Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linwood Meadows Care Center during CMS and state inspections, most recent first.
A resident did not receive a prescribed dose of enoxaparin sodium because the medication was unavailable, and there was no documentation that the physician was notified as required by facility policy. An LVN confirmed the medication was not administered and could not provide evidence of physician notification, and the DON stated that the physician should have been informed.
Three residents reported incidents of physical abuse by a CNA during showers, including rough handling and inappropriate behavior. Despite these allegations being communicated to department leadership, the DON and DSD were not aware of all incidents, and the required reports to CDPH were not made within the mandated timeframe.
The facility did not offer, obtain, or document advance directives (ADs) for multiple residents, and failed to follow up or maintain copies of ADs in resident records as required by policy. Some residents who indicated they had an AD did not have documentation or follow-up in their charts, and others were not provided with information or assistance regarding ADs.
Four residents with varying cognitive and physical needs did not receive individualized activities as outlined in their care plans. One resident who enjoyed going outside was not offered this opportunity by staff, another was left without reading materials or in-room activities, a third expressed sadness and a desire for fresh air but was not taken outside, and a fourth resident with dementia was left alone without appropriate sensory activities. The activities director confirmed that these deficiencies were not addressed or documented.
The facility did not ensure RN coverage for at least eight hours per day, seven days a week, as required by policy. Staffing records and staff interviews confirmed that on multiple days, no RN was present for the required shift duration, with only one RN scheduled as a floor nurse and the others in administrative roles.
The facility did not ensure that several CNAs received the required 12 hours of annual in-service education, with some receiving less than the mandated amount. Additionally, annual performance evaluations were not completed for some CNAs, as required by facility policy. These deficiencies were confirmed through interviews and record reviews with facility leadership.
Two residents were served food items contrary to their documented preferences, such as being given green beans and bread despite clear instructions to avoid them. Another resident did not receive whole milk as ordered by the physician. Staff confirmed these errors should have been identified during meal tray checks.
Surveyors found that opened food items in storage were not labeled with open dates and a dented can of pinto beans was stored with regular canned goods. The Dietary Manager Assistant confirmed these actions were not in accordance with facility policy, which requires proper labeling of opened foods and separation of dented cans for discard.
Surveyors found that clean personal laundry was stored in the dirty area of the laundry room, contrary to facility policy requiring separation of clean and soiled linens. Additionally, a housekeeper failed to perform hand hygiene between glove changes after cleaning a resident's restroom, in violation of hand hygiene protocols.
A resident with a urinary tract infection was prescribed cephalexin by telephone order before urine culture results were available. When the culture later identified Proteus Mirabilis and provided antibiotic susceptibility, there was no evidence the physician was notified, and the resident did not receive the most effective antibiotic. The facility also failed to ensure the practitioner assessed the resident within 72 hours of the telephone order, contrary to its antibiotic stewardship policy.
A facility failed to provide COVID-19 in-service education to 143 out of 186 staff, with only 43 staff attending the required training in the past year. Interviews with the ADON and DON revealed a lack of review and absence of a policy for COVID-19 education.
Several resident rooms were found to be above the required temperature range, with temperatures measured between 82 and 85°F. Residents reported feeling hot and uncomfortable, and one used a portable fan for relief. Maintenance staff confirmed the elevated temperatures and noted that thermostat settings had been altered, contributing to the persistent warmth in the affected area.
The facility did not ensure that CNAs completed the required annual five hours of dementia care training, with several staff receiving less than the mandated hours or none at all. Additionally, at least one CNA did not receive annual abuse prevention training, contrary to facility policy.
Two residents did not have proper informed consent for psychotropic medications: one received Mirtazapine without a physician's signature on the consent form, and another was given Buspirone without a signed or properly documented consent, despite being able to provide one. Facility policy requires informed consent, including discussion of risks and benefits, to be obtained and documented before administering or changing psychotropic medications.
