurse’s notes documented that the nurse only discovered the NP’s order to resume Eliquis after the resident’s report, and leadership later confirmed that the order to resume the medication at the scheduled time was not followed, contrary to the facility’s medication administration policy.
A resident with Alzheimer’s disease, dementia, psychosis, and severe cognitive impairment repeatedly exhibited aggressive and antagonistic behavior toward roommates, including verbal threats, physical attacks, and disruptive actions such as touching a roommate, opening privacy curtains, and turning lights on and off. Despite multiple psychology and psychiatry notes documenting that the resident became aggressive whenever a roommate was placed in the room and warning that the resident might hurt himself or others, the care plan was not revised with new, individualized interventions beyond separating residents after incidents. Progress notes described ongoing anger outbursts, inability to be redirected, and hostile behavior observed by family and reported by roommates, yet the facility continued assigning roommates to this resident. In interviews, an LVN and the DON acknowledged that the resident’s behavior issues occurred when he had a roommate and that interventions to prevent these triggered behaviors were not implemented, contrary to facility policies requiring thorough behavioral assessment, individualized interventions, and immediate safety strategies.
A resident with a left shoulder RCT and neuropathy did not receive a timely orthopedic follow-up as ordered, because staff did not schedule the consult within the specified timeframe, did not document the reason for the consult, and did not incorporate the order into the care plan. The same resident’s gabapentin dose for neuropathy was increased from 100 mg to 300 mg TID without a documented nursing assessment or rationale, despite ongoing documentation of zero pain scores. Later, a neurology referral was obtained after the resident requested to see a neurologist, but staff did not document the assessment or reason for the referral and did not add the referral to the care plan, leaving other nurses unaware of the consult’s purpose.
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.
A resident with a fractured right arm did not receive timely physical therapy after an orthopedic consultation due to the facility's failure to follow up on new medical orders. The resident returned from the appointment without an AVS, and staff did not document or act on the orthopedic doctor's therapy recommendations for seven days, resulting in a delay in care.
Surveyors observed that kitchen staff did not wear hairnets properly, with hair escaping from the top, sides, and nape of their necks. Additionally, a staff member responsible for dishwashing failed to change gloves after handling dirty kitchenware before touching clean, sanitized pans, and rinsed soiled kitchenware near clean beverage cups and glasses. The facility's policies lacked clear procedures for transitioning between dirty and clean tasks, contributing to these deficiencies.
The facility did not provide the required transfer/discharge notices to the State LTC Ombudsman before two residents, one with pneumonia and sepsis and another with heart failure, were discharged home. Notices were only sent after the residents had left, contrary to facility policy and regulatory requirements.
A resident with chronic pain and multiple pain medication orders did not receive pain management in accordance with physician instructions. Hydrocodone was administered for higher pain levels instead of Percocet as ordered, and staff did not match the pain scale to the correct medication. The DON confirmed that the orders were not followed and that staff did not notify the physician to adjust the medication regimen despite frequent PRN use.
Nursing staff did not follow manufacturer-specified contact times when disinfecting shared blood pressure cuffs and stethoscopes for two residents, and a CNA failed to wear a disposable gown during high-contact care for a resident on Enhanced Barrier Precautions due to wounds and medical devices. These actions were not in accordance with facility policy or infection prevention protocols.
A resident with asthma was found to be self-administering an albuterol inhaler without proper assessment or authorization, despite facility policy requiring an interdisciplinary team determination and physician order. The inhaler was kept unsecured at the bedside, and staff were unaware of its presence or use by the resident.
A resident with significant height and multiple mobility-related diagnoses was not provided with a bed long enough to accommodate his stature, despite repeated requests and staff awareness. Instead, a makeshift cardboard footrest was used, causing ongoing discomfort and requiring the resident to bend his knees or position his feet awkwardly.
A resident with a history of peripheral arterial disease was observed with dirty, uncleaned fingernails, which had not been attended to for about a month. The resident was alert and able to express needs, and staff interviews confirmed that CNAs are responsible for daily nail care but failed to notice or address the issue. This resulted in a lack of necessary hygiene care as required by the resident's care plan and facility policy.
A resident with diabetes mellitus, who was cognitively intact, received Insulin Lispro from a nurse even though their blood sugar was below the physician-ordered hold parameter. The DON confirmed that the insulin should have been withheld and that the nurse did not follow the physician's order or document the reason for administration, contrary to facility policy.
A resident receiving enteral nutrition via gastrostomy tube was observed on multiple occasions lying flat in bed while tube feeding was running, despite physician orders, care plan instructions, and facility policy requiring the head of bed to be elevated to at least 30 degrees during and after feeding. Both an LVN and the DON confirmed the necessity of proper positioning to prevent complications, but the required care was not provided.
A resident with significant respiratory and cardiac conditions was observed receiving oxygen at rates higher than the physician-ordered 2 LPM via nasal cannula. Both an LVN and the ADON confirmed the discrepancy, acknowledging that the physician's order was not followed, contrary to facility policy.
A resident with multiple diagnoses and prescribed CNS-acting medications experienced several unwitnessed falls, including one requiring hospital evaluation. Despite changes in the resident's condition and medication regimen, the consultant pharmacist did not identify or report the potential for medication-related fall risk during monthly reviews, and the facility did not request additional medication reviews after each fall, contrary to facility policy.
A resident's wheelchair was found to be unsafe due to broken brakes and an improper fit, posing a safety risk. The resident, with hemiplegia and hemiparesis, struggled with mobility and comfort. The Director of Rehabilitation Services confirmed the safety concern, highlighting the need for operable brakes, especially during transfers. The facility's maintenance policy requires equipment to be safe and operable, but this was not upheld, resulting in the deficiency.
A facility failed to follow its grievance policy when a family representative raised concerns about a resident's injury. The resident, with major depressive disorder, Parkinsonism, and dementia, had a wound on the right forearm. Conflicting accounts of the injury's cause were given, and the facility did not respond promptly to the family's request for incident details and corrective actions. The grievance policy, which requires staff to guide residents and representatives on filing complaints, was not adhered to.
A resident with severe cognitive impairment experienced 16 falls due to inadequate evaluation and implementation of fall prevention interventions. Despite being at high risk, the facility failed to consistently conduct post-fall reviews and IDT meetings, leading to repeated falls and injuries, including head lacerations and fractures.
A resident with a history of COPD and bipolar disorder caused harm to two other residents due to inadequate supervision while smoking. The facility failed to enforce its smoking policy, allowing residents to keep smoking materials and lacking consistent staff supervision on the smoking patio. This led to incidents where one resident was burned with a cigarette and another was hit in the face.
