Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lassen Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Unsafe food storage, preparation, and kitchen sanitation practices were observed in the LTC kitchen. Meat was thawed improperly, and water from thawing ground turkey splashed onto cooked vegetables in an adjacent sink compartment. Staff did not perform hand hygiene after handling dirty dish machine items and before touching clean utensils and food service items, and another staff member entered the kitchen and touched food prep surfaces without washing hands. Multiple items and surfaces were dirty or damaged, including pans, a can opener, cutting boards, a mixer, a knife holder, dry storage items, uncovered water cups, hood filters, vents, fans, a broken floor tile, and kitchen walls, and hairnets and beard covers were not consistently worn.
Delayed Call Light Response: The facility failed to answer call lights timely for multiple residents, including residents who needed help with toileting, pain medication, bed changes, and emptying urinary drainage equipment. Several residents reported waiting 30 minutes to more than an hour, especially at night, weekends, and holidays, and confidential interviews and Resident Council Minutes described call lights being turned off, long waits, and missed assistance. CNA interviews also noted short staffing and the need for another CNA position to help with call lights.
FNS staff were not shown to have the needed competencies to safely perform kitchen duties. A dietary aide gave incorrect manual dishwashing steps, a staff member did not follow the pureed pork recipe and added water and thickener without measuring, expired sanitizer test strips were used for chlorine and quat testing, and two staff failed to perform proper hand hygiene when entering the kitchen and after handling dirty items. The DM stated there was no documented kitchen-specific training or competency assessment for staff.
Alternate Entree Not Equal in Nutritive Value: A facility served an egg salad sandwich and potato chips to 11 residents who requested an alternate entree, but they did not receive the other menu items on the tray. The DM and RD stated they did not compare the nutritive value of alternate entrees to the main menu item, and the DM said there was no recipe for the egg salad sandwich and he did not know its protein content or whether it was nutritionally equal to the pork roast meal.
Call Lights Not Kept Within Reach: Three residents were observed with call lights out of reach or improperly positioned. One resident with acute respiratory failure, anxiety, and HF had the call light hanging off the bed while waiting to return to bed; a CNA left it out of reach during repeated room entries before finally placing it in the resident's hand. Another resident with cancer, CAD, HTN, DM, and Alzheimer's could not reach the call bell from a wheelchair, and a third resident with post-op digestive surgery, AFib, HTN, DM, HF, and sleep apnea had the call light stretched to the bed rail, obstructing the walkway and repeatedly detaching.
The facility failed to ensure professional standards of quality were met when an RD was not onsite to complete timely and comprehensive nutrition assessments. The RD stated she worked remotely most of the time, was onsite about once every 3 to 4 weeks, and did not complete the physical portion of nutrition assessments remotely. The Administrator confirmed the RD was onsite about once a month, and the facility assessment did not include staffing needs for Food and Nutrition Services or RD services.
Two residents who required feeding assistance were left waiting in the dining room with uncovered hot meals in front of them while staff were occupied elsewhere. One resident with dysphagia, dementia, and weight loss and another resident with Alzheimer’s disease, dementia, and adult failure to thrive did not begin eating until staff later provided help, despite being seated for assisted dining and needing partial/moderate assistance with meals.
A resident admitted with COPD, urinary retention, heart failure, anxiety, and weakness had an indwelling urinary catheter removed shortly after admission, but the facility did not complete a bladder assessment or implement an individualized toileting/bladder training program afterward. The resident reported difficulty reaching the toilet and ongoing incontinence, CNA documentation showed toileting assistance needs and incontinence episodes, and the DON confirmed the continence records were not reflective of an individualized bladder training program.
The facility failed to ensure the Dietary Manager received frequently scheduled consultation from the RD and met a State qualification requirement for the role. The DM stated the RD worked remotely, rarely entered the kitchen, and did not provide kitchen consultation, while the RD said she mainly provided clinical nutrition services and only came on site every few weeks. The DM also stated he had no Title 22 training, and the Admin said she was unaware the CDM/Dietary Manager position required it.
Prescribed nutritional supplements were not provided to two residents. One resident had dysphagia, respiratory failure, and weight loss, and another had heart failure and significant recent weight loss; both had MD orders for Magic Cups. During meal observations, their trays had no Magic Cups even though the meal tickets listed them, and dietary staff said the facility was out of Magic Cups and substituted ice cream instead, which the RD confirmed was not the same nutritive value.
Kitchen Equipment Leaks Not Tracked or Reported: The facility failed to maintain kitchen equipment safely because maintenance issues were handled mostly by verbal report with no reliable work order tracking. A roll-in food cart refrigerator was observed leaking with water pooling underneath and inside, and the DM stated he had not entered a work order or notified maintenance. Water was also observed leaking from plumbing behind the ice machine onto the floor near an electrical outlet, and the DM stated he had known about the leak but had not submitted a work order.
Failure to Prevent Resident and Staff Abuse: The facility failed to protect residents from abuse when one resident struck another resident after an altercation, another resident spit on and pulled another resident’s hair, and an NA sprayed a resident in the face with a shower nozzle, tossed her onto the bed, and made verbal threats. The involved residents had diagnoses including dementia, bipolar disorder, diabetes, weakness, and cognitive impairment, and facility notes and witness statements documented the aggressive and abusive behaviors.
Failure to Report Abuse Allegation: The facility failed to report an abuse allegation to CDPH, the Ombudsman, and law enforcement after a resident told the DON and FA that a CNA was harsh, brutal, and mean to two other residents. The DON and FA acknowledged the allegation and investigation, but the FA stated it was not reported. The two affected residents had dementia and significant cognitive impairment, and the reporting policy required immediate reporting of abuse allegations.
A resident with atrial fibrillation, peripheral vascular disease, and chronic respiratory failure had been receiving Eliquis 5 mg PO BID until transfer to the hospital for respiratory issues, where the anticoagulant was discontinued with instructions to restart at the primary provider’s discretion. After the resident’s return, an FNP wrote an order to restart Eliquis, but an LPN incorrectly entered the order as a discontinuation, and the medication was not administered for an extended period. MARs showed Eliquis was not given for weeks, while the FNP’s monthly progress notes inaccurately documented that the resident was receiving Eliquis and referenced a plan to restart it. The error was not recognized by nursing staff or the FNP until the resident developed right leg pain, was hospitalized, and diagnosed with a vascular occlusion requiring thrombectomy/embolectomy, after which leadership confirmed a significant medication error had gone undetected for 42 days.
A resident with a urostomy and history of UTIs had a physician order for urostomy bag changes twice weekly, but the Treatment Administration Record showed that one scheduled change was not completed as ordered. Staff interviews revealed confusion about where urostomy supplies were stored, with reports that bags had been moved between the med room, the resident’s drawer, central supply, and the treatment cart. The DON confirmed the missed treatment and that supplies could have been obtained from central supply or a local hospital if needed. The report notes that this failure had the potential to cause infection.
Three residents with significant medical conditions and severe weight loss did not receive immediate medication regimen reviews because the DON did not notify the Pharmacy Consultant as required by facility policy. As a result, no pharmacy review was conducted to assess whether medications contributed to the residents' weight loss.
Three residents with complex medical conditions were not consistently provided with physician-ordered therapeutic diets, including fortified meals and double protein portions. Observations and staff interviews confirmed that some meals were not fortified as required, and one resident did not consistently receive double protein portions, despite care plans and physician orders specifying these dietary needs.
Three residents with significant weight loss did not receive timely nutrition assessments, as required by facility policy. The RD did not attend weight variance IDT meetings or document progress notes for missed meetings, and there was no communication or collaboration between the RD and the dietary department. Both the RD and facility leadership were unfamiliar with the contract outlining their responsibilities, and the facility did not provide written notification to the RD about residents with significant weight loss.
A resident with cognitive impairment and a preference for privacy was required to eat in a group dining area despite repeated requests to return to her room. During lunch, the resident expressed discomfort and was assessed for abdominal pressure by an LN at the dining table in front of other residents, violating her right to privacy and dignity. Staff interviews confirmed awareness of the resident's preferences and acknowledged that her rights were not upheld.
A resident with a history of depression, anemia, fatigue, and neurocognitive disorder experienced a notable decline in physical function and weight loss, requiring increased assistance and use of a wheelchair. Despite these changes, staff did not complete a required MDS assessment for significant change in condition, as the MDS nurse was not informed. This resulted in a delay in reviewing and updating the resident's care plan.
A resident with multiple health conditions was prescribed Boost as a nutritional intervention for being underweight, but staff did not document the amount consumed. Interviews and record reviews confirmed that there was no system in place to record the intake of the supplement, preventing effective monitoring and evaluation of the intervention's success.
A resident with cognitive impairment and a history of depression repeatedly received large food portions and multiple chocolate-flavored supplements, despite expressing a preference for smaller portions and a dislike of chocolate. Staff were aware of the resident's complaints but did not update the dietary profile or notify the dietary department, resulting in continued provision of meals and supplements that did not match the resident's stated preferences.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment and depression had a wedding ring stolen while under the care of staff. The theft was discovered by a family member, and investigation revealed a CNA assigned to the resident had been arrested for stealing resident property, with the ring later identified through a police operation.
The facility did not report a reasonable suspicion of theft involving two residents' wedding rings by a CNA to the California Department of Public Health or the Ombudsman, as required by policy. Although the police were notified after suspicions arose, mandated reporting to state authorities was not completed for two residents with significant care needs.
