Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 La Paz Geropsychiatric Center during CMS and state inspections, most recent first.
A resident with schizophrenia, depression, and impaired decision-making received PRN Zyprexa IM with Benadryl for banging on doors and severe agitation without documented informed consent. An LVN administered the medication but did not verify consent, and the ADON confirmed there was no evidence of an informed consent form for the psychotropic order.
Failure to document PRN Zyprexa and Benadryl administration: A resident with schizophrenia, movement disorder, and major depressive disorder became physically aggressive and was given IM olanzapine and diphenhydramine after the physician was notified, but the MAR did not show the meds were administered and the e-kit log did not show removal of the doses. The RNS said she gave the injections and documented them in progress notes, while the ADON confirmed the MAR was missing the administration record.
A resident with schizophrenia, severe cognitive impairment, and delusions pushed another resident from a wheelchair after a loud verbal exchange was heard by an LVN, who observed the push in a safety mirror but was not close enough to intervene or redirect them. Shortly afterward, the same resident, who had admitted feeling angry and hearing voices during an interview with the Clinical Director and Social Worker, was left unsupervised in a shared room with a roommate who had schizoaffective disorder and visual conditions. While staff stood outside the room, the roommate reported being punched in the face and nose after the first resident pulled back the curtain between their beds. The facility relied on a single zone monitor and had policies requiring visual supervision, redirection of high-risk residents, and prevention of abuse, but these were not effectively carried out, resulting in two resident-to-resident physical abuse incidents.
Two residents with schizophrenia and intact cognition exhibited escalating aggressive and confrontational behaviors, including verbal abuse, noncompliance with medications, physical altercations with another resident, and a documented moderate risk for aggression. Despite these behaviors and existing orders for frequent safety checks, staff confirmed that no individualized, person-centered care plans were developed or updated to address the residents’ aggressive behaviors, define specific interventions, or establish measurable goals and monitoring parameters, contrary to facility policy and assessment findings.
A CNA pre-charted Q15 safety observations for multiple residents by recording future time slots after an earlier round, and later backfilled missed observation times for another resident based on a single hallway encounter rather than direct checks at the scheduled intervals. The CNA did not notify other staff when unable to locate a resident at required times and completed the 24-hour observation checklist entries despite not performing the actual observations. Facility leadership and an RN confirmed that this practice violated policies requiring real-time, factual documentation only after direct observation and prohibiting pre-charting or documenting events that did not occur.
Two residents with behavioral health diagnoses engaged in physical altercations with peers, resulting in injuries, after staff failed to follow care plan interventions and did not intervene before escalation. In one case, a resident was pushed and held down during a group activity, and in another, a resident was struck and scratched by her roommate. Facility policies prohibiting abuse were not effectively implemented.
Failure to Monitor Weight and Report Repeated Meal Refusals: A resident with schizoaffective disorder, MDD, constipation, and GERD had no recorded weights for several months despite a monthly weight order, while meal records showed repeated refusals of breakfast, lunch, and dinner. Staff did not promptly notify the MD or RD of the poor intake, and the resident’s weight loss was not identified until after hospitalization, when the resident was found to have lost 37 lbs. and had failure to thrive, altered mental status, hypernatremia, and hypokalemia.
A Dietary Aide was observed in the kitchen food prep area holding a cup with a straw and not wearing a hairnet before entering the area. She stated she had just walked in and then put on a hairnet and washed her hands after being approached. The DFS confirmed that staff entering the kitchen were required to wear hairnets and wash hands before entering the food prep area, and the facility policy required food service staff to wear an approved hair restraint and hairnets when assembling meals or snacks.
Failure to Protect Resident Privacy and Dignity: A resident was found without a privacy curtain in the room, and two other residents received medications while the privacy curtain was left open during med pass. The residents had diagnoses including mental health conditions and DM, and staff interviews confirmed that privacy curtains were important to protect resident privacy and rights.
Missing and Lapsed Psychotropic Medication Consent: The facility did not obtain informed consent before starting psychotropic medications for three residents, including residents with diagnoses such as schizoaffective disorder, schizophrenia, anxiety, depression, and dementia-related conditions. Staff stated the residents or their conservators were not informed of risks and benefits before the medications began. For another resident, the chart contained only older or unclear consent documents that did not match the current Lexapro, olanzapine, and Depakote doses, and the DON stated the consent was lapsed when doses changed.
Failure to notify the LTC Ombudsman of resident transfers and discharge. The facility did not document Ombudsman notification for two residents transferred to GACH and one resident discharged from the facility. Records showed the residents had psychiatric diagnoses, and staff interviews confirmed the Ombudsman was not consistently notified even though facility policy required notification of the resident, representative if applicable, and the LTC Ombudsman for facility-initiated transfers and discharges.
The facility failed to document required signatures on medication donation and controlled medication disposal records. A review of donation logs showed only one licensed nurse signature for donated noncontrolled psychotropic medications, even though policy required two licensed staff signatures. A review of controlled drug records for medications such as lorazepam, zolpidem, and temazepam showed the DON destroyed the medications without the pharmacist present and without the required pharmacist and RN signatures on the disposal records.
The facility failed to follow infection control practices in several areas. A laundry aide handled clean linens without hand hygiene, and laundry staff did not maintain a washer temperature log or ensure the water heater was functioning before using the washers. During med pass, an LPN did not wash hands after checking a resident’s BG and before giving insulin, did not disinfect the BG monitor after use, and another LPN used the resident BG monitor for personal use. Staff also did not clean or disinfect medication cart counters between residents, and a resident’s privacy curtain was observed touching the floor.
A social worker did not properly report or investigate incidents of inappropriate sexual behavior between residents, assuming nursing staff would handle the reporting. Despite being a mandated reporter, the social worker failed to complete required abuse reports or notify authorities, and the facility did not follow its abuse prevention and reporting policy. Staff interviews confirmed that mandated procedures were not followed and residents were not monitored after the incidents.
Failure to Notify Physician of Suicidal Ideation: An LVN heard a resident with schizoaffective disorder and dementia state that she wanted to die, but the physician was not notified and there was no documentation of notification. The DON stated suicidal ideation required immediate physician notification, and the facility policy required the licensed nurse to promptly inform the provider of sudden or marked changes in emotional or behavioral condition.
A resident with schizophrenia, DM, cataract, and a mood disorder was observed in a shared bathroom with a peeling baseboard, and the resident reported that a shower room had inadequate water flow and weak pressure. Staff later observed the shower water not flowing adequately and acknowledged the peeling baseboard in the shared bathroom. Housekeeping and the HS stated the condition could create a hazardous situation and that such issues should be reported to maintenance.
A facility failed to monitor psychotropic medication use for two residents. One resident prescribed Abilify and Haldol for behaviors had no documented monitoring of target behaviors, and another resident prescribed Zyprexa for psychosis had no documented monitoring of side effects. The RNS confirmed the gaps, and the DON stated behavior and side effect monitoring must be done for all psychotropic medications per facility policy.
The facility failed to develop individualized care plans with measurable goals, time frames, and interventions for two residents. One resident with schizophrenia, anxiety, and HTN had right hip pain and repeatedly refused PT, dentistry, optometry, and an ordered hip X-ray, yet no care plan addressed the pain or refusals. Another resident with schizoaffective disorder, dementia, DM, and HTN stated she wanted to die, but no comprehensive care plan was initiated or revised to address the suicidal ideation. Staff and the DON acknowledged the missing care plans.
Failure to Provide Meaningful Activities and Room Visits: A resident with anxiety, schizoaffective disorder, and muscle weakness was observed lying quietly in bed and stated that no one had offered in-room activities he enjoys. He preferred room-based activities because group activities were too cold and noisy. The AD could not find recent documentation of activities offered or refused, and the last activity note was dated months earlier; the DON stated activities should be encouraged for all residents and refusals documented.
Failure to monitor and address constipation for a resident at risk for hard stool formation related to psychotropic medications. The resident went four consecutive days without a BM on two separate occasions, and the chart showed no documented follow-up by the LVN or RN when no BM was recorded for more than two days. The DON stated bowel movements should be monitored daily and that lack of monitoring can lead to abdominal discomfort, distention, and bowel obstruction.
A resident with muscle weakness and physician-ordered RNA exercises did not receive ordered ROM services when the RNA misread the order and believed it had been discontinued. The RNA flow sheet for the day was unsigned and undocumented, and the RNA stated she missed the active order. The DON stated RNAs were expected to follow physician orders accurately and document tasks immediately after completion.
A resident’s privacy curtain was not fully attached to the curtain rack, with five hooks missing and the curtain hanging on the floor. The resident said it had been that way for six months. CNA, LVN, and DON interviews confirmed the curtain should not be touching the floor, and the resident’s record showed schizophrenia, anxiety, insomnia, intact cognition, and independence with ADLs.
Inadequate Pain Medication Administration: A resident with schizophrenia, anxiety, bilateral knee OA, and intact cognition had a care plan for pain control and an order for Tylenol PRN only for mild pain rated 1 to 3. Staff observed the resident complaining of bilateral knee pain, yet the MAR showed Tylenol was given when pain was rated 4 and 5. An LPN stated the medication would not be effective at those pain levels, and the DON stated the nurse should have contacted the physician for additional pain treatment.
The facility failed to ensure an LVN received required in-service training on physician notification, weight loss, nutrition, and hydration. The LVN stated she had not received training on weight loss, nutrition, or hydration and could not recall training on physician notification, while record review showed the in-service sign-in sheets did not document her attendance or required identifying information. The DON stated staff who missed the in-services were emailed to attend when they returned to work, and stated the LVN would not know how to proceed with implementing resident care without attending the trainings.
Nursing staffing hours were not posted in a visible area for residents and the public. The Daily Schedule posted near the nursing station was updated with call offs and add ons, but it did not show actual hours worked or get updated throughout the day. The DON confirmed the form did not include actual nursing hours worked, and the facility policy did not address actual hours worked.
