Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Kei-ai South Bay Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of falls, femur fracture, gait abnormalities, muscle weakness, moderate cognitive impairment, poor standing balance, and impaired safety awareness was identified as high risk for falls through a Morse Fall Risk Screen, PT evaluation, and MDS assessment. The initial fall risk care plan included general assistance with ADLs, transfers, ambulation, and toileting but did not specify staff monitoring or supervision. After multiple unwitnessed falls in which the resident slid from the bed, the IDT documented that the resident perceived themself as independent and forgot to call for help, and added measures such as a falling star program, post-fall assessments, education to use the call light, and environmental adjustments. Despite these repeated falls and documented risk factors, the care plans created after each incident did not define the frequency or level of staff supervision or monitoring, contrary to facility expectations described by nursing leadership.
Food labeling and cookware sanitization deficiency: A clear container of dehydrated mashed potatoes was observed without a use by date, and multiple cookware items at the sanitation sink were not fully submerged in the sanitizing solution. DS1, DS2, and the DSS all acknowledged that opened dry food products need date marking and that cookware must be completely submerged to be properly sanitized.
A resident with dysphagia, hemiplegia, GERD, and severely impaired cognition was dependent on staff for eating and was on a pureed, mildly thick diet. During lunch, a CNA was observed standing over and feeding the resident instead of sitting at eye level. The CNA and an LVN stated staff should be seated when feeding residents to support dignity and avoid making the resident feel rushed.
Missing informed consent for antipsychotic medication: A resident with schizophrenia and no cognitive impairment was receiving Seroquel at bedtime, but no consent was found in the chart. An LVN stated the consent was meant to ensure the resident agreed to the medication and understood potential side effects, and the ADON confirmed the consent was missing and should have been obtained for the antipsychotic.
Failure to Obtain Admission and Follow-Up Weights: A resident with BPH, dermatitis, and GERD was not weighed on admission or after admission despite an order for weekly weights. RN staff confirmed there was no documented weight, and both RNA and LVN stated the facility could not track whether the resident was gaining or losing weight without it.
Two residents lacked individualized care plans for important clinical needs. One resident receiving Seroquel for schizophrenia had no care plan with goals, interventions, or monitoring for side effects and behaviors, and another resident with a PICC line had no care plan to guide staff care and monitoring. Staff and the DON acknowledged the missing care plans, and the facility policy required comprehensive care plans with measurable objectives and timetables.
Care plans for two residents were not revised to include interventions for LAL mattress use. One resident had dementia, sepsis, and encephalopathy with severe cognitive impairment and dependence for ADLs, and the other had brain cancer, epilepsy, and acute kidney failure with moderate cognitive impairment and dependence for ADLs. An LVN stated the care plan should have been updated when the LAL was put into use, and the DON stated care plans are the blueprint for resident care and interventions.
Failure to Apply Ordered Right Shoulder Sling: A resident with cerebral infarction, muscle weakness, and impaired mobility was ordered to wear a right shoulder sling at all times to prevent subluxation and dislocation. During two observations, the resident was found without the sling on the right arm, and an RNA and LVN confirmed the sling should always have been in place to support the shoulder.
Incorrect LAL Mattress Weight Settings: The facility failed to ensure LAL mattresses were set to the correct weight settings for three residents. One resident with dementia, sepsis, and encephalopathy had a mattress set at 450 lbs despite weighing 98 lbs; another resident with brain cancer, epilepsy, and acute kidney failure had a mattress set at 350 lbs despite weighing 275 lbs; and a third resident with osteoarthritis, muscle weakness, and schizophrenia had a mattress set at 280 lbs despite weighing 242 lbs. Staff stated the settings should be based on resident weight and comfort.
A resident with an indwelling catheter, impaired cognition, and partial/moderate dependence for toileting care had sediment observed in the Foley tubing. Staff acknowledged that sediment can be an early sign of UTI and that the physician should be notified, but the report indicates this was not done. Facility catheter-care policy required observation for catheter complications and immediate reporting of UTI signs and symptoms to the physician or supervisor.
Unlabeled PICC Dressing: A resident with a PICC line and diagnoses including sepsis, MRSA, and paraplegia was observed with an unlabeled dressing on the right upper arm. An RN stated PICC/IV dressings should be labeled with the date, time, and initials when changed, and the DON’s designee stated unlabeled dressings meant staff would not know when the dressing was placed. The facility policy addressed preventing catheter-related infections.
Failure to obtain physician orders before starting LAL mattress therapy for two residents. One resident had dementia, sepsis, and encephalopathy with severe cognitive impairment and dependence for ADLs; the other had brain cancer, epilepsy, and acute kidney failure with moderate cognitive impairment and dependence for ADLs. Both were observed with LAL mattresses in place and operating, but LVN and ADON review found no physician orders for either mattress, despite facility policy requiring a physician or licensed prescriber order.
A resident with glaucoma, hemiplegia, COPD, and anxiety had Timolol eye drops left on the nightstand instead of being stored in the med cart after administration. The resident stated she did not self-administer meds and that nurses gave them to her. An LVN and the DON both stated the eye drops should not be left at the bedside and should be returned to secure storage after use.
Outside Trash Bin Lids Left Open: The facility failed to ensure 3 of 4 outside trash bin lids were fully closed. During observation, one trash bin had both covers open and another had one cover partially open, with no staff nearby. DS3 and the DSS stated trash bin lids should be kept closed, and the facility policy required garbage and refuse containers to remain covered when not in use.
Uncovered Urinal Bottle Observed at Bedside: A resident with cellulitis, local skin infection, sepsis, DM, HTN, CHF, and a colostomy had a partially filled urinal bottle hanging from the bedside railing without a cover. An LVN stated an uncovered urinal could spill and affect others with bacteria in the urine, and the IP stated urinal bottles should always have a cover because a spill could contaminate the area. The facility policy stated to cover the urinal immediately with a urinal cover or paper towel.
Incomplete discharge transfer summary and missing report to receiving facility: A resident with DM, HTN, and hyperlipidemia was discharged to an ILF with home health and PT, but the transfer summary was not completed and the receiving facility was not given a telephone report. The IDT meeting was not documented before discharge, the SS did not verify the ILF could meet the resident’s needs, and the discharge instructions were incomplete. The ILF did not administer meds or check blood glucose, and the resident reported only medication reminders and no insulin administration.
Two residents with cognitive impairment and significant medical conditions were involved in a physical altercation after one became verbally aggressive and struck the other. A CNA present attempted to verbally de-escalate but did not immediately separate the residents or call for help, contrary to facility policy. This lack of prompt intervention resulted in one resident being hit.
A resident with severe cognitive impairment and a history of wandering was not accurately assessed on the MDS, despite multiple progress notes, care plans, and staff interviews confirming frequent wandering and the need for redirection. The MDS assessment failed to reflect this behavior, and staff acknowledged the inaccuracy.
Surveyors identified that call light buttons were not placed within reach for four residents with significant medical and cognitive needs, including those with a history of falls and mobility limitations. Staff interviews and documentation review confirmed that call lights were either left out of reach or not provided due to assumptions about residents' abilities, contrary to facility policy.
The facility failed to provide written transfer notifications to three residents and their representatives, as required by policy. A resident with a subdural hematoma, another with hemiparesis, and a third with quadriplegia were transferred to hospitals without written notice, although their representatives were informed by phone. The facility lacked a process for issuing written notices, potentially violating residents' rights.
A facility failed to ensure that a physician performed the initial face-to-face visit and signed admitting orders for a resident with complex medical conditions, as required by policy and federal regulations. Instead, all documentation was signed by an NPP, with no evidence of physician involvement, raising concerns about the adequacy of care.
A resident with an indwelling catheter was not provided with a privacy bag, compromising their dignity. The resident, who was cognitively intact and dependent on staff for personal care, was observed without a privacy bag, which was confirmed by an LVN and a CNA. The facility's policy on dignity, which requires catheter bags to be covered, was not followed.
A resident with severe cognitive impairment and multiple health issues did not have their call light within reach on two occasions, as observed by surveyors. Facility staff acknowledged the oversight, which contradicted the facility's policy requiring call lights to be accessible to residents. This deficiency highlights a lapse in ensuring the resident's ability to request assistance.