The facility did not ensure that all staff attended mandatory in-services as required by policy, with several key training sessions having very low attendance or not being conducted at all. The Director of Staff Development confirmed that make-up classes were not formally provided, and missed training was only sometimes addressed informally through one-on-one education or team huddles.
Multiple residents with good cognition reported that meals were unpalatable, cold, overcooked, and contained an unpleasant spice, leading to dissatisfaction and refusal to eat. Staff and dietary management confirmed ongoing issues with food temperature, incomplete documentation of food temps, and insufficient use of warming equipment, while resident council notes reflected persistent complaints about meal quality.
Staff failed to use required PPE and perform hand hygiene during high-contact care activities for multiple residents, including those with urinary devices and wounds. In one case, a staff member touched a resident's foley catheter without gloves, and EBP signage and supplies were missing outside the room. These lapses occurred despite facility policies requiring enhanced barrier precautions for residents with certain conditions.
Multiple residents with good cognitive status reported experiencing long delays—sometimes up to two hours—for staff to respond to call lights, leading to emotional distress and requiring some to seek help in hallways or use bathroom emergency lights for faster assistance. Family members and residents raised these concerns repeatedly in Resident Council meetings, and staff interviews confirmed the ongoing nature of the problem.
A resident with a suprapubic catheter did not have a urologist's order for daily sterile water flushes implemented, and nursing staff failed to document catheter care and assessment after a reported complication. The treatment nurse confirmed the procedure was performed but not recorded, contrary to facility policy.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses and inadequate care for residents. Several residents reported long wait times for assistance, particularly during meal times, leading to incidents such as falls and being left in soiled conditions. Observations and staff interviews confirmed the issue of insufficient staffing, impacting the quality of care provided.
The facility failed to serve meals at a palatable temperature, affecting multiple residents who reported cold and bland food. Observations showed meal trays were exposed to cold air for extended periods before being served. Residents with various medical conditions expressed dissatisfaction, noting that meals were often late and unappetizing.
The facility's kitchen was found to be unclean, with a pest control device covered in a dark substance, black debris and gray patches on the floor and walls near food preparation areas, grime on storage room doors, and black stains on ceilings from dirty vents. The RD confirmed these areas should be cleaned monthly.
A facility failed to maintain effective infection control when an LVN did not perform hand hygiene during medication administration, increasing infection risk. Additionally, a resident's water tumbler was found dirty, with the facility not having a process for cleaning personal items, as confirmed by the DSD and RD.
Two residents experienced a lack of dignity during meal times. One resident was fed while facing a wall, unable to see the CNA assisting her, contrary to facility policy. Another resident received her breakfast late, as it was mistakenly delivered to her room and not brought to the dining room, causing her to feel forgotten. These incidents highlight the facility's failure to provide a dignified dining experience.
The facility failed to maintain a homelike environment and proper cleanliness of equipment. Two residents' rooms had walls that were unpainted and scratched, which the Maintenance Supervisor acknowledged needed fixing. Additionally, a Hoyer lift used for resident care was found soiled with dried matter and remained uncleaned for several days, despite being used on residents. A nurse confirmed the cleaning responsibility lay with the night shift, and the Administrator later took the lift to be washed.
A facility failed to report an allegation of abuse to CDPH when a resident claimed to have heard another resident being raped. The incident was reported to an LVN, but there was no documentation in the medical record, and the facility did not file the required report. Interviews revealed no recollection of the incident by the residents involved, and the alleged victim denied any issues. Despite police involvement, the facility did not report the allegation, risking ongoing undetected abuse.
A facility was found to have a 10% medication error rate during a medication pass, exceeding the acceptable threshold of 5%. An LVN incorrectly prepared COQ-10 and Omega-3 supplements in incorrect dosages and failed to administer Lasix due to unavailability in the medication cart. The Lasix was later confirmed to be available in the facility's Cubex but was not retrieved. The DON verified that the medication should have been administered as prescribed.
The facility did not date an open multi-dose vial of Tubersol, used for TB skin tests, as required by policy and manufacturer instructions. The vial was found in a medication room refrigerator without a date, and the DON confirmed it should not be used due to potential ineffectiveness.
The facility failed to offer snacks to residents between meals and at bedtime without requiring them to ask, affecting several residents. Observations and interviews revealed that residents were not being offered snacks, leading to hunger and discomfort. The facility's policy indicated snacks should be easily accessible, but a change in procedure required residents to request snacks, which was not well-received. A resident with intact cognition and multiple diagnoses expressed dissatisfaction with the current system.
A resident with a nephrostomy tube did not receive care according to physician's orders, as staff routinely removed the dressing during showers, leaving the site exposed. This practice was confirmed by multiple staff members, despite the importance of maintaining sterility as emphasized by a wound treatment nurse and an infection prevention nurse.
The facility failed to meet the needs of six residents, resulting in delays in toileting, showers, and hydration. Residents experienced unrelieved pain and neglect due to untimely responses to call lights across all shifts. The administration acknowledged staffing issues but did not include them in their Quality Assurance Performance Improvement plans, and the Director of Staff Development lacked time for oversight due to other responsibilities.
The facility failed to ensure sufficient staffing, resulting in delays in activities of daily living for six residents. Residents reported waiting up to an hour for call lights to be answered, leading to unrelieved pain and feelings of being forgotten. Staff confirmed the short-staffing issue, and the Administrator admitted that it was not addressed in their Quality Assurance Performance Improvement plans.
A resident with a history of severe pain conditions did not receive appropriate pain management, resulting in constant pain. The nursing staff administered incorrect pain medications multiple times, and the facility's pain management policies were not followed. Interviews revealed issues with pain assessments and slow adjustments to pain medication prescriptions.
The facility failed to provide nursing staff with necessary competencies, resulting in incorrect pain medication administration for one resident and inadequate diabetic care for another. The deficiencies led to increased pain and discomfort for both residents.
A resident experienced a six-month delay in obtaining a Urology consultation, resulting in increased pain and multiple urinary tract infections. The facility failed to coordinate and document the necessary referral, leading to a lack of timely treatment and care.
A facility failed to ensure the MD addressed and documented a medication irregularity, leading to a resident experiencing unmanaged pain. Despite recommendations from the consultant pharmacist, the MD did not act on clarifying multiple analgesic PRN orders, resulting in improper pain management. Interviews revealed that new nurses were not performing pain assessments correctly, and there was no documentation of review and action by the DON and MD.
The facility failed to ensure a resident did not receive unnecessary medication when a diabetic medication was unavailable. Instead of adjusting the medication regimen appropriately, the facility increased the doses of other diabetic medications, leading to frequent low blood sugar levels. The physician was not notified in a timely manner to adjust the medications accordingly.
A facility failed to promptly notify a physician of lab results for a resident, leading to delayed treatment and increased pain. The resident had a urinalysis ordered, but the sample was collected late, and the final urine culture report showing significant bacterial growth was not communicated to the physician. The resident experienced confusion, back pain, weight loss, and lack of appetite, and the facility did not perform or document an infection screen.
The facility failed to inform residents' representatives of significant dental issues identified by the RDHAP, including missing teeth, visible cavitation, retained roots, and general demineralization. This lack of communication prevented the RPs from participating in decision-making regarding dental care.
Unsafe Food Storage, Preparation, and Kitchen Sanitation Practices
Penalty
Summary
Food was not stored, prepared, and served in a safe and sanitary manner in the kitchen. During observations, two slabs of pork shoulder were thawing in a clear bucket in the food preparation sink with half of each slab not submerged and water running to the side of the meat. Later, a white bag containing ground turkey was also observed thawing in a container with water running onto the bag while part of the bag remained above the water line. The Dietary Manager stated the water should have been flowing directly over the meat. Cross contamination was observed when cooked vegetables were drained in a colander in one sink compartment while packaged ground turkey was thawing in the adjacent compartment. Water splashed from the thawing meat package into the cooked vegetables, and the Dietary Manager confirmed the splash occurred and stated the vegetables were not safe to eat. Staff hygiene practices were also observed to be deficient. A dietary aide handled items on the dirty side of the dish machine and then touched clean utensils, pitchers, tubs, and food service items without washing hands. Another staff member entered the kitchen, did not wash hands, and then touched the food preparation table and recipe binder. Multiple kitchen equipment and storage issues were observed. Cooking pans had heavy buildup, pitting, scratches, and damaged coating; the can opener blade and holder had brown residue; cutting boards were scratched, chipped, and discolored; the standing mixer had yellowish residue; and the knife holder had white particles and a sticky surface. Thickener was stored uncovered and unlabeled, dry goods were improperly labeled or expired, a scoop was stored directly in rice, sugar was contaminated with black bits, and water cups in the nourishment refrigerator were uncovered. Cold food was not stored appropriately, range hood filters and swamp cooler vents were dirty, two fans were dusty, one floor tile was broken, kitchen walls had orange residue, and hairnets and beard covers were not consistently worn by kitchen and maintenance staff.