QAPI oversight failed to address abuse reporting and weight loss monitoring. A resident reported that another resident touched her inappropriately after admission, and the allegation was not reported to CDPH until after the surveyor spoke with the ADM. Surveyors also found significant weight loss in another resident; the CD said at-risk residents were tracked through weekly meetings and weights, but the DON stated this resident was not identified due to a staff competency problem.
Failure to protect a resident from sexual abuse: A resident with schizoaffective disorder reported that another resident touched her hips and buttocks in the hallway after admission. The other resident had documented inappropriate sexual behaviors, including exposing himself, kissing a female resident, touching a female resident's buttock, and making inappropriate sexual comments toward staff and residents. Staff interviews confirmed awareness of his behavior, and his care plan reflected a history of sexual acting out and aggression.
Excessive Room Occupancy: The facility failed to ensure resident bedrooms did not exceed the maximum occupancy allowed. A record review showed Rooms 12, 13, 20, and 21 each housed six residents, and additional rooms housed five residents each. Surveyors observed no noted concerns with space, privacy, care, or safety in the affected rooms, and the DON stated there were no complaints from residents in those rooms. The facility policy stated no more than four residents shall be accommodated in one room.
A female resident with a history of depression and schizophrenia, who was cognitively intact, experienced a loss of privacy and dignity when a male resident with severe cognitive impairment and poor impulse control entered the restroom while she was urinating. The incident left the resident feeling embarrassed and violated, and the DON confirmed that such events compromise resident dignity.
A resident with a history of severe cognitive impairment and aggressive behavior entered another resident's bathroom while she was using it and punched her in the face after a struggle over a trash can, causing pain and emotional distress. The aggressive resident was known to wander and had previously threatened staff and entered other residents' rooms, yet was unsupervised at the time of the incident.
A male resident with severe cognitive impairment and a history of wandering and poor impulse control entered an occupied female restroom, exposing and physically assaulting a female resident. Staff were not present in the hallway to supervise or prevent the incident, despite facility policy requiring increased observation for residents with aggressive behaviors.
Two residents in an LTC facility experienced delays in receiving Tamiflu due to a medication shortage. The staff failed to notify the physician about the unavailability of the medication, which was intended to treat symptomatic influenza. The facility's policies require resolving medication concerns with the provider, but this was not documented or followed, potentially delaying medical interventions.
The facility failed to implement care plans for several residents by not monitoring vital signs every four hours as required. A resident with respiratory issues and others with similar conditions had care plans that included frequent monitoring due to Influenza, but records showed inconsistencies in following these plans. The DON confirmed the lack of adherence to the care plans, which were meant to ensure proper monitoring and care.
Two residents experienced a delay in receiving Tamiflu due to a medication shortage at the facility. Despite orders being placed, the medication was not administered until days later, as the pharmacy ran out of stock. The facility's policy for timely antiviral treatment was not followed, leading to potential increased flu cases.
The facility failed to enforce its influenza outbreak policy by not retesting contaminated samples and delaying the reorder of test kits for two symptomatic residents. Resident 5 and Resident 4, both with respiratory conditions, had contaminated tests on 12/27/2024 and were confirmed positive for Influenza A on 12/30/2024. The delay in retesting and reordering test kits compromised the facility's infection prevention and control program, as acknowledged by the IPN and ADON. Staff interviews revealed a lack of clarity and communication regarding the retesting process and test kit availability.
The facility failed to honor the rights of nine residents who were smokers by not allowing them to continue smoking in designated areas, as per the facility's policy. Despite the policy stating that current residents should be allowed to smoke, the facility prohibited smoking, affecting residents' quality of life. Some residents expressed dissatisfaction, and the facility did not provide nicotine replacement therapy to all who requested it or monitor withdrawal symptoms.
The facility failed to maintain proper food safety and sanitation practices, as expired bagels were found on shelves, and the kitchen floor had food crumbs and dirt buildup. Additionally, a drain face plate used for multiple kitchen equipment was observed with a slimy black substance. These lapses were acknowledged by the Dietary Supervisor, Infection Preventionist, and Administrator, who noted the potential health risks to residents.
The facility's QAPI program failed to oversee and implement corrective actions for deficiencies in abuse reporting and smoking cessation. An LVN did not report an abuse allegation between two residents, and the facility did not address smoking cessation properly, leading to potential withdrawal symptoms among residents. These failures resulted in repeated deficiencies.
The facility staff failed to ensure call lights were within reach for three residents, each requiring assistance with daily activities. Observations showed call lights on the floor or behind beds, preventing residents from calling for help. Interviews with CNAs highlighted potential frustration and increased fall risk due to this deficiency.
Two residents experiencing tremors affecting their ADLs were not properly monitored or reported to their physicians, as required by facility policy. Despite observations of tremors impacting daily activities, such as eating and writing, the staff failed to document these episodes and notify the physicians, leading to a deficiency in care.
The facility failed to provide individualized activities for three residents, impacting their mental and psychosocial well-being. Despite having no cognitive impairments, the residents were observed sleeping in bed during multiple observations, with no documentation of activities conducted. Staff interviews highlighted the importance of activities for psychological well-being, yet the facility's activity notes lacked evidence of engagement, indicating a failure to implement the facility's policy on program activities.
The facility failed to ensure that three CNAs completed their mandatory dementia and sexual harassment training. The Director of Staff Development lacked an effective tracking system, leading to incomplete training, which posed a potential risk to resident safety.
A resident with schizoaffective disorder and schizophrenia physically assaulted another resident, causing a small cut on the forehead, due to inadequate monitoring and intervention by the facility. Despite known behavioral issues, staff failed to de-escalate the situation, leading to the incident.
A resident with schizoaffective disorder, anxiety, and major depressive disorder did not have a comprehensive care plan addressing these conditions. The facility's ADON/IPN and DON confirmed the omission, acknowledging the need for a care plan to guide staff in providing necessary care. The facility's policy required addressing co-occurring disorders, which was not adhered to.
A resident's care plan for vision was not updated to reflect a diagnosis of cataracts, despite an ophthalmology report confirming the condition. The care plan continued to address suspected glaucoma, which was no longer applicable. Facility staff acknowledged the oversight, noting that the care plan should have been revised to ensure appropriate care and interventions.
The facility's Director of Staff Development (DSD) failed to manage the online education program effectively, resulting in incomplete mandatory training for several CNAs. The DSD lacked training on generating reports to verify staff training completion, leading to significant gaps in required dementia and sexual harassment training. The Administrator confirmed the DSD's responsibility for maintaining the education department, but an ineffective tracking system contributed to the oversight.
A resident was prescribed antibiotics without obtaining necessary cultures or blood tests, contrary to the facility's Antibiotic Stewardship protocol. The resident, who did not meet the criteria for a cellulitis skin infection, was given Bactrim and doxycycline without diagnostic procedures to identify the bacteria being treated. The facility's policy emphasizes evidence-based guidelines and review of culture reports, which were not followed, leading to inappropriate antibiotic use.
The facility was found to be non-compliant with regulations limiting the number of residents per room, as several rooms accommodated more residents than allowed. Despite this, no concerns with privacy, safety, or care were observed, and the Administrator reported no complaints from residents.
A resident with schizophrenia and anxiety was stabbed on the right index finger by another resident with schizophrenia and hearing loss, resulting in a one-inch cut. Both residents were alert and oriented, with varying levels of assistance needed for daily activities. The facility's policy prohibits mistreatment, but the incident occurred, and the reason for the abuse was not established.
The facility failed to protect residents from abuse, resulting in two incidents where residents were physically assaulted by others. A resident with schizophrenia and anxiety disorder exhibited hallucinations and delusions but was not reported to a physician, leading to an assault on another resident. Similarly, another resident with severe cognitive impairment showed agitation and mood swings, which were not communicated to a physician, resulting in an attack on a fellow resident. The facility did not adhere to its policies on abuse prevention and physician notification.
Informed consent not obtained before PRN Zyprexa administration
Penalty
Summary
The facility failed to obtain informed consent for one resident before administering Zyprexa (olanzapine) intramuscularly for banging on doors and severe agitation. The resident was admitted with diagnoses including schizophrenia, extrapyramidal and movement disorder, and major depressive disorder. A psychiatric progress note dated 4/6/2026 described the resident as alert and oriented to person, place, and situation with mild confusion, but with impaired insight and judgment due to ongoing psychotic symptoms. The MDS dated 3/26/2026 indicated moderate impairment in the ability to think or make decisions. On 5/18/2026, the resident was observed banging and punching the entrance double door and displaying physical aggression while attempting to hit staff during redirection. The resident received olanzapine 10 mg intramuscularly with Benadryl 50 mg. The MAR showed the dose was administered that day, and the physician's order for Zyprexa and diphenhydramine had been started on 5/5/2026 for banging on doors and severe agitation, to be given as needed. During interview, the LVN stated she administered the medication during the incident but did not get a chance to verify whether informed consent for Zyprexa had been obtained. The ADON reviewed the resident's informed consents and stated there was no evidence that staff obtained an informed consent document for the Zyprexa order. The facility policy stated that every person served received information from the prescriber regarding psychoactive medications and that informed consent was to be documented and signed by the resident or legal guardian as applicable.
Failure to Document PRN Antipsychotic and Antihistamine Administration
Penalty
Summary
The facility failed to ensure that Resident 3’s PRN Zyprexa (olanzapine) and Benadryl (diphenhydramine) administration was documented on 5/5/2026. Resident 3 was admitted with diagnoses including schizophrenia, extrapyramidal and movement disorder, and major depressive disorder. Psychiatric progress notes dated 4/6/2026 described the resident as alert and oriented to person, place, and situation with mild confusion, and noted impaired insight and judgment due to ongoing psychotic symptoms. The MDS dated 3/26/2026 indicated moderate impairment in the ability to think or make decisions and that the resident required staff supervision with personal hygiene and setup assistance with showering. Progress notes dated 5/5/2026 documented that Resident 3 was banging and kicking on a door near the room, was not redirectable, became physically aggressive, and attempted to strike and push staff. The physician was notified and PRN orders for Zyprexa and Benadryl were received, noted, and administered. However, the MAR for 5/2026 did not show that the medications were given on 5/5/2026, and the e-kit log also did not show that the medications were removed from the emergency kit. During interview, the RNS stated she administered the IM dose and documented it in progress notes, while the ADON confirmed the MAR did not reflect the administration.