A resident with COPD and fluctuating decision-making capacity was found with dirty and untrimmed fingernails, contrary to the facility's policy requiring daily cleaning and trimming. Staff acknowledged the oversight, noting the potential for infection and self-injury due to the resident's nail condition.
A resident with severe cognitive impairment and a history of pressure ulcers had their low air loss (LAL) mattress incorrectly set at 400 pounds instead of their actual weight of 135 pounds. This discrepancy was observed by an LVN, who confirmed that the settings should match the resident's weight to prevent skin breakdown. The facility's policies lacked specific guidance on the correct use of LAL mattresses, contributing to the deficiency.
A resident with COPD was observed receiving oxygen therapy at 3 liters per minute, contrary to the physician's order of 2 liters. An LVN confirmed the discrepancy, noting potential risks due to the higher oxygen level. The facility's policy requires adherence to physician orders for safe oxygen administration.
A resident with a history of heart conditions did not receive their prescribed Metoprolol on time, as it was administered outside the facility's one-hour window policy. Both an LVN and the Administrator acknowledged the late administration and the associated risks, highlighting a failure to adhere to the medication schedule.
The facility failed to maintain a medication error rate below 5%, resulting in a 6.67% error rate. A resident with heart conditions received their Metoprolol late, and another resident with psychosis and dementia did not receive their Depakote on time due to it not being ordered. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not followed.
A resident missed nine doses of Depakote due to the facility's failure to order the medication from the pharmacy. The resident, with diagnoses including psychosis and dementia, was dependent on staff for daily activities. The absence of the medication was discovered during an interview with an LVN, who found that the pharmacy had not received a faxed order. The facility's policy required documentation for withheld or delayed medications, but this was not followed.
The facility failed to label and date a Ziplock bag containing 52 Tylenol suppositories in the medication storage room, as observed by an LVN. The lack of labeling posed a risk of medication errors, as confirmed by the Administrator, who noted the importance of labeling to determine medication ownership and expiration. The facility's policy requires refrigerated medications to be stored securely and labeled, which was not followed.
A resident with dementia and other health issues experienced a delay in dental care due to the facility's failure to follow up on necessary denture realignment. Despite monthly visits from the dental service, the resident's loose dentures were not addressed for a year, as confirmed by the Social Services Director and the Administrator.
A facility failed to change a resident's oxygen tubing within the required seven-day period, as per their infection prevention and control policy. The resident, with chronic health conditions, was observed with tubing that had not been changed for over a week, placing them at risk for infection. Staff interviews confirmed the oversight and the importance of adhering to the policy.
A resident with multiple health issues experienced a significant change in condition when a new wound was identified, and new treatment orders were issued. The facility failed to notify the resident's representative within 24 hours, as required by policy, resulting in a violation of the resident's rights.
A resident with multiple health conditions developed a new wound, but the facility failed to implement a care plan despite new treatment orders. The absence of a care plan meant the resident might not receive proper care, as confirmed by an LVN.
A facility failed to provide a resident with a physician-ordered CT scan and general surgeon referral. The resident, with a history of multiple myeloma, ulcerative colitis, and end-stage renal disease, required these services due to ascites and localized swelling. Despite physician orders, the facility did not follow up with the necessary medical providers after initial contact, leading to a delay in care. Interviews revealed that desk nurses and the resident's assigned nurse were responsible for organizing these services, but failed to do so, contrary to the facility's policy on referrals.
A resident with multiple health conditions, including MRSA, did not receive proper infection control measures in an LTC facility. The resident's soiled wound dressing was not changed, and a CNA failed to wear required PPE while providing care. These actions were against the facility's infection prevention policies and physician's orders.
A resident with multiple health conditions experienced a change of condition, including wheezing and vomiting, but the LVN failed to reassess the resident or notify the physician, leading to the resident's death. The care plan required prompt reporting of such symptoms, but the LVN prioritized other tasks, neglecting to follow the facility's policy for reassessment and documentation.
A resident with complex medical needs experienced shortness of breath, wheezing, vomiting, and sweating. An LVN administered treatment but failed to document follow-up vital signs, which was required by the facility's policy. Interviews with staff indicated that the resident's symptoms were a change of condition, necessitating reassessment and documentation, which were not performed. This lack of documentation potentially contributed to the resident's death.
A nurse in an LTC facility failed to perform hand hygiene between glove changes during wound care for three residents, potentially leading to cross-contamination. The residents had various conditions, including sepsis, dementia, and pressure ulcers. The facility's policy requires hand washing between glove changes, which was not followed.
A resident with acute respiratory failure, metabolic encephalopathy, and a UTI refused to participate in the RNA program due to pain. Despite documentation of the resident's refusal over several dates, the facility failed to timely develop a comprehensive care plan addressing this issue. The ADON acknowledged the delay in creating a care plan, which was against the facility's policy requiring updates for significant changes in a resident's condition.
A facility failed to monitor a resident's elevated skin condition as per physician's orders and facility policy. The resident, with multiple diagnoses, had a lump on the left posterior thigh that required monitoring for changes in size, pain, and drainage. However, staff did not document measurements of the lump, preventing proper assessment of its progression. Interviews with staff confirmed the lack of documentation, which was against the facility's policy requiring a full wound assessment.
A resident with multiple health conditions experienced unmanaged pain due to the facility's failure to conduct a pain assessment and administer prescribed medication. Despite complaints of pain and refusal to participate in activities, there was no documentation of pain management interventions, contrary to the facility's policy.
A resident with a history of acute respiratory failure, metabolic encephalopathy, and UTI experienced a delay in treatment due to the facility's failure to promptly notify the physician of abnormal urinalysis results. The urinalysis showed abnormal findings, but the physician was not informed until several days later, contrary to the facility's policy requiring timely communication in cases of acute illness or condition change.
The facility failed to report the misappropriation of funds for a resident within the required two-hour window, leading to a delay in investigation. Despite being informed by the resident's family and the Ombudsman, the staff did not take prompt action, violating the facility's abuse policy.
The facility failed to investigate unauthorized charges on a resident's credit card after the Ombudsman reported the issue. Despite the resident's family notifying the administrator and social worker, no investigation was conducted, and the Ombudsman's emails went unanswered. The facility's policy on investigating theft and misappropriation of resident property was not followed.
The facility failed to accurately document the provision of Restorative Nursing Assistant (RNA) services for three residents, potentially affecting their care. Despite residents confirming they received RNA services, documentation was missing on multiple dates. The Director of Nursing emphasized the importance of consistent documentation for patient well-being.
The facility failed to report an abuse incident where a resident threw water at another resident within the required 2-hour timeframe. Despite the incident being reported internally, it was not communicated to the CDPH as mandated by the facility's policy.
The facility failed to investigate an allegation of abuse and separate two residents after one reported throwing water at the other. Despite the incident being reported to an LVN, no further action was taken, and the residents were not separated until much later when the DON was informed.
Failure to Revise Fall Care Plan to Include Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize a resident’s care plan to include person-centered safety measures such as staff supervision and monitoring, despite multiple indicators of high fall risk. The resident was admitted with a history of falls and a left femur fracture, anxiety disorder, gait and mobility abnormalities, and muscle weakness. A Morse Fall Risk Screen identified the resident as high risk for falls, and a PT evaluation documented decreased strength, functional mobility, postural alignment, poor standing balance, and impaired safety awareness, with risk factors including falls and further functional decline. An MDS assessment showed moderate cognitive impairment and a need for substantial/maximal assistance with ADLs and partial/moderate assistance with transfers and walking. The initial care plan for high risk of falls, dated shortly after admission, included general interventions such as assistance with ADLs, transfers, ambulation, and toileting, but did not specify monitoring or supervision parameters. After an unwitnessed fall in which the resident slid off the bed while using a urinal, an IDT meeting documented that the resident perceived himself as independent and forgot to call for assistance, and added a falling star program as a new intervention. A care plan for this actual fall focused on assessing for pain or injury and educating the resident to call for help, but again did not address monitoring or supervision. Subsequent unwitnessed falls occurred with similar circumstances of the resident sliding from the bed, and IDT documentation again cited the resident’s perception of independence and forgetting to use the call light. Following each of the additional unwitnessed falls, new care plans were created that emphasized post-fall assessments such as checking range of motion, neuro checks, PT consults, vital signs, and reinforcing the need to call for assistance, as well as environmental measures like keeping areas free of clutter. However, none of these care plans specified the frequency or level of staff monitoring or supervision for this high-risk resident. Interviews with an LVN, the ADON, and the DON confirmed that the care plans did not include clear directions on monitoring or supervision, despite facility practice and policy indicating that high fall-risk residents should receive frequent monitoring and that care plans must be revised when resident condition changes or when desired outcomes are not met.
