Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Long Beach Care Center, Inc during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and multiple comorbidities, including metabolic encephalopathy, COPD, and type 2 DM, was punched in the face by another cognitively intact resident, causing lip lacerations and abrasions that required first aid and hospital evaluation. A CNA reported seeing the victim waving his hands toward the other resident in the dining room, briefly looking away, and then observing the other resident punch him, after which staff separated and supervised both residents. The resident who struck the other admitted he hit the victim after being startled and stated he did not know why he did it, while the DON confirmed that the facility’s investigation substantiated that one resident hit another despite a policy stating residents must be free from abuse by anyone, including other residents.
A resident with intact cognition and mental health diagnoses was not consistently involved in IDT care conferences or in the development and implementation of her person-centered care plan. Assessment records showed it was very important to her to participate in discussions about her care, and she was documented as capable of making medical decisions. She reported not always being informed when IDT meetings occurred and expressed a desire to participate. Review of records showed one IDT meeting was not rescheduled after she requested postponement due to not feeling well, and the next meeting months later lacked documentation of her participation, despite facility policy and resident rights documents requiring resident involvement in care planning.
A resident with mental health diagnoses and intact cognition reported that several 2025 consultation notes were missing from her medical record after being informed of this by her physician. Review of the chart with the Medical Records Director confirmed that orthopedic and neurology consultant reports had not been placed in or uploaded to the record, despite facility policy requiring complete, accurate, and up-to-date medical records reflecting all care and services. The DON also acknowledged that consultant notes are expected to be included in the resident’s medical record.
A resident with severe cognitive impairment and psychiatric diagnoses kicked another cognitively impaired resident out of bed, then threw a water pitcher and a urine-filled urinal onto the resident, soaking the resident’s face and chest. A CNA witnessed the assault, attempted to intervene but was pushed away, and called for help while the aggressor continued the behavior. Nursing notes documented swelling and redness to the victim’s head, legs, and chest, and ED records later confirmed a left maxillofacial contusion. An LVN found the victim on a fall mattress with fluids on the floor and the aggressor pacing and stating he had beaten the other resident. The DON acknowledged this as physical abuse and stated staff should have separated the residents after the first kick.
A resident with morbid obesity, osteoarthritis, intact cognition, and a documented fall risk slipped on a wet bathroom floor while getting up from the toilet, fell onto the right arm and shoulder, and immediately reported severe shoulder pain. Nursing notes and an LVN confirmed the bathroom floor was wet, and the resident had to scoot to the door to call for help. Over the following months, the resident continued to report frequent severe right shoulder pain and inability to raise the arm. An orthopedic consult and MRI later confirmed a full thickness supraspinatus tendon tear with retraction and associated bursal fluid. Facility policies required a hazard‑free environment and fall prevention, but housekeeping staff only cleaned rooms during daytime hours and janitorial staff did not routinely check resident rooms unless notified, allowing the wet bathroom floor to remain unaddressed.
A resident with a history of aggressive behavior and a care plan requiring one-to-one monitoring was not assigned dedicated supervision. As a result, this resident physically assaulted another resident on the smoking patio. Staff interviews confirmed that the required one-to-one monitoring assignment was missed, leading to the incident.
A resident with schizophrenia and a history of aggressive behaviors was not provided the one-to-one monitoring specified in their care plan. As a result, the resident was able to punch another resident while on the smoking patio, as the only staff present was not assigned as a one-to-one monitor. Staff interviews confirmed the monitoring assignment was missed, leading to the incident.
Facility staff did not notify a physician when a resident missed a scheduled dose of Heparin for DVT prophylaxis and also failed to inform the physician when the resident was not transferred to a hospital as ordered. The missed medication was only discovered after the resident reported it, and the physician was not informed until days later. Additionally, the resident's decision to delay transfer was not communicated to the physician in a timely manner, contrary to facility policy.
A resident with intact cognition and dependent on staff for mobility was physically attacked in his room by another resident with schizophrenia and impaired cognition. The aggressor entered the room, yelled accusations, and struck the resident multiple times with a plastic water pitcher and fists, causing an abrasion and multiple areas of redness that required immediate first aid. Staff and another resident witnessed the incident, and documentation confirmed the injuries and sequence of events.
Staff did not report a resident's allegation of sexual abuse to the state agency as required. A resident with cognitive impairment accused another resident of rape in front of staff, but the CNA omitted this from her report, assuming the RN would handle it. The RN informed the DON, who failed to include the allegation in the report to CDPH. The Administrator was unaware of the allegation and stated it should have been reported.
A resident with cognitive impairment and psychiatric diagnoses accused another resident of rape during a physical altercation, witnessed by staff and another resident. Although the DON was aware of the allegation, no formal investigation or documentation was completed, contrary to facility policy requiring immediate and thorough investigation of abuse allegations.
A resident with recent fractures and immobility did not receive a scheduled dose of Heparin for DVT prophylaxis because an LVN failed to administer the medication while the resident was at physical therapy and then incorrectly documented that it had been given. The omission was discovered after the resident reported swelling and missing the dose, leading to hospital transfer and diagnosis of extensive acute DVTs.
A nurse documented the administration of a Heparin injection to a resident when the medication had not actually been given, and later made further inaccurate edits to the medical record. The error was discovered after the resident reported not receiving the dose, and another nurse confirmed the omission. Facility policy required that the MAR be signed only after medication administration, but this was not followed, resulting in inaccurate medication records.
The facility failed to update its Facility Assessment Tool for all residents by leaving out the IPN from the staff needed for daily operations and emergencies and by not assessing the cultural and ethnic makeup of the resident population. During record review and interview, the Administrator confirmed the omissions in the facility assessment and stated that the cultural backgrounds of residents should be assessed to better meet their needs.
A facility failed to ensure psychotropic medications were properly justified and monitored for three residents. One resident received PRN Ativan for inability to relax without documented nonpharmacological interventions first, another resident on Mirtazapine was not monitored for adverse effects, and a third resident received Risperidone for vague behavioral disorder documentation even though records showed no specific aggressive behaviors. Staff and the DON acknowledged the missing documentation and monitoring, and facility policy required specific indications, behavior documentation, and monitoring for adverse effects.
A facility failed to develop and implement individualized, person-centered care plans with measurable goals and interventions for three residents. One resident with severe cognitive impairment and ROM limitations in all extremities had no care plan to maintain or prevent further decline in ROM, another resident with dementia and anxiety had a PRN Ativan order that was not reflected in the care plan when the order was started, and a third resident with PTSD had vague care planning that did not identify specific triggers or staff interventions to avoid retriggering trauma.
The facility failed to maintain and/or improve ROM for two residents with documented ROM limitations. One resident with severe cognitive impairment and impaired ROM in both hands had an OT eval that did not objectively measure hand joints with a goniometer, and staff later observed closed fists and limited upper-extremity movement. Another resident on hospice with severe cognitive impairment and ROM limitations in both arms and both legs was observed with significant positioning limitations, and staff confirmed the resident was not receiving RNA ROM services despite being identified as needing ROM during care.
Failure to Assess Trauma History and Triggers: The facility failed to complete trauma-informed assessments for two residents. One resident with PTSD, anxiety, and dementia reported trauma from the Vietnam War, but the social service assessment did not document triggers or how the trauma affected him. Another resident with bipolar disorder, MDD, and anxiety had no documented trauma history or trigger assessment, and no follow-up assessment was completed. The DSS and DON stated that trauma screening should occur on admission so care can be tailored to avoid re-traumatization.
Annual performance evaluations were not completed for three sampled employees, including an RNS, an LVN, and a CNA. Record review with the DSD showed the employee files were missing yearly evaluations, and both the DSD and DON stated evaluations are to be done annually to review staff performance, attendance, work ethics, teamwork, and standard of care. The facility policy also required each employee’s job performance to be reviewed at least annually.
Pureed Sweet Potatoes Served With Lumpy Texture: A facility failed to ensure 18 residents on a pureed diet received sweet potatoes prepared to IDDSI Level 4 standards. Surveyors observed the tray line product was lumpy and not smooth, with chunks of potato present, and a taste test with the DS, a cook, and the DM confirmed the texture required chewing before swallowing. The facility recipe and IDDSI guidance both specified a smooth, lump-free pureed consistency.
Unsafe food storage and unsanitary kitchen conditions were observed in the dietary area. Open juice boxes on the dispenser had no date, expired ice cream cups were found in the freezer, and raw eggs and raw bacon were stored next to milk and cooked macaroni. A dirty cart with crumbs and sticky residue was kept near the prep area, dry storage cans had damaged or missing labels with sticky residue, and the coffee maker’s glass gauge pipe had dark brown buildup.
Incomplete and inaccurate resident records were identified for three residents. One resident with severe cognitive and physical impairment had unclear RNA splint orders for both hands and knees, and the RNA stated the wear time and alternation schedule were confusing. Another resident’s chart identified a public guardian, but conservatorship papers were missing from the record. A third resident’s admission documentation failed to note a pre-existing right forearm deformity that staff, family, and later notes confirmed was present on admission.
Arbitration agreements for three residents did not include a venue selection that was convenient to both parties. Records showed each resident had intact cognitive skills for daily decision-making, and the BOM confirmed the blank agreement did not provide for a convenient venue as required by facility policy.
A resident with dementia with psychotic disturbance, MDD, and GAD had severely impaired cognitive skills and required significant assistance with ADLs. The resident was ordered Risperidone daily and PRN Ativan, but RNSs confirmed there was no informed consent for either psychotropic medication. The DON stated informed consent should be obtained before psychotropic meds are given, and the facility policy required written consent before starting them.
Call Light Not Within Reach: A resident with dementia, a history of falls, and osteoporosis was observed lying in bed with the call light on the floor and out of reach. An LVN later placed the call light within reach after entering the room and noted the resident needed to be repositioned and changed. The DON stated the call light on the floor meant it was not within reach and that residents should always have access to it when needed.