Two residents in an LTC facility experienced inadequate pain management due to the facility's failure to administer medications in accordance with physician orders and care plans. One resident with pemphigus vulgaris received pain medication inconsistently with her reported pain levels, while another resident reported irregular administration of her pain and muscle relaxant medications, affecting her sleep. The facility's policies on pain management and medication administration were not followed, leading to this deficiency.
A resident with pemphigus vulgaris experienced a delay in receiving new medications after a specialist appointment due to the facility's failure to promptly obtain and implement new physician orders. The resident returned without necessary paperwork, and despite attempts by staff and family to contact the consulting physician's office, the new orders were not started until four days later, leading to a lack of continuity of care.
A resident was not properly assessed for bladder and bowel incontinence, leading to inadequate care. Initially documented as continent, the resident experienced prolonged periods in soiled diapers, causing skin redness. The MDS coordinator later corrected the error, acknowledging the resident's incontinence status.
A resident with anxiety, major depressive disorder, and Alzheimer's disease reported financial abuse by a caregiver, but the LTC facility failed to document the allegation or develop a care plan. Staff, including an RN, CNA, and LVN, were unaware of the incident, and the facility's policy for handling abuse allegations was not followed, leaving the resident at risk for further abuse.
A resident with Alzheimer's disease reported unauthorized withdrawal of $70,000 by a caregiver. The facility failed to report the financial abuse allegation to CDPH within the required two-hour timeframe, as the DON received the report on May 13, 2024, but the initial report was made on May 12, 2024. The facility's policy requires immediate reporting of such allegations.
The facility failed to implement a system to quickly and accurately identify code status in an emergency, leading to staff initiating CPR on a resident with a DNR order. The resident endured painful resuscitation procedures, sustained injuries, was hospitalized, and expired the following day. The deficiency was due to the use of an outdated POLST form and failure to maintain accurate records.
The facility failed to prevent potential cross-contamination during food preparation. A cook did not wear a beard restraint while preparing drinks, and another cook did not wash hands or change gloves between tasks. These actions had the potential to affect all 125 residents receiving meals from the dietary department.
The facility failed to test staff identified via contact tracing for COVID-19 and did not document staff testing, leading to a lapse in infection control. Additionally, a CNA performed perineal care in an unsanitary manner, contaminating clean washcloths. The facility lacked detailed policies and proper training for these procedures.
The facility failed to ensure accurate Level I PASRR screenings for two residents, leading to discrepancies in their mental health diagnoses and required evaluations. Staff did not thoroughly review PASRRs completed at hospitals, resulting in incorrect assessments of serious mental illnesses.
A facility failed to update a Level I PASRR for a resident following a new diagnosis of anxiety. Despite the resident's history of schizophrenia and the new diagnosis, the required PASRR update was not completed, as confirmed by staff interviews and record reviews.
A resident with a history of schizophrenia and anxiety had a PRN order for lorazepam that was not re-evaluated after 14 days, contrary to facility policy. The resident's care plan included antianxiety medication, but the facility failed to ensure the PRN order had a stop date or duration, leading to unnecessary medication use.
The facility failed to follow vital sign parameters when administering amiodarone to a resident with hypertension and heart failure, resulting in the medication being given despite low systolic blood pressure readings. Staff interviews revealed awareness of the importance of these parameters, but no clear explanation for the error was provided.
A resident was inaccurately documented with schizophrenia, leading to the inappropriate administration of Seroquel. The error was discovered through record reviews and staff interviews, revealing the resident actually had psychosis related to Parkinson's Disease.
Residents Smoked in Non-Designated Area Without Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision when four residents were observed smoking in front of the facility in the parking area, which was not the designated smoking location. During the observation, the four residents were sitting in their wheelchairs and smoking outside the front of the building, and in a concurrent interview they stated they were not allowed to smoke there. The Administrator stated that the designated smoking area was at the back of the facility and that residents were to be supervised by staff when smoking there. The Administrator also stated residents were evaluated for the ability to smoke independently and were required to sign a smoking contract. Resident 1, who was one of the residents observed smoking, stated he usually does not smoke but was approached by the other residents and began smoking in front of the facility, and he acknowledged that smoking was only allowed in the designated area. Resident 1's record showed diagnoses including diabetes mellitus and a history and physical indicating he had the capacity to understand and make decisions. The facility's Smoking Contract policy stated that smoking was only permitted in the designated resident smoking area located in the back patio next to a specified room.
Verbal Abuse Toward a Resident During Personal Care
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by staff. Resident 3, who was cognitively intact with a BIMS score of 15 and had diagnoses including morbid obesity, reported that a CNA threw wipes at her groin during care, looked at her disgusted, and told her, "Looks like the diaper does not fit, you are too fat," before leaving the room. Resident 3 also stated the CNA later spoke with two other CNAs outside her door and called her a "fat bitch," and that the CNAs laughed. Resident 3 stated she reported the incident to social services the next day. The grievance record documented that she complained the CNA left her during care because the brief did not fit and had an attitude. The record also showed the DSD responded by texting the CNA to work on communication skills in a professional manner, but it did not show that the Administrator or designee conducted a further investigation into the CNA's attitude toward the resident. During interviews, the SSA stated that calling a resident a derogatory statement is verbal abuse and that the expectation would be to start an investigation and remove the staff member from caring for the resident. The SSD stated the resident complained that a CNA became frustrated when unable to adjust the brief and that further investigation should have been carried out. CNA 2 stated CNA 1 made comments in the hallway about not liking fat people, joked about the resident being fat, and called Resident 3 a "fat bitch" after answering her call light and completing the task.
Failure to Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure its abuse policy was implemented when Resident 3 reported that a CNA made derogatory statements about her to other staff. Resident 3, who was cognitively intact with a BIMS score of 15 and had diagnoses including morbid obesity, stated that CNA 1 threw wipes at her groin during care, told her the diaper did not fit and that she was too fat, and then left the room. She also stated CNA 1 spoke to other CNAs outside her door and called her a fat bitch while the staff laughed. Resident 3 stated she reported the incident to social services and filed a complaint the next day. The grievance record documented that she complained CNA 1 left her during care because the brief did not fit and had an attitude, and the DSD responded by texting CNA 1 to work on communication skills in a professional manner. The grievance did not show that the Administrator or designee conducted a further investigation into the nature of CNA 1's conduct toward Resident 3. During interviews, the SSA stated he did not receive a complaint from Resident 3 about the derogatory statement and said calling a resident a derogatory statement is verbal abuse and should trigger an investigation and removal of the staff member from resident care. The SSD stated she did not ask further questions when Resident 3 complained and believed the issue could be neglect because the CNA may have left before completing care. CNA 2 later stated CNA 1 commented that he did not like fat people, joked about the resident being fat, and called Resident 3 a fat bitch in the hallway. The Administrator stated the grievance should have been thoroughly investigated, while the facility policy required all allegations of abuse or neglect to be immediately reported and thoroughly investigated, with the accused employee placed on leave with no resident contact until the investigation was complete.
