Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Lakewood Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, legal blindness, and severely impaired cognition did not receive a radio headset that had been purchased and delivered for his use, despite confirmation that facility staff signed for the package. The Social Services Designee reported receiving, labeling, and placing the headset on the resident's nightstand, after which it went missing. Review of records, including social services notes and personal effects inventories, showed no documentation of the headset or its delivery, and no follow-up or grievance was initiated. This was not consistent with facility policy requiring that resident personal property be safeguarded and that inventories be completed and updated for all belongings.
A resident with osteoarthritis, prior bilateral knee surgeries, and impaired cognition experienced a fall and subsequently reported new onset left knee pain, limited range of motion, and a popping noise in the knee. Despite care plan directives to monitor and report joint pain and related symptoms to the physician, nursing staff did not ensure that the MD was promptly notified or that follow-up occurred when the pain and mechanical symptoms were reported. The resident stated that her pain was not effectively managed for months, and the DOR later noted crepitus on examination while the resident reported she had repeatedly informed nursing and rehab staff of the ongoing pain and popping.
A resident with chronic pain and impaired cognition experienced ongoing unaddressed pain when therapy staff failed to report pain-related refusals of PT and OT sessions to nursing, and nursing staff did not consistently reassess and document pain after administering medications. Therapy notes showed the resident refused ambulation and reported joint pain, yet no pain medications were given on those days and nursing was not notified. The resident later reported severe, widespread 10/10 pain, was prescribed PRN Tramadol for severe pain, but the MAR showed no administration of Tramadol or other pain medication following that report. Medication administration records also lacked numerical pain reassessments on multiple dates, and there was no IDT evaluation or modification of pain interventions after the onset of severe pain, contrary to the facility’s pain management policy.
A resident with osteoarthritis, schizophrenia, anxiety, gait abnormalities, and moderately impaired cognition had an At Risk for Fall care plan that required ensuring appropriate footwear when ambulating. Despite a documented fall risk and the need for assistance with ADLs and supervision for walking, progress notes contained no evidence that staff monitored the resident’s footwear. The resident later experienced a fall while returning from the restroom and was found barefoot, and an RN confirmed that the lack of documented footwear monitoring meant the fall-prevention intervention could not be verified as implemented.
A resident with schizophrenia, hyperlipidemia, and severe cognitive impairment, who required assistance with ADLs and supervision for bed mobility, was tied to the bed with linen by a CNA to prevent falls while the CNA attended another resident. The CNA reported securing linen across the resident’s chest and ankles to the bed, effectively restricting movement. Other staff, including another CNA, an LVN, and a PT, stated that using linen in this way constituted a restraint, removed the resident’s ability to move, stand, and walk, and required a physician’s order. The DON, referencing the facility’s Restraints and Resident Rights policies, confirmed that this action violated the resident’s right to be free from restraints imposed for non-medical reasons and to move freely with dignity and respect.
A resident with a history of falls, impaired mobility, and moderate cognitive impairment was being assisted to the restroom by a CNA who failed to follow the facility's ambulation policy. Instead of walking next to or slightly behind the resident as required, the CNA walked in front, resulting in the resident losing balance and falling. The resident sustained a laceration above the eyebrow that required hospital treatment and sutures.
A resident with bilateral hip fractures, severe cognitive impairment, and declining mobility did not receive ordered ROM care for the legs after an ortho visit failed to clarify WB and ROM limits, and the facility did not track or report the resident’s ROM changes. The resident also missed ordered RNA AROM to both arms on multiple scheduled days, and later records showed bilateral knee contractures and abnormal lower-body positioning.
A resident with severe cognitive impairment and dependence for bed mobility fell from bed while a CNA provided incontinence care alone and without placing the LALM in static mode, resulting in a facial injury and hospital transfer. Other residents were observed without ordered safety measures in place: one was not wearing an ordered helmet, one had sharpened pencils without adequate supervision, and one was smoking without the required cigarette extender. Staff interviews and record review showed the ordered precautions were not consistently implemented.
PHI was found in regular trash when a diet type report and menu tickets containing resident names, room numbers, allergies, diet orders, and other identifying information were discarded instead of shredded. Staff stated this had been their routine practice. In addition, one resident with dementia and Parkinson’s disease was observed unclothed with the curtain open and visible to others, and another resident was observed during care with the curtain not fully closed, leaving the resident exposed while a CNA assisted with dressing and transfer.
A facility failed to provide ordered meds, supplements, screenings, and skin-related monitoring for multiple residents, while also failing to assess and document changes in condition. One resident with severe dementia and COPD missed routine meds, nutrition support, and monitoring; another resident with schizophrenia and HTN missed BP meds and COVID screening; a resident with a rash had no documented COC assessment or MD notification; a resident ordered to wear a helmet was repeatedly observed without it while the EMAR falsely showed it was applied; and another resident with a spreading rash and pressure ulcers had no documented dermatology follow-through or ongoing skin assessment.
Failure to follow physician orders resulted in two residents not receiving ordered meds, supplements, and monitoring. One resident with HTN and schizophrenia missed amlodipine, clonidine, Ingrezza, a house supplement, and COVID screening, while another resident with COPD and dementia missed donepezil, ferrous sulfate, a probiotic, ipratropium-albuterol, supplements, diabetic snacks, blood sugar monitoring, and COVID screening. RN confirmed there was no documentation showing the orders were carried out.
Surveyors found discontinued controlled meds mixed with active meds in multiple med carts. Lorazepam and temazepam labeled for several residents, including one discharged resident, remained in carts even though current orders were no longer in place. Staff and the DON acknowledged the meds should have been removed, separated, and handled per policy, but they were still stored with current resident meds.
Kitchen staff failed to consistently prepare IDDSI level 4 puree and level 6 soft bite-sized foods according to recipes and size/texture standards. An employee preparing puree vegetables used an unlevel measuring cup and added about 2 cups of potato flakes, while the RD found some puree items too thick or watery on spoon tilt testing. Another employee served soft bite-sized stir fry vegetables with zucchini pieces about 2 to 2.5 cm and then mashed them with a whisk instead of chopping them to the required 1.5 cm size.
Food Temperature, Presentation, and Texture Deficiencies: A RD observed multiple lunch items served at improper temperatures, including hot foods that were lukewarm and cold items that were too warm, and noted crowded trayline presentation with a tortilla touching beans on a double portion tray. The RD also observed soft bite-sized stir-fried vegetables being mashed with a whisk rather than remaining appropriately chopped, and stated the food did not meet standards for appetizing appearance and texture.
Incorrect Texture and Size Preparation for Puree and Soft Bite-Sized Diets: A facility failed to prepare puree/IDDSI level 4 and soft bite-sized/IDDSI level 6 foods to the required consistency and size. Puree items were observed as too thick or watery during IDDSI testing, and soft bite-sized vegetables contained zucchini pieces larger than the required 1.5 cm size and were mashed rather than properly chopped. The diet manual and recipes required specific texture and size standards for these diets.
Kitchen food safety and sanitation practices were not maintained. The walk-in refrigerator and freezer had temperature log entries outside required ranges, dented cans were stored with undented cans, and staff were observed wearing jewelry while handling plates and serving food in tray line. The ice machine had a torn gasket, food storage containers had tape residue, pots and pans were stacked wet instead of air-dried, and scratched cutting boards were in use.
A review of the facility's Room Waiver Request showed multiple rooms did not meet the required 80 sq. ft. per resident in shared rooms, including several 4-bed rooms and several 2-bed rooms with less space than required. During survey observations, no adverse effects were noted related to residents' care, privacy, health, or safety, and the ADM stated the facility typically admitted residents for behavioral and psychological problems.
Failure to provide language interpretation and communication tools for two residents with documented language barriers. One resident with severe cognitive impairment and a Korean-only communication care plan was spoken to in English, and no communication board was at the bedside; staff said they were unaware of translator services and had not been trained to use them. A second resident with severe cognitive impairment and preferred languages of Korean and Chinese also had no bedside communication tools, and staff again reported speaking English and not knowing the resident’s preferred language or how to access translator services.
A resident with multiple psychiatric diagnoses and a smoking care plan was unable to exercise her choice to smoke when an LVN told her she could not go out during the first smoking break because of a mix-up. The resident said she was being ignored and that her doctor had allowed her to smoke, while another RN later stated the LVN should not have told her she could not smoke. The facility had designated smoking times and a smoking policy for residents who smoke.
Unsanitary shower and restroom conditions were observed in multiple cottages, with stained grout, visible brown to black buildup, and mosquitoes and gnats in one shower area. Two residents with impaired cognition and ADL support needs reported feeling dirty, uncomfortable, and itchy, and one resident said the condition had been present since admission. An LVN and the HS both stated the areas were not acceptably clean, and facility policy required a clean, sanitary, comfortable, and homelike environment.
Failure to Provide Ordered One-to-One Supervision Allowed Resident-on-Resident Physical Abuse: A resident with schizoaffective disorder, impaired judgment, and a history of impulsive aggression was ordered for one-to-one monitoring, but was only checked every 30 minutes instead of being continuously supervised. As a result, the resident punched another resident in the nose while he slept after prior incidents of hitting, choking, and scratching had already been documented.
Inaccurate MDS Oral/Dental Assessment: A resident with dysphagia, schizophrenia, and bipolar disorder was assessed on the MDS as having no oral/dental issues, even though she was observed eating pureed food and stated she did not have her teeth. The MDS nurse later confirmed the oral/dental status was coded incorrectly and should have reflected that the resident was edentulous.
The facility failed to develop individualized care plans for two residents with identified needs. One resident with severely impaired cognition spoke Farsi and could not understand English, but no language barrier care plan or communication board was in place. Another resident with intact cognition had multiple broken and missing teeth, reported difficulty chewing, and had no care plan addressing the dental issue despite staff awareness.
A resident with muscle weakness, hemiplegia, psychosis, and impaired cognition had significant recent weight loss and was ordered weekly weights plus dietary supplements, snacks, and added fluids. Staff did not obtain the ordered weekly weight after the initial four-week period, and the resident was observed hungry, asleep during lunch service, with an unopened supplement at the bedside. The CNA documented lunch intake inaccurately, and the DON stated the intake should have reflected minimal consumption.
Medication administration errors exceeded the allowable rate when an LVN failed to check a resident’s HR before giving carvedilol, furosemide, sacubitril-valsartan, and spironolactone, and also gave metformin, carvedilol, and senna outside their ordered times. The resident had HTN with heart failure, DM, and mildly impaired cognition, and the DON confirmed the medications should have been given within the ordered time frame and with the required vital sign checks.
