Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laguna Honda Hospital & Rehabilitation Ctr D/p Snf during CMS and state inspections, most recent first.
A resident with blindness, schizoaffective disorder bipolar type, and HIV infection was found living in a severely cluttered and unsanitary room, with trash, linens, food containers, personal items, and equipment covering surfaces and the floor, preventing EVS from performing required daily cleaning tasks such as trash removal, surface disinfection, and floor care. Staff interviews and documentation showed a longstanding pattern of the resident refusing or postponing room cleaning, hoarding items, and at times becoming upset when staff attempted to clean, resulting in persistent environmental concerns and an environment that did not promote cleanliness, orderliness, or infection control.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
The facility did not report four allegations of abuse to CDPH within the required two-hour timeframe. In two separate incidents, staff observed inappropriate or abusive interactions between residents with cognitive impairments, but delayed reporting due to internal decisions and confusion about reporting requirements, despite facility policy mandating immediate notification to authorities.
Surveyors found that an outdoor garbage bin near the kitchen was left open and filled to the top with used food containers, while over 60 compost and recycle bins behind the kitchen had visible black residue, food waste, and attracted flies. Facility leadership confirmed the bins were not clean and that cleaning occurred only monthly, failing to meet federal requirements for refuse management.
Surveyors observed small flies in multiple kitchen areas, including near refuse and food production zones. Staff documented and reported the issue, and pest control serviced the area regularly, but the fly problem persisted and was not effectively eliminated, as confirmed by the FSD and FSS.
A resident with quadriplegia and a history of stimulant use disorder refused a physician-ordered urine toxicology screen, as documented by staff. Despite this refusal, staff collected and sent a urine sample for testing, violating the resident's right to make medical decisions about their care.
A resident with impaired mobility, left hemiparesis, and dysphagia was found self-administering Metamucil at bedside without proper assessment, physician order, or care plan in place. Nursing staff left the medication at the bedside and did not ensure the full dose was taken, contrary to facility policy requiring interdisciplinary assessment and documentation before allowing self-administration.
A resident admitted with complex medical conditions did not have a baseline care plan for ADL oral care developed within 48 hours, as required by facility policy. Staff interviews confirmed the delay, and records showed the dental care plan was initiated several days after admission, resulting in a lapse in timely care planning.
The facility did not follow physician orders for oxygen therapy and medication administration for three residents. One resident received oxygen at an incorrect flow rate and without proper documentation of oxygen saturation. Another resident was given Glipizide after breakfast instead of before, as ordered. A third resident had a Lidocaine patch applied to the wrong body area, contrary to the prescriber's instructions. These actions did not meet professional standards of quality.
A resident's Methadone Concentrate waste was improperly disposed of by an RN, who placed both the medication and measuring cup into a container for non-controlled pharmaceutical waste instead of using the designated RX Destroyer for controlled substances. This action was confirmed through staff interviews and was not in accordance with facility policy, which requires controlled substances to be disposed of in the RX Destroyer.
Kitchen staff failed to follow manufacturer instructions for testing sanitizer strength on food contact surfaces, with improper immersion times and immediate color comparison instead of the required procedure. In-service training did not cover the correct method, and facility policy lacked specific guidance, resulting in staff not being competent in accurate sanitizer testing.
Surveyors found that two residents' food items, including deli meat and frozen products, were not stored or labeled according to manufacturer instructions. Opened lunch meat was kept beyond the recommended period without proper labeling of the open date, and frozen foods were stored in a refrigerator instead of a freezer. Nursing staff and the FSD confirmed these practices, and facility policy requiring adherence to manufacturer guidelines was not followed.
The facility failed to maintain kitchen sanitation standards, including cracked tiles and dust build-up, improper sanitization of steam jacket kettles, and uncovered frozen food items. Additionally, a resident's egg-salad sandwich was not discarded within the appropriate time frame, posing a risk of food poisoning.
The facility's kitchen had a persistent fruit fly infestation, with flies observed in the warewashing room above trash and compost bins. Despite weekly pest control services, reports consistently documented the presence of fruit flies from August to October. The Pest Control Technician indicated that additional measures were needed to address the issue, as current efforts were insufficient.
A facility failed to develop a comprehensive care plan for a resident on comfort care, who was admitted with seizure and brain injury. The resident was observed with oxygen and not verbally responsive. Despite having a DNR/DNI status and comfort-based goals of care, the care plan lacked documentation of comfort care, contrary to facility policy.
A resident with swallowing difficulties was not reassessed by an SLP after an esophageal dilation procedure, despite recommendations to continue a puree diet and thin liquids. The resident, with conditions including paraplegia and schizophrenia, was maintained on a regular diet, accepting the risk of aspiration, contrary to the SLP's advice.
A facility failed to document a clinical rationale for a PRN Ativan prescription exceeding 14 days for a resident with paraplegia, epilepsy, and insomnia. Initially, the order lacked justification, contrary to facility policy. Later, a doctor modified the order, citing chronic insomnia as the reason for the extended duration.
The facility exceeded the acceptable medication error rate with a 6% error rate during a medication pass. An LVN administered insulin at an incorrect angle, and an RN failed to rotate insulin injection sites for two residents. These actions contradict recommended practices for insulin administration.
A resident with Peripheral Vascular Disease and other medical conditions did not receive foot care for over three months, resulting in long, painful toenails. Despite a podiatry referral, the facility failed to initiate care, and the resident was unaware of available services. Observations showed excessively long nails, and the unit manager could not explain the neglect, violating the facility's foot care policy.
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to deficiencies in their care. Specific issues included the lack of care plans for medical conditions, medications, and necessary interventions, as well as inconsistent implementation and documentation of care plan interventions.