Failure to Prevent and Supervise Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by not effectively intervening and supervising a resident with known unpredictable, impulsive behaviors. Resident 1, who had schizophrenia, anxiety, major depressive disorder, severely impaired cognition, and delusions, was newly readmitted and dependent on staff for several activities of daily living. On the date of the incident, LVN 1 heard a loud verbal exchange between Resident 1 and Resident 2, who also had schizophrenia, anxiety, major depressive disorder, and moderately impaired cognition. LVN 1 looked into a security mirror and saw Resident 1 standing near Resident 2, who was seated in a wheelchair, place her hand on Resident 2’s back and then push Resident 2 out of the wheelchair and onto the floor. LVN 1 stated she was not within arm’s reach or in the residents’ line of sight and could not reach them in time to redirect or deescalate the situation, and she did not recall any other staff nearby who could have intervened. Following this altercation, Resident 1 was interviewed in her shared room by the Clinical Director, LVN 1, and the Social Worker. During the interview, Resident 1, using a phone translator, stated she pushed Resident 2 because she was angry and admitted to hearing voices at that time. The Clinical Director observed Resident 1 responding to internal stimuli and appearing agitated. After the interview, the Clinical Director, LVN 1, and the Social Worker stepped out of the room to discuss next steps, leaving Resident 1 unsupervised in the room with her roommate, Resident 3. Resident 3 had schizoaffective disorder, cataracts, blepharochalasis, and intact cognition. While the staff were standing outside the room, Resident 3 yelled that Resident 1 had hit her. Resident 3 later reported that Resident 1 pulled open the curtain between their beds and reached out to punch her in the face and nose. The Clinical Director stated she saw Resident 1 backing into the hallway with her fists clenched, followed by Resident 3, who reported being hit. The facility’s Summary Investigative Report documented that LVN 1 had witnessed Resident 1 push Resident 2 out of her wheelchair, unprovoked, via the safety mirror, and that shortly after this incident, Resident 3 reported being struck in the face by Resident 1. The Administrator stated the facility used a single zone monitor to patrol the building, redirect residents, and track their whereabouts, and acknowledged that to effectively redirect residents to safety, staff needed to be physically close enough to prevent altercations. The facility’s policies on Zone Management, Residents’ Rights, and Abuse Prevention and Reporting emphasized visual supervision, redirection of high-risk residents, intervention in verbal altercations, and residents’ right to be free from abuse, which were not effectively implemented in these events.
Failure to Develop and Update Person-Centered Care Plans for Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop and update person-centered care plans addressing aggressive behaviors for two residents following admission and readmission. For Resident 1, who had diagnoses including schizophrenia and bipolar disorder and was cognitively intact, the facility readmitted the resident from a general acute care hospital with aggressive behavior identified as a primary concern. Progress notes from 2/6/2026 through 2/8/2026 documented hyperverbal and aggressive behavior, including yelling, pulling down a privacy curtain, refusing oral medications, throwing medications on the floor, refusing an EKG, being verbally abusive and loud to staff and peers, spitting at a peer on the patio, pacing in the hallway while cursing at staff and other residents, and exhibiting intermittent demanding behavior. An order was in place for safety precautions every 15 minutes for 48 hours related to the readmission, and staff interviews confirmed that Resident 1’s behaviors were more severe than in previous admissions and that no care plan was developed or updated to address these increased aggressive behaviors prior to an altercation with another resident. The report further notes that Resident 1 was involved in an incident with another resident (Resident 2), who had diagnoses including schizophrenia and convulsions and was cognitively intact, requiring only setup or cleanup assistance for some ADLs and being independent in eating and toileting hygiene. A post-event assessment documented that a CNA witnessed Resident 1 grabbing Resident 2’s wrists during an altercation. Interviews with nursing staff, including an RN and a CNA, confirmed that Resident 1 had exhibited worsening verbal aggression and demanding behaviors in the days leading up to this incident and that the required person-centered care plan upon readmission, which should guide staff in managing such behaviors, had not been developed or updated. For Resident 6, who had paranoid schizophrenia, intact cognition, and independence in ADLs, psychiatric progress notes dated 1/21/2026 documented that the resident remained oppositional, verbally confrontational with staff, and at moderate risk for aggressive behavior. Staff interviews indicated that this resident was known to be combative and required careful approaches due to safety concerns, and that the resident had a history of aggressive and assaultive behaviors that could result in physical harm to other residents, including neighbors. Despite this, there was no specific care plan developed or updated to address, monitor, or prevent potential future assaultive behaviors. The MDS Coordinator stated that a specific care plan with measurable goals, clearly defined interventions, monitoring parameters, and direction for notifying the physician should have been in place, consistent with the facility’s policy requiring individualized, measurable, resident-centered care plans for behavioral problems.
Inaccurate Q15 Safety Observation Documentation by CNA
Penalty
Summary
The deficiency involves inaccurate and incomplete maintenance of 24-hour observation checklists for residents on every-15-minute safety monitoring. On one date, a CNA documented the 10:00 a.m. and 10:15 a.m. observations for three residents in advance of the scheduled times, after conducting rounds at approximately 9:45 a.m. The CNA acknowledged that documentation was entered before directly observing the residents at the required times. For another resident, the same CNA initially left the 9:45 a.m. and 10:00 a.m. observation entries blank because the resident was not observed at those times. On the following day, review of that resident’s checklist showed that the CNA later completed the previously blank 9:45 a.m. and 10:00 a.m. entries after seeing the resident at approximately 10:14 a.m. in the hallway, despite not having observed the resident at the scheduled times. The CNA stated she had attempted but was unable to locate the resident earlier and did not notify other staff, and that she filled in the missed times because she believed the form could not be left blank. The DSD and an RN stated that staff must directly observe residents before documenting, that pre-charting or documenting without direct observation is not acceptable and may be considered false charting, and that documentation must be accurate, timely, and reflect actual observations in accordance with facility policies on levels of observation and general documentation guidelines.
Failure to Protect Residents from Physical Abuse and Implement Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from physical abuse and did not ensure the implementation of care plan interventions for residents with known behavioral issues. In one incident, a resident with a history of psychotic behavior, verbal aggression, and intrusiveness became agitated during a group activity after another resident blew his nose nearby. The agitated resident expressed discomfort, stood up, and physically pushed the other resident back onto the couch, holding his arm down and verbally instructing him to stop. Staff did not intervene before the situation escalated, and the Rehabilitation Activity Leader left the two residents alone to seek help, during which time the altercation continued. The care plan for the resident with behavioral issues specifically required staff to intervene before agitation escalated, guide the resident away from the source of distress, and engage in calm conversation, but these interventions were not followed. Another incident involved a resident being physically assaulted by her roommate, who grabbed her breast and hit her in the face, resulting in a four-centimeter scratch on the left side of her face. The aggressor admitted to the action, expressing a delusional belief that the other resident had stolen her breast. The incident was discovered by a CNA, who observed the injury and blood on the resident's gown. The residents had no prior history of altercations, and both required varying levels of assistance with activities of daily living due to mental health diagnoses such as schizoaffective disorder and major depressive disorder. The facility's policy on abuse prevention and reporting prohibits any form of mistreatment, including abuse and neglect, and requires timely investigation and reporting of all allegations. Despite these policies, the facility failed to prevent physical altercations between residents and did not ensure staff followed established care plans and interventions designed to de-escalate potentially aggressive behaviors. These failures resulted in residents sustaining physical harm and not being protected from abuse as required.
Failure to Monitor Weight and Report Repeated Meal Refusals
Penalty
Summary
The facility failed to ensure a resident with schizoaffective disorder, major depressive disorder, constipation, and GERD was weighed as ordered and monitored for significant weight loss. The resident’s record showed a weight of 154.6 lbs. on 4/26/2025, but no weight was recorded from 5/2025 through 8/2025 despite a physician order to weigh monthly. The RD documented on 6/27/2025 that the resident mostly ate snacks, drank Ensure twice daily, and had repeatedly refused to be weighed, with a goal to maintain a stable weight of 155 lbs. and interventions to monitor oral intake and monthly weight trends. Meal intake records showed repeated refusals of breakfast, lunch, and dinner. From 6/23/2025 through 8/31/2025, the resident refused meals 50 times, and from 9/1/2025 through 9/11/2025, the resident refused all daily meals except one dinner on 9/2/2025. Progress notes documented refusal to go to the dining room, refusal to eat when the tray was brought to the room, and continued refusal of breakfast, lunch, and dinner. On 9/11/2025, the resident was described as disorganized, disheveled, isolated, argumentative, and combative, and was sent to the GACH for further evaluation due to a change in condition. The resident’s weight loss was not identified until 9/19/2025, when the resident weighed 117 lbs., reflecting a loss of 37 lbs. over five months. The MDS after return from the hospital indicated the resident had lost 5% or more in the last month or 10% or more in the last six months. Staff interviews confirmed that meal refusals were not reported promptly to the charge nurse, physician, or RD, and that the resident’s weight had not been monitored before hospitalization. The GACH records documented failure to thrive, altered mental status, hypernatremia, hypokalemia, and elevated CK, and the resident received potassium chloride and a normal saline bolus.
Improper Hand Hygiene and Hair Restraint Use in Food Prep Area
Penalty
Summary
The facility failed to ensure proper food handling practices were followed when a Dietary Aide was observed in the kitchen food preparation area holding a cup with a straw and not wearing a hairnet. During the tray line observation, the Dietary Aide stated that she had just walked in and then immediately put on a hairnet and washed her hands after being approached by the surveyor. During interview, the Dietary Aide stated she was aware of the requirement to wear a hairnet and wash her hands before entering the kitchen, and said she made a mistake by not following the protocol. The Director of Food Services stated that all staff entering the kitchen were required to wear hairnets or hair coverings and wash their hands before entering the food preparation area, and that failure to follow proper hand hygiene can lead to food contamination. Review of the facility policy titled Uniform Dress Code showed that food service staff must wear an approved hair restraint and wear hairnets when assembling a meal or snack.
