Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Long Beach Healthcare Center during CMS and state inspections, most recent first.
Failure to Notify MD After Medication Refusal: A resident with HTN, CHF, and COPD did not receive his 9 a.m. meds, including BP meds, until later in the day. The resident said he had not refused the meds and was worried about elevated BP, while an LVN stated he had refused them but the refusal was not documented and the MD was not notified. The resident’s BP was elevated when checked, and the DON stated refusals should be documented and the MD notified if the resident continued to refuse.
An LVN verbally abused a resident during an altercation by telling him to hit her so he could be sent out, after the resident became upset when his overbed table was moved and his breakfast tray fell. Two CNAs stated the resident did not throw the tray at the LVN, and the LVN continued to be assigned to the resident's care afterward. The resident had CHF, COPD, difficulty walking, and lack of coordination, and was cognitively intact and dependent on staff for several ADLs.
Failure to Immediately Report Alleged Verbal Abuse: A resident with CHF, COPD, and mobility limitations became upset when his overbed table was moved during care for another resident, causing food to fall from the table. Witnesses stated an LVN told the resident to hit her so he could be sent out, but the allegation was not immediately reported to the ADM. The DON and ADM were unaware of the LVN's statement, which delayed the investigation and the report to CDPH.
A resident with CHF, COPD, difficulty walking, and intact cognition reported that staff on the night shift did not answer his call light or change his brief, leaving him in soiled briefs until morning. During observation, a CNA was found asleep in a chair while on duty and did not wake when approached. The CNA stated he was not on break and should not have been asleep, and the RN and DON stated sleeping on duty was not acceptable and meant residents’ needs could go unanswered.
Medication administration was not performed according to policy for one resident when an LPN prepared morning meds but another nurse administered them without verifying each order. For a second resident, gabapentin was discontinued after the resident reported tachycardia, yet the medication remained in the cart and was still placed in the resident’s med cup on multiple occasions. Staff acknowledged not following the usual MAR verification and removal process, and the DON stated discontinued meds were supposed to be removed from the cart to prevent accidental administration.
Failure to Refer Resident Request for Drop Arm Commode to OT: A resident who became non weight bearing and had intact cognition requested a drop arm commode after she could no longer safely use a standard commode. The DOR, a COTA, told her she did not need the device and suggested using the existing commode or a bedpan instead, without notifying the supervising OT for an evaluation. The resident then used adult diapers for toileting and reported feeling humiliated, angry, and frustrated.
A resident with MS, depression, and right-sided hemiplegia had months of itching and rash before a dermatologist confirmed scabies by skin scraping and microscopy, documenting mites, ova, nodules, and burrows. The dermatologist ordered permethrin and ivermectin, but the facility placed both orders on hold while waiting for a second opinion and did not start treatment promptly. The resident and family reported burning, intense itching, and poor sleep, and staff later acknowledged the delay in starting the prescribed scabies treatment.
A resident on contact precautions for presumed scabies had a PPE disposal bin in the room without a lid. A family member, the TXN, the IP, and the DON all noted that used PPE was being discarded in an uncovered receptacle, and the facility policy stated PPE disposal bins shall remain covered when applicable.
Failure to Assist Residents at Eye Level During Mealtimes: Staff were observed assisting three residents with meals while standing or using an inappropriate seated position instead of sitting at eye level. A CNA fed one resident from a highchair while the resident lay in bed, a PT stood while feeding another resident with severe cognitive impairment and dysphagia, and an OT stood while assisting a resident with Parkinson’s disease and dysphagia. The DON and RN stated staff should sit next to residents at eye level during mealtime assistance to maintain dignity and allow better observation of the resident’s mouth.
Two residents had repeated refusals during restorative nursing services, but staff did not timely complete a COC or notify the physician. One resident with bilateral BKA and difficulty walking showed a decline in ambulation after refusing to walk multiple times, and staff said the resident had pain and a locked knee. Another resident with hemiplegia/hemiparesis and diabetes repeatedly refused to wear a left AFO during RNA, with staff noting possible discomfort or fit issues. The RN supervisor and DON stated these patterns met criteria for a COC, but it was not completed when the changes occurred.
Incomplete ROM and splint documentation: Two residents with hemiplegia/hemiparesis and documented ROM limitations were receiving restorative nursing services, but one resident’s OT eval did not include objective ROM measurements for the affected LUE joints, and staff did not document when the resident’s elbow extension splint and resting hand splint were applied or removed. For another resident, the RNA task for a left AFO did not include a safe wear-time parameter, and staff also did not document when the AFO was applied and removed. RNAs, the RN supervisor, and the DON all stated the system lacked fields or instructions for these details.
Failure to protect a resident from physical abuse occurred when one resident kicked another resident after believing the other resident took his snacks and phone. The resident who kicked the other resident had CHF and mental and behavioral disorders, while the other resident had schizophrenia and severe intellectual disabilities. A housekeeper witnessed the incident, and an RN later documented that the resident admitted to the kick.
A resident with HTN, CVA, and severely impaired cognition was transferred to a GACH, but the Notice of Proposed Transfer/Discharge was not provided to the Ombudsman at the time of transfer. Staff later confirmed the notices were faxed weeks to months after the transfers, and the DON stated the Ombudsman should have been notified immediately.
A resident with epilepsy and other significant diagnoses had a Dilantin level drop to less than 2 mcg/mL while receiving Dilantin 100 mg TID. Staff stated the MD was informed, but the low level was not documented as a COC, and an RN said licensed nurses should have documented the COC immediately and informed the resident and family. The resident’s care plan called for monitoring lab values within the therapeutic range, and the facility policy required staff to document and monitor acute condition changes.
Inaccurate MDS Did Not Reflect Resident Fall: The facility failed to code a resident’s fall on the MDS even though the resident was found face down on the floor with a bump to the temple and abrasions to the hip and back. The resident had ESRD, hemiplegia, hemiparesis on the right side, a gastrostomy, and severely impaired cognitive skills, and the RN, DMDS, and DON all acknowledged the MDS incorrectly showed no fall history.
PASARR Level II screenings were not completed for two residents after positive Level I findings for serious mental illness. One resident had schizophrenia and bipolar disorder, and the other had schizoaffective disorder with severe cognitive impairment and multiple medical diagnoses. Record review showed the Level II evaluations were not completed because facility staff were unresponsive to repeated attempts by the PASRR authority.
A resident with epilepsy and other diagnoses had a recent hospitalization for a high Dilantin level and later had an active order for Dilantin 100 mg TID. During record review, an LVN and an RN both confirmed there was no care plan for Dilantin in the chart, even though the resident should have had one. The facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables.
The facility failed to update care plans for two residents after changes in condition. One resident, who had legal blindness, depression, a history of falls, and cognitive impairment, was found on the floor, but the fall-related care plan was not revised. Another resident, with depression, DM, bipolar disorder, and total ADL dependence, developed a ruptured blister on the left hip, but the wound care plan was not updated to match the current treatment orders and wound consult findings. The TXN and DON stated the care plans should reflect the residents’ current care needs.