A cognitively intact resident with PVD and cellulitis of the left toe reported that staff removed his wheelchair from his room for cleaning against his wishes, leaving it unavailable when he wanted to use it. The DSS confirmed the resident had objected to the wheelchair being taken, RN 1 said staff were not aware of his wishes, and the DON stated the resident’s wishes should have been honored and communicated across departments.
Incomplete Advance Directive Acknowledgment Form: The facility failed to ensure an AD Acknowledgment form was accurate and fully completed for a resident with intact cognitive skills and documented capacity to make decisions. The signed and witnessed form did not indicate whether the resident chose to formulate an AD or not, and the DSS and DON both stated the form should have reflected the resident’s specific directives and been completed during the admission process.
Failure to Notify Ombudsman of Resident Transfer: The facility failed to send the required written notice of transfer to the State LTC Ombudsman for a resident with PTSD, homicidal and suicidal ideations, and paranoid schizophrenia. The resident had intact cognition on the MDS, was noncompliant with meds and treatments, continued responding to internal stimuli, and was transferred to a GACH for further evaluation. Staff confirmed there was no documented evidence that the ombudsman was notified, despite the facility policy requiring the Notice of Proposed Transfer and Discharge to be sent.
Failure to Update Care Plan After MDS Assessment: The facility failed to update a resident’s care plan after the comprehensive assessment. The resident had multiple diagnoses including major depressive disorder, metabolic encephalopathy, DM2, Alzheimer’s disease, CKD, and HTN, with severely impaired cognitive skills and extensive assistance needs for ADLs. LVN and DON interviews confirmed the care plan should have been reviewed and revised by the IDT after the MDS assessment, but it was not updated as required by facility policy.
Failure to Assess and Monitor Splint Fit and Wear Time: A resident with quadriplegia and ESRD had orders for a right wrist/hand splint and a right elbow splint, but there were no PT or OT notes showing a formal assessment of splint appropriateness, fit, or wear tolerance. The DOR confirmed the resident was never formally evaluated by PT or OT, and the resident reported wearing the splints almost every day and needing staff to ensure they fit correctly and were not pressing on his skin. The DON stated rehab was responsible for determining splint type and wear time.
A resident with asthma, COPD, severe cognitive impairment, and dysphagia was on a pureed diet with aspiration precautions and a care plan calling for upright positioning during meals. During observation, a CNA fed the resident pureed food and juice while the resident was lying in bed with the HOB elevated less than 30 degrees; the CNA acknowledged this was not a safe position. ST and the DON confirmed residents should be seated upright while eating, and the facility policy required the head and upper body to be as upright as possible.
Facility staff failed to keep a resident’s buspirone in stock for on-time administration, resulting in a late dose after the medication had to be obtained from the pharmacy. Staff also failed to document receipt of another resident’s morphine sulfate concentrate on the controlled drug record, even though the container showed the quantity received. The DON stated meds should be ordered in advance and that controlled substances must be signed for when received.
Improper Storage of Refrigerated Medications: The Station B medication refrigerator was observed at 50 F, outside the required 36 F to 46 F range, while it contained multiple refrigerated medications including gabapentin, tuberculin, Lantus, and sealed comfort kits with morphine, lorazepam, acetaminophen, and other meds. The LVN stated the unit had been 32 F earlier and was being adjusted, and the DON stated refrigerator temps should be checked each shift and out-of-range meds moved to a working refrigerator per policy.
Failure to follow up on an unfitting denture for a resident who was edentulous and had malnutrition and dementia. The resident reported pain while eating or chewing, embarrassment when talking to others, and difficulty eating without the denture. The dental note showed the full upper and lower dentures were adjusted, but the DSS did not know the status of the denture and there was no documentation in the social service notes about follow-up or whether the denture was delivered and fitting properly.
Menu Not Followed for Resident on Renal CCHO Diet: A resident on a renal CCHO small portions diet was served a chopped beef patty with brown gravy and baked sweet potatoes instead of the menu items of glazed baked pork chop, no gravy, and mashed potatoes. The DS stated the resident did not receive lunch according to the menu and renal diet guidelines, and the cook stated the menu was not followed.
Failure to Renew Informed Consent for Psychotropic Medication: A resident with dementia, psychotic disturbance, MDD, and GAD had Valproic Acid ordered for mood stabilization, but the informed consent on file was not renewed every 6 months. LVN staff confirmed the facility did not renew psychotropic consents as required by State law, and the DON stated informed consent should be obtained before psychotropic meds are given. The facility policy did not address the 6-month renewal requirement.
A resident on EBP due to a G-tube and MDRO in the nares received restorative nursing care from an RNA who wore gloves but did not wear an isolation gown. The RNA assisted with PROM exercises and applied splints, then later confirmed the gown was required for direct contact care. The IPN stated that staff providing direct care to residents on EBP must wear gown and gloves, and the DON stated proper infection control protocols were important.
A resident with severe cognitive impairment was physically assaulted by another resident after a dispute over personal belongings, resulting in facial injury. Staff failed to intervene during the altercation and did not adequately assess the injured resident during rounds, as confirmed by CNA, LVN, and DON interviews. Facility policy requires protection from abuse by anyone, including other residents.
A resident with schizoaffective disorder and psychosis was denied readmission after a hospital transfer for a behavioral incident, without the facility conducting required assessments or reviewing updated care needs. The DON and interdisciplinary team made the decision without documentation or consultation of hospital records, contrary to facility policy.
A resident with severe cognitive impairment and mental health diagnoses was physically assaulted by another resident, but the facility failed to update the care plan to address physical abuse or resident-to-resident altercations. The care plan only included interventions for the physical injury, not for the abuse event itself, despite facility policy requiring comprehensive care planning.
The facility did not transmit required MDS assessments for all residents in Medicare/Medicaid-certified beds to CMS for over a year, resulting in outdated assessments and care plans. The issue was discovered after notification from the state health department, and both the MDS coordinator and DON confirmed the lapse in timely submission and validation of resident data.
A resident with polyneuropathy and anxiety disorder, requiring significant assistance and exhibiting moderate cognitive impairment, did not receive a timely neurology consult as ordered by the physician. The Social Services staff responsible for coordinating appointments was unaware of the order until informed by the resident, and there was no documentation of appointment scheduling or follow-up, resulting in a delay of care.
A resident was physically assaulted by another resident following a verbal argument in the patio area, which was witnessed by a CNA and an LVN who failed to intervene. The victim, with a history of aggressive behavior and cognitive impairment, sustained significant injuries requiring hospital treatment. The assailant, also with mental health issues, was not adequately supervised, leading to the incident.
A resident with Alzheimer's and dementia became agitated and physically aggressive when CNAs continued personal care despite her refusal. The resident, requiring substantial assistance, kicked a CNA during an attempt to change her adult brief. Staff interviews revealed that the CNAs did not honor the resident's refusal, escalating the situation and potentially violating her rights.
A resident with hemiplegia and hemiparesis required two-person assistance for transfers, as per their care plan. However, a CNA attempted to transfer the resident alone, resulting in the resident's leg getting caught in the wheelchair wheels and sustaining a laceration requiring sutures. The facility's policy on safe transfers was not followed, leading to the injury.
The facility failed to maintain the privacy and dignity of two residents during ADLs by not closing the privacy curtain, leaving them exposed to others. Both residents had severe cognitive impairments and required assistance. Interviews with CNAs and an LVN confirmed the need for privacy, aligning with the facility's policy on resident privacy.
A resident assessed as high-risk for wandering eloped from the facility due to inadequate supervision and monitoring. The resident's care plan, which required constant observation and monitoring for wandering, was not effectively implemented. Staff failed to respond to the entrance/exit door alarm, and the resident's wander guard was found broken. The resident, with a history of schizophrenia and hypertension, was found days later in a neighborhood, having missed their medication.
The facility failed to label and date food items in storage, risking foodborne illness due to potential spoilage. Additionally, the dishwasher's sanitizing chemical levels were insufficient, risking contamination of dishes and utensils. These deficiencies were confirmed through observations and staff interviews, highlighting non-compliance with facility policies.
A facility failed to maintain Refrigerator #1, leading to a pool of water at the bottom, observed during the defrosting of meats. Staff reported the issue had persisted for two weeks, with maintenance notified but not yet resolved. The Regional Dietary Manager had informed the Administrator, who was responsible for follow-up, but a technician was delayed in addressing the problem.
A facility failed to treat three residents with dignity and respect. Two residents experienced delays in call light responses, despite staff being aware of the signals. Another resident was fed by a CNA who did not maintain eye level, contrary to facility policy. These actions violated the residents' rights and facility policies on timely call light response and promoting dignity.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, resulting in injury. One resident with moderately impaired cognition and medical conditions including metabolic encephalopathy, COPD, and type 2 DM was punched in the face by another resident. According to nursing progress notes, the incident occurred in the early evening when the injured resident reported that the other resident had come to his room, knocked on his door, and then punched him when he came out. The injured resident was observed with a moderate amount of bleeding and sustained a laceration to the right lower lip, an open area on the right inner lip, and an abrasion to the right upper lip. CNA 1 reported that she was in the dining room assisting residents with meals and observed the injured resident waving his hands toward the other resident, who was about six feet away, as the second resident entered the dining room. While scanning the room, CNA 1 briefly looked away, and when she looked back, she saw the second resident punch the first resident in the face, immediately causing visible bleeding from the lip. Staff then separated and supervised the residents. Subsequent observation showed the injured resident with a scab on the right side of his lower lip, and the resident confirmed that another resident had punched him, causing the cut and leading to his transfer to the hospital for evaluation. The resident who delivered the punch had intact cognition and diagnoses including metabolic encephalopathy, COPD, and type 2 DM. Nursing progress notes for this resident documented that he admitted to hitting the other resident, stating he had been startled and did not know why he hit him and did not intend to do so. The DON acknowledged that residents have the right to be free from physical abuse and that the facility’s investigation substantiated that one resident hit another. The facility’s abuse, neglect, and exploitation policy stated that each resident has the right to be free from abuse and that residents must not be subject to abuse by anyone, including other residents.