Failure to Check HR Before Administering BP Medications: An LVN gave carvedilol, furosemide, sacubitril-valsartan, and spironolactone to a resident with HTN and heart failure without checking the ordered HR parameter first. The resident’s BP was taken, but the HR was not verified before the medications were prepared and administered. The DON and CP stated the HR check was required because carvedilol and the other BP medications can affect HR and BP, and the carvedilol dose was also given outside the scheduled time.
Failure to Transcribe Hospice Ativan Order: A resident with end-stage Alzheimer's disease and severe cognitive impairment was receiving hospice services when a hospice medication change for Ativan was communicated to an LVN, but the verbal order was not transcribed into the EMR at the time it was received. The hospice record showed the resident's Ativan dose was adjusted and the facility's DON stated verbal orders were expected to be entered into the EMR promptly, consistent with the facility policy.
Failure to implement EBP for two residents with indwelling urinary catheters. One resident had UTI, BPH, CKD, and schizophrenia, and another had BPH, Alzheimer's disease, dementia, and schizoaffective disorder. Observations showed both residents had Foley catheters in place, but no EBP signage or PPE was posted outside either room. Staff and the IPN confirmed EBP should have been in place for catheter care, and the facility policy required signage and PPE for residents with indwelling medical devices.
A resident with schizophrenia, DM2, contractures, and moderately impaired cognition was exposed during dressing assistance when the privacy curtain did not fully enclose the bed. The CNA left the curtain partially open because the resident preferred to see outside, and staff observed that the curtain lacked enough length to close completely, leaving the resident visible during care. The DSD and DON stated the curtain should be fully closed to prevent viewing the resident during care.
A resident with schizophrenia, epilepsy, and severely impaired cognitive skills did not have a working call light available in the room. Surveyors observed the call light button attached to the bed while the cord was not connected to the wall system. A CNA stated she had not checked whether it was functional, and an RN stated staff were responsible for ensuring call lights were within reach and working so residents could call for help as needed.
Staff were not trained on the location or use of communication boards and interpreter services, and multiple CNAs, LVNs, and an RN stated they were unaware of the language translation line. A resident with severely impaired cognition and a Farsi language barrier could not understand English questions, and no communication board was observed in the room. Facility records showed communication training did not include translator services, even though policy referenced communication boards/charts and interpreter services.
Excessive Occupancy in Resident Bedroom: A room was observed housing eight residents even though the facility census and accommodation analysis showed the room had capacity for eight residents and the survey cited a deficiency for exceeding the limit of no more than four residents per room. The ADM reviewed the room waiver request and stated the facility normally admitted residents for behavioral and psychological problems and would continue to request a waiver.
A resident with severe cognitive impairment and a history of aggressive behavior struck another resident in his room, leaving the victim feeling violated and unsafe. Staff witnessed the incident and intervened, but failed to properly document, report, or implement protective interventions as required by facility policy. Key personnel, including the DON and social services, were unaware of the event, and no updates were made to care plans or records following the altercation.
Staff failed to report a witnessed altercation between two residents, one with severe cognitive impairment and another with moderate impairment, to the appropriate authorities as required. Although CNAs observed and reported the incident to an LVN, no documentation or further reporting occurred, and the event was not communicated to administration or CDPH. This lack of action delayed investigation and did not comply with facility policy for abuse reporting.
Two residents with significant cognitive and mental health impairments were involved in an altercation that was witnessed and reported by CNAs, but not documented or investigated by nursing staff as required by facility policy. The incident was not reported to administration or CDPH, and no clinical records reflected the event, resulting in a delay in investigation and a failure to follow abuse reporting procedures.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with COPD, schizoaffective disorder, and interstitial lung disease was admitted with physician orders for oxygen therapy, but no care plan was developed or implemented to address this need. Staff interviews and policy review confirmed that a care plan should have been in place to guide monitoring and interventions for oxygen administration.
A resident with COPD and cognitive impairment received oxygen at higher flow rates than prescribed, and the nasal cannula in use was not labeled with an open date as required by facility policy. Nursing staff confirmed the oxygen was not set according to the physician's order and that infection control protocols for labeling and changing the nasal cannula were not followed.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
A resident with severe cognitive impairment and behavioral disturbances was not provided with required 1:1 monitoring as ordered by the physician following a resident-to-resident altercation. Staff did not assign personnel for 1:1 monitoring on multiple days, and there was no documentation of behavioral reassessment or physician notification to clarify the ongoing need for monitoring.
A resident with cognitive impairment and multiple medical conditions was identified as an elopement risk, but staff did not follow the care plan intervention to monitor and document wandering behavior. Despite the care plan's directive, no episodes were recorded, and the resident ultimately left the facility unnoticed. Staff interviews confirmed the intervention was not implemented as required.
A resident with cognitive impairment and a history of fluctuating decision-making capacity eloped from the facility after staff failed to regularly inspect the exterior gate and did not document wandering behavior as required by the care plan. The gate's old padlock and chain were not routinely checked, and staff did not monitor or record episodes of wandering, despite facility policies mandating these actions.
A resident with impaired cognition and inability to make medical decisions was involved in an abuse allegation but the responsible party was not notified due to incorrect documentation on the face sheet. Staff interviews confirmed that the nurse did not contact the responsible party, relying on inaccurate records, despite facility policy requiring such notification.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with cognitive impairment and multiple medical conditions was treated roughly and spoken to disrespectfully by a CNA during personal care, leading the resident to feel unvalued and uncomfortable. The CNA admitted to being abrupt and did not report the resident's complaint of head pain to nursing staff, contrary to facility policy requiring respectful, person-centered care and prompt reporting of resident discomfort.
A resident with multiple medical and mental health diagnoses continued to smoke after a neurologist issued an order to avoid smoking due to health risks. The facility did not update the care plan or implement new interventions such as smoking cessation education or behavioral support, and the Interdisciplinary Team did not meet to address the new order. Staff acknowledged the care plan was not revised to reflect the smoking restriction.
A resident with multiple medical and mental health diagnoses did not receive ordered dental and podiatry services, nor was a neurologist's order for weekly drug testing clarified or implemented. The resident was observed with long, untrimmed toenails and reported dental discomfort, while staff confirmed that no appointments or drug testing had been arranged as required by physician orders and facility policy.
A resident with severe cognitive impairment and multiple medical conditions was able to exit the facility through an unsecured window due to the absence of a required screw, incomplete elopement risk assessment that did not include input from the responsible party, and lack of monitoring for known elopement triggers. Staff were unaware of the window's vulnerability and did not actively monitor the resident's behaviors related to elopement risk.
A resident with cognitive impairment and skin conditions did not receive prescribed hydrocortisone cream for dermatitis, and a dermatology consult order was not implemented. Nursing staff confirmed the orders were not transcribed or carried out, contrary to facility policy and expectations.
Two cognitively impaired residents, both at risk for falls, were left in their room during deep cleaning with a wet floor and an unattended bottle of Clorox spray. The housekeeping staff left the room to perform another task, leaving the residents exposed to potential hazards, despite facility policies and care plans indicating the need for supervision and removal of hazards during such procedures.
Failure to Safeguard and Document Resident Personal Property
Penalty
Summary
The facility failed to safeguard and document a resident's personal property, specifically a radio headset purchased and delivered for the resident's use. The resident had dementia, legal blindness, severely impaired cognitive skills for daily decision-making, and required supervision for ADLs. The resident's H&P noted fluctuating capacity to understand and make medical decisions. The resident's representative reported that the resident never received the radio headset, despite confirmation from the delivery company that facility staff had signed for the package. The headset was intended to support the resident due to his legal blindness and enjoyment of music. Review of the resident's admission record, Social Services Progress Notes, Inventory Lists, and Electronic Personal Effects Inventory Forms over several months showed no documentation of the radio headset or of its delivery. The Social Services Designee stated it was standard practice to document deliveries and update the resident's inventory list to reflect all personal belongings, and recalled receiving the delivery, labeling the item, and placing it on the resident's nightstand. The Social Services Designee further stated the item later went missing and no follow-up or grievance was initiated to locate or replace it, and acknowledged that the delivery should have been documented and a grievance filed. The facility's Personal Property policy required that residents' personal property be respected, safeguarded, and properly documented, with an inventory completed on admission and updated for additions, removals, or changes, which was not done in this case.
Failure to Promptly Notify Physician of New Onset Knee Pain After Fall
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician and ensure appropriate follow-up when a resident reported new onset left knee pain and functional changes following a fall. The resident, who had a history of osteoarthritis, prior bilateral knee surgeries, schizophrenia, anxiety, chondrocostal junction syndrome, and gait and mobility abnormalities, was initially admitted on an unspecified date. Her MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for assistance with ADLs including toileting, showering, dressing, and supervision or touching assistance for walking. Her care plan for arthritis, initiated 4/1/2025, directed staff to monitor, document, and report to the physician signs and symptoms such as joint pain, stiffness, swelling, decline in mobility or self-care, contracture formation, joint shape changes, crepitus, and pain after exercise or weight bearing. On 10/9/2025, a change of condition note documented that the resident was found sitting on the floor by her bed after losing her balance while returning from the restroom, indicating a fall event. On 10/12/2025, three days after the fall, licensed nursing staff were made aware of the resident’s report of new onset left knee pain and limited range of motion, but the facility did not ensure confirmation of physician notification. On 1/24/2026, the resident again complained of left knee pain accompanied by a popping noise, yet there was no confirmation that the physician had been notified at that time. During interviews, the resident reported that she had undergone two prior knee surgeries, felt that metal hardware was moving in her knee, and stated that her pain had not been effectively managed for three months. During an observation and interview on 1/27/2026, the Director of Rehabilitation examined the resident’s knee, noted a clicking consistent with crepitus, and the resident reported that the popping noise had worsened since the fall and that she had consistently reported the popping and pain to nursing and rehabilitation staff. These documented inactions and lack of confirmed physician notification and follow-up constituted the cited deficiency.