Two residents with impaired cognition and ADL dependence were observed with long, untrimmed fingernails and dark brown deposits underneath the nails. One resident stated she wanted her fingernails trimmed. CNAs, the IPN, and the DON all acknowledged that resident nails should be kept clean and trimmed, and the facility policy stated nail care includes daily cleaning and regular trimming.
Failure to Follow and Clarify Physician Orders: A resident with DM, HTN, and a recent DKA hospitalization had orders for a nicotine patch, diclofenac topical gel, and blood sugar checks three times daily, but the orders were not followed as written. RN and LVN interviews confirmed the nicotine patch and diclofenac were entered as PRN instead of scheduled, and blood sugars were only checked one or two times daily rather than three times daily as ordered.
Delayed Incontinence Care: A resident who was incontinent of urine and stool and needed substantial assistance was left in a soiled brief after asking for help through the call light. CNA 1 acknowledged the request but did not change the resident because she was caring for other residents and said he was not assigned to her; the concern was later relayed to an LVN. The resident reported feeling upset and unwell, and CNA 2 later provided incontinent care, with the brief changed hours after the initial request.
A resident with ESRD, DM, and dependence on hemodialysis did not have the ordered emergency kit at the bedside. The resident had a chest dialysis catheter and received dialysis three times weekly, but observation and staff interviews confirmed the kit was not in the room. The RN and DON stated the kit should be readily available for bleeding from the dialysis site, and the facility policy called for safe, appropriate care in coordination with the dialysis center.
A resident with anemia and severe cognitive impairment received the wrong multivitamin instead of the ordered multivitamin with minerals. Another resident with COPD and acute respiratory failure did not have ordered diclofenac gel available for pain, and ordered respiratory meds were not consistently available in stock. The PSD also found respiratory neb meds stored without proper labeling and stated unused meds were discarded without disposal documentation, while RT documentation listed the wrong medications.
A resident with COPD and acute respiratory failure had aformoterol nebulizing solution documented on the MAR, but staff could not initially locate it in the med cart or respiratory carts. The PSD later found five packets in a medication room stored in a cabinet inside a clear bag without a pharmacy label or open date, with only a typed resident-name label. The RPH stated the medication should remain in its original labeled packaging and should not be repackaged or relabeled by the facility.
A resident with no upper teeth and multiple missing lower teeth did not have the Social Services Initial Psychosocial Assessment completed, leaving the dental ancillary services section blank. Staff stated there was no dental mobile consult pending, and the DSS, DON, and an LVN acknowledged the resident's dental needs were not identified or followed up through the admission assessment process.
A resident with COPD and acute respiratory failure had inaccurate respiratory treatment documentation. The MAR showed aformoterol and levalbuterol nebulizing solutions were documented as given, but the RT progress note recorded albuterol/Atrovent instead. The PSD stated the documented medications were incorrect, and staff interviews showed confusion about which department was responsible for the treatments and that the ordered medications were not available in the respiratory carts.
A CNA was observed passing lunch trays room to room without performing hand hygiene between resident care activities or before entering and exiting resident rooms. The CNA stated she was rushing and forgot, while the IPN and DON stated staff are expected to perform hand hygiene when handling meal trays and when entering or exiting rooms. The facility policy states hand hygiene is the primary means to prevent the spread of healthcare-associated infections and is indicated after touching a resident's environment.
Failure to Collect Ordered Urine Toxicology Specimen: A resident with anxiety disorder, opioid dependence, and COPD had an acute change in condition with ALOC, pinpoint pupils, and later lethargy, hallucinations, jerking movements, and bowel loss, requiring Narcan and transfer for further evaluation. After readmission, a urine toxicology test was ordered, but the specimen was collected in the wrong container and could not be completed; staff also failed to communicate the need to recollect the sample and the resident's refusal to the oncoming shift.
Missing Documentation of Refusal for Urine Toxicology Sample: A resident with anxiety disorder, opioid dependence, and COPD had a change in condition with ALOC, pinpoint pupils, and later lethargy, hallucinations, jerking movements, and bowel loss, requiring Narcan and transfer for further evaluation. After readmission, a CBC, CMP, UA, and urine tox were ordered, but the specimen was collected in the wrong media and the RNS stated the resident refused to provide another urine sample; however, he did not document the refusal in the chart or communicate it to the next shift.
A resident with an AKA, difficulty walking, HTN, and DM was scheduled for outside appointment transportation and return by wheelchair van, but after the appointment ended she and a CNA waited in the lobby for hours when the ride did not arrive. The resident reported repeated unanswered calls to the facility, being told by the transport company she was a no show, and remaining in the lobby without food, water, or restroom access until a later ride arrived after 7 p.m. The DON stated the facility should have had a system in place to get the resident back when she was not picked up as expected.
Failure to Document Resident Abuse Allegation: A resident with impaired cognition and assistance needs alleged that a CNA handled her roughly during toileting assistance, including elbowing her knee and pushing her shoulder. RN 2 confirmed the resident reported the incident and acknowledged he did not document the abuse allegation in the clinical record, despite facility policy requiring documentation of changes in condition and resident incidents.
Failure to prevent resident-to-resident physical abuse: a resident with paranoid schizophrenia, violent behavior, and cognitive impairment struck another resident in the nose after a verbal exchange over tissue paper, causing a nosebleed. The injured resident said she did not want to be around him anymore and believed he needed assistance and supervision. The striking resident had a care plan for physical aggression with 1:1 supervision, but staff reported the supervision had been discontinued and the incident was not witnessed, only heard in the hallway.
Staff failed to follow EBP PPE requirements when two CNAs provided post-shower care to a resident with a foot ulcer without donning required PPE in the room. The resident had diagnoses including anxiety disorder, PTSD, and type 2 diabetes with a foot ulcer, and the facility’s EBP policy required gown and gloves for high-contact care such as bathing, showering, and hygiene/grooming.
A resident with dementia, HTN, lack of coordination, and wheelchair dependence, who required partial to total assistance with ADLs, was found in bed with the call light hanging against the wall and touching the floor, out of reach, despite a care plan intervention directing staff to keep the call light within reach and encourage its use. The resident reported needing a nurse but being unable to call for assistance because the call light could not be located. A CNA on her first day later found and repositioned the call light, acknowledging she had not checked all call lights, while an LVN noted the resident had not used the call light and that the roommate typically activated it for help. The DON and facility policy both stated that call lights must be easily accessible to residents and that all staff are responsible for ensuring this accessibility.
A resident with morbid obesity, EPS, neuropathy, generalized weakness, hypotension, and a history of falls had a care plan and MDS indicating moderate fall risk and a need for maximal assistance and a two‑person full body lift for transfers. Despite this, a CNA, who was unaware of the two‑person assist requirement and had routinely transferred the resident alone, assisted the resident from a shower chair to the bed without additional staff. The resident stood with a walker by the bed, held the bed rail, reported sudden leg weakness, and was eased to the floor, landing on her bottom with bent knees and feet. Later, the resident developed bilateral leg pain, swelling, and discoloration, and hospital evaluation revealed displaced distal fibular and bilateral bimalleolar fractures of both ankles. The DON acknowledged that assistance should have been requested and that nursing staff should have communicated the resident’s two‑person transfer needs, contrary to the facility’s fall risk policy.