Delayed Call Light Response
Penalty
Summary
The facility failed to ensure call lights were answered timely for 8 of 19 sampled residents and for four of seven confidentially interviewed residents. The facility policy titled, "Answering the Call Light," stated the purpose was to ensure timely responses to residents' requests and needs and directed staff to answer the resident call system immediately. Survey findings showed that dependent residents were not receiving timely assistance with needs such as toileting, pain medication, bed changes, and emptying urinary drainage equipment. Resident interviews described repeated delays in call light response, often during nights, weekends, and holidays. Resident 73 said staff were slow to answer call lights at night. Resident 98 said call lights took too long and it would take a long time to get help. Resident 3 reported waiting up to an hour, said nights, weekends, and holidays were a problem, and stated staffing seemed to be an issue; Resident 85 said the call light and pain medications took an hour or a long time to get. Resident 93 said staff often took well over 30 minutes to respond and that delays occurred with bed changes and bathroom assistance. Resident 74 reported waiting more than 30 minutes for restroom help and having episodes of incontinence before assistance arrived. Resident 6 said they often waited more than an hour, sometimes all night, and found their urinary drainage bag full in the morning on a couple of occasions because it had not been emptied overnight. Resident 57 said call lights were sometimes not answered during the night and that they had waited more than an hour for assistance. Additional interviews and resident council minutes supported the same pattern. CNA F stated the residents in one room used the call light a lot and staff did their best to answer timely even when short staffed, and CNA G said another CNA position would help with call lights. Confidential interviews reported call light waits of 45 minutes or longer, one resident not receiving pain medication on time after waiting for the nurse, and one resident having an accident because the call light was not answered in time. Resident Council Minutes from January through June 2026 stated call lights were being turned off and no one came back to assist residents, and that residents were having to wait 20 to 30 minutes for call lights to be answered.
FNS Staff Lacked Competency in Dishwashing, Recipe Use, Sanitizer Testing, and Hand Hygiene
Penalty
Summary
Food and Nutrition Services staff were not shown to have the competencies and skill sets needed to safely and effectively carry out department functions. The Dietary Manager stated he had nine kitchen staff, six of whom were new and less than a month on the job, and he did not have documented inservices or competency assessments for kitchen staff. He also stated he relied on on-the-job training because he was too busy to provide documented training, and the Director of Staff Development stated onboarding training did not include kitchen-specific training. The facility’s personal file checklist did not include kitchen-specific competencies. During observations and interviews, two staff demonstrated incorrect manual dishwashing procedures. One dietary aide described manual dishwashing as sanitizing in the first sink, rinsing in the second sink, and air drying, and stated she would not use soap. The Dietary Manager described a different process and confirmed the posted directions for the two-sink method showed wash, rinse, and sanitize. The manager also stated the directions were normally posted above the sink but had been removed. In addition, one staff member prepared pureed pork by adding water and thickening agent without measuring either ingredient, and the Dietary Manager stated this did not follow the recipe for pureed pot roast and likely resulted in bland food because too much water was added. The survey also found sanitizer testing was performed with expired test strips. One dietary aide used chlorine test papers with an expiration date of 10/1/25, and the Dietary Manager stated he did not know the strips had an expiration date. On another observation, quat test strips with an expiration date of 5/2026 were also confirmed to be expired. Finally, two staff did not follow hand hygiene procedures: one touched dirty items and then clean food service and food preparation items without washing hands, and another entered the kitchen, touched hair to put on a hair net, and touched a food preparation surface and recipe binder without washing hands. The facility policy required handwashing when entering or re-entering the kitchen, before contact with food surfaces, and after handling soiled equipment or utensils.
Alternate Entree Not Equal in Nutritive Value
Penalty
Summary
The facility failed to provide alternate entrees of equal nutritive value to the entree served. During tray line service, 11 residents who requested an egg salad sandwich alternate entree received an egg salad sandwich and potato chips instead of the menu items listed for the meal, including mashed potatoes, Italian blend vegetables, and a roll with margarine. The Dietary Manager stated residents were given menus for the week and only received what they marked on the menus, and he confirmed the egg salad sandwich was used as the alternate entree only. The Dietary Manager and the Registered Dietitian both stated they did not compare the nutritive value of alternate entrees to the menu entree. The Dietary Manager said he did not know the protein content of the egg salad sandwich, did not know whether it was of equal nutritive value to the pork roast meal, and there was no egg salad sandwich recipe available. He also stated residents should still receive the rest of the meal, such as vegetables or a salad, when an alternate entree is served. The Registered Dietitian stated she relayed resident preferences but did not compare nutritive values when meal planning and did not observe alternate meals being served.
Call Lights Not Kept Within Residents' Reach
Penalty
Summary
The facility failed to provide basic safety measures for three residents when call lights were not kept within reach. The report states that the facility policy titled, "Answering the Call Light," required timely responses to resident requests and directed that call lights be accessible when a resident is in bed, from the toilet, from the shower or bathing facility, and from the floor. Facility orientation and inservice documents also identified call lights as a training topic for new employees and weekly CNA/RNA meetings. Resident 1, who had diagnoses including acute respiratory failure with hypoxia, anxiety disorder, and heart failure, was observed sitting in a wheelchair by the bedside with the call light hanging from the far side of the bed onto the floor. The resident said they wanted to go back to bed and had been sitting there for 30 minutes without the call light. During follow-up observation, a CNA entered and exited the room three times after the surveyor initiated the call light, and the call light remained out of reach until the third interaction when it was placed in the resident's hand. Resident 64, who had cancer, coronary artery disease, high blood pressure, diabetes, and Alzheimer's, was observed in a wheelchair with the call light at the bottom of the bed out of reach and stated they could not reach the call bell. Resident 93, who had diagnoses including aftercare following surgery on the digestive system, atrial fibrillation, high blood pressure, diabetes, heart failure, and sleep apnea, was observed with the call light stretched from the wall to the bed rail at knee level, obstructing the walkway and likely to detach if the bed rail was lowered. The resident stated the call light had been in that condition for three days and had frequently become detached, and described needing to wait for assistance to use the bathroom and for a bed change.
RD Not Onsite for Timely Nutrition Assessments
Penalty
Summary
The facility failed to ensure professional standards of quality were met when one of the Registered Dietitians was not onsite to complete timely and comprehensive nutrition assessments. The report states that nutrition-focused physical findings are a fundamental part of a comprehensive nutrition assessment and that the physical assessment is used to evaluate for malnutrition and other nutrition-related factors. The facility policy required a nutritional assessment for each resident upon admission and when there was a change in condition placing the resident at risk for impaired nutrition. The Registered Dietitian stated she had worked for the facility for nine to twelve months and provided clinical nutrition services. She reported working remotely about one day per week and onsite about once every three to four weeks, and said she completed resident assessments remotely unless she was onsite. She acknowledged that the physical portion of the assessment was not done remotely and said she would guess she would complete that part later when onsite. The Administrator confirmed the RD worked remotely and was onsite about once a month. The facility assessment showed an average daily census of approximately 86 to 92 residents, but it did not include staffing needs for Food and Nutrition Services or Registered Dietitians.
Delayed Feeding Assistance During Assisted Dining
Penalty
Summary
The facility failed to ensure two residents who required assistance with eating received timely help during assisted dining. Resident 26 had diagnoses including dysphagia, seizures, and dementia, and records showed significant weight loss and a care plan for nutritional problems with interventions to assist with meals. Resident 30 had diagnoses including Alzheimer’s disease, unspecified dementia with mild agitation, cognitive communication deficit, and adult failure to thrive, and her care plan also identified nutritional problems with an intervention to assist with meals as needed. Both residents’ quarterly MDS assessments indicated partial/moderate assistance was required with eating. During lunch service in the assisted dining room, residents were seated and meal trays arrived, but the hot food was left uncovered and untouched in front of Resident 26 and Resident 30 while they sat with their eyes closed and did not begin eating. Resident 26 was observed at 1:16 PM slumped over in a wheelchair with her food in front of her and not eating; Resident 30 was observed at the same table from 1:16 PM to 1:31 PM with her food untouched and uncovered. Another resident at the same table was able to eat independently. CNA K briefly assisted Resident 26 with a few bites while also feeding another resident at an adjacent table, then returned later to assist again. CNA H did not begin assisting Resident 30 until 1:31 PM, after she had already been sitting with her meal in front of her for an extended period. Staff interviews showed the dining room was supposed to have one staff per table or one staff per resident needing feeding assistance, but there were call-offs and fewer staff than expected. CNA J stated there were call-offs and she did not ask for help, and CNA K stated there were usually four CNAs or less assisting dependent residents in the dining room lately. CNA H acknowledged he was assigned to the dining room but was late getting there to assist Resident 30. The DSD stated staff should have asked for help when there were not enough assistants and that hot food should remain covered if residents could not be assisted right away. The facility policy stated residents shall receive assistance with meals in a manner that meets their individual needs.
Failure to Assess and Implement Bladder Continence Interventions After Catheter Removal
Penalty
Summary
The facility failed to comprehensively assess and implement appropriate interventions to restore bladder continence after removal of an indwelling urinary catheter for one resident. The resident was admitted with diagnoses including COPD, urinary retention, heart failure, anxiety disorder, and muscle weakness. MDS documentation showed mild cognitive impairment and extensive assistance needed with bed mobility, transfers, and toileting. The resident arrived with an indwelling urinary catheter, which was removed shortly after admission, and the record showed the resident had episodes of both continence and incontinence afterward. The resident stated they had difficulty reaching the restroom in time, needed staff help to transfer on and off the toilet, and had trouble controlling their bladder since catheter removal. The resident also stated staff sometimes responded too slowly to the call light and that they had not been asked about bladder control. CNA documentation showed the resident required one-person assistance with toileting, had at least one episode of incontinence during the prior shift, and was not on a scheduled toileting program. The LVN stated a voiding trial was completed after catheter removal, but the resident had not been evaluated for a specific individualized toileting program. Record review showed the bowel and bladder screener identified the resident as alert and oriented, willing for bladder training, and at risk for incontinence. The DON reviewed bladder continence documentation showing multiple continent and incontinent episodes across April, May, and June, and confirmed the documentation was not reflective of an individualized bladder training program. The DON and nursing staff stated the resident was not considered for bladder training, with reasons including incontinence episodes, diuretic use, fluid restriction, and other factors, and RN A confirmed the resident was not assessed for bladder training after catheter removal or for the type of incontinence being experienced. The record did not show evidence of a bladder assessment for the type or cause of the incontinence or an individualized toileting training program.