Failure to Protect Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when Resident 55 did not have a privacy curtain in the room. Resident 55 was admitted with diagnoses including schizoaffective disorder, bipolar type, antisocial personality disorder, and diabetes mellitus. The MDS dated 7/17/2025 indicated Resident 55 had intact cognition and was independent with oral hygiene, toileting hygiene, dressing, bed mobility, and transfer from a bed to a chair. During an observation and interview on 10/21/2025, Resident 55 was lying in bed and there was no privacy curtain hanging in the room. Resident 55 stated he would like to have a curtain in the room so he could have privacy. The facility also failed to close privacy curtains during medication administration for Resident 41 and Resident 134 while both residents were in the same room. Resident 41 had diagnoses including insomnia, major depressive disorder, and anxiety disorder, and was observed receiving gabapentin 400 mg without the privacy curtain being closed while Resident 134 was also present. Resident 134 had diagnoses including schizoaffective disorder, bipolar type, type 2 diabetes mellitus, and major depressive disorder, and was observed receiving gabapentin 600 mg, metformin 850 mg, and ziprasidone 80 mg without the privacy curtain being closed while Resident 41 was also in the room. During interviews, CNA 6 stated privacy curtains were important to ensure privacy and that Resident 55 would feel bad without one because it was a resident right to have privacy. HSK 1 and the Housekeeping Supervisor stated missing privacy curtains should be reported to Maintenance. LVN 3 stated it was important to close privacy curtains during medication administration to provide privacy, and the DON stated nursing staff should pull the privacy curtain during medication pass to provide privacy and protect residents' rights. The facility policy titled Residents' Rights stated the facility will treat each resident with respect and dignity and provide an environment that will maintain and enhance quality of life.
Missing and Lapsed Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medications was obtained before starting treatment for Resident 2, Resident 8, and Resident 138. Resident 2’s record showed diagnoses including schizoaffective disorder, anxiety, and insomnia, with the MDS indicating severely impaired cognition and use of antipsychotic, antidepressant, and anticonvulsant medications. The active orders included Abilify, Depakote, fluoxetine, Haldol, and mirtazapine, all started on the same date. During interview, the RNS stated the residents were not notified about the risks and benefits of taking psychotropic medications and that neither the residents nor their conservators were informed before the medications were started. Resident 8’s record showed diagnoses including schizoaffective disorder, depression, and Alzheimer’s disease. The H&P described the resident as alert and oriented, while the MDS noted memory problems and use of antipsychotic, antidepressant, and anticonvulsant medications. The active medication list included Depakote, lithium, mirtazapine, Risperdal, and two Zyprexa orders, with psychotropic medications started on different dates. Resident 138’s record showed diagnoses including schizophrenia, anxiety, and insomnia, with the H&P describing the resident as alert and oriented and the MDS indicating intact cognition. The active orders included Abilify injection, Ativan, Depakote, Latuda, and zolpidem. The RNS and DON stated informed consent had not been completed for these residents before psychotropic medications were started, and the DON stated informed consent should be discussed prior to starting the medications and then every six months. The facility also failed to maintain current informed consent documentation for Resident 90’s psychotropic medications. Resident 90 had diagnoses including schizoaffective disorder, major depressive disorder, and unspecified dementia with anxiety, and the MDS indicated intact cognition. The resident was receiving Lexapro 10 mg, olanzapine 10 mg, and Depakote ER 750 mg daily, with MARs showing these medications were administered throughout multiple months. Staff could not initially locate the informed consent, and the available consent documents included an older consent for Lexapro 5 mg and olanzapine 10 mg, plus another scanned document that was difficult to read and appeared to list Lexapro 5 mg, olanzapine 10 mg, and Depakote 750 mg with a dose range. The DON stated that if the dose changed, a new informed consent was needed and that the prior consents would be considered lapsed.
Failure to Notify LTC Ombudsman of Transfers and Discharge
Penalty
Summary
The facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the LTC Ombudsman at the time of discharge or transfer for three sampled residents. The record review showed that Resident 2, who had diagnoses including schizoaffective disorder, anxiety, and insomnia, was admitted to GACH after a ventricular tachycardia event and later readmitted to the facility. Resident 6, who had diagnoses including schizophrenia, insomnia, and constipation, was sent to GACH for pneumonia and later readmitted to the facility. The facility’s policy stated that in cases of facility-initiated transfers and discharges, staff shall notify the resident, the designated representative if applicable, and the LTC Ombudsman. During interview, the ADON stated that when residents are admitted to GACH, the LTC Ombudsman needs to be notified, but the Ombudsman was not notified of Resident 2’s admission to GACH or Resident 6’s admission to GACH. The DON stated she was aware the LTC Ombudsman was not notified for these residents and confirmed the Ombudsman needs to be notified because they are the advocate for the residents. The DON also stated this could possibly be a violation of the residents’ rights. For Resident 154, who had diagnoses including schizophrenia and hypertension and whose cognition was intact, the record showed an order to discharge the resident and a progress note documenting discharge, but there was no indication the Ombudsman was notified. During interview, LVN 1 stated that part of the discharge process is to notify the Ombudsman and document it in a progress note, and after reviewing the record there was no indication this occurred. The RNS stated he was unsure if the Ombudsman is to be notified when a resident is discharged, while the DON stated the Ombudsman should be notified because they advocate for residents’ well-being and ensure the discharge is appropriate.
Missing Required Signatures on Medication Donation and Controlled Medication Disposal Records
Penalty
Summary
The facility failed to include signatures of two licensed nurses on medication donation records for 35 records reviewed across three sampled pages in the donation log. During a concurrent interview and record review, LVN 4 reviewed the medication donation records titled Medication Destruction Record and stated the records were for donated, noncontrolled psychiatric medications sent from the facility to another location. The records for August, September, and October 2025 showed only one licensed nurse signature, and LVN 4 stated the witness signature was missing. During interview, the DON stated one of the facility’s charge nurses handled the donation process and acknowledged that the donation form should have been corrected to reflect that it was a donation record rather than a destruction record. The DON also stated that, according to the facility’s donated medications policy, two licensed nurses’ signatures should have been documented. The facility’s P&P titled Donated Medications, dated 10/10/2024, required the donation log to include the name of the drug and signatures of two licensed staff. The facility also failed to ensure controlled medication disposition or destruction records included signatures of a pharmacist in addition to an RN or DON on six sampled records. During record review, six narcotic sheets for six residents with controlled medications, including lorazepam, zolpidem, and temazepam, were found without signatures showing disposition and without medication cards or containers attached. The DON stated she had destroyed the six controlled medications without waiting for the facility pharmacist to be present as a witness and that no witness was present. The facility’s P&P titled Accounting for Administered and Wasted Medications including Expired Medications, dated 6/11/2025, required controlled medication disposal to be completed by one RN and one pharmacist, with both signatures documented on the disposal log.
Infection Control Failures During Laundry, Medication Pass, and Resident Room Observation
Penalty
Summary
The facility failed to maintain infection control practices in the laundry room when a Laundry Aide unloaded the washer and handled clean linens without performing hand hygiene first. During the observation, the aide stated she should have washed her hands before handling the clean linens because not doing so could spread infection and germs. The Infection Prevention Nurse and the DON both stated that staff should wash their hands before handling clean linens to prevent cross contamination. The facility also failed to monitor laundry washing conditions as required. During observation, the Laundry Aide stated there was no washer temperature log, that she checked the washer water temperatures, and that she did not know whether the water temperature was hot enough to kill bacteria. She also stated the water heater was not working properly, the gauge read 78 degrees Fahrenheit, and she had not informed anyone. The Housekeeper Supervisor stated the aide should have reported the water heater problem and should not have been using the washers, and the Infection Prevention Nurse and DON stated a temperature log should be maintained to ensure the water was hot enough to kill germs. During medication administration, an LVN checked Resident 140's blood glucose, did not wash hands after the check and before administering insulin, and did not disinfect the blood glucose monitor after use. Resident 140 had type 2 DM and severely impaired cognition. Another LVN used the blood glucose monitor from the medication cart to check her own blood glucose because she was not feeling well, then put the monitor away without cleaning or disinfecting it. In addition, two LVNs were observed preparing medications for residents without cleaning or disinfecting the medication cart counter before, after, or between residents. The report also noted that Resident 138's privacy curtain was missing hooks and was touching the floor, and staff stated this was an infection control issue because germs from the floor could get on the curtain.
Failure to Train and Ensure Abuse Reporting by Social Worker
Penalty
Summary
The facility failed to ensure that a social worker received effective training on abuse reporting, specifically regarding the identification and reporting of inappropriate sexual behavior between residents. The deficiency was identified when a social worker did not properly report or investigate incidents involving a resident who engaged in inappropriate touching and kissing of two other residents. The social worker assumed that nursing staff would handle the reporting and did not complete the required abuse report or notify the appropriate authorities, despite being a mandated reporter. The residents involved had various mental health diagnoses, including schizoaffective disorder, paranoid schizophrenia, and anxiety, but were assessed as having clear comprehension and varying levels of independence in daily activities. The incidents included one resident tapping another on the buttocks and kissing a different resident, with staff intervening to separate the individuals. However, the required steps for abuse reporting and investigation were not followed, and the incidents were not reported to the administrator, ombudsman, or Department of Health as required by facility policy. Interviews with facility staff, including the Director of Nursing, confirmed that the abuse prevention and reporting policy was not followed. The facility's policy mandates immediate reporting and investigation of all alleged violations involving abuse, neglect, or mistreatment, but these procedures were not carried out. Additionally, the residents involved were not monitored following the incidents, and the lack of proper reporting and investigation was acknowledged by facility leadership.
