Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lawndale Healthcare & Wellness Centre Llc during CMS and state inspections, most recent first.
The facility failed to ensure accurate in‑service education and competency documentation when the DSD signed multiple in‑service sign‑in sheets as the instructor during a period she was on vacation and not in the building, and CNAs signed as attendees despite not participating in the trainings. Topics falsely documented as completed included resident transfer and ambulation, interpersonal communication, skin integrity and positioning, catheter and perineal care, confidentiality/HIPAA, documentation, and sexual abuse. CNAs reported that the DSD and ADSD brought sign‑in sheets around and asked staff to sign them without attending, and the DON confirmed the DSD’s absence and that sign‑in sheets should identify the actual trainer, contrary to the DSD job description and the facility’s in‑service training and record‑keeping policy.
Food storage and sanitation testing deficiencies were identified when surveyors found a personal water bottle and opened disinfecting wipes in the dry storage area, along with expired food items in the kitchen and an expired chlorine test strip used for dishwasher sanitation checks. The DSS stated personal items and chemical products should be kept separate from food, dietary staff were responsible for checking food expiration dates, and an expired test strip could produce an inaccurate sanitation reading.
Failure to Document Legionella and Waterborne Pathogen Testing: The facility failed to follow its Water Management policy for testing Legionella and other opportunistic waterborne pathogens. The water management binder contained blank testing logs and only backflow testing receipts from the city water company, with no documentation that Legionella or other waterborne pathogens were tested. The IPN, Adm, and MS all stated they were unsure whether such testing had been completed and noted there were no invoices or records showing it was done.
Staff competency records were incomplete and undated for multiple employees, including CNA, LVN, and RN competency validations. In addition, an RN left unlabeled medications on a med cart for a resident with COPD, DM, and dementia, then later used those medications after they had been prepared earlier, while the DON stated this did not demonstrate competency in medication administration.
Resident rights were not protected when one resident repeatedly screamed loudly throughout the day and night, creating a noisy environment for another resident who was cognitively intact and dependent on staff for ADLs. The affected resident reported the yelling occurred every few minutes, disrupted sleep, and caused discomfort and anger, while staff acknowledged prior complaints and stated an ordered medication for the screaming resident had not been administered. The screaming resident had schizophrenia, bipolar disorder, psychosis, major depressive disorder, and severely impaired cognition.
Chipped Paint in Resident Room Bathroom Door: A resident with rheumatoid arthritis, muscle weakness, and neuralgia was found with scattered chipped paint on the bathroom door in her room. She stated she had already reported it to management and felt depressed because it was not a homelike environment. The MS said the door needed repair and painting, and the AIT acknowledged the condition was not aesthetically pleasing.
Failure to follow a physician order for an LSO brace: a resident with low back pain, COPD, and bipolar disorder was observed without the brace while out of bed, despite an order and care plan directing its use. The resident said staff did not put on the brace and that he needed it to reduce pain; CNA and LVN staff were unaware of the order, while the PT and DON confirmed the brace was ordered for pain management and should be followed.
Incorrect Low Air Loss Mattress Setting: A resident with acute respiratory failure, sepsis, schizophrenia, and type 2 DM was observed on a low air loss mattress set at 450 lbs even though the resident weighed 197 lbs. An LVN confirmed the setting was incorrect and stated low air loss mattress settings were based on resident weight; the mattress was intended to provide pressure relief and help prevent further skin breakdown.
A resident with COPD, bipolar disorder, nicotine dependence, and impaired cognition was identified in the care plan as an assisted smoker requiring supervision, but the Smoking and Safety assessment incorrectly classified him as an independent smoker. The MDSN stated the assessment should have reflected balance problems and inability to light smoking products safely, and the DON stated the tool is used to determine whether a resident can smoke safely.
Failure to Administer Oxygen as Ordered: Two residents with respiratory diagnoses, including acute respiratory failure and COPD, had physician orders for oxygen at 2 L/min via nasal cannula to maintain oxygen saturation at or above 92%, but were observed receiving 3 L/min and 4 L/min instead. An RN and an LVN confirmed the oxygen settings did not match the orders, and the DON stated oxygen should be given as prescribed because residents with COPD are at risk for carbon dioxide retention and decreased breathing drive when receiving more oxygen than ordered.
A resident with rheumatoid arthritis, muscle weakness, and neuralgia was readmitted for skilled care, but the record showed no initial comprehensive physician visit within the first 30 days of readmission. The resident stated she had not seen her physician for 4 months and wanted to discuss her medical conditions. The DON confirmed the resident was seen by an NP on multiple occasions, but not by a physician, despite facility policy requiring the attending physician to complete the initial visit during the first 90 days.
Failure to Administer PRN Medication for Constant Screaming: A resident with schizophrenia, bipolar disorder, psychosis, major depressive disorder, and severe cognitive impairment was observed yelling and screaming in his room across multiple shifts. The resident had a PRN order for Ativan for anxiety manifested by constant screaming, but the MAR showed it was not administered, even after non-pharmacological interventions were documented as ineffective. An RN acknowledged the medication should have been given as ordered.
Unlabeled medications prepared for a resident with COPD, DM, and dementia were left on an RN's med cart after the family requested they be given after breakfast. The RN later used the same medications about an hour after preparation, despite facility policy stating meds are to be administered at the time they are prepared. The RN and DON both acknowledged that storing unlabeled prepared medications placed the resident at risk for medication errors.
A resident with COPD, DM, and dementia had four medications left on top of a medication cart and unattended while the RN was out of sight in the DON’s office. The RN stated meds should never be left unattended or out of the nurse’s line of sight, and the DON confirmed skilled nurses must keep medications secured; facility policy also required the cart to be closed and locked when out of sight and prohibited medications from being kept on top of the cart.
The facility failed to complete physician-ordered lab tests for two residents. One resident with CVA, hemiplegia, HF, and dementia had CBC and CMP orders that were not drawn, and another resident with CVA, HF, and DM had BNP and PT panel orders that were not drawn. RN stated the results were unavailable, and the DON stated ordered labs are important to establish a baseline and monitor residents' health conditions.
Failure to Refer Resident for Denture Adjustment: A resident with edentulism and denture use reported that his dentures were loose, fell out, and were not fitting properly, so he stopped wearing them and had difficulty eating without them. Staff, including a CNA and SSD, confirmed the dentures were loose and that the resident could have been referred for dental adjustment or reline, but no referral was documented in the report.
A resident’s chart contained inaccurate identifying information, and the record also included inconsistent documentation of severe cognitive impairment, ADL dependence, and behaviors. The MAR showed 0 behaviors despite constant screaming and yelling being observed, and a progress note incorrectly documented the resident as A&O x3. RN stated the behavioral and cognitive documentation was inaccurate and that the resident should have received medication and MD notification for the constant screaming.
Failure to Timely Report Abuse Allegation to CDPH: A resident with psychosis, depression, anxiety, cerebral infarction, and moderately impaired cognition had bruising noted on the forearm and hand, and stated that staff beat her. The DON said the allegation was reported to police and the ombudsman and told the Admin, who was responsible for notifying the ombudsman, LAPD, and CDPH within 2 hours, but the Admin could not provide documentation showing CDPH was reported in a timely manner.
The facility failed to develop and implement a comprehensive care plan and abuse-prevention measures for a resident with a documented history of sexually inappropriate and aggressive behavior, leading to sexual and physical abuse of two other residents. The aggressive resident, who had schizoaffective disorder and prior incidents of exposing his genitals and harassing female staff and residents, repeatedly made sexually explicit comments and inappropriately touched staff without any corresponding behavioral care plan being created. Later, he entered a cognitively impaired resident’s room, kissed her, pulled his pants down, and digitally penetrated her vagina without consent, and on the same day entered his roommate’s room, repeatedly requested to perform oral sex, attempted to pull down the roommate’s blanket to expose his genitals, and punched the roommate’s leg multiple times when resisted. Despite these events and a hospital transfer for sexually and physically aggressive behavior, the facility did not revise the resident’s care plan to address his sexual behaviors or implement targeted monitoring and safety interventions, contrary to its own care-planning and abuse-prevention policies.
The facility failed to report to CDPH two separate allegations of sexual and physical abuse involving the same resident aggressor and two other residents. One resident with dementia and significant physical limitations reported that another resident entered her room, removed both their pants, kissed her face, and touched her vagina, which was corroborated by staff observations and documentation. Another dependent resident reported that the same resident entered his room, stated he wanted to suck his penis, tried to remove his blankets, and hit him on the leg multiple times, which was also documented and reported up the chain of command. Although staff notified the DON and Administrator, and facility policies defined such conduct as physical and sexual abuse and required all allegations to be reported to CDPH within two hours, leadership did not submit the required report, resulting in the cited deficiency.
The facility failed to investigate multiple alleged sexual and physical abuse incidents involving one resident with schizoaffective disorder and a history of sexually inappropriate behavior toward others. One resident with dementia and limited capacity reported that this resident entered her room, removed her pants, removed his own pants, and kissed her face, while documentation only described “inappropriate behavior” and showed no abuse investigation. Another dependent, bedridden resident reported that the same resident repeatedly requested to perform oral sex, tried to pull down his blanket to expose his genitals, and then punched his leg several times; a police report documented similar details. Despite SBAR notes and police involvement, the clinical records for the involved residents contained no documentation of an abuse investigation, and the Administrator stated he was informed of the sexual and physical assaults but did not initiate an investigation, contrary to the facility’s abuse policy requiring interviews of residents, witnesses, and others with relevant information.
A resident with muscle weakness, hypertension, fluctuating decision-making capacity, and dependence for toileting and other ADLs was not provided timely incontinence care and assistance, despite care plan directions to assist with ADLs as needed. The resident reported sitting in urine for hours and using the call light without response, and surveyors observed staff walking past the room and declining to provide care, citing workload and a rule prohibiting cleaning residents during meal tray pass. Staff later claimed the resident had refused care, which the resident denied. This conflicted with facility policy requiring incontinent residents to be kept clean, dry, and comfortable.