Propranolol Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure propranolol was assessed and evaluated for continued use for one resident who was admitted with diagnoses including fibromyalgia and had a history and physical indicating the resident had the capacity to understand and make decisions. The resident had a physician’s order for propranolol 20 mg by mouth in the morning for hypertension, with instructions to hold the medication if SBP was less than 110 or HR was less than 60. The resident stated she rarely takes propranolol because she has low blood pressure. A review of the MAR for February, March, and April 2026 showed propranolol was held multiple times because SBP was below 110, including 21 of 28 doses in February, 22 of 31 doses in March, and 7 times from April 1 through April 7, 2026. The MAR also showed propranolol was administered on several occasions when SBP was below 110, including February 13, February 25, March 2, March 10, and March 15, 2026. The ADON stated the physician should be notified if the medication was being held multiple times because it was outside parameter to evaluate the need for the medication, and that the nurse should follow the physician’s order to hold the medication when outside the vital signs parameter.
Failure to Resume Anticoagulant as Ordered After Procedure
Penalty
Summary
The deficiency involves the facility’s failure to administer Eliquis according to physician orders for a resident with atrial fibrillation. The resident, cognitively intact with a BIMS score of 15, had a history of atrial fibrillation and was on Eliquis 5 mg twice daily. Orders in the medical record directed that Eliquis be held prior to and immediately after a suprapubic catheter placement, with a specific order dated March 12, 2026, to resume Eliquis on the morning of March 14, 2026. The facility’s MAR showed that Eliquis was held from the morning of March 9, 2026, through the morning dose on March 14, 2026, and that the medication was not administered until 10:22 a.m. on March 14, 2026, outside the ordered 6:00 a.m. administration time. During an interview, the resident reported that Eliquis was supposed to be resumed 48 hours after the procedure and that the LN did not administer the medication as ordered until the resident reminded the nurse. Nurse’s notes from March 14, 2026, documented that the resident stated her Eliquis was supposed to be held for 48 hours and restarted that day, and that after the nurse researched the record, an order from the NP to resume Eliquis on Saturday was discovered and the medication was then given by the charge nurse. In a subsequent interview and record review, the ADON and DON confirmed that the physician’s order to resume Eliquis on the morning of March 14, 2026, at 6:00 a.m. was not followed and that the facility’s own medication administration policy required medications to be administered in accordance with prescriber orders and within one hour of the prescribed time.
Failure to Implement Effective Behavioral Interventions for Aggressive Resident Toward Roommates
Penalty
Summary
The deficiency involves the facility’s failure to implement and update effective interventions for a resident with dementia and psychosis who repeatedly demonstrated aggressive and antagonistic behavior toward roommates. The resident had diagnoses including Alzheimer’s disease, dementia, and psychosis, and was documented as having severe cognitive impairment with a BIMS score of 3. A psychologist’s progress note from April 4, 2025, recorded that the resident expressed a desire to physically harm his roommate, stating he wanted to kill him for “stealing his space,” and was difficult to redirect due to cognitive impairment. A psychiatry note dated December 5, 2025, documented that the resident had recently attacked his roommate and became aggressive each time a new resident was placed in his room, with a warning that psychotropic medication adjustment would be needed or the resident might hurt himself or others. The resident’s care plan, initiated January 24, 2025, identified an altered behavior pattern and risk for behavioral symptoms such as striking out, grabbing others, and being verbally or physically abusive, with general interventions like documenting episodes, managing environmental factors, and reducing stimulation. A December 1, 2025 care plan entry noted the resident’s involvement in an altercation where aggression occurred toward a peer, and both residents were separated and monitored for distress; however, no new or individualized interventions were added beyond separating the residents. Subsequent psychiatry notes, including one on December 19, 2025, described the resident as agitated, angry, with disorganized thoughts and speech, becoming aggressive and attacking staff or any resident placed in his room, and another on January 9, 2026, documented the resident cursing, exhibiting erratic speech, and not allowing staff to prepare the room for a new roommate, again noting the need for psychotropic medication adjustment to prevent potential harm. Progress notes in March 2026 continued to show a pattern of anger outbursts and antagonistic behavior specifically triggered by having a roommate, including refusal to accept education about having a roommate, multiple outbursts where the resident could not calm down, cursing at staff and roommates, and requiring staff to leave the room to defuse situations. On March 16, 2026, the resident’s daughter observed antagonistic behavior toward a roommate, and the roommate reported ongoing hostility such as the resident repeatedly opening the privacy curtain, turning lights on and off, and moving personal belongings, leading the roommate to request a room change. Another note the same day described the resident standing over the roommate, creating a disruptive environment, and continuing the behavior despite staff verbal redirection, prompting notification of the physician and transfer for psychiatric evaluation. Despite these documented behaviors and the identified trigger of having a roommate, the record showed no evidence that the facility revised the care plan with new, targeted interventions for the aggressive behavior, and the facility continued assigning roommates to the resident. In interviews, an LVN and the DON confirmed that the resident consistently had issues with roommates and that his behavior problems occurred when he had a roommate, and the DON acknowledged that the facility did not implement interventions to prevent the resident’s anger outbursts toward roommates because they could not provide a private room, despite facility policies requiring behavioral assessment, individualized interventions, and safety strategies to protect residents and others from harm.