Failure to Involve Cognitively Intact Resident in IDT Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to involve a cognitively intact resident in Interdisciplinary Team (IDT) care conferences and the development and implementation of her person-centered plan of care. The resident, originally admitted in 2022 and readmitted in early 2023, had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder. Her MDS assessment indicated she understood others, was understood by others, had intact daily decision-making abilities, and that it was very important to her to participate in discussions about her care. A History and Physical documented that she was alert, oriented to person, place, time, and situation, and had the capacity to understand and make medical decisions. During an interview, the resident reported she was not always made aware when her IDT care conferences were being held and became tearful, stating she wanted to participate in these meetings about her care. Review of IDT conference records with the Infection Prevention Nurse showed that one scheduled IDT meeting was not rescheduled after the resident requested a postponement due to not feeling well, and the next meeting occurred three months later. Documentation for that later meeting contained no evidence of the resident’s participation. The Infection Prevention Nurse acknowledged that if residents request rescheduling, the meeting should be rescheduled and that residents need to be part of their IDT meetings. The DON stated residents or their representatives should always be part of IDT care conferences, and facility policies and resident rights documents confirmed that residents have the right to participate in the development and revision of their care plans and to be informed in advance of changes to the care plan.
Missing Consultant Reports in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records when consultation reports for one resident were missing from the resident’s chart. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder, was originally admitted in 2022 and readmitted in early 2023. An MDS assessment indicated the resident had intact cognition and was able to understand and be understood by others. The resident reported that she had several consultation appointments in 2025 and that her physician informed her that the consultation notes were not present in her medical record. During a concurrent interview and record review with the Medical Records Director, it was confirmed that not all of the resident’s 2025 consultation reports were in the medical record and that they should have been placed in the chart or uploaded. The missing documents included orthopedic and neurology consultation notes, which the Medical Records Director stated should be available so physicians and staff could refer to them and have a clearer picture of the resident’s health. The DON also stated that consultant notes should be in the resident’s medical record. The facility’s undated policy titled “Accuracy of Medical Records” indicated that all medical records are to be complete, accurate, and updated to reflect care and services provided to each resident.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with encephalopathy, schizoaffective disorder, anxiety disorder, and severe cognitive impairment was originally admitted on 3/1/2025 and required set-up assistance with eating, oral hygiene, and personal hygiene. Another resident, admitted on 9/24/2025 with encephalopathy, heart failure, dementia, schizoaffective disorder, mood disorder, anxiety disorder, and severe cognitive impairment, required supervision with eating, partial assistance with oral hygiene, and substantial assistance with personal hygiene, showering, and toileting hygiene. Both residents had significant cognitive and functional impairments at the time of the incident. According to CNA 1’s written statement and interview, the aggressor resident was standing on the left side of the other resident’s bed while the victim was lying in bed. The aggressor kicked the resident on the left side of the body, then kicked again, causing the resident to roll off the bed and fall onto the floor mat on the right side. CNA 1 attempted to intervene but was pushed away by the aggressor and then called for help. During this time, the aggressor reached for and threw a water pitcher, with the pitcher and water landing on the resident’s face, and then grabbed and threw a urinal filled with urine, which landed on the resident’s chest. Nursing documentation on 1/26/2026 at 2:15 p.m. indicated the resident had been hit by another resident and presented with slight swelling of the left temporal area, redness on the left shin, right knee, and chest, and responded to name by saying yes or moaning. Emergency Department records later that evening documented a left maxillofacial contusion after being hit in the face. LVN 2 reported hearing calls for help, finding the victim resident on all fours on the fall mattress, the aggressor pacing and stating, “I beat him up,” and observing fluids (water and urine) on the floor and on the resident. The DON stated that residents have the right to be free from abuse, acknowledged that the aggressor physically abused the other resident, and stated that staff should have physically separated the residents after the first kick to prevent the subsequent kicks and the throwing of the water pitcher and urinal.
Failure to Maintain Dry Bathroom Floor Leads to Resident Fall and Shoulder Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain a hazard‑free environment and prevent accidents when a resident’s bathroom floor was wet, leading to a slip and fall. The resident, who had morbid obesity and osteoarthritis, was cognitively intact and required supervision with toileting hygiene, with a documented fall risk and a care plan intervention to maintain a hazard‑free and safe environment. On the morning of 10/19/2025, the resident went to the bathroom, used the toilet, stood up, pulled up her pants, took a step forward, slipped on the wet bathroom floor, and fell, landing on her right arm and shoulder. Following the fall, nursing documentation recorded that the resident reported the floor was wet and that she lost her balance because of it, with right shoulder pain rated 8/10. An LVN who responded to the incident confirmed that the bathroom floor was wet, though not flooded, and acknowledged that floors should not be wet because they are hazardous and can cause residents to slip and fall. The resident reported calling for help without response, then scooting on her back to the bathroom door to open it and call out, after which assistance arrived. The facility’s fall team notes identified the fall as related to an environmental factor, specifically wet floor surfaces, particularly risky for residents with balance limitations. Subsequent clinical records documented ongoing and frequent right shoulder pain over the next several months, with repeated complaints of severe pain and limited ability to raise the arm. An orthopedic consultation noted the resident’s report that she slipped on a slippery bathroom floor while getting off the toilet and had significant right shoulder pain since the fall. An MRI later showed a full thickness tear of the supraspinatus tendon with retraction and fluid in the subacromial and subdeltoid bursa. Facility policies on hazardous areas and falls stated that hazards are anything with potential to cause injury and that staff will try to prevent resident falls with identified interventions, but housekeeping coverage for resident rooms did not extend to early morning hours, and janitorial staff only checked rooms when specifically alerted, contributing to the unaddressed wet bathroom floor.
Failure to Assign One-to-One Monitoring Results in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with a history of aggressive behaviors and a care plan requiring one-to-one monitoring was not assigned dedicated staff for supervision. The resident in question had diagnoses including schizophrenia, moderate cognitive impairment, and exhibited physical aggression such as kicking, hitting, and pushing. Despite care plan interventions specifying one-to-one monitoring and nursing notes indicating the need for constant supervision, the facility did not assign a staff member to provide this level of monitoring. As a result, the resident was left unsupervised on the smoking patio, where he punched another resident on the left side of the chest. The incident was witnessed by an activities assistant, who was present to provide smoking supplies and general supervision but was not assigned as the one-to-one monitor for the aggressive resident. Interviews with staff confirmed that the assignment for one-to-one monitoring was missed, and the Director of Nursing acknowledged that a dedicated one-to-one staff member could have potentially prevented the incident. Both residents involved had schizophrenia, but the victim had intact cognition and required only supervision or touch assistance for activities of daily living. The facility's policy stated that residents should not be subject to abuse by anyone, including other residents.
Failure to Implement One-to-One Monitoring Results in Resident-to-Resident Aggression
Penalty
Summary
The facility failed to implement a care plan intervention of one-to-one monitoring for a resident with a diagnosis of schizophrenia, who exhibited aggressive behaviors such as yelling, verbal aggression, and attempts to strike out at staff. The resident's care plan, developed after previous episodes of aggression and exit-seeking behavior, specifically included one-to-one monitoring as an intervention to minimize these behaviors. However, on the day of the incident, the assigned one-to-one monitoring was not provided, and the only staff present on the smoking patio was an Activities Assistant who was not designated as the resident's one-to-one monitor. As a result of this lapse, the resident was able to approach and punch another resident on the left side of the chest while unsupervised. Interviews with staff confirmed that the one-to-one monitoring assignment was missed, and the intervention outlined in the care plan was not followed. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but the failure to implement the specified intervention led to an incident of resident-to-resident aggression.
Failure to Notify Physician of Missed Medication Dose and Delayed Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's physician when a scheduled dose of Heparin, prescribed for DVT prophylaxis, was missed. The resident, who had a history of a displaced intertrochanteric fracture and was dependent on staff for activities of daily living, reported to an LVN that her afternoon dose of Heparin was not administered after returning from physical therapy. The LVN confirmed with the nurse responsible for the dose that it had been forgotten, but did not report the missed dose to the registered nurse or the physician, citing fear of being labeled a snitch. The physician was not informed of the missed dose until several days later by the Director of Nursing. Additionally, the facility staff did not notify the physician when the resident was not transferred to a general acute care hospital as ordered. Although the physician had ordered a stat venous doppler and authorized transfer to the hospital for further evaluation, the resident expressed a preference to remain at the facility until the doppler could be completed. The LVN on duty did not inform the physician of the resident's decision to delay transfer, instead planning to endorse the situation to the next shift. The physician only learned of the resident's decision and subsequent transfer the following day. Review of facility policies and job descriptions confirmed that staff were required to report changes in resident condition and medication errors to the physician and appropriate supervisory staff. However, these procedures were not followed, resulting in the physician being unaware of both the missed medication dose and the delay in hospital transfer, as documented in interviews and record reviews.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. One resident, who had a diagnosis of metabolic encephalopathy and intact cognition but was dependent on staff for bed mobility, was attacked in his room by another resident diagnosed with metabolic encephalopathy and schizophrenia, with moderately impaired cognition and requiring substantial assistance with activities of daily living. The attacking resident entered the victim's room, yelled accusations, threw a banana, and struck the resident multiple times with a plastic water pitcher and her fists. The incident resulted in the victim sustaining a 1 cm x 0.5 cm abrasion on the right side of his forehead, multiple areas of redness on his forehead and right forearm, and required immediate first aid for seven days. The event was witnessed by staff and another resident. Staff responded to yelling and screaming, finding the aggressor in the victim's room, and intervened to separate the two. The aggressor was described as very combative and continued to yell and scream even after being removed from the room. The victim reported feeling shocked and scared, using his arms and a blanket to protect himself during the attack, and called for help until staff arrived. The aggressor accused the victim of giving her a shot and raping her, according to both staff and another resident who witnessed the incident. Documentation reviewed included admission records, Minimum Data Sets, change of condition forms, skin integrity sheets, and treatment administration records, all confirming the injuries and the sequence of events. The facility's policy on abuse, neglect, and exploitation states that residents should not be subject to abuse by anyone, including other residents. However, in this instance, the facility failed to prevent one resident from physically abusing another, resulting in physical injury and emotional distress.