The facility failed to provide a safe environment by not properly documenting and monitoring Aero Scout devices for two residents, increasing the risk of elopement. Additionally, the facility did not follow the care plan for a resident requiring two staff members for assistance, resulting in a fall and hospitalization.
The facility failed to ensure a comprehensive infection prevention and control program, leading to multiple deficiencies including improper handling of contact precautions, failure to follow TB screening protocols, and inadequate cleaning procedures. These lapses increased the risk of spreading infections among residents.
The facility failed to maintain essential kitchen equipment and the physical environment, leading to water leaks from a dish machine, non-operational temperature gauges, missing grout in floor tiles, and improper maintenance of ice machines. Despite multiple work orders and monitoring claims, these issues persisted, indicating ongoing maintenance failures.
The facility failed to visually monitor a physical restraint device for a resident with Huntington's Disease, resulting in gaps in required documentation and potential safety risks. Staff interviews and record reviews confirmed the lack of consistent monitoring as per facility policy.
The facility failed to report an allegation of abuse within the required 2-hour timeframe. Two residents were involved in a physical altercation, and the incident was reported to the California Department of Public Health the next day. Regulatory Affairs Nurses believed the abuse was not intentional, leading to the delay. Facility policy mandates reporting within 2 hours.
The facility failed to update the care plan for a resident who received new dentures, resulting in the resident not wearing the dentures and PCAs being unable to provide proper care. The care plan did not include specific dental instructions, contrary to facility policy.
The facility failed to document specific dental care instructions for a resident's new dentures, leading to inconsistent care and the resident not wearing his dentures. The omission was identified during an observation and interview with the Nurse Manager, who confirmed that the instructions were not transcribed into the EHR as required by facility policy.
The facility failed to provide necessary mealtime assistance for a resident with left extremity weakness and dementia. The resident struggled to feed herself and open containers, and staff did not intervene to assist, despite the facility's policy requiring such assistance.
A skilled nursing facility failed to monitor and document the wound progression of a resident with a left lower leg infection. Despite treatment with antibiotics, staff did not record the wound's status for 21 days, making it difficult to assess its healing. Interviews revealed that nursing staff were aware of the infection but failed to document it, contrary to the facility's policy requiring weekly wound assessments.
The facility failed to provide and document Passive Range of Motion (PROM) exercises for a resident as per active orders, potentially impacting the resident's mobility and functional status. The Nursing Manager confirmed that PROM was not documented during the day shift on multiple dates.
The facility failed to maintain a medication error rate of less than 5%, with five errors observed out of fifty-five opportunities, resulting in a 9% error rate. Incidents included improper administration of Metformin without food, incorrect technique in administering eye drops, and failure to follow nasal spray administration policy.
The facility failed to respond to refrigerated temperature excursions for medications and did not document follow-up actions for several instances where storage temperatures deviated outside the acceptable range. Additionally, the facility failed to monitor the temperature of the medication room in the Pavilion Mezzanine skill nursing area, as there was no sensor installed. These failures could have compromised medication stability and patient safety.
The facility failed to ensure ready-to-eat foods from Vendor 1 met current food safety standards. Over 10 cases of such food were found in the walk-in refrigerator, and the Director of Food Services (DFS) admitted that no follow-up inspections had been conducted since a Registered Dietitian's visit 12-18 months ago. Despite a yearly review process, the facility had not requested additional information from the vendor regarding food safety concerns identified by the FDA in April 2023.
The facility failed to follow its policy on influenza immunizations for a resident, resulting in an incomplete medical record. Despite the resident stating that the vaccine was offered and refused twice, there was no documentation of the vaccine administration or refusal. The Director of Infection Prevention confirmed the absence of required documentation.
Failure to Maintain Clean and Safe Environment Due to Resident Room Clutter
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, comfortable, and orderly environment for one resident. The resident had active diagnoses including blindness, schizoaffective disorder bipolar type, and HIV infection, which required a clean, safe, hazard‑free, calm, and predictable environment. Despite this, an observation of the resident’s room showed extensive clutter on surfaces, furniture, and the floor, including dented juice cans, multiple spray bottles, numerous lotion bottles, clothing, plastic food containers, mouthwash, used paper and medication cups, and other unidentified items. A large open trash bag on the floor contained various items spilling onto the floor, and additional food packaging was observed on the floor. Further observation revealed that a bookshelf and drawers near the bed were filled and overflowing with facility linens, open paper and plastic bags, gloves, and other items, with more linens and an open shipping package stacked on a large box in front. A nearby chair was covered with a urinal, unfolded sheets, a blue tarp, and a clear plastic bag of items, with additional bags and items underneath and around the chair, including empty soda cans, used gloves, non‑skid socks, clothing, and a blue tarp covering more items. This cluttered condition prevented staff from performing required environmental cleaning tasks outlined in the facility’s EVS Standard Cleaning Procedure, including trash removal, high dusting, cleaning and disinfecting high‑ and low‑touch surfaces, floor cleaning, and completing a second round of trash removal and spot cleaning. The report states that this failure resulted in an environment that did not promote cleanliness, orderliness, or infection control and placed the resident at risk for accidents and unsafe conditions. Interviews with staff indicated that the resident’s room had been consistently cluttered for years and that the condition had worsened over time. A PCA reported ongoing clutter, acknowledged it as a problem, and noted occasional fruit flies and comments from other residents about the room’s messiness. The nurse manager and CNAs stated that the resident frequently refused room cleaning, postponed cleaning by telling staff to return later, and sometimes became very upset or deliberately created a mess after staff cleaned. EVS leadership reported longstanding environmental concerns since about 2024, including prior feces‑throwing behavior and current hoarding behaviors, and noted that the resident often refused to allow staff to clean the room or restricted cleaning to specific EVS staff. Documentation reviewed by surveyors, including an EVS refusal log, a cleaning log, a resident care team note, and a nursing weekly summary, showed a history of refusals, unsanitary room conditions, and litter throughout the room, while also indicating that clutter and resident refusals impeded consistent implementation of the facility’s daily cleaning procedures in this resident’s room.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Allegations of Abuse to State Authorities
Penalty
Summary
The facility failed to report four separate allegations of abuse within the required two-hour timeframe to the California Department of Public Health (CDPH). In one incident, two residents with significant cognitive impairments and BIMS scores of 0 were involved in a resident-to-resident sexual abuse event. Staff observed one resident attempting to open the brief of another resident during the night. Although the incident was reported internally, the team initially decided it was not reportable, and the mandated report to CDPH was delayed until a physician later determined it should be reported. In another incident, a staff member observed inappropriate touching between two residents in a common area. The staff member reported the event to the team leader, who dismissed the concern, stating that the residents were friends. The incident was later discussed in a team huddle, but there was confusion among staff about whether the event was reportable. The mandated report to CDPH and other agencies was delayed as the team attempted to contact the family of one resident and debated the necessity of reporting, despite facility policy requiring reporting within two hours. Facility policy clearly states that all employees, contractors, and volunteers are mandated reporters and must report alleged abuse to CDPH, the Ombudsman, and Nursing Operations within specified timeframes. However, in both cases, staff failed to adhere to these requirements, resulting in delayed reporting of abuse allegations. Interviews with staff and review of clinical notes confirmed that confusion about what constitutes a reportable event and internal decision-making processes contributed to the reporting delays.