Failure to Assess, Communicate, and Manage a Resident’s Pain
Penalty
Summary
The deficiency involves the facility’s failure to effectively assess, reassess, and manage pain for a resident with chronic conditions including osteoarthritis, schizophrenia, anxiety, chondrocostal junction syndrome, and gait abnormalities. The resident’s MDS showed moderately impaired cognition and a need for assistance with ADLs. The care plan for arthritis directed staff to monitor, document, and report joint pain and related symptoms, and the chronic pain care plan instructed staff to anticipate pain needs and respond immediately to any complaint of pain. After a fall on 10/9/2025 that led to hospital evaluation, the resident reported worsening popping sensations and pain in the knee, which she stated she had repeatedly reported to nursing and rehabilitation staff, and she reported going 11 days without pain medication despite numerous complaints. On multiple occasions, therapy staff did not communicate the resident’s pain complaints and therapy refusals to nursing for assessment and intervention. On 10/15/2025, a physical therapy note documented a refusal to ambulate without a reason, and the MAR showed no pain medication given that day; the PTA later stated the resident had complained of pain and that he did not notify nursing. On 10/22/2025, the physical therapy note documented joint pain and refusal to ambulate, with no corresponding pain medication on the MAR, and the PTA acknowledged the resident continued to complain of left knee pain and that he should have notified the charge nurse. On 1/27/2026, the resident told an occupational therapist she was in pain and declined an OT session, but the OT did not notify the assigned LVN, who reported she had not been informed of any pain complaints. During interviews and observation on 1/27/2026, the resident was seen holding her knee, appearing uncomfortable, and reporting 10/10 pain and that staff were not addressing her pain. Nursing staff also failed to document numerical pain reassessments after administering pain medication and did not implement ordered pharmacologic interventions for new-onset severe pain. Review of Medication Administration Progress Notes for 12/2025 through 1/2026 showed that numerical pain ratings were not documented to evaluate the effectiveness of pain medication on several dates, which RN 1 confirmed meant the facility did not accurately assess and track the medication’s effectiveness. A change of condition note on 10/28/2025 documented new-onset 10/10 pain in both arms, both legs, and the coccyx; the resident refused Tylenol and ibuprofen and was prescribed Tramadol 50 mg PO every eight hours PRN for severe pain. The MAR contained no documentation that Tramadol or any other pain medication was administered following this report of 10/10 pain, and the DON stated the resident’s pain was not treated as ordered. Review of 2025 IDT notes showed no interdisciplinary evaluation or modification of pain management interventions after the new-onset 10/10 pain was reported, which the DON stated was a missed opportunity to address the resident’s pain management needs. The facility’s pain management policy required IDT review of pain assessments, resident-centered care planning, administration and documentation of pain medications, timely re-evaluation of pain within one hour after medication, and physician notification for new-onset or unrelieved pain, which were not followed in this case.
Failure to Implement Fall-Prevention Footwear Intervention
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement an existing At Risk for Fall care plan for one resident. The resident’s admission record showed diagnoses including osteoarthritis, schizophrenia, anxiety, chondrocostal junction syndrome, and gait and mobility abnormalities. An MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for moderate assistance with toileting, showering, and dressing, and supervision for walking. The resident’s At Risk for Fall care plan, initiated 4/10/2025, included an intervention to ensure the resident wore appropriate footwear when ambulating. A Fall Risk Evaluation dated 10/6/2025 indicated the resident was at risk for a fall. On 10/9/2025, a Change of Condition Note documented that the resident was found sitting on the floor by the bed and reported losing balance and falling while returning from the restroom to the bed. A Post Fall Evaluation from the same date indicated the resident was barefoot at the time of the fall. During an interview and concurrent record review with an RN on 1/27/2026, the resident’s progress notes from 10/2025 and the At Risk for Fall care plan were reviewed, and the progress notes lacked documentation that the resident’s footwear was monitored. The RN stated that, because there was no documented monitoring of footwear, the intervention could not be verified as implemented and that this lack of effective implementation of the care plan placed the resident at increased risk for a fall. The facility’s Comprehensive Person-Centered Care Planning policy required development and implementation of a comprehensive care plan with measurable objectives and timeframes to meet identified needs.
Unauthorized Use of Linen as a Physical Restraint
Penalty
Summary
The deficiency involves the use of physical restraints without a physician’s order when a CNA tied a resident to the bed using linen. The resident had diagnoses including schizophrenia and hyperlipidemia and, per a recent MDS, had severe cognitive impairment, required partial/moderate assistance for ADLs such as bathing, and needed supervision or touching assistance for movements like rolling and changing positions. According to the facility’s five-day investigation report, the CNA acknowledged placing linen to the bed of this resident to protect and ensure the resident did not sustain a fall while the CNA attended to another resident. In a later interview, the CNA stated they had tied linen across the resident’s breast and ankles to the bed to ensure the resident would not fall while the CNA was occupied elsewhere. Multiple staff interviews confirmed that using linen in this manner restricted the resident’s movement and constituted a restraint. CNA 1 stated staff should not use an object across a resident’s lap to keep them in bed because it takes away the resident’s right to move, stand, and walk. LVN 1 stated staff should not use linen across a resident because it restricted movement, even if the resident was a fall risk. The PT stated that tying the resident to the bed using linen across the lap was a type of restraint that required a doctor’s order and that the facility does not use blankets as restraints. CNA 2 acknowledged that tying the resident to the bed was a form of restraint and could have affected the resident’s dignity, and that they should have called other staff for help instead. The DON, referencing the facility’s Restraints and Resident Rights policies, stated that CNA 2 did not follow policy by not honoring the resident’s right to move freely, and the written policies indicated residents have the right to be free from restraints imposed for reasons other than treatment of medical symptoms and to be treated with kindness, respect, and dignity.
Failure to Follow Ambulation Policy Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's ambulation policy and procedure for a resident with a history of falls, abnormal gait, osteoporosis, and moderately impaired cognition. The resident required moderate assistance with walking and was identified as being at risk for falls. On the day of the incident, the resident attempted to get out of bed to use the restroom, and a CNA, who was monitoring the resident, approached to assist. Instead of following the policy, which required staff to stand on the resident's weakest side and slightly behind during ambulation, the CNA walked in front of the resident while leading her to the restroom. The CNA stated that the resident did not like to be touched or held, and as the CNA reached for the restroom door, the resident lost her balance and fell. Because the CNA was in front, she was unable to catch the resident or prevent the fall. As a result of the fall, the resident sustained a laceration above the right eyebrow, requiring transfer to an acute care hospital for evaluation and sutures. The facility's Director of Rehab and Director of Nursing confirmed that the staff member should have walked next to or slightly behind the resident to provide proper supervision and assistance, as outlined in the facility's ambulation policy.
Failure to Provide ROM Services and Monitor Mobility Changes
Penalty
Summary
The facility failed to provide ROM services and monitor mobility changes for a resident with bilateral femoral neck fractures and significant cognitive impairment. The resident had been independent with bed mobility, transfers, and ambulation without an assistive device before the hip fractures, but after the fractures the resident was repeatedly placed on orders for non-weightbearing and no ROM to both legs until cleared by the orthopedic physician. After the orthopedic appointment, the physician note did not document weight-bearing status or ROM parameters, and the facility continued the prior restrictions without clarifying the orders with the physician. From 9/17/2025 through 12/4/2025, the resident did not receive ROM exercises to both legs. The report states the facility also did not identify or report changes in ROM to the primary care physician and responsible party during that period. The resident’s therapy records showed ROM impairments in both hips and knees, and later PT evaluation documented the resident positioned with both legs rotated to the right, both hips and knees bent, and contractures in both knees. The report states these failures resulted in undetected contractures to both knees and abnormal positioning of the lower spine and both hips into rotation toward the resident’s right side. The facility also failed to provide ordered AROM to both arms three times per week after the resident was discharged from OT and the RNA was ordered to provide the exercises. Documentation survey reports for multiple dates in October, November, and December showed missing entries for the ordered RNA AROM sessions. In addition, the facility did not implement its Contracture - Prevention and Management policy, which required monitoring and assessing ROM limitation upon admission and quarterly. The resident’s records also showed severe impaired cognition, dependence for multiple ADLs, and limited mobility throughout the period reviewed.
Failure to Follow Safety Interventions for Bed Mobility, Helmet Use, Sharp Objects, and Smoking
Penalty
Summary
The facility failed to provide care and services to prevent accidents for four residents. One resident with morbid obesity, generalized muscle weakness, a history of falls, osteoarthritis, and severe cognitive impairment was dependent on staff for rolling in bed and toileting hygiene, and her care plan indicated she was dependent on staff for repositioning and turning in bed. She also had an order for a low-air-loss mattress for skin integrity maintenance and prevention. On 11/27/2025, while CNA 4 was providing perineal hygiene and repositioning care, the resident rolled over and fell from the bed, striking her face on the floor. The resident was later transferred to an acute care hospital, where records showed a left orbital floor fracture, left orbital proptosis, and soft tissue swelling and hematoma to the left eye and maxillary area. During interview, CNA 4 stated he was performing care alone even though the resident required two-person assistance for repositioning and incontinence care. He also stated he did not adjust the low-air-loss mattress to static mode before care and that the resident was less than six inches from the edge of the mattress when she slid off the bed. The MDS nurse stated the resident was dependent and required two staff at the bedside for repositioning and toileting hygiene, and the DON stated the fall was avoidable. The DSD stated staff had been educated to use two-person assistance and to place the mattress in static mode before providing care to residents on a low-air-loss mattress. A second resident with metabolic encephalopathy, psychosis, right-sided weakness, lack of coordination, gait and mobility abnormalities, and a history of falls had a physician order and care plan directing staff to apply a helmet at all times, but observations showed the resident repeatedly in bed without a helmet. A charge nurse stated the resident did not have a helmet in her belongings and that she was responsible for ensuring orders were implemented. Another resident with paranoid schizophrenia, cognitive impairment, fluctuating disorganized thinking, and delusions was observed carrying sharpened pencils in the hallway without supervision, and sharpened pencils were also found in the resident's bedside drawer. Staff interviews indicated the resident was unpredictable and that pencils should not have been in her possession, while the DON stated the resident should have supervision while using pencils. A fourth resident with schizoaffective disorder, alcohol abuse, anxiety disorder, muscle weakness, lack of coordination, and major depressive disorder was identified as a smoker and had a smoking assessment and care plan requiring a cigarette holder/extender. The resident was observed smoking on the patio without the extender on more than one occasion. The Activities Director stated the extender was required to help prevent burns, that extenders were kept with residents' cigarettes in assigned drawers, and that no extender was present in this resident's drawer at the time of observation.