A resident with severe dementia and hearing loss was provided with a communication board in English, but staff repeatedly observed that the resident did not understand the board or its symbols. Despite this, staff continued to use the board as a primary communication tool without assessing or revising the care plan, and no alternative communication methods or interpretation services were utilized, resulting in unmet communication needs.
A resident's medication regimen review included a pharmacist's recommendation to clarify and potentially continue allopurinol 100 mg daily, as previously advised by a hospitalist. However, there was no physician order for the medication, and facility staff did not document that the attending physician was notified or that the recommendation was reviewed, contrary to facility policy.
Two residents with significant toenail and skin issues, including thickened, discolored, and deformed nails as well as fungal infections, had these conditions omitted from their Nursing Weekly Summaries. Despite staff observations and podiatry notes detailing these problems, the NWS only documented other skin issues or stated no new skin issues, resulting in incomplete and inaccurate medical records.
Maintenance staff did not perform or document required bed rail risk assessments and measurements for two newly admitted residents, both of whom had significant medical conditions and cognitive impairment. In one case, no documentation of measurements was available, and in the other, the assessment was not done due to broken equipment, contrary to facility policy.
A facility failed to accurately assess a resident's fall risk, leading to staff being unaware of the resident's fall history. The resident experienced three falls within six months, but the Nursing Post Fall Review inaccurately reported no history of falls, classifying the resident as a low fall risk. The Director of Nursing confirmed the inaccuracy, which contradicted the facility's policy requiring a review of fall history and potential links to medication changes.
The facility failed to maintain complete in-service training records as per its policy, with missing details such as dates, times, and instructor information. This was confirmed by the DSD and DON during a review, highlighting a lapse in adherence to the facility's recordkeeping procedures.
The facility failed to ensure staff awareness of the Enhanced Barrier Precaution (EBP) protocol, which involves using PPE for infection control. Despite the presence of indicators like a blue PPE caddy and a blue heart above the resident's bed, staff were unaware of which resident required EBP. The Infection Preventionist and DON confirmed that staff should have been trained and aware of these protocols.
The facility failed to notify the responsible representatives of two residents about changes to their POLST forms, resulting in one resident being intubated without consent. Both residents had cognitive impairments and lacked the capacity to make such decisions. The facility's DON acknowledged the oversight, which was against the facility's policy to inform representatives of medical care changes.
The facility failed to develop and implement care plans for two residents following unwitnessed falls. One resident's care plan included a medication review to assess fall risk, but no evidence of completion was found. The second resident had no care plan for skin tears despite medical orders for treatment. The DON acknowledged these oversights, indicating non-compliance with the facility's care plan policy.
Failure to Notify Physician When Medication Not Administered
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident's prescribed medication, enoxaparin sodium, was not administered as ordered. Review of the resident's Order Summary Report showed an active order for enoxaparin sodium to be given daily for ten days. The Medication Administration Record indicated that on one day, the medication was not administered, with a note to see the nurse's note. Progress notes documented that the medication was not available and was pending delivery. During interviews, an LVN confirmed that the medication was unavailable and acknowledged that facility policy required physician notification in such cases, but could not provide documentation that the physician had been notified. The Director of Nursing also confirmed that the physician should have been notified when the medication was not available. Facility policy reviewed stated that the prescriber must be contacted if medication delivery is delayed or unavailable.
Failure to Timely Report Allegations of Physical Abuse
Penalty
Summary
The facility failed to report allegations of physical abuse to the California Department of Public Health (CDPH) within 24 hours for three residents. One resident with moderate cognitive impairment reported that during a shower, a CNA was rough, applied excessive soap to her face, and did not stop until the resident screamed. The resident stated she reported the incident to the department head, who said they would monitor the CNA, but the CNA continued to work in the facility and entered her room. The DON was not aware of this incident until several days later. Another resident, who was cognitively intact, reported that a CNA was rough and pulled her paralyzed arm during a shower, and later confronted her about reporting the incident. A third resident, also cognitively intact, stated that the same CNA was rough during a shower, causing pain, and has since refused showers from that CNA. Interviews with the DON and DSD revealed that they were not aware of all three abuse allegations prior to the survey, and the incidents were not reported to CDPH as required by facility policy.