Failure to Implement Orthopedic Follow-Up and Document Assessments for Pain Management and Neurology Referral
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and to conduct and document appropriate assessments for a resident with a left shoulder rotator cuff tear and neuropathy. The resident was admitted with diagnoses including a left shoulder rotator cuff tear and neuropathy and reported limited movement and pain in the left shoulder. Hospital records from an acute stay documented that orthopedics had recommended an outpatient follow-up after an MRI confirmed a rotator cuff tear, with discharge instructions specifying an orthopedic surgery follow-up in 2–3 weeks. A physician order dated October 10, 2025, directed an orthopedic follow-up in 2–3 weeks, but the order did not specify the reason for the consult, it was not incorporated into the care plan, and there was no documentation that an orthopedic appointment was scheduled within the ordered timeframe. Record review and staff interviews confirmed that the orthopedic follow-up order was not implemented as written. The care plan addressing the resident’s musculoskeletal disorder and left shoulder rotator cuff tear did not include the physician’s order for an orthopedic consult. The RN acknowledged that there was no record of an appointment being scheduled within 2–3 weeks of the October 10 order and that the appointment was not scheduled until February 2026. The DON stated that staff were expected to call and set up such appointments within 72 hours of the order, that no one from the facility made the call, that the reason for the orthopedic consult was not documented in the order, and that the order was not added to the care plan. These omissions resulted in a delay in the resident being seen by an orthopedic physician for the rotator cuff tear. The deficiency also includes failures related to pain management and specialty referral for the resident’s neuropathy. The resident had an admission order for gabapentin 100 mg three times daily for neuropathy, with an order to monitor pain every shift. Pain level documentation from late October to November 10, 2025, showed pain levels of 0 each shift. On November 10, 2025, the gabapentin dose was increased to 300 mg three times daily, but there was no documented nursing assessment prior to obtaining this order and no documented rationale for the dose increase in the progress notes. LVN 1, who obtained and carried out the order, stated that the resident reported the medication was not working and requested the physician be called, but LVN 1 did not perform or document a pain assessment before obtaining the increased dose, despite facility policy requiring pain assessment and management steps. Additionally, on December 12, 2025, an order for a neurology referral was carried out for the same resident, who had neuropathy and had requested to be seen by a neurologist. There was no documented assessment indicating the need for the neurology referral and no documentation in the progress notes explaining why the referral was needed. The order for the neurology referral was also not added to the resident’s care plan. RN 1 stated that LVN 2 did not document the reason for the neurology consult, so the RN did not know what it was for. LVN 2 confirmed that he called the physician after the resident requested to see a neurologist but did not document the reason for the referral or add it to the care plan. These actions and omissions occurred despite facility policies requiring that referrals for medical services be based on physician evaluation and orders, coordinated with appropriate disciplines, and that comprehensive, person-centered care plans describe the services to be furnished and be revised as resident conditions and information change.
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.
Delay in Implementing Therapy Orders After Orthopedic Consultation
Penalty
Summary
A deficiency occurred when the facility failed to implement new medical orders in a timely manner following an orthopedic consultation for a resident with a fractured right humerus. The resident, who was admitted with a broken right arm and had the capacity to make decisions, reported not receiving any physical therapy (PT) for his right arm since admission. Medical records showed that after a follow-up orthopedic appointment, there was no documentation or evidence that the facility followed up with the orthopedic doctor for new orders or recommendations. The resident returned from the appointment without an After Visit Summary (AVS), and staff interviews confirmed that no follow-up or documentation was completed regarding the consultation or any new therapy orders until several days later. Further review revealed that the orthopedic doctor had ordered physical therapy for the resident's right arm, but this order was not received or implemented by the facility until seven days after the consultation. Staff, including the Occupational Therapist Assistant and Social Service Assistant, confirmed that the lack of documentation and follow-up led to a delay in therapy services. The Director of Nursing acknowledged that the expected process for following up on specialty appointments was not followed, resulting in a delay in care. The facility was unable to provide a policy or procedure for following up on new orders or recommendations from consulting doctors for residents who attended specialty appointments.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Several deficiencies in food safety practices were observed during an unannounced visit to the facility's kitchen. Multiple kitchen staff, including the Dietary Supervisor and two Dietary Aides, were seen wearing hairnets that did not fully contain their hair, with hair escaping from the top, sides, and nape of their necks. The Dietary Supervisor confirmed that staff were expected to have all hair tucked into hairnets, and that hairspray was suggested during training to help keep hair in place. The facility's dress code policy required hats or hairnets to completely cover hair, depending on its length. Additionally, improper glove use and dishwashing procedures were observed. The staff member responsible for dishwashing was seen rinsing dirty kitchenware with gloved hands and then, without changing gloves, handling clean and sanitized stainless steel pans. The staff member acknowledged this lapse, and the Dietary Supervisor confirmed that gloves should have been changed to prevent cross-contamination. Furthermore, the dishwasher was observed rinsing kitchenware with crusted food residue above and beside beverage cups and glasses, which were placed upside down on racks. The Dietary Supervisor stated that kitchenware should be scraped and soaked prior to dishwashing and that items used for meal preparation should be washed before those from patient care areas. The facility's dishwashing policy did not specify procedures for transitioning between dirty and clean tasks.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the Notice of Proposed Transfer/Discharge to the State Long-Term Care Ombudsman prior to the planned discharge dates for two residents. Both residents were scheduled for discharge to home, with one having diagnoses including pneumonia and sepsis, and the other with heart failure. The notices were given to the residents and acknowledged, but the copies intended for the Ombudsman were only sent after the residents had already been discharged from the facility. Interviews with facility staff, including the Social Services Director, Director of Nursing, and Administrator, confirmed that the required notifications to the Ombudsman were not made before the residents left. The facility's own policy required that such notices be sent to the Ombudsman in advance of discharge, but this procedure was not followed for the two residents in question.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to provide pain management according to the physician's orders and the resident's care plan for one resident. The resident had orders for pain to be monitored every shift and for specific pain medications to be administered based on the pain scale: Percocet for severe pain (level 7-10) and Hydrocodone for moderate to severe pain as needed. However, a review of the Medication Administration Record (MAR) showed that Hydrocodone was administered for pain levels of 7 and above multiple times, which did not align with the physician's order specifying Percocet for those pain levels. The resident was receiving PRN pain medications multiple times daily without the pain scale being matched to the correct medication as ordered. Interviews with the resident confirmed frequent administration of pain medications, and the DON acknowledged that the physician's orders were not being followed as written. The facility's own pain management policy required appropriate assessment and treatment of pain, including reviewing the MAR to determine the frequency and effectiveness of PRN pain medication use. Despite these procedures, the staff did not ensure that pain medications were administered according to the prescribed pain scale, nor did they contact the physician to adjust the medication regimen when frequent PRN use was observed.
Failure to Follow Infection Control Protocols for Equipment Disinfection and Enhanced Barrier Precautions
Penalty
Summary
Nursing staff failed to follow proper infection control practices when disinfecting shared blood pressure cuffs and stethoscopes for two residents during medication administration. Specifically, staff did not adhere to the manufacturer's specified contact time for the disinfectant wipes used on the equipment. One nurse used a Micro-Kill One wipe but did not ensure the equipment remained wet for the required one minute, while another used a Micro-Kill Bleach wipe but did not maintain the necessary three-minute contact time. Both the Infection Preventionist and Director of Nursing confirmed that staff are expected to follow the manufacturer's instructions for disinfecting shared equipment, as outlined in facility policy and the product labeling. Additionally, a certified nursing assistant failed to use a disposable gown while providing high-contact care to a resident who required Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including burns, a pressure ulcer, a colostomy, and an indwelling urinary catheter. The resident's care plan and physician's orders specified the use of gown and gloves during high-contact activities, but the CNA provided care without donning a gown, later stating she forgot to do so. The Infection Preventionist confirmed that a gown should have been used during direct care for this resident. Facility policies reviewed indicated that reusable or shared equipment must be disinfected according to manufacturer instructions before reuse, and that EBP, including gown and glove use, is required for residents with wounds or indwelling devices during high-contact care. The observed failures to follow these protocols resulted in deficiencies related to infection prevention and control practices.