A resident with muscle weakness, HTN, fluctuating decision-making capacity, and dependence for toileting and transfers received incontinence care during which a CNA failed to change gloves or perform hand hygiene between dirty and clean tasks. The CNA cleaned the resident’s perineal area, handled the bed remote, repositioned the resident, removed a soiled brief, applied a clean brief, and then left the room to obtain a clean gown while still wearing the same contaminated gloves and without hand hygiene. This conduct was inconsistent with the facility’s PPE and hand hygiene policies, which require single-use gloves, proper disposal, and hand hygiene before and after glove removal and after contact with body fluids.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital, after which their bed was reassigned to another individual without providing the required written notice or reason for the room change, as mandated by facility policy. The DON confirmed the lapse in procedure.
A resident with severe cognitive impairment and multiple medical conditions was not readmitted to the facility after a hospital transfer due to the facility's failure to honor the required bed hold and miscommunication among staff, the hospital, and the public guardian. The resident's bed was reassigned, and the resident remained in the hospital longer than necessary.
A resident with multiple chronic conditions was not readmitted to the facility after a hospital stay, despite available beds and facility policy requiring readmission. The admissions coordinator reported the denial was due to an insurance change, a decision made by the regional marketer without informing the DON.
A resident with no cognitive impairment reported a grievance about her roommate's behavior to staff, but the concern was not documented in the grievance log or followed up on as required by facility policy. Interviews with the SSD and DON confirmed that the issue was not properly recorded or investigated, resulting in the resident's complaint remaining unaddressed.
A resident with a history of hypertensive heart disease and requiring substantial ADL assistance reported mild pain on two occasions, but staff did not document thorough pain assessments, administer ordered acetaminophen, or provide non-pharmacological interventions as directed. The DON confirmed that pain management protocols, including reassessment and documentation, were not followed.
Two residents who required substantial assistance with daily activities were found without working call lights or alternative alert systems at their bedsides. Both residents had no cognitive impairment and were unable to summon staff when needed, with one resident reporting the issue persisted for two weeks. Staff and maintenance records confirmed the ongoing malfunction and lack of alternative devices, contrary to facility policy.
A resident with severe cognitive and physical impairments experienced a fall and was found on the floor with a head bump. On the day of the incident, only four CNAs were present instead of the scheduled seven, resulting in reduced direct care hours. The assigned CNA was assisting another resident at the time, and documentation did not specify how long the resident was on the floor before being found. The DON acknowledged that the staffing shortage could have delayed the response to the resident's needs.
Staff failed to follow food safety protocols by not wearing masks while plating food, not changing gloves after touching non-food items, and storing expired food products in the kitchen. These actions were observed during meal preparation and confirmed in staff interviews, with facility policies indicating that such practices were required for infection control and food safety.
A CNA was observed entering a resident care area wearing an N95 respirator mask incorrectly, with the string hanging in front, which did not provide a proper seal as required by facility policy. The CNA acknowledged the improper use and described the correct method, but failed to follow it, resulting in noncompliance with the Respiratory Protection Program and potentially affecting all residents and staff.
A resident with a history of lack of coordination and muscle weakness, identified as high fall risk, did not receive a complete fall risk assessment after a fall. The Fall Risk Evaluation omitted documentation of the fall, the resident's level of consciousness, gait, balance, medications, and did not provide a fall risk score, contrary to facility policy. The DON confirmed the assessment was not properly completed.
Three residents did not have timely or appropriate care plans developed or implemented for their specific needs, including restorative nursing services, antipsychotic medication management, and nail care. Staff and record reviews confirmed that care plans were either missing or delayed, resulting in inconsistent care and unmet resident needs.
A resident with multiple medical conditions, including diabetes and cognitive impairment, who was dependent on staff for ADLs, was found with long fingernails that had not been trimmed. The resident stated that no one had offered nail care, and staff acknowledged the nails were excessively long and should have been addressed according to facility policy, but the need was not reported or acted upon.
Two residents with severe cognitive and physical impairments did not consistently receive physician-ordered passive range of motion (PROM) therapy five times a week, and required documentation was missing for multiple days and weeks. Staff interviews confirmed lapses in both the provision and documentation of restorative nursing services, in violation of facility policy and physician orders.
A staff member prepared a pureed breakfast meal with French toast that was served in a liquid consistency, rather than the required smooth, pudding-like texture. The staff member did not follow the established recipe, and both the Kitchen Supervisor and DON confirmed that proper consistency is essential for residents with swallowing difficulties. Facility policy requires pureed foods to be smooth and hold their shape, which was not met during this meal service.
A resident with significant physical and cognitive needs was left without access to a functioning call light for several days due to a broken clip, resulting in the resident repeatedly having to scream for help. Staff and maintenance were unaware of the issue until it was brought to their attention, despite facility policy requiring prompt repair and alternative alert systems when call devices are defective.
A resident with severe cognitive impairment, legal blindness, and poor mobility was assessed as needing bilateral side rails to promote independence and assist with bed mobility. Although the need for side rails was identified and ordered, the care plan addressing their use was not created until after the resident experienced a fall. Nursing staff and the DON confirmed the care plan was delayed, resulting in the resident not having the appropriate interventions in place as required by facility policy.
A resident with severe cognitive and physical impairments, including legal blindness and poor bed mobility, did not have side rails installed as ordered and recommended by assessment. Despite documented need and physician orders, the side rails were not in place at the time the resident experienced a fall, as confirmed by nursing staff and the DON.
A resident with schizophrenia and bipolar disorder was prescribed Risperidone and Depakote for mood disorders. The facility failed to monitor and document the resident's aggressive behaviors and the indication for an increased dose of Depakote. Staff interviews revealed inconsistent behavior monitoring, and the facility did not follow its policy for documenting behavior occurrences and medication effectiveness.
A resident with schizoaffective disorder and impaired cognitive skills slapped another resident with Parkinson's disease in the face. The aggressive resident had a history of outbursts and was not adequately monitored or managed, leading to the incident. The facility's abuse prevention policy was not effectively implemented.
A resident with cognitive impairments and a history of wandering was not monitored hourly as required by their care plan, leading to multiple incidents of the resident entering other residents' rooms. Despite staff attempts to redirect the resident, the facility did not adhere to the care plan's directive for hourly visual monitoring, placing the resident at risk for altercations.
A resident in an LTC facility was unable to reach her call light while in bed, as it was found behind the bedside table and later on the floor. The resident, with diagnoses including dementia and polyneuropathy, required assistance for daily activities and was dependent on staff for mobility. The facility's policy required call lights to be within reach, but this was not followed, leading the resident to yell for help.
Three residents with varying medical conditions were found with cigarette lighters and smoking unsupervised, despite requiring supervision according to their care plans. The facility failed to ensure safe storage of smoking materials, leading to potential safety hazards.
A facility failed to implement a comprehensive care plan for the safe storage of smoking materials for three residents. Observations showed residents had unsupervised access to lighters, despite policies requiring safe storage and supervision. Care plans lacked details on storing smoking materials, posing a fire risk to all residents, staff, and visitors.
The facility failed to report a resident-to-resident altercation within the required timeframe, as per its abuse policy. A resident with cerebral infarction and fluctuating cognitive capacity reported being physically assaulted by another resident with dementia and schizoaffective disorder. The DON was unaware of the incident, which was not reported to the appropriate agencies, placing residents at risk for further abuse.
The facility staff failed to notify the physician when a resident continued to refuse her medications, leading to delayed medical intervention and unnecessary hostile behavior. Despite the care plan indicating the need to administer psychotropic medications, the resident refused multiple times, and the licensed nursing staff did not complete a Change of Condition (COC) or notify the physician as required by the facility's policies and procedures.
The facility failed to prevent verbal abuse between two residents. One resident, with multiple diagnoses including depression and anxiety, reported being verbally abused by another resident with fluctuating capacity due to schizophrenia and bipolar disorder. Despite being aware of the situation, staff did not immediately separate the residents, leading to further incidents of verbal abuse.
The facility failed to provide a written report of findings for an investigation of verbal abuse within the mandated five working days. A resident verbally abused another resident using racial slurs and profanity. The incident was reported via email, but the required written report was not submitted on time, as confirmed by the Administrator.
Falsified In‑Service Training Records and Inaccurate Staff Competency Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that in‑service education and competency records accurately reflected training actually provided to nursing staff. Review of in‑service/meeting sign‑in sheets for multiple topics, including resident transfer and ambulation, interpersonal communication, skin integrity and positioning, catheter and perineal care, confidentiality/HIPAA, documentation, and sexual abuse, showed the Director of Staff Development (DSD) listed as the instructor and multiple nursing staff listed as attendees over a period when the DSD was on vacation and not in the building. In interviews, the DSD acknowledged being on vacation during the dates in question, stated she signed the in‑service sign‑in sheets as the instructor because she forgot she was on vacation and thought she had provided the trainings, and admitted she should not have signed the documents and was unsure who actually provided the trainings. Certified Nursing Assistants (CNAs) reported that they either did not recall attending the trainings or did not attend them at all, despite their signatures appearing on the sign‑in sheets. One CNA stated she worked 3:00 p.m. to 11:00 p.m. during the relevant period and could not remember attending the training on assisting resident transfer and ambulation. Another CNA stated she did not attend any of the in‑services listed for that period and that the last training she attended was about abuse several months earlier; she reported that the DSD and Assistant DSD brought the sign‑in sheets around and asked staff to sign them even though they had not attended the trainings. A third CNA similarly stated she signed in‑service sign‑in sheets at the request of the DSD and Assistant DSD without attending the in‑services, with her last meeting being several months ago regarding abuse. The DON confirmed that the DSD was on vacation during most of the period in question and stated that sign‑in sheets should not have been signed by the DSD if she did not provide the training and should instead list the staff member who conducted the training, contrary to the facility’s job description and policy requiring the DSD to coordinate and document in‑service education and maintain accurate training records.