A resident with intact cognition and multiple medical conditions reported that his wallet, which contained credit cards and other personal items, went missing around the time of a hospital transfer, and later discovered an unauthorized $800 charge that his bank reversed. Facility records showed the wallet was reported missing and later replaced, but key sections on the theft/loss form, such as estimated value, were left blank. The resident reported the missing wallet and unauthorized charge to social services staff, and leadership acknowledged that the circumstances suggested possible misappropriation and should have been reported to regulatory and law enforcement agencies. Despite facility policies requiring timely reporting of suspected theft or misappropriation to CDPH and other authorities, staff did not report the allegation of the missing $800 and suspected theft to CDPH.
A resident with intact cognition and multiple medical conditions reported that his wallet, which contained credit cards, identification cards, and cash, went missing while he was hospitalized, and that an unauthorized $800.00 charge was made to his bank account using one of the cards. The resident and a family member informed social services staff that the wallet and contents were missing and raised concerns that no investigation had been conducted. Although the loss was documented and the wallet itself was later replaced, key sections of the theft report were left blank, and no timely investigation or police report was initiated, despite facility policy requiring prompt and thorough investigation of all theft or misappropriation allegations.
A resident experiencing cardiac arrest and airway obstruction could not be suctioned during an emergency because the required connector for the portable suction machine was missing from the crash cart. Staff were unable to locate the missing piece, and interviews confirmed that crash cart checks had not ensured all critical components were present and functional as required by facility policy.
A resident reported being repeatedly touched and having his arm pulled by his roommate, who had cognitive impairment and psychiatric diagnoses. The incident was reported to a CNA and RN, but the administrator classified it as a grievance rather than suspected abuse and did not report it to authorities, contrary to facility policy.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a failure to meet notification requirements.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with chronic kidney disease and diabetes mellitus reported chest pain, leading to a physician's order for a 12-lead EKG. The RN carried out the EKG order but did not assess or document the resident's chest pain or discomfort, despite facility policy requiring assessment after a change in condition. This resulted in no documentation or knowledge of the resident's medical status at the time.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple medical conditions experienced severe unplanned weight loss due to the facility's failure to implement RD recommendations, monitor and report weight changes, conduct required IDT meetings, and develop a comprehensive care plan. Staff did not follow established policies for addressing significant weight loss, and communication lapses contributed to the resident's continued decline.
Three residents with significant physical and cognitive impairments did not have clear or accurate documentation of their Restorative Nursing Aide (RNA) services. Staff used unclear notations in the electronic medical record, and documentation prompts often did not match the actual RNA tasks performed, making it impossible for facility leadership to determine if services were provided as ordered.
Surveyors observed that staff failed to properly disinfect shared cloth gait belts, did not consistently perform hand hygiene before and after resident care, and did not maintain clean environmental surfaces such as curtains. These lapses were confirmed by staff interviews and were not in accordance with facility policies or manufacturer instructions.
The facility did not perform required inspections or preventative maintenance on three types of electrical therapy equipment in the therapy gym, as confirmed by the DOR, Maintenance Director, and DON. User manuals for the devices specified regular maintenance and safety checks, which were not followed, and the facility's own policy required adherence to manufacturer-recommended schedules.
Three residents experienced deficiencies in care, including lack of documentation for missed lab draws, failure to perform a timely skin assessment after an abuse allegation, and failure to notify a physician about persistent hyperglycemia. These actions resulted in delays in care and treatment.
Staff assisted two residents with feeding while standing over them, rather than at eye level, despite both residents requiring significant help due to cognitive and physical impairments. This practice was inconsistent with facility policy and was acknowledged by both a CNA and the DON as undermining resident dignity and comfort.
A resident with severe cognitive impairment and inability to make medical decisions was asked to sign consents for psychoactive medications, including Ativan, Buspirone, and Lamictal, without proper involvement of a responsible party. Nursing staff and the DON confirmed the resident's incapacity, and facility policy requiring informed consent from a representative was not followed.
Failure to Notify Physician After Medication Refusal
Penalty
Summary
The facility failed to ensure the physician was notified when a resident with HTN refused his 9 a.m. medications, including blood pressure medications. The resident had diagnoses including HTN, CHF, COPD, difficulty walking, and lack of coordination. His H&P indicated he was oriented to person, place, and time, and his MDS indicated intact cognition. His care plan for episodes of refusing his 9 a.m. medications and BP checks directed staff to document refusals, monitor for complications related to refusal of medications and vital sign checks, and notify the MD for significant changes promptly. The physician’s orders included Metoprolol Succinate ER 50 mg daily for HTN, Telmisartan 40 mg daily for HTN, Furosemide 20 mg daily for HTN, Aspirin 81 mg daily, Ezetimibe 10 mg daily, Empagliflozin 10 mg daily, and Gabapentin 300 mg four times daily. The medication administration audit showed the resident’s 9 a.m. medications on 7/27/2026 were not given until 12:21 p.m. During an interview, the resident stated he had not received his morning medications, that he had blood pressure medications due, and that he was concerned his blood pressure would become elevated. He also stated he had not refused the medications and frequently had to use his call light to ask for them. During observation, the resident requested his morning medications and his BP was checked at 11:57 a.m., showing 161/96 in the left arm and 166/96 in the right arm with heart rates of 58 and 55. Nursing progress notes contained no documented evidence that he refused his 9 a.m. medications or that the physician was notified. An LVN stated the resident refused the medications when offered at 9 a.m., but the refusal was not documented and the physician was not notified. The DON stated that if a resident refused medications, staff should document the refusal, explain the risks and consequences, attempt to give the medications two more times, and notify the physician if the resident continued to refuse.
Verbal abuse by LVN during resident altercation
Penalty
Summary
The facility failed to protect a resident from verbal abuse when an LVN taunted him during an altercation by saying, "Go ahead and hit me so we can send you out," and then continued to be assigned to his care afterward. The resident had diagnoses including CHF, COPD, difficulty walking, and lack of coordination, and his H&P and MDS indicated he was oriented and cognitively intact. He required staff assistance for eating, toileting, dressing, and bathing. The incident occurred while staff were trying to assist the resident's roommate with a shower and needed to move the resident's overbed table to make room for a mechanical lift. The resident became upset when his table was moved and his breakfast tray fell, and staff described him as yelling, swiping items off the table, and pushing the table out of the way. Two CNAs stated the resident did not throw the tray at the LVN, and both reported that the LVN told the resident to hit her so he could be sent out of the facility. One CNA stated the LVN also held up her hands to prevent staff from approaching and said, "Let him hit me if he wants to hit me." The LVN did not address the statement attributed to her during interview, and the DON and ADM stated they were not aware that she had made that comment. The facility's staffing assignments showed the LVN continued to be assigned to the resident on multiple days after the incident. The DON stated that if the comment had been known, the LVN would have been reassigned from the resident's care, and the ADM stated the LVN would have been removed from the resident's assignment if he had known what was said. A later nursing progress note also documented that the resident refused medications from the LVN and should continue to receive medications from another nurse if he allowed it.