Failure to Assess and Authorize Self-Administration of Albuterol Inhaler
Penalty
Summary
The facility failed to ensure that an appropriate assessment and evaluation for self-administration of medication was completed for a resident who possessed and used an albuterol inhaler. The resident, who had a history of asthma and was alert and oriented, was observed retrieving an albuterol inhaler from his pocket and later keeping it on his bedside table. The resident stated he had been using the inhaler for a long time, obtained it from his own doctor, and wanted it accessible in case of an asthma attack. However, the resident's admission records and a self-administration assessment indicated he did not want to self-administer medication, and there was no documentation or physician order authorizing self-administration of the inhaler. Licensed staff, including the LVN, MDS Coordinator, RN Supervisor, and DON, were unaware that the resident had the inhaler at his bedside or was self-administering it. The facility's policy required an interdisciplinary team determination and physician order for self-administration, as well as secure storage of self-administered medications. The inhaler was not stored securely, and staff confirmed that the resident should not have been self-administering the medication without proper assessment and authorization.
Failure to Provide Appropriate Bed for Tall Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who was significantly taller than average, measuring 6 feet 8 inches in height. Despite the resident's repeated requests over several months for a longer bed to fit his height, the facility did not provide an appropriate bed. Instead, a makeshift cardboard footrest was placed at the foot of the bed by the maintenance director at the resident's request. Observations confirmed that the resident had to keep his feet on either side of the footrest or bend his knees to fit in the bed, resulting in discomfort while lying down. Multiple staff members, including a CNA, the maintenance director, the central supplies director, and the assistant director of nursing, acknowledged that the current bed was inadequate and that the cardboard footrest was not an appropriate solution. The resident's medical record indicated a history of cervical disc degeneration, inclusion body myositis, polyneuropathy, and difficulty walking, all of which increased his need for comfort and proper positioning in bed. The care plan documented the resident's risk for pain, discomfort, and complications of immobility, and specified that his needs should be anticipated and met by staff. The facility's own policy required adaptations to the physical environment, such as providing appropriately sized furniture, to accommodate individual resident needs and preferences. Despite these requirements, the facility did not provide a suitable bed for the resident, resulting in ongoing discomfort.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide necessary care and services to maintain the cleanliness and hygiene of a resident's fingernails. During observation, the resident was found with blackish material under all fingernails and reported that his nails had not been cleaned for about a month. The resident was alert, oriented, and able to verbalize needs, and stated he would not mind if staff cleaned his nails. Interviews with a CNA, the Infection Preventionist, and nursing leadership confirmed that CNAs are responsible for daily hygiene, including nail care, and acknowledged that dirty fingernails could be a source of bacteria and infection. The CNA who cared for the resident did not notice the dirty fingernails. The resident's care plan indicated an actual risk for decline in activities of daily living (ADL) and required staff assistance to meet needs. The facility's policy stated that residents unable to perform ADLs independently should receive services to maintain grooming and personal hygiene. Despite these requirements, the resident's fingernails were not cleaned as needed, resulting in a failure to meet the standard of care outlined in the facility's policy and the resident's care plan.
Insulin Administered Below Hold Parameter
Penalty
Summary
A nurse administered Insulin Lispro to a resident with diabetes mellitus despite the resident's blood sugar being below the physician-ordered hold parameter. The resident, who was cognitively intact and had decision-making capacity, reported that the nurse gave him insulin when his blood sugar was low, specifically noting a blood sugar reading of 32 at the time of the incident. Record review confirmed that on a separate occasion, the resident received 3 units of Insulin Lispro subcutaneously for a blood sugar of 89, which was below the prescribed threshold of 90 for holding the medication. The Director of Nursing confirmed that the nurse did not follow the physician's order, as the insulin should have been held and the reason for not administering it should have been documented. Facility policy requires medications to be administered safely and as prescribed, in accordance with prescriber orders. The failure to adhere to these standards resulted in the resident receiving insulin when it should have been withheld according to the order.
Failure to Maintain Proper Head of Bed Elevation During Tube Feeding
Penalty
Summary
A resident with a history of dysphagia following a stroke, who was admitted with orders for enteral feeding via gastrostomy tube, was observed on multiple occasions receiving tube feeding while lying flat in bed. Observations on two separate days showed the resident's head of bed (HOB) was not elevated as required during active tube feeding. During one observation, a Licensed Vocational Nurse confirmed that the HOB was too low and should be elevated to at least 45 degrees. The Director of Nursing also stated that the HOB should be elevated between 30-45 degrees during and for 30 minutes after feeding. Review of the resident's care plan and physician orders confirmed the requirement for HOB elevation to at least 30 degrees during and after tube feeding to prevent complications such as aspiration. Facility policy also addressed the need for proper positioning during enteral nutrition. Despite these documented requirements, the resident was not positioned appropriately during tube feeding, constituting a failure to provide care in accordance with physician orders, care plan, and facility policy.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory and cardiac diagnoses, including heart failure, chronic pulmonary edema, acute respiratory failure with hypoxia, pleural effusion, pneumonia, and anemia, was not provided respiratory care in accordance with the physician's order. The resident was observed on two separate occasions receiving oxygen via nasal cannula at rates of 3.5 and 4 liters per minute (LPM), despite a physician's order specifying oxygen administration at 2 LPM. Both a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) confirmed that the oxygen was being administered at a higher rate than ordered and acknowledged that the physician's order was not followed. The facility's policy on oxygen administration requires verification and adherence to physician orders, which was not done in this case.
Failure to Conduct Timely Medication Regimen Review After Resident Falls
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly medication regimen review (MRR) for a resident who experienced multiple falls and changes in condition. Despite the resident being prescribed several medications known to have sedating effects—Prozac (fluoxetine), Valproic Acid, and Risperdal (risperidone)—the consultant pharmacist did not identify or report the potential for these medications to contribute to increased fall risk during the monthly MRRs. Additionally, after each fall and change in the resident's condition, the facility did not request an additional medication review as outlined in their own policies and procedures. The resident in question had a complex medical history, including contracture of the right upper arm, spastic hemiplegia, cerebral palsy, dementia, major depressive disorder, anxiety, and psychosis. Over a period of several months, the resident experienced at least five unwitnessed falls, one of which resulted in a hospital transfer for evaluation and treatment of a right knee abrasion. The resident's medication regimen was adjusted during this time, with increases in Valproic Acid dosage and the addition of Risperdal, both of which have documented sedating effects and potential to impair cognitive and motor function, especially when combined with other CNS-acting drugs. Despite these significant changes in the resident's condition and medication regimen, the consultant pharmacist's monthly reviews for December, January, and February did not include any recommendations regarding the potential contribution of these medications to the resident's falls. Interviews with facility staff, including the DON and ADON, confirmed that the consultant pharmacist was not notified after the resident's falls and that no additional medication review was requested. The facility's policy specifically states that an acute change of condition may prompt a request for a medication regimen review, but this procedure was not followed.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a resident's wheelchair in a safe and operable condition, which was identified during an unannounced visit. The resident, who was admitted with hemiplegia and hemiparesis following a stroke, was observed attempting to use the wheelchair brakes, which were broken and non-functional. Additionally, the wheelchair was too small for the resident, causing discomfort and limiting mobility. This issue was confirmed through observation and interview with the resident, who expressed difficulty in using the wheelchair due to its size and malfunctioning brakes. The Director of Rehabilitation Services acknowledged the safety concern, emphasizing the importance of having a wheelchair with operable brakes, especially during transfers. The facility's maintenance policy, dated December 2009, mandates that equipment be maintained in a safe and operable manner at all times. However, the failure to adhere to this policy resulted in the resident using a wheelchair that posed a safety risk. The maintenance department is responsible for ensuring equipment safety, but in this instance, the necessary maintenance was not performed, leading to the deficiency.