Food Storage and Sanitation Testing Deficiencies
Penalty
Summary
The facility failed to keep personal items and chemical products out of the dry storage area. During observation with the Dietary Food Supervisor, a personal water bottle was found in the dry storage area, and an opened container of disinfecting wipes was also found there. The Dietary Food Supervisor stated that staff personal items should not be kept in the dry storage area and that disinfecting wipes and chemical solutions should be stored in the designated chemical room because of possible cross contamination with food items. The facility policy titled, Storage of Food and Supplies, stated that food storage areas should be used only for food and that bleach, soap, and other cleaning supplies should be stored in separate and specific areas. The facility also had expired food items in the kitchen and an expired chlorine test strip used for dishwashing machine sanitation testing. In the kitchen, surveyors found 9 cans of prune juice with a best buy date of 11/10/2025 and 4 bags of hotdog buns with a best buy date of 1/6/2026. The Dietary Food Supervisor stated dietary staff are responsible for checking food items to ensure they are not expired and stated that using food items past their best buy date could cause abdominal discomforts to residents. In the dishwashing machine area, a Dietary Aide used a chlorine test paper strip bottle that had an expiration date of 8/2025, and stated he forgot to check the expiration date. The Dietary Food Supervisor stated that using an expired chlorine test paper strip would give an inaccurate reading and that plates and utensils would not be properly sanitized.
Failure to Document Legionella and Waterborne Pathogen Testing
Penalty
Summary
The facility failed to follow its policy and procedures for testing Legionella and other opportunistic waterborne pathogens within its water systems. During review of the water management binder, the binder contained blank testing logs for Legionella and other water pathogens and only two annual receipts for water backflow testing from the city's water company. The Infection Preventionist Nurse stated the city's water company had come to the facility for water backflow testing in 2024 and 2025, but she did not know whether Legionella or other opportunistic waterborne pathogens were tested, and there was no documentation showing that such testing had been completed. During interviews, the Administrator stated the facility had its water backflow tested by the city's water company but was not sure whether the water was tested for Legionella or other waterborne pathogens, and said he had been under the impression that testing was being done but it was not. The Maintenance Supervisor stated there were no invoices showing the company had tested for Legionella or other waterborne bacteria in the facility's water supply and stated the facility's water should be tested every year for Legionella or any other waterborne pathogens. Review of the facility's Water Management policy, dated 12/22/2025, showed the team leader would survey the facility using a risk assessment to determine its risk for Legionella growth and spread.
Undated Competencies and Improper Medication Preparation
Penalty
Summary
The facility failed to ensure annual competencies were dated and completed for five of six randomly selected staff members. During review of employee files, CNA 2 had missing dates for the CNA Skills Competency Log, Repositioning Competency, Mechanical Lift Competency, and Sit-to-Stand Competency Log. CNA 3 had missing dates and no scores listed for Confidentiality/HIPPA Written Competency, Palliative Care/End of Life Written Competency, and Change in Condition Written Competency. LVN 3 had no competencies in the file for 2024, 2025, or 2026, with the last competency tests completed in 2023. LVN 4 had a missing date for the New Employee General Orientation Checklist. RN 2 had missing dates for Blood Glucose Monitoring Observations Competency, Intramuscular Injection Observational Competency, Enteral Feeding Tube Observational Competency, and Nurse Medication Pass Competency. The DSD stated competencies were to be completed upon hire and annually, and were to be signed and dated upon completion. The facility also failed to ensure RN 2 was competent in securing and preparing medications when administering medications to Resident 27. Resident 27 was admitted with COPD, DM, and dementia, and the H&P stated the resident did not have the capacity to understand or make decisions; the MDS indicated moderate cognitive impairment and dependence on staff for eating, toileting, and bathing. During observation, RN 2 had a medication cup with four unlabeled medications on the medication cart for Resident 27, stated the medications were for the resident, and placed the cup back into the cart when the family member requested they be given after breakfast. Later, RN 2 took the unlabeled medication cup from the cart and stated she would use the medications prepared earlier and continued preparing the remaining medications. The DON stated leaving medications unattended on the medication cart and preparing unlabeled medications an hour before administration did not demonstrate competency in medication administration.
Resident Rights Not Protected From Persistent Noise
Penalty
Summary
The facility failed to ensure resident rights were protected from a noisy environment caused by a resident who was yelling and screaming repeatedly throughout the day and night. One resident, who had rheumatoid arthritis, type 2 diabetes, chronic kidney disease, and polyneuropathy, was cognitively intact on the MDS and dependent on staff for ADLs. That resident stated that another resident down the hall screamed loudly every 3 to 5 minutes for hours each day and night, with only brief periods of sleep, and said the yelling made him feel uncomfortable and angry, especially when trying to sleep. He also stated he had informed staff about the screaming, but nothing had been done. The other resident involved had schizophrenia, bipolar disorder, psychosis, and major depressive disorder. The H&P stated that resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition and dependence on staff for ADLs. An RN stated the facility’s protocol for a loud resident was to talk to and redirect the resident, and if that did not work, medication could be administered as ordered. The RN stated the facility had received a physician’s order for medication related to the resident’s constant screaming, but the medication had not been administered. The facility policy on Residents Rights stated residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to facility rules and applicable laws.
Chipped Paint in Resident Bathroom Door
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident when chipped paint was observed scattered on the bathroom door in the resident’s room. During a concurrent observation and interview, the resident stated she had already informed management about the chipped paint, but nothing had been done. She also stated that seeing the peeling chipped paint made her feel depressed and that it was not a homelike environment. The resident had diagnoses including rheumatoid arthritis, muscle weakness, and neuralgia. Her H&P indicated she had the capacity to understand and make decisions, and her MDS showed she was independent in cognitive skills for daily decision making and able to make herself understood and understand others. The MDS also indicated she was dependent on staff for toileting hygiene and lower body dressing. The Maintenance Supervisor stated the bathroom door needed to be repaired and painted and did not have a log showing the room was maintained in a sanitary condition. The AIT stated chipped paint in a resident’s room was not aesthetically pleasing.
Failure to Follow LSO Brace Order
Penalty
Summary
Ensure services provided by the nursing facility met professional standards of quality was deficient when the facility did not follow a physician order for a resident to wear an LSO brace when out of bed. The resident was admitted and readmitted to the facility with diagnoses including low back pain, COPD, and bipolar disorder. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated moderately impaired cognitive skills for daily decision making, with the ability to make self-understood and understand others. The care plan identified that the resident may wear the LSO when out of bed for back pain and included an intervention to apply the brace as ordered. The physician progress note stated the resident intermittently wore the LSO when out of bed and it appeared to help with pain, and the order summary showed a telephone order for the resident to wear the LSO when out of bed for back pain. During a concurrent observation and interview, the resident was seen in the activity room without the LSO brace and stated the nurse did not put on the back brace even though he was supposed to use it every day. The resident stated he had back pain and needed the brace to reduce his pain. CNA 1 stated she was not aware the resident needed the back brace when out of bed, and LVN 1 stated she was not aware the resident had a physician order to wear the LSO when out of bed. The PT stated the physician made the determination for the resident to wear the LSO when out of bed and that the physician order should be followed. The DON stated the LSO was prescribed as conservative treatment to minimize pain and that failure to follow the order would result in more discomfort that could affect the resident's quality of life.
Incorrect Low Air Loss Mattress Setting
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured when the facility failed to set a low air loss mattress correctly for one resident. The resident’s face sheet showed admission and readmission to the facility, and the resident’s diagnoses included acute respiratory failure, sepsis, schizophrenia, and type 2 DM. The H&P dated 12/17/2025 stated the resident had the capacity to make needs known but not medical decisions, and the MDS dated 12/23/2025 indicated moderately impaired cognitive skills and dependence on staff for ADLs. During observation on 1/20/2026, the resident was lying in bed on a low air loss mattress set at 450 pounds. The resident’s weight record reviewed the same day showed a weight of 197 pounds. On 1/22/2026, an LVN stated the mattress was still set at 450 pounds and confirmed that low air loss mattress settings were based on resident weight in pounds. The LVN also stated the resident’s setting was incorrect and that the purpose of the mattress was to prevent further skin breakdown in residents with pressure ulcers or skin issues. The facility policy titled Mattresses stated mattresses were to provide stimulation and pressure relief to residents at risk for skin breakdown and distribute body weight to relieve areas of pressure.
Inaccurate Smoking Safety Assessment for a Resident Requiring Supervision
Penalty
Summary
The facility failed to ensure that the smoking assessment was completed accurately for one resident who was admitted and later readmitted to the facility with diagnoses including COPD, bipolar disorder, nicotine dependence, and low back pain. The resident’s H&P stated he could make needs known but could not make medical decisions, and the MDS showed moderately impaired cognitive skills for daily decision making, though he could make himself understood and understand others. The care plan identified him as an assisted smoker requiring supervision, with an intervention to conduct a smoking safety evaluation on admission and as needed. During interview and record review, an Activity Assistant stated the resident needed supervision during smoking. The MDS Nurse reviewed the Smoking and Safety assessment and stated it incorrectly identified the resident as an independent smoker. The MDS Nurse stated the assessment should have included balance problems while sitting or standing and inability to light tobacco or other smoking products safely, and stated the resident needed supervision during smoking because of poor cognition. The DON stated the Smoking and Safety assessment is used to identify whether a resident can smoke safely and that an inaccurate assessment could lead to fire. The facility policy stated it would accommodate residents who smoke while taking reasonable precautions by providing a safe environment and protecting non-smoking residents.