Failure to Offer, Obtain, and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to offer, obtain, and complete advance directives (ADs) for 10 out of 26 sampled residents. During interviews and record reviews, the Assistant Director of Nursing (ADON) was unable to provide documentation that AD information was offered or that an AD had been completed for several residents. In each case, the ADON confirmed that the residents did not have an AD on file, and there was no evidence that the facility had provided the required information or assistance regarding ADs. For some residents who indicated on their admission questionnaires that they had executed an AD, the Social Services Director (SSD) was unable to provide a copy of the AD in the residents' charts. There was also no documentation that staff had followed up with these residents to obtain a copy of their ADs. In interviews, residents confirmed that the facility had not requested a copy of their ADs or provided additional information about executing one, despite their expressed interest or indication of having an AD. A review of the facility's policy and procedure on advance directives revealed that staff are required to inquire about the existence of ADs upon admission, provide written information about the right to formulate an AD, and assist residents in establishing one if needed. The policy also requires that copies of executed ADs be maintained in the resident's medical record and be readily retrievable by staff. The facility did not follow these procedures for the affected residents.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide activities of interest and individualized engagement for four residents, as evidenced by observations, interviews, and record reviews. One resident with multiple sclerosis, paraplegia, and monoplegia, who was cognitively intact, expressed a desire to go outside and listen to birds but reported only being able to do so when visitors took him out. The activities director was unaware of this resident's preferences and acknowledged that activities staff had not offered or documented outdoor activities for him, despite his care plan indicating a preference for going outside and walking. Another resident with COPD, palliative care needs, and hearing loss, who was also cognitively intact, was observed alone in her room without any activity materials. She stated she did not participate in activities and only watched television, with no in-room activities provided. The activities director confirmed that staff did not leave reading materials in resident rooms and could not provide documentation of in-room activities for this resident, despite the care plan specifying the provision of such materials. A third resident with dementia, anxiety, and depression, who had recently lost her husband, expressed feelings of sadness and a desire to go outside for fresh air, but reported that no one had taken her outside. The activities director confirmed that this resident had not been provided with in-room activities or outdoor opportunities, despite her care plan and assessment indicating the importance of such activities. Additionally, a fourth resident with dementia and hearing loss, who was unable to complete a cognitive assessment, was observed alone in the dining room with only a communication board and no engagement from activities staff. The activities director acknowledged that this resident should have been provided with sensory activities and 1:1 engagement as outlined in her care plan, but this was not done or documented.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours a day, seven days a week, as required. Interviews with staff revealed that only one RN was scheduled as a floor nurse, while the other two RNs held administrative roles as the Director of Nursing (DON) and Assistant Minimum Data Set (AMDS) nurse, and were not utilized to provide direct resident care. Review of the staffing schedule for May 2025 showed that there were 11 days within a 21-day period when no RN worked an eight-hour shift, which was confirmed by the Assistant Director of Nursing (ADON). The facility's policy on staffing requires an RN to provide services for at least eight consecutive hours every 24 hours, seven days a week. Despite this policy, the facility did not have RN coverage for the required hours on multiple days, as documented in the staffing records and acknowledged by the ADON. This deficiency was identified through interviews and record reviews conducted by surveyors.
Failure to Provide Required CNA In-Service Training and Annual Performance Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) received the required 12 hours of annual in-service education and annual performance evaluations as outlined in facility policy. Specifically, three out of six sampled CNAs did not complete the mandated 12 hours of in-service training for the year, with one CNA receiving only ten hours, another eleven hours, and a third only six hours. The Assistant Director of Nursing confirmed these deficiencies during record reviews and interviews. The facility's policy requires all nurse aide personnel to participate in no less than 12 hours of in-service education per employment year to ensure continuing competency. Additionally, the facility did not complete annual performance evaluations for two out of eight sampled CNAs. One CNA's last performance evaluation was completed over a year prior, and two recently hired CNAs had no documented performance evaluations in their employee files. The Director of Staff Development Assistant was unable to provide current evaluations for these staff members, despite facility policy requiring annual performance reviews for all employees.