Failure to Follow Grievance Policy for Resident's Injury
Penalty
Summary
The facility failed to adhere to its grievance policy and procedure when a family representative expressed concerns about a resident's care. The resident, who was admitted with diagnoses including major depressive disorder, Parkinsonism, and dementia, was observed with a wound on the right forearm. The family representative reported receiving conflicting accounts of how the injury occurred, initially being told it was due to arm-to-arm contact with staff, and later that it was caused by hitting a side rail. The Director of Nursing (DON) was informed of the incident during a change of condition discussion with the Interdisciplinary Team. The DON reviewed the situation based on a statement from a Certified Nursing Assistant (CNA) who was not assigned to the resident but responded to an alarm. The CNA reported that the resident became aggressive and hit the CNA's arm, leading to the injury. Despite the family representative's concerns and request for a copy of the incident report and corrective actions, the facility did not respond promptly. The facility's grievance policy, which encourages staff to guide residents and their representatives on how to file complaints, was not followed. The family representative's email to the DON and other staff members regarding the incident and the lack of response highlights the facility's failure to address the grievance appropriately. This lack of action may have contributed to a delay in addressing the concerns raised by the family representative.
Failure to Prevent Repeated Falls in Resident
Penalty
Summary
The facility failed to ensure the effectiveness of interventions to prevent falls for a resident, resulting in 16 falls over a period of several months. The resident, who had a history of falls and severe cognitive impairment, experienced multiple falls due to behaviors such as getting up unassisted. Despite being at high risk for falls, the facility did not consistently evaluate the effectiveness of interventions or implement new strategies to prevent further incidents. The resident's care plan included interventions such as keeping the bed in a low position, using fall mats, and encouraging the resident to call for assistance. However, these measures were insufficient as the resident continued to fall, sustaining injuries including a laceration to the head, a skin tear, and multiple fractures. The facility's documentation revealed that post-fall reviews and interdisciplinary team (IDT) meetings were not consistently completed after each fall, and new interventions were not always implemented. Interviews with staff indicated that the resident's falls could have been minimized with a 1:1 sitter, which was not consistently provided. The Director of Nursing acknowledged that the falls were not properly evaluated to address their causes and implement appropriate interventions. The facility's policy required post-fall reviews and IDT meetings to discuss and document the resident's plan of care, but these were not consistently conducted, contributing to the repeated falls and injuries.
Inadequate Supervision Leads to Resident Harm During Smoking
Penalty
Summary
The facility failed to provide adequate supervision for residents while smoking, leading to incidents involving Resident C, who caused physical harm to Resident A and Resident B. On June 9, 2024, Resident C burned Resident A's arm with a lit cigarette and hit Resident B in the face while they were at the smoking patio. Observations and interviews revealed that residents were allowed to keep their own cigarettes and lighters, contrary to the facility's policy, which required smoking materials to be stored by staff and residents to be supervised while smoking. Interviews with residents and staff indicated a lack of supervision on the smoking patio. Resident F, who witnessed the incident, stated that there was no staff present to supervise the residents while smoking. This was corroborated by Resident B, who mentioned that staff only came to the patio if they were looking for a resident. The Director of Staff Development and the Activities Director acknowledged that there was no formal schedule for monitoring residents on the patio, and supervision was inconsistent. Resident C's medical records showed a history of COPD and bipolar disorder, with a care plan indicating the need for supervision during smoking due to non-compliance with smoking rules. Despite this, Resident C was allowed to keep smoking materials, which led to the incidents on June 9, 2024. The facility's smoking policy required residents to be assessed for their ability to smoke safely and mandated staff supervision for those who were not independent smokers, but these protocols were not followed, resulting in harm to other residents.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to manage the pain of two residents, Resident D and Resident E, in accordance with professional standards of practice and their comprehensive person-centered care plans. Resident D, who suffers from pemphigus vulgaris, reported experiencing significant pain from lesions on her arms and a sore mouth, which made eating difficult. A review of Resident D's Medication Administration Record (MAR) revealed that out of 51 doses of prescribed pain medication administered over a 25-day period, 24 doses were not given in accordance with the physician's orders. This included instances where the dosage did not match the pain level reported by the resident, and medications were administered outside the prescribed time frames. Resident E expressed concerns about not receiving her medications on time, particularly her muscle relaxant and pain medication, which affected her ability to sleep due to pain. Her MAR indicated that she received Tramadol, a medication for severe pain, 14 times over a 21-day period, with three instances where it was administered for a pain level of 6, contrary to the physician's orders. Resident E's care plan emphasized the need for administering medications as ordered and assessing pain every shift, but these directives were not consistently followed. Interviews with the Director of Nursing (DON) highlighted the need for adjusting medication times to better accommodate the residents' needs and the importance of reevaluating medication regimens if pain levels are not being controlled. The facility's policies on pain assessment and management, as well as medication administration, stress the importance of administering medications in accordance with prescribed orders and addressing unrelieved pain through a multidisciplinary approach. However, these policies were not adhered to, resulting in inadequate pain management for Residents D and E.