Failure to Administer Oxygen as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to ensure oxygen was administered as ordered for two residents. One resident had diagnoses including acute respiratory failure, sepsis, schizophrenia, and type 2 diabetes, and had a physician order for oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation at 92% or above every shift for shortness of breath. However, the resident was observed on one occasion with oxygen running at 3 liters per minute, and on another occasion the same setting was confirmed by an RN. The RN stated the resident should have been receiving 2 liters per the physician order and that the resident should not have received 3 liters. Another resident had diagnoses including pneumonia, COPD, and diabetes mellitus, and had a physician order for oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation at or above 92% every shift for COPD. During a concurrent observation and interview, the resident was observed receiving 4 liters of oxygen via nasal cannula, and the LVN stated the resident should have been on 2 liters as ordered. The LVN and DON both stated oxygen should be administered as ordered by the physician, and the DON stated residents with COPD are at risk for carbon dioxide retention and decreased breathing drive when receiving more oxygen than ordered. The facility policy titled Oxygen Therapy stated to administer oxygen and obtain oxygen saturation levels as ordered by the provider.
Failure to Ensure Required Physician Face-to-Face Visits
Penalty
Summary
Ensure the resident and his/her doctor meet face-to-face at all required visits was not met for Resident 6. Resident 6 was initially admitted to the facility and later readmitted for skilled care services. Her diagnoses included rheumatoid arthritis, muscle weakness, and neuralgia. The History and Physical dated 7/20/2025 indicated she had the capacity to understand and make decisions, and the MDS dated 12/2/2025 indicated she was independent in cognitive skills for daily decision making, able to make herself understood and understand others, but dependent on staff for toileting hygiene and lower body dressing. During interview, Resident 6 stated she had not seen her physician in the facility for 4 months and wanted to see her physician to discuss her multiple medical conditions. The DON reviewed the record and stated Resident 6 was readmitted in 11/2025 for skilled care services, had no initial comprehensive visit by her physician within the first 30 days of readmission, and was last visited by her physician on 7/20/2025. The DON stated Resident 6 was seen by an NP on 11/26/2025, 12/7/2025, and 1/4/2026, but not by a physician, and stated the physician should come and visit the resident monthly and as needed. The facility policy titled Physician Services and Visits stated that for the first 90 days, the initial visit must be conducted by the attending physician.
Failure to Administer PRN Medication for Constant Screaming
Penalty
Summary
The facility failed to ensure appropriate medication treatment was administered for one resident with schizophrenia, bipolar disorder, psychosis, and major depressive disorder who also had severe cognitive impairment and no capacity to understand and make decisions. The resident’s MDS indicated dependence on staff for ADLs. On observation, the resident was lying in bed yelling and screaming in his room while looking up at the ceiling and did not appear to be in distress. He was observed continuing to yell and scream throughout various shifts over several days, including yelling every 3 to 5 minutes while in his room. The resident had a physician’s order for Ativan 0.5 mg, 1 tablet every 6 hours as needed for anxiety manifested by constant screaming, with non-pharmacological interventions documented as attempted but ineffective. The MAR showed the medication had not been administered since the order start date. During interview and record review, an RN stated that when a resident constantly yells after non-pharmacological interventions are ineffective, medication should be administered as ordered, and acknowledged that no medication had been given despite the resident yelling and screaming for 3 days.
Unlabeled Medications Stored Before Administration
Penalty
Summary
The facility failed to ensure medications were administered at the time of preparation for one resident. Resident 27 was admitted on 12/11/2023 and later readmitted with diagnoses including COPD, DM, and dementia. The resident's H&P dated 11/8/2025 stated the resident did not have the capacity to understand or make decisions, and the MDS indicated moderate cognitive impairment with dependence on staff for eating, toileting, and bathing. During a concurrent observation and interview on 1/22/2026 at 8:05 a.m., RN 2 was observed with a medication cup containing four unlabeled medications on the medication cart in front of Resident 27's room. RN 2 stated the medications were for Resident 27, but the family member requested they be given after breakfast, so the cup was placed back into the cart. At 9:00 a.m., RN 2 was observed preparing Resident 27's medications and removed the same unlabeled medication cup from the cart, stating she would use the medications prepared at 8:00 a.m. and continued preparing the remaining medications due at that time. RN 2 later stated she should not have stored unlabeled medications prepared for Resident 27 and that facility policy required medications to be administered right after preparation. The DON reviewed the facility policy stating medications are administered at the time they are prepared and agreed that administering unlabeled medications an hour after preparation places residents at risk for medication errors.
Unsecured medications left unattended on medication cart
Penalty
Summary
Medications were left unsecured and out of the administering nurse’s line of sight for one resident with significant cognitive impairment. Resident 27 was admitted with diagnoses including COPD, DM, and dementia, and the H&P stated the resident did not have the capacity to understand or make decisions. The MDS indicated moderate cognitive impairment and dependence on staff for eating, toileting, and bathing. During an observation, a cup containing four medications was seen on top of the medication cart in front of Resident 27’s room with no nursing staff or licensed personnel present. RN 2 later stated she had left the medications unattended on top of the cart while she went into the DON’s office and acknowledged that medications should never be left unattended or out of sight. The DON also stated skilled nurses need to ensure medications are always secured and never left unattended, and the facility policy stated the medication cart must be kept closed and locked when out of sight and that no medications are to be kept on top of the cart.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to implement physician-ordered laboratory tests for two sampled residents. One resident had diagnoses including cerebral infarction with hemiplegia, heart failure, and dementia, and the H&P indicated the resident could make needs known but could not make medical decisions. The MDS showed moderately impaired cognitive skills for daily decision making, with the resident able to make self-understood and understand others, and requiring substantial assistance with toileting hygiene, showering, and lower body dressing. The physician placed a telephone order for CBC and CMP, but during record review the RN stated the laboratory tests were not drawn and results were not available. A second resident had diagnoses including cerebral infarction, heart failure, and DM, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS showed severely impaired cognitive skills for daily decision making, with the resident dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. The physician placed a telephone order for BNP and PT panel, but the RN stated the laboratory tests were not drawn and results were not available. The RN stated the process for ordering laboratory tests was to place the order electronically and place the laboratory order form in the binder, and the DON stated it was important to complete all laboratory tests as ordered by the physician so residents would have a baseline and their health condition could be monitored. The facility policy stated laboratory services should be provided in an accurate and timely manner to meet resident needs per attending physician orders.
Failure to Refer Resident for Denture Adjustment
Penalty
Summary
The facility failed to ensure that one sampled resident with edentulism and denture use was referred to dental services for readjustment of dentures. The resident was admitted and readmitted to the facility with diagnoses including low back pain, COPD, and bipolar disorder. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated moderately impaired cognitive skills for daily decision making, with the ability to make self-understood and understand others. The care plan identified a risk for oral infections related to edentulism and denture use and included coordination with Social Services to arrange regular dental check-ups to monitor dentures and oral tissues. During observation, the resident had no upper or lower dentures and stated he did not use them because they fell out and did not fit properly. He said he had informed staff about the problem two weeks earlier and had difficulty eating without his dentures. A CNA stated the resident refused to wear the dentures because they were loose. The SSD stated the resident had last been seen by the dentist, who recommended new full upper and lower dentures when eligible, and acknowledged the resident could have been referred for denture adjustment or reline. The SSD also stated ill-fitting dentures could result in the resident not properly eating and leading to weight loss. The DON stated loose-fitting dentures could cause discomfort. The facility policy stated it would provide oral healthcare and dental services for preventive care and treatment.
Inaccurate resident documentation and behavioral charting
Penalty
Summary
Safeguarding resident-identifiable information and maintaining accurate medical records was deficient for one sampled resident. The resident’s face sheet incorrectly listed another resident’s name on the admission and readmission information. The resident’s record also showed diagnoses of schizophrenia, bipolar disorder, psychosis, and major depressive disorder, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS dated 12/1/2025 indicated the resident’s cognitive skills were severely impaired and that the resident was dependent on staff for ADLs. The resident’s January 2026 MAR documented 0 behaviors while monitoring for anxiety with constant screaming, even though the resident was heard and observed constantly screaming and yelling throughout various times of the day in the facility. A nursing progress note dated 1/19/25 documented the resident as alert and oriented x3, communicated verbally with clear speech, and was able to understand and be understood when speaking. During interview and record review, RN 2 stated the behavioral documentation was inaccurate, that the resident should have been given medication for constant screaming and the doctor notified, and that the progress notes indicating A&O x3 were inaccurate because the resident was actually A&O x0. The facility policy titled Completion & Correction stated the facility would work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation.
Failure to Timely Report Abuse Allegation to CDPH
Penalty
Summary
The facility failed to report an abuse allegation involving one resident to the California Department of Public Health (CDPH). The resident had diagnoses including psychosis, depression, anxiety, and cerebral infarction, and the Minimum Data Set indicated moderately impaired cognitive skills and maximal assistance needs with activities of daily living. On 11/20/2025, staff observed bruising to the resident’s left forearm and hand during rounds and notified the charge nurse. The Change of Condition note stated the bruising was reddened to purplish without swelling, open areas, or pain, and when asked what happened, the resident stated, "staff beat me," but could not provide names or details. The note also stated the resident frequently banged her bed remote on the rails and had a history of vague or exaggerated stories about being hurt. During interviews, the resident later stated she could not recall being hit and said she felt safe at the time. The DON stated she informed the police and ombudsman and told the Administrator, who said he would report the allegation to the appropriate agencies. The DON and Administrator stated the reporting time frame was within 2 hours, and the Administrator identified the ombudsman, LAPD, and CDPH as the agencies that should be notified. However, the Administrator could not provide documentation or evidence that the facility reported the allegation to CDPH in a timely manner. The facility policy titled Abuse Prevention and Management stated the Administrator or designated representative must notify law enforcement immediately, or as soon as practicably possible, but no longer than 2 hours, and send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within 2 hours.