Food Labeling and Cookware Sanitization Deficiency
Penalty
Summary
Food was not properly labeled and cookware was not properly sanitized in the kitchen. During an observation on 1/20/2026 at 8:25 a.m., a clear container labeled mashed potatoes was seen on the counter near the sink without a use by date. During an interview at 8:27 a.m., DS1 stated there should be a use by date once the product is opened and said the item would be thrown away because the expiration date was unknown and residents could get sick if the opened product did not have a use by date. During another observation on 1/20/2026 at 8:35 a.m. at the sanitation sink, multiple cookware items were not submerged in the sanitizing solution. During an interview at 8:37 a.m., DS2 stated sanitized items should be fully submerged in the water with the sanitation solution and that items not submerged are not properly sanitized and can cause illness. During an interview on 1/23/2026, the DSS stated cookware must be completely submerged in sanitizing fluid and dry food products must have an open date and a use by date. Facility policy also stated commercially prepared dry storage food items will follow expiration dates, and manual dishwashing policy stated pots and pans are to be sanitized in the third compartment.
Feeding Assistance Not Provided at Eye Level
Penalty
Summary
The facility failed to ensure that CNA 1 was seated while feeding Resident 61 during lunch. Resident 61 was admitted and readmitted to the facility, had diagnoses including dysphagia, hemiplegia, and GERD, and was documented in the H&P as lacking capacity to make decisions. The MDS indicated the resident had severely impaired cognition, was dependent on staff for eating, showering, and dressing, and had a swallowing disorder with difficulty swallowing. The care plan for impaired nutritional and hydration listed assistance during mealtime, and the physician order specified a regular small portions diet with pureed texture and mildly thick consistency. During observation, CNA 1 was seen standing over Resident 61 while feeding her in her room at lunchtime. In interview, CNA 1 stated she should have been sitting at eye level while feeding the resident and that seating would help the resident feel connected to the eating process and more dignified. LVN 1 stated staff should be sitting when feeding residents and that standing over Resident 61 could make her feel rushed to eat and could affect her well-being. The facility policy on dignity stated residents shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and the policy on assisting impaired residents with in-room meals stated that if seated during feeding, a chair should be positioned conveniently for both staff and resident.
Missing informed consent for antipsychotic medication
Penalty
Summary
The facility failed to ensure that Resident 103 had informed consent for Seroquel 25 mg, ordered as 0.5 mg by mouth at bedtime for schizophrenia. Resident 103’s record showed diagnoses of osteoarthritis, muscle weakness, and schizophrenia, and the MDS dated 12/30/2025 indicated no cognitive impairment, dependence on staff for eating, showering, and dressing, and use of an antipsychotic medication. During a concurrent interview and record review with an LVN and later with the ADON, the resident’s consent documents were reviewed and no consent for Seroquel was found. The LVN stated the medication was being administered at bedtime and that consent was intended to ensure the resident agreed to take the medication and understood potential side effects. The ADON also stated there was no consent for Seroquel, that it should have been consented, and that obtaining consent for antipsychotic medication was a requirement to educate residents about medication side effects. The facility policy on informed consent stated that residents were to be involved in care decisions by facilitating information and obtaining consent for psychotropic drugs, and that informed consent was to be obtained when there was a new or increased psychotropic drug.
Failure to Obtain Admission and Follow-Up Weights
Penalty
Summary
The facility failed to ensure that Resident 112 was weighed on admission and after admission. Resident 112’s face sheet showed admission to the facility, and the resident’s MDS dated 1/19/2026 indicated moderately impaired cognition and partial to moderate dependence on staff for toileting hygiene, showering, and dressing. The physician’s order summary dated 1/15/2026 directed weekly weights every Monday for 30 days, but the weights and vitals summary dated 1/20/2026 showed no documented weight. During a concurrent interview and record review on 1/21/2026, RNA 1 stated Resident 112 was not weighed on admission and was not weighed on Monday 1/19/2026, and stated the facility had no way of knowing if the resident was gaining or losing weight. LVN 1 also stated the resident was admitted and was not weighed after admission, and that without a weight staff would not be able to keep track of whether the resident became malnourished or needed certain medications requiring weight. The facility’s admission assessment policy dated 10/2022 stated the purpose of the procedure was to gather information and conduct a physical assessment of the resident including vital signs.
Missing Care Plans for Antipsychotic Medication and PICC Line
Penalty
Summary
Resident 103 did not have a comprehensive individualized care plan addressing the use of Seroquel for schizophrenia. The resident’s record showed diagnoses of osteoarthritis, muscle weakness, and schizophrenia, and the MDS indicated no cognitive impairment, dependence on staff for eating, showering, and dressing, and risk for pressure ulcer/injury with pressure-reducing devices in use. The physician order summary showed Seroquel 25 mg, 0.5 tablet by mouth at bedtime for schizophrenia. During record review with an LVN, staff stated there was no care plan for Seroquel and that a care plan should include goals, interventions, and monitoring for side effects and behaviors to report. The facility’s care plan policy stated care plans were to include measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs. Resident 77 also did not have a care plan for a PICC line. The resident’s record showed admission with diagnoses including sepsis, MRSA, and paraplegia, and the MDS indicated clear cognition with dependent assistance for transferring, toileting, lower body dressing, and partial dependence for positioning and upper body dressing. During a concurrent interview and record review with an RN, no PICC line care plan was found, and the RN stated one should have been implemented. The RN stated that without a care plan there would not be a way to know if all patient-centered interventions were performed and monitored. The DON stated a care plan was a blueprint for the resident’s care, needs, interventions, and goals, and that if a care plan was not created it was possible the resident would not receive complete care.
Care Plans Not Updated for Low Air Loss Mattress Use
Penalty
Summary
The facility failed to review, update, and revise the care plans for two residents to address use of a Low Air Loss (LAL) mattress. Resident 2 was admitted and later readmitted to the facility with diagnoses including dementia, sepsis, and encephalopathy. The H&P stated the resident did not have the capacity to make decisions, and the MDS indicated severe cognitive impairment, dependence on staff for ADLs such as oral hygiene, toileting, showering, and positioning, and risk for pressure ulcers/injuries. Resident 14 was admitted with diagnoses including malignant neoplasm of the brain, epilepsy, and acute kidney failure. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated moderate cognitive impairment, dependence on staff for ADLs such as toileting, showering, dressing, and positioning, and risk for pressure ulcers/injuries. During a concurrent interview and record review, the care plans for Resident 2 and Resident 14 were reviewed and the skin breakdown care plan was not revised to include interventions for LAL mattress use. The LVN stated the care plan should have been revised when the LAL was put into use and that care plans serve as a guide for nursing staff to ensure patient-centered care and interventions are not missed. The DON stated a care plan is a blueprint for the resident's care, needs, interventions, and goals, and that if a care plan is not revised, residents may not receive complete and updated care. The facility policy stated care plans are revised as resident conditions change and that the interdisciplinary team must review and update the care plan when there is a significant change, after readmission, and at least quarterly; the LAL mattress policy stated nursing staff and the wound care nurse will incorporate LAL mattress use into the comprehensive care plan.
Failure to Apply Ordered Right Shoulder Sling
Penalty
Summary
The facility failed to ensure that Resident 97 had a right shoulder sling in place as ordered. Resident 97 was admitted with diagnoses including cerebral infarction, muscle weakness, and abnormalities of mobility. The MDS dated 11/10/2025 indicated the resident sometimes had the ability to make self-understood and was dependent on staff for eating, showering, and dressing. A physician order dated 2/25/2025 directed staff to provide a right shoulder sling at all times to prevent subluxation and at risk for dislocation. During observations on 1/20/2026 at 9:05 a.m. and again at 11:09 a.m., Resident 97 was in his room without a sling on the right arm. During a concurrent interview and pictured record review on 1/21/2026, RNA 1 stated the resident was to always wear the sling and that it was to support the right shoulder. LVN 1 also stated the sling was to be worn at all times to prevent risk for dislocation of the right shoulder. Facility policies reviewed stated CNAs assist with application of slings and that the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents.