Improper Disposal and Maintenance of Outdoor Refuse and Recycle Bins
Penalty
Summary
Surveyors observed that one outdoor garbage bin located near the kitchen loading dock was filled to the top with used food containers and had its lid left open. This was confirmed by the Food Service Director and the Director of Emergency Management, who acknowledged that the lid should have been closed. Additionally, over 60 compost and recycle bins stored behind the kitchen were found to have black residue on both the inside and outside surfaces, with flies present around the bins. Several bins were opened and found to contain empty food containers, food residue, and garbage, with the inside surfaces covered in black residue and some bins being wet inside. The Executive Director of Facility Services confirmed that the bins were not clean, and the Director of Emergency Management stated that the bins were emptied once daily and pressure washed once per month. According to the 2022 Federal Food Code, outdoor refuse, recyclables, and returnables receptacles are required to have tight-fitting lids and be cleaned frequently enough to prevent buildup and attraction of pests. The facility failed to meet these requirements, as evidenced by the open garbage bin and unclean recycle and compost bins.
Failure to Maintain Kitchen Free from Flies
Penalty
Summary
The facility failed to maintain the kitchen free from flies, as observed during multiple inspections. On several occasions, small flies were seen on the ceiling and walls in the dish machine room, particularly around bins for shredded paper, refuse, and recycling, as well as in the food production and trayline areas. The Food Service Director (FSD) confirmed the presence of flies and was unaware of their occurrence until notified. Although the pest control company serviced the kitchen three times a week, specific actions to eliminate the flies were not taken when fly activity was identified. Documentation and interviews revealed that staff, including the Food Service Supervisor (FSS), regularly identified and documented the presence of flies and placed work orders for pest control intervention. Work orders and inspection checklists confirmed repeated sightings and pest control responses, such as vacuuming fruit flies. However, despite these reports and interventions, the fly problem persisted, and there was uncertainty about whether all necessary work orders were consistently placed. The ongoing presence of flies in food preparation and storage areas was not effectively addressed, as required by the 2022 Federal Food Code.
Resident's Right to Refuse Urine Toxicology Test Not Honored
Penalty
Summary
A cognitively intact resident with quadriplegia, chronic pain syndrome, and a history of stimulant use disorder was admitted to the facility and had a physician's order for a urine toxicology screen. According to nursing notes and staff interviews, the resident refused the urine toxicology test, and this refusal was documented in the electronic health record. Despite the resident's refusal, staff proceeded to collect a urine sample and sent it to the laboratory for toxicology screening, which later returned positive for amphetamines. Interviews with nursing staff confirmed that the resident's right to refuse the test was not honored, even though facility policy requires resident rights to be protected and promoted. The resident was alert, oriented, and able to communicate his wishes, explicitly stating that he had refused the test. The facility's actions resulted in a violation of the resident's right to make medical decisions regarding their care and treatment.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including impaired mobility, impaired activities of daily living, left hemiparesis, and dysphagia was observed self-administering Metamucil mixed with orange juice at their bedside. The medication was left at the bedside, and the resident consumed it at their own pace without direct observation by nursing staff. The resident was not assessed or approved for self-administration of medication, and there was no physician's order, care plan, or interdisciplinary team documentation authorizing self-administration. The facility's policy required an assessment and care plan before allowing bedside medication storage and self-administration, which was not followed in this case. Nursing staff acknowledged that the resident could not open the medication packet independently and did not consume the medication in a timely manner. The nurse manager confirmed that the resident had not been assessed for self-administration capability and that the medication was left at the bedside without ensuring the full dose was taken. The lack of assessment and authorization for self-administration, combined with the resident's medical conditions, resulted in a failure to appropriately administer medication as required by facility policy.
Failure to Develop Baseline Care Plan for ADL Oral Care Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, specifically regarding activities of daily living (ADL) for oral care. The resident was admitted with multiple diagnoses, including stroke, dysphagia, heart failure, aphasia, and systemic lupus erythematosus. Interviews with facility staff confirmed that the baseline assessment and care plan, which should have been completed within 48 hours as per facility policy, were not developed in the required timeframe. Staff also indicated that without the care plan, essential ADL care such as oral care would not be performed, as they rely on the care plan for daily care instructions. Review of the clinical record showed that the dental care plan was not initiated until several days after admission.