Failure to Care Plan and Monitor Resident With Known Sexual and Physical Aggression Resulting in Abuse of Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not developing and implementing care plans and abuse-prevention measures for a resident with known sexually inappropriate and aggressive behaviors. Resident 2 was admitted with diagnoses including muscle weakness and schizoaffective disorder, bipolar type, and a documented history from an acute care hospital of increasing psychosis resulting in inappropriate exposure of his private parts and harassment of female staff and residents. Despite this history, the facility did not create a care plan upon admission to address Resident 2’s sexual misconduct risk. Progress notes dated 12/13/2025 documented that Resident 2 made sexually explicit and inappropriate verbal comments toward a CNA on two occasions, and on 12/15/2025 he was seen touching a CNA inappropriately and telling her he wanted to go to bed with her. These behaviors were only redirected in the moment, and no corresponding care plan interventions were developed to manage or monitor his sexually inappropriate behavior. Resident 1, who had dementia and was documented as lacking capacity to consent due to dementia, required moderate to total assistance with most ADLs and had a care plan for cognitive impairment that included visual monitoring for safety. Her MDS indicated she was usually able to understand and be understood. On 12/19/2025, an SBAR documented that she was exposed to inappropriate behavior by Resident 2, that she was assessed with no injuries and no immediate distress, and that she would be monitored for emotional distress and kept separated from Resident 2. However, her clinical record did not contain any indication of consent to sexual activity with Resident 2. A police incident report documented that Resident 1 stated Resident 2 entered her room, sat on her bed, shook her shoulders aggressively, kissed her cheeks multiple times, pulled his pants down to his thighs, reached into his shorts to touch his penis (though she did not see it exposed), then put his hands inside her shorts, past her diaper, and penetrated her vagina with his fingers while she called for help. Staff interviews corroborated that Resident 1 reported that Resident 2 kissed her, touched her, and put his fingers inside her vagina, and that staff observed Resident 2 pulling his pants up when they entered the room. Resident 1 later stated she was traumatized by the incident, had to sleep with the lights on for two weeks, and was afraid Resident 2 would enter her room again. Resident 6, who had muscle weakness and low back pain and was dependent or required significant assistance for most ADLs, had capacity to understand and make decisions and was able to communicate effectively. On 12/19/2025, his progress notes and a change-of-condition form documented that he reported being struck three times on his legs by Resident 2 and that Resident 2 was removed from his room. A police incident report further documented that Resident 6 reported Resident 2, his roommate, entered the room, repeatedly requested to perform oral sex on him, advanced toward him despite being told to leave, attempted to pull down his blanket to potentially expose his penis, and, when resisted, punched his right knee approximately three times with a balled fist before leaving. Resident 6 confirmed in interview that Resident 2 asked to suck his penis, tried again after being told no, attempted to pull down his blanket, and then hit his right leg three times. A CNA reported hearing Resident 6 screaming for help and that he alleged Resident 2 had asked to suck his penis. Resident 6’s record contained no indication of consent to sexual activity with Resident 2. Despite Resident 2’s known history of sexual misconduct and the documented sexually inappropriate behaviors toward staff shortly after admission, the facility did not develop or revise a comprehensive, person-centered care plan to address his sexual behaviors, monitor his whereabouts, or implement specific safety interventions for other residents. The existing care plan for Resident 2 addressed risk for wandering/elopement but did not address his sexually inappropriate behavior. After the sexually abusive and physically aggressive incidents toward Residents 1 and 6 on 12/19/2025 and Resident 2’s transfer and readmission from an acute care hospital for management of aggression and sexually inappropriate behavior, his care plan still did not include interventions related to his sexually inappropriate behavior toward other residents or monitoring for behavioral changes and safety concerns. The DON acknowledged that no care plan was created at admission or after the documented incidents on 12/13/2025 and 12/15/2025, and stated that if care plans had been created, they might have protected Residents 1 and 6 from Resident 2’s sexually inappropriate behavior and physical aggression. The facility’s own policies on Comprehensive Person-Centered Care Planning and Abuse Prevention and Management required review and revision of care plans with new problems or behavior changes and required identification, correction, and intervention in situations where abuse is more likely to occur, but these were not implemented in relation to Resident 2’s behaviors.
Failure to Report Allegations of Sexual and Physical Abuse to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of sexual and physical abuse to the California Department of Public Health (CDPH) as required by policy and regulation. On 12/19/2025, a resident with dementia, hemiplegia/hemiparesis, depression, and anxiety, who lacked capacity to consent but was usually able to understand and be understood, reported that another resident entered her room, removed his pants, removed her pants, kissed her face, and touched her vagina. An SBAR dated 12/19/2025 documented that this resident was exposed to inappropriate behavior by the alleged perpetrator. A CNA observed the alleged perpetrator in the resident’s room lowering his pants, and the resident reported to the CNA and RN Supervisor that her vagina had been touched. The RN Supervisor reported the incident to the DON. The same day, another resident, who had muscle weakness and low back pain and had capacity to understand and make decisions, reported that the same alleged perpetrator entered his room, stated he wanted to suck the resident’s penis, attempted to pull off his blankets to expose him, and, when unsuccessful, hit him on the right leg three times. A Change in Condition Evaluation dated 12/19/2025 documented that this resident reported being struck on his legs three times by the other resident. CNA 3 stated that the resident told her about the sexual statement and being hit, and she reported this to LVN 1. LVN 1 confirmed that the resident reported being hit on the leg and being asked if the alleged perpetrator could suck his private part. The facility’s records for the alleged perpetrator showed schizoaffective disorder, behavioral symptoms including public sexual acts and disrobing, and an SBAR documenting that he entered the first resident’s room, lowered his pants, and exhibited sexually inappropriate behavior. Despite these documented allegations and staff reports, the DON stated she did not report the incidents to CDPH because she believed that the described behaviors (exposing private parts and hitting on the leg) were not considered abuse. The Administrator stated he was informed of both incidents on 12/19/2025 and did not report them to CDPH. Facility policies titled “Abuse Prevention and Management” and “Abuse-Reporting and Investigations” defined abuse to include physical and sexual abuse and required that all allegations of abuse and criminal activity be promptly reported, with the Administrator or designee submitting a written SOC 341 report to CDPH Licensing and Certification within two hours. The failure of the DON and Administrator to report these allegations to CDPH constituted the cited deficiency.
Failure to Investigate Multiple Alleged Sexual and Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to investigate multiple alleged incidents of sexual and physical abuse by one resident against other residents, as required by its Abuse Prevention and Management policy. Resident 1, who had dementia and was documented as not having capacity to consent, was assessed as usually able to understand and be understood, and required varying levels of assistance with ADLs and mobility. An SBAR dated 12/19/2025 documented that Resident 1 was exposed to “inappropriate behavior,” was promptly assessed with no injuries or distress noted, and that she would be monitored and kept separated from Resident 2. However, the clinical record contained no documentation that an abuse investigation was conducted regarding Resident 2’s sexually abusive behavior toward Resident 1 on that date. Resident 2 had diagnoses including muscle weakness and schizoaffective disorder, bipolar type, with a history of increasing psychosis resulting in inappropriate exposure of his private parts and harassment of female staff and residents. An SBAR for Resident 2 dated 12/19/2025 documented that he entered Resident 1’s bedroom, lowered his pants, and exhibited sexually inappropriate behavior toward her, after which staff redirected him, administered medication, and planned transfer to an acute care hospital for further evaluation and behavior management. Despite these documented behaviors and his known history, Resident 2’s clinical record contained no documentation that an investigation was conducted into the incidents of sexually assaulting two residents and physically assaulting one of them on 12/19/2025. Resident 6, who had muscle weakness and low back pain and was dependent or required significant assistance for most ADLs and mobility, reported that Resident 2 entered his room, repeatedly requested to perform oral sex, attempted to pull down his blanket to expose his penis, and, when resisted, punched his right leg three times. A police crime/incident report corroborated that Resident 6, who was bedridden, described Resident 2’s repeated sexual requests, attempts to pull down his blanket near his genital area, and punching of his right knee with a balled fist. Resident 6’s clinical record, however, contained no documentation that an investigation was conducted into the sexual abuse and physical assault by Resident 2 on that date. In an interview, the Administrator acknowledged being informed that day about Resident 2 sexually assaulting two residents and hitting one resident, and stated that no investigation was done because the events occurred on a Friday afternoon, despite the facility’s policy requiring the Administrator or designee to interview residents, witnesses, family, and others who may have relevant information. The facility’s Abuse Prevention and Management policy, dated 6/12/2024, specified that the Administrator or designated representative conducting an investigation should interview individuals who may have information relevant to the allegation or suspected crime, including the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, and visitors. The absence of any documented investigations in the clinical records of Residents 1, 2, and 6, combined with the Administrator’s admission that no investigation was initiated after being informed of the alleged sexual and physical assaults, demonstrates that the facility did not follow its own policy and procedures for responding to and investigating alleged abuse incidents involving Resident 2 and the affected residents.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living and incontinence care to keep a resident clean, dry, and comfortable in accordance with the resident’s needs and the facility’s own policy. The resident had diagnoses including muscle weakness and hypertension, fluctuating capacity to understand and make decisions, and required varying levels of assistance for ADLs, including dependence for toileting hygiene and lower body dressing. The resident’s care plan indicated assistance with ADLs as needed. On the survey date, the resident reported not being cleaned all morning and sitting in urine for hours, despite repeatedly calling staff for help. Observations showed the resident using the call light while a CNA walked past the room without responding. The resident stated that staff did not respond to call lights and ignored her. During subsequent observations and interviews, CNA 1 stated she was too busy to assist the resident, citing responsibility for nine residents and indicating she had already responded several times to requests to adjust the bed. CNA 1 left the room while the resident verbally expressed discomfort and a need for help. When CNA 2 entered, the resident again requested to be cleaned, but CNA 2 stated she could not clean the resident because she was about to pass meal trays and asserted that residents had to wait during tray pass per facility rules. CNAs stated they could not clean residents during tray pass and that all residents had to wait. Later, CNA 2 told the Infection Prevention Nurse that the resident had refused care that morning, while the resident stated CNA 2 had never asked to clean her. The facility’s bowel and bladder policy required that incontinent residents be kept clean, dry, and comfortable, and the DON acknowledged residents should not be left in urine for a long period of time because it could lead to skin breakdown and make residents feel neglected or ignored.