Failure to Honor Food Preferences and Follow Diet Orders
Penalty
Summary
The facility failed to honor food preferences for two residents and did not follow physician diet orders for another resident. Specifically, one resident who had a documented dislike for green beans was served green beans on her lunch tray, and another resident who was not supposed to receive bread was served bread. Additionally, a third resident who was ordered to receive 4 fluid ounces of whole milk did not have milk provided on her lunch tray. These deficiencies were identified during concurrent observations, interviews, and record reviews with facility staff, who confirmed that the errors should have been caught during meal tray checks.
Failure to Label Opened Food and Discard Dented Cans
Penalty
Summary
Surveyors observed that the facility failed to ensure opened food items in the cold storage room were labeled with an open date. During an inspection with the Dietary Manager Assistant (DMA), several opened items—including a jar of lemonade, bottles of ketchup and mayonnaise, bottles of sweet relish, and a jar of sliced pickles—were found without open dates. The DMA confirmed that these items should have been labeled and dated according to the facility's policy and procedure, which requires all opened food items to be labeled with an open date and used within specified storage guidelines. Additionally, a dented can of pinto beans was found stored on the shelf with other canned foods in the kitchen's dry storage room. The DMA acknowledged that the dented can should not have been stored with regular cans and should have been separated for discard, as outlined in the facility's policy. The policy specifies that food in dented, rusty, or otherwise compromised containers must not be retained or used and should be placed in a designated area for return to the vendor.
Infection Control Lapses in Laundry Storage and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices in two key areas. First, three large barrels containing residents' clean personal laundry were observed stored in the dirty area of the laundry room, directly next to barrels containing soiled linen. The Director of Maintenance acknowledged that the clean laundry was placed in the dirty area due to lack of storage space, and the Social Services Director confirmed that clean laundry should not be stored in the dirty area. Facility policy requires that soiled and clean linen, along with their respective containers, be kept separate at all times. Second, a housekeeper was observed cleaning a resident's restroom while wearing gloves, then exiting the restroom and placing cleaning tools back on the housekeeping cart without removing gloves. The housekeeper then removed the gloves and put on a new pair without performing hand hygiene in between glove changes. The housekeeper admitted to failing to perform hand hygiene as required. Facility policy states that hand hygiene must be performed before applying non-sterile gloves.
Failure to Notify Physician of Culture Results and Inadequate Antibiotic Stewardship
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for a resident who exhibited signs of infection, including an elevated temperature and confusion. The attending physician gave a telephone order for cephalexin prior to the availability of urine culture and sensitivity results. When the urine culture later identified Proteus Mirabilis and provided susceptibility results, there was no evidence that the physician was notified of these findings. The infection preventionist stated it was the floor nurse's responsibility to inform the physician, but no documentation was provided to confirm that this occurred. As a result, the resident did not receive an antibiotic with the highest efficacy for the identified bacteria, as indicated by the culture and sensitivity report. Additionally, the facility did not follow its own policy requiring the primary care practitioner to assess the resident within 72 hours of a telephone order for antibiotics. Review of the physician's progress notes showed no documentation that the resident was evaluated for the urinary tract infection following the initial telephone order. The facility's policy on antibiotic stewardship specifically states that lab results and the current clinical situation should be communicated to the prescriber as soon as available, and that the practitioner should assess the resident within 72 hours of a telephone order, both of which were not followed in this case.
Failure to Provide COVID-19 In-Service Education to Staff
Penalty
Summary
The facility failed to provide in-service education on COVID-19 to 143 out of 186 staff members, as evidenced by a review of attendance records for the in-service education titled 'Prevention of Covid-19.' Only 43 staff attended the training within the last 12 months. During interviews, the Assistant Director of Nursing stated they had not reviewed the in-service education and were not present when it was conducted. The Director of Nursing confirmed the total staff count and acknowledged that the facility did not have a policy for providing in-service education on COVID-19 to staff and residents.