Failure to Follow Physician Orders for Oxygen and Medication Administration
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards of quality in several instances. One resident with chronic obstructive pulmonary disease (COPD) and a history of obstructive sleep apnea was observed receiving oxygen therapy at a rate of 1 liter per minute via nasal cannula, contrary to the physician's order for 2 liters per minute as needed to maintain oxygen saturation above 92%. Documentation of oxygen saturation was not completed on the day of observation, and the last recorded value was two days prior. The care plan and facility policy required adherence to the physician's order and proper documentation, which was not followed. In another instance, a resident prescribed Glipizide 10 mg tablet for type 2 diabetes mellitus was administered the medication after breakfast, despite the physician's order specifying administration before breakfast. The nurse confirmed that the medication was given at the incorrect time, as breakfast had already been completed prior to administration. This action was not in accordance with the prescriber's parameters for medication timing. Additionally, a resident with an order for two Lidocaine 5% patches to be applied to the right shoulder and right rib area for pain received one patch incorrectly applied to the mid-lower back. The nurse acknowledged the error and corrected the application after it was identified. The facility's policy on medication administration required adherence to the six rights, including correct route and site, which was not followed in this case.
Improper Disposal of Controlled Substance Documented
Penalty
Summary
The facility failed to accurately dispose of and record the disposal of a controlled drug, specifically Methadone Concentrate, for one resident. During an observation in the medication room, an Omnicell receipt showed that 90 mg of Methadone was administered and 10 mg was wasted for the resident. The waste was witnessed and documented by two registered nurses. However, the nurse responsible for the disposal described placing both the 10 mg of Methadone and the measuring cup into a black container designated for non-controlled pharmaceutical waste, rather than using the PRO SERIES RX Destroyer, which is specifically labeled for controlled substance waste. This process was confirmed by the nurse during an interview. Further interviews with nursing staff confirmed that the correct procedure, as outlined in the facility's policy, requires controlled substances like Methadone to be disposed of in the RX Destroyer, with only the measuring cup being placed in the non-controlled waste container. The nurse did not follow this protocol, and the error was acknowledged by supervisory staff. The facility's policy, last revised in February 2025, clearly states that controlled substances must be disposed of in the RX Destroyer located in the medication rooms.
Improper Sanitizer Testing by Food Service Staff
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in testing the sanitizer strength used for sanitizing food contact surfaces. During an observation and interview, the Food Service Supervisor (FSS) demonstrated improper technique by immersing the test strip in the sanitizer solution for 20-21 seconds and immediately comparing the color, instead of following the manufacturer's instructions to immerse for 5 seconds and evaluate the color 10 seconds after removal. When questioned, the FSS stated the strip should be held for about 10 seconds, which was also incorrect according to the manufacturer's label. A review of facility documents showed that the FSS had attended an in-service training on the Three Bucket Sanitizing Method, but the training did not include specific instructions on how long to immerse the test strip. The facility's policy required supervisors or designated staff to test sanitizer concentration twice daily, but did not specify the correct procedure as per the manufacturer's instructions. This lack of proper training and adherence to manufacturer guidelines resulted in the staff not being competent in accurately testing sanitizer strength, potentially compromising infection control and resident safety.
Improper Storage and Labeling of Resident Food Items
Penalty
Summary
Surveyors observed that food stored in a resident refrigerator located in a great room was not managed according to professional food safety standards. Specifically, an opened package of sliced ham was found with a facility-applied expiration label matching the manufacturer’s expiration date, but the package instructions required use within seven days of opening. The facility’s labeling did not indicate the date the package was opened, and nursing staff confirmed they used the manufacturer’s expiration date rather than the open date for discarding lunch meat. The Food Service Director (FSD) confirmed that the manufacturer’s instructions should be followed and referenced FDA guidelines recommending a shorter storage period after opening. Additionally, the same refrigerator contained a turkey pot pie and a box of Uncrustables sandwiches, both of which were labeled by the facility but stored in a refrigerator rather than a freezer, contrary to the manufacturer’s instructions to keep these items frozen until use. Nursing staff confirmed that the great rooms only had refrigerators and not freezers, and the FSD stated he was unsure where residents’ personal frozen foods should be stored, expressing concerns about cross-contamination if stored in galley kitchens. Facility policies required food from outside sources to be stored and discarded according to manufacturer recommendations, but these procedures were not followed for the observed items.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain the kitchen floor in the steam jacket kettle area, resulting in cracked tiles and missing grout. During an observation, it was noted that the floor was wet, and water seeped out from beneath the tiles when pressure was applied. The Food Service Director (FSD) acknowledged that a work order had been placed weeks prior to address the issue, but the problem persisted. The Director of Facilities confirmed the broken tiles and missing grout, indicating that the area needed to be resurfaced with a more durable material. The facility also failed to maintain the ceiling above the manual dishwashing area, which had a significant dust build-up. The FSD admitted that the ceiling was cleaned only once a year, and the last cleaning was done several months ago. This lack of regular maintenance could lead to the growth of microorganisms and potential contamination of food. Additionally, the facility did not sanitize steam jacket kettles as part of the cleaning process. A Food Service Worker responsible for cleaning the kettles confirmed that the sanitizing step was omitted, which was against the facility's policy. Furthermore, frozen food items were not properly covered in the freezer, increasing the risk of cross-contamination. During an inspection, multiple uncovered food items were found in the walk-in freezer. The FSD acknowledged the oversight and admitted that the facility could improve its food storage practices. Additionally, an egg-salad sandwich served to a resident was not discarded within the appropriate time frame, posing a risk of food poisoning. The sandwich, served the previous night, was still present in the resident's room the following morning, which was confirmed by the Nurse Supervisor.