Incorrect LAL Mattress Weight Settings
Penalty
Summary
The facility failed to ensure low air loss (LAL) mattresses were set to the appropriate weight settings for three sampled residents. Resident 2 had diagnoses including dementia, sepsis, and encephalopathy, lacked decision-making capacity, and was assessed as having severe cognitive impairment, dependence for multiple ADLs, and risk for pressure ulcers. During observation, Resident 2’s LAL mattress was operating at a setting of 450 pounds, while the resident’s recorded weight was 98 pounds. Resident 14 had diagnoses including malignant neoplasm of the brain, epilepsy, and acute kidney failure. The resident was documented as able to make needs known but unable to make medical decisions, and was assessed as having moderate cognitive impairment, dependence for ADLs including toileting, showering, dressing, and positioning, and risk for pressure ulcers. During observation, Resident 14’s LAL mattress was set at 350 pounds, while the resident’s recorded weight was 275 pounds. Resident 103 had diagnoses including osteoarthritis, muscle weakness, and schizophrenia. The resident was assessed as having no cognitive impairment, dependence for eating, showering, and dressing, and risk for pressure ulcer/injury, with a physician order for an LAL mattress for skin maintenance. During observation, Resident 103’s LAL mattress was set at 280 pounds, while the resident’s recorded weight was 242 pounds. Staff interviews stated LAL mattress settings should be based on resident weight and comfort, and that incorrect settings could reduce circulation and increase the risk for pressure ulcers.
Failure to Notify Physician of Sediment in Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the physician was notified when sediment was observed in Resident 112’s indwelling catheter tubing. Resident 112 was admitted with diagnoses including benign prostatic hyperplasia, dermatitis, and GERD, and the MDS dated 1/19/2026 indicated moderately impaired cognition and partial/moderate dependence for toileting hygiene, showering, and dressing. The resident also had an indwelling catheter, and the physician order directed staff to monitor for redness, irritation, swelling, and signs and symptoms of UTI. During an observation on 1/20/2026 at 9:15 a.m., sediment was seen in Resident 112’s indwelling catheter. A later concurrent observation and interview with LVN 6 on 1/21/2026 at 2:18 p.m. again found sediment in the Foley catheter, and LVN 6 stated that sediment in the urine could indicate a UTI and that the physician should be notified. The ADON stated during interview on 1/21/2026 at 3:17 p.m. that the indwelling catheter should be monitored every shift and that early signs of a UTI such as sediment should be reported to the physician. The facility policy on catheter care stated to observe for complications and signs and symptoms of UTI and report findings to the physician or supervisor immediately.
Unlabeled PICC Dressing
Penalty
Summary
A resident with diagnoses including sepsis, MRSA, and paraplegia had a PICC line in the right upper arm. The resident’s MDS indicated clear cognition and dependence on staff for several ADLs, including transferring, toileting, lower body dressing, and partial dependence for positioning and upper body dressing. During observation, the PICC dressing was noted to be unlabeled. During interview, an RN stated that IV or PICC line dressings were to be labeled with the date, time, and initials as soon as they were changed, and that dressings were changed every seven days and as needed. The RN and ADON both stated that unlabeled IV dressings created a risk of infection because staff would not know when the dressing had been placed. The facility policy titled Peripheral IV Dressing Changes stated the purpose of the procedure was to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings.
Failure to Obtain Physician Orders Before Starting LAL Mattress Therapy
Penalty
Summary
The facility failed to obtain physician orders before initiating low air loss (LAL) mattress therapy for two residents. Resident 2 was admitted and later readmitted with diagnoses including dementia, sepsis, and encephalopathy. The H&P dated 12/1/2025 stated Resident 2 did not have the capacity to make decisions, and the MDS dated 12/23/2025 indicated severe cognitive impairment, dependence for ADLs including oral hygiene, toileting, showering, and positioning, and risk for pressure ulcers/injuries. On 1/21/2026, Resident 2 was observed in bed with a LAL mattress in place and operating. Resident 14 was admitted with diagnoses including malignant neoplasm of the brain, epilepsy, and acute kidney failure. The H&P dated 12/11/2025 stated Resident 14 could make needs known but could not make medical decisions, and the MDS indicated moderate cognitive impairment, dependence for ADLs including toileting, showering, dressing, and positioning, and risk for pressure ulcers/injuries. On 1/21/2026, Resident 14 was observed in bed with a LAL mattress in place and operating. During a 1/22/2026 interview and record review, LVN 3 found no physician orders for a LAL mattress for either resident and stated an order was required before initiating the mattress. The ADON later stated a physician order was required for a low air loss mattress and that placing it without an order was outside the nursing scope of practice. The facility policy stated LAL mattresses shall be used when clinically indicated and ordered by a physician or other licensed prescriber.
Eye Drops Left at Bedside
Penalty
Summary
The facility failed to ensure that one sampled resident’s Timolol eye drops were properly stored. Resident 99 had diagnoses including hemiplegia, COPD, anxiety, and glaucoma, and the record indicated the resident had the capacity to understand and make decisions with no cognitive impairment. The physician order directed Timolol Maleate Ophthalmic Solution 0.5% to be instilled as one drop in both eyes twice daily for glaucoma. During an observation and interview, the Timolol eye medication was found on Resident 99’s nightstand in the resident’s room. Resident 99 stated she did not self-administer her medications and that nurses administered them. An LVN stated the eye drops were supposed to be returned to the medication cart after administration and should not be left at the bedside. The ADON also stated no medication should be left on the nightstand and that after administration it should be put back into the medication cart. The facility policy stated all drugs and biologicals shall be stored in a safe, secure, and orderly manner, and nursing staff were responsible for maintaining medication storage.
Outside Trash Bin Lids Left Open
Penalty
Summary
The facility failed to ensure 3 of 4 outside trash bin lids were completely closed. During an observation on 1/20/2026 at 1:43 p.m., one trash bin had both covers open and another trash bin had one cover partially opened, with no staff in the immediate area. During an interview on 1/20/2026 at 1:44 p.m., DS3 stated that trash cans should be covered and that if trash is uncovered, rain and animals can get into the trash. During an interview on 1/23/2026 at 9:10 a.m., the DSS stated that the lids on the trash bins should be closed at all times. Review of the facility policy titled, Food-Related Garbage and Refuse Disposal, dated October 2017, indicated that all garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.
Uncovered Urinal Bottle Observed at Bedside
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when a urinal bottle for Resident 113 was observed hanging from the upper left bedside railing without a cover. During observation on 1/20/2026 at 11:37 a.m. in room [ROOM NUMBER]C, the urinal bottle was partially filled and had no top for containing the urine. Resident 113’s admission record dated 1/15/2026 showed diagnoses of cellulitis of the right lower limb, local infection of the skin and subcutaneous tissue, and sepsis. The resident’s order summary dated 1/15/2026 indicated a regular diet and a 5150 hold due to episodes of agitation and verbally aggressive behavior toward staff. During interview, LVN2 stated that if the urinal bottle is uncovered it could spill on the floor and someone can be affected by the bacteria in the urine. The IP stated urinal bottles should always have a cover and that it could contaminate the area if it spills. The IP also stated everyone is responsible for making sure urinal bottles are covered. The facility’s policy and procedure titled Bedpan/Urinal, offering/Removing, dated February 2018, stated to cover the urinal immediately with a urinal cover or paper towel.