Delay in Implementing New Physician Orders for Resident with Skin Disease
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This deficiency occurred when new physician orders from a consulting physician's office were not initiated promptly after the resident returned to the facility. The resident, who has a rare skin disease called pemphigus vulgaris, was sent to the facility for 24-hour care and rehabilitation needs. After attending a specialist appointment, the resident returned without the necessary paperwork, and the facility did not follow up effectively to obtain the new orders. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurse Two (LVN 2) revealed that the facility's process for handling new orders from external appointments was not followed. The DON stated that upon a resident's return from an appointment, the charge nurse or RN supervisor should review and enter any new physician orders. However, in this case, LVN 2, who was responsible for the resident on the day of the appointment, did not receive the necessary paperwork and attempted to contact the consulting physician's office twice without success. The resident's family member also tried to obtain the orders but faced difficulties. Consequently, the new medications were not started until four days after the appointment, leading to a delay in treatment. Further interviews with the Registered Nurse (RN) and Medical Records (MR) staff confirmed the delay in medication administration. The RN acknowledged that there was a delay in starting the new medications and that progress notes should have been written over the weekend to document the resident's care. The MR staff indicated that the facility received the documents on the day after the appointment, but the orders were not entered into the system until later. This delay in implementing the new treatment plan resulted in a lack of continuity of care for the resident, who was at risk for delayed healing and infection due to their skin condition.
Inadequate Assessment of Resident's Incontinence
Penalty
Summary
The facility failed to properly assess a resident, identified as Resident E, for bladder and bowel control, which led to inappropriate care. Upon admission on May 22, 2024, Resident E was noted to have bladder and bowel incontinence, with a toileting program set to check and change every two hours. However, the Minimum Data Set (MDS) assessment on June 4, 2024, inaccurately recorded Resident E as always continent for both urinary and bowel functions. This discrepancy in documentation resulted in Resident E not receiving the appropriate care for her incontinence. During an interview, Resident E reported sitting in soiled diapers for one to two hours before staff responded to her calls for assistance, leading to redness in her groin and peri-area. The MDS coordinator later acknowledged a data entry error in the MDS, which was subsequently corrected to reflect Resident E's incontinence status. Despite the correction, the initial failure to accurately assess and document Resident E's condition resulted in inadequate care and potential discomfort for the resident.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure on abuse for a resident who was a victim of financial abuse. The resident, who had been diagnosed with anxiety, major depressive disorder, and Alzheimer's disease, reported that a caregiver had withdrawn $70,000 from her bank account without her consent. Despite the resident's report to the police, the facility staff, including a registered nurse, a certified nurse assistant, and a licensed vocational nurse, were unaware of the incident. There was no documentation of the allegation in the resident's medical record, and no plan of care was developed to ensure the resident's safety. Interviews with facility staff revealed that the facility's process for handling such allegations was not followed. The Director of Nursing confirmed that there was no documentation of the financial abuse allegation and no care plan was initiated to address the issue. The facility's policy required the administrator to determine necessary actions for resident protection upon receiving any allegations of abuse, but this was not done. As a result, the staff was not informed of the necessary information to ensure the resident's safety and protection, placing the resident at risk for further abuse.
Failure to Timely Report Financial Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of financial abuse involving a resident to the California Department of Public Health (CDPH) within the required timeframe. The incident involved a resident who had been admitted with diagnoses including anxiety, major depressive disorder, and Alzheimer's disease. The resident reported that a caregiver, whom she had known for over five months, had withdrawn $70,000 from her bank account without her authorization. The resident attempted to report the incident to the county's police department but was unsuccessful. The Director of Nursing (DON) acknowledged receiving the report of the financial abuse allegation from the Social Services Designee on May 13, 2024, although the initial report was made to a Registered Nurse (RN) by the General Acute Hospital (GACH) on the evening of May 12, 2024. The facility submitted the SOC 341 form and contacted CDPH on May 13, 2024, but this was not within the required two-hour timeframe. The facility's policy mandates immediate reporting of such allegations to the state licensing/certification agency, defined as within two hours if the allegation involves abuse or results in serious bodily injury.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to implement a system that allowed staff to quickly and accurately identify code status in the event of an emergency and failed to honor the advance directive of one resident. Specifically, staff initiated cardiopulmonary resuscitation (CPR) on a resident who was found unresponsive, despite the resident having a signed physician's order for life-sustaining treatment (POLST) and an advance directive on file that indicated the resident elected do not resuscitate (DNR). As a result, the resident endured painful resuscitation procedures, sustained injuries, was hospitalized, and expired in the hospital the following day. The deficiency was identified when staff could not locate the resident's most recent POLST form, which indicated DNR, and instead used an outdated POLST form that indicated full code. The resident's POLST form from 2016, which reflected full code, was in the POLST book at the nurse's station, while the updated POLST form from 2021, indicating DNR, was not readily accessible. This led to the initiation of CPR and subsequent hospitalization of the resident. Interviews with staff revealed that the process for maintaining and accessing POLST forms was not followed correctly. The Director of Nursing (DON) and the Administrator acknowledged that the POLST process was broken, and the resident's wishes were not honored due to the failure to update and maintain accurate records. The facility's non-compliance with the requirements of participation caused serious harm to the resident, resulting in injuries and prolonged death.
Failure to Prevent Cross-Contamination in Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared and served in a manner to prevent potential cross-contamination. Specifically, Cook #6 was observed working in the kitchen with a full beard and did not wear a beard restraint while preparing drinks for the lunch meal service. Despite being reminded by the Dietary Director earlier that morning, Cook #6 completed the lunch meal service without wearing a beard restraint. During an interview, Cook #6 acknowledged the facility's expectation for dietary staff to wear hair restraints and admitted to forgetting to wear one due to being busy. The Dietary Director confirmed that staff were expected to restrain all hair before entering the kitchen and that beard restraints were available for staff use. Additionally, Cook #7 was observed plating food during the lunch meal service and then turning away from the meal service line to use a spatula to flip a quesadilla on the grill without washing hands or changing gloves between tasks. Cook #7 admitted, through a translator, that he was aware of the requirement to change gloves when changing tasks. The Director of Nursing (DON) and the Administrator both confirmed the facility's policy that dietary staff must wear hairnets or covers, including beard covers if applicable, and change gloves between tasks. These failures had the potential to affect all 125 residents who received meals from the dietary department.
Infection Control and Perineal Care Deficiencies
Penalty
Summary
The facility failed to test staff identified via contact tracing as having a high-risk COVID-19 exposure, which had the potential to affect all residents. The Infection Preventionist (IP) did not maintain a log or documentation of staff testing, and staff were instructed to self-test without proper follow-up. One staff member, CNA #11, did not complete the required testing and worked while symptomatic, leading to a positive COVID-19 test result. The Director of Nursing (DON) and the Administrator confirmed that staff testing should be documented and conducted on days one, three, and five, regardless of work schedule, and that symptomatic staff should not work without a test. However, these protocols were not followed, resulting in a lapse in infection control measures. The facility also failed to ensure that perineal care was performed in a sanitary manner for a resident with severe cognitive impairment and multiple diagnoses, including sepsis and a stage 4 pressure ulcer. During an observation, CNA #10 was seen placing soiled washcloths in the same bag as clean ones and then using another washcloth from the contaminated bag to continue cleaning the resident. This practice was confirmed by the IP, DON, and Administrator as improper, as it contaminated the clean washcloths. The facility lacked a detailed policy on the steps for performing perineal care, and the Director of Staff Development (DSD) indicated that there was no set procedure being taught to staff. These deficiencies highlight significant lapses in the facility's infection prevention and control program, as well as in the training and execution of basic care procedures. The lack of proper documentation, adherence to testing protocols, and clear guidelines for perineal care contributed to these failures, potentially compromising the health and safety of the residents.