Failure to Report Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident with metabolic encephalopathy and schizophrenia, who had moderately impaired cognition and required substantial assistance with activities of daily living. The resident accused another resident of rape in the presence of staff and other residents. A CNA witnessed the incident and provided a written report to an RN but omitted the rape allegation, assuming the RN would report it. The RN overheard the allegation and reported it to the DON. Despite being informed, the DON did not include the sexual abuse allegation when reporting the incident to the California Department of Public Health (CDPH). The Administrator was unaware of the allegation and stated that, had he known, he would have reported it as required by mandated reporter regulations. The facility's policy indicated that suspected abuse should be reported to the State Agency, but this was not followed, resulting in the failure to timely notify CDPH of the allegation.
Failure to Investigate Resident's Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse made by a resident with metabolic encephalopathy and schizophrenia, who was assessed as having moderately impaired cognition and requiring substantial assistance with activities of daily living. On the morning in question, staff responded to yelling and found the resident in another resident's room, where she struck him with a water pitcher and accused him of rape. Multiple witnesses, including a roommate and a CNA, confirmed hearing the resident make the allegation, and staff documented her aggressive behavior and need for one-to-one monitoring following the incident. Despite being aware of the allegation, the Director of Nursing did not document or conduct a thorough investigation into the claim, relying instead on his own assessment that the accused resident could not have committed the act due to his physical limitations. The facility's policy required immediate investigation and documentation of all abuse allegations, including interviews and chronological records, but no such documentation was provided for this incident. This failure resulted in the inability to determine whether the alleged abuse occurred.
Failure to Administer and Accurately Document Anticoagulant Medication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to administer Heparin as ordered by the physician for a resident who was admitted with a displaced intertrochanteric fracture of the right femur and a fracture of the right lower leg. The physician's order specified that the resident was to receive Heparin 5000 units/mL, 1.0 mL subcutaneously every eight hours for deep vein thrombosis (DVT) prophylaxis. On the day of the incident, the resident attended physical therapy and was not present in her room at the scheduled medication time. The LVN did not administer the scheduled dose and mistakenly documented in the Medication Administration Record (MAR) that the dose had been given. Later that day, the resident reported to another LVN that she had not received her afternoon dose of Heparin and was experiencing swelling in her legs. Upon review, the second LVN confirmed with the first LVN that the dose had indeed been missed. The resident continued to complain of swelling, and her left lower extremity was observed to be swollen. The physician was notified, and a venous doppler was ordered but could not be performed due to the presence of a soft leg cast and brace. The resident was subsequently transferred to a general acute care hospital for further evaluation. At the hospital, the resident was assessed and diagnosed with extensive acute DVTs of the left lower extremity. Interviews with facility staff confirmed that the missed dose of Heparin was due to the resident being away at physical therapy and the proximity to shift change. The LVN acknowledged both the failure to administer the medication and the erroneous documentation. The facility's policy required medications to be administered as ordered and documented accurately, which was not followed in this instance.
Falsification of Medication Administration Record for Anticoagulant Therapy
Penalty
Summary
Facility staff failed to ensure accurate documentation of medication administration for a resident who was admitted with a displaced intertrochanteric fracture of the right femur and a fracture of the right lower leg. The resident was cognitively intact but dependent on staff for activities of daily living. Physician orders required the resident to receive Heparin injections subcutaneously every eight hours for DVT prophylaxis. On a specified date, the Medication Administration Record (MAR) indicated that the resident was not available for her scheduled Heparin dose at 2 p.m. due to participation in therapy, and a subsequent audit report showed documentation of administration at 2:18 p.m., with later changes to the record. The resident reported to another nurse that she did not receive her afternoon Heparin dose after returning from therapy. The second nurse reviewed the MAR, which showed the dose as given, and upon contacting the original nurse, confirmed that the dose had not been administered. The resident experienced swelling in her left leg later that shift, which was assessed and reported to the registered nurse and physician. Interviews with the involved nurse revealed that he had not administered the medication because the resident was not present and that he had erroneously documented the administration in the MAR. He also admitted to making further inaccurate edits to the medical record at a later date. The Director of Nursing confirmed that the nurse admitted to both failing to administer the medication and documenting it as given. Facility policy required that the MAR be signed only after medication administration, which was not followed in this instance. The inaccurate documentation resulted in an incorrect depiction of the resident's medication management and had the potential to disrupt continuity of care.
Facility Assessment Missing IPN and Cultural Assessment
Penalty
Summary
The facility failed to update its facility-wide assessment for 137 out of 137 residents by not including the Infection Prevention Nurse as part of the staff needed for daily operations and emergencies, and by not assessing the cultural and ethnic makeup of the resident population. During a concurrent interview and record review, the Administrator reviewed the Facility Assessment Tool dated 7/10/2025 and confirmed that it did not indicate the IPN was part of the staff needed to function for the resident population every day and during emergencies. The Administrator also stated that the tool was missing a specific assessment of the different culture and ethnic backgrounds of the facility residents, and acknowledged that it was important to assess cultural backgrounds to better cater to resident needs. Review of the facility's Facility Assessment Policy showed that the facility conducts a comprehensive assessment that evaluates its resident population and resources.
Unnecessary psychotropic medication use and inadequate monitoring
Penalty
Summary
The facility failed to ensure three sampled residents were free from unnecessary psychotropic medication use. For one resident with dementia, major depressive disorder, and generalized anxiety disorder, Ativan 1 mg by mouth every 6 hours as needed for inability to relax was ordered, but the record review and concurrent interview showed no documented evidence that nonpharmacological measures were attempted before the medication was given. The DON stated that nonpharmacological measures need to be attempted prior to administration of psychotropic medications, and the facility policy stated the interdisciplinary team would evaluate non-pharmacological interventions before or alongside medication use. For another resident with major depressive disorder and severely impaired cognitive skills for daily decision-making, Mirtazapine 15 mg by mouth at bedtime was ordered for poor meal intake. During record review and interview, staff confirmed the resident was not monitored for adverse side effects associated with Mirtazapine use. The DON stated residents need to be monitored for adverse effects of medication use to make sure there were no complications, and the facility policy stated staff would monitor residents for potential adverse effects. For a third resident with PTSD, anxiety disorder, and dementia, Risperidone 0.5 mg by mouth twice a day was ordered for behavioral disorder associated with dementia manifested by aggressive behavior. The MDS indicated the resident did not have hallucinations, delusions, or physical and verbal behavioral symptoms directed toward others, and the MAR showed no behavioral episodes with documentation of zero aggressive behavior. Staff and the psychiatric NP stated the target behavior was not specific and measurable, and the DON stated aggressive behaviors could be many things and should be clarified. The facility policy required behaviors to be documented clearly and concisely, including specific behaviors, time and frequency, triggers, interventions used, and outcomes.
Incomplete Person-Centered Care Plans for ROM, PRN Ativan, and PTSD
Penalty
Summary
The facility failed to develop and implement individualized care plans with measurable objectives, timeframes, and interventions for three residents. The report identified deficiencies related to range of motion care for one resident, use of Lorazepam for another resident, and PTSD-related care planning for a third resident. Facility staff, including the MDS coordinator, MDS nurse, DON, and other department leaders, confirmed during interviews and record review that the care plans did not contain the needed resident-specific details at the time the issues were identified. For one resident with diagnoses including Alzheimer's disease, chronic kidney disease, and polyneuropathy, the MDS showed severe cognitive impairment, dependence in activities of daily living, and functional ROM limitations in both arms and both legs. The JMA documented minimal limitation in the left shoulder, both wrists, and both hands; moderate to severe limitation in the right shoulder and both ankles; and severe limitation in both hips and both knees. During observation, the resident was lying in bed hunched to the left side with blankets covering the left arm and both legs, and the legs were rotated to the left with both hips and knees bent and toes pointing downward. Staff stated the resident had limited ROM and needed assistance with ROM, but the care plan did not include goals or interventions to maintain or prevent decline in ROM despite the identified limitations. For another resident with dementia, history of falling, and anxiety, an order for Lorazepam 0.5 mg every 12 hours as needed for anxiety manifested by irritability was entered, but the care plan did not address the medication use until it was brought to the facility's attention. The DON reviewed the orders and care plan and stated the Ativan interventions should have been initiated when the order was first received. For the third resident, who had bipolar disorder, major depressive disorder, anxiety, and PTSD, the social service assessment did not address PTSD triggers or how the facility could help manage trauma-related needs. The resident's care plan listed PTSD as a diagnosis, but the goals and interventions were vague and did not identify specific triggers or guidance for staff on how to avoid retriggering or manage symptoms if trauma was triggered. Staff confirmed the care plan lacked the person-centered detail needed for this diagnosis.
Failure to Measure Limited Hand ROM and Provide ROM Services
Penalty
Summary
The facility failed to provide appropriate care to maintain and/or improve ROM for two residents with documented ROM concerns. One resident was admitted with diagnoses including COPD, cerebral palsy, and Parkinson’s disease, and the MDS showed severe cognitive impairment, dependence for multiple ADLs, and functional ROM limitations in both arms and both legs. The OT evaluation for this resident documented impaired ROM in both hands and all fingers, but the evaluation did not include objective goniometer measurements of the hand joints. During a later restorative nursing observation, the resident was seen in a wheelchair with both hands closed in fists, limited shoulder movement, and inability to fully extend both elbows, and the restorative aide had difficulty straightening the fingers to place a splint. During interview and record review, the OT stated goniometers are used to objectively measure joint mobility and confirmed he did not use one to measure the resident’s hands even though the resident had ROM limitations. The OT stated the resident’s baseline ROM of both hands was not determined because the limitations were not measured objectively. The DOR also reviewed the evaluation and confirmed the resident’s impaired hand ROM should have been measured with a goniometer but was not, and stated the lack of objective measurements affected the staff’s ability to monitor and detect changes in ROM. A second resident, who had diagnoses including Alzheimer’s disease, CKD, and polyneuropathy and was on hospice services, had severe cognitive impairment, dependence for care and mobility, and functional ROM limitations in both arms and both legs. The quarterly JMA documented minimal to severe ROM limitations across the shoulders, wrists, hands, hips, knees, and ankles, and noted that nursing was to integrate ROM exercises during care. During observation, the resident was positioned hunched to one side in bed with both legs rotated left, hips and knees bent, and toes pointed downward; staff were unable to fully straighten the hips and knees. An LVN stated the resident had limited ROM in all extremities and needed assistance with ROM, and a CNA stated the resident required total care and needed assisted ROM. Facility staff confirmed the resident was not receiving RNA services, stated the resident was at high risk for contracture development, and acknowledged they were unsure why RNA services were never considered. Staff also stated they were unsure whether CNAs were providing ROM during daily care because ROM was not documented during those care activities.