Persistent Fruit Fly Infestation in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as evidenced by the consistent presence of fruit flies. During an initial tour of the kitchen, small flies were observed on the ceiling in the warewashing room, particularly above the trash and compost bins. The Food Service Director confirmed the presence of these flies and noted that a pest control technician serviced the kitchen weekly. However, pest reports from August to October consistently documented the presence of fruit flies, indicating an ongoing issue that had not been effectively addressed. Interviews with the Environmental Services Director and the Pest Control Technician revealed that a work order for the flies was submitted, but the issue persisted. The Pest Control Technician explained that the presence of breeding material, such as food residue, promoted the presence of fruit flies. Despite weekly services, the technician suggested that additional measures, such as increased service frequency or the use of pesticides in drains, were necessary to eliminate the flies. The facility's current pest control measures were insufficient to address the problem, leading to a potential risk of contamination in the kitchen.
Failure to Develop Comprehensive Care Plan for Comfort Care
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 62, who was admitted with a diagnosis including seizure and brain injury. During an observation, Resident 62 was found in bed with oxygen via nasal cannula and was not verbally responsive. An interview and record review with the Nurse Manager revealed that Resident 62 was on comfort care, as indicated by the Health Care Advance Directive and Advanced Care Planning, which stated the goals of care were comfort-based with a DNR/DNI status. However, a review of the resident's care plan showed no documentation of comfort care, which was acknowledged by the Nurse Manager as an oversight. The facility's policy requires a comprehensive person-centered care plan that includes advance care planning and palliative care, which was not met in this case.
Failure to Follow SLP Recommendations for Resident's Diet
Penalty
Summary
The facility failed to adhere to the recommendations of a speech language pathologist (SLP) for a resident with swallowing difficulties. The SLP had recommended that the resident continue on a puree diet and thin liquids until a reassessment could be conducted following an esophageal dilation procedure. However, the resident was maintained on a regular diet without the necessary reassessment by an SLP, which could lead to an inaccurate assessment of the resident's swallowing ability. The resident in question had multiple medical issues, including paraplegia and schizophrenia, and underwent an esophagogastroduodenoscopy (EGD) where the esophagus was dilated. Despite the SLP's recommendations, the resident's care plan indicated that the resident accepted the risk of aspiration while on a regular diet. A physician's treatment plan document noted that the resident wanted to continue with a regular diet despite the risks of aspiration.
Failure to Document Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a clinical rationale for a PRN medication order of a psychotropic drug beyond 14 days for one of the residents. The resident, who was admitted in 2019, has medical conditions including paraplegia, epilepsy, and insomnia. The resident was prescribed Ativan, a sedating medication, for 90 days to manage sleep issues. However, the facility's policy requires that PRN non-antipsychotic medications be limited to 14 days unless a longer duration is justified by a physician with documented rationale. This requirement was not initially met for the resident's Ativan prescription. During a review, it was found that the medication order for Ativan was initially documented without a specific reason for extending beyond 14 days. The pharmacist noted that the order might have been a typo, and there was no clear rationale provided. Upon further review, the medical doctor modified the order to include a rationale, stating that the resident's chronic insomnia with fluctuating frequency justified the PRN order for more than 14 days. The doctor noted that the benefits of quality rest outweighed the risks of the medication.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 6% during a medication pass. This was due to two medication errors out of thirty-two opportunities involving two residents. The first error involved a licensed vocational nurse (LVN 1) who administered 4 units of NPH insulin to a resident at an incorrect angle of approximately 20 degrees instead of the recommended 90 degrees. This improper technique could affect the insulin's effectiveness and the resident's blood glucose levels. LVN 1 acknowledged the mistake and the need to improve his injection technique. The second error involved a registered nurse (RN 1) who failed to rotate the insulin injection site for a resident with a blood sugar level of 334. The resident received 4 units of Lispro insulin in the right lower quadrant, the same site as the previous injection. This failure to rotate injection sites goes against the recommendations of the American Diabetes Association and the American Association of Diabetes Educators, which aim to prevent lipodystrophy and ensure consistent insulin absorption. The nurse confirmed the oversight, and the Nurse Educator stated that there is a protocol in place to ensure proper rotation of injection sites.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide adequate foot care to a resident, resulting in long, crooked, and jagged toenails that caused the resident pain and discomfort. The resident, who was admitted with diagnoses including Peripheral Vascular Disease, a left foot wound, and dementia, had not received foot or hand care for over three months. During an office visit, it was noted that all ten toenails were long, and the resident complained of pain in the left foot. Despite a podiatry referral being ordered, it was not initiated, and the resident remained unaware that foot and fingernail care could be provided at the facility. Observations and interviews revealed that the resident's toenails and fingernails were excessively long, with the right thumbnail being approximately two inches long. The resident expressed discomfort and a lack of knowledge about available care services. The unit manager could not provide a reason for the neglect in nail care. The facility's foot care policy outlines responsibilities for nursing assistants and licensed nurses in inspecting and maintaining foot health, but these procedures were not followed, leading to the deficiency.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to deficiencies in their care. For Resident 1153, there was no care plan addressing the diagnosis of Hepatic Encephalopathy or the use of rifAXIMin antibiotic, despite the resident's complex medical history including dementia, pneumonia, traumatic brain injury, and seizure disorder. The lack of a specific care plan for these conditions meant that nursing staff were not adequately informed about the necessary interventions and monitoring for medication effectiveness and side effects, potentially compromising the resident's health outcomes. Both the Registered Nurse and the Director of Nursing acknowledged the absence of these care plans and the risks associated with it during their interviews and record reviews. Resident 1151's care plan also lacked specific interventions for the use of Calamine Zinc Ointment to relieve itching, despite the resident's diagnoses of dementia, congestive heart failure, recurrent urinary tract infections, depression, and fragile skin. The Registered Nurse and the Director of Nursing confirmed that a care plan should have been created to monitor the effectiveness and side effects of the medication. Similarly, Resident 1253's care plan included an intervention for Passive Range of Motion (PROM) exercises, but these were not consistently implemented or documented, as confirmed by the Nursing Manager during a review of the resident's electronic health records. Other deficiencies included the absence of a care plan for the frequency of Range of Motion exercises for Resident 56, the failure to provide continuous close observation by an assigned coach for Resident 859, and the lack of care plans for a Peripherally Inserted Central Catheter (PICC) line and Contact Isolation Precautions for Resident 1303. These omissions were confirmed through interviews with nursing staff and record reviews, highlighting a systemic issue in the facility's care planning process. The facility's policies and procedures were not followed, leading to potential risks for the residents involved.