Failure to Follow Hand Hygiene and Glove Use Protocol During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement infection prevention and control measures during incontinence care for one resident. The resident had diagnoses including muscle weakness and hypertension, fluctuating capacity to understand and make decisions, and required substantial to maximal assistance for bed mobility and was dependent for toileting hygiene, lower body dressing, and transfers. During an observation in the resident’s room, a CNA wearing gloves opened the resident’s soiled incontinence brief, cleaned the pubic area, then used the bed remote control to reposition the bed without changing gloves or performing hand hygiene. The CNA then turned the resident to the left side, cleaned the buttocks and buttocks fold, removed the soiled brief, and applied a clean brief, again without changing gloves or performing hand hygiene. After completing the incontinence care, the CNA left the resident’s room still wearing the same soiled gloves and without performing hand hygiene in order to obtain a clean gown for the resident. In an interview, the CNA stated she did not realize she had not changed her gloves because she was trying to finish the incontinence care quickly. The Infection Prevention Nurse stated that staff should change gloves and perform hand hygiene when moving from dirty to clean areas, and that failure to do so could lead to the spread of germs and place residents at risk for infections. Review of the facility’s PPE policy indicated gloves are to be used once, discarded in the appropriate receptacle in the room, and that hands are to be washed before and after removing gloves. The facility’s hand hygiene policy identified hand hygiene as the primary means to prevent the spread of infections and required hand hygiene after contact with body fluids and before donning and after doffing PPE, as well as upon entering and exiting a resident room.
Failure to Provide Written Notice for Room Change After Hospital Transfer
Penalty
Summary
The facility failed to provide written notice with a reason for a room change for one resident. The resident, who had diagnoses including metabolic encephalopathy, pneumonia, type 2 diabetes mellitus, and schizophrenia, was noted to have severely impaired cognitive skills and was dependent on staff for activities of daily living. The resident was transferred to a general acute care hospital due to a change in condition, specifically a persistent cough and increased secretions despite IV antibiotics for pneumonia. Upon review of the facility's census, it was found that the resident's bed was assigned to another individual the day after the hospital transfer, resulting in the resident losing their bed. The DON confirmed that a room change occurred without knowledge of the reason and acknowledged that written notice was not provided as required by facility policy. The facility's policy mandates timely advance written notice with reasons for any room or roommate change, which was not followed in this instance.
Failure to Honor Bed Hold and Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure the readmission of a resident who was transferred to a general acute care hospital (GACH) for treatment of pneumonia and other medical conditions. The resident, who had severe cognitive impairment, was dependent on staff for activities of daily living and lacked decision-making capacity. After being transferred to the hospital, the facility did not honor the required 7-day bed hold, and the resident's bed was reassigned to another individual within one day of transfer. Confusion and miscommunication occurred between facility staff, the hospital, and the resident's public guardian (PG). The facility's Regional Marketer (RM) and Admission Coordinator (AC) both reported being told by hospital staff or the PG that the resident would not be returning, but the PG denied ever making such a statement. The hospital social worker reported that the facility stopped answering calls and stated the resident would not be readmitted, despite discharge orders being in place for the resident to return. The RM and AC did not verify the information with the PG or the hospital, leading to further delays and the resident remaining in the hospital beyond the necessary period. The Director of Nursing (DON) was not informed of the situation and only became aware after reviewing the census, which showed the resident's bed had been reassigned. The facility's policy required honoring a 7-day bed hold for residents transferred to the hospital, but this was not followed. The failure to coordinate and communicate effectively among facility staff, the hospital, and the PG resulted in the resident not being readmitted as required by policy, prolonging the hospital stay.
Failure to Readmit Hospitalized Resident Despite Available Bed
Penalty
Summary
A resident with diagnoses including metabolic encephalopathy, spinal stenosis, type 2 diabetes, and COPD was admitted to the facility and was noted to have intact cognitive skills but required substantial assistance with activities of daily living. The resident was transferred to a general acute care hospital due to increased confusion and at the family's request. Following the hospitalization, the facility failed to readmit the resident, despite available female beds during the relevant period, resulting in the resident remaining in the hospital for 30 days. The admissions coordinator, responsible for facilitating returns after hospitalization, stated that the resident was denied readmission due to a change in insurance, a decision made by the regional marketer. The director of nursing was not informed of the denial and indicated that the regional marketer did not have the authority to deny readmission. Facility policy required that previously admitted residents be allowed to return, but this was not followed in this case.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to implement its grievance policy and procedure for one resident who reported an issue with her roommate repeatedly touching the privacy curtain, which caused her distress. The resident, who had no cognitive impairment and was able to make her own decisions, stated that she reported the issue to a staff member, but no action was taken. The facility's grievance log did not contain any record of this concern, and there was no documentation of any investigation or follow-up regarding the resident's complaint. Interviews with the Social Services Director and the Director of Nursing confirmed that the grievance should have been documented and addressed according to facility policy, which requires grievances to be logged and investigated with appropriate follow-up. The Social Services Director acknowledged that a room change was offered but declined by the resident, yet this was not documented. The lack of documentation and follow-up meant the resident's grievance was not formally acknowledged or resolved as required by the facility's policy.
Failure to Provide Effective Pain Management and Documentation
Penalty
Summary
Facility staff failed to provide effective pain management for a resident who reported pain levels of 4 out of 10 on two consecutive days. Despite physician orders to administer acetaminophen for mild pain and to use non-pharmacological interventions such as heat, repositioning, relaxation breathing, food/fluids, massage, exercise, and immobilization, there was no documentation that these interventions were provided. Additionally, the resident's pain was not thoroughly assessed or reassessed after the initial complaint, as required by both physician orders and facility policy. The resident involved had diagnoses including lack of coordination and hypertensive heart disease, and required substantial assistance with activities of daily living. The resident was cognitively intact and able to communicate pain. Facility records, including the Medication Administration Record and Medication Administration Notes, did not show evidence of pain assessments, administration of pain medication, or implementation of non-pharmacological interventions on the dates in question. Interviews with the DON confirmed the lack of documentation and intervention following the resident's pain reports.
Failure to Provide Functional Call Devices for Residents
Penalty
Summary
The facility failed to provide functional call devices for two out of three sampled residents, resulting in the absence of a means for these residents to communicate their needs to staff. Both residents had no cognitive impairment and required substantial to maximal assistance with activities of daily living, including toileting, transfers, and mobility. Observations revealed that the call lights in their rooms did not activate when pressed, and no alternative call bells or devices were available at their bedsides. One resident reported that her call light had not worked for two weeks, requiring her to go to the nurse’s station for assistance. A review of the facility’s maintenance log confirmed that the call light issues for these residents began several days prior and had not been resolved. The facility’s policy required that if the call alert system could not be repaired immediately, an alternative process such as tap bells or auxiliary aids should be implemented, but this was not done. Staff interviews acknowledged the lack of functional call lights and the absence of alternative alert systems for the affected residents.
Insufficient Staffing Led to Delayed Response After Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care and safety needs of a resident with significant cognitive and physical impairments. On the date in question, only four CNAs were present for the morning shift when seven were scheduled, resulting in a lower than planned direct care hours per patient day. The resident involved had diagnoses including muscle weakness, glaucoma, legal blindness, and severe cognitive impairment, and was dependent on staff for all activities of daily living and mobility. The resident experienced a fall and was found sitting on the floor with a bump on the forehead, but the documentation did not specify how long the resident was on the floor before being discovered. The assigned CNA was attending to another resident at the time of the fall, and another CNA found the resident on the floor. The Director of Nursing acknowledged that the reduced staffing could have led to a delayed response in providing care to the resident after the fall. Facility policy required resident checks at least every two hours, but the staffing shortage may have impacted the ability to meet this standard. The incident resulted in the resident being sent to the hospital for evaluation, though no injuries were found.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation practices in the kitchen. During breakfast tray line service, both the cook and a dietary aide were observed plating food without wearing masks, contrary to facility policy and infection control standards. Additionally, the dietary aide was seen returning to the tray line and handling food after touching non-food items in dry storage, without changing gloves or washing hands. The dietary aide acknowledged the importance of changing gloves and hand hygiene to prevent cross contamination but did not follow these procedures during the observed event. Further observations revealed expired food items stored in the kitchen, including bread, marshmallows, spices, and cartons of chocolate milk, some of which were unlabeled or past their expiration dates. Staff interviews confirmed that expired products were not always removed promptly and that proper procedures for checking expiration dates were not consistently followed. Facility policies reviewed indicated clear requirements for mask use, glove changes, and monitoring of food expiration dates, but these were not adhered to during the survey.
Improper Use of N95 Respirator Mask by Staff
Penalty
Summary
The facility failed to implement proper infection control interventions in accordance with its Respiratory Protection Program policy and procedure. During an observation, a Certified Nurse Assistant (CNA) was seen entering a resident care area wearing an N95 respirator mask incorrectly, with the string hanging in front of the mask. The CNA acknowledged during an interview that the mask was not worn properly, which did not provide a proper seal and could allow germs to enter or escape, potentially contributing to the spread of COVID-19. The CNA also described the correct method for donning the N95 mask, which was not followed at the time of the observation. A review of the facility's Respiratory Protection Program policy indicated that respirators must be used as certified by NIOSH or the manufacturer, and that employees are required to perform positive and negative pressure user seal checks each time they wear a respirator. The improper use of the N95 mask by the CNA was not in compliance with these established procedures, impacting all residents and staff in the facility.