Failure to Assess Trauma History and Triggers
Penalty
Summary
The facility failed to identify and intervene in the trauma histories and triggers of two residents, resulting in a deficiency for trauma-informed and culturally competent care. For one resident, the admission record showed diagnoses including PTSD, anxiety disorder, and dementia, and the H&P noted fluctuating capacity to understand and make decisions. The resident’s social service history and initial assessment documented that he stated he had trauma from the Vietnam War, but there was no documentation of his trauma triggers or how they affected him. During interview, the DSS stated she could not obtain much information about the resident’s trauma and triggers from the resident or his wife, and acknowledged she should have contacted the resident’s psychiatrist and veterans’ hospital social service workers to obtain information regarding his PTSD. The DSS stated the trauma assessment was important because care would be different based on the assessment, and that the resident’s care plan was not person centered because a proper trauma assessment had not been completed. The DON stated that when a resident has PTSD, the DSS should assess triggers and past history to prevent re-traumatization, and that the care plan could not be resident centered if the trauma assessment was not done correctly. For the second resident, the admission record showed diagnoses including bipolar disorder, major depressive disorder, and anxiety, and the H&P indicated the resident had capacity to understand and make decisions. The social service assessment did not address PTSD, trauma triggers, or how the facility could help the resident with past traumas, and no other assessment was completed after the initial assessment. The DSS stated the assessment did not include questions about trauma history or triggers, and the DON stated residents should be properly assessed for trauma upon admission so staff are aware of triggers and can tailor trauma-informed care accordingly. The facility policy required each resident to be screened for a history of trauma upon admission and to account for residents’ experiences, preferences, and cultural differences to eliminate or mitigate triggers that may cause re-traumatization.
Annual Performance Evaluations Not Completed
Penalty
Summary
The facility failed to ensure employee files were maintained and kept up to date when annual performance evaluations were not completed for three of six sampled employees. During a concurrent interview and record review on 9/5/2025 at 10:54 a.m. with the Director of Staff Development, the employee files for the DON, RNS 1, LVN 2, CNA 4, CNA 5, and the DSD were reviewed. There were no annual performance evaluations for RNS 1, LVN 2, and CNA 4. During interviews, the DSD stated that performance evaluations should be completed yearly to ensure staff are meeting the standard of care and performing the duties of licensed staff in the facility, and that if they were not done, licensed staff may not be up to date with the standard of practice. The DON also stated performance evaluations should be done yearly and described them as a review of staff performance, attendance, work ethics, and teamwork. The facility policy titled Performance Evaluations, revised January 2025, stated the job performance of each employee shall be reviewed and evaluated at least annually, including after the 90-day probationary period and at least annually thereafter.
Pureed Sweet Potatoes Served With Lumpy Texture
Penalty
Summary
The facility failed to ensure that 18 residents on a pureed diet received sweet potatoes prepared in a form that met their needs and aligned with IDDSI Level 4 requirements. During tray line service for lunch, the pureed sweet potatoes were observed to be lumpy and not smooth, with chunks of potato present on the plate. In a concurrent observation and interview, a taste test of the pureed sweet potatoes with the Dietary Supervisor, a cook, and the District Manager showed the same lumpy appearance. During the interview and taste test, the pureed sweet potatoes were found to have a lumpy texture with chunky pieces of potato that required chewing and moving around in the mouth before swallowing. The Dietary Supervisor stated the consistency was not smooth and that some lumpy pieces required chewing before swallowing, and also stated residents on a pureed diet can have difficulty swallowing. The cook stated the sweet potatoes should have been blended longer for a smooth texture. The facility recipe for pureed-level 4 sweet potatoes stated the product should be blended until smooth with no lumps, and the IDDSI guideline reviewed by surveyors stated Level 4 pureed foods should have no lumps and should hold shape without liquid separating from solids.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen. During observation, three boxes of juice were open and connected to the juice dispenser with no date marked. The Dietary Supervisor stated the juices should have an open date so they can be discarded when appropriate and said juice left beyond the use-by date would go bad. In the same area, a box of 24 ice cream cups was found in the reach-in freezer with an expired date of 2/2025, and the Dietary Supervisor discarded the ice cream cups after the finding. Food items were also stored in a manner that allowed cross contamination. Raw shelled eggs and raw liquid eggs were stored on the top shelf of the refrigerator next to milk, and a box of raw bacon was stored next to a container of cooked macaroni. The Dietary Supervisor stated the staff made a mistake and stored the items incorrectly after breakfast service, and acknowledged that raw eggs and bacon should be stored separately from ready-to-eat food to prevent cross contamination. Facility policy required foods to be wrapped or covered, labeled and dated, and arranged to prevent cross contamination, and the FDA Food Code cited in the report required separation of raw animal foods from cooked ready-to-eat food. The kitchen and storage areas also contained dirty and improperly maintained equipment and supplies. A cart stored next to the food preparation area was stained with sticky residue, had crumbs and food particles on it, and had dust on the wheels and floor behind it. The cook stated the cart was used as a storage surface and needed to be cleaned, while the District Manager stated it should not be in the food preparation area. In dry storage, cans of grape jelly had damaged or missing labels and some had clear sticky droplets on them. The coffee maker’s glass gauge pipe contained dark brown residue, and the Dietary Supervisor stated the pipe was not cleaned because the special tool was not available and acknowledged it was dirty.
Incomplete and inaccurate resident records
Penalty
Summary
Resident 5’s restorative nursing aide splinting orders were documented inaccurately and without clear wear-time instructions. The resident had diagnoses including COPD, cerebral palsy, and Parkinson’s disease, and the MDS showed severely impaired cognition, dependence for transfers and toileting hygiene, and functional limitations in range of motion in both arms and both legs. The order summary listed RNA orders for hand carrot splints to both hands and knee splints to both knees, each to be applied five times a week for four to six hours, but the orders did not specify how long each splint should remain on each side or when the splints should be alternated. During observation of the RNA session, the RNA applied splints to the resident’s right hand and right knee and stated she would return in three hours to alternate the splints to the left side for three hours. She stated she was initially unsure how long to leave the splints on and when to alternate them because the orders were unclear and confusing. She also stated she did not know whether the four-to-six-hour wear time applied to each splint on each side or to both sides total for the day, and whether the splints were to be alternated the same day or every other day. The DOR later clarified the intended wear time and schedule, but the written orders were never changed to reflect that clarification. Resident 66’s medical record did not include conservatorship documents even though the social service history and initial assessment identified the resident as having a public guardian. The DSS reviewed the chart and stated the conservatorship papers should have been in the medical record so nurses would know who to obtain consent from and to protect the resident’s rights. The DON also stated the conservatorship papers needed to be in the chart to identify the responsible party. Resident 124’s admission documentation did not capture a right forearm deformity even though the deformity was present on admission. The skin note and nursing admission note from the day of admission did not mention the deformity, but a later change-of-condition evaluation documented it and noted that family stated it was not new. During observation, the resident’s right forearm was visibly deformed, with the two bones appearing crossed in an unnatural position, while the resident denied pain and had no swelling or bruising. Family stated the resident had an old injury from a carpenter accident many years earlier and had been admitted with the deformity. RN staff stated the deformity had been present since admission and that the nursing staff failed to capture it in the resident’s documentation until the later evaluation.
Arbitration Agreement Lacked Convenient Venue Selection
Penalty
Summary
The facility failed to ensure that the Binding Arbitration agreements for Resident 29, Resident 104, and Resident 156 provided a selection of a venue that was convenient to both parties. During record review, Resident 29 was noted to have diagnoses including dementia, and the MDS dated 6/28/2025 indicated the resident’s cognitive skills for daily decision-making were intact. Resident 29’s Resident-Facility Arbitration Agreement was signed on 3/18/2022. Resident 104 was originally admitted with diagnoses including metabolic encephalopathy, and the MDS dated 6/10/2025 indicated cognitive skills for daily decision-making were intact; the arbitration agreement was signed on 9/19/2022. Resident 156 was originally admitted with diagnoses including anxiety disorder, and the MDS dated 6/10/2025 indicated cognitive skills for daily decision-making were intact; the arbitration agreement was signed on 11/14/2022. During a concurrent interview and record review on 9/3/2025 at 10:15 a.m. with the BOM, a facility blank Resident-Facility Arbitration Agreement was reviewed. The BOM confirmed the agreement did not provide for the selection of a venue that is convenient to both parties. The facility policy titled Binding Arbitration Agreements, undated, stated the agreement must provide for selection of a venue convenient to both parties.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medications to one sampled resident. Resident 7 was readmitted with diagnoses including dementia with psychotic disturbance, major depressive disorder, and generalized anxiety disorder. The resident’s MDS dated 7/28/2025 indicated severely impaired cognitive skills for daily decision-making and the resident required varying levels of assistance with activities of daily living, including moderate assistance with eating and oral hygiene, maximal assistance with personal hygiene, and dependent assistance with toileting hygiene and showering. A review of the order summary showed Risperidone 1 mg by mouth daily starting 8/8/2025 and Ativan 1 mg by mouth every 6 hours as needed for inability to relax starting 8/24/2025. During a concurrent interview and record review, RNS 1 and RNS 2 confirmed Resident 7 did not have consent for either psychotropic medication. LVN 1 stated informed consent was important so the resident or family knows about treatment options, and the DON stated informed consent should be obtained prior to administration of psychotropic medications. The facility policy titled Psychotropic Medication Management Policy stated written informed consent for treatment would be obtained before initiating psychotropic medications.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one of eight sampled residents, Resident 124. During an observation on 9/2/2025 at 2:50 p.m., Resident 124 was lying in bed and the call light was on the floor to the left side of the bed. Resident 124 had a gold star next to his name plaque indicating high fall risk. Resident 124 was admitted on 5/1/2025 with diagnoses including dementia, history of falling, and age-related osteoporosis. The MDS dated 8/8/2025 indicated severe cognitive impairment, partial/moderate assistance needed for personal hygiene, and supervision or touching assistance needed for bathing and showering. When LVN 3 entered the room at 2:53 p.m. after being alerted that Resident 124 appeared to need assistance, she picked the call light up from the floor and placed it within reach, and stated the resident needed to be repositioned and changed. The DON later stated that finding the call light on the floor meant it was not within reach and that it was important for the call light to always be within reach so residents could access it when needed.