Failure to Notify Physician of Suicidal Ideation
Penalty
Summary
The facility failed to notify the physician of a change in condition for one sampled resident after the resident verbalized suicidal ideations. Resident 117 was admitted with diagnoses including schizoaffective disorder bipolar type, dementia, diabetes mellitus, and hypertension. The resident’s H&P indicated impaired judgement and insight, and the MDS showed severely impaired cognition with the need for staff supervision for toileting hygiene, dressing, and eating. During observation on 10/22/2025, an LVN was in the resident’s room when Resident 117 stated in her primary language that she wanted to die. A review of the nursing notes showed no documentation that the physician was notified of the suicidal statement, and the RNS stated the physician was not notified during the morning shift. The DON stated she was not aware of the suicidal ideation and said such statements required immediate physician notification so the physician could adjust medication and determine the resident’s needs. The facility policy stated the licensed nurse is responsible for informing the physician or other prescriber of changes in emotional, behavioral, or physical condition and to promptly notify the appropriate provider of any sudden or marked adverse change in signs, symptoms, or behavior.
Unsafe Shower Water Flow and Peeling Bathroom Baseboard
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for a resident who was admitted with schizophrenia, diabetes mellitus, unspecified cataract, and a mood disorder. The resident’s MDS dated 8/30/2025 indicated intact cognition and independence with bathing or showering, dressing, toileting hygiene, and bed mobility. During observation and interview on 10/21/2025, the resident pointed out a shared bathroom with a peeling baseboard and stated that the shower head in one of the shower rooms was not flowing adequately and that the water pressure was not strong enough for a shower. The resident said she preferred a strong flow of water to ensure she was clean thoroughly after showering. During a later observation and interview with Maintenance Assistant in the shower room, the water in Shower room [ROOM NUMBER] was observed not flowing adequately, and the assistant stated he would replace and fix the shower. In a separate observation and interview in the resident’s shared bathroom, the peeling baseboard was again observed, and the Maintenance Assistant stated it would be fixed. Housekeeping staff and the Housekeeping Supervisor stated that peeling baseboard in a shared bathroom could create a hazardous situation and that housekeeping should notify maintenance about such issues. The facility policy titled Safe and Comfortable Environment stated that the facility would protect and promote residents’ rights to a safe, clean, comfortable, and homelike environment by keeping the building and equipment maintained in good repair.
Failure to Monitor Psychotropic Medication Behaviors and Side Effects
Penalty
Summary
The facility failed to ensure monitoring was completed for psychotropic medications for two residents. One resident was admitted with diagnoses including schizoaffective disorder, anxiety, and insomnia, and the record showed severe cognitive impairment and use of antipsychotic medication. That resident was prescribed Abilify 10 mg at night for attention seeking behaviors and striking out, and Haldol 200 mg at bedtime every 28 days for hyperverbal behavior and aggressiveness. During record review and interview, the RNS stated the resident’s targeted behaviors for these medications were not being monitored. A second resident was admitted with diagnoses including schizoaffective disorder, depression, and Alzheimer’s disease. The record showed memory problems and use of antipsychotic medication. That resident was prescribed Zyprexa 10 mg daily and Zyprexa 20 mg at bedtime for psychosis manifested by paranoid delusions and labile mood. During the concurrent interview and record review, the RNS stated the resident’s side effects for Zyprexa were not being monitored. The DON stated she was made aware that the targeted behavior monitoring for the first resident and the side effect monitoring for the second resident had not been done. The DON stated behavior monitoring and side effect monitoring must be done for all psychotropic medications because psychotropic medications have a lot of negative side effects, and the residents have the potential to be come over medicated and could possibly isolate themselves in their rooms. Facility policies stated licensed nurses will monitor psychotropic medication side effects every shift and that behavioral parameters or target behaviors will be established, monitored, and documented for each antipsychotic medication.
Failure to Develop Care Plans for Pain, Refusal of Care, and Suicidal Ideation
Penalty
Summary
The facility failed to develop individualized comprehensive care plans with measurable objectives, time frames, and interventions for two sampled residents. For one resident, the record showed diagnoses including schizophrenia, anxiety, and hypertension, with moderately impaired cognition on the MDS. The resident had right hip pain with an order for a right hip X-ray, but also refused physical therapy, dentistry, optometry, and the ordered X-ray. During interviews, LVN 1, RNS 1, and the DON stated that a care plan should have been in place for the resident’s pain and refusal of care and treatment, but no such care plan was present. For the second resident, the record showed diagnoses including schizoaffective disorder bipolar type, dementia, diabetes mellitus, and hypertension, with impaired judgment and insight on the H&P and severely impaired cognition on the MDS. The resident required staff supervision for toileting hygiene, dressing, and eating. During observation, the resident stated in her primary language that she wanted to die. A review of the care plan report showed no comprehensive care plan had been initiated to address the resident’s suicidal ideation, and RNS 3 stated licensed nurses were responsible for updating the care plan to ensure resident safety. The DON reviewed the care plan report and stated there was no revision to address the suicidal ideation. The facility policy stated the comprehensive care plan is an individualized written plan based on resident needs, including goals, interventions, and the discipline responsible for each element of care, and that staff witnessing or identifying a problem or change in condition must create a care plan to address it.
Failure to Provide Meaningful Activities and Room Visits
Penalty
Summary
The facility failed to provide one of 18 sampled residents, Resident 88, with meaningful activities or regular room visits as part of an ongoing program designed to support the resident’s individual choices and preferences. Resident 88 was admitted with diagnoses including anxiety, schizoaffective disorder, and muscle weakness. The MDS dated 10/01/2024 indicated the resident’s cognitive skills for daily decision making were intact and that the resident required setup or clean-up assistance for ADLs. During observations on 10/21/2025 and 10/22/2025, Resident 88 was found lying quietly in bed, staring at the walls or lying on his back. During interview, the resident stated that no one had offered him any in-room activities that he enjoys, and that he did not like group activities outside his room because it was sometimes too cold and noisy. He stated he would prefer activities provided in his room. The Activities Director stated the resident does not typically enjoy group activities, that staff offer options such as a radio and other items, and that the resident often refuses. She was unable to locate recent documentation of activities offered, and the last activity note was dated 01/27/2024. She stated there was no documentation reflecting what was offered or refused, and that staff should document all activity offerings, conduct regular room visits, and engage the resident with personalized activities such as reading or playing music. The DON stated activities should be encouraged for all residents and that if residents refuse, staff should offer alternatives based on preferences and document what was offered and the resident’s response.
Failure to Monitor and Address Constipation
Penalty
Summary
The facility failed to assess and provide treatment for constipation for one resident who did not have a bowel movement for four consecutive days on two separate occasions. The resident was admitted with diagnoses including major depressive disorder, schizoaffective disorder, and a movement disorder. A psychiatric progress note indicated the resident required frequent reorientation to reality, while the MDS dated 10/7/2025 indicated intact cognition and independence with personal hygiene, dressing, and toileting. The care plan identified the resident as at risk for hard stool formation related to psychotropic medications and directed staff to monitor bowel movements and follow the bowel management protocol as ordered. During review of the bowel movement record, the resident had no bowel movement from 10/10/2025 to 10/13/2025 and again from 10/16/2025 to 10/19/2025. An LVN confirmed the resident went four consecutive days without a bowel movement on two separate occasions and stated the importance of monitoring for constipation. The nursing notes showed no documented follow-up by either the LVN or RN when the resident had no bowel movement for more than two days. The DON stated the LVN or RN should have followed up on the dates the resident had no bowel movement and that bowel movements should be monitored daily.
Missed Ordered ROM Exercises
Penalty
Summary
The facility failed to ensure that a resident with physician-ordered restorative nursing exercises received the ordered ROM services. Resident 88 was admitted with diagnoses including anxiety, schizoaffective disorder, and muscle weakness. The resident’s order summary included an order dated 08/11/2025 for RNA exercises daily, Monday through Friday, including sit-to-stand as tolerated, AROM and PROM to the hips, knees, ankles, shoulders, elbows, and wrists in all planes, as well as supine-to-sit and prolonged sitting with moderate assistance as tolerated. The resident’s MDS indicated intact cognitive skills for daily decision-making and that the resident required setup or clean-up assistance for ADLs. During concurrent interview and record review, RNA 1 reviewed the RNA flow sheet for 10/22/2025 and found that ROM exercises were not performed for Resident 88 that day. The flow sheet was not signed and no documentation was present. RNA 1 stated she misread the order and thought it had been discontinued, explaining that she had looked at the discontinued order and missed the active order for 10/22/2025. RNA 1 stated that ROM exercises were important to perform as ordered, especially for residents unable to do the movements independently, and that without consistent ROM exercises staff could not accurately assess whether a resident was improving or declining in mobility. The DON stated that RNAs were expected to read and follow physician orders accurately and document their tasks immediately after completion, and that if staff were unclear they should seek clarification.
Privacy Curtain Left Hanging on Floor
Penalty
Summary
The facility failed to ensure that the privacy curtain in Resident 138’s room was secured to the curtain rack. During observation, the curtain was not fully attached, was missing five hooks, and was hanging on the floor. Resident 138 stated the curtain had been like that in the room for six months. Resident 138’s admission record showed diagnoses including schizophrenia, anxiety, and insomnia, and the H&P described the resident as alert and oriented. The MDS indicated cognition was intact and that the resident was independent with ADLs. During interviews, CNA 7 stated the privacy curtain should not be touching the floor and identified it as a safety concern because the resident could possibly fall and get injured. LVN 7 stated the curtain should not be on the floor because Resident 138 could fall and get injured. The DON also stated the curtain should not be touching the floor and said residents could become anxious and fall trying to get through the privacy curtain. The facility policy for a safe and comfortable environment stated the physical space should be free of accident hazards to the extent possible/practicable.