Failure to Monitor Aero Scout Devices and Follow Care Plan
Penalty
Summary
The facility failed to provide a safe environment for three residents by not properly documenting and monitoring the placement and function of Aero Scout devices, which are used to monitor wandering patients. For Resident 61, who was admitted with dementia, there were multiple instances of missing documentation regarding the Aero Scout device. Staff interviews revealed that they did not regularly check the bracelets or keep a log of their status. The Resident Asset List (RAL) and Resident Asset List Audit (RALA) showed numerous dates with no documentation, confirming the lack of monitoring. Resident 61's care plan indicated a high elopement risk, requiring Aero Scout monitoring every shift, which was not adhered to by the staff. Similarly, Resident 1302, who had a traumatic brain injury and severe cognitive impairment, also had missing documentation for the Aero Scout device. Staff interviews confirmed that the functionality of the Aero Scout was not individually monitored or documented for each resident. The facility's policy required every shift to verify the placement and functionality of the Aero Scout, but this was not consistently done, increasing the risk of elopement for Resident 1302. Additionally, the facility failed to follow the care plan for Resident 805, who required two staff members for assistance during care. On one occasion, only one PCA was present, resulting in the resident falling out of bed and being sent to the hospital. Interviews with staff revealed that they were not aware of the care plan requirements, and the PCA assigned to Resident 805 did not check the medical record to confirm the resident's needs. The facility's policy on change of shift hand-off was not followed, leading to inadequate communication about the resident's care needs.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to ensure the infection prevention and control program (IPCP) included a facility-wide program for the surveillance, prevention, and control of healthcare-associated infections (HAIs) and other infectious diseases. For Resident 1303, the facility did not follow their policy on contact precautions and encouraged group activities despite a physician's order for continuous contact precautions. The resident was observed participating in group activities without proper precautions, and there was no documentation of an interdisciplinary team assessment determining it was safe for the resident to do so. Additionally, the facility did not follow the manufacturer's instructions for the use of Oxivir Disinfectant Cleaner while performing environmental cleaning for Resident 451, as the treated area was not allowed to remain wet for the required one minute before placing items back on the cleaned surface. The facility also failed to follow their policy on Tuberculosis (TB) symptom screenings upon readmission for Residents 553 and 1303. There was no documentation that showed a TB symptom screening assessment was completed upon their readmission to the facility. Furthermore, the facility did not follow the manufacturer's instructions on cleaning and maintaining linen warming cabinets, as observed with Blanket Warmer 1, which contained contaminated blankets and debris. For Resident 355, postings for isolation precautions were not visible, and staff did not wear proper protective equipment when entering the resident's room. Staff were also unaware of the reason for transmission-based precautions. Additionally, the facility did not ensure that a staff member wore the proper personal protective equipment (PPE) upon entry into a contact and airborne precaution room for Resident 404. For Residents 460, 461, 462, and 463, the facility did not ensure that a staff member handled and distributed clean linen in a safe manner, as the staff member was observed carrying clean linen from room to room, which could contribute to the spread of infections. These failures created an increased risk of spreading infections and communicable diseases to the residents receiving care in the facility.
Maintenance Failures in Kitchen Equipment and Flooring
Penalty
Summary
The facility failed to ensure proper maintenance of essential kitchen equipment and the physical environment, leading to several deficiencies. One of the two dish machines in the kitchen had been leaking water from both the top and bottom for about a month. The final rinse temperature gauge on the dish machine was non-operational, and despite multiple work orders and attempts to fix the issues, the problems persisted. Observations revealed water pooling on and around the machine, and significant residue buildup, indicating ongoing maintenance failures. Interviews with the Food Service Supervisors and Facility Services staff confirmed that the issues were known but not resolved, with conflicting reports on the status of work orders and repairs. Additionally, the facility failed to maintain the integrity of the flooring in the hot and cold food production areas. More than ten tiles had missing grout, leading to the accumulation of moisture and food debris. This condition was observed during general dietetic services inspections, and interviews with the Director of Food Services and Food Service Supervisor revealed that while monitoring was claimed, there was no documentation to validate requests for floor repairs. The Chief Clinical Dietitian's monthly reviews did not identify these issues, and the facility's checklist for kitchen inspections was not effectively utilized. Furthermore, the preventive maintenance of the ice machines was inadequate. A flush tube for the ice machine filter was inserted directly into a soiled floor sink, which had a buildup of black slime and brown unidentified material. The placement of the ice machine and its plumbing made it difficult to clean the floor sink properly. These observations were confirmed during interviews with the Facilities Engineer and the Director of Food Services, highlighting a lack of proper maintenance and cleanliness in critical areas of the facility's dietetic services.