Resident’s wheelchair removed against his wishes
Penalty
Summary
The facility failed to honor the choices of a cognitively intact resident regarding the care and cleaning of his wheelchair. The resident, who was admitted with peripheral vascular disease and cellulitis of the left toe, stated that staff took his wheelchair out of his room for cleaning against his wishes. During observation, he was walking in the hallway with his bilateral legs wrapped in ace bandages and said he was upset because he could not find his wheelchair when he wanted to use it. The Director of Social Services stated the resident had previously reported that staff removed his wheelchair for cleaning when he did not want it removed, and that he had been very upset. The DSS also stated the resident had the right to request that no one remove the wheelchair from his room and that he could clean it himself if that was his wish. RN 1 stated nursing staff had not been aware of the resident's wishes, which was why the wheelchair was removed, and the DON stated that resident wishes should be communicated across departments and honored because they are the resident's right.
Incomplete Advance Directive Acknowledgment Form
Penalty
Summary
The facility failed to ensure that an Advance Directive (AD) was accurate and completed according to policy for one of two sampled residents, Resident 156. Resident 156 was admitted with diagnoses including bipolar disorder, major depressive disorder, and PTSD. The resident’s MDS dated 8/6/2025 indicated intact cognitive skills for daily decision-making and need for assistance with self-care and mobility. A history and physical dated 1/30/2025 stated the resident had the capacity to understand and make decisions. A review of Resident 156’s AD Acknowledgment form dated 11/3/2022 showed that it did not indicate whether the resident chose to formulate an AD or chose not to formulate one, even though the form was signed and witnessed by facility staff. During interview and record review, the DSS stated the top portion of the form should have reflected the resident’s specific directives and that the form was incomplete. The DON stated the AD is completed during the admission process, that the AD Acknowledgment form should indicate whether the resident had an AD, wanted to formulate one, or did not want one, and that staff should ensure the form was filled out completely. The facility’s Advance Directive Policy stated residents are to be informed of their rights regarding advance directives and that admission staff shall provide information on advance directives during the admission process.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that written notice of transfer was provided to the State Long-term Care Ombudsman for one of four residents reviewed, Resident 13. Resident 13 was originally admitted with diagnoses including PTSD, homicidal ideations, suicidal ideations, and paranoid schizophrenia. A review of the MDS dated 8/11/2025 indicated the resident’s cognition was intact. Progress notes dated 8/29/2025 at 8:59 a.m. documented that Resident 13 was noncompliant with medications and treatments, continued to have episodes of responding to internal stimuli, and the physician ordered transfer to a general acute care hospital for further evaluation. Progress notes later that day at 1:12 p.m. documented the resident was transferred to the GACH. During interview and record review, RNS 2 stated the facility did not notify the ombudsman of the transfer. The MRD stated there was no documented evidence that a fax was sent informing the Ombudsman of the transfer, and the DON stated the written Notice of Proposed Transfer and Discharge Form needed to be faxed to the ombudsman. The facility policy titled Transfer and Discharge (including AMA) indicated a copy of the Notice of Proposed Transfer and Discharge would be sent to the ombudsman.
Failure to Update Comprehensive Care Plan After Assessment
Penalty
Summary
The facility failed to update Resident 9’s care plan after the resident’s comprehensive assessment. Resident 9 was readmitted with diagnoses including major depressive disorder, metabolic encephalopathy, type 2 diabetes, Alzheimer’s disease, chronic kidney disease, and hypertension. The resident’s MDS dated 8/23/2025 indicated severely impaired cognitive skills for daily decision-making and documented the need for moderate assistance with oral hygiene, maximal assistance with toileting hygiene, showering, and personal hygiene, and dependence on staff for eating. During a concurrent interview and record review on 9/4/2025, LVN 1 reviewed Resident 9’s care plans and found they should have been updated or reviewed on 8/21/2025. LVN 1 stated the MDS nurse should have updated all care plans to ensure interventions were revised or continued as needed. During an interview on 9/5/2025, the DON stated that care plans need to be updated and reviewed to evaluate the effectiveness of interventions for residents. The facility’s policy titled Comprehensive Care Plans, revised 1/2025, stated the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Failure to Assess and Monitor Splint Fit and Wear Time
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints for one resident with quadriplegia and end stage renal disease. The resident was admitted to the facility on 1/14/2018 and re-admitted on 1/30/2025. The resident’s MDS dated 7/15/2025 indicated cognitive intactness, dependence in eating, hygiene, bathing, dressing, and mobility, and functional limitations in ROM in one arm and both legs. The resident had physician orders dated 7/22/2025 for RNA to apply a right wrist/hand splint for 4 to 6 hours every day, 6 times a week, and a right elbow splint for 4 to 6 hours every day, 6 times a week. A rehab screen signed by the DOR on 7/23/2025 indicated the resident would benefit from a right elbow and right-hand splint and that skilled therapy services were not warranted. During observation on 9/2/2025, the resident was sleeping in bed and wearing a splint on the left elbow. During a later observation on 9/5/2025, the resident was lying in bed with the right arm bent at the elbow and fingers curled inward toward the palm. The MRD stated there were no PT or OT notes in the electronic medical record for the resident. The resident stated he was paralyzed from the neck down, could not actively move his arms or legs, could not feel anything below the upper chest, wore the right elbow and right wrist/hand splints almost every day, and needed staff to ensure the splints fit correctly and were not pressing on his skin. The DOR stated a licensed PT or OT must assess a resident’s need for splints, determine wear tolerance and the splint wear schedule through periodic assessment, and document the findings, but confirmed the resident was never formally evaluated by PT or OT and that there was no documented evidence of splint assessments or determination of wear time tolerance for either splint. The DON stated rehab was responsible for assessing splint types and determining splint wear time for residents.
Resident Fed While Lying Down Instead of Upright
Penalty
Summary
The facility failed to ensure that Resident 45 was sitting upright while eating lunch. Resident 45 was admitted on 8/25/2023 and re-admitted on 11/7/2024 with diagnoses including asthma and chronic obstructive pulmonary disease. The 6/2/2025 MDS indicated severely impaired cognition and that the resident required supervision or touching assistance for eating. A speech therapy discharge summary identified dysphagia and recommended a pureed diet with aspiration precautions. The care plan also identified a puree diet, potential for choking, and interventions including assisting the resident during meals as needed and sitting the resident upright while eating. During a concurrent observation and interview on 9/3/2025 at 12:38 pm, Resident 45 was lying in bed with the head of the bed elevated to less than 30 degrees while a CNA fed the resident pureed food and juice. The CNA stated the resident was being fed while lying down with the head of the bed slightly elevated and acknowledged this was not a safe position because the resident was not upright. The CNA stated the resident should be seated upright and should not be laying down while eating because he could choke. ST 1 later confirmed residents should always be seated upright while eating and stated the ideal position was fully upright at an 80-to-90-degree angle. The DON also stated all residents should be seated upright while eating to prevent choking and aspiration. The facility policy on Meal Supervision and Assistance stated the resident should be positioned so the head and upper body were as upright as possible.
Medication Availability and Controlled Substance Receipt Documentation Failures
Penalty
Summary
Facility staff failed to ensure Resident 114’s buspirone 10 mg, ordered three times daily for anxiety, was available in stock for administration at the scheduled time. Resident 114 was admitted with diagnoses including anxiety disorder, dementia with behavioral disturbance, and PTSD. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognition. During observation, an LVN looked for the buspirone in the medication cart, found the medication card empty, and stated the facility did not have the medication in stock at that time. The buspirone was scheduled for 1:00 p.m., but the pharmacy delivery receipt showed the medication was received at 2:11 p.m., and the medication administration audit report showed it was administered at 2:32 p.m. The DON stated licensed nursing staff should order medications five to seven days in advance before running out of stock, and stated the facility policy required medications to be administered within 60 minutes before or after the scheduled time. The DON also stated that because the buspirone was not in stock, its administration was delayed and management of the resident’s anxiety was delayed. Facility staff also failed to ensure the controlled drug record for Resident 7’s morphine sulfate concentrate was signed to show receipt from the pharmacy. Resident 7 had diagnoses including Alzheimer’s disease and unspecified dementia with psychotic disturbance, and the MDS showed the resident needed varying levels of assistance with ADLs. During inspection of Station B Medication Cart 3, the morphine sulfate oral concentrate container was sealed with a quantity of 15 mL, and the controlled drug record also showed 15 mL, but there was no documented signature or initials from licensed nursing staff and no date received from the pharmacy. The pharmacy delivery receipt showed the morphine sulfate oral solution was delivered to the facility, and the DON stated it was important for licensed nursing staff to document the quantity and sign the narcotic sheet when received from the pharmacy to aid in proper tracking and prevent diversion.