Inadequate Pain Medication Administration
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for a resident with schizophrenia, anxiety disorder, bilateral osteoarthritis of the knees, and extrapyramidal movement disorder. The resident’s MDS dated 7/9/2025 indicated intact cognition and independence with bed mobility, toileting hygiene, and dressing. The care plan for altered comfort related to pain from osteoarthritis of both knees, initiated on 1/23/2024 and revised 5/30/2025, included a goal that the resident’s pain would be controlled and interventions to administer medicine and evaluate its effectiveness in relieving pain. The resident had a physician order for Tylenol 325 mg, two tablets by mouth every eight hours as needed for mild pain rated 1 to 3. During observation on 10/21/2025, the resident was sitting in bed and complained of bilateral knee pain, stating staff would only give Tylenol and it did not relieve her pain. Review of the MAR showed Tylenol was administered when the resident’s pain was assessed at 4 on 10/22/2025 and at 5 on 10/24/2025. LVN 2 stated the Tylenol would not be effective for pain rated 4 because it was ordered for pain level 1 to 3, and LVN 3 stated the physician should have been contacted for additional pain medication because the resident’s pain was rated 5. The DON stated the licensed nurse should have notified the physician to obtain treatment or medicines to relieve the resident’s pain.
Failure to Ensure LVN Competency Through Required In-Service Training
Penalty
Summary
The facility failed to ensure LVN 4 received in-service training on physician notification, weight loss, nutrition, and hydration. During an interview, LVN 4 stated she worked on a per diem basis and had not received in-service training related to weight loss, nutrition, or hydration, and she could not recall whether she had received training on physician notification procedures. During record review with the DSD, the In-Service Sign-In Sheets titled Notification of the Physician and Weight Loss, Nutrition, and Hydration were reviewed. The documentation showed LVN 4 did not complete the required fields for employee name, signature, title, and department, and the sheets did not document her attendance or required identifying information. The DON stated staff who were not present for the in-services were sent emails to attend when they returned to work, and stated LVN 4 would not know how to proceed with implementing care for residents without attending the in-services.
Nursing Staffing Hours Not Posted
Penalty
Summary
The facility failed to ensure that actual nursing hours worked were posted in an area visible to residents and the public. During observations on 10/22/2025 at 10:28 a.m. and 10/23/2025 at 7:40 a.m., the nurse staffing document titled Daily Schedule was posted by the entrance between the staff restroom and living room near the nursing station, and it was updated with staff call offs and add ons but did not indicate actual hours worked. During a concurrent interview and record review on 10/24/2025 at 10:06 a.m., the DON stated the facility's total nursing staff of 24 included the infection prevention nurse and MDS nurse, that the Daily Schedule did not include actual nursing hours worked, and that the nursing hours were not updated throughout the day. The DON also stated the requirement was for posting to be somewhere visible to residents and the public and for the form to be updated throughout the day. Review of the facility policy titled Daily Nursing Staffing Sheet or Equivalent dated 05/03/2025 showed the policy did not specify anything about actual hours worked.
QAPI Oversight Failed to Address Abuse Reporting and Weight Loss Monitoring
Penalty
Summary
The facility's QAPI program failed to maintain effective oversight and develop actions to correct identified and potential problems. During review of the prior recertification survey dated 10/18/2024, the CMS 2567 showed the facility had failed to ensure a resident was free from abuse. The plan of correction stated that resident behavior monitoring logs would be added to the RN shift report so the charge nurse could communicate with the physician about any resident exhibiting aggressive behavior, document orders and interventions, and include findings in monthly QAPI meetings, with quality audits reviewed by the Administrator. During an interview on 10/24/2025, Resident 63 stated that Resident 146 touched her hip and behind while she was on the phone two days after admission, which made her feel scared. She reported the incident to a nurse, the Administrator, and a male social worker, and the allegation was reported to CDPH after the surveyor spoke with the Administrator on 10/21/2025. During the recertification survey from 10/21/2025 to 10/24/2025, surveyors also identified significant weight loss for Resident 8. The Clinical Director stated that residents at risk for weight loss were identified through weekly meetings and weekly weights, while the DON stated Resident 8 was not identified for weight loss and that staff were not able to let them know due to a problem with staff competency. The Administrator stated that QAPI was important to identify problems and improve quality of care. The facility's QAPI policy stated the program must be effective, comprehensive, data driven, ongoing, and capable of addressing the full range of care and services provided.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that one of three sampled residents was free from sexual abuse by another resident. Resident 63 was admitted with diagnoses including schizoaffective disorder, diabetes mellitus, hyperlipidemia, and vitamin D deficiency. Her MDS indicated she had clear comprehension, was independent with most activities of daily living, and needed setup or clean-up assistance with eating and showering. During an interview, Resident 63 stated that two days after admission she was in the hallway using the phone when Resident 146 touched her on the hips and buttocks, and she reported the incident to a CNA and a male SW. She stated the incident occurred at night while she was in the hallway. Resident 146 had diagnoses including schizoaffective disorder, drug induced subacute dyskinesia, insomnia, and anxiety. His psychiatric progress notes documented inappropriate behavior, including showing his private part to staff during a shower, standing too close to staff, and not giving enough boundaries. His MDS showed clear comprehension and that he needed supervision or touching assistance with showering and transferring, and setup or clean-up assistance with eating and personal hygiene. A Sexual Activity Screening documented that he exposed himself in public, kissed a female resident, and touched a female resident's buttock. Staff interviews reflected awareness that Resident 146 had inappropriate sexual behaviors. A CNA stated he liked to talk to women and had to be watched for inappropriate behaviors. An LVN stated he needed a lot of redirection for speaking inappropriate sexual comments toward staff and residents. Social services stated he exposed himself to other residents, did inappropriate touching, and tried to kiss a staff member, and that he had been placed on monitoring for touching a female resident. The care plan for Resident 146 identified a history of aggression and inappropriate sexual behaviors toward residents and staff, including exposing, masturbating, touching buttocks, and kissing, and an order summary included 15-minute observation and monitoring related to allegedly touching a female resident.
Excessive Room Occupancy
Penalty
Summary
The facility failed to ensure that resident bedrooms did not accommodate more than four residents, as required. A record review of the Client Accommodations Analysis Form completed by the facility on 10/21/2025 showed that Rooms 12, 13, 20, and 21 each accommodated six residents, and rooms [ROOM NUMBER], 47, and 48 each accommodated five residents. During observation of the requested rooms during the annual recertification survey from 10/21/2023-10/24/2023, surveyors noted no concerns with space, privacy, care, or safety issues for the residents. During interview, the DON stated there were no complaints about care, privacy, or safety issues from residents in the rooms where more than four residents were accommodated. The facility policy titled, Safe and Comfortable Environment, dated 4/30/2025, stated that no more than four residents shall be accommodated in one room within the facility.
Resident Privacy and Dignity Compromised During Restroom Incident
Penalty
Summary
A deficiency occurred when a resident's privacy was not maintained, resulting in a violation of dignity. Specifically, a cognitively intact female resident with a history of major depressive disorder and schizophrenia was using the restroom when another resident, a male with severe cognitive impairment and poor impulse control, entered the restroom while she was urinating with her pants down. The female resident reported feeling embarrassed, bad, and nasty as a result of this incident. The male resident who entered the restroom had a care plan in place to closely monitor and minimize triggers for aggression, and his psychiatric notes indicated resistance to redirection and episodes of poor impulse control. The facility's policy states that residents are to be treated with respect and dignity, and to be free from abuse. The Director of Nursing acknowledged that such an incident could compromise a resident's sense of safety and dignity, especially when a male enters a female restroom.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was cognitively intact and had no behavioral symptoms, was using her bathroom when another resident, who had a history of schizoaffective disorder, severe cognitive impairment, and aggressive behaviors, entered the bathroom uninvited. The intruding resident attempted to take a trash can from the bathroom, and when the first resident intervened, he punched her in the face, leaving a red mark and causing pain. The incident occurred while the resident was sitting on the toilet with her pants down, which left her feeling mad, embarrassed, and violated. Prior to the incident, the resident who committed the abuse had a documented history of psychiatric issues, including disorganized thought processes, aggressive behavior, paranoid delusions, and poor impulse control. Staff interviews and care plan reviews indicated that this resident was known to become easily agitated, had previously threatened staff, and had a pattern of entering other residents' rooms without permission. Despite these known risks, the resident was ambulatory and allowed to walk freely throughout the facility, including unsupervised access to hallways and other residents' rooms. Observations and staff interviews revealed that there was a lack of staff presence in the hallway near the incident location at the time of the event. The facility's policy on abuse prevention and reporting defined resident-to-resident abuse as aggressive or inappropriate behavior, including hitting and threatening gestures. The failure to provide adequate supervision and monitoring allowed the aggressive resident to access another resident's private space and commit physical abuse, resulting in physical and emotional harm.
Failure to Supervise Resident with Wandering and Aggressive Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent a male resident with a history of wandering and severe cognitive impairment from entering an occupied female restroom. The male resident, who had diagnoses including schizoaffective disorder and was noted to be resistant to redirection with poor impulse control, entered the restroom while a cognitively intact female resident was using it. This resulted in the female resident being exposed and subsequently punched in the right cheek by the male resident. Observations on multiple occasions revealed that no staff were present in the hallways near the resident rooms, and interviews confirmed the male resident's history of wandering into other residents' rooms. The facility's policy required increased observation for residents presenting risks such as aggression or assault, but this was not implemented effectively, as staff were not present to monitor or intervene during the incident.
Failure to Notify Physician of Tamiflu Unavailability
Penalty
Summary
The facility staff failed to notify the physician when Tamiflu, a medication used to treat influenza, was unavailable for two residents who were symptomatic. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, was supposed to start Tamiflu on December 28, 2024, but the medication was not available until December 30, 2024. The Assistant Director of Nursing (ADON) confirmed that the medication order was discontinued due to unavailability and that there was no documentation indicating the physician was notified of this issue. Similarly, Resident 4, who had diagnoses including acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also experienced a delay in receiving Tamiflu. The medication was ordered on December 27, 2024, but was not administered until December 30, 2024, due to a shortage. The Director of Nursing (DON) acknowledged that the delay in treatment could have led to more positive flu cases and stated that the doctor should have been notified when the medication was unavailable. Interviews with facility staff, including the Registered Nurse Supervisor (RNS) and ADON, revealed that there was a lack of documentation regarding communication with the physician about the medication shortage. The facility's policy and procedure on medication administration and orders emphasize resolving medication concerns with the provider, but this was not followed in these instances. The failure to notify the physician and document the communication could have delayed medical interventions for the residents.