Incomplete Fall Assessment Following Resident Fall
Penalty
Summary
The facility failed to perform an accurate fall assessment for one resident following a fall incident. The resident, who was admitted with diagnoses of lack of coordination and muscle weakness, was identified as high risk for falls and had a care plan in place indicating the need to follow the facility's fall protocol. Despite this, after the resident experienced a fall, the Fall Risk Evaluation completed did not document the fall event, nor did it include critical assessment elements such as the resident's level of consciousness, gait and balance, or medications. Additionally, the evaluation did not provide a fall risk score. During an interview and record review, the DON confirmed that the Fall Risk Evaluation was not completed properly and acknowledged the omission of essential information, including the recent fall and relevant assessment details. The facility's policy required a new fall risk evaluation to be conducted post-fall, but this was not done in accordance with the policy, resulting in an incomplete assessment for the resident.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in deficiencies related to individualized care. For one resident with diagnoses including cerebral infarction, hemiplegia, and quadriplegia, there was an order for Restorative Nursing Assistance (RNA) involving passive range of motion exercises. Despite the resident's cognitive impairment and dependence on staff for activities of daily living, no care plan for RNA services was created until after the issue was identified during the survey. Staff interviews confirmed that a care plan should have been in place to guide interventions and evaluate the effectiveness of the RNA program. Another resident, diagnosed with muscle wasting, degenerative nervous system disease, and quadriplegia, was prescribed Risperdal, an antipsychotic medication, for schizophrenia. The medical record review revealed that there was no care plan addressing the use of antipsychotic medication. Staff acknowledged that a care plan is required for any resident receiving such medications to ensure appropriate monitoring and care. The absence of a care plan meant that staff lacked guidance on managing the resident's medication regimen and monitoring its effects. A third resident, with metabolic encephalopathy, spinal stenosis, and type 2 diabetes, was observed to have long fingernails and reported that no one had offered to trim them, despite being dependent on staff for personal care. Although a care plan was eventually created to address the risk of infection and injury related to long nails, it was not initiated at the time the problem was identified. Staff interviews and care plan history confirmed the delay in care plan development, resulting in the resident's needs not being promptly addressed.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including grooming and personal hygiene, was not provided with necessary nail care. The resident, who had diagnoses including metabolic encephalopathy, spinal stenosis, and type 2 diabetes mellitus, was observed to have long fingernails. The resident reported that no one had offered to trim her nails and expressed a desire for them to be trimmed. Multiple staff members, including a CNA, LVN, and the DON, observed and acknowledged that the resident's fingernails were excessively long and could harbor dirt and germs. The facility's policy required that residents with diabetes have their nails trimmed by a licensed nurse, but this was not done for the resident in question. Interviews with staff revealed that the long fingernails had not been reported or addressed, despite being noticeable during daily care. The DON stated that CNAs should have identified the need for nail care and reported it to the charge nurse, but this did not occur. The failure to provide appropriate nail care was confirmed through observation, interviews, and record review, resulting in the resident not receiving care and services necessary to maintain good grooming and personal hygiene.
Failure to Provide and Document Ordered Restorative Nursing Care for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative nursing program (RNA) care as ordered by physicians for two residents with limited range of motion (ROM). Both residents had significant neurological and musculoskeletal diagnoses, including cerebral infarction, hemiplegia, quadriplegia, muscle wasting, and degenerative nervous system disease, resulting in severe cognitive and physical impairments. Physician orders specified that each resident was to receive passive range of motion (PROM) exercises to both upper and lower extremities five times a week, as tolerated. Record reviews revealed multiple days in February and March when RNA services were not provided to either resident, despite the standing orders. Additionally, weekly interdisciplinary team (IDT) progress notes documenting the residents' response to therapy and progress were missing for several weeks. Staff interviews confirmed that RNA services were not always documented, and in some cases, the therapy may not have been performed. The RNA staff acknowledged that documentation was required each time therapy was provided and that missing documentation indicated the therapy was not done. Facility policies required daily and weekly documentation of RNA services and adherence to physician orders. The Director of Nursing (DON) confirmed the importance of daily and weekly documentation to monitor residents' progress and determine if further interventions were needed. The lack of consistent RNA services and documentation for these two residents constituted a failure to follow physician orders and facility policy, resulting in a deficiency.
Failure to Follow Pureed Diet Recipe Results in Improper Food Consistency
Penalty
Summary
During a breakfast meal service, a staff member was observed preparing a pureed diet for a resident, which included pureed French toast and pureed eggs. The French toast was served in a cup and had a liquid consistency, rather than the required smooth, pudding-like texture. The staff member acknowledged that the consistency was incorrect and attempted to correct it by adding more bread and blending it further, but did not follow or review the established pureed recipe. The staff member stated the importance of proper preparation for resident safety and to prevent choking. Interviews with the Kitchen Supervisor and the Director of Nursing confirmed that recipes for pureed diets are to be strictly followed to ensure appropriate consistency and nutritional value. Both emphasized that pureed foods must be smooth, hold their shape, and not be watery or liquid, as improper consistency could make swallowing difficult for residents, especially those with a history of stroke. Review of the facility's policy indicated that pureed items should be smooth, free of lumps, and not weep, which was not adhered to during the observed meal preparation.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who required substantial assistance for daily activities and was at high risk for falls did not have access to a functioning call light in their room. The resident, who had a history of muscle weakness and major depressive disorder, was observed on multiple occasions screaming for help because the call light was not within reach. The call light's clip was broken, causing it to fall to the floor and remain inaccessible for at least three days. The resident reported having to scream for help daily, which made them feel angry and forgotten. On two separate occasions, the resident's roommate had to use their own call light to summon staff assistance for the resident. Staff interviews confirmed that the call light was supposed to be on the bed but kept falling due to the broken clip. Certified Nurse Assistants acknowledged that not having the call light within reach could lead to accidents or the resident feeling neglected. The Maintenance Director stated that he had not been informed about the broken call light until the morning of the second observation, despite having replacement clips available. Facility policy required that call lights be kept within reach and that defective devices be reported for immediate repair, with alternative alert systems provided if immediate repair was not possible.
Failure to Timely Develop Care Plan for Side Rail Use
Penalty
Summary
The facility failed to develop a timely care plan for the use of side rails for one resident. The resident, who was admitted with diagnoses including muscle weakness, glaucoma, and legal blindness, was assessed as having severe cognitive impairment and was dependent on staff for activities of daily living and mobility. Documentation showed that a bed rail assessment conducted on 3/4/2025 recommended bilateral side rails to promote independence and assist with bed mobility due to poor trunk control. However, although the need for side rails was identified in the assessment and supported by physician orders, the corresponding care plan addressing the use of side rails was not created until 3/18/2025, which was after the resident experienced a fall on 3/15/2025. Interviews with nursing staff and the DON confirmed that the care plan for side rails should have been implemented at the time of the assessment, but was delayed. The facility's policies required that care plans be updated based on assessed needs and specifically addressed the development of a care plan for bed rail use. The delay in care planning resulted in the resident not having the appropriate interventions in place at the time of the fall, as the side rails were not in use despite being indicated by assessment and requested by the resident's family.
Failure to Provide Ordered Side Rails Resulting in Resident Fall
Penalty
Summary
The facility failed to provide side rails as ordered for a resident with significant physical and cognitive impairments. The resident, who was legally blind, had muscle weakness, poor bed mobility, poor trunk control, and was dependent on staff for most activities of daily living. Documentation showed that a bed rail assessment recommended bilateral side rails to promote independence and provide safety, and physician orders were in place for side rails due to the resident's poor mobility. Despite these orders and assessments, side rails were not installed on the resident's bed at the time of a fall incident. On the date of the incident, the resident was found sitting on the floor with a small red lump on the forehead but no bleeding or reported pain. Interviews with nursing staff and the Director of Nursing confirmed that side rails had been recommended and ordered since earlier in the month, but were not in place at the time of the fall. The facility's policies required completion of a bed rail evaluation and installation by maintenance, but these procedures were not followed, resulting in the resident not having the necessary side rails as part of their fall prevention plan.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of a resident who was prescribed Risperidone, a psychotropic medication, for mood disorder. The resident, who had a history of schizophrenia, schizoaffective disorder, bipolar disorder, psychosis, and anxiety, exhibited aggressive behaviors such as destroying property and entering other residents' rooms. Despite these behaviors, there was no documented evidence of the number of outbursts, which was necessary to assess the effectiveness of the medication and prevent further incidents. Interviews with staff revealed that the resident had moments of aggression, but these were not consistently recorded, and the facility did not contact the doctor to reassess the medication. Additionally, the facility did not document the indication for an increased dose of Depakote, another medication prescribed to the resident for mood disorder. The dose was increased from 500 mg to 750 mg twice a day without proper documentation on the Situation, Background, Assessment, and Recommendation (SBAR) form. The Nurse Practitioner indicated that the increase was due to heightened behaviors, but this was not recorded as per the facility's standard practice. The facility's policy required monthly documentation of behavior occurrences and any adverse reactions, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in one resident slapping another on the face. Resident 1, who has Parkinson's disease, polyosteoarthritis, and major depressive disorder, was admitted to the facility in 2017 and readmitted in 2025. His cognitive skills for daily decision-making were moderately impaired. Resident 2, admitted in 2024, has schizoaffective disorder, psychosis, and anxiety disorder, with similarly impaired cognitive skills. Prior to the incident, Resident 2 exhibited aggressive behavior, including throwing objects and having outbursts. On the day of the incident, Resident 2 accused Resident 1 of stealing his girlfriend, an accusation that was unfounded and not based in reality. Despite previous aggressive behavior, there was no documented evidence of monitoring or intervention to prevent such altercations. A Registered Nurse witnessed Resident 2 slap Resident 1 while assisting him to the bathroom. The facility's policy on abuse prevention and management, which prohibits any form of resident abuse, was not effectively implemented, as staff failed to monitor and address Resident 2's behavior adequately.