Dietary Manager Lacked Required RD Consultation and State Training
Penalty
Summary
The facility failed to ensure that its Dietary Manager received frequently scheduled consultation from a qualified dietitian and failed to ensure the Dietary Manager met a State requirement for the position. The report states that a licensed health facility employing a dietitian less than full time must also employ a full-time dietetic services supervisor who receives frequently scheduled consultation from a qualified dietitian, and that one qualification for the role includes being a Certified Dietary Manager who has received at least six hours of in-service training on specific California dietary service requirements before assuming full-time duties. During observation and interviews, the Dietary Manager stated he was the Dietary Manager and a Certified Dietary Manager, and that he had been in the position for about one year. He reported that the Registered Dietitian worked remotely, came on site every few weeks, and rarely entered the kitchen. The Registered Dietitian stated she provided mainly clinical nutrition services, did not provide consultation to kitchen staff, did not perform kitchen sanitation review, worked remotely about one day per week, and was physically in the facility only once every three to four weeks. The Administrator stated the RD was supposed to check in with the Dietary Manager and answer questions as needed, but she was unaware that the RD and Dietary Manager were not collaborating. The Dietary Manager also stated he did not have Title 22 training and did not know what Title 22 was, and the Administrator stated she was unaware that the CDM/Dietary Manager position required Title 22 training.
Prescribed Nutritional Supplements Not Provided
Penalty
Summary
The facility failed to ensure two residents received their prescribed nutritional supplements. Resident 27 had diagnoses including gastritis, dysphagia, and respiratory failure, had unanticipated weight loss, and was on a mechanically altered diet. Resident 27’s care plan included providing nutritional supplements as ordered by the physician, and the physician’s order report indicated Magic Cups twice daily for risk of malnutrition. Resident 35 had diagnoses including heart failure, low blood pressure, and muscle weakness, had a history of weight loss, and was documented as having lost 13 pounds between 4/30/26 and 5/13/26. Resident 35’s care plan included increasing Magic Cup to three times a day, and the physician’s order report indicated Magic Cups with meals for malnutrition. During dining and tray line observations, both residents’ lunch meal tickets indicated Magic Cup with the meal, but no Magic Cup was placed on either tray. The Dietary Manager stated the facility was out of Magic Cups and had not known they were out. Dietary staff stated they substituted ice cream for the Magic Cup, and later stated there were still no Magic Cups available. The Dietary Manager stated the facility ran out because nursing asked dietary aides to give extra Magic Cups that were not physician ordered. The Registered Dietitian stated Magic Cups were to be given only to residents with physician orders and confirmed that ice cream was provided in place of Magic Cups, but was not of the same nutritive value.
Kitchen Equipment Leaks Not Tracked or Reported
Penalty
Summary
The facility failed to maintain kitchen equipment safely because there was no system to track maintenance requests, and maintenance issues were mostly reported verbally. The Dietary Manager stated he was responsible for reporting kitchen maintenance issues and that requests were usually given to maintenance verbally because repairs were often completed quickly. He also stated there was not a way to track most maintenance requests because they were not entered as work orders. During observations, refrigerator number six, a tall roll-in food cart refrigerator, had water pooling underneath it, black wet residue at the floor edges, and a puddle of water inside. The Dietary Manager stated the refrigerator leaked sometimes, that he had tried to monitor it, and that he did not put in a work order or notify maintenance about the leak. He also confirmed the refrigerator had water pooled underneath and appeared rustier inside. In addition, water was observed leaking from plumbing behind the ice machine onto the tile floor, creating pooled water near an electrical outlet. The Dietary Manager stated he was aware of the leak but had not put in a work order, and the Maintenance Technician stated he was unaware of the issue when observed. The Dietary Manager later stated he had known about the leak behind the ice machine since the prior week.
Failure to Prevent Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from abuse when Resident 2 struck Resident 1 in the arm twice after Resident 1 rolled toward Resident 2 and reached for the back of Resident 2’s wheelchair. Resident 1 had a diagnosis that included dementia and muscle weakness, and the MDS showed a BIMS score of 3, indicating severe cognitive impairment. Resident 2 had diagnoses that included diabetes, substance abuse, bipolar disorder, and chronic pain, and the MDS showed a BIMS score of 15, indicating cognitive intactness. A COTA observed Resident 2 yell at Resident 1 and open-handedly hit Resident 1 a few times, and a witness statement documented Resident 2 punching toward Resident 1 while yelling threats. The facility also failed to prevent resident-to-resident abuse involving Resident 3 and Resident 4. Resident 2 reported that Resident 3 spit on Resident 4 and then grabbed Resident 2’s hair, pulling out a chunk, after which Resident 2 pulled Resident 3 to the ground. Resident 3 had diagnoses that included bipolar disorder, dementia, and muscle weakness, and the MDS showed a BIMS score of 3. Facility documentation described Resident 3 as having aggressive behaviors toward others, including spitting, wandering, agitation, verbal aggression, and physical aggression. Resident 4 stated that Resident 3 walked up to where she was sitting and spit on her, and a social service note recorded Resident 4 saying Resident 3 had spit on her. The facility further failed to prevent abuse by staff when NA 2 sprayed Resident 5 in the face with the shower nozzle, tossed her onto the bed, and verbally threatened her. Resident 5 had diagnoses that included weakness, bipolar disorder, and diabetes, and the MDS showed a BIMS score of 9, indicating moderate cognitive impairment. Resident 5 stated that a staff member was mean to her in the shower, and NA 1 witnessed NA 2 grab the shower head, threaten Resident 5 with cold water if she hit her, spray Resident 5 in the face, and later toss Resident 5 onto her bed while saying she would learn not to talk back. A social service note documented Resident 5 stating that NA 2 hit her and sprayed her face.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal and physical abuse to CDPH, the Ombudsman, and local law enforcement after Resident 3 told the Administrator that CNA A was harsh, brutal, and mean to Residents 1 and 2. The facility policy stated that alleged abuse must be promptly reported to the state licensing/certification agency, the Ombudsman, and law enforcement, and that abuse allegations must be reported immediately, but not later than 2 hours when abuse is involved. During interviews, the DON confirmed that an abuse allegation had been reported and investigated, but stated, "I didn't think it rose to that kind of an event." The FA also confirmed that Resident 3 made the allegation around 5/5/26 and stated, "The concern was not physical and believed [CNA A] was sounding burned out," and confirmed, "No. I didn't report it." Resident 1 had diagnoses including dementia and bipolar disorder and a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Resident 2 had diagnoses including mild dementia and bipolar disorder and a BIMS score of 0 out of 10, indicating severe cognitive impairment. Resident 3 had a BIMS score of 15, indicating no cognitive impairment, and stated that CNA A was harsh and brutal to roommates, ripped Resident 1's shirt off, made Resident 2 scared, and was mean and disrespectful. Resident 1 and Resident 2 were unable to respond to interview questions.
Failure to Restart Anticoagulant Order Leading to Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an order to restart the anticoagulant Eliquis was not carried out and went unrecognized for 42 days. The facility’s policies required that medications be administered only upon clear, complete, signed orders, that prescribers be contacted to clarify confusing orders, and that medication reconciliation be performed to prevent interruptions in needed medications. The attending provider was also responsible for reviewing and acknowledging the resident’s program of care and periodically reviewing all prescribed medications. Despite these policies, the process for restarting the resident’s Eliquis after a hospitalization did not function correctly. The resident had diagnoses including atrial fibrillation, peripheral vascular disease, and chronic respiratory failure with hypoxia, and had been receiving Eliquis 5 mg PO twice daily until being sent to the hospital for respiratory complications and hemoptysis. The hospital discharge summary indicated Eliquis was discontinued and would be restarted at the discretion of the primary care provider. After the resident returned to the facility, the Family Nurse Practitioner wrote an order on 12/28/25 to restart Eliquis 5 mg PO twice daily. However, the Order Audit Report showed that on the same date a licensed nurse incorrectly transcribed this restart order as a discontinuation, resulting in Eliquis not being administered for the remainder of December and all of January. The resident’s MARs for December, January, and February showed that Eliquis was not given from 12/17/25 until it was finally restarted on 2/17/26. During this period, the FNP conducted monthly visits on 1/1/26 and 2/1/26 and documented in progress notes that Eliquis 5 mg BID was among the medications currently being administered and that the plan of care included restarting Eliquis on 12/28/25, indicating the FNP did not recognize that the medication had been discontinued in error. The medication error remained unidentified by nursing staff and the FNP until the resident complained of right leg pain on 2/8/26, at which time the resident was sent to the hospital, diagnosed with a right distal superficial femoral and popliteal artery occlusion requiring thrombectomy/embolectomy, and later reported having experienced very painful leg clotting before returning to the facility feeling improved. The administrator and DON confirmed that a significant medication error occurred and went unrecognized for 42 days.