Failure to Implement Care Plans for Vital Sign Monitoring
Penalty
Summary
The facility failed to implement the care plans for four residents, specifically by not monitoring vital signs every four hours as required. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, had a care plan initiated to monitor vital signs and oxygen saturation every four hours due to testing positive for Influenza. However, the records showed that vital signs were not consistently monitored every four hours, as confirmed by the Director of Nursing (DON). Similarly, Resident 4, admitted with acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also had a care plan requiring vital sign monitoring every four hours due to Influenza. The records indicated that the monitoring was not performed consistently every four hours, which was acknowledged by the DON during the review. Resident 3, with diagnoses including acute lower respiratory infection, hypertension, and schizophrenia, had a care plan with the same requirement for monitoring vital signs and oxygen saturation every four hours. The DON confirmed that the interventions were not implemented as per the care plan. The facility's policy and procedure emphasized the importance of individualized care plans based on assessments, but the failure to adhere to these plans was evident in the review.
Delay in Tamiflu Administration Due to Medication Shortage
Penalty
Summary
The facility failed to ensure timely administration of Tamiflu to two residents, leading to a delay in necessary medication. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, had an order for Tamiflu on 12/27/2024, which was not administered until 12/30/2024 due to unavailability. The Medical Administration Record indicated that the medication was unavailable on 12/28/2024, and the facility pharmacy confirmed that Tamiflu would be delivered on 12/30/2024. Interviews with the Licensed Vocational Nurse and review of the progress notes revealed that the medication was not available and that the delay could have minimized the spread of symptoms. Similarly, Resident 4, who had acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also experienced a delay in receiving Tamiflu. The order for Tamiflu was placed on 12/27/2024 but was not administered until 12/30/2024 due to a shortage. The Assistant Director of Nursing confirmed that the pharmacy ran out of Tamiflu on 12/27/2024, and most residents did not start receiving the medication until 12/30/2024 or later. The Director of Nursing acknowledged that the delay in receiving Tamiflu could have resulted in more positive flu cases among residents. The facility's policy and procedure for medication orders and influenza outbreak management were not effectively followed, as the antiviral treatment was not started within the recommended timeframe. The pharmacist stated that no orders for Tamiflu were received on 12/27/2024, and the facility did not keep Tamiflu in stock, leading to the delay. The facility's policy indicated that antiviral treatment should be started as soon as possible for residents with suspected or confirmed influenza, but this was not achieved due to the medication shortage and lack of timely ordering.
Failure to Timely Retest and Reorder Test Kits During Influenza Outbreak
Penalty
Summary
The facility failed to enforce its policy related to an influenza outbreak by not retesting contaminated samples and not reordering test kits in a timely manner for two symptomatic residents. Resident 5, who was admitted with respiratory syncytial virus, acute lower respiratory infection, and hypertension, had a contaminated influenza test on 12/27/2024. The retest on 12/30/2024 confirmed Influenza A. Similarly, Resident 4, with acute lower respiratory infection, Type II Diabetes Mellitus, and hypertension, also had a contaminated test on 12/27/2024 and was confirmed positive for Influenza A on 12/30/2024. The facility's infection prevention and control program was compromised due to the delay in retesting and reordering test kits. The Infection Preventionist Nurse (IPN) and Assistant Director of Nursing (ADON) acknowledged the delay in retesting symptomatic residents and the failure to reorder test kits promptly. The facility had initially ordered 70 test kits on 12/27/2024 but received only 50, and the contaminated samples were not retested until 12/30/2024. The ADON admitted that the facility could have called the lab for a stat order to obtain test kits over the weekend, but this was not done. Interviews with staff, including the Director of Nursing (DON) and Registered Nurse Supervisor (RNS), revealed a lack of clarity and communication regarding the retesting process and the ordering of test kits. The DON and RNS were unsure why the retesting did not occur sooner, and the facility did not have test kits readily available. The facility's policy on influenza disease surveillance and outbreak management was not followed, leading to a delay in identifying and treating the influenza outbreak among residents.
Facility Fails to Honor Smoking Rights of Residents
Penalty
Summary
The facility failed to honor the rights of nine residents who were smokers by not allowing them to continue smoking in designated areas, as per the facility's policy. The policy, approved on January 31, 2024, stated that if the facility changes its policy to prohibit smoking, current residents who smoked should be allowed to continue smoking in an area that maintains their quality of life. However, the facility did not adhere to this policy, resulting in a failure to honor the residents' choices and affecting their quality of life. Several residents expressed their dissatisfaction with the new non-smoking policy. For instance, one resident stated that smoking helped with their mood and relaxation, while another mentioned feeling sick and upset after being prohibited from smoking. The facility had implemented a no-smoking agreement for newly admitted residents and offered nicotine patches or gum to current smokers, but some residents refused these alternatives and expressed a desire to continue smoking. The facility's actions were inconsistent with their policy, as they did not provide nicotine replacement therapy to all residents who requested it, nor did they assess or monitor nicotine withdrawal symptoms. Interviews with residents and staff revealed that the facility had stopped allowing smoking due to health reasons and the COVID-19 outbreak, but this decision was not aligned with the facility's stated policy of maintaining the quality of life for residents who smoked.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices, as observed during a survey. Expired bagels were found on the shelves, indicating a lapse in monitoring and removing outdated food items. The Dietary Supervisor acknowledged the oversight, stating that expired food should not be served to residents due to the potential health risks. Both the Infection Preventionist and the Administrator confirmed that serving expired food poses a risk for foodborne illnesses. Additionally, the kitchen floor was observed to have food crumbs and dirt buildup, particularly along the walls and in the corners. The Dietary Supervisor and Infection Preventionist emphasized the importance of maintaining a clean and sanitary environment to prevent pest infestations and bacterial growth. Furthermore, the drain face plate used for multiple kitchen equipment was found to have a slimy black substance, which could harbor bacteria. The facility's policies on sanitation and infection prevention were reviewed, highlighting the need for regular cleaning to prevent contamination and ensure food safety.
Deficiencies in Abuse Reporting and Smoking Cessation Management
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) program failed to effectively oversee and implement the plan of correction for deficiencies identified in a previous recertification survey. Specifically, the facility did not ensure proper reporting of an abuse allegation between two residents. A resident reported being hit by another resident, but the incident was not reported by the Licensed Vocational Nurse (LVN) who was informed of the event. The LVN did not believe the incident occurred and failed to report it to supervisors, which was a requirement according to the facility's policy. Additionally, the facility did not adequately address issues related to smoking among residents. Despite a policy that allowed current residents to continue smoking in designated areas, the facility stopped residents from smoking after a COVID-19 outbreak. This decision was not included in the QAPI program, and there was no documented assessment or monitoring of potential withdrawal symptoms from nicotine among residents who used to smoke. The facility's policy required an appropriate care plan for residents recommended for smoking cessation, which was not implemented. The facility's failure to maintain an effective QAPI program and address these issues resulted in repeated deficiencies. The lack of oversight and failure to implement corrective actions for abuse reporting and smoking cessation could potentially violate residents' rights and compromise their quality of life.
Call Light Accessibility Deficiency
Penalty
Summary
The facility staff failed to ensure that the call lights were within reach for three residents, identified as Resident 132, Resident 140, and Resident 141. Each of these residents was observed on multiple occasions with their call lights on the floor, making them inaccessible. Resident 132 and Resident 140 were both admitted with diagnoses including schizoaffective disorder, essential hypertension, and hyperlipidemia, and were noted to have no cognitive impairments but required assistance with some activities of daily living. Resident 141, diagnosed with schizophrenia, also had no cognitive impairments and required similar assistance. Observations on consecutive days revealed that the call lights for these residents were consistently out of reach, either on the floor or behind the bed, preventing them from calling for assistance when needed. Interviews with Certified Nursing Assistants (CNAs) highlighted the potential impact of this deficiency on the residents' well-being. CNA 6 noted that the inability to reach the call light could lead to frustration and affect the residents' psychosocial state, while CNA 5 emphasized the increased risk of falls and injuries due to the residents' inability to call for help. The facility's policy on the nursing call light system mandates that all staff and residents be oriented to its functions, ensuring that residents can notify staff from their bedside, toilet, or shower when they need assistance. However, the observations and interviews indicate that this policy was not effectively implemented for the three residents in question.
Failure to Notify Physicians of Residents' Tremors
Penalty
Summary
The facility failed to notify the physicians of two residents, Resident 14 and Resident 108, who were experiencing tremors that affected their activities of daily living (ADLs). Resident 14, diagnosed with schizophrenia, extrapyramidal and movement disorder, Parkinson's Disease, and chronic diastolic congestive heart failure, was observed to have hand tremors from October 15 to October 17, 2024, which impacted her ability to eat. Despite these observations, there was no documentation in the progress notes, and the physician was not notified, which was against the facility's policy. Resident 108, diagnosed with bipolar disorder and tremor, was also experiencing tremors that affected her ability to write. She had requested a reduction in her lithium dosage due to the tremors. However, the facility staff failed to document these episodes of extrapyramidal symptoms (EPS) in the resident's chart and did not notify the physician, as required by the facility's policy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of proper monitoring and documentation. The facility's policy on monitoring possible side effects from psychotropic medications required licensed nurses to monitor residents every shift for side effects and notify the physician of any positive findings. The policy also required documentation of new or increased EPS in the progress notes. The failure to adhere to these procedures resulted in the deficiency noted in the report, as the residents' conditions were not properly communicated to their physicians, potentially affecting their treatment plans and quality of life.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized activities that meet the interests of three residents, potentially impacting their mental and psychosocial well-being. Resident 3, who was admitted with diagnoses including paranoid schizophrenia, type II diabetes mellitus, and essential hypertension, was observed sleeping in bed during multiple observations over several days. Despite having no cognitive impairment and requiring supervision for personal hygiene, there was no documentation of Resident 3 engaging in any activities during this period. Similarly, Resident 21, diagnosed with schizoaffective disorder, seizures, and hypotension, was also observed sleeping in bed during various times over several days. The resident's care plan included interventions to encourage participation in group activities, yet there was no evidence of such activities being conducted. Resident 21 required assistance for all activities of daily living and had no cognitive impairment, indicating a need for structured engagement. Resident 104, with diagnoses of schizophrenia, insomnia, and major depressive disorder, was found in bed sleeping during multiple observations. The resident was dependent on assistance for all activities of daily living and had no cognitive impairment. Interviews with facility staff, including a CNA, RN, and the Rehabilitation Director, emphasized the importance of activities in improving residents' psychological well-being and managing mental health challenges. However, the facility's activity notes lacked documentation of any activities for these residents during the observed period, indicating a failure to implement the facility's policy on program activities.