Failure to Monitor Physical Restraint Device
Penalty
Summary
The facility failed to visually monitor a physical restraint device for one resident, identified as Resident 1301, who had a seat belt type restraint used during the day when in his chair or wheelchair. Resident 1301, diagnosed with Huntington's Disease and severe cognitive impairment, was observed with a non-releasing seat belt across his lap while in a wheelchair. The facility's policy required visual checks every two hours, but documentation showed gaps on five specific days, indicating a failure to monitor the restraint as required. Interviews with staff confirmed the lack of consistent documentation and monitoring. A Patient Care Assistant and a Registered Nurse both acknowledged the need for every two-hour checks and documentation, but the flowsheet review revealed missing entries on multiple days. The facility's policy emphasized the importance of ongoing monitoring and documentation to ensure the resident's safety and prevent injury, but this was not adhered to, leading to the identified deficiency.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe. A review of Form SOC 341, dated 10/24/23, indicated that two residents were involved in a physical altercation on 10/23/23 at approximately 1 p.m. The report was submitted to the California Department of Public Health on 10/24/23 at 11:06 a.m., which was beyond the mandated 2-hour reporting window. During an interview on 11/30/23, Regulatory Affairs Nurses stated they believed the abuse was not intentional, which led to the delay in reporting. The facility's policy, dated 11/14/23, mandates that all allegations of abuse be reported within 2 hours.
Failure to Update Care Plan for New Dentures
Penalty
Summary
The facility failed to revise the care plan for a resident who received new dentures on July 21, 2023. This oversight resulted in the resident not being compliant with wearing his new dentures, and the Patient Care Assistants (PCAs) were unable to implement the specific care required for the new dentures. The care plan did not include the specific dental instructions provided by the resident's dentist, which were essential for proper denture maintenance and usage. During observations and interviews conducted on November 27, 28, and 29, 2023, it was noted that the resident was not wearing his dentures during meals and required reminders to use them. The resident's care plan, which should have been updated to reflect the new denture care instructions, remained unchanged from August 1, 2023, to November 1, 2023. The nursing staff acknowledged that the care plan was not updated as required when the resident received his new dentures. The facility's policy on Resident Care Plans mandates that care plans be person-centered, evaluated during weekly or monthly summaries, and revised as needed during changes in condition. However, this policy was not followed in the case of the resident's new dentures, leading to a deficiency in providing the necessary care and instructions for the resident's oral health needs.
Failure to Document Dental Care Instructions
Penalty
Summary
The facility failed to document specific dental care instructions for a resident who received new dentures. This omission was identified during an observation and interview with the Nurse Manager, where it was noted that the resident was not wearing his dentures and required reminders to use them before eating. The resident, who was cognitively intact and required total dependence on personal hygiene, had received detailed dental care instructions that were not transcribed into the facility's electronic health record (EHR). This failure prevented Patient Care Assistants from implementing the specific care needed for the resident's new dentures. The dental progress notes indicated that the resident had received complete maxillary and mandibular resin-based partial dentures, along with home care instructions. However, these instructions were not entered into the EHR, as confirmed by the Nurse Manager. The Patient Care Assistant who attended to the resident was unaware of the specific dental care instructions and followed a different cleaning routine, which included using a denture brush and cleaning tablets. This discrepancy in care routines was observed during multiple interviews and record reviews. The facility's policy on the transcription and processing of orders requires licensed nurses to acknowledge and transcribe orders prescribed during their shift. The Nurse Manager admitted that the dental instructions should have been transcribed into the EHR, allowing staff to view and implement the specific care required for the resident's dentures. The failure to document these instructions led to inconsistent care and the resident not wearing his dentures as needed.
Failure to Provide Necessary Mealtime Assistance
Penalty
Summary
The facility failed to provide necessary assistance during mealtime for one resident, identified as Resident 451. During lunch, Resident 451, who has a history of right thalamic hemorrhage with residual left extremity weakness and dementia, was observed struggling to feed herself. She was positioned sideways to her lunch tray and had difficulty opening a juice container, which she attempted to open with her teeth. The Certified Nursing Assistant (CNA 1) assigned to her did not intervene to assist. Similarly, during breakfast, Resident 451 was observed having difficulty eating pudding from a small container, which moved around the tray with each spoonful. CNA 2 acknowledged the difficulty but did not provide the necessary assistance. Both CNAs were not familiar with Resident 451's specific meal assistance needs. A review of Resident 451's clinical record indicated that she required setup assistance with meals. However, her care plans did not include specific personalized interventions for meal assistance. The Registered Nurse (RN 9) confirmed that staff were supposed to set up the meal tray and provide assistance when needed but was unaware of the resident's difficulties. The Nursing Supervisor (NS 2) mentioned that an Occupational Therapy referral should be ordered for residents with extremity weakness for possible adaptive devices. Resident 451 confirmed through a translator that she needed more assistance during meals. The facility's policy on assisting residents during mealtime was not followed, as it required staff to assist with opening containers and preparing food for eating, which was not done for Resident 451.
Failure to Monitor Wound Progression
Penalty
Summary
The skilled nursing facility failed to monitor wound progression for Resident 351, who had developed an infection on his left lower leg. Despite being treated with antibiotics for left lower extremity cellulitis, there was no documentation in the medical record describing the status of the infection. This lack of documentation persisted for 21 days after the resident's readmission to the facility, during which time staff did not record the condition of the wound, making it difficult to assess its progression or healing status. Interviews with the nursing staff revealed that they were aware of the infection but failed to document its status. RN 1 confirmed the absence of documentation, and RN 3 admitted to observing redness on the resident's left upper thigh but did not record it. During a dressing change, RN 2 and RN 3 could not confirm the exact location of the infection, indicating a lack of proper wound assessment and documentation. The facility's policy required weekly documentation of wound assessments, including location, description, and progress towards healing, which was not followed in this case.