PHI Discarded in Trash and Resident Privacy Not Maintained During Care
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential by allowing documents containing protected health information to be discarded in regular trash instead of being shredded. During observation, a diet type report was seen in the trash can by the handwashing sink, and it contained residents’ names, room numbers, drug and food allergies, diet orders, diet texture, diet consistency, supplements, and additional directions. During observation of the dishwashing process, staff were seen throwing menu tickets into a gray garbage can. The Dietary Supervisor stated the menu tickets and diet list contained resident names, room numbers, diet information, allergies, and medication information, and acknowledged they were being thrown in the trash rather than shredded. The facility’s policy stated that protected health information in paper records must be destroyed in a manner that renders it unreadable and unrecognizable, including shredding, and that whole documents may not be disposed of in the trash. The Dietary Supervisor stated the menu tickets had been thrown in the trash “forever” and that the diet list and menu tickets were not supposed to be in the trash because someone could get the residents’ information and use it. The report identified this as affecting 295 of 295 residents because the documents contained resident-identifying information. The facility also failed to maintain resident privacy during personal care for two residents. One resident with major depressive disorder, toxic encephalopathy, dementia, and Parkinson’s disease, and who lacked capacity and had severely impaired cognition, was observed sitting on the bed unclothed with the privacy curtain open, visible from the hallway and to other residents in the room. The resident’s brief was untaped and falling off, exposing the buttocks, and the resident stated she was cold. A CNA who was not assigned to the resident observed the situation, acknowledged it was a dignity issue, but did not dress the resident or provide privacy before leaving the room. Another resident with schizophrenia, Type 2 diabetes mellitus, and contractures was observed during care with the curtain drawn only to the foot of the bed rather than fully closed. The resident’s incontinence brief and both legs were exposed while a CNA was assisting with dressing and transferring the resident. The resident stated she did not mind the curtain not being fully drawn, and the CNA stated the curtain was left that way because the resident preferred to see outside while being changed. The DSD and DON stated the curtain should be completely closed during care to prevent viewing the resident in a vulnerable state, and the DSD noted the resident did not have a care plan for a preference to keep the curtain open during care.
Missed Treatments, Poor Skin Monitoring, and Inaccurate Documentation
Penalty
Summary
The facility failed to assess and monitor changes in condition, implement ordered and care-planned interventions, ensure timely administration of medications, and maintain accurate medical records for five residents. The report documents missed medications, supplements, and monitoring for one resident with hypertension and schizophrenia who was severely cognitively impaired and dependent on staff for multiple activities of daily living. On a reviewed day, the resident’s MAR showed no licensed staff initials for routine blood pressure medications, Ingrezza, a house supplement, or COVID screening, and the progress notes contained no explanation for why the medications were not given or why the physician was not notified. Another resident with severe dementia and COPD had multiple ordered medications, nutritional supplements, diabetic snacks, and monitoring requirements that were not documented as completed on the same reviewed day. The MAR lacked licensed staff initials for donepezil, ferrous sulfate, probiotic, ipratropium-albuterol inhalation solution, Ensure, a house supplement, diabetic snacks, COVID screening, and hyperglycemia monitoring. The progress notes also lacked documentation explaining why the resident did not receive the ordered care or whether the physician was notified. The facility policy stated medications are to be administered as prescribed and any missed dose must be documented on the MAR. The report also describes a resident with a rash on both forearms whose condition was observed during the survey, but the nursing progress notes did not document a change in condition, assessment, or physician notification. Staff interviews indicated the rash should have been assessed and reported, and the DON stated it should have been treated as a change in condition with physician notification and care plan updates. In addition, a resident ordered to wear a helmet at all times was repeatedly observed without the helmet, while the charge nurse documented that the helmet had been applied even though she stated she had not applied it and had clicked the wrong documentation in the EMAR. Finally, a resident with stage 4 pressure ulcers and a fungal rash had a care plan calling for a dermatology consult, but the record lacked documentation that the dermatologist was contacted or that the consult occurred. The resident was observed with circular brown to pink rashes across the legs, lower back, and lower abdomen, and staff stated the rash had spread from the pubic area. The nursing progress notes and skin checks lacked documentation of ongoing assessment, progression, response to treatment, or modification of interventions, and staff interviews confirmed the consult order had not been followed through or documented.
Failure to Follow Physician Orders for Medications, Supplements, and Monitoring
Penalty
Summary
The facility failed to ensure physician orders were followed for two residents. One resident had diagnoses including hypertension and schizophrenia, was documented as lacking capacity to understand and make decisions due to paranoid schizophrenia, and was severely cognitively impaired and dependent on staff for multiple activities of daily living. The resident’s orders included amlodipine, clonidine, Ingrezza, house supplement/milkshakes, and daily COVID-19 screening, but the December MAR showed these medications, the supplement, and the day-shift COVID screening were not provided on 12/13/2025, with no licensed staff initials documenting administration. A second resident had diagnoses including COPD and dementia, was described as very confused from severe dementia, and was severely cognitively impaired with extensive assistance needs for eating and personal care. The resident’s orders included donepezil, ferrous sulfate, a probiotic, ipratropium-albuterol inhalation solution, sugar-free house supplement/milkshake, diabetic snacks, Ensure, and monitoring for hypoglycemia and hyperglycemia. The December MAR showed the resident did not receive the ordered medications, supplements, diabetic snacks, or blood sugar monitoring on 12/13/2025, and the resident was not monitored or screened for COVID symptoms during the day shift. During interviews, RN 5 stated residents must receive their medications daily, that licensed nurses are expected to administer all medications, and that if a medication is not administered it must be documented in the nursing progress notes or MAR. RN 5 also stated there was no documented evidence that either resident received the ordered medications, supplements, or monitoring on 12/13/2025, and confirmed the licensed nurses did not follow the physician orders. The facility policy stated medications are to be administered as prescribed, recorded before staff go off duty, and documented on the MAR if a dose is not administered.
Discontinued controlled medications left in medication carts
Penalty
Summary
The facility failed to remove and separate discontinued controlled medications from current residents’ medications in multiple medication carts. During observation, interview, and record review, surveyors found discontinued lorazepam and temazepam stored together with active medications in West Station Medcart 1, South Station Medcart 1, and [NAME] Station Medcart 2. The facility’s policy required discontinued controlled medications to be removed from the medication cart, marked, stored separately, and given to the DON for disposal or destruction. In West Station Medcart 1, surveyors found two discontinued lorazepam supplies labeled for Resident 59, including 13 tablets from one fill and 56 tablets from another fill. Record review showed Resident 59 had been hospitalized and later readmitted with a new lorazepam order at a different station, and staff stated the discontinued medication should not have remained in the cart once the resident was no longer assigned there. The DON stated the medication should have already been given to the DON for destruction, and staff also stated that if a discontinuation occurred on a Friday, the medication might remain in the cart until Monday because the DON may not be at the facility on the weekend. In South Station Medcart 1, surveyors found discontinued controlled medications for seven residents stored with current residents’ controlled medications, including lorazepam for Residents 24, 29, 63, 127, and 288, temazepam for Resident 257, and lorazepam and temazepam for discharged Resident 45. Record review showed these residents did not have current physician orders for the medications found in the cart, and Resident 45 was no longer in the facility. Staff acknowledged the medications should have been given to the DON and stored separately. In [NAME] Station Medcart 2, surveyors found a medication card labeled for Resident 237 containing lorazepam after the order had been discontinued. The DON stated the medication should not have been in the cart and should have been separated for disposal. The facility policy stated discontinued medications are to be stored in a separate location and controlled medications remaining after discontinuation are to be retained in a securely double locked area until destroyed.
Kitchen staff failed to prepare IDDSI puree and soft bite-sized foods to required standards
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and demonstrated competency when preparing IDDSI level 4 puree foods and IDDSI level 6 soft bite-sized foods. During observation of puree food preparation, [NAME] 2 prepared puree stir fry vegetables by using a white perforated scoop to measure vegetables, adding broth, and blending the food, but then added approximately 2 cups of potato flakes using a measuring cup that was not leveled. [NAME] 2 stated he used broth and followed the recipe, and also stated he added potato flakes and liquid thickener to achieve the right consistency and would place the puree vegetables back in the oven and check after. The Dietary Supervisor stated cooks should follow the recipe, keep puree foods smooth and in the right portion sizes, and perform the spoon tilt test, and stated unlevel measuring cups would make the recipe inaccurate and could result in too much potato flakes being added. During concurrent observation and interview of the puree test tray, the Registered Dietitian and Dietary Supervisor observed puree fried rice, puree Chinese roasted chicken, and puree salad. The RD stated the puree fried rice and puree Chinese roasted chicken were a little thick because they left a thick film during the spoon tilt test, and the puree salad was watery because it fell too quickly during the spoon tilt test. The RD stated puree foods that were not in the right consistency would not be palatable and could affect swallowing and nutritional intake. The facility’s diet manual and recipes stated puree foods should be smooth, free of lumps, hold their shape, and pass IDDSI level 4 testing requirements, and the recipe for puree vegetables specified 1 1/2 to 3 cups of instant potatoes as a stabilizer for 48 servings. During observation of soft bite-sized stir fry vegetables at the trayline, big chunks of zucchini were seen measuring approximately 2 to 2.5 cm. [NAME] 1 was observed mashing the vegetables in the steam well using a whisk. The RD stated the vegetables were not consistent in size because the zucchini pieces were bigger than 1.5 cm and that the vegetables looked mashed rather than chopped. The facility’s diet manual for IDDSI level 6 stated all food must be chopped into pieces no larger than 1.5 cm by 1.5 cm and that cooked vegetables not meeting size specifications should be avoided. Records showed both [NAME] 1 and [NAME] 2 had completed IDDSI-related training and had competency documentation signed by the Dietary Supervisor, and the in-service records showed [NAME] 1 attended IDDSI transition training while [NAME] 2 did not sign the attendance record.
Food Temperature, Presentation, and Texture Deficiencies
Penalty
Summary
Food was not prepared and served at safe, appetizing temperatures during lunch observations. On 12/1/2025, the Registered Dietitian observed and took temperatures of the regular diet test tray and found cinnamon apricots at 64.9 F, country baked beans at 103.1 F, a roast beef melt on a soft roll at 104 F, and lettuce and tomatoes at 92.3 F. During a separate observation the same day of the soft bite-sized tray, the RD recorded French onion soup with chopped vegetables at 106.7 F, a minced and moist roast beef melt on a soft roll at 113 F, soft chopped country baked beans at 110.1 F, soft chopped cinnamon apricot at 64.7 F, and milk at 47.3 F. The facility's daily cook's spreadsheet showed these items were intended for regular and IDDSI level 6 diets, and the RD stated the food temperatures did not meet standards because hot food should be served hot and cold food cold. Plate presentation was also observed to be crowded and unattractive during trayline assembly. On 12/15/2025, a double portion tray was observed overflowing, and the quesadilla was on top of the bowl of beans. During interview, the RD stated plate presentation should be appetizing and that crowded food is acceptable for double portions only if the tortilla is not going or touching the beans. The RD stated the tortillas could get soft and acceptability could be affected, resulting in residents not eating the food. The facility also failed to maintain the intended texture of soft bite-sized vegetables. On 12/16/2025, an employee was observed mashing the soft bite-sized stir-fried vegetables with a whisk in the steam well. The RD stated the vegetables were not consistent in size because the zucchini pieces were too large and that the vegetables looked mashed rather than chopped. The facility's food preparation policy stated the dietary department is responsible for preparing nutritionally adequate, attractive, well-balanced meals and maintaining standards of food quality.