Failure to Follow Physician Order for Urostomy Bag Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide urostomy care in accordance with physician orders and facility policy for one resident. The facility’s medication administration policy required that treatments be administered in accordance with physician orders, including required time frames. The resident was admitted with a history of urinary tract infections and an artificial opening of the urinary tract (urostomy). The Treatment Administration Record for January 2026 showed a physician’s order for the resident’s urostomy bag to be changed every Wednesday and Saturday, but there was no documentation that the bag was changed on Saturday 1/3/26, indicating the order was not followed. Interviews with staff revealed confusion and inconsistency regarding the storage and availability of urostomy supplies. A licensed nurse reported that urostomy bags had been moved multiple times—from the medication room, to the resident’s drawer, and then to central supply—and that at one point nursing staff believed they were out of bags before later finding them in the resident’s drawer. The central supply lead stated that urostomy bags were stored in central supply and that nurses could obtain them from a local hospital if the facility ran out. The DON confirmed that urostomy bags were kept in central supply or on the treatment cart and acknowledged that the resident’s urostomy bag should have been changed as ordered. The report states that this failure had the potential to cause infection.
Failure to Notify Pharmacy Consultant for Immediate Medication Review After Resident Weight Loss
Penalty
Summary
The facility failed to notify the Pharmacy Consultant (PC) to conduct immediate medication regimen reviews (MRR) for three residents who experienced significant weight loss. Facility policies required that the PC be alerted for an immediate MRR when a resident experienced a change in condition, such as weight loss, to evaluate whether medications could be contributing factors. However, interviews and record reviews confirmed that the Director of Nursing (DON) did not notify the PC, and there was no documentation of immediate MRRs being performed for these residents. The three residents involved had complex medical histories, including diagnoses such as major depression, Alzheimer's disease, dementia, adult failure to thrive, and type 2 diabetes with neuropathy. Each resident experienced severe weight loss over a 180-day period, as documented in their weight summaries. Despite facility policies and procedures outlining the need for prompt pharmacy review in such cases, the required notifications and reviews were not completed, and the PC confirmed no pharmacy review had been conducted regarding the weight loss for these residents.
Failure to Provide Physician-Ordered Therapeutic Diets and Fortified Meals
Penalty
Summary
The facility failed to consistently provide physician-ordered therapeutic diets to three sampled residents. Specifically, two residents with diagnoses including major depression, anemia, fatigue, dementia, and adult failure to thrive were not consistently provided with fortified meals as ordered by their physicians. Observations revealed that while some meals, such as breakfast, were fortified, other meals like lunch and dinner were not, despite the meal tray tickets indicating a fortified diet. The Certified Dietary Manager (CDM) confirmed that not all meals were fortified, and the Registered Dietician (RD) stated that every meal should have been fortified according to the care plan and physician's orders. For one resident with Alzheimer's, dementia, and type 2 diabetes with diabetic neuropathy, the facility failed to provide double portions of protein as ordered. Observations and interviews with the resident's responsible party indicated that the resident was not consistently receiving double portions of protein, particularly during dinner, and staff had to obtain additional food to meet the order. The CDM acknowledged ongoing issues with the evening cook not providing double portions and confirmed that no resident lunches had been fortified. The facility's policy required that therapeutic diets be provided as prescribed by the attending physician to support the resident's treatment and plan of care. However, the facility did not adhere to these requirements, resulting in residents not receiving the necessary fortified meals or double protein portions as ordered. These failures were confirmed through observations, interviews with staff and responsible parties, and review of physician orders and care plans.
Failure to Provide Timely Nutrition Assessments and Interdisciplinary Collaboration for Residents with Weight Loss
Penalty
Summary
The facility failed to maintain an adequate food and nutrition department for three residents who experienced significant weight loss. Timely nutrition assessments were not performed after weight loss triggered a change of condition for all three residents. In one case, a nutritional assessment was completed 26 days after severe weight loss was identified, while in another, the assessment was completed 46 days after the trigger. For the third resident, the assessment occurred 77 days after the weight loss was noted. These delays were contrary to the facility's policy, which required prompt nutritional assessments upon a change of condition that placed residents at risk for impaired nutrition. The Registered Dietician (RD) did not participate in weight variance interdisciplinary team (IDT) meetings, nor did the RD document progress notes indicating review of IDT meeting notes. The RD stated that meeting times conflicted with other obligations and was unaware of the expectation to enter weekly progress notes for missed meetings. The Director of Nursing (DON) and Administrator confirmed that the RD had not attended any weight meetings since starting at the facility, and no progress notes were entered for missed meetings. This lack of participation and documentation hindered the collaborative approach required for managing residents with weight loss. Communication and collaboration between the RD and the dietary department were also lacking. The Certified Dietary Manager (CDM) reported no direct communication with the RD regarding residents experiencing weight loss, and the RD confirmed not having spoken to the CDM. Additionally, the RD did not notify the facility of completed assessments or recommendations for the residents in question. Both the RD and the facility's Administrator were unfamiliar with the Agreement to Provide Dietetic Consultation Services contract, which outlined responsibilities such as orientation to facility policies and written notification of significant weight loss. The Administrator admitted not notifying the RD in writing about residents with significant weight loss, and the RD was unaware of the facility's policies.
Failure to Ensure Resident Privacy and Dignity During Dining and Medical Assessment
Penalty
Summary
A deficiency occurred when a resident with a history of major depression, anemia, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease was not treated with dignity and respect regarding her preferences for privacy and dining location. The resident, who was not her own responsible party, repeatedly expressed a desire to return to her room during lunch and showed clear signs of distress and refusal to eat in the RNA dining room. Despite her verbal and non-verbal refusals, staff continued to encourage her to eat and did not promptly honor her request to leave the dining area. During the lunch period, the resident complained of abdominal pressure and expressed discomfort. Instead of providing a private assessment, a Licensed Nurse assessed the resident's lower abdomen at the dining table in the presence of three other residents. The nurse also discussed the resident's need to use the bathroom in front of others, which the resident later stated should have been a private and confidential conversation. Staff interviews confirmed that the resident was more comfortable eating in her room and that her rights to privacy and dignity were not upheld during this incident. Facility policy required staff to treat residents with respect and dignity, provide privacy and confidentiality, and support residents in exercising their rights. However, staff actions did not align with these policies, as the resident's preferences were not respected, and her medical concerns were addressed publicly. The Director of Staff Development acknowledged that the resident's rights were violated during this event.
Failure to Complete MDS Assessment After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition. According to the facility's own policies, a significant change in status assessment should be performed when the interdisciplinary team determines that the resident meets the criteria, which include a decline that does not resolve on its own, requires staff intervention, impacts more than one area of health status, and necessitates review or revision of the care plan. In this case, the resident, who had a history of major depression, anemia, fatigue, and a major neurocognitive disorder, experienced a functional decline and weight loss. Documentation showed that the resident, previously independent in several activities of daily living, now required much more assistance, including the use of a wheelchair and help with transfers due to weakness and balance problems. Despite these changes, no significant change MDS assessment was completed within the required timeframe. Staff interviews confirmed that the resident's decline and weight loss should have triggered a change of condition MDS, but the assessment was not performed because the MDS nurse was not informed of the change. The absence of this assessment delayed the review and revision of the resident's care plan, as confirmed by both the MDS nurse and the facility administrator.
Failure to Document and Monitor Nutritional Supplement Intake
Penalty
Summary
Facility staff failed to monitor and document the consumption of a prescribed nutritional supplement, Boost, for a resident who was underweight and had multiple medical conditions, including major depression, anemia, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease. The care plan for this resident included an intervention to provide Boost with breakfast and lunch, as ordered by the physician. However, interviews with staff, including a CNA, LN, RD, DSD, and RNA, revealed that there was no system in place to document the specific amount of Boost consumed by the resident. The Medication Administration Record (MAR) and fluid intake reports did not include a section for recording Boost intake, and staff confirmed that only combined fluid intake was documented, not the intake of individual supplements like Boost. As a result, the facility was unable to monitor or evaluate the effectiveness of the nutritional intervention as required by their own policies and procedures. The lack of documentation meant that staff could not determine whether the resident was receiving the intended nutritional support, and there was no way to assess if the intervention was achieving its goal of addressing the resident's underweight status. The deficiency was identified through interviews and record reviews, which confirmed the absence of documentation and the inability to track the resident's supplement intake.
Failure to Honor Resident Food Preferences for Portion Size and Flavor
Penalty
Summary
The facility failed to honor a resident's food preferences regarding portion size and flavor, despite documented assessments and repeated verbalizations from the resident. The resident, who had a history of major depression, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease, was observed to consistently receive large food portions and multiple chocolate-flavored nutritional supplements, even after expressing dissatisfaction with both. Facility policy required that food preferences be assessed and communicated to dietary staff, and that staff confer with the physician if a resident was unhappy with their diet. Observations and interviews revealed that the resident repeatedly stated she was tired of chocolate and found the food portions too large, which discouraged her from eating. Despite these statements, the dietary department was not notified of her preferences, and her meal trays continued to include large portions and chocolate-flavored drinks. Staff interviews confirmed awareness of the resident's complaints, but no action was taken to update her dietary profile or consistently offer alternative flavors or smaller portions. Documentation showed that while small portions were previously ordered, this was discontinued after a noted weight loss, and the resident's ongoing preference for smaller portions was not reinstated or communicated. Multiple staff members, including CNAs, LNs, and dietary management, acknowledged the resident's dissatisfaction but did not ensure her preferences were reflected in her meal service. The resident's dietary profile still listed chocolate as a liked preference, and staff were unaware of the need to notify dietary or nursing when preferences changed. As a result, the resident continued to receive meals and supplements that did not align with her stated preferences, as evidenced by uneaten food and partially consumed supplements observed during multiple meals.
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 record review, indicating that the required protocols for protecting confidential information or properly maintaining medical records were not followed as expected. No additional details regarding specific residents, staff actions, or the exact nature of the records involved are provided in the report.