Failure to Immediately Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator when staff witnessed an LVN tell a resident, "Go ahead and hit me so we can send you out." The resident had been admitted with diagnoses including CHF, COPD, difficulty walking, and lack of coordination, and his MDS indicated his cognition was intact. He required staff assistance for eating, toileting, dressing, and bathing. On the day of the incident, staff were assisting another resident with a shower in the same room and needed to move the resident's overbed table to make space for a mechanical lift. The resident became upset when the table was moved and food fell from it. The resident stated the LVN accused him of throwing food at her and then told him to hit her so he could be sent out. Two CNAs were present and later stated the resident did not throw the tray at the LVN, and that the LVN made the statement to the resident during the altercation. The DON and ADM stated they were not aware of what the LVN said to the resident because the statement was not reported to them at the time. The ADM stated staff contacted him during the altercation but only reported that the resident threw his food tray. Because the verbal abuse allegation was not immediately reported, the facility did not conduct a timely investigation and did not report the allegation to CDPH. The facility policy required alleged abuse to be reported immediately, and no later than two hours when abuse is involved.
CNA asleep on duty and not responding to resident care needs
Penalty
Summary
The facility failed to ensure a CNA remained awake and available to respond to resident care needs during the 11 p.m. to 7 a.m. shift. Resident 1 was admitted with diagnoses including CHF, COPD, difficulty walking, and lack of coordination. The resident’s H&P indicated he was oriented to person, place, and time, and the MDS showed intact cognition. The MDS also indicated he required set-up and clean-up assistance for eating and maximal assistance for toileting, lower-body dressing, and showering/bathing. Resident 1 reported that during the night shift staff did not change his brief and did not respond to his call light. He stated he had previously filed a grievance about call light concerns, that staff responded better for a short period, and then returned to not responding. He also stated staff ignored him when he asked to be changed, leaving him in soiled briefs until morning for a shower and brief change. During a concurrent observation and interview, Resident 1 stated he had seen CNA 1 asleep in the corner during the night shift and said CNA 1 frequently slept there, including times when other residents called for assistance and he did not respond. During observation, CNA 1 was found covered with a blanket and asleep in a chair outside the shower room at the end of the hallway for approximately 10 minutes and did not wake when approached. CNA 1 stated he was not on break and was not supposed to be asleep while on duty. RN 2 stated it was not acceptable for CNA 1 to be asleep while on duty and said staff must be fully awake because sleeping while on duty was a safety issue. RN 2 stated CNA 1 was assigned to the East Station and was covering the area for the CNA assigned to Resident 1. The DON stated she was unaware CNA 1 was sleeping during the shift or that Resident 1 did not want CNA 1 assigned to his care because of concerns with sleeping. The ADM stated he was aware of Resident 1’s concerns about call lights and not being changed, but was not aware CNA 1 was sleeping during the night shift.
Medication Administration and Discontinued Medication Handling Failures
Penalty
Summary
Medication administration was not carried out according to the facility’s stated process for one resident who had multiple morning medication orders, including aspirin, empagliflozin, ezetimibe, furosemide, gabapentin, metoprolol succinate, and telmisartan. Medication cups containing the resident’s 9 a.m. medications were observed on a tray on top of the medication cart, and one LVN stated she asked another LVN to give the resident the medications after they had already been prepared. The medications were then administered by a nurse other than the one who had prepared them. The facility’s policy stated that the nurse administering the medication should check the label three times and verify the right resident, right medication, right dosage, right time, and right route before giving the medication, and that licensed nurses verify the physician’s order before administering any medication. For another resident, gabapentin was discontinued after the resident reported feeling her heart rate increase after taking it. The physician was notified, and the medication was discontinued. The resident stated that after the discontinuation, nursing staff continued to place gabapentin in her medication cup on at least three occasions, and she refused it each time. She stated she kept telling staff the medication had been discontinued. During interview, an RN stated he did not remove the discontinued gabapentin from the drawer and instead told the assigned medication nurse to remove it and place it in the discontinued medication bin. The RN also stated the facility’s practice was for the licensed nurse receiving the discontinuation order to immediately remove the medication from the cart, but he did not follow that process. A later observation of the medication cart showed gabapentin still present in the drawer for the resident eight days after it had been discontinued. An LVN stated she prepared the resident’s oral medications, placed them in one cup, and handed the cup to the resident, who identified gabapentin as one of the medications that had been discontinued. The LVN then reviewed the MAR and saw gabapentin was still listed for administration. She stated she did not follow the proper medication administration process and did not remove the discontinued medication from the drawer because she was busy. The DON stated nurses were required to confirm each medication and dosage against the MAR, ensure the medication was ordered before preparing and administering it, and remove discontinued medications from the medication cart to prevent accidental administration.
Failure to Refer Resident Request for Drop Arm Commode to OT
Penalty
Summary
The facility failed to ensure the Director of Rehabilitation, who was a COTA working under the supervision of a licensed OT, referred a resident to OT when the resident requested a drop arm commode after becoming non weight bearing on both legs. The resident had diagnoses including anorexia nervosa, polyneuropathy, and abnormalities of gait and mobility, and records showed she had the capacity to understand and make medical decisions and was cognitively intact. After the resident was ordered to be non weight bearing until seen by orthopedics, she told the DOR that she could no longer use a standard commode because she previously pivoted onto it but now had significant wrist pain that made scooting difficult. The DOR told her she did not need a drop arm commode, suggested she continue using the existing commode by scooting, and later suggested she use a bedpan. The DOR stated she should have informed the supervising OT because she could not screen or evaluate residents, but the OT stated she had not been informed of the request and had not completed an evaluation. The resident stated that because she could not obtain the drop arm commode, she began wearing adult diapers to urinate and defecate and felt humiliated, angry, and frustrated. She also stated she cleaned herself independently after toileting in the diaper because she was embarrassed to have anyone else clean her. The DON stated she was not aware of the request or that the DOR had attempted to address the resident's toileting needs without notifying the supervising OT or nursing, and stated that requests for specialized equipment must be promptly communicated to the licensed OT for proper evaluation.