Incomplete discharge transfer summary and missing report to receiving facility
Penalty
Summary
The facility failed to ensure Resident 1’s transfer summary was completed and that a telephone report was called to the receiving facility before discharge. Resident 1 was admitted with diagnoses including DM, HTN, and hyperlipidemia, and the record showed intact cognition with supervision or touching assistance needed for ADLs such as dressing, toileting, personal hygiene, transfer, and mobility. The care plan indicated discharge planning was part of the resident’s plan of care, and the physician ordered discharge to an ILF with home health services and PT. The record review and interviews showed the discharge process was not completed as described in the facility’s policies. The IDT meeting notes did not show a documented IDT meeting before discharge, and the SS stated the meeting was not scheduled prior to discharge. The SS also stated the facility did not check with the ILF to confirm it could accommodate Resident 1’s needs, including medication administration, blood glucose checks, and room availability. The DON stated the facility’s protocol was to call the receiving facility to make sure it could accommodate the resident’s needs, and RN 1 stated the receiving ILF was not called prior to discharge and the discharge instructions summary was incomplete. The facility’s policy titled Discharging the Resident stated that if a resident is discharged to another facility, a transfer summary should be completed and telephone report called to the receiving facility. The discharge summary policy also required a recapitulation of the resident’s stay and final status, including nutrition status, special treatments or procedures, and medication therapy. The ILF owner stated the ILF does not administer medications or check blood glucose levels, and the complainant reported that Resident 1 was staying on a couch in a small living area with other people in the home. Resident 1 stated the ILF caregiver reminded him about medications but did not administer insulin shots.
Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate staff supervision for two residents, resulting in a physical altercation. Both residents had moderately impaired cognitive skills and required varying levels of assistance with daily activities. One resident, who had end stage renal disease, COPD, and diabetes, was struck on the left side of the face by another resident with a history of urinary tract infection, bilateral below-knee amputation, and COPD. The incident occurred when the second resident, while sitting in his wheelchair and eating lunch, became verbally aggressive and called the first resident names, telling him to get out of the way. A certified nurse assistant (CNA) was present in the room and observed the verbal aggression. The CNA stood between the two residents and attempted to verbally de-escalate the situation by telling the aggressive resident to be nice. Despite this, the aggressive resident suddenly hit the other resident. The CNA later acknowledged that she should have separated the residents immediately or called for help, and that the incident could have been prevented with prompt action. Interviews with facility leadership, including the Director of Staff Development and the Director of Nursing, confirmed that the facility's policy requires immediate separation of residents during altercations to prevent harm. Review of facility policies also indicated that resident safety, supervision, and prompt intervention during altercations are priorities. The failure to separate the residents promptly and provide adequate supervision directly led to the physical altercation and the resulting deficiency.
Plan Of Correction
F689 Corrective action for residents found to have been affected by this deficiency: CNA 1 was provided a one-on-one in-service and education regarding immediate separation and de-escalation of potential resident-to-resident altercation on 8/4/25. Corrective action for residents that may be affected by this deficiency: On 7/31/25, the Director of Staff Developer/designee interviewed staff to identify any resident roommate incompatibility to ensure supervision and communication to prevent potential resident incidents. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above Plan of Correction (POC) will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above POC will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends.
Inaccurate MDS Assessment of Wandering Behavior
Penalty
Summary
A deficiency was identified when the facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment regarding wandering behavior. The resident in question had a history of Alzheimer's disease, anxiety, and dementia, with documentation indicating severe cognitive impairment and an inability to make decisions. Multiple progress notes and care plans described the resident as exhibiting wandering behavior, including entering other residents' rooms and taking their belongings, which required staff intervention and redirection. Despite this documented behavior, the MDS assessment completed for the resident did not indicate any wandering behavior. Interviews with facility staff, including a CNA, the MDS Coordinator Nurse, the Director of Nursing (DON), and the Social Service Assistant (SSA), confirmed that the resident did, in fact, wander and required frequent redirection. The DON and SSA both acknowledged that the MDS assessment was inaccurate and did not reflect the resident's actual behavior. The facility's policy and procedure on the Resident Assessment Instrument stated that each discipline assigned to complete a section of the MDS is responsible for the accuracy of the information. The failure to accurately document the resident's wandering behavior on the MDS assessment was confirmed through record review and staff interviews, resulting in a deficiency for not ensuring the assessment accurately reflected the resident's status.
Plan Of Correction
F641 Corrective action for residents found to have been affected by this deficiency: Resident number 1 was kept safe. Roommate that was involved was moved to another room immediately on 7/7/25. Resident 1 was monitored for any signs and symptoms of emotional distress, none noted. On 8/5/25, MDS consultant gave one-on-one in-service and education to SSA 1 regarding proper and accurate behavioral coding, i.e., resident exhibiting wandering behavior. Corrective action for residents that may be affected by this deficiency: On 8/5/25, MDS coordinator reviewed residents with behavior emphasizing on residents with wandering behavior. None were noted. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/5/25, MDS consultant provided in-service and education training to MDS nurses and Social Services staff in regards to proper and accurate behavior assessment and coding. MDS accuracy will be reviewed by IDT member to ensure behaviors were accurately captured and documented during admission record review and scheduled residents' care conference. MDS consultant will validate compliance twice a month as scheduled. Findings will be reported to DON for follow-up. Measures that will be put into place to ensure that this deficiency does not reoccur: The above POC will be reviewed in the QAPI committee for 3 months and as needed thereafter. Administrator and/or Designee will report trends.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
Surveyors found that the facility failed to ensure call light buttons were placed within reach for four out of six sampled residents. During inspection, call light buttons were observed to be inaccessible: one was behind a pillow at the head of a bed, another was on the floor, and two were on beds but out of reach. Interviews with residents confirmed they could not access their call lights, and staff interviews revealed that in some cases, the call lights were not placed within reach after care was provided or were not provided due to assumptions about residents' abilities to use them. The facility's policy requires call lights to be placed within reach before staff leave the room. The residents affected had significant medical conditions, including diabetes, heart failure, kidney failure, epilepsy, osteoarthritis, hypertension, encephalopathy, schizophrenia, dementia, dysphasia, and physical limitations such as a contracted hand. Some had a history of falls and required assistance with mobility and transfers. Documentation reviewed included admission records, MDS assessments, care plans, and nurse notes, which indicated the need for call lights to be accessible as part of fall prevention and to allow residents to communicate their needs.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the provision of written notifications of transfer for three residents who were transferred to general acute care hospitals. Resident 1, who lacked the capacity to make medical decisions due to a subdural hematoma, was transferred to a hospital without written notification being provided to their representative. Similarly, Resident 2, who had the capacity to make medical decisions and a history of hemiparesis following a stroke, was transferred without written notification to their emergency contact, despite being informed via telephone. Resident 3, who had quadriplegia and the capacity to make medical decisions, was also transferred without written notification to their representative, although they were informed by phone. Interviews with the Registered Nurse and the Director of Nursing revealed that the facility did not have a process in place to provide written notices of transfer, as required by their policy. The policy, dated December 2016, mandates that residents and their representatives receive written notification detailing the reason, time, and location of the transfer, as well as information about their rights, including the right to appeal the transfer. The lack of written notification potentially violated the residents' rights and left their representatives uninformed about the transfer details.
Failure to Ensure Physician Face-to-Face Visits and Orders
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding physician services, specifically in ensuring that physicians perform the initial face-to-face visit, sign admitting physician orders, and alternate visits with a non-physician practitioner (NPP). This deficiency was identified for one resident who was admitted with a history of subdural hematoma, end-stage renal disease requiring dialysis, and multiple myeloma. The resident's admission record and subsequent medical documentation, including the history and physical, physician orders, and progress notes, were all signed by an NPP, with no evidence of a physician's face-to-face contact. The Director of Nursing confirmed that the facility's policy required physician visits and documentation to comply with current regulations, which mandate that physicians must perform the initial comprehensive visit and sign admission orders. The review of the Code of Federal Regulations further supported that NPPs are not permitted to perform these initial tasks in skilled nursing facilities. The lack of physician involvement in the resident's care raised concerns about the thoroughness of assessments and the safety and adequacy of care provided.