Failure to Protect Resident Property from Misappropriation
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal property when the resident's wedding ring was stolen. The resident, who had severe cognitive impairment due to dementia and major depression, required significant assistance from staff for personal hygiene and dressing. Documentation confirmed that the resident possessed a yellow ring with clear stones, and the ring was listed among the resident's possessions. The resident was not their own responsible party, and the loss was first noticed by a family member, who reported the missing ring to the facility. Interviews and record reviews revealed that a Certified Nursing Assistant (CNA) assigned to the resident during the relevant shift was later arrested for stealing from residents. The administrator observed an online post by the CNA offering jewelry for sale, which raised suspicion and led to police involvement. The family member identified the ring in a photograph provided by law enforcement, confirming it belonged to the resident. The facility's policy stated residents have the right to be free from misappropriation, but this right was not upheld in this instance.
Failure to Report Suspected Theft of Resident Property to State Authorities
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime, specifically the suspected theft of two wedding rings by a Certified Nurse Assistant (CNA), to the California Department of Public Health (CDPH) and the Ombudsman's office as required by facility policy. The policy states that all allegations of suspected or actual abuse, including misappropriation of resident property, must be reported to the local police, Ombudsman, and CDPH within two hours. In this case, two residents were affected: one with severe cognitive impairment and requiring significant assistance with daily activities, and another with intact cognition but severe hearing and vision loss, also requiring substantial staff assistance. Both residents were not their own responsible parties. The events leading to the deficiency included reports from family members that the residents' wedding rings were missing, and subsequent suspicion that CNA D, who was assigned to both residents, had stolen the rings. The administrator confirmed that after noticing an online post from CNA D selling jewelry and being informed of the missing rings, the police were notified immediately. However, the facility did not report the suspicion of theft to CDPH or the Ombudsman's office as required, despite having reasonable suspicion of a crime involving resident property.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for its staff as required by its own policies and procedures. According to the facility's policy, all personnel are required to attend scheduled training classes, and make-up classes should be provided for any missed sessions. However, record review and interviews with the Director of Staff Development (DSD) revealed that attendance at several mandatory in-services was extremely low, with only two or three staff members attending each session. Specific in-services with poor attendance included topics such as Theft and Loss-Residents Personal Property, Dementia Module #2, Abuse and Neglect, and Advanced Directives and POLST. Some required in-services were not conducted at all during the year, and others were not rescheduled after being missed. The DSD confirmed that, although in-services were scheduled twice a week to allow staff a second opportunity to attend, there were no formal attempts to provide make-up classes for those who missed both sessions. Instead, missed content was sometimes addressed through one-on-one education or during team huddles, but there was no documentation or structured process for these alternatives. This lack of adherence to the facility's own training attendance policy had the potential to impact residents' ability to attain or maintain their physical, mental, and psychosocial well-being.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately tempered meals to all five sampled residents, as required by its own Food and Nutrition Services policy. Multiple residents with good cognitive status reported that the food was unappetizing, often cold, overcooked, and contained an unpleasant, pervasive spice. Observations confirmed that residents grimaced and declined to eat meals due to these issues, and staff acknowledged ongoing concerns with food quality, including tough meats and repetitive menu items such as rice. Resident Council meeting notes and suggestion forms documented repeated complaints about cold food and inadequate meal temperatures. The facility attempted to address these concerns by repairing equipment and implementing time logs for meal delivery, but interviews and records indicated that these measures were not fully effective. Residents continued to express dissatisfaction with food temperature and quality, and some reported simply not eating disliked items without informing staff. Record reviews and interviews with dietary staff revealed significant lapses in monitoring and documentation. Food temperature logs were incomplete or missing for multiple meals over several days, and cart audit logs were not consistently filled out by staff, making it impossible to determine whether cold food resulted from dietary preparation or delayed tray delivery. The Dietary Manager admitted to insufficient training on temperature log procedures and acknowledged a shortage of warming pellets, further contributing to the problem.
Failure to Follow Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow safe infection control practices for three out of four sampled residents. In one instance, a student nurse aide entered a resident's room, climbed onto a mattress without wearing any personal protective equipment (PPE), and made direct contact with the mattress using both hands and knees. The aide then adjusted her own clothing and proceeded to touch another resident in the same room without performing hand hygiene before or after resident contact. The aide confirmed that she did not use PPE as required for high-contact activities, despite signage indicating the need for gowns and gloves during such care for residents on Enhanced Barrier Precautions (EBP). The Assistant Director of Nursing, who was present, acknowledged not instructing the aide to use PPE. In another instance, a resident with a foley catheter and a wound did not have EBP signage or PPE available outside the room, as required by facility policy. During care, a certified nurse assistant handled the resident's foley catheter tube with bare hands and attempted to reattach it without gloves. The infection preventionist confirmed that the resident should have been on EBP and that the necessary signage and PPE were missing. The CNA later acknowledged that gloves should have been worn during the procedure.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for five out of five sampled residents, resulting in prolonged wait times for assistance. Multiple residents, all with good cognitive status as indicated by their BIMS scores, reported waiting up to two hours for their call lights to be answered. One resident, who had chronic obstructive pulmonary disease (COPD), major depressive disorder, and was dependent on supplemental oxygen, described having to leave her room to seek help in the hallway after her call light was not answered. Another resident confirmed witnessing this event and stated that staff were observed laughing and joking outside the room while call lights were ignored. Residents expressed frustration and emotional distress due to these delays, with one resident reporting feelings of anger, worthlessness, and a lack of motivation to eat or participate in daily activities. Family members and residents reported these concerns to facility staff and during Resident Council meetings, where the issue of delayed call light response was repeatedly raised as ongoing. Facility records and interviews confirmed that department heads were conducting daily call light audits in response to these concerns. On one occasion, the Assistant Director of Nursing found a resident in the hallway seeking help after a long wait, and staff were unable to provide documentation of timely responses or progress notes regarding the incident. The facility's policy required call lights to be answered as soon as practicable, but this standard was not met according to resident and family reports, as well as direct observations. Additional residents corroborated the ongoing nature of the problem, with one stating that while they did not frequently use the call light, other residents continued to experience long wait times. Roommates confirmed that during extended delays, they would use the bathroom emergency light to prompt a faster response from staff. Resident Council meeting notes from multiple months documented persistent concerns about untimely call light responses, indicating that the deficiency was not an isolated event but a recurring issue affecting multiple residents.
Failure to Implement Catheter Orders and Document Care
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with a suprapubic catheter. Specifically, the facility did not implement a urologist's order for daily sterile water flushes of the resident's suprapubic catheter on days when Renacidin was not used. Review of the resident's medical record and interviews with facility staff confirmed that the order for daily flushes was not entered into the electronic medical record, and nursing staff did not follow up to ensure the order was implemented. The resident had a history of urinary tract infection and obstructive and reflux uropathy, and was not their own responsible party. Additionally, the treatment nurse failed to document the care provided or an assessment after a complication was reported with the resident's suprapubic catheter. Progress notes indicated the resident had no urine output overnight and the treatment nurse was to flush the catheter, but there was no documentation of the procedure or assessment in the medical record. The treatment nurse later confirmed that the catheter was flushed and there was sediment present, but acknowledged that the procedure and outcome were not documented as required by facility policy.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient and qualified nursing staff to meet the needs of residents, resulting in delayed responses to call lights and inadequate care. This deficiency was observed in nine of the 22 sampled residents and three of five confidentially interviewed residents. The lack of timely response to call lights led to incidents such as falls, residents being left in soiled conditions, and extended waiting times for assistance, which could potentially result in adverse health outcomes. Several residents reported that call lights were not answered promptly, particularly during meal times when staff were occupied with other duties. Residents expressed concerns about inadequate staffing levels, which affected their ability to receive timely assistance. For instance, one resident mentioned having to plan their needs around staff availability, while another reported waiting over 30 minutes for help, leading to a fall. These accounts highlight the impact of staffing shortages on the quality of care provided to residents. Observations and interviews with staff further corroborated the issue of insufficient staffing. A CNA noted that some staff members did not respond to call lights if the resident was not assigned to them, and the DON acknowledged that some staff required additional coaching to fulfill their responsibilities. These findings indicate systemic issues within the facility's staffing and response protocols, contributing to the deficiency in meeting residents' needs effectively.
Cold and Unappetizing Meals Served to Residents
Penalty
Summary
The facility failed to provide meals at a palatable temperature, affecting 10 of 22 sampled residents and five confidentially interviewed residents who reported that the food was cold and bland. The facility's policy requires hot foods to be held at 135 degrees or above and cold foods at 41 degrees or below until served. However, during an observation, meal trays were placed in a tray transportation cart at 7:55 AM, and the cart arrived in the dining room at 8:06 AM. The cart doors were opened immediately, exposing the trays to cold air, and the first tray was not served until 8:22 AM, 27 minutes after the cart's arrival. The Registered Dietitian (RD) checked the food temperatures and found scrambled eggs at 126 degrees, indicating they were cold. Interviews with residents revealed consistent complaints about the food being cold and unappetizing. Resident 12, who is cognitively intact, expressed dissatisfaction with receiving food items they disliked and noted that it took an hour to receive alternatives. Resident 67, with moderate cognitive impairment, reported skipping breakfast due to cold food. Other residents, including those with conditions such as Parkinson's, dementia, and muscle weakness, also reported similar issues with meal temperatures and palatability. The deficiency was further highlighted by interviews with residents who consistently reported that meals were served cold and often late. Residents with various medical conditions, including diabetes, depression, and COPD, expressed dissatisfaction with the meal service, noting that it affected their willingness to eat. The facility's failure to adhere to its policy on meal temperatures and timely service contributed to the residents' complaints and dissatisfaction with the food quality.