Failure to Perform and Document PROM Exercises
Penalty
Summary
The facility failed to provide Passive Range of Motion (PROM) exercises to a resident as per the active orders. The resident, who had no cognitive impairment or memory issues, reported that staff did not regularly perform PROM exercises on his legs and could not recall the last time they were done. The active orders specified that PROM should be performed on both lower extremities every shift to prevent further contractures. However, a review of the resident's Work List Task History revealed that PROM was not charted as performed during the day shift on multiple dates, indicating non-compliance with the active orders. During an interview, the Nursing Manager confirmed that the PROM exercises were not documented as performed during the day shift on several dates. The facility's policy and procedure for Restorative Nursing Care required that exercises be individualized, planned, monitored, evaluated, and documented in the resident's medical record. The failure to document and potentially perform the PROM exercises as ordered had the potential to negatively impact the resident's mobility and functional status.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with five medication errors observed out of fifty-five opportunities, resulting in an error rate of 9%. One incident involved RN 11 administering Metformin 850 mg to a resident without food, despite the manufacturer's recommendation to take it with food to reduce the risk of stomach upset. The resident had not had breakfast, and RN 11 acknowledged forgetting the guideline during an interview. Another incident involved RN 11 administering three different eye drops to the same resident without following proper technique, including avoiding contact between the bottle tip and the patient's eyelashes and compressing the inner eye area after drop instillation. RN 11 admitted to being unaware of the proper technique guidelines during an interview. Additionally, LVN 4 administered Saline Nasal Spray to another resident without following the facility's nasal spray administration policy. The policy required advising the resident to simultaneously squeeze the lower portion of the bottle, continue sniffing 3-4 times, and avoid blowing their nose for at least two minutes. LVN 4 did not follow these instructions and admitted to being unaware of the proper technique required by the facility policy during an interview.
Failure to Monitor and Document Medication Storage Temperatures
Penalty
Summary
The facility failed to respond to refrigerated temperature excursions for medications when the continuous temperature monitoring system Temptrak alarmed. There was no evidence of a response in accordance with facility policy. Specifically, the pharmacy did not document follow-up actions for several instances where storage temperatures deviated outside the acceptable range, triggering temperature excursion alarms during November. The temperature log failed to provide details on any corrective actions undertaken in response to the alarm events on 11/1/2023, 11/7/2023, and 11/10/2023 when temperatures reached 35.4 F, 35.8 F, and 35.3 F respectively. Additionally, there were multiple alarms identified in August and September with no documentation indicating that the pharmacy addressed these temperature excursions when the alarms went off. The Director of Pharmacy acknowledged the need for improvement in their system when the medication refrigerators trigger alarms and emphasized the importance of proper documentation and follow-up to ensure that temperature excursions do not compromise the stability of medications. The facility also failed to monitor the temperature of the medication room located in the Pavilion Mezzanine skill nursing area. During an observation and interview, the medication nurse stated that the medication in the refrigerator and in the medication room were monitored by Temptrak, but she could not locate the temperature sensor for monitoring the ambient room temperature of the medication room. The Facility Engineer confirmed that there was no sensor installed in that medication room. The facility's policy and procedure indicated that all medication rooms should be part of the wireless temperature monitoring system, but this was not adhered to in this instance. These failures could have resulted in medications not being stored in accordance with manufacturers' recommendations, potentially compromising medication stability, potency, and patient safety. The lack of adherence to the facility's updated policy on temperature logs and the absence of a temperature sensor in the medication room highlight significant gaps in the facility's protocol compliance.
Failure to Verify Vendor's Food Safety Corrective Actions
Penalty
Summary
The facility failed to ensure that ready-to-eat foods obtained from Vendor 1 met current standards for food safety. During an initial tour of the walk-in refrigerator, it was observed that there were more than 10 cases of ready-to-eat food from an outside vendor. The Director of Food Services (DFS) stated that these items were used in various settings, including the resident units' pantry and the cafe. The DFS mentioned that a Registered Dietitian had evaluated the vendor's food safety aspects 12-18 months ago, but no other inspections had been conducted since then. The DFS also noted that the vendor had submitted a food safety inspection as part of the contract implementation process. However, the facility had not followed up on the issues identified by the US Food and Drug Administration (FDA) during their inspection of the vendor's operations in April 2023, which listed four food safety concerns requiring attention. In an interview, the DFS explained that the facility's contracting process for food services included a request for pertinent certifications at the time of contract implementation and a yearly review called a Vendor Preference Request. This review monitored product quality, temperature at delivery, and cleanliness of the delivery vehicle. If issues were identified, they would be incorporated into the departmental performance improvement program and the vendor preference report. Despite these procedures, the facility had not requested additional information from the vendor regarding the identified food safety concerns as of the date of the report.
Failure to Document Influenza Immunization or Refusal
Penalty
Summary
The facility failed to follow its policy and procedure on influenza immunizations for Resident 1303. The medical record did not include documentation of influenza immunization information or the refusal of the vaccine. Resident 1303, who was readmitted with diagnoses including sepsis and multiple drug-resistant organism (MDRO) Carbapenem-resistant Enterobacterales (CRE), did not have any record of receiving information on the risks and benefits of the influenza vaccine or documentation of refusal. Despite Resident 1303 stating that the vaccine was offered and refused twice, there was no corresponding documentation in the medical record. During an interview, the Director of Infection Prevention confirmed the absence of documentation in Resident 1303's medical record regarding the vaccine administration or the reason for its omission. The facility's policy requires that the licensed nurse document the resident's vaccine administration and education in the electronic health record, and if the vaccine is not given, the reason must be documented. This failure resulted in an incomplete medical record that did not reflect Resident 1303's preferences or care needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lawton Skilled Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 9 | 0 |
| The Avenues Transitional Care Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Jewish Home & Rehab Center D/p Snf | 2.1 mi | ★★★★★ | 19 | 0 |
| Hayes Convalescent Hospital | 2.2 mi | ★★★★★ | 2 | 0 |
| California Pacific Medical Ctr- Davies Campus Hosp | 2.2 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.