Failure to Provide Privacy Bag for Catheter Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a privacy bag, which compromised the resident's dignity. The resident, who was cognitively intact and dependent on staff for personal care, was observed without a privacy bag for the catheter. This observation was confirmed by both a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), who acknowledged that the absence of a privacy bag could lead to embarrassment and a loss of dignity for the resident. The facility's policy on Quality of Life-Dignity, which mandates that residents be cared for in a manner that promotes dignity and respect, was not adhered to in this instance. The policy specifically prohibits practices that compromise dignity, including the requirement to keep urinary catheter bags covered. The failure to provide a privacy bag for the resident's catheter was a direct violation of this policy, as confirmed by staff interviews and the facility's documentation.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 45, had their call light within reach, which is a critical aspect of meeting the resident's needs and preferences. Resident 45, who was readmitted to the facility with diagnoses including heart failure, acute myocardial infarction, and a syndrome causing colon expansion, was observed on two separate occasions without the call light within reach. The resident's cognitive abilities were severely impaired, and they were dependent on staff for personal care, making the accessibility of the call light essential for their safety and ability to request assistance. During interviews with facility staff, both a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) acknowledged that the call light was not within reach and emphasized the importance of having it accessible to prevent falls and ensure the resident could call for help. The facility's policy and procedure on call light answering, dated December 2023, clearly stated that the call device should be placed within the resident's reach before leaving the room, and staff should check its placement during care. The failure to adhere to this policy resulted in a deficiency in providing adequate care to Resident 45.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure that one of the sampled residents, Resident 144, had properly trimmed fingernails. This deficiency was observed during a room visit where Resident 144 was found to have dirty and long untrimmed fingernails. The resident's Minimum Data Set (MDS) indicated that they were dependent on staff for personal hygiene, including nail care. Interviews with the Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) confirmed that the resident's fingernails were not maintained as per the facility's policy, which requires daily cleaning and regular trimming to prevent infections and skin injuries. Resident 144 had a medical history that included chronic obstructive pulmonary disease (COPD), respiratory failure, and pleural effusion, and was noted to have fluctuating decision-making capacity. The facility's policy on nail care, dated February 2018, outlines the importance of maintaining clean and trimmed nails to prevent infections and skin problems. Despite this policy, the staff acknowledged the oversight, noting that the resident's untrimmed and dirty fingernails could harbor bacteria and potentially cause self-injury or infection.
Incorrect LAL Mattress Settings for Resident
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was set correctly for a resident, leading to a potential risk of skin breakdown. The resident, who was severely cognitively impaired and dependent on staff for personal care, had a history of pressure ulcers and was using a LAL mattress to prevent further skin damage. During an observation, it was noted that the LAL mattress was set at 400 pounds, while the resident's actual weight was 135 pounds. A Licensed Vocational Nurse (LVN) confirmed that the mattress settings should be adjusted to match the resident's weight to effectively prevent and treat pressure ulcers. The facility's policies on support surfaces and pressure ulcer prevention did not provide specific guidance on the correct use of LAL mattresses. The policy outlined the need for pressure-reducing devices based on various risk factors, but lacked detailed instructions on setting the LAL mattress according to the resident's weight. This oversight in policy and practice contributed to the deficiency, as the incorrect mattress settings could compromise the resident's skin integrity and impede the healing of existing pressure ulcers.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy according to the physician's orders. Resident 143, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, and pleural effusion, was observed receiving oxygen therapy set at 3 liters per minute. However, the physician's order specified that the resident should receive 2 liters of oxygen via nasal cannula continuously every shift. This discrepancy was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged that the physician's orders were not being followed. The LVN expressed concern that administering oxygen at 3 liters could be dangerous for the resident, particularly given their COPD diagnosis, as it could lead to discomfort or oxygen poisoning. The facility's policy and procedure for oxygen administration, dated October 2010, requires verification of a physician's order and adherence to the specified guidelines for safe oxygen administration. The failure to follow these orders and procedures had the potential to impact the resident's medical care adversely.
Late Administration of Blood Pressure Medication
Penalty
Summary
The facility failed to administer blood pressure medication in a timely manner for one resident, identified as Resident 36. This resident had a history of atrial fibrillation, atherosclerotic heart disease, and hypertensive heart disease, and was dependent on staff for various activities of daily living. The physician's order for Metoprolol, a medication used to manage hypertension, specified a daily dose of 25 milligrams to be administered at 7:30 a.m. However, during an interview and record review, it was revealed that the medication was administered late, outside the one-hour window before or after the scheduled time, as per the facility's policy. Licensed Vocational Nurse 1 confirmed that the medication was considered late and acknowledged the potential risks associated with delayed administration, such as fluctuations in blood pressure. The facility's Administrator also confirmed the late administration and reiterated the importance of adhering to the prescribed medication schedule to avoid adverse side effects and maintain consistency with the resident's medication regimen. The facility's policy on medication administration emphasized the importance of administering medications within the specified time frame, which was not adhered to in this instance.
Medication Error Rate Exceeds 5% Due to Late and Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a combined error rate of 6.67% during the observation of medication administration. Two residents were affected by this deficiency. Resident 36, who has a history of atrial fibrillation, atherosclerotic heart disease, and hypertensive heart disease, did not receive their prescribed Metoprolol on time. The medication was scheduled for 7:30 a.m. but was administered late, which could potentially affect the resident's blood pressure and heart condition. Resident 148, diagnosed with psychosis, dementia, urinary tract infection, and dehydration, did not receive their prescribed Depakote as it was not available in the medication cart or facility. The medication had not been ordered, and the pharmacy was contacted to deliver it later in the day. This delay in medication administration could lead to medication errors and affect the resident's behavior. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not adhered to in these cases.
Failure to Order Medication Results in Missed Doses
Penalty
Summary
The facility failed to ensure that medication was ordered from the pharmacy for one of the residents, resulting in the resident missing nine doses of Depakote, a medication used to treat aggression. The resident, who was admitted with diagnoses including psychosis, dementia, urinary tract infection, and dehydration, had severely impaired cognitive skills and was dependent on staff for various activities of daily living. The absence of the medication was discovered during an observation and interview with a Licensed Vocational Nurse (LVN), who stated that the pharmacy had not received a faxed order for the medication, leading to the missed doses. The facility's Administrator confirmed that licensed staff were responsible for calling and faxing new physician orders to the pharmacy, and that medications could be delivered the same day or the following day if ordered late. However, there was no explanation provided for why the medication was not ordered and filled. The facility's policy required documentation if a drug was withheld, refused, or given at a different time, but this was not adhered to in this case. The deficiency had the potential to result in the resident exhibiting physical aggression, restlessness, and manic behavior, creating an unsafe environment.
Unlabeled Tylenol Suppositories in Medication Storage
Penalty
Summary
The facility failed to ensure that Tylenol suppositories stored in a clear Ziplock bag in the Station 1 Medication Storage room were labeled and dated. During an observation and interview with an LVN, it was noted that the bag containing 52 rectal Tylenol suppositories was unlabeled and undated. The LVN acknowledged that the bag should have been labeled with an open date and expiration date, and expressed concern that the lack of labeling could lead to medication errors. The LVN was unable to determine if the medication was expired, if it belonged to a resident, or even what the medication was. The facility's Administrator confirmed that all medications in the storage room should be labeled and dated with open and expiration dates. The Administrator also highlighted the risk of medication errors due to the presence of unlabeled medication in the storage refrigerator, noting that it would be unclear whether the medication belonged to a resident or was a house medication, and whether it was expired. The facility's policy on medication storage requires that medications needing refrigeration be stored in a secured location and labeled accordingly, which was not adhered to in this instance.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure dental services were provided for a resident, identified as Resident 35, who had been experiencing issues with loose upper dentures for the past year. Despite the facility's dental service, Golden Age Dental Care, visiting residents monthly, there was no follow-up to address the resident's need for a denture realignment. The resident's son reported the issue, and it was confirmed by the Social Services Director (SSD) that the last dental appointment was on November 1, 2024, with no subsequent action taken to resolve the denture problem. The SSD acknowledged that the Social Services department was responsible for coordinating dental services, including setting appointments and follow-ups. The lack of follow-up was confirmed during an interview with the Administrator, who stated that the responsibility for dental service coordination lay with Social Services. The facility's policy, revised in December 2016, indicated that Social Services should assist residents with dental appointments and related arrangements, but this was not adhered to in the case of Resident 35.