Incorrect Texture and Size Preparation for Puree and Soft Bite-Sized Diets
Penalty
Summary
The facility failed to prepare foods in the correct texture and size for residents ordered puree/IDDSI level 4 and soft bite-sized/IDDSI level 6 diets. For residents on puree diets, the daily cook’s spreadsheet listed puree Chinese roasted chicken, puree fried rice, puree stir fry vegetables, puree mandarin Asian salad, and puree citrus cake with puree pineapple fluff topping. During observation of puree food preparation, a cook used broth and a blender for the vegetables, then added an unmeasured amount of potato flakes and liquid thickener to achieve the desired consistency. The Dietary Supervisor stated measuring cups should be leveled to ensure accuracy, but the cook did not level the cups and instead added potato flakes until the food was smooth and free of lumps. During the puree test tray observation, the Dietary Supervisor and Registered Dietitian evaluated puree salad, puree fried rice, and puree Chinese roasted chicken. The RD stated the puree fried rice and puree Chinese roasted chicken were a little thick and left a thick film during the spoon tilt test, while the puree salad was watery and fell too quickly during the test. The facility’s diet manual and recipes for IDDSI level 4 foods required pureed items to be smooth, free of lumps, hold their shape, not be too firm or sticky, and pass IDDSI level 4 testing requirements, including the spoon tilt and fork drip tests. The facility’s policy also stated standardized recipes were to be used and recipe accuracy concerns were to be reported for evaluation and modification. For residents on soft bite-sized/IDDSI level 6 diets, the daily cook’s spreadsheet listed chopped tender Chinese roasted chicken, chopped soft-moist fried rice, chopped soft stir fry vegetables, chopped mandarin Asian salad, and chopped citrus cake. During observation at the trayline, the soft bite-sized stir fry vegetables contained large chunks of zucchini measuring approximately 2 to 2.5 cm. A staff member was observed mashing the vegetables in the steam well with a whisk. The RD stated the vegetables were not consistent in size because the zucchini pieces were larger than 1.5 cm and had been mashed rather than chopped. The facility’s diet manual defined soft bite-sized foods as chopped into pieces no larger than 1.5 cm by 1.5 cm and stated cooked vegetables that do not meet size specifications should be avoided.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
Food safety practices were not maintained in the kitchen and dietary storage areas during multiple observations and record reviews. The walk-in refrigerator had no internal thermometer visible during observation, and the external gauge read 33 F, while the walk-in freezer also had no internal thermometer visible and the external gauge read 2 F. Review of the refrigerator/freezer temperature log showed the refrigerator at 42 F on 12/10/2025 and the freezer at 10 F on 12/3/2025 and 12/14/2025. The Dietary Supervisor and Assistant Dietary Supervisor stated the acceptable ranges were 41 F or below for the refrigerator and 0 F or below for the freezer, and that temperatures outside those ranges could allow food to spoil and become unsafe for resident consumption. In the dry storage area, three dented cans were stored on the same shelf as non-dented canned foods. The Dietary Supervisor stated dented cans were defined as cans with dents in the seam or body and that dented cans were supposed to be kept in a separate labeled area in the preparation area. The facility’s receiving policy stated dented, rusted, or damaged cans should not be accepted. The report also documented that the Dietary Supervisor and Dietary Aide were observed wearing jewelry while working in food service areas: the Dietary Supervisor wore a spiral elastic bracelet with a dangling key that touched plates and equipment in tray line, and the Dietary Aide wore a gold ring with a stone while serving food in tray line. The Registered Dietitian stated the key on the wrist was not allowed, and that kitchen staff were not allowed to wear rings for infection control. Additional sanitation issues were observed in the kitchen. The ice machine had a torn gasket, and the Dietary Supervisor stated the black seal was coming off. Two plastic food storage containers had tape and sticker residue on them. Pots and pans were stacked wet in the storage area instead of being air dried, and the Dietary Supervisor and Registered Dietitian stated wet stacking was not appropriate because items should be completely air-dried. Three cutting boards were observed with scratches, and the Dietary Supervisor stated scratched cutting boards should be replaced because they can harbor harmful bacteria and cause cross-contamination. The report identified these conditions in the dietary department serving food and ice to medically compromised residents.
Room Size Below Required Square Footage in Multiple-Occupancy Rooms
Penalty
Summary
The facility failed to meet the required room size measurement of 80 sq. ft. per resident in multiple-occupancy rooms. A review of the facility's Room Waiver Request Letter, dated 8/6/2025, showed that several rooms did not meet the required space: ACU-1A, ACU-3A, ACU-4A, ACU-6A, ACU-7A, and ACU-8A each had 4 beds and 310 sq. ft. instead of the required 320 sq. ft.; ACU-4B had 2 beds and 154 sq. ft. instead of 160 sq. ft.; ACU-5B had 2 beds and 152 sq. ft. instead of 160 sq. ft.; and S7 had 2 beds and 141 sq. ft. instead of 160 sq. ft. During observations throughout the survey from 12/15/2025 to 12/18/2025, no adverse effects were observed related to residents' care, privacy, health, or safety in connection with the reduced living space. During a concurrent interview and record review on 12/18/2025 at 2:35 p.m., the ADM reviewed the Room Waiver Request and stated the facility normally admitted residents for behavioral and psychological problems and would ensure residents' health and safety were not adversely affected. The facility's P&P titled Room Waiver, revised 12/1/2015, stated the management team would observe rooms to ensure they were in accordance with residents' special needs and would not adversely affect residents' health and safety or impede their ability to attain their highest wellbeing.
Failure to Provide Language Interpretation and Communication Tools
Penalty
Summary
The facility failed to ensure translator services or communication boards were provided for two residents with documented language barriers. Resident 155 was admitted with diagnoses including metabolic encephalopathy, psychosis, right-sided weakness, lack of coordination, gait and mobility abnormalities, and a history of falls. Her MDS indicated severe cognitive impairment and dependence on staff for mobility in bed, eating, oral hygiene, and upper-body dressing. Her care plan identified her as Korean-speaking only and directed staff to provide a translator and use alternative communication tools as needed. During observation and interview, CNA 1 was speaking to Resident 155 in English and stated she could not remember the resident’s preferred language. No communication tools were observed at the bedside, and CNA 1 stated there was no communication board or alternative communication tool available. CNA 1 also stated she was not aware of any translator services and had never been trained to use them. LVN 1 stated she did not know how to check the resident’s preferred language, had always spoken to her in English, and acknowledged the care plan indicated Korean and translator use. Resident 159 was admitted with diagnoses including dementia, anxiety disorder, and major depressive disorder. Her MDS indicated severe cognitive impairment, dependence on staff for all ADLs and mobility, and preferred languages of Korean and Chinese. Her care plan identified Korean as her preferred language and directed staff to provide a translator and use alternative communication tools as needed. At the bedside, CNA 2 found no communication board or other communication tools, and CNA 3 stated she provided care in English, had not been told the resident’s preferred language, and had not been trained to use translator services. LVN 1 stated she did not know the resident’s preferred language was Korean and spoke to her in English. The facility policy stated residents’ individual needs and preferences were to be accommodated and staff were to interact in a way that promoted communication and maintained dignity.
Resident Denied Scheduled Smoking Opportunity
Penalty
Summary
The facility failed to ensure that Resident 104 was able to exercise her choice to smoke. Resident 104 was admitted and later readmitted to the facility and had diagnoses including major depressive disorder, anxiety disorder, metabolic encephalopathy, paranoid schizophrenia, schizoaffective disorder, and bipolar type. Her H&P dated 12/4/2025 indicated she had the capacity to understand and make decisions and that she was a smoker, while her MDS dated 11/23/2025 indicated severely impaired cognition, supervision needed for eating, dependence for toileting and bathing, and wheelchair use for mobility. Her smoking care plan and smoking/safety assessment identified her as a smoker requiring supervision, with designated smoking locations and times based on facility policy. During observation and interview on 12/17/2025 at 11:33 a.m., Resident 104 was standing at the nurse's station speaking loudly and using profanity toward LVN 3 while trying to request her smoking break. Resident 104 stated she was being ignored and said she was not allowed to smoke earlier that morning even though her physician had given her permission to smoke. LVN 3 stated Resident 104 was not allowed to smoke during the first smoking break due to a mix-up and said she would contact Activities to see if the resident could go out to smoke, then walked away without further explanation. RN 3 later stated Resident 104 had previously been told she could not smoke when she returned from the hospital, but that this was not a recent instruction, and stated LVN 3 should not have told the resident she could not smoke. The facility's smoking schedule listed designated smoking times, and the smoking policy stated residents would be informed of designated smoking areas and any set smoking schedules.
Unsanitary shower and restroom conditions
Penalty
Summary
The facility failed to maintain resident shower rooms and restrooms in clean, sanitary, and homelike conditions in Cottages 4, 5, 6, and 7. Surveyors observed shower grout and restroom grout with visible black to brown-colored substance and brown staining. In Cottage 6, mosquitoes and gnats were observed along the shower walls. The condition was observed in areas used by residents for bathing and toileting, and the facility's housekeeping supervisor stated that deep cleaning of the restrooms occurred once a month and that the showers did not appear to have been cleaned properly for an extended period. Resident 74, who had diagnoses including anxiety, major depressive disorder, and schizophrenia, was admitted with moderately impaired cognitive skills for daily decision making and required set-up or clean-up assistance with ADLs. During interview, Resident 74 stated she saw several bugs, insects, mosquitoes, and flies in her cottage. Resident 48, who had diagnoses including anxiety, major depressive disorder, and bipolar disorder, also had moderately impaired cognitive skills for daily decision making and required set-up or clean-up assistance with ADLs. During observation and interview, Resident 48's restroom and shower in Cottage 4 were noted to have stained grout with a brown to black-colored substance, and Resident 48 stated the restroom and shower had been dirty since admission. Resident 48 stated the dirty restroom and shower made him feel dirty, uncomfortable, and itchy. The LVN who observed the restrooms and showers in Cottages 5, 6, and 7 stated the conditions were not consistent with how she would clean her own home and were not acceptable to her standard of cleanliness. The LVN also stated that persistent visible dirt, soap scum, and the presence of mosquitoes and gnats had the potential to make residents feel uncomfortable and unclean, and posed a safety concern related to infection control. Facility policy required a pleasant, clean, orderly, safe, sanitary, and comfortable environment for residents.