Kitchen Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, as observed during a survey. An electric pest control device above a refrigerator was covered with a dark substance, indicating a lack of regular cleaning. The floor and wall near food preparation areas were found to have black debris and gray patches, further highlighting the neglect in maintaining hygiene standards. Additionally, grime was present on the door and doorknob of the food storage room, and black stains were observed on the ceiling from air blowing out of vents in two storage rooms. These conditions were confirmed by the Registered Dietitian, who acknowledged that the areas should be cleaned at least monthly according to the facility's cleaning schedule.
Infection Control Deficiencies in Hand Hygiene and Personal Item Sanitation
Penalty
Summary
The facility failed to maintain an effective infection control program as evidenced by the actions of a Licensed Vocational Nurse (LVN) who did not perform hand hygiene during medication administration. The LVN was observed administering medications, a breathing treatment, and nasal sprays to a resident without performing hand hygiene before preparing the next resident's medications. Additionally, the LVN wiped a liquid from the medication cart with her hand and dried it on her clothes, again failing to perform hand hygiene before proceeding to the next resident's room with medications. These actions were acknowledged by the LVN, who admitted that hand hygiene should have been performed to prevent the spread of infections. The facility also failed to ensure the cleanliness of a resident's personal item, specifically a water tumbler. The tumbler was observed to be covered with dust, white and brown spots, and black particles. The resident expressed a desire for the tumbler to be washed. The Director of Staff Development confirmed the tumbler's dirty condition and admitted to not knowing the process for washing it, as it was owned by the resident. The Registered Dietitian indicated that the facility had not been washing residents' personal items, which should be done to maintain sanitation.
Failure to Maintain Dignity During Meal Times
Penalty
Summary
The facility failed to maintain dignity and respect for two residents during meal times. For Resident 39, a Certified Nursing Assistant (CNA) assisted her with her lunch meal while sitting behind her, causing the resident to face the wall and be unable to see the CNA or other residents. This was contrary to the facility's policy which emphasized providing a dignified dining experience and encouraging socialization during meals. The CNA acknowledged that it would be better if Resident 39 could see her, and the Director of Nursing confirmed that the resident should face the staff member assisting her. Resident 285 experienced a delay in receiving her breakfast, which was delivered to her room instead of the assisted dining room where she was supposed to eat. The breakfast tray was placed out of her reach, and when she was brought to the dining room, her tray was not delivered. As a result, she had to wait while other residents were eating, and she expressed feeling forgotten. The Assistant Director of Nursing acknowledged that this was a dignity issue, as Resident 285 had to wait for her meal. Both incidents highlight the facility's failure to adhere to its policies regarding dignified dining experiences and proper assistance with meals. These deficiencies were observed through interviews, record reviews, and direct observations, indicating a lapse in ensuring residents' rights to dignity and self-worth during meal times.
Deficiencies in Maintaining a Homelike Environment and Equipment Cleanliness
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by the condition of the walls in two residents' rooms and the state of a Hoyer lift used for resident care. In the case of Resident 285, the wall next to the bed was covered with unpainted mud, which the resident confirmed needed painting. Similarly, Resident 76's room had a wall that was scratched and chipped, with black marks. The Maintenance Supervisor acknowledged the need for repairs, citing that the walls often get scratched by beds and that there was insufficient time to paint before residents were moved in. Additionally, the facility did not adhere to its policy on cleaning and disinfecting resident-care equipment. A Hoyer lift, observed in the hallway, was found to be soiled with dried brown and white matter. Despite being informed of the issue, the lift remained in a dirty condition for several days. A Licensed Vocational Nurse confirmed that the lift was used on residents and stated that it was the night shift's responsibility to clean such equipment. The Administrator later mentioned that the lift was taken to be washed, but it was not cleaned promptly after the issue was identified.
Failure to Report Alleged Abuse to CDPH
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) when a resident alleged that she heard another resident being raped. The incident was initially reported by the resident to a Licensed Vocational Nurse (LVN), who then informed the oncoming day shift nurse. However, there was no documentation of the incident in the resident's medical record, and the facility did not report the allegation to CDPH. The Administrator (ADM) and Director of Nursing (DON) confirmed during interviews that the facility conducted an investigation but did not substantiate the claim and did not file the required SOC-341 (Elder Abuse) report with CDPH. The residents involved had varying levels of cognitive function, with the alleged victim and the reporting resident both scoring 15 on the Brief Interview for Mental Status (BIMS) test, indicating normal mental function. The alleged perpetrator scored 11, indicating mild cognitive impairment. Interviews with the residents involved revealed no recollection of the incident, and the alleged victim denied any problems or discomfort. Despite the police being called and involved, the facility did not follow through with the necessary reporting to CDPH, which created the potential for ongoing undetected resident abuse.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a 10% medication error rate during a medication pass, exceeding the acceptable threshold of 5%. This was observed when three medication errors occurred out of 30 opportunities. The errors involved a Licensed Vocational Nurse (LVN) who incorrectly prepared medications for a resident. The LVN prepared COQ-10 and Omega-3 supplements in incorrect dosages, providing only half of the prescribed amounts. Additionally, the LVN failed to administer Lasix, a medication for fluid retention, because it was unavailable in the medication cart. The LVN acknowledged the discrepancies in the medication dosages and the unavailability of Lasix. It was later confirmed by another LVN that the Lasix was available in the facility's Cubex, a locked cabinet for emergency medications, but was not retrieved. The Director of Nursing verified that the Lasix should have been administered as prescribed by accessing the Cubex. The facility's policy requires medications to be administered safely, timely, and as prescribed, which was not adhered to in this instance.
Failure to Date Opened Tubersol Vial
Penalty
Summary
The facility failed to ensure that an open multi-dose vial of Tubersol, a solution used for TB skin tests, was dated when opened. This oversight was identified during an observation, interview, and document review involving the Director of Nursing (DON). The open vial was found in the refrigerator of a medication room and was available for use without a date indicating when it was opened. According to the facility's policy and the manufacturer's instructions, multi-dose vials should be dated when opened and discarded within a specified timeframe, which in this case was 30 days. The DON confirmed that the vial was not dated and acknowledged that it should not be used as it might not be effective.
Failure to Provide Snacks Without Resident Request
Penalty
Summary
The facility failed to ensure that snacks were offered to residents between meals and at bedtime without the residents having to ask, affecting one of 22 sampled residents and five confidentially interviewed residents. Observations and interviews revealed that residents were not being offered snacks, leading to feelings of hunger and discomfort. One resident mentioned that snacks used to be provided but were stopped without explanation, while another resident expressed that the absence of snacks left them feeling hungry. The facility's policy on snacks, revised in September 2010, indicated that snacks should be placed within easy reach of residents to provide adequate nutrition. However, the Registered Dietitian confirmed that the facility had changed its snack distribution procedure, requiring residents to request snacks instead of having them delivered to their rooms. This change was not well-received by the residents, as they preferred the previous system where snacks were brought to their rooms. Resident 27, who had intact cognition and was admitted with diagnoses including lung disease and chronic pain, expressed dissatisfaction with the current system, preferring snacks to be delivered to his room.
Failure to Follow Nephrostomy Care Orders
Penalty
Summary
The facility failed to adhere to physician's orders regarding the care of a nephrostomy tube for a resident, leading to a deficiency. The resident, who was admitted with multiple fistulas and a history of urinary tract infections, had specific physician's orders to keep the nephrostomy site covered during showers to prevent infection. However, observations and interviews revealed that staff routinely removed the dressing before showers, contrary to the physician's instructions. This practice was confirmed by multiple staff members, including a Licensed Vocational Nurse (LVN), the Director of Nursing (DON), and a Certified Nursing Assistant (CNA), who all stated that the dressing was removed to clean the area with water and replaced afterward. Further interviews with a wound treatment nurse and an infection prevention nurse highlighted the importance of maintaining sterility at the nephrostomy site, emphasizing that the site should remain covered and sterile at all times. Despite this, the practice of removing the dressing during showers persisted, as confirmed by another LVN who believed that warm soapy water was used to clean the site. This deviation from the prescribed sterile procedure increased the risk of infection for the resident, as the nephrostomy site was left exposed during showers.