Failure to Change Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not changing the oxygen tubing for Resident 66 within the required seven-day period. Resident 66, who has chronic obstructive pulmonary disease, heart failure, and chronic kidney disease, was observed with oxygen tubing dated 12/18/2023, which had not been changed by 12/26/2023. This oversight was confirmed through interviews with the Licensed Vocational Nurse, Assistant Director of Nursing, and Infection Preventionist Nurse, all of whom acknowledged the importance of changing the tubing weekly to prevent infection. The facility's policy, as outlined in their Infection Prevention and Control Program and Respiratory Therapy-Prevention of Infection procedures, mandates the change of oxygen cannula and tubing every seven days to prevent infection. The failure to comply with this policy placed Resident 66 at risk for infection, as confirmed by the staff interviews and the facility's documented procedures.
Failure to Notify Resident's Representative of Significant Health Change
Penalty
Summary
The facility failed to notify a resident's representative within 24 hours of a significant change in the resident's health status, violating the resident's rights. The resident, who was unable to make medical decisions, had a history of multiple myeloma, type II diabetes mellitus, and end-stage renal disease. On 11/28/2024, a new wound was identified on the resident, and new physician orders for medications and a wound culture were issued. However, the resident's representative was not informed of these changes until 11/30/2024, two days later. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, confirmed that the facility's policy required notifying a resident's representative of significant changes in condition within 24 hours. Despite this policy, the Licensed Vocational Nurse admitted that the representative was not notified promptly. The facility's policy on changes in a resident's condition was reviewed and indicated that significant changes requiring staff intervention must be communicated to the resident's representative within the specified timeframe.
Failure to Implement Care Plan for Resident's New Wound
Penalty
Summary
The facility failed to develop and implement a care plan for a resident after a new wound was identified. The resident, who was admitted with a history of multiple myeloma, type II diabetes mellitus, and end-stage renal disease, was found to have an abscess on the right buttock with copious pus drainage, indicating an infection. Despite receiving new physician orders for multiple antibiotics and a wound culture on November 28, 2024, there was no corresponding care plan created to address the resident's wound and treatment needs. During a review of the facility's records, it was noted that the resident's care plans dated December 2024 did not include any information related to the new wound or the treatment orders. A Licensed Vocational Nurse confirmed that a care plan should have been implemented when the wound was discovered and when the treatment was modified. The absence of a care plan meant that the resident had the potential to not receive proper care and services for the condition, as the facility's policy requires care plans to be revised as the resident's condition changes.
Failure to Provide Physician-Ordered CT Scan and Surgeon Referral
Penalty
Summary
The facility failed to provide a resident with a physician-ordered CT scan and a referral to a general surgeon. The resident, who was unable to make medical decisions, had a history of multiple myeloma, ulcerative colitis with rectal bleeding, and end-stage renal disease requiring dialysis. The physician orders dated 11/14/2024 and 11/20/2024 indicated the need for a general surgeon referral due to ascites and a CT scan of the right gluteus maximus area due to localized swelling, mass, and lump. However, the facility did not follow up on these orders, as there were no progress notes indicating contact with the general acute care hospital or the general surgeon after 11/25/2024. Interviews with licensed vocational nurses revealed that the facility's desk nurses and the resident's assigned nurse were responsible for organizing the CT scan orders and general surgery referrals. Despite this responsibility, there was a lack of follow-up communication with the necessary medical providers. The facility's policy and procedure on referrals indicated that social services should collaborate with nursing staff to arrange physician-ordered services, but this collaboration did not occur, leading to a delay in care for the resident.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention precautions for a resident with a history of multiple myeloma, type II diabetes mellitus, and end-stage renal disease. The resident's wound dressing was observed to be soiled with old, dried stool, and it was not changed as required by the physician's orders. The Licensed Vocational Nurse (LVN) acknowledged that the dressing was soiled and should have been changed to prevent infection. The facility's job description for charge nurses indicated that they must administer professional services such as applying and changing dressings, which was not adhered to in this instance. Additionally, the facility did not enforce the required contact isolation precautions for the resident, who had a wound infected with Methicillin-resistant Staphylococcus aureus (MRSA). A Certified Nursing Assistant (CNA) was observed not wearing a gown while providing care to the resident, contrary to the physician's orders and the facility's infection prevention and control program. The LVN confirmed that all staff and visitors must follow the contact precautions to prevent the spread of infection. The facility's policy indicated that infection prevention includes implementing measures to avoid complications, which was not followed in this case.
Failure to Reassess and Notify Physician Leads to Resident's Death
Penalty
Summary
The facility failed to provide necessary care and services for a resident, resulting in the resident's death. The resident, who had multiple diagnoses including hydrocephalus, diabetes mellitus, and was dependent on enteral feeding, experienced a change of condition characterized by wheezing, vomiting, and sweating. Despite these symptoms, the Licensed Vocational Nurse (LVN) did not reassess the resident after administering medications and failed to notify the physician of the change in condition. The resident's care plan required staff to observe and report symptoms such as shortness of breath, wheezing, and vomiting to the physician promptly. However, the LVN prioritized administering medications to other residents over reassessing the resident and notifying the physician. The LVN acknowledged that the resident's airway should have been the priority and that reassessment was crucial to determine the effectiveness of the interventions. Interviews with other staff members, including a Registered Nurse (RN) and the Assistant Director of Nursing (ADON), confirmed that the LVN did not follow the care plan's interventions, which included notifying the physician and reassessing the resident's condition. The facility's policy and procedure also required detailed documentation and physician notification in the event of a change in condition, which was not adhered to in this case.
Failure to Document Vital Signs After Treatment
Penalty
Summary
The facility failed to document vital signs after administering treatment for shortness of breath, wheezing, vomiting, and sweating for a resident. This resident had a complex medical history, including hydrocephalus, diabetes mellitus, aphasia, gastro-esophageal reflux disease, a gastrostomy, and right-sided hemiplegia and hemiparesis. The resident was dependent on staff for personal care and required tube feeding. On the day of the incident, the resident exhibited symptoms of vomiting and sweating, and was assessed by an LVN who noted shortness of breath and wheezing. The LVN administered medications but failed to document follow-up vital signs after the interventions. Interviews with facility staff revealed that the resident's symptoms were considered a change of condition, and the LVN should have reassessed the resident's condition at regular intervals after administering treatment. The facility's policy required documentation of all services provided, changes in the resident's condition, and the resident's response to care. However, the LVN did not document the necessary follow-up assessments, and the ADON confirmed that the lack of documentation indicated that the vital signs were not taken. This failure to document and reassess the resident's condition potentially contributed to the resident's death.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a licensed nurse during wound care procedures for three residents. Observations revealed that the nurse did not perform hand washing or hand sanitizing between changing gloves while attending to the residents' wounds. This practice was noted during wound care for a gastric tube site, sacral area, and other skin treatments, which could potentially lead to cross-contamination and infection spread. Resident 2, who was admitted with diagnoses including sepsis and pressure ulcers, was observed receiving wound care without the nurse sanitizing hands between glove changes. Similarly, Resident 3, with a history of dementia and hemiplegia, also received wound care without proper hand hygiene. Resident 4, diagnosed with colon cancer and pressure ulcers, was another case where the nurse failed to sanitize hands between glove changes during wound care. The facility's policy on dressing changes requires hand washing between glove changes, which was not adhered to by the nurse. The nurse acknowledged the importance of hand hygiene in preventing infection spread and admitted to not following the protocol during the wound care procedures for the residents.
Failure to Develop Comprehensive Care Plan for Resident Refusing RNA Program
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was refusing to participate in the Restorative Nurse Assistant (RNA) program due to pain. The resident, who was admitted with acute respiratory failure, metabolic encephalopathy, and a UTI, was documented as having the capacity to understand and be understood according to the Minimum Data Set (MDS). Despite this, the resident consistently refused to walk with the RNA due to pain over several dates in March and April 2022, as noted in the RNA Documentation Survey Report and progress notes. The Assistant Director of Nursing (ADON) acknowledged that the resident's refusal to participate in the RNA program due to pain should have been addressed in a care plan. However, a care plan for noncompliance was only created on April 21, 2022, after a significant delay. The facility's policy and procedure required that individualized comprehensive care plans be developed and updated when there was a significant change in the resident's condition, which was not adhered to in this case.