Failure to Implement Hourly Monitoring for Wandering Resident
Penalty
Summary
The facility failed to implement a critical intervention in a resident's care plan, which required hourly visual monitoring for a resident at risk of wandering and elopement. This deficiency was identified during a review of the care plan and order summary report, which indicated that the intervention for the resident's risk of wandering and elopement included visual hourly monitoring. However, the Director of Nursing confirmed that no visual hourly monitoring was conducted for the resident from July 6, 2024, through August 5, 2024. The resident in question, identified as Resident 2, was admitted with diagnoses including polyneuropathy, paranoid schizophrenia, and cognitive communication deficit. The resident's Minimum Data Set (MDS) indicated a need for partial to substantial assistance with activities of daily living and supervision for mobility. Despite these needs, the facility did not adhere to the care plan's requirement for hourly visual monitoring, which was crucial given the resident's tendency to wander into other residents' rooms, as observed on multiple occasions. Interviews with staff, including registered nurses and licensed vocational nurses, revealed that the resident frequently wandered into other residents' rooms, sometimes causing distress. Staff attempted to redirect the resident but did not consistently follow the care plan's directive for hourly monitoring. This lack of adherence to the care plan placed the resident at risk for altercations with other residents, as evidenced by an incident where another resident reported being attacked by the wandering resident.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident while she was in bed. This deficiency was identified during a survey where it was observed that the call light was behind the bedside table and later found on the floor behind the resident's bed. The Director of Nursing (DON) confirmed that the call light was supposed to be within reach of the residents, acknowledging that the current placement would prevent the resident from getting help if needed. The resident involved in this deficiency had been admitted and readmitted to the facility with diagnoses including polyneuropathy, dementia, and paranoid personality disorder. The resident's history and physical indicated she did not have the capacity to understand and make decisions. Despite this, the Minimum Data Set (MDS) assessment showed that the resident was usually understood and able to understand others, requiring varying levels of assistance from staff for daily activities and being dependent on staff for mobility. The facility's policy and procedure on the call system, dated 2012, stated that call cords should be placed within the resident's reach to allow prompt communication with nursing staff. However, the failure to adhere to this policy resulted in the resident having to yell to get help, as she did not have a phone or accessible call light. This oversight had the potential to delay the resident's ability to receive timely assistance from the staff.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents who were smokers. Resident 1, diagnosed with schizoaffective disorder and nicotine dependence, was found with a cigarette lighter in her purse, unsupervised during some cigarette breaks, and without a clear plan for the safe storage of smoking materials. The care plan and smoking safety form for Resident 1 were inconsistent, leading to confusion about the necessary supervision and storage of smoking materials. Resident 2, with a diagnosis of metabolic encephalopathy and unsteadiness on feet, was observed with a cigarette lighter on his wheelchair seat. Despite requiring assistance and supervision when smoking, Resident 2 kept his smoking materials and smoked without staff supervision. The care plan did not specify how his smoking materials should be stored, and the facility's protocol for storing smoking materials was not followed. Resident 3, with severe cognitive impairment and a history of schizoaffective disorder, was seen holding a lighter and smoking unsupervised. The facility's smoking safety evaluation indicated that Resident 3 required supervision, but the smoking materials were stored in an unsecured tacklebox, raising concerns about safety. The facility's manual stated the need for a safe and hazard-free environment, which was not upheld in these cases.
Failure to Implement Safe Smoking Practices
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for the safe storage of smoking materials for three residents who were smokers. Observations revealed that Resident 1 had a cigarette lighter in her purse, Resident 2 had a lighter on his wheelchair seat, and Resident 3 was holding a lighter while coming out of his room. These incidents occurred despite the facility's policy requiring the interdisciplinary team to create individualized plans for the safe storage and supervision of smoking materials. Resident 1's care plan and smoking safety form were inconsistent, leading to confusion among staff about the necessary interventions for safe smoking practices. The care plan indicated that Resident 1 required supervision while smoking, but it did not specify how her smoking materials should be stored. Similarly, Resident 2's care plan failed to address the storage of smoking materials, even though the resident was supposed to be supervised during smoking. Resident 3's care plan also lacked details on the storage of smoking materials, despite the resident's need for supervision during smoking times. The facility's failure to ensure the safe storage of smoking materials posed a significant risk to the health and safety of all residents, staff, and visitors. The lack of proper storage and supervision could potentially lead to fires, as residents had unsupervised access to lighters and cigarettes. The facility's nursing manual outlined the need for assessments and individualized care plans for smoking residents, but these were not effectively implemented, resulting in the identified deficiencies.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding the timely reporting of resident-to-resident altercations. Specifically, the facility did not report an altercation between two residents to the State Survey Agency and Ombudsman within the required two-hour timeframe. Resident 1, who has a history of cerebral infarction, atrial fibrillation, and celiac disease, reported an incident where Resident 2 blocked the door with his wheelchair and grabbed Resident 1's private parts, leading to a physical altercation. Resident 1's cognitive assessment indicated fluctuating capacity to understand and make decisions, while Resident 2, diagnosed with cardiomegaly, dementia, and schizoaffective disorder, was assessed as lacking the capacity to understand and make decisions. The Director of Nursing (DON) was unaware of the altercation, which occurred on 6/16/2024, and confirmed that the incident was not reported as per the facility's abuse policy. The facility's policy, dated 3/2018, mandates that all allegations of abuse be reported to the Administrator and appropriate agencies promptly, with serious bodily injury incidents requiring notification within two hours. The failure to report this incident placed Resident 1 and other residents at risk for further abuse, as the facility did not adhere to its established procedures for handling such situations.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility staff failed to notify the physician when a resident continued to refuse her medications, including Remeron, Buspirone, and Seroquel. This resulted in the physician being unaware of the resident's change of condition, leading to delayed medical intervention and the resident experiencing unnecessary hostile behavior. The resident, who had diagnoses including schizophrenia, bipolar disorder, metabolic encephalopathy, depression, and anxiety, was admitted with fluctuating capacity to understand and make decisions. Despite the care plan indicating the need to administer psychotropic medications as ordered, the resident refused the medications multiple times, and the licensed nursing staff did not complete a Change of Condition (COC) or notify the physician as required by the facility's policies and procedures. During interviews and record reviews, it was found that the licensed vocational nurse and the Director of Nursing acknowledged that the COC was not completed and the physician was not notified. The facility's policies and procedures clearly stated that the attending physician must be notified promptly in case of a significant change in the resident's condition, including refusal of treatment. The failure to notify the physician in a timely manner put the resident at risk for health complications and hospitalization, as evidenced by the resident's subsequent hospitalization for behavioral evaluation.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, specifically involving Resident 1 and Resident 2. Resident 1, who was admitted with diagnoses including diabetes, hypertension, dysphagia, depression, and anxiety, reported a verbal altercation with Resident 2. Resident 2, who had fluctuating capacity to understand and make decisions due to schizophrenia, bipolar disorder, depression, and anxiety, called Resident 1 derogatory names and used profanity. This incident was initially reported by Resident 1 to CNA1, who did not immediately report it to the charge nurse as required by the facility's policy. CNA1 later witnessed Resident 2 verbally abusing Resident 1 again and reported it to LVN1. Despite being aware of the situation, LVN1 did not transfer Resident 2 to a different room, believing Resident 2 did not appear aggressive or hostile at that time. This inaction led to another incident where Resident 2 became very agitated and verbally abusive towards Resident 1 and staff. The Director of Nursing (DON) was informed of the situation but was not aware that Resident 2 had not been transferred immediately. The facility's policies on abuse prevention and resident-to-resident altercations were not followed. The staff failed to separate the residents promptly and did not take appropriate actions to prevent further verbal abuse. The DON acknowledged that the staff should have transferred Resident 2 to a different room immediately to ensure Resident 1's safety and prevent further incidents of verbal abuse.
Failure to Report Verbal Abuse Incident Within Mandated Timeframe
Penalty
Summary
The facility failed to provide the State Survey Agency with a written report of findings for the investigation of an allegation of verbal abuse within five working days. This incident involved Resident 1, who was verbally abused by Resident 2. Resident 1 was admitted to the facility with diagnoses including diabetes, hypertension, dysphagia, depression, and anxiety, and was totally dependent on staff for oral, toileting, and personal hygiene. Resident 2, who had fluctuating capacity to understand and make decisions, was admitted with diagnoses including schizophrenia, bipolar disorder, depression, and anxiety. On the day of the incident, Resident 2 became very agitated and verbally abusive towards Resident 1, using racial slurs and profanity. The incident was reported to the State Survey Agency via email, but the required written report of findings was not submitted within the mandated five-day period. During an interview, the Licensed Vocational Nurse (LVN1) confirmed hearing the commotion and witnessing the verbal abuse. The progress notes indicated that Resident 2 was transferred to the hospital for a behavioral evaluation following the incident. The facility's Policy and Procedure on Reporting Abuse, revised in 2018, mandates that a written report of findings be provided to the appropriate agencies within five working days of the incident. However, the Administrator admitted that this report was not submitted to the Health Department, resulting in a failure to comply with federal and state regulations regarding the reporting of abuse incidents.
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What surveyors actually found near you
We read the 6,233 citations issued within 25 miles in the last 12 months — including the 31 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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Nursing homes near Lawndale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Camino Healthcare | 0.9 mi | ★★★★★ | 21 | 0 |
| Las Flores Convalescent Hospital | 1.3 mi | ★★★★★ | 18 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 2.3 mi | ★★★★★ | 13 | 0 |
| Clear View Convalescent Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Clear View Sanitarium | 2.3 mi | ★★★★★ | 10 | 0 |
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