Failure to Provide Ordered One-to-One Supervision Allowed Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse for two sampled residents when it did not ensure one-to-one supervision was provided for a resident with documented impulsive and physically aggressive behaviors. Resident 45 had diagnoses including schizoaffective disorder, anxiety, COPD, and hypertensive heart disease, and the MDS indicated moderately impaired cognitive skills for daily decision making and a need for supervision or touching assistance with ADLs. The H&P stated the resident did not have the capacity to understand and make decisions, and the physician progress note described ongoing behavioral fluctuations, impaired judgment, functional limitations in self-care, and the need for close monitoring. Resident 45’s record showed repeated aggressive incidents involving another resident, including striking, hitting, choking, and scratching, with IDT notes documenting plans to transfer the resident to the GACH after these events. The behavior care plan directed one-to-one monitoring for safety every shift and intervention as necessary to protect the rights and safety of others, and an order summary showed one-to-one supervision was ordered. However, the monitoring sheet indicated the resident was monitored every 30 minutes by CNA 5 rather than being continuously supervised, and at approximately 2:55 a.m. on 12/5/2025, Resident 45 punched Resident 110 on the right side of his nose while he slept.
Inaccurate MDS Oral/Dental Assessment
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident by not correctly addressing oral and dental status. Resident 72 was admitted with diagnoses including dysphagia, schizophrenia, and bipolar disorder, and the MDS dated 9/26/2025 indicated severely impaired cognition and the need for moderate assistance with ADLs. The same MDS also indicated the resident had no oral and/or dental issues. During a concurrent observation and interview on 12/15/2025, Resident 72 was seen eating breakfast and stated she was eating pureed food because she did not have her teeth. During a later interview and record review with the MDS nurse, the MDS oral/dental status was reviewed and identified as coded incorrectly because it did not reflect that the resident was edentulous. The MDS nurse stated the assessment should have reflected that the resident did not have her natural teeth and acknowledged that the inaccurate coding did not match the resident's actual oral and dental status.
Failure to Care Plan Language Barrier and Dental Needs
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans for two residents addressing identified needs. One resident had schizophrenia, hypertension, dorsalgia, presbyopia, and severely impaired cognition, and during observation was speaking Farsi and unable to understand questions asked in English. No communication board was observed in the resident’s room, and the chart did not contain a language barrier care plan. An RN stated that residents with a language barrier required a specific care plan to ensure effective communication and that this resident needed an individualized care plan addressing the identified language barrier. Another resident had dysphagia, schizophrenia, and diabetes mellitus, with intact cognition and capacity to understand and make decisions. During observation, the resident was noted to have multiple broken and missing natural teeth and stated it was hard to chew anything and that the resident had not seen a dentist in a long time. Review of the resident’s care plans showed no plan addressing the dental status, and the MDS nurse stated the resident did not have a care plan for broken and missing teeth even though the issue was known. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet each resident’s medical, nursing, mental, and psychosocial needs.
Failure to follow ordered weekly weights and document meal intake accurately
Penalty
Summary
The facility failed to implement dietary recommendations for a resident with nutrition concerns by not performing the ordered weekly weights and by inaccurately documenting lunch intake. The resident was admitted on 11/12/2025 and had diagnoses including general muscle weakness, hemiplegia following cerebral vascular disease affecting the left non-dominant side, and unspecified psychosis. The MDS dated 11/12/2025 indicated the resident had difficulty communicating some words or finishing thoughts, usually understood verbal content, had clear speech, moderately impaired cognition, and required substantial/maximal assistance for eating. The resident’s weight log showed weekly weights of 139.6 pounds on 11/12/2025, 139.8 pounds on 11/17/2025, 135.6 pounds on 11/24/2025, 130.2 pounds on 12/1/2025, and 129 pounds on 12/8/2025. A Nutrition/Dietary Note dated 12/2/2025 documented a 5.4-pound, 4% weight loss in one week and directed the house shake supplement to be given three times daily with meals, snacks to be added three times daily, and 8 ounces of water to be added with meals. The physician also ordered weekly weights for four weeks, and the care plan was revised to include weekly weights for four weeks and monitoring meal percentage with physician notification if supplements were refused. On 12/16/2025, the resident was observed in bed with a bedside table holding an unopened chocolate house shake supplement and water. The resident stated feeling hungry and said, "I can't stop thinking about food," and did not know when lunch was served. CNA 6 placed the lunch tray on the bedside table while the resident was sleeping, and the resident remained asleep during later observation. RNA 1 stated the resident was not weighed that week because the four weeks of weekly weights after admission had been completed, while the RD stated the resident should have been weighed again on 12/15/2025 and that the facility did not know whether the resident had gained or lost weight. The DON stated the resident should have been weighed on 12/15/2025 and that the meal intake should have been documented as 0-25% if the resident drank two sips of the meal replacement shake.
Medication administration errors exceeded the allowable rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%. During observation, interview, and record review, six medication errors were identified out of 25 opportunities, resulting in a 24% medication error rate for one sampled resident observed during medication administration at the East Station medication cart. The resident involved had diagnoses including hypertensive heart disease with heart failure, diabetes mellitus, and gastroesophageal reflux disease without esophagitis. The resident’s MDS indicated mildly impaired cognition. The care plan identified hypertension and risk for hypotension and falls, and included interventions to give antihypertensive medications as ordered. The physician orders included carvedilol, furosemide, sacubitril-valsartan, spironolactone, metformin, and senna, with specific hold parameters for blood pressure and heart rate for several of the medications. During the medication pass, the LVN was observed checking the resident’s blood pressure but not the heart rate before preparing and administering medications that required vital sign assessment. The LVN prepared and administered carvedilol, furosemide, sacubitril-valsartan, and spironolactone without first checking the resident’s HR. The LVN also administered metformin at 10:34 a.m. even though the order was for 7:30 a.m. with a meal, and carvedilol and senna were also not administered at their scheduled times. The LVN stated the resident’s HR should have been checked before giving the blood pressure medications and acknowledged that the doctor was not notified when metformin and the other scheduled medications were given at different times from ordered. The DON confirmed that the medications should have been given within one hour of the scheduled time and that the physician should have been notified if medications were to be administered at a different time.
Failure to Check HR and Follow Medication Parameters Before Giving BP Medications
Penalty
Summary
The facility failed to ensure Resident 53 was free from significant medication errors when several blood pressure-related medications were administered without following the physician’s ordered parameters. Resident 53 was admitted and readmitted to the facility with diagnoses including hypertensive heart disease with heart failure, diabetes mellitus, and GERD without esophagitis. The care plan, initiated in February 2025, identified HTN and risk for hypotension and falls, and directed staff to give antihypertensive medications as ordered. The resident’s MDS dated October 2025 indicated mildly impaired cognition, HTN, and DM. Resident 53’s medication orders included carvedilol 6.25 mg twice daily for HTN, furosemide 40 mg daily for BLE edema, sacubitril-valsartan 24/26 mg twice daily for HTN, and spironolactone 25 mg daily for CHF, each with instructions to hold for specified BP and/or HR parameters. During a medication pass observation, the LVN obtained a BP of 116/82 mmHg but did not check the resident’s HR before preparing and administering the medications. The LVN prepared and gave multiple morning medications, including carvedilol, furosemide, sacubitril-valsartan, and spironolactone, without first verifying the HR as required by the orders and facility policy. During interview, the LVN stated she usually checks both BP and HR but forgot to check the HR before giving the medications. She also stated the HR should have been checked before preparing and giving the blood pressure medications and that interactions between carvedilol and the other BP medications were not checked. The DON stated the LVN should have checked BP and HR before administering these medications because they can affect BP and cause hypotension if given below the ordered parameters. The DON also stated carvedilol was scheduled for 8:00 a.m., should be given within one hour of the scheduled time, and the physician should be notified if it is given at a different time, with the notification documented in the nursing progress notes. The consultant pharmacist stated carvedilol is usually given with food and may reduce HR, making HR checks important before administration.
Failure to Transcribe Hospice Ativan Order
Penalty
Summary
The facility failed to ensure staff transcribed a verbal order for Ativan for a resident receiving hospice services. Resident 64 was admitted and later re-admitted to the facility with diagnoses including encounter for palliative care, repeated falls, history of falling, and Alzheimer's dementia. The resident's H&P dated 12/19/2025 indicated the resident did not have the capacity to understand and make decisions and was admitted to hospice care due to end-stage Alzheimer's disease. The MDS dated 12/29/2025 indicated severe cognitive impairment and dependence on facility staff for all ADLs. During a telephone interview, the hospice clinical manager stated Resident 64 was ordered Ativan 0.5 mg every 6 hours as needed from 12/29/2025 to 1/1/2026, and that the dose was increased to 1 mg every 6 hours as needed on 1/1/2026 after hospice staff communicated the change to LVN 4 during an in-person visit. The hospice record indicated the hospice physician adjusted the resident's medications, LVN 4 was updated on the changes, and a new medication list was faxed to the facility. The resident's discontinued physician orders reflected the Ativan dose changes, and the DON stated that when a verbal order is received, the nurse is expected to transcribe it into the EMR at the time it is taken. The facility policy also stated the licensed nurse receiving the verbal or telephone order was to transcribe the order into the medical record at the time the order is taken.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to implement enhanced barrier precautions for two residents with indwelling urinary catheters. Resident 300 was admitted with diagnoses including UTI, BPH with lower urinary tract symptoms, CKD, and schizophrenia. His H&P indicated he had the capacity to understand and make decisions, while the MDS indicated moderately impaired cognition. His care plan for an indwelling catheter, initiated on 12/7/2025, did not include enhanced barrier precautions, and the order summary showed an active order for an indwelling catheter via gravity drainage for BPH. During observation, Resident 300 was lying in bed with an indwelling urinary catheter secured to the right leg and covered under his pant leg. He stated he emptied the urinary drainage bag himself in the restroom. No enhanced barrier precautions signage or PPE was observed outside his room. LVN 6 stated EBP signage and PPE should have been implemented upon admission, and the Infection Preventionist Nurse stated Resident 300 should have been placed on EBP because of the indwelling urinary catheter and that licensed nursing staff were responsible for identifying residents requiring EBP without waiting for IPN review. The IPN acknowledged the EBP had been overlooked. Resident 28 was originally admitted and later readmitted with diagnoses including BPH, Alzheimer's disease, dementia, and schizoaffective disorder. The MDS indicated severely impaired cognition and maximum assistance with ADLs. The order summary showed an active order for Foley catheter care every shift. During observation, Resident 28 was lying in bed with an indwelling urinary catheter and drainage bag secured to the right side of the bed, and there was no EBP signage or PPE outside the room. TXN 1 confirmed the signage had not been posted and PPE was not available at the room entrance, and the IPN stated the required signage and PPE were not present and that staff could unknowingly provide care without appropriate PPE. The facility policy stated residents with indwelling urinary catheters require EBP, including signage at the room entrance and PPE outside the room.