Failure to Monitor Skin Condition
Penalty
Summary
The facility failed to thoroughly assess and monitor an elevated skin condition, described as a lump, on a resident's left posterior thigh according to the physician's order and the facility's Policy and Procedure (P&P). The resident was admitted with multiple diagnoses, including acute respiratory failure, metabolic encephalopathy, and a UTI. The physician's order required monitoring of the lump for pain, drainage, and increase in size every shift. However, the facility did not document measurements of the lump's size, which was necessary to determine any changes. Interviews with the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) confirmed that the required measurements were not taken, preventing staff from assessing whether the lump was increasing in size. The facility's P&P required a full wound assessment, including size and description, to be documented in the resident's clinical records, which was not done. This oversight had the potential to delay necessary treatment and worsen the resident's skin condition.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, leading to a deficiency in care. The resident, who was admitted with acute respiratory failure, metabolic encephalopathy, and a urinary tract infection, was noted to have complained of pain and refused to walk and stand with the Restorative Nursing Assistant (RNA) for several days. Despite the RNA reporting the resident's pain to the charge nurse, there was no documentation of a pain assessment being conducted by the Registered Nurse (RN) or any administration of the prescribed Norco medication for pain relief. The Assistant Director of Nursing (ADON) confirmed that the resident's progress notes and Medication Administration Record (MAR) did not indicate any pain assessment or administration of the prescribed pain medication. The facility's policy required a comprehensive pain assessment and documentation of interventions, which were not followed in this case. This oversight had the potential to impact the resident's activities of daily living and mobility due to unmanaged pain.
Delayed Physician Notification of Abnormal Urinalysis Results
Penalty
Summary
The facility failed to ensure timely notification to the physician for a resident's abnormal urinalysis results, leading to a delay in treatment for a urinary tract infection. The resident, who was admitted with diagnoses including acute respiratory failure, metabolic encephalopathy, and a UTI, had a urinalysis and culture ordered due to a change in condition. The urinalysis, collected and resulted on the same day, showed abnormal findings, but the physician was not notified until several days later. Interviews with the Infection Prevention Nurse and the Assistant Director of Nursing revealed that the urinalysis results were not promptly communicated to the physician, contrary to the facility's policy. The delay in notification was acknowledged by the ADON, who stated that the late reporting could lead to a delay in care and potential complications. The facility's policy required prompt notification of physicians in cases of acute illness or condition change, which was not adhered to in this instance.
Failure to Report Misappropriation of Funds
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not reporting the misappropriation of funds to the State Licensing Agency within two hours for one resident. Resident 2, who had a history of falling and was admitted with personal items including credit cards, experienced unauthorized charges totaling $2,286.57 over two billing periods. Despite being informed by the resident's family and the Ombudsman, the facility's staff, including the Administrator and the Director of Social Services, did not report the incident or investigate it promptly. The Director of Nursing was also unaware of the missing wallet and fraudulent charges. The facility's policy required immediate reporting of such incidents to local authorities, but this was not followed. The delay in reporting resulted in a delay in the investigation by the California Department of Public Health. The Director of Social Services admitted to not taking action because the report came from the Ombudsman and not directly from the resident or family members. This inaction led to a failure in addressing the misappropriation of Resident 2's funds in a timely manner, as required by the facility's abuse policy and procedure.
Failure to Investigate Unauthorized Charges on Resident's Credit Card
Penalty
Summary
The facility failed to conduct a thorough investigation after the Ombudsman reported unauthorized charges on a resident's credit card. Resident 2, who was admitted with a history of a left femur fracture, hypertension, and falls, had intact cognitive skills and required moderate assistance with daily activities. The resident's inventory list included personal items such as two cell phones, a charger, a wristwatch, clothing, dentures, and a wallet with identification, cards, and cash. Unauthorized charges totaling $928.18 and $1,358.39 were found on Resident 2's credit card statements for two different periods. Despite the Ombudsman notifying the facility's business office manager via email, the business manager was unaware of the issue, and the social worker and administrator did not investigate further or contact the resident or family members. The Director of Social Services admitted to receiving the email but did not act on it, assuming the Ombudsman would provide more information. The Director of Nursing was also unaware of the missing wallet and fraudulent charges and stated that a theft and loss report should have been opened and investigated by the administrator and social worker. Family member 1 reported the missing credit cards and cash to the administrator, who promised to investigate but did not follow through. The family member also left several voicemails for the social worker, which were not returned, leading them to report the issue to the Ombudsman. The Ombudsman confirmed sending two emails to the facility inquiring about an official investigation but received no response. The facility's policy on investigating theft and misappropriation of resident property, dated December 2006, mandates prompt and thorough investigations of such reports, which was not followed in this case.
Failure to Document Restorative Nursing Services
Penalty
Summary
The facility failed to accurately document the provision of Restorative Nursing Assistant (RNA) services for three residents, which had the potential to negatively affect their care. Resident 1, who was admitted with diagnoses including respiratory failure and hemiplegia, had physician orders for RNA to provide Active Assistance Range of Motion (AAROM) to both legs five times a week. However, there was no documentation of RNA services on several dates in April and May 2024. During an interview, Resident 1 confirmed receiving RNA services, but the RNA admitted that documentation was sometimes incomplete due to assisting as a Certified Nurse Assistant (CNA). The Director of Nursing (DON) emphasized the importance of consistent documentation for patient well-being. Resident 5, admitted with osteoarthritis and muscle weakness, had orders for RNA to ambulate using a platform walker and perform Active Range of Motion (AROM) to both arms five times a week. Similar to Resident 1, there was no documentation of RNA services on multiple dates in April and May 2024. Resident 5 confirmed receiving RNA services and noted improvements in mobility. However, the RNA responsible for documentation admitted to using a phone for documentation, which did not reflect on the RNA sheets. Resident 6, who had diagnoses including contracture of the right hand and major depressive disorder, had orders for RNA to provide AAROM to both arms, passive range of motion (PROM) to the right wrist and fingers, and apply a wrist hand splint. Again, there was no documentation of RNA services on several dates in April and May 2024. Resident 6 confirmed receiving RNA services and showed improvement. The facility's policy and procedure for charting and documentation emphasized the need for complete and accurate records to facilitate communication between the interdisciplinary team. The DON reiterated that lack of documentation could be interpreted as services not being provided as ordered.
Failure to Report Abuse Incident Timely
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) titled, Abuse Reporting and Investigation, which required all allegations of abuse to be reported to the California Department of Public Health (CDPH) within 2 hours. This failure was observed in the case of two residents, where Resident 1 threw water towards Resident 4. Despite the incident being reported to a Licensed Vocational Nurse (LVN) by a Certified Nursing Assistant (CNA), the LVN did not report the incident to the CDPH, believing it was not physical abuse. The Director of Nursing (DON) was unaware of the incident until much later and confirmed that any kind of abuse should have been reported immediately to the CDPH. Resident 1, who had a history of respiratory failure, hemiplegia, and hemiparesis following a stroke, admitted to throwing water at Resident 4 due to being upset by the noise of the curtain. Resident 4, who had diagnoses including traumatic subdural hemorrhage and muscle weakness, was unable to understand or make medical decisions. The incident was not reported to the CDPH within the required timeframe, leading to a potential delay in the investigation and underreporting of abuse incidents.
Failure to Investigate and Separate Residents After Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and separate two residents after one resident reported throwing water at the other. Resident 1, who has a history of respiratory failure, hemiplegia, and hemiparesis, admitted to throwing water at Resident 4 because of the noise from the curtain. Despite this admission, the incident was not reported or investigated by the Licensed Vocational Nurse (LVN) who was informed of the event. The LVN did not consider the act as physical abuse and did not take further action. Resident 4, who has a history of traumatic subdural hemorrhage and muscle weakness, was not separated from Resident 1 following the incident. The Director of Nursing (DON) was unaware of the incident until much later and only initiated an investigation and room change after being informed. The facility's policy requires thorough investigation and separation of residents involved in alleged abuse, which was not followed in this case.
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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 Gardena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardena Convalescent Center | 0.2 mi | ★★★★★ | 16 | 0 |
| Rosecrans Care Center | 0.5 mi | ★★★★★ | 6 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 0.6 mi | ★★★★★ | 13 | 0 |
| Clear View Convalescent Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Clear View Sanitarium | 0.7 mi | ★★★★★ | 10 | 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.