Failure to Complete Mandatory Training for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) completed their mandatory continuing education requirements. Specifically, CNA 1, CNA 2, and CNA 3 did not complete the required yearly dementia training, with each missing four out of five hours. Additionally, CNA 2 and CNA 3 did not complete the mandatory one-hour sexual harassment training. This lack of training compliance was identified during an interview and record review with the Director of Staff Development (DSD), who acknowledged the absence of an effective tracking system for monitoring training completion. The Administrator confirmed that the DSD was responsible for managing the education department and ensuring that all mandatory training requirements were met. However, the DSD failed to utilize available tools and did not have a system in place to track training completion, leading to the oversight. The facility's policy and procedures outlined the DSD's role in providing and maintaining staff education, including mandatory training required by regulatory agencies. The failure to complete these training requirements posed a potential risk to resident safety, as staff may not be adequately equipped to care for residents.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, specifically Resident 65, who was injured by her roommate, Resident 37. Resident 37, who has a history of schizoaffective disorder and schizophrenia, exhibited delusional behavior and physically assaulted a staff member before hitting Resident 65 with a table, resulting in a small cut on Resident 65's forehead. Despite Resident 37's known behavioral issues, including delusions and aggression, the facility did not adequately monitor or intervene to prevent the escalation of her behavior. Resident 65, who has diagnoses of paranoid schizophrenia and unspecified dementia, was independent in mobility and had intact cognition. On the day of the incident, Resident 65 sought help at the nursing station with a bleeding forehead after being hit by a table thrown by Resident 37. The facility's records indicate that Resident 37 was experiencing delusional thoughts and accused her roommate of causing harm, which led to the aggressive incident. Interviews with staff, including a CNA, RN Supervisor, ADON, and DON, revealed that there were missed opportunities to intervene and de-escalate Resident 37's behavior. Staff acknowledged that Resident 37's behavior was unpredictable and that someone should have checked on her after she hit a staff member and slammed the door. The facility's policy on abuse prevention requires staff to intervene and correct situations where abuse may occur, but this was not effectively implemented in this case.
Failure to Develop Comprehensive Care Plan for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with schizoaffective disorder, anxiety, and major depressive disorder. The resident, who was admitted with these diagnoses, required various levels of assistance from nursing staff for daily activities, as indicated in the Minimum Data Set (MDS). Despite the resident's active diagnosis of schizoaffective disorder, the care plan did not address this condition, which was confirmed during a review by the Assistant Director of Nursing/Infection Preventionist Nurse (ADON/IPN). The ADON/IPN acknowledged that the care plan should have included interventions for schizoaffective disorder to ensure the resident received necessary care and services. The Director of Nursing (DON) also confirmed the need for a care plan to guide nursing staff in providing appropriate care and interventions. The facility's policy and procedure on Individual Plans emphasized the importance of addressing co-occurring disorders in an integrated manner, which was not followed in this case.
Failure to Update Vision Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a care plan for vision was revised and updated for a resident, identified as Resident 108, who was part of a sample of 33 residents. Resident 108 was admitted with diagnoses including bipolar disorder, tremor, pre-glaucoma, and age-related bilateral nuclear cataract. Despite a consultation report from an ophthalmologist indicating that the resident had bilateral cataracts and no evidence of glaucoma, the care plan continued to address suspected glaucoma without updating it to reflect the cataract diagnosis. This oversight was identified during a review of the resident's care plan, which had not been revised since November 2023, even though the ophthalmology consultation in October 2024 confirmed the presence of cataracts. Interviews with the resident and facility staff, including a Registered Nurse Supervisor, Assistant Director of Nursing, and Director of Nursing, revealed that the care plan was outdated and did not include the resident's current diagnosis of cataracts. The staff acknowledged that the care plan should have been updated to reflect the resident's actual condition to ensure appropriate care and interventions. The facility's policy and procedure indicated that individual plans should be reviewed and updated according to changes in treatment needs, but this was not adhered to in the case of Resident 108.
Inadequate Staff Training Management by DSD
Penalty
Summary
The facility failed to ensure that the Director of Staff Development (DSD) was competent in managing the online education program used for staff training. During an interview and record review, the DSD admitted to not having received training on how to generate reports to verify staff completion and competency on mandatory in-services. As a result, the DSD was unable to provide data on the completion of mandatory training for staff members, including Certified Nurse Assistants (CNAs). Specifically, CNA 1, CNA 2, and CNA 3 were missing significant portions of their required yearly dementia training, and CNA 2 and CNA 3 were also missing part of their mandatory sexual harassment training. The Administrator confirmed that the DSD was responsible for maintaining the education department and ensuring that staff completed their mandatory training. However, the DSD did not have an effective tracking system in place and relied on checking each staff member individually, which led to the oversight. The facility's policy and procedures outlined the DSD's responsibilities, including maintaining records and reports of all staff education and providing mandatory education required by regulatory agencies. The failure to complete mandatory training was acknowledged as potentially putting resident safety at risk.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement their protocol for Antibiotic Stewardship for one of the sampled residents by not obtaining a culture or blood tests before prescribing antibiotic medication. This deficiency was identified in the case of a resident who was screened for cellulitis but did not meet the criteria for a cellulitis skin infection according to the Healthcare-associated Infections Suggested Definitions of Infections for Surveillance Purposes. Despite this, the resident was prescribed Bactrim and doxycycline for skin infections without diagnostic procedures to determine the actual bacteria being treated. The Assistant Director of Nursing/Infection Preventionist Nurse acknowledged that a culture should have been done for any skin issue or possible infection, but it was not performed for this resident. The Director of Nursing also stated that the goal of Antibiotic Stewardship is to avoid unnecessary antibiotics and follow guidelines, which were not adhered to in this case. The facility's policy on Antibiotic Stewardship emphasizes compliance with evidence-based guidelines and the review of culture and sensitivity reports, which was not followed, leading to the inappropriate use of antibiotics for the resident.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as rooms 12, 13, 20, and 21 were found to accommodate six residents each, and rooms 47 and 48 accommodated five residents each. This was identified during a review of the Client Accommodations Analysis Form completed by the facility on October 15, 2024. Despite these findings, observations made during the annual recertification survey from October 15 to October 18, 2024, did not indicate any concerns with privacy, safety, or residents' care. Additionally, during an interview on October 18, 2024, the Administrator stated that residents' care was not affected, and there were no complaints about room crowding affecting mobility and safety. The facility's policy and procedure titled 'Safe and Comfortable Environment' indicated that no more than four residents should be accommodated in one room.
Resident Stabbed by Another Resident with a Pen
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 1, who has schizophrenia, anxiety, and hypertension, was stabbed on the right index finger with a pen by Resident 2, who also has schizophrenia, hearing loss, and hypertension. The incident resulted in a one-inch cut on Resident 1's finger. Resident 1 was alert and oriented to name only, while Resident 2 was alert and oriented to name, place, and time. The Minimum Data Set (MDS) assessments indicated that both residents required varying levels of assistance with daily activities, but neither required assistance with personal hygiene or toileting. The Director of Nursing (DON) and the Administrator (ADM) confirmed the incident, with Resident 2 admitting to stabbing Resident 1. The facility's policy on abuse prevention and reporting strictly prohibits any form of mistreatment, including physical abuse. Despite this policy, the incident occurred, and the ADM could not establish the reason behind the abuse. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, as required by their policies.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, specifically involving two incidents. In the first incident, Resident 1, who was diagnosed with schizophrenia and anxiety disorder, exhibited behaviors such as auditory hallucinations, paranoid delusions, and visual hallucinations. Despite these behaviors being documented in the Medication Administration Record (MAR) over several days, the facility did not inform Resident 1's physician. This lack of communication resulted in Resident 1 entering Resident 2's room and hitting him in the face, driven by delusional beliefs that Resident 2 had raped him. In the second incident, Resident 3, who had severe cognitive impairment and was diagnosed with schizophrenia, exhibited agitation, anxiety, and mood swings. These behaviors were noted in the MAR, but again, the facility failed to inform the physician. Consequently, Resident 3 hit Resident 4 in the face while she was sitting in her wheelchair in the hallway. Resident 4, who had mild cognitive impairment and was diagnosed with schizoaffective disorder and anxiety disorder, was unable to defend herself or call for help effectively. The facility's policy and procedure on abuse prevention and reporting, as well as the notification of physician/prescriber, were not followed. The Director of Nursing acknowledged that the facility did not take action to control Resident 1's behavior until it escalated, and the Director of Rehab noted the lack of staff presence during the incident involving Resident 3 and Resident 4. These failures highlight the facility's inability to protect residents from abuse and ensure timely communication with physicians regarding significant behavioral changes.
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Illustrative
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 Paramount
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paramount Convalescent Hosp. | 1 mi | ★★★★★ | 24 | 0 |
| Bellflower Post Acute | 1.3 mi | ★★★★★ | 20 | 0 |
| Villa Del Sol Post Acute | 1.4 mi | ★★★★★ | 28 | 0 |
| Rose Villa Health Care Center | 1.5 mi | ★★★★★ | 6 | 0 |
| Sunset Villa Post Acute | 1.7 mi | ★★★★★ | 26 | 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.