Failure to Maintain Required Ambient Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain the required ambient temperature range of 71 to 81 degrees Fahrenheit in several resident rooms, as evidenced by direct observations and interviews. Three sampled resident rooms were found to have temperatures ranging from 82 to 85 degrees Fahrenheit. Residents in these rooms reported feeling hot and uncomfortable, with one resident using a portable electric fan and not wearing a gown or shirt due to the heat. The Assistant Maintenance Supervisor confirmed the elevated temperatures and stated that it had always been warm in that area of the facility. Further, it was noted that someone had altered the thermostat settings, which may have contributed to the temperature issue. Facility documentation requires maintaining ambient temperatures within the specified range, which was not met in these instances.
Failure to Provide Required Dementia and Abuse Prevention Training to CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required minimum of five hours of annual dementia care training. Record reviews and interviews with the Assistant Director of Nursing (ADON) revealed that six sampled CNAs had not completed the mandated training hours, with some receiving as little as zero to four hours of dementia training within the year. The facility's own policy required annual in-service education on dementia care, but documentation showed that these requirements were not met for the sampled staff. Additionally, the facility did not ensure that all CNAs received annual abuse prevention training. Specifically, one CNA had not completed abuse prevention training within the last 12 months, as confirmed by a review of the personnel file and interview with the Director of Staff Development Assistant (DSDA). The facility's policy stipulated annual training in both dementia management and resident abuse prevention, but this was not consistently provided to all staff.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper informed consent procedures for psychotropic medication administration for two residents. For one resident with diagnoses including anxiety disorder, psychotic disorder, and unspecified mood affective disorder, the informed consent form for Mirtazapine was signed by the resident's representative but not by the physician prior to medication administration. The Assistant Director of Nursing confirmed that the physician's signature and date were required on the informed consent form. In another instance, a resident receiving Buspirone for anxiety did not have a signed informed consent form, and only verbal consent was documented. The resident reported that the physician had not discussed informed consent for Buspirone and that she had neither signed nor given verbal consent for the medication. The Assistant Regional Director acknowledged that the physician should have explained the risks, benefits, and alternatives to the resident and that a signature was required if the resident was able to sign. The facility's policy indicated that informed consent, including discussion of risks and benefits, must be obtained and documented prior to initiating or changing psychotropic medications.
Failure to Assess Effectiveness of Communication Board for Severely Impaired Resident
Penalty
Summary
The facility failed to assess the effectiveness of a communication board used for a resident with severe cognitive impairment and hearing loss. The resident, who was admitted with unspecified dementia and hearing loss, was unable to verbally communicate and did not respond to verbal greetings, though she smiled. Staff, including the Infection Preventionist and Certified Nursing Assistants, attempted to use a communication board with English-language symbols and pictures to communicate with the resident. However, multiple staff members observed that the resident did not appear to understand the board or its symbols, and her responses to the board were not meaningful or indicative of her needs. Despite this, staff continued to use the communication board as a primary communication tool. The resident's records indicated she was not capable of understanding her rights or participating in her treatment plan, and her BIMS score showed she was unable to complete the cognitive assessment. Staff were unsure of the resident's primary language, though it was noted her family spoke Mandarin, and no staff spoke Mandarin. The DON confirmed that the resident was severely impaired and unable to comprehend the communication board, and that interpretation services had not been used due to her cognitive status. The facility did not evaluate or revise the care plan to address the ineffectiveness of the communication board, resulting in a failure to identify and meet the resident's communication needs.
Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to act on a recommendation from the consultant pharmacist regarding a resident's medication regimen review. Specifically, the pharmacist identified that a hospitalist had recommended the continuation of allopurinol 100 mg daily for a resident, but there was no corresponding physician order for this medication. The pharmacist's recommendation was documented in the medication regimen review, but there was no evidence that the attending physician was notified or that the recommendation was evaluated and addressed. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that there was no documentation showing the physician had been made aware of the pharmacist's recommendation or had reviewed it. The facility's policy required that such recommendations be communicated to the prescriber and addressed within a specified timeframe, but this process was not followed for the resident in question.
Failure to Accurately Document Residents' Skin and Toenail Conditions
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents by not documenting their skin, toe, and toenail conditions in the Nursing Weekly Summary (NWS). For one resident with right-sided paralysis, observations revealed red, swollen, and thickened yellow toenails, as well as long and discolored toenails on both feet. Despite these findings, the NWS for several weeks indicated that the resident's skin was clear and intact, with no new skin issues documented. Staff interviews confirmed that the resident's toe and toenail conditions were not addressed or recorded in the NWS, even though podiatry notes indicated ongoing issues such as dystrophic and thickened nails with onychomycosis. Another resident was observed to have deformed, thick, long, and discolored toenails with a fungus-like appearance, as well as dry and ashy skin on the toes. The resident reported pain in the toenails. The podiatry evaluation documented nail dystrophy, fungal infection, and hammer toe deformities. However, the NWS for this resident consistently documented only moisture-associated skin damage (MASD) in the peri and sacrococcygeal areas, without any mention of the condition of the feet, toes, or toenails. Staff acknowledged that these conditions should have been included in the nursing assessment and documented in the medical record. The facility's policy required nurses to record information related to changes in a resident's condition or status in the medical record. Despite this, the observed and documented conditions of the residents' feet and toenails were not reflected in the NWS, resulting in incomplete and inaccurate medical records for both residents.
Failure to Conduct Bed Rail Risk Assessments and Measurements for New Admissions
Penalty
Summary
The facility failed to ensure that maintenance staff conducted proper bed rail risk assessments, including evaluation of the bed and measurements of siderails and potential bed entrapment zones, for two newly admitted residents. For one resident with muscle wasting, atrophy, morbid obesity, and moderate cognitive impairment, documentation of a bed rail evaluation with corresponding measurements was not provided. Although maintenance staff stated that bed rails were checked monthly and during admission, the inspection forms only indicated that rooms were assessed without recording the actual measurements required to identify entrapment risks. The facility's policy requires compatibility checks and measurements prior to use, but these were not documented. For another resident with osteoarthritis, generalized muscle weakness, and moderate cognitive impairment, no bed entrapment assessment was performed at admission because the measuring equipment was broken. The resident's siderail evaluation for risk of bed entrapment was not completed as required. The facility's policy specifies that bed frames, mattresses, and bed rails must be checked for compatibility and size, and that maintenance staff must routinely inspect all beds and related equipment for potential entrapment risks, but these procedures were not followed for the two residents.
Inaccurate Fall Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate fall assessment for Resident 1, which had the potential to leave staff unaware of the resident's risk for falls. On 12/31/24, Resident 1 was found on the floor after being heard yelling from their room. A Nursing Post Fall Review (NPFR) completed on the same date inaccurately indicated that Resident 1 had no history of falls in the last six months and was a low fall risk. However, previous SBARs documented that Resident 1 had experienced three falls within that period, including an unwitnessed fall and a fall while on leave of absence. During an interview, the Director of Nursing acknowledged the inaccuracy of the NPFR, which should have identified the increased risk factors for Resident 1's falls. The facility's policy requires a review of a resident's fall history, especially within the last 90 days, to identify any links between falls and changes in medication.