Delayed Treatment for Confirmed Scabies
Penalty
Summary
The facility failed to ensure timely treatment and care according to orders for a resident who was diagnosed with scabies. The resident had a history of multiple sclerosis, depression, and right-sided hemiplegia, and was documented as cognitively intact and able to make decisions. She had reported itching and skin lesions for months, with notes describing papular lesions and ongoing rash symptoms that were treated as dermatitis before the scabies diagnosis was confirmed. On the day of the dermatology visit, the resident was evaluated by a dermatologist who performed a skin scraping and dermatoscope examination and documented mites, ova, scabietic nodules, and linear burrows consistent with scabies. The dermatologist ordered permethrin 5% cream, ivermectin by mouth, and triamcinolone cream for itching. However, the facility placed the permethrin and ivermectin orders on hold because the interdisciplinary team wanted a second dermatology opinion and a confirmatory skin scraping, even though the resident had already been seen by a dermatologist and neither the resident nor her POA were present at the IDT meeting. The resident did not receive the prescribed scabies treatment until several days later, after staff followed up for the dermatologist's progress note and the orders were resumed. Interviews with the resident, family member, CNA, treatment nurse, PCP, IP, and DON all described a delay in care. The resident and family member stated she was burning, very itchy, and having trouble sleeping, and staff acknowledged that the treatment should have started when scabies was diagnosed. The facility policy stated that physician orders are to be received, reviewed, implemented, documented, and monitored in a timely manner and that medications and treatments are to be initiated promptly according to urgency.
Uncovered PPE Disposal Bin During Contact Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure a PPE trash receptacle had a cover for one resident who was on contact precautions for presumed scabies. The resident was admitted and readmitted with diagnoses including MS, depression, and right-sided hemiplegia, and the MDS indicated intact cognition, total dependence with ADLs, and capacity to understand and make decisions. The physician’s order dated 7/6/2026 directed staff and visitors to apply gloves and gown before entering the room and remove them before exiting, and the care plan addressed presumed scabies with contact precautions and topical steroid cream as ordered for itching. During a family member’s visit, it was observed that the trash receptacle used for dirty PPE had no lid. On 7/14/2026, the treatment nurse observed the same condition and stated a lid was required on the receptacle to prevent the spread of infection from cross-contamination, noting the resident had scabies and it was highly contagious. The infection preventionist stated the trash receptacle used for PPE disposal needed a lid to contain organisms that might be on contaminated PPE and that there was a potential for cross-contamination and for scabies to spread because the receptacle was not covered. The DON also stated used PPE needed to be disposed of in a covered container to contain germs and prevent the spread of infection through cross-contamination. The facility policy stated PPE disposal bins shall remain covered, clean, in good condition, and not be overfilled.
Failure to Assist Residents at Eye Level During Mealtimes
Penalty
Summary
The facility failed to ensure staff assisted residents at eye level during mealtimes for three sampled residents. The deficiency was identified through observation, interview, and record review and involved Resident 70, Resident 119, and Resident 85. The report states these residents were not assisted in a manner that maintained dignity and respect during meals, and staff involved acknowledged that they were not positioned at eye level while feeding or assisting the residents. Resident 70 had diagnoses including Parkinson’s disease with dyskinesia, difficulty walking, and lack of coordination. The MDS indicated moderately impaired cognitive skills, partial/moderate assistance with eating, and impaired vision. During observation, a CNA was sitting on a highchair while feeding Resident 70, who was lying in bed in an upright position. The CNA later stated she did not use a chair appropriate for feeding a resident within eye level and said it was important to sit next to the resident within eye level to support communication, prevent choking, and maintain dignity. Resident 119 had diagnoses including pneumonia, dysphagia, hemiplegia and hemiparesis following cerebrovascular disease, and epilepsy. The MDS indicated severe cognitive impairment and dependence on staff for eating and other care needs. During observation, a PT was standing while feeding Resident 119, who was sitting on the edge of the bed with legs dangled. The PT stated he was feeding the resident because nursing staff were busy and later said he stood because it was easier for balance. Resident 85 had diagnoses including Parkinson’s disease with dyskinesia, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. The MDS indicated the resident required set up or clean up assistance with eating. During observation, an OT was standing next to Resident 85 while assisting with lunch and later stated she should have sat down next to the resident to be at eye level. The DON and RN stated staff should sit in a chair at eye level during mealtime assistance to see the resident’s mouth and maintain dignity.
Delayed COC and physician notification for repeated restorative care refusals
Penalty
Summary
The facility failed to complete a change of condition (COC) and notify the physician timely when two residents had significant changes in physical status during restorative nursing services. The deficiency involved one resident with bilateral below-knee amputations and difficulty walking, and another resident with hemiplegia/hemiparesis after cerebral infarction and diabetes mellitus. In both cases, staff documented repeated refusals during restorative nursing treatment, but the changes were not addressed as a COC at the time the refusals and declines were occurring. For the first resident, the record showed restorative ambulation was part of the care plan and that the resident had been walking substantial distances earlier in the month. The documentation then showed repeated refusals to ambulate over several days, followed by a marked decline in walking distance. During interview, restorative nursing staff stated the resident had been walking with an aide when the left knee locked up, after which the resident did not want to walk because of pain and staff reported the refusals to nursing. The RN supervisor reviewed the record and stated a COC should have been completed after the third refusal because the resident’s condition had changed and was affecting activities of daily living, but no COC had been completed. For the second resident, the care plan included restorative nursing for splinting with a left AFO, along with ROM exercises. The documentation showed multiple refusals to wear the left AFO across June and July, and restorative staff observed that the resident refused to wear it during treatment. Staff stated the refusal may have been due to discomfort or poor fit and that the refusal was reported to the charge nurse. The RN supervisor stated that after three refusals in a row, a COC assessment should have been completed and the physician notified, but the COC was delayed. The DON stated that multiple refusals to use a splint in restorative nursing were considered a COC and should be completed immediately.
Incomplete ROM and splint documentation
Penalty
Summary
The facility failed to provide services to maintain or prevent further decline in ROM for two residents who had documented functional limitations and were receiving restorative nursing services. One resident had diagnoses including hemiplegia and hemiparesis following an intracerebral hemorrhage, and the MDS indicated functional limitations in ROM of one upper extremity and one lower extremity. The resident’s care plan included restorative nursing with a left UE elbow extension splint and resting hand splint. During observation, the resident’s left third through fifth fingers were bent, and the resident could move the left arm only a little. However, the OT evaluation dated 9/14/2025 documented impaired ROM in the left shoulder, elbow/forearm, wrist, hand, thumb, and fingers without objective ROM measurements. The OT later stated the evaluation did not include exact measurements and that she could not tell whether the limitation was significant or minimal because it was not documented. For the same resident, the facility did not document the application and removal of the left elbow extension splint and left resting hand splint. The June 2026 restorative nursing documentation survey report required documentation of minutes spent providing splint assistance and whether the resident complained of or showed signs of pain or discomfort, but it did not show when the splints were applied or removed. RNA staff stated the electronic documentation system only captured how long staff spent putting on and taking off splints, not the actual application and removal times, and that there was nowhere to document those times. The RN supervisor and DON both stated the documentation did not track when the splints were applied and removed, and the DON stated RNAs should document when a splint was applied and removed. A second resident had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and Type 2 diabetes mellitus. The MDS indicated functional limitation in ROM of one upper extremity and one lower extremity, and the care plan included restorative nursing with a left AFO as tolerated with skin checks. During observation, the RNA completed ROM treatment and stated the resident refused to wear the left AFO. The RNA and RN supervisor stated the documentation system did not include a place to record when the AFO was applied and removed, and the RNA task did not include how long the resident should wear the AFO. The RN supervisor and DON stated the wear time should be written so staff would know how long to apply the AFO, and both stated the documentation did not track when the AFO was applied and removed each day.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when one resident kicked another resident on 6/27/2026. The resident who kicked the other resident had diagnoses including CHF and mental and behavioral disorders, and his MDS dated 6/29/2026 indicated cognition was intact and that he required setup assistance with ADLs. The resident who was kicked had diagnoses including schizophrenia and severe intellectual disabilities, and his MDS indicated cognition was moderately impaired and that he was dependent with ADLs. During an interview on 7/7/2026, Housekeeper 1 stated he saw the resident kick the other resident. During a phone interview on 7/8/2026, RN 3 stated Housekeeper 1 told her he witnessed the kick, and RN 3 stated the resident admitted to kicking the other resident because he thought the other resident took his snacks and phone. The facility's Residents Rights policy stated residents have the right to live in a safe, secure, and healthy environment and to be free from physical abuse.