Incomplete Privacy Curtain During Resident Care
Penalty
Summary
The facility failed to provide a privacy curtain that fully enclosed one resident’s bed during care. Resident 188 had diagnoses including schizophrenia, Type 2 diabetes mellitus, and contractures of multiple muscle sites including both ankles and knees. The resident’s MDS indicated the resident could express ideas and wants, understood verbal content, had clear speech, had moderately impaired cognition, and required substantial to maximal assistance for toileting, upper body dressing, and lower body dressing. During observation, Resident 188 was being assisted with dressing while sitting at the edge of the bed, with the incontinence brief and both legs exposed as a CNA placed the resident’s legs through pants. The room door was open and a soiled linen cart was directly outside the room. The privacy curtain was drawn between the resident and the roommate, but it did not completely close around the bed and lacked about three feet to fully enclose it. The CNA stated the curtain was drawn to the foot of the bed because the resident preferred to see outside while being changed. The DSD and HS observed that pulling the curtain around the bed caused the opposite end to open between the resident’s bed and the roommate’s bed, and the DSD stated the curtain did not completely close around the bed for privacy. The DON stated the privacy curtain should be closed completely to prevent viewing the resident during care.
Nonworking Call Light Not Available to Resident
Penalty
Summary
A working call system was not available in a resident's room and bathing/toileting area when surveyors observed the resident's call light button attached to the bed but the cord not attached to the call light system on the wall. The resident involved had schizophrenia and epilepsy, and the H&P stated the resident did not have the mental capacity to understand and make decisions. The MDS indicated the resident's cognitive skills for daily decision making were severely impaired, and the resident required supervision for eating and oral hygiene, as well as moderate assistance for toileting hygiene, dressing, shower/bathing, and personal hygiene. During interviews, a CNA stated staff were supposed to check residents' call lights at the beginning of every shift to ensure they were within reach and working, but she did not know whether this resident's call light was functional because she had not checked it and did not notice it was not attached to the wall system. An RN stated it was every staff member's responsibility to make sure residents had a call light within reach and working, and that everyone entering the room should have noticed it was not hooked up. The facility's policy stated it would maintain a communication system allowing residents to call for staff assistance from their rooms and toileting/bathing facilities.
Failure to Train Staff on Communication Boards and Interpreter Services
Penalty
Summary
The facility failed to ensure staff were aware of and trained on the location and use of the communication board and language translation line for residents with language barriers. During interviews, CNA 1, CNA 3, LVN 1, CNA 14, LVN 4, and RN 4 stated they were not aware of translator services or the language translation line, and several staff stated they had not been trained to use translator services. The Director of Staff Development stated staff received communication training and that communication methods were to be resident-centered, but also stated she was not aware of translator services in the facility at first and later stated translator services were available but were not included in staff in-services or training. Review of the facility’s 2022 Communicating Effectively training and the 7/2025 Resident Rights/Communication in-service showed that availability of and use of translator services were not taught to staff. Resident 32 was admitted on 08/21/2013 and re-admitted on 09/26/2018 with diagnoses including hypertension, dorsalgia, presbyopia, fracture of the nasal bones, and dysphagia oropharyngeal phase. The resident’s MDS dated 10/10/2025 indicated severely impaired cognition and a need for supervision or touching assistance. During observation, Resident 32 was speaking Farsi and was not able to understand questions asked in English, responding only with “Farsi. Farsi.” No communication board was observed in the resident’s room. During interviews in the resident’s room, CNA 14 stated the resident could vocalize basic needs and use basic hand gestures but could not ask or answer more in-depth questions because of the language barrier, and CNA 14 was not aware of a communication board location or the existence of a language translation line. LVN 4 stated the resident was understood through body language but was unaware of whether a communication board was in the room, at the nursing station, or elsewhere in the facility, and was also not aware of a language translation line. RN 4 stated a communication board should be available at every nurse’s station and that all staff should be trained on the location and use of communication boards and translation lines. The facility policy titled Accommodation of Residents’ Communication Needs stated staff would provide adaptive devices as needed, including communication boards/charts and interpreter services for foreign languages and sign language.
Excessive Occupancy in Resident Bedroom
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents in one of 98 rooms, Room S4. The Facility Census dated 12/15/2025 showed Room S4 had the capacity to accommodate eight residents, and the Client Accommodation Analysis dated 8/5/2025 showed Room S4 measured 655 square feet. During the initial tour on 12/15/2025 at 11:35 a.m., Room S4 was observed occupied by eight residents. During observations throughout the survey from 12/15/2025 to 12/18/2025, surveyors noted no adverse effects related to adequacy of space, nursing care, comfort, or privacy for the residents in Room S4, and the room had enough space for the residents' beds and dressers. During a concurrent interview and record review on 12/18/2025 at 2:35 p.m., the Administrator reviewed the facility's Room Waiver Request dated 8/6/2025 and stated Room S4 had eight residents in the room and that the facility would continue to request a room waiver.
Failure to Protect Resident from Physical Abuse and Lack of Incident Reporting
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident reported being struck by another resident who entered his room. The resident who committed the act had a documented history of severe cognitive impairment, fluctuating behavior, agitation, aggression, and previous incidents of intrusive and aggressive actions toward others and staff. Despite these behavioral concerns and a recent wrist fracture of unknown origin, there was no documentation in the clinical records regarding the altercation, no updated care plans, and no evidence of protective interventions implemented after the incident. Multiple staff interviews revealed that two certified nursing assistants (CNAs) witnessed the aggressive resident attempting to strike the other resident, who was in bed at the time. The CNAs responded to calls for help and intervened to prevent further aggression. The incident was reported to the charge nurse, but not to the administrator or other required parties. The charge nurse and registered nurse supervisor both denied knowledge of the altercation, and there was no documentation or reporting of the event in the clinical records for either resident. The social services representative and director of nursing also confirmed they were unaware of the incident and emphasized that such events should be reported and investigated promptly. The facility's own policy prohibits any form of resident abuse and requires reporting and intervention. However, the lack of documentation, failure to update care plans, and absence of protective measures following the altercation demonstrate a breakdown in communication and adherence to policy. The incident left the affected resident feeling violated and unsafe, and the facility did not take the necessary steps to address or prevent further abuse.
Failure to Timely Report Resident-to-Resident Altercation to Authorities
Penalty
Summary
The facility failed to report a witnessed resident-to-resident altercation involving two residents to the California Department of Public Health (CDPH), as required by law and facility policy. The incident involved one resident with severe cognitive impairment and fluctuating behavior, who attempted to strike another resident with moderate cognitive impairment and a history of delusions. The altercation was witnessed by two Certified Nursing Assistants (CNAs), who responded to calls for help and observed the aggressive behavior. Both CNAs reported the incident to a Licensed Vocational Nurse (LVN), but the LVN did not notify the administrator, document the incident, or initiate a report to CDPH. A review of the clinical records for both residents revealed no documentation of the altercation, and interviews with the LVN and Registered Nurse Supervisor (RN) confirmed they were unaware of the incident. The LVN only reported a complaint of wrist pain as an injury of unknown origin, without linking it to the altercation. The Director of Nursing (DON) stated that any allegation of abuse, including resident-to-resident altercations, should be reported within two hours, and acknowledged that yelling for help should have triggered an abuse report. The facility's policies require prompt reporting and investigation of all allegations of abuse, including resident-to-resident altercations. However, the lack of documentation, failure to notify appropriate authorities, and absence of timely reporting delayed an onsite investigation by CDPH and did not ensure the safety and protection of all residents in the facility.
Failure to Investigate and Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its Abuse Reporting and Investigations policy by not thoroughly investigating allegations of resident abuse involving two residents. Both residents had significant cognitive and mental health impairments, with one resident having severe dementia and fluctuating decision-making capacity, and the other diagnosed with major depressive disorder, psychosis, and schizophrenia. Despite these vulnerabilities, there was no documentation in the clinical records regarding a resident-to-resident altercation that occurred between them. Certified Nursing Assistants (CNAs) reported witnessing an incident where one resident attempted to strike another while the latter was in bed. The CNAs responded to calls for help and observed aggressive behavior, subsequently reporting the incident to a Licensed Vocational Nurse (LVN). However, the LVN denied knowledge of the altercation, did not notify the administrator, failed to document the incident, and did not initiate a report to the California Department of Public Health (CDPH). The Registered Nurse Supervisor (RN) was also unaware of the incident, and there was no clinical documentation of the event. Interviews with facility leadership confirmed that abuse allegations should be investigated promptly, with intervention required for any type of abuse. The facility's policies require prompt reporting, investigation, and documentation of resident-to-resident altercations. However, the lack of documentation, failure to notify appropriate personnel, and absence of an investigation into the reported altercation constituted a failure to follow established procedures, resulting in a delay in the onsite investigation by CDPH and a deficiency in protecting residents from potential abuse.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident who required oxygen therapy. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), schizoaffective disorder, and interstitial lung disease, was admitted and readmitted to the facility with orders for oxygen administration at two liters per minute via nasal cannula to maintain oxygen saturation at or above 92%. Despite these medical needs and physician orders, a review of the resident's electronic record revealed that no care plan addressing oxygen administration was created. Interviews with facility staff, including an LVN and the DON, confirmed that a care plan for oxygen therapy should have been developed to provide guidance on monitoring, interventions, and the specifics of oxygen delivery. The facility's policies and procedures also required comprehensive, person-centered care planning based on physician orders and resident needs. The absence of a care plan for oxygen therapy meant there was no documented guidance for staff on how to manage the resident's oxygen needs.
Failure to Administer Oxygen Therapy Safely and According to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not administering oxygen therapy according to the physician's orders and not following infection control protocols. Observations revealed that the resident was receiving oxygen at varying flow rates of 5 LPM and 3 LPM, while the physician's order specified oxygen at 2 LPM via nasal cannula to maintain oxygen saturation at or above 92%. Additionally, the nasal cannula in use was not labeled with an open date, contrary to facility policy, which requires nasal cannulas to be changed weekly and labeled to ensure proper infection control. Interviews with nursing staff confirmed that the oxygen flow rate was not set according to the doctor's order and that the nasal cannula lacked the required date label. The staff acknowledged that licensed nurses are responsible for setting oxygen as prescribed and for labeling and changing nasal cannulas as per policy. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and cognitive impairment, requiring supervision and assistance with daily activities. The facility's policy and procedure on oxygen therapy emphasized the need for safe administration and proper labeling of equipment, which was not followed in this instance.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Follow Physician Order for 1:1 Monitoring
Penalty
Summary
The facility failed to follow physician orders for one resident who had a documented need for 1:1 monitoring. The resident, who had diagnoses including polyarthritis and severe cognitive impairment due to unspecified dementia with behavioral disturbances, was involved in a resident-to-resident altercation. Following this incident, physician orders were issued for 1:1 monitoring and additional 30-minute checks every shift for a specified period. However, staff interviews and record reviews revealed that the facility did not assign staff to provide 1:1 monitoring on at least two days, and there was no documentation that the resident's behaviors were evaluated or that the physician was contacted to clarify the ongoing need for 1:1 monitoring. Further review indicated that the care plan and physician orders were clear about the need for 1:1 monitoring, but the facility did not have a policy stating that such orders should automatically end after a certain period. The Director of Nursing and Director of Staff Development both acknowledged that staff should have reassessed the resident and communicated with the physician regarding the continuation of the order. The facility's policy required licensed nurses to ensure physician orders were clear and complete, including the duration when appropriate, but this was not followed in this case.