Improper Storage of Refrigerated Medications
Penalty
Summary
Medications requiring refrigeration were found stored in the Station B Medication Room refrigerator at 50 F, which was outside the facility’s required range of 36 F to 46 F and contrary to manufacturer labeling. During the observation, the refrigerator contained one almost full bottle of gabapentin 250 mg/5 mL, one opened vial of tuberculin 5 TU/0.1 mL, one sealed vial of tuberculin 5 TU/0.1 mL, one sealed vial of Lantus 100 units/mL, one open Lantus Solostar Pen 100 units/mL, and two sealed comfort kits containing medications including morphine sulfate, lorazepam, bisacodyl, acetaminophen, Zofran ODT, atropine, hyoscyamine, senna, morphine sulfate, acetaminophen suppositories, and Duoneb vials. During interview, the LVN stated the refrigerator temperature had been 32 F earlier and was now 50 F while adjustments were being made. The DON stated the temperature should have been checked each shift for the Station B Medication Refrigerator and that refrigerated medications should have been moved to a working refrigerator if the temperature was out of range. The facility’s Medication Storage policy stated refrigerated medications must be stored between 36 F and 46 F, temperatures are to be recorded daily, and malfunctioning refrigerators must be promptly reported to Maintenance for emergency repair.
Failure to Follow Up on Unfitting Dentures
Penalty
Summary
The facility failed to follow up on the status of unfitting dentures for one resident who was edentulous and had diagnoses including moderate protein-calorie malnutrition and dementia. The resident’s care plan identified a risk for decreased food intake related to missing teeth and included interventions to check dental condition and refer for dental evaluation. During observation, the resident had no natural teeth and no dentures at the bedside, and stated that he had been having problems with an unfitting denture since the beginning of the year, with pain while eating or chewing, embarrassment when talking to people, and difficulty eating without the denture. Record review showed an onsite mobile dental note indicating the resident’s full upper and lower dentures were adjusted, but the facility did not document follow-up regarding whether the denture was delivered or whether it fit properly. The Director of Social Services stated she did not know the status of the denture and acknowledged she should have followed up with the dental office and the resident. Social service progress notes contained no documentation about the denture, and the DON stated that timely provision of a well-fitting denture was important because it could affect eating and social interaction.
Menu Not Followed for Resident on Renal CCHO Diet
Penalty
Summary
The facility failed to ensure the lunch menu and food portions/serving guide were followed for one resident on a renal CCHO small portions diet. The resident’s physician diet order, dated 5/22/2025, indicated a renal CCHO small portions diet. On 9/2/2025, the facility’s lunch menu for the renal/CCHO diet listed glazed baked pork chop, no gravy, peas, mashed potatoes, a dinner roll, and sliced pears. During tray line observation at 12:00 PM, the resident was served chopped beef patty with brown gravy and baked sweet potatoes instead of the menu items of glazed pork chop, no gravy, and mashed potatoes. In a concurrent interview, the Dietary Supervisor stated the resident did not receive lunch according to the menu and renal diet guidelines, and explained that brown gravy is salty and sweet potatoes are high in potassium. The cook stated a mistake was made and that the menu was not followed, adding that mashed potatoes and no gravy should have been served.
Failure to Renew Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 7’s informed consent for Valproic Acid was renewed after 6 months. Resident 7 was readmitted with diagnoses including dementia with psychotic disturbance, major depressive disorder, and generalized anxiety disorder. The 7/28/2025 MDS indicated the resident’s cognitive skills for daily decision-making were severely impaired, and the resident required assistance with eating, oral hygiene, personal hygiene, toileting hygiene, and showering. The order summary showed Valproic Acid 250 mg/5 mL by mouth twice daily beginning 10/17/2024. During a concurrent interview and record review, LVN 1 reviewed the Valproic Acid consent and confirmed it was dated 9/5/2024. LVN 1 stated the facility does not renew consents every 6 months as required by State law and explained that informed consent is important so the resident or family knows about treatment options. The DON stated that informed consent should be obtained prior to administration of psychotropic medications. The facility’s Psychotropic Medication Management Policy did not state that consents need to be renewed every 6 months, while AFL 24-07 required written informed consent to be renewed every six months and for facilities to provide residents with any recommended dosage adjustments and the option of revoking consent.
Failure to Use Required PPE During Restorative Care
Penalty
Summary
The facility failed to ensure Restorative Nursing Aide 1 wore an isolation gown while providing restorative nursing exercises to Resident 5, who was on Enhanced Barrier Precautions. Resident 5 was admitted on 8/31/2018 and re-admitted on 6/26/2025 with diagnoses including COPD, cerebral palsy, and Parkinson's disease. The resident had a physician's order dated 7/8/2025 to be on EBP due to the presence of a gastrostomy tube and MDRO in the nares. During an observation on 9/4/2025, RNA 1 entered Resident 5's room wearing gloves but no isolation gown and assisted the resident with passive range of motion exercises to both arms and the right leg, then applied splints to the right hand and right knee. RNA 1 later confirmed she did not wear an isolation gown while providing the care and stated she should have worn one because she had direct contact with a resident on EBP. The IPN stated that all staff providing direct patient care, including RNA exercises, to residents on EBP must wear an isolation gown and gloves, and the DON stated it was important for staff to follow proper infection control protocols.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident punched another in the face, resulting in swelling and discoloration near the left eye. The incident occurred after one resident became upset that another was wearing his shoes and, after asking for them to be removed without staff intervention, resorted to physical violence. The injured resident, who had a history of schizophrenia and anxiety disorder and was assessed as having severely impaired cognitive skills, was unable to recall or explain the incident during interviews. The aggressor had diagnoses of schizoaffective disorder and unspecified psychosis, with intact cognitive skills according to assessments. Staff interviews revealed that the assigned CNA did not visually assess the injured resident during night rounds, as the resident was asleep with his head covered, and the CNA preferred not to disturb sleeping residents. The LVN on duty was not informed of the incident and did not observe any abnormalities during her rounds, admitting she did not see the resident's face during shift changes. The DON confirmed that staff are expected to check on all residents face-to-face during rounds to ensure their safety. The facility's policy states that residents must not be subject to abuse by anyone, including other residents.
Resident Denied Readmission Without Proper Assessment After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident who was transferred to a general acute care hospital was properly evaluated for readmission and was denied return to the facility without adequate assessment. The resident, who had a history of schizoaffective disorder and unspecified psychosis, was initially admitted with intact cognitive skills and required supervision or assistance with daily activities. The resident was transferred to the hospital after an incident where he hit his roommate, which was the first occurrence of such behavior. Despite this, the facility did not document any efforts to determine if the resident's needs could still be met or if he continued to pose a danger to others upon potential return. Interviews revealed that the DON instructed hospital case workers not to return the resident, citing danger to others, but admitted there was no documentation or assessment to support this decision. The DON also acknowledged that the facility's interdisciplinary team made the decision without reviewing hospital reports, treatment plans, or consulting the resident's physician. The facility's policy required a review of the discharge plan, current condition, care needs, diagnosis, treatment plan, and behavioral or psychosocial support needs, but this process was not followed in this case.
Failure to Develop Comprehensive Care Plan After Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing physical abuse for a resident who was punched by another resident. The resident involved had a history of schizophrenia and anxiety disorder, with severely impaired cognitive skills for daily decision-making, and required assistance with several activities of daily living. Despite the incident of physical abuse, the care plan was only updated to address the resulting hematoma and redness on the resident's left eye, but did not include interventions or goals related to the abuse event itself. During a review of the care plan, the Director of Nursing confirmed that there was no updated care plan for physical abuse or resident-to-resident altercation, even though such an incident was documented in the electronic health record. The facility's policy requires the interdisciplinary team to develop individualized, comprehensive care plans for each resident, but this was not followed in this case, resulting in a lack of documented strategies to address and prevent further abuse.
Failure to Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for all residents in Medicare/Medicaid-certified beds were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) from August 2024 onward. Review of the facility's MDS 3.0 NH Final Validation Report confirmed that the last successful transmission and validation occurred on 7/31/2024, with no subsequent submissions verified up to 8/11/2025. Interviews with the MDS coordinator revealed that she became aware of the transmission failure only after being notified by the California Department of Public Health, and that the facility's IT staff were working to resolve the issue and transmit the backlog of assessments. The MDS coordinator acknowledged that her responsibilities included ensuring timely and accurate MDS submissions and that the lack of transmission resulted in outdated assessments and care plans for residents. The Director of Nursing (DON) confirmed that the last MDS transmission occurred in 7/2024 and recognized that failure to submit MDS assessments in a timely manner leads to outdated care plans, which are essential for reflecting the current care provided to residents. Review of the facility's policy and procedure indicated that the MDS coordinator is responsible for transmitting assessments, correcting errors, and ensuring validation reports are received. The deficiency was identified through interviews and record review, with the absence of federally mandated resident assessment data affecting all residents in certified beds during the specified period.
Failure to Schedule and Follow Up on Ordered Neurology Consultation
Penalty
Summary
The facility failed to schedule and follow up on a physician-ordered neurology consultation for a resident with diagnoses including polyneuropathy and anxiety disorder. The resident, who had moderate cognitive impairment and required significant assistance with daily activities, had an order for a neurology consult documented in the Physician Order Summary. Despite this, there was no evidence in the resident's chart that the appointment had been scheduled or confirmed, and the Social Services staff responsible for coordinating such appointments was unaware of the order until the resident personally informed her. Interviews revealed that the resident had expressed concerns about his symptoms and the need for a neurology evaluation, and staff acknowledged that the process for scheduling specialty consultations was not initiated as required. The facility's policy indicated that ancillary services should be scheduled promptly based on physician orders, with nursing staff responsible for notifying the appropriate department. The lack of timely coordination resulted in a delay in care and services for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him on the left upper cheek. This incident occurred after a verbal argument between the two residents was witnessed by a CNA and an LVN, who did not intervene in time to prevent the escalation. The argument took place in the patio area, where the residents were unsupervised, leading to the physical altercation. Resident 1, who was the victim of the assault, had a history of aggressive behavior and impaired cognitive ability due to conditions such as dementia and schizophrenia. His care plan included interventions to manage his aggressive episodes, such as removing other residents from the area if he became aggressive. However, these interventions were not followed, resulting in Resident 1 sustaining significant injuries, including a black eye, laceration, and fractures, which required hospital evaluation and treatment. Resident 2, who committed the assault, also had a history of mental health issues, including schizophrenia and delusions. His care plan included strategies to manage his potential for aggressive behavior, such as refocusing his attention and altering his environment. Despite these measures, the lack of supervision and timely intervention by staff allowed the situation to escalate, leading to the physical abuse of Resident 1.