Incomplete Staff In-Service Training Records
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding staff in-service training records, resulting in incomplete documentation. During an interview and record review with the Director of Staff Development (DSD), it was found that three in-service training logs were missing critical information. The first log had three staff signatures, and the second had one, but both lacked the date, start time, end time, course title, instructor name, and instructor signature. The third log contained five staff signatures but was missing the start time, end time, instructor name, and instructor signature. The DSD confirmed that these elements are required for the logs to be considered complete. Further review with the Director of Nursing (DON) confirmed the incompleteness of the in-service training logs. The facility's policy and procedure titled "Recordkeeping, Staff Development" dated February 2008, mandates that individual training records for each employee must include the date of each training class attended, the subject of the class, class length, and the instructor of each class. These records are to be completed by the in-service training coordinator and/or department supervisor. The failure to maintain complete training records suggests a lapse in the facility's adherence to its own policies, potentially impacting the adequacy of staff training.
Failure to Implement Enhanced Barrier Precaution Protocol
Penalty
Summary
The facility failed to ensure that three staff members, including a Restorative Nursing Assistant, a Registered Nurse, and a Certified Nursing Assistant, were aware of the Enhanced Barrier Precaution (EBP) protocol. This protocol is crucial for infection control and involves placing a blue heart above the bed of the affected resident to indicate the need for personal protective equipment (PPE) when providing care. During interviews, all three staff members admitted to being unaware of how to identify which resident required EBP, despite the presence of a blue PPE caddy on the door, which should have signaled the need for such precautions. The Infection Preventionist and the Director of Nursing both confirmed that staff should have been aware of the EBP protocol before providing care. The facility's policy and procedure document, dated March 2024, indicated that staff are to be trained on EBPs and that signs should be posted outside the resident's room to indicate the type of precautions and PPE required. However, the lack of awareness among the staff members suggests a failure in the implementation of this training and communication protocol.
Failure to Notify Representatives of POLST Changes
Penalty
Summary
The facility failed to ensure that the responsible representatives of two residents were notified and informed of changes made to their Physician Orders for Life-Sustaining Treatment (POLST). This resulted in one resident being intubated without consent. Resident 1, who had a diagnosis of Vascular Dementia and a BIMS score indicating moderate impairment, had previously signed an Advance Health Care Directive appointing a Power of Attorney (POA) to make healthcare decisions and expressed a wish for a Do Not Resuscitate (DNR) status. However, a new POLST form was signed by Resident 1, indicating a change to full resuscitation, which led to intubation without the POA's consent. Similarly, Resident 2, with a BIMS score indicating severe cognitive impairment, had a POLST form signed by their responsible representative indicating a DNR status. However, a new POLST form was signed by Resident 1, indicating a change to full resuscitation. The facility's Director of Nurses (DON) acknowledged that both residents lacked the mental capacity to make such decisions and that it was the facility's practice to notify and inform residents' representatives of any changes in medical care. The facility's policy stated that if a resident is deemed incompetent, their rights should be exercised by their appointed representative.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, which could lead to unmet care needs. For the first resident, an SBAR dated 8/9/24 indicated that the resident experienced an unwitnessed fall and was at risk for changes in neurological status and fear of falls. The care plan for this resident included a medication regimen review to evaluate side effects that might increase fall risk. However, during a review with the Director of Nursing (DON), there was no evidence that the medication review was completed, indicating a lapse in implementing the care plan. For the second resident, an SBAR dated 8/12/24 documented an unwitnessed fall resulting in a bump on the head, hip pain, and skin tears. Although medical orders were given for treating the skin tears, a review of the resident's care plans revealed that no care plan was developed for these injuries. The DON acknowledged that a care plan should have been created, highlighting a failure to adhere to the facility's policy on comprehensive person-centered care plans, which requires updates when there is a significant change in a resident's condition.
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Illustrative
What surveyors actually found near you
We read the 275 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Visalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westgate Gardens Care Center | 0.1 mi | ★★★★★ | 5 | 0 |
| Sequoia Vista | 0.6 mi | ★★★★★ | 13 | 0 |
| Kaweah Health Skilled Nursing Center | 2.8 mi | ★★★★★ | 11 | 0 |
| Delta Healthcare & Wellness Center, Lp | 2.9 mi | ★★★★★ | 3 | 0 |
| Visalia Post Acute | 4.1 mi | ★★★★★ | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.