Failure to Implement Care Plan Intervention for Wandering Behavior
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as an elopement risk. The resident, who had diagnoses including schizophrenia, type 2 diabetes mellitus, and anemia, was noted to have fluctuating capacity for decision-making and moderately impaired cognitive skills, requiring supervision for daily activities. Although the care plan specified that wandering behavior should be documented and diversional interventions attempted, staff did not monitor or document any episodes of wandering, as they believed the resident had not exhibited such behavior. This lack of documentation and monitoring occurred despite the care plan's directive and the resident's identified risk factors. Interviews with facility staff, including a registered nurse and the assistant director of nursing, confirmed that the intervention to document wandering behavior was not followed. The staff acknowledged the importance of documenting such behaviors to prevent incidents and ensure continuity of care. The facility's policy required comprehensive, person-centered care planning, but there was no evidence that the specified intervention was implemented, resulting in the resident leaving the facility unnoticed.
Failure to Prevent Resident Elopement Due to Lapses in Gate Inspection and Documentation
Penalty
Summary
The facility failed to prevent a resident from eloping by not conducting regular inspections of the exterior gate and by not documenting the resident's wandering behavior as required by the care plan. The resident, who had diagnoses including schizophrenia, type 2 diabetes mellitus, and anemia, was admitted with fluctuating capacity to understand and make decisions. The Minimum Data Assessment indicated the resident had moderately impaired cognitive skills and required supervision for daily activities, but had not previously exhibited wandering behavior. Despite this, the care plan identified the resident as an elopement risk and required documentation of wandering episodes. On the day of the incident, the resident was last seen early in the morning and was later found missing. Interviews revealed that the Director of Maintenance had not kept a documented log of routine inspections for the exterior gate, which was secured with an old padlock and chain. The padlock was found to be disengaged, likely due to force applied by the resident. Additionally, nursing staff did not monitor or document the resident's wandering behavior as outlined in the care plan, and there was no evidence of tracking or reporting these episodes. Facility policies required both regular maintenance inspections and documentation of elopement risks and interventions, but these were not followed, resulting in the resident leaving the facility unsupervised.
Failure to Notify Responsible Party of Abuse Allegation
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident following an abuse allegation involving another resident. The resident in question had a history of schizoaffective disorder, major depressive disorder, and anxiety disorder, and was assessed as having moderately impaired cognition. Although the resident could make needs known, medical records indicated that the resident could not make medical decisions, and the RP was listed as the first emergency contact. On the date of the incident, the resident reported being grabbed by the neck and hit on the head by another resident. However, the RP was not informed of this allegation or the resident's condition following the event. Interviews with staff revealed that the licensed nurse responsible for the resident did not notify the RP, as the resident's face sheet incorrectly listed the resident as their own RP. The nurse relied on this inaccurate documentation and did not contact the RP, despite facility policy requiring notification of the RP in such situations. The Director of Nursing confirmed that the RP should have been notified, as they were responsible for making medical decisions and being involved in the resident's care plan. The facility's policy also specified that the RP must be informed of abuse allegations and assessment findings.
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 types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during care. The resident, who had diagnoses including schizophrenia, hypertension, and dysphagia, and was assessed as having moderately impaired cognition and being dependent on staff for activities of daily living, reported that the CNA was rough and abrupt while assisting her back into bed after personal hygiene care. The resident stated that the CNA spoke in a disrespectful tone, did not provide care gently, and did not offer further assistance or reassurance after the resident voiced discomfort and a headache. The CNA later acknowledged being abrupt and not as gentle or respectful as required, citing a desire to finish tasks quickly before the end of her shift. The CNA also failed to notify the nurse of the resident's complaint of head pain at the time. The incident was reported by the resident to social services staff, who confirmed the resident's concerns about future care from the CNA. The registered nurse was informed and assessed the resident, who reiterated that the CNA had been rough and disrespectful. Facility policy required staff to treat residents with kindness, respect, and dignity, and to report any complaints of pain or distress immediately. The actions and inactions of the CNA did not align with these policies, resulting in the resident feeling unvalued and disrespected.
Failure to Revise Care Plan and Implement Interventions After Smoking Restriction Order
Penalty
Summary
The facility failed to revise the comprehensive care plan and implement new interventions for a resident after receiving a neurologist's order instructing the resident to avoid smoking due to medical risks. The resident, who had diagnoses including dementia, schizoaffective disorder, major depressive disorder, diabetes mellitus, and anxiety, continued to smoke despite the new medical order. The resident's Minimum Data Set indicated moderately impaired cognition and a need for moderate assistance with activities of daily living. The resident was able to make needs known but could not make medical decisions. Interviews and record reviews revealed that the neurologist's order to avoid smoking was not incorporated into the resident's care plan, and no new interventions such as smoking cessation education or behavioral support were implemented. The Interdisciplinary Team did not conduct a conference to address the new order, and there was no documentation of care plan revision or additional support measures. The responsible party expressed concern that the facility was not following the neurologist's order or providing necessary support to help the resident comply. Facility staff, including the RN and DON, acknowledged that the care plan should have been updated and interventions put in place following the new order.
Failure to Implement Physician Orders for Dental, Podiatry, and Drug Testing Services
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident by not implementing physician's orders for dental and podiatry services, and by not clarifying and carrying out a neurologist's order for drug testing. The resident, who had diagnoses including dementia, schizoaffective disorder, major depressive disorder, diabetes mellitus, and anxiety, was moderately cognitively impaired and required moderate assistance with activities of daily living. Physician orders for dental and podiatry consultations were in place, and care plans indicated the need for these services, but there was no documented evidence that the resident received either service since readmission. During observation, the resident was found to have long, irregular toenails with debris and reported discomfort, expressing a need to see a podiatrist. The resident also reported tooth discomfort and a need for dental evaluation. The responsible party confirmed that the resident had not been seen by a podiatrist or dentist since readmission and expressed concern about the lack of follow-through on these services. Social Services staff confirmed that they were responsible for arranging such services and acknowledged that no appointments had been made, placing the resident at risk for foot discomfort, infection, and worsening dental pain. Additionally, a neurologist's order for weekly drug testing was not clarified or implemented. The nurse attempted to clarify the order by contacting the neurologist's office but did not follow up after leaving a message, and no drug testing was performed. Facility policy required that unclear orders be clarified and documented, and that outside services be coordinated as ordered by the physician, but these procedures were not followed in this case.
Failure to Prevent Resident Elopement Due to Inadequate Window Security and Risk Assessment
Penalty
Summary
A resident with diagnoses including paranoid schizophrenia, COPD, anxiety, hypertension, and type 2 diabetes mellitus, who was noted to be confused and have severe cognitive impairment, was able to elope from the facility through a window. The window in the resident's room was not properly secured with a screw on the top track, which allowed the resident to lift and open the window, remove the screen, and exit the building. The maintenance supervisor later confirmed that the window did not have the required screw, and that all windows should have been secured to prevent such incidents. The facility failed to thoroughly and accurately assess the resident's risk for elopement. The elopement evaluation completed at admission did not identify the resident as being at risk, and staff did not interview the responsible party, who later reported that the resident had a history of elopement from other facilities. The assessment relied on the resident's own denial of elopement history, despite the resident's severe cognitive impairment, and did not include input from the responsible party or a review of prior incidents. Additionally, the facility did not monitor the resident's known triggers for elopement, such as confusion and agitation, as outlined in the care plan. Staff interviews revealed that behaviors related to elopement risk were not actively monitored, and staff were unaware of the need to check window security. The resident was last seen by a roommate, who observed the resident leaving through the window, and staff only became aware of the elopement after being alerted by another resident.
Failure to Implement Physician Orders for Medication and Specialist Consult
Penalty
Summary
The facility failed to implement physician's orders for a resident who had been diagnosed with encephalopathy and cellulitis of the lower limbs. The resident, who had moderate cognitive impairment and required partial to moderate assistance with activities of daily living, developed a generalized body rash. The physician ordered hydrocortisone 1% cream to be applied daily for 30 days to treat dermatitis, but the Treatment Administration Record showed that the medication was not administered for several days following the order. Additionally, when the resident developed redness in both lower legs, the physician ordered a dermatology consult, but this order was not entered or implemented. Interviews with nursing staff confirmed that the orders for both the hydrocortisone cream and the dermatology consult were not transcribed or carried out as required. The Director of Nursing stated that all physician orders should be implemented on the day they are received, and facility policy requires licensed nurses to transcribe and implement orders promptly. Review of the resident's records and facility policies confirmed that these steps were not followed, resulting in the deficiency.
Residents Left Unattended During Deep Cleaning with Hazards Present
Penalty
Summary
Housekeeping staff failed to ensure a safe environment for two cognitively impaired residents who were at risk for falls by leaving them in their room during a deep cleaning process. The floor was wet, and a bottle of Clorox spray, a powerful bleach-based cleaner, was left unattended on a bedside table. Both residents had documented diagnoses of dementia, abnormalities of gait and mobility, and lack of coordination, and required varying levels of assistance with activities of daily living. Their care plans identified them as being at risk for falls due to confusion and poor safety awareness, with interventions to anticipate and meet their needs. During the deep cleaning, the housekeeping staff left the room to attend to another task, leaving the residents exposed to wet floors and cleaning chemicals. The registered nurse, housekeeping staff, housekeeping supervisor, and director of nursing all confirmed that residents should not have been present during deep cleaning and that cleaning supplies should not have been left unattended. Facility policies required staff to be considerate of residents and to keep cleaning equipment out of residents' way, as well as to ensure a safe and sanitary environment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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Illustrative
What surveyors actually found near you
We read the 6,528 citations issued within 25 miles in the last 12 months — including the 34 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Downey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Downey Community Health Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Southland | 1.7 mi | ★★★★★ | 7 | 0 |
| Downey Post Acute | 1.8 mi | ★★★★★ | 5 | 0 |
| Intercommunity Healthcare & Rehabilitation Center | 1.9 mi | ★★★★★ | 31 | 0 |
| The Springs Post-acute | 1.9 mi | ★★★★★ | 5 | 0 |
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