Failure to Address Staffing Issues and Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure that direct care staff met the needs of six residents, resulting in delays in activities of daily living such as toileting, showers, and hydration. This led to residents experiencing unrelieved pain, feeling closed in, and feeling forgotten. The facility's policy on grievances and complaints was reviewed, which indicated that grievances should be promptly investigated and resolved. However, the facility did not adhere to this policy, as evidenced by the lack of administrative responses or solutions to ongoing staffing issues reported in resident council meeting minutes over several months. Interviews with residents and family members revealed that call lights were not being answered timely across all shifts, leading to significant delays in receiving assistance. Residents reported waiting up to an hour for help with toileting, experiencing pain due to delayed care, and feeling neglected. One resident mentioned having to wait over nine hours to be put back into bed, resulting in severe pain. Family members also observed that urinary bags were not being emptied when full, and residents had to seek assistance themselves due to the lack of staff response. The facility's administration acknowledged the staffing issues but had not included them in their Quality Assurance Performance Improvement plans. The Director of Staff Development admitted to not having time to audit call lights or provide oversight due to other responsibilities, such as conducting CNA training and handling human resources tasks. The Administrator and Director of Nursing were unaware of the extent of the resident complaints about call light response times and had not conducted a root cause analysis to address the issue. This lack of action and oversight contributed to the ongoing deficiencies in resident care.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of six out of nine residents, resulting in delays in activities of daily living such as toileting, showers, and hydration. Residents reported waiting up to an hour for call lights to be answered, leading to feelings of being closed in and forgotten. Specific instances included residents waiting for pain medication, assistance with urinary bags, and being put back into bed, causing severe pain and embarrassment. The issue was noted across all shifts, with particular emphasis on the evening shift. Family members and residents consistently reported these delays, and the resident council meeting minutes corroborated these ongoing issues. Interviews with staff, including the Director of Social Services, Administrator, and Director of Staff Development, confirmed the facility's short-staffing problem. The facility had recently let go of five CNAs due to certification testing issues, and there was no use of registry staff to supplement the workforce. The Administrator admitted that staffing issues were not included in their Quality Assurance Performance Improvement plans, and no root cause analysis had been conducted. The Director of Staff Development also highlighted the lack of time to audit call lights and monitor staff due to her responsibilities in clinical training and human resources.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, resulting in the resident experiencing constant pain without receiving routine pain medication. The nursing staff administered the wrong pain medication for the wrong pain level multiple times, leading to the resident not being properly medicated when in severe pain. The facility's policies on pain management were not followed, and the resident's pain assessments were inconsistent and inadequately documented. The resident, who had a history of vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, reported experiencing pain frequently and rated her pain as high as 10 out of 10. Despite this, the resident did not receive scheduled pain medication and was often given PRN medications that were not effective. The resident expressed dissatisfaction with the pain management, stating that the medication did not help and that she was in constant pain. Interviews with the nursing staff and the Director of Nursing revealed that there were issues with new nurses not conducting pain assessments correctly and the Medical Director being slow to adjust pain medication prescriptions. The resident's Medication Administration Records showed numerous instances of incorrect medication administration, with pain levels not matching the prescribed medication. The facility's failure to adhere to its pain management policies and properly address the resident's pain needs led to the deficiency.
Deficiencies in Pain Management and Diabetic Care
Penalty
Summary
The facility failed to provide nursing staff with the necessary competencies and skill sets to meet the care and services for residents' needs, resulting in increased pain and discomfort for two residents. Resident 1, who had multiple diagnoses including vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, was given incorrect pain medications multiple times over several months. The medication administration records (MARs) showed numerous instances where Resident 1 was given the wrong medication at the wrong pain level. Additionally, a urinalysis ordered for Resident 1 was delayed, and the positive results indicating a urinary tract infection were not communicated to the medical director in a timely manner. Resident 1 reported constant pain and confusion, and the staff failed to perform and document an infection screen after the urinalysis was ordered and collected. Resident 2, who had type 2 diabetes and heart disease, experienced frequent low blood sugar levels that were not properly managed. The facility's pharmacy was out of Resident 2's prescribed Trulicity, leading to an increase in Metformin and Levemir dosages. Despite a downward trend in blood sugar levels, the medical director was not notified, and the medications were not adjusted when Trulicity became available again. Resident 2 reported low blood sugar levels and inadequate diabetic medication management, which was confirmed by a licensed nurse who admitted that the physician should have been notified about the blood sugar trends and medication availability. Interviews with staff and record reviews revealed that the facility had new nurses who were not performing pain assessments correctly, and there was confusion and inconsistency in the charting of Resident 1's pain medication. The medical director expressed expectations for timely reporting of changes in condition and timely processing of lab tests, which were not met. The administrator and director of nursing acknowledged the deficiencies in pain medication management and communication of lab results, contributing to the residents' increased pain and discomfort.
Failure to Ensure Timely Urology Consultation
Penalty
Summary
The facility failed to ensure a timely Urology consultation for a resident, resulting in delayed treatment, increased pain, and discomfort. The resident, who had multiple urinary tract infections and pain caused by her nephrostomy, experienced a six-month delay in scheduling and obtaining a Urology consult. The facility's policy required Social Services to coordinate referrals and document them in the resident's medical record, but this was not done in a timely manner for the resident in question. The resident was admitted with diagnoses including vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness. Despite multiple urinary tract infections and hospitalizations, the resident did not receive the necessary Urology consultation. The resident's medical records indicated multiple instances of urinary tract infections and related symptoms, but the facility did not arrange for the required specialist consultation. Interviews with staff revealed that there was a lack of communication and coordination between the facility's Social Services and nursing staff. The Director of Social Services was unaware of the resident's need for a Urology appointment, and the Director of Nursing confirmed that no plan was in place for the resident to see a Urologist. The Medical Doctor also noted that care coordination did not happen, and the resident missed an appointment due to hospitalization, further delaying necessary treatment.
Failure to Address Medication Irregularity
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) addressed and documented an identified medication irregularity for one of the residents. The consultant pharmacist had recommended clarifying multiple analgesic PRN orders with a narrative grading and/or numerical pain scale to avoid potential duplicate therapies. Despite this recommendation, the MD did not review, document, or act upon it, leading to improper pain management for the resident. The resident, who had a history of vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, experienced significant pain due to the lack of proper medication management. The resident's clinical records showed multiple instances where pain medications were administered at incorrect pain levels, resulting in inadequate pain relief. The resident reported constant pain and dissatisfaction with the pain medication, which was corroborated by her roommate and the Licensed Nurse (LN). Interviews with facility staff, including the LN, MD, and Director of Nursing (DON), revealed that the new nurses were not performing pain assessments correctly, and there was no documentation that the DON and MD had reviewed and acted upon the pharmacist's recommendations. This oversight led to the resident suffering from unmanaged pain, highlighting a significant deficiency in the facility's medication management process.
Failure to Properly Manage Diabetic Medications
Penalty
Summary
The facility failed to ensure that Resident 2 did not receive unnecessary medication when a diabetic medication, Trulicity, was unavailable. Instead of adjusting the medication regimen appropriately, the facility increased the doses of Metformin and Levemir. This adjustment was not reverted once Trulicity became available again, leading to frequent low blood sugar levels for Resident 2. The resident's blood sugar levels were often below 100 mg/dL, with a notable instance of 64 mg/dL, which is considered dangerously low according to the National Institute of Diabetes. Despite these low readings, the physician was not notified in a timely manner to adjust the medications accordingly. Resident 2, who has type 2 diabetes and heart disease, experienced frequent low blood sugar levels due to the improper management of her diabetic medications. The facility's Licensed Nurse (LN) confirmed that the physician was not informed about the downward trend in blood sugar levels or the availability of Trulicity, which should have prompted a review and adjustment of the medication regimen. This oversight resulted in Resident 2 experiencing low blood sugar levels, which could have been avoided with proper communication and timely adjustments to her medication regimen.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results for a resident, leading to delayed treatment and increased pain and discomfort. The resident had a urinalysis ordered on 4/11/2024, but the urine sample was not collected until 4/13/2024. The preliminary report of the urinalysis was sent to the physician on 4/14/2024, but the final urine culture report, which showed significant bacterial growth, was not communicated to the physician at all. The resident, who had a history of vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, experienced confusion, back pain, weight loss, and lack of appetite. Despite these symptoms, the facility did not perform an infection screen or document it in the resident's medical record after the urinalysis was ordered and collected. The Infection Preventionist was unaware of the positive urine culture report, and the physician was not notified of the final results. Interviews with staff revealed that the facility had issues with tracking antibiotic usage and infection screening. The physician expressed expectations for timely reporting of any changes in the resident's condition, including signs of a possible urinary tract infection. However, the facility's delays in processing and communicating lab results contributed to the resident's prolonged discomfort and untreated infection.
Failure to Inform Representatives of Dental Health Status
Penalty
Summary
The facility failed to fully inform residents' representatives (RPs) of the residents' dental health status and allow participation in decision-making for care to be provided. Specifically, the Registered Dental Hygienist of Alternative Practice (RDHAP) identified oral issues and changes in conditions for three residents, but their respective RPs were not notified of these findings or the potential need for a dentist consult. This lack of communication was evident in the cases of Resident 1, Resident 2, and Resident 3, where significant dental issues such as missing teeth, visible cavitation, retained roots, and general demineralization were documented but not communicated to the RPs. Resident 1 had several dental evaluations indicating missing teeth, visible cavitation, retained roots, and general demineralization. Despite these findings, RP 1 was not informed, and there was no discussion about dental issues during the multidisciplinary care conference. Similarly, Resident 2's dental evaluation showed several missing teeth, retained roots, general demineralization, and fractured teeth, but RP 2 was not notified, and dental issues were not addressed during the care conference. Resident 3's evaluation revealed white spot lesions, general demineralization, and visible cavitation, yet RP 3 was also not informed, and dental issues were not discussed during the care conference. Interviews with the Social Services Director (SSD) and the RDHAP confirmed that there was no communication regarding the need for further dental treatment from a dentist for these residents. The RDHAP expected that their evaluation results would be discussed during care conferences, but this did not occur. The Administrator also confirmed that no communications were made to the RPs about obtaining further dental treatment, as the RDHAP did not make any recommendations for dentist referrals. This failure to inform the RPs and involve them in decision-making regarding dental care led to a deficiency in the facility's compliance with its policy on notifying residents and their representatives of changes in medical or dental conditions.
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Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Susanville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seneca District Hospital D/p Snf | 31.4 mi | ★★★★★ | 9 | 0 |
| Plumas District Hospital Dp/snf | 36.6 mi | — | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.