Inaccurate PASRR Screenings for Mental Disorders
Penalty
Summary
The facility failed to ensure the accuracy of Level I PASRR screenings for two residents, leading to discrepancies in their mental health diagnoses and the required evaluations. Resident #12 was admitted with diagnoses including schizophrenia, major depressive disorder, and bipolar disorder. However, the Level I PASRR screening incorrectly indicated that the resident did not have a serious mental illness, resulting in a negative screening and no Level II evaluation. This was despite the resident's care plan and MDS indicating severe cognitive impairment and active diagnoses of serious mental illnesses, including the use of antidepressant and antipsychotic medications. Similarly, Resident #110 was admitted with diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder. The Level I PASRR screening initially indicated a positive result due to suspected mental illness, but a subsequent review by the California Department of Healthcare Services concluded that the resident did not have a serious mental illness, negating the need for a Level II evaluation. This was inconsistent with the resident's care plan and MDS, which documented active diagnoses of anxiety disorder, depression, and bipolar disorder, along with the use of psychotropic, antianxiety, and antidepressant medications. Interviews with facility staff revealed a lack of clarity and responsibility in verifying the accuracy of PASRR screenings completed at hospitals. MDS nurses and the marketer responsible for new admissions did not thoroughly review the PASRRs for accuracy, leading to the discrepancies. The Director of Nursing and the Administrator both expected the PASRRs to accurately reflect the residents' clinical conditions, but this expectation was not met, resulting in the identified deficiencies.
Failure to Update PASRR Following New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a status change to a Level I PASRR following a new mental health diagnosis for a resident. Specifically, the resident had a prior positive Level I PASRR but was later diagnosed with anxiety, and the facility did not update the PASRR evaluation. The resident was admitted with a history of schizophrenia and later diagnosed with anxiety, receiving medications for both conditions. Despite the new diagnosis, the facility did not complete an updated PASRR as required by policy and state guidelines. Interviews with facility staff, including MDS nurses and the Director of Nursing, confirmed that a new Level I PASRR should have been completed when the resident received the new diagnosis. The Administrator was unaware of the need to update the PASRR for new mental health diagnoses. The failure to update the PASRR was identified during a review of the resident's medical records and facility policies, which indicated that all new psychiatric diagnoses should prompt a new PASRR evaluation.
Failure to Re-evaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications. Specifically, a resident had an order for lorazepam, a benzodiazepine used to treat anxiety, that was started without a stop date or re-evaluation for continued use. The facility's policy required that PRN orders for psychotropic medications not be renewed beyond 14 days unless the healthcare practitioner evaluated the resident for the appropriateness of the medication and documented the rationale for continued use. However, this policy was not followed in the case of the resident, who had a PRN order for lorazepam that was not re-evaluated after 14 days, leading to a deficiency in medication management. The resident, who was admitted to the facility with a medical history that included schizophrenia and anxiety, had a BIMS score indicating cognitive intactness. The resident's care plan included the use of antianxiety medication due to anxiety manifested by verbalization of anxiousness. Despite the facility's policy and the expectations of the pharmacist and the Director of Nursing, the PRN order for lorazepam was not re-evaluated after 14 days, and there was no stop date or duration included in the order. Interviews with the pharmacist, DON, and Administrator confirmed that the facility did not adhere to the required re-evaluation process for PRN psychotropic medications, resulting in the resident receiving unnecessary medication.
Failure to Follow Vital Sign Parameters for Medication Administration
Penalty
Summary
The facility failed to follow vital sign parameters when administering medications to a resident with a history of hypertension and heart failure. Specifically, the staff did not hold the medication amiodarone when the resident's systolic blood pressure (SBP) was less than 110 mmHg, as outlined in the physician's order. This occurred six times in both February and March 2024, despite the clear instructions in the resident's medication administration record (MAR) and the facility's policy on administering medications safely and as prescribed. Interviews with the nursing staff revealed that they were aware of the importance of following vital sign parameters to prevent adverse effects such as hypotension. However, the staff members involved could not provide a clear explanation for why the medication was administered despite the low SBP readings. One nurse suggested it might have been a click error, while another nurse could not explain the discrepancy. The Director of Nursing (DON) and the facility's physician both emphasized the critical nature of adhering to these parameters to ensure resident safety. The resident involved was cognitively intact and had a documented history of heart failure and hypertension. The physician reiterated that administering amiodarone with a low SBP could exacerbate the resident's condition, potentially leading to severe hypotension and other complications. The facility's failure to follow the prescribed medication administration guidelines directly contradicted their own policies and the physician's orders, putting the resident at risk for adverse health events.
Inaccurate Medical Records and Unnecessary Medication
Penalty
Summary
The facility failed to maintain accurate medical records for a resident who was prescribed unnecessary medications. The resident was admitted with a diagnosis of schizophrenia, which was later found to be inaccurately documented by the MDS Nurse. The resident's medical records, including the Minimum Data Set (MDS), care plan, and Medication Administration Record (MAR), all reflected this incorrect diagnosis, leading to the administration of Seroquel for schizophrenia, a condition the resident did not have. The error was discovered during a review of the resident's records and interviews with facility staff. The MDS Nurse admitted to mistakenly entering the diagnosis of schizophrenia into the resident's medical record, believing it was supported by the psychiatry notes. However, further review revealed that the resident was actually experiencing psychosis related to Parkinson's Disease, not schizophrenia. The Consultant Pharmacist and Psychiatric Mental Health Nurse Practitioner (PMHNP) confirmed that the resident did not have a diagnosis of schizophrenia. Interviews with the Director of Nursing (DON) and the facility Administrator highlighted the importance of accurate diagnoses for residents. The DON emphasized that residents must have appropriate diagnoses based on psychiatric evaluations, and the Administrator stated that it was his expectation for resident diagnoses to be accurate. The facility's failure to ensure accurate documentation led to the inappropriate use of psychotropic medication for the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 994 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Pacifica Convalescent Hospital | 0.5 mi | ★★★★★ | 0 | 0 |
| Vista Pacifica Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Riverside Behavioral Healthcare Center | 2.9 mi | ★★★★★ | 15 | 0 |
| Community Care On Palm | 3.1 mi | ★★★★★ | 15 | 0 |
| The Grove Care And Wellness | 3.4 mi | ★★★★★ | 2 | 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.