Failure to Honor Resident's Refusal of Care
Penalty
Summary
The facility failed to honor a resident's right to refuse care, leading to increased agitation and physical aggression. Resident 1, who was admitted with Alzheimer's disease, dementia, depression, and unspecified psychosis, exhibited fluctuating capacity to understand and make decisions. The resident required substantial assistance with personal care tasks. During an incident, the resident became physically aggressive, kicking a CNA when informed that her adult brief would be changed. Despite the resident's agitation and refusal to return to bed, the CNAs continued with the personal care, which escalated the resident's aggression. Interviews with staff revealed that the CNAs did not honor the resident's refusal and continued to provide care despite the resident's physical aggression. The CNAs acknowledged that they should have stopped the care and returned later to prevent further agitation and potential injury. The facility's policy on resident rights emphasizes treating residents with respect and dignity, which was not adhered to in this instance, as the staff continued care against the resident's wishes, potentially violating her rights.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer from a wheelchair to a bed, resulting in an injury. The resident, who had impairments on both sides of the upper and lower extremities due to hemiplegia and hemiparesis following a stroke, required total assistance from two to three persons for transfers as per their care plan. However, Certified Nursing Assistant (CNA) 4 attempted to transfer the resident alone, contrary to the care plan and facility policy, leading to the resident's left leg getting caught in the wheelchair wheels and sustaining a laceration that required ten sutures. The incident occurred when CNA 4 lifted the resident by placing one arm under the armpit and holding the pants with the other hand. During the transfer, the resident's left leg was caught in the wheelchair's wheel, causing a deep cut. The resident was then transferred to a General Acute Care Hospital for evaluation and treatment of the laceration. Interviews with the resident and staff confirmed that the resident should have been transferred with two-person assistance due to their condition, which included left-sided paralysis and the inability to fully support their body during transfers. The facility's policy on Safe Resident Handling/Transfers was not followed, as it mandates that residents be handled and transferred safely to prevent injury. The care plan for the resident clearly indicated the need for two to three staff members for transfers, which was not adhered to by CNA 4. This oversight in following the care plan and facility policy directly led to the resident's injury during the transfer process.
Failure to Ensure Resident Privacy During ADLs
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during the performance of Activities of Daily Living (ADLs) by not closing the privacy curtain. This deficiency was observed in the cases of two residents, both of whom had severe cognitive impairments and were dependent on assistance for daily tasks. The failure to close the privacy curtain left these residents visually exposed to other staff and residents, which could lead to feelings of embarrassment and a violation of their right to personal privacy. Interviews with multiple Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) confirmed that the privacy curtain should have been closed completely during ADLs to maintain resident privacy and dignity. The facility's policy on privacy and confidentiality also indicated that residents have a right to personal privacy. Despite this, the CNAs involved did not adhere to these guidelines, resulting in the exposure of the residents during personal care activities.
Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident assessed as high-risk for wandering, resulting in the resident eloping from the facility. The resident, who had a history of wandering and required frequent monitoring, was not observed or tracked as indicated in their care plan. The care plan specified constant observation and monitoring for episodes of wandering or attempted elopement every shift, but these measures were not effectively implemented. The facility's staff did not respond to the entrance/exit door alarm when the resident left the facility. The alarm system was not clearly audible due to a second set of glass doors that muffled the sound, and there was no designated staff to monitor the entrance and exits continuously. Additionally, the resident's wander guard was found broken on their bedside table, indicating a failure in the system meant to alert staff of potential elopement. The resident, who had fluctuating capacity to understand and make decisions, was found in the neighborhood where their family lives after being missing for several days. The resident had a history of schizophrenia, psychosis, paraplegia, and hypertension, and was at risk for medical complications due to missing their high blood pressure medication. The facility's reliance on the wander guard system without additional interventions such as hourly monitoring and designated staff for monitoring contributed to the resident's unnoticed departure.
Removal Plan
- The facility has implemented measures to locate the resident, including notifying the local police, contacting local hospitals, notifying Resident 1's responsible party, and staff searching the vicinity.
- Assigned a Certified Nurse Assistant (CNA) as a Rounder to document at least every hour to identify the whereabouts of residents at risk for wandering and elopement.
- Each facility exit door is equipped with a security camera for monitoring. The Administrator, the DON, and/or RN Supervisor will be responsible for monitoring video footage.
- The front entrance/exit door alarm was made more audible by outfitting the glass doors with an audible door alarm.
- A facility staff (Door Monitor) was assigned to provide continuous supervision of the exit door located between stations B and C.
- The RN Supervisor will be responsible for activating/deactivating door alarms and will conduct rounds to ensure exit doors are properly secured and alarmed.
- The DON initiated in-services to licensed nurses, CNAs, and registry staff regarding the facility's systems on resident supervision and elopement prevention.
- Staff in-serviced on the need to follow up, develop, and implement a care plan for residents assessed as a risk for wandering.
- A Resident Location Tracking log was implemented to document visual checks at least hourly of each resident at risk for wandering and elopement.
- Each exit door is outfitted with an audible door alarm that will set off a piercing horn sound when a door is opened after the alarm has been activated.
- The DON initiated reassessment of residents in the facility and identified those at high risk for wandering and elopement. Care plan revisions were done for all residents identified as high risk.
- Developed a list of residents at high risk for wandering and elopement, made available at each station for all incoming staff. A huddle will be conducted at the beginning of each shift to communicate which residents are at risk.
Deficiencies in Food Labeling and Dishwasher Sanitization
Penalty
Summary
The facility failed to properly label and date food items stored in their refrigerators and freezers, as observed during a survey. Specifically, several food items, including turkey breasts, broccoli, cookie dough, ham, bacon, chicken, ice cream, and various other items, were found without labels indicating the date received or expiration date. This lack of labeling was confirmed through interviews with dietary aides and the cook, who acknowledged that labeling is essential to ensure food is discarded when expired, preventing potential foodborne illnesses. The facility's policy requires all food to be labeled and dated, but this was not adhered to, placing residents at risk. Additionally, the facility did not maintain proper chemical levels in the dishwasher used for sanitizing dishes. During an observation, the test strip used to check chlorine levels in the dishwasher did not change color, indicating a 0 ppm level of chlorine, which is insufficient for sanitization. Interviews with dietary aides and the regional dietary manager confirmed that the dishwasher's chemical levels should be adequate to kill germs on dishes, as per the facility's policy. This deficiency could lead to the use of contaminated dishes and utensils, posing a risk of foodborne illness to the residents.
Refrigerator Malfunction Leads to Potential Contamination Risk
Penalty
Summary
The facility failed to maintain Refrigerator #1 in proper working condition, as observed on 7/16/2024, when a pool of water was found at the bottom of the refrigerator. This issue was noted during the defrosting of ham, chicken, and bacon, with standing water observed under the container of defrosting chicken. An interview with a staff member revealed that water had been dripping from the top of the refrigerator and collecting at the bottom for the past two weeks. The staff member confirmed that maintenance had been notified and had checked the refrigerator, acknowledging that the situation was not normal and could lead to bacterial growth. Further interviews revealed that the Regional Dietary Manager (RDM) had sent a weekly report to the Administrator (ADM), who was responsible for following up with maintenance. The report, dated 7/11/2024, indicated significant water condensation in Refrigerator #1. The ADM confirmed receiving the report and stated that maintenance assessed the refrigerator on 7/17/2024. The Maintenance Supervisor (MS) reported being notified about the issue on 7/11/2024 or 7/12/2024, assessed the refrigerator, and cleaned the coils, noting the bottom was dry at that time. However, a technician was unable to visit until 7/18/2024, leaving the issue unresolved at the time of the survey.
Failure to Respond to Call Lights and Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as observed during a survey. Resident 10 and Resident 33 experienced delays in response to their call lights, which were not promptly acknowledged by staff. Resident 10, who was cognitively intact and required substantial assistance for personal care, expressed frustration over the repeated delays in answering her call light. During the survey, it was observed that a Licensed Vocational Nurse (LVN) ignored the call light signals for both residents, despite being in close proximity and aware of the activated signals. The facility's policy required all staff to respond to call lights, but this was not adhered to, leading to potential safety risks and unmet needs for the residents. Resident 61, who had moderate cognitive impairment and required assistance with eating, was not treated with dignity during mealtime. A Certified Nurse Assistant (CNA) was observed feeding Resident 61 while standing, rather than sitting at eye level, which is necessary to promote dignity and respect. The facility's policy emphasized the importance of maintaining eye contact and treating residents with respect during feeding, but this was not followed in Resident 61's case. The CNA acknowledged the oversight and the importance of being at eye level to ensure the resident's comfort and dignity. The facility's policies on call light response and promoting resident dignity were not followed, as evidenced by the staff's actions and inactions. Interviews with staff, including the Director of Staff Development and a Registered Nurse, confirmed that all staff members were responsible for responding to call lights and that feeding residents at eye level was crucial for maintaining dignity. The failure to adhere to these policies resulted in the residents feeling neglected and disrespected, highlighting a deficiency in the facility's care practices.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Intercommunity Care Center | 0 mi | ★★★★★ | 39 | 0 |
| Ocean Ridge Post Acute | 1.1 mi | ★★★★★ | 23 | 0 |
| Coral Cove Post Acute | 1.1 mi | ★★★★★ | 8 | 0 |
| Courtyard Care Center | 1.5 mi | ★★★★★ | 28 | 0 |
| Marlora Post Acute Rehab Hosp | 1.5 mi | ★★★★★ | 29 | 1 |
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