Delayed Ombudsman Notification for Transfer/Discharge
Penalty
Summary
The facility failed to ensure the Notice of Proposed Transfer/Discharge form was provided to the Office of the State Long-Term Ombudsman at the time of transfer to a General Acute Care Hospital for one resident. The resident had been originally admitted to the facility and later readmitted with diagnoses including HTN and CVA. The resident's MDS dated 6/20/2026 indicated severely impaired cognition and dependence with ADLs. During interview and record review, staff stated the Ombudsman should be notified when a resident is transferred or discharged. RN 2 reviewed the resident's Notices of Proposed Transfer/Discharge and stated one notice dated 3/24/2026 was faxed to the Ombudsman on 7/7/2026, 105 days later, and another notice dated 5/16/2026 was faxed on 7/7/2026, 52 days later. The DON stated the form should have been completed and faxed immediately when the resident was transferred to the GACH. The facility policy titled Transfer or Discharge stated transfers and discharges require resident or representative notification, orientation, and documentation in the medical record.
Failure to Document Change of Condition for Critically Low Dilantin Level
Penalty
Summary
The facility failed to document a change of condition for a resident with epilepsy, hemiplegia, hemiparesis, and paranoid schizophrenia when the resident’s Dilantin level dropped to less than 2 mcg/mL. The resident had been admitted and later readmitted to the facility, and the history and physical noted the resident had capacity to understand and make decisions and had recently been hospitalized for a high Dilantin level. The resident’s order summary showed Dilantin 100 mg three times daily for seizures, and the care plan included maintaining lab values within the therapeutic range with ordered lab monitoring. During record review, the lab result dated 5/12/2026 showed the resident’s Dilantin level was less than 2. An LVN stated the doctor was informed of the result, but there was no change of condition documented for the low Dilantin level. An RN stated the lab result had been missed and that licensed nurses should have documented a COC immediately for Dilantin less than 2 and informed the resident and the resident’s family. The facility policy on acute condition changes stated nursing staff should collect pertinent details, monitor and document the resident’s progress and responses to treatment, and the physician would adjust treatment accordingly.
Inaccurate MDS Did Not Reflect Resident Fall
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for one resident was accurate by not coding a fall that occurred when the resident was found lying on the floor face down beside the bed with a bump to the right temporal area and abrasions to the right hip and back. The resident had been admitted and readmitted with diagnoses including ESRD, hemiplegia, hemiparesis affecting the right dominant side, dependence on renal dialysis, and a gastrostomy. The resident’s MDS also indicated severely impaired cognitive skills for decision making and dependence on staff for dressing, toileting hygiene, bathing, and personal hygiene. The Change of Condition record documented the fall and noted that the physician and family member were notified. However, the MDS completed after the event indicated the resident had no history of falls since admission, reentry, or prior assessment. During interviews, the RN, DMDS, and DON all acknowledged that the fall was not coded correctly on the MDS and that the assessment should have reflected the event. The facility policy on Comprehensive Assessments stated that an error in assessment occurs when a resident’s overall clinical status is not accurately represented or miscoded.
PASARR Level II screenings not completed for two residents with positive Level I findings
Penalty
Summary
The facility failed to ensure that PASARR Level II screenings were completed for two residents who had positive Level I screenings indicating serious mental illness. For one resident, the admission record showed diagnoses including schizophrenia and bipolar disorder, and the PASARR Level I screening dated 5/9/2026 indicated that a Level II screening was required. No PASARR Level II was found in the record. During interview and record review, the MDSA confirmed the Level I screening was positive and that a Level II PASARR was required, and reviewed a Notice of Attempted Evaluation stating the Level II was not completed because facility staff were unresponsive in two or more separate attempts. For the second resident, the face sheet showed admission and readmission to the facility with diagnoses including schizoaffective disorder depressive type, type 2 diabetes mellitus with diabetic polyneuropathy, and metabolic encephalopathy. The MDS dated 06/01/2026 indicated the resident was severely cognitively impaired and required setup or clean-up assistance with eating, oral hygiene, and upper body dressing. The PASRR Level I screening dated 12/01/2025 indicated severe mental illness and required a Level II mental health evaluation. The Notice of Evaluation for Level II screening completion dated 12/03/2025 stated the Level II assessment was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. The facility policy stated that all residents must be screened for mental illness through the PASRR process prior to admission and as required post-admission, and that if Level I is positive, the facility must refer to the state PASRR authority for Level II evaluation. During interview, the MDSA stated the PASARR screening determines what residents may need and assists with creating the plan of care, and the DON stated it was important that PASARR screenings be done accurately to identify whether the resident was appropriately placed and to provide additional resources.
Missing care plan for Dilantin use
Penalty
Summary
The facility failed to ensure that Resident 9 had a care plan created, initiated, and implemented for Dilantin use. Resident 9’s record showed diagnoses including epilepsy, hemiplegia, hemiparesis, and paranoid schizophrenia. The history and physical dated 3/11/2026 stated the resident had the capacity to understand and make decisions and had recently been hospitalized from 3/7/2026 to 3/10/2026 because of a high Dilantin level. The MDS dated 4/23/2026 indicated the resident could express ideas and wants and required substantial to maximal assistance with toileting, showering, dressing, personal hygiene, and transferring. The order summary showed that on 5/12/2026 Resident 9 had an order for Dilantin 100 mg three times a day for seizures. During interviews and record review, CNA 11 stated the resident had been hospitalized a couple of months earlier for an elevated Dilantin level. LVN 1 and RN 2 both reviewed the care plans and stated there was no care plan for Dilantin in the chart, and both stated the resident should have one. The facility policy stated a comprehensive, person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident within seven days of the required MDS assessment and no more than 21 days after admission.
Failure to Update Care Plans for a Fall Event and a Wound Change
Penalty
Summary
The facility failed to revise the care plan for a resident identified as at risk for falls after the resident was found lying on the floor. The resident’s admission record listed diagnoses including legal blindness, depression, and a history of falling. The MDS indicated moderate cognitive impairment and total dependence with ADLs, and the H&P noted fluctuating capacity to understand and make decisions. A care plan titled “At risk for fall related to leaning to the left while seated in the wheel chair” was in place, but it was not updated after the resident’s fall event documented in the change of condition evaluation. For another resident, the facility failed to revise the care plan to reflect the current plan of care for a ruptured blister on the left hip. The resident’s admission record listed diagnoses including depression, diabetes mellitus, and bipolar disorder. The MDS indicated intact cognition, total dependence with ADLs, and an unhealed pressure injury, while the H&P noted fluctuating capacity to understand and make decisions. A change of condition evaluation documented scattered open blisters on the left buttock, and the care plan addressed treatment and a wound consult for those blisters. Subsequent records showed the wound had progressed to a new ruptured blister on the left hip, with orders for cleansing with normal saline, packing with calcium alginate, applying Santyl to the deeper area, and covering with a waterproof adhesive foam dressing daily and as needed. The wound consult assessment also documented the new ruptured blister and the same treatment approach. During interviews, the treatment nurse stated the care plan should have been revised to reflect the current wound care, and the DON stated care plans need revised interventions when the level of care changes.
Untrimmed, Dirty Fingernails Observed in Two Residents
Penalty
Summary
The facility failed to ensure that two sampled residents had their fingernails trimmed and free from accumulation of unknown substances underneath the nails. Resident 32 was admitted and later readmitted with diagnoses including rheumatoid arthritis and muscle weakness, and the MDS dated 4/21/2026 indicated severely impaired cognition and the need for moderate assistance with ADLs. Resident 113 was admitted with diagnoses including hemiplegia and hypertension, and the MDS indicated moderately impaired cognition and dependence with ADLs. During observations, Resident 113’s fingernails were untrimmed with dark brown deposits underneath, and Resident 113 stated she wanted her fingernails trimmed. Resident 32 was also observed with untrimmed fingernails and dark brown deposits underneath. CNA 5 stated Resident 32’s fingernails were long and needed to be trimmed, and CNA 6 stated Resident 113’s fingernails were long and dirty and should be kept clean and short. The IPN stated resident nails should be kept trimmed and clean, and the DON stated cleaning and trimming fingernails was a CNA task required when nails were observed to be long and unclean. The facility policy stated nail care included daily cleaning and regular trimming.
Failure to Follow and Clarify Physician Orders
Penalty
Summary
The facility failed to clarify and follow physician orders for one resident admitted after a recent hospitalization for diabetic ketoacidosis, diabetes mellitus, and hypertension, with cognition documented as intact. During record review and interviews, the resident’s orders were found to include a nicotine patch, diclofenac topical gel, and blood sugar checks three times daily, but the orders were not being carried out as written. The admitting instructions were entered incorrectly as PRN for the nicotine patch and diclofenac, even though the admitting doctor had ordered them as scheduled. During the survey, RN 1 reviewed the resident’s blood sugar summary and stated the resident’s blood sugars were only being checked one or two times a day instead of three times daily as ordered. LVN 4 stated the inpatient discharge instructions were the admitting orders used on admission and acknowledged that the diclofenac 1% topical gel and nicotine 14 mg patch had been entered as PRN when they were ordered as scheduled. The DON stated the nicotine patch was not ordered as PRN, that it was important the resident receive it daily, that not receiving the pain cream could cause uncontrolled pain, and that blood sugar checks should have been followed because not doing so could result in uncontrolled diabetes and DKA.
Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for one resident who was incontinent of both urine and stool and required substantial to maximal assistance with toileting hygiene, bathing, and upper body dressing. The resident’s care plan directed staff to answer the call light promptly and keep the resident clean, dry, and changed as needed. The resident also had diagnoses including COPD, osteoarthritis, hypertension, and CHF, and had intact cognition per the MDS. On 7/6/2026, the resident told CNA 1 at about 7:10 a.m. that his incontinence brief was soiled with urine and stool and needed to be changed. CNA 1 stated she did not change him because she had other residents to care for and he was not assigned to her, though she reported the concern to LVN 5 during the morning huddle. LVN 5 stated the resident should have been cleaned and changed right away when he used his call light, and that no CNA had yet been assigned to him at around 7:30 a.m. because staffing had to be revised after a staff member called in sick. The resident stated he had to get into his wheelchair to tell staff to change him and that he felt upset and unwell sitting in a soiled brief for hours. During observation later that morning, CNA 2 was providing incontinent care, and CNA 2 stated the brief was changed around 11:00 a.m. Staff interviews confirmed that the resident was left soiled for an extended period after requesting assistance, and multiple staff stated that timely changing should have occurred when the resident first requested help.
Missing dialysis emergency kit at bedside
Penalty
Summary
The facility failed to ensure that Resident 17, who had ESRD, dependence on renal dialysis, and diabetes mellitus, had an emergency kit at the bedside as ordered for hemodialysis care. Resident 17’s admission record, MDS, order summary, and care plan all reflected the need for an emergency kit by the bedside and monitoring for signs and symptoms of bleeding, hemorrhage, and bacteremia. During observation and interview, Resident 17 stated he had a dialysis catheter in his chest and received dialysis every Tuesday, Thursday, and Saturday, but no dialysis emergency kit was present in his room. On subsequent observation and interview, LVN 5 confirmed there was no emergency kit at Resident 17’s bedside drawer or in the room and stated the kit should always be ready in case of bleeding from the dialysis site. RN 1 stated the emergency kit should always be readily available because Resident 17 was at high risk for uncontrolled bleeding from the dialysis site. The DON stated that if Resident 17 were actively bleeding from the dialysis site, staff would not be able to stop the bleeding right away because the emergency kit was not available for use. The facility policy for hemodialysis residents stated the facility would provide safe and appropriate care in coordination with the dialysis center.
Medication Errors, Stocking Failures, and Improper Disposal Documentation
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for one resident when the resident was given the wrong multivitamin. The resident had diagnoses including anemia, alcohol abuse, and cirrhosis of the liver, and the H&P noted fluctuating capacity to understand and make decisions. The MDS indicated severely impaired cognition and dependence or need for assistance with multiple ADLs. During medication administration, the resident spit out the multivitamin and lamotrigine, and the LVN later stated she had administered a multivitamin without minerals instead of the ordered multivitamin with minerals, identifying it as a medication error. Pharmaceutical services were also not maintained for another resident because ordered medications were not available in stock when needed. That resident had diagnoses including COPD with acute exacerbation, acute respiratory failure with hypoxia, and low back pain, and the MDS indicated intact cognition with varying levels of assistance needed for ADLs. During medication administration, the resident complained of left leg pain and requested diclofenac gel, but the LVN stated the gel was not available in stock and would need to be ordered. The LVN also stated the resident could remain in discomfort and pain because the diclofenac gel was not available. The same resident’s respiratory medications were not consistently available and were not properly documented for disposal. The MAR showed aformoterol and levalbuterol nebulizing solutions documented as administered multiple times, but the PSD and surveyor could not initially locate the medications in the respiratory carts. The PSD stated the medications had run out and were pending pharmacy delivery, and later found five packets of aformoterol in the North Station medication room stored in a clear bag without a pharmacy label or open date. The PSD also stated RT staff discarded unused nebulizing solution by emptying it in the sink and did not have documentation for disposal, and the RT progress note documented albuterol and Atrovent instead of the ordered aformoterol and levalbuterol.
Improper Storage and Labeling of Respiratory Medication
Penalty
Summary
The facility failed to ensure safe and secure storage and proper labeling of aformoterol nebulizing solution for a resident with COPD and acute respiratory failure with hypoxia. The resident’s record showed intact cognition and need for assistance with several ADLs. During observation, an LVN prepared medications for the resident, but the resident’s aformoterol and levalbuterol were not included in the medications prepared for administration. The resident’s MAR showed aformoterol tartrate inhalation nebulization solution was documented as administered 12 times. However, when staff searched for the medication, the LVN stated it was not in the medication cart because nursing did not administer it and that respiratory therapy usually administered it. The PSD initially could not locate the medication in the respiratory carts and stated it must have run out and was pending pharmacy delivery. The RPH stated the medication had been delivered as 30 vials and could be stored in the refrigerator or at room temperature for up to 6 weeks if dated when removed from refrigeration. Later, the PSD found five packets of aformoterol in the North Station Medication Room. The packets were stored at room temperature in a cabinet inside a clear bag without a pharmacy label and without an open date. The clear bag had a typed label with the resident’s name and the medication name. The PSD stated he did not realize this and would educate respiratory therapy staff. The RPH stated the box should have a pharmacy label and that the facility should not repackage or change medication labels, and the DON stated medications should be properly stored and labeled with a pharmacy label.
Failure to Assess and Follow Up on Dental Needs
Penalty
Summary
The facility failed to assess and follow up with necessary dental services for one resident who had no upper teeth and multiple missing lower teeth with no partial dentures. The resident was admitted with diagnoses including COPD, osteoarthritis, hypertension, and CHF, and the MDS dated 4/14/2026 indicated intact cognition and substantial to maximal assistance needed with toileting hygiene, bathing, and upper body dressing. The care plan noted the resident had no teeth in the upper jaw and multiple missing teeth in the lower jaw and included interventions to coordinate dental care and refer the resident to a dentist for evaluation. The Social Services Initial Psychosocial Assessment dated 5/8/2026 was not completed, and the ancillary services section for vision, dental, hearing, and podiatry was left blank. During observation on 7/7/2026, the resident was seen with missing upper and lower teeth. SSA 1 stated there was no dental mobile consult done or pending. The DSS stated he was responsible for the admission assessment and that the psychosocial assessment should have been completed to capture necessary ancillary services, and that without it the resident's dental needs would not be met or identified. The DON and LVN 5 also stated the resident's missing teeth could affect chewing and care, and the Social Services Specialist job description stated the role included ensuring residents receive necessary evaluation for dental needs and follow up as required.
Inaccurate Documentation of Respiratory Medications
Penalty
Summary
The facility failed to ensure accurate respiratory treatment documentation for one resident with COPD with acute exacerbation and acute respiratory failure with hypoxia. The resident’s record showed intact cognition and need for varying levels of assistance with activities of daily living. On 7/7/2026, during a concurrent observation and interview, an LVN prepared seven medications for the resident, but the medications observed did not include levalbuterol and aformoterol nebulizing solutions. Review of the resident’s MAR showed that aformoterol tartrate inhalation nebulization solution was documented as administered 12 times and levalbuterol hydrochloride inhalation nebulization solution was documented as administered 25 times during the review period. However, during the same day’s observation and record review, the resident’s respiratory treatment progress note documented that RT 1 administered HHN treatment with unit-dose albuterol/Atrovent via mask followed by CPT, rather than documenting aformoterol and levalbuterol. The PSD stated that the medications documented in the progress note were incorrect because the administered medications should have been aformoterol and levalbuterol. During interviews, the LVN stated nursing did not have aformoterol and levalbuterol in the medication cart because nursing did not administer those medications for the resident, and that the respiratory therapists were responsible for the breathing treatments. The PSD also stated that aformoterol was supposed to be administered by nursing and levalbuterol by RT, and when the respiratory carts were checked, the resident’s medications could not be found and were said to be pending pharmacy delivery. The facility policy required medications to be administered using the Five Rights and documented in the resident’s medical record, including the medication administered, date and time, dose, and route.
Failure to Perform Hand Hygiene During Meal Tray Delivery
Penalty
Summary
The facility failed to implement and maintain infection control when CNA 7 did not perform hand hygiene between resident care activities and before entering and exiting resident rooms. During a concurrent observation and interview on 7/7/2026 at 12:44 p.m., CNA 7 was observed passing lunch trays while going room to room without performing hand hygiene. CNA 7 stated she did not perform hand hygiene because she was rushing and forgot, and stated she should have performed hand hygiene to prevent the spread of germs which could result in residents getting sick. During interviews, the IPN stated staff should perform hand hygiene each time they grab a meal tray and when entering and exiting a room, and the DON stated staff are expected to perform hand hygiene before handling meal trays, before entering a resident's room, and when exiting a resident's room to prevent the spread of germs and infection. The facility policy titled Handwashing/Hand Hygiene, revised 10/2023, states hand hygiene is the primary means to prevent the spread of healthcare-associated infections and is indicated after touching a resident's environment.
Failure to Collect Ordered Urine Toxicology Specimen
Penalty
Summary
The facility failed to ensure a urine specimen ordered for a urine toxicology test was collected for one resident after a change in condition and transfer to the GACH. The resident had diagnoses including anxiety disorder, opioid dependence, and COPD. After being found with altered level of consciousness, pinpoint pupils, and only responding to painful stimuli, the resident was given Narcan and became alert and verbally responsive. Later that evening, the resident was observed lethargic with visual hallucinations, jerking movements, and loss of bowels, and was transferred by paramedics for further evaluation and treatment. Upon readmission, CBC, CMP, UA, and a urine toxicology test were ordered. The urine toxicology specimen could not be completed because it was collected using the wrong media, and the specimen needed to be recollected with a new order obtained. During interviews, an LVN stated she received report that the urine sample needed to be recollected but did not endorse that information to the oncoming shift. An RNS stated he saw that the urine toxicology screen had not been completed because the specimen was collected in the wrong container, and that the resident refused to give a urine sample during the shift, but he did not pass that information on because he got busy and forgot. The DON stated the refusal should have been endorsed to the next shift so nurses could have attempted to collect the specimen.
Missing Documentation of Resident Refusal for Urine Toxicology Sample
Penalty
Summary
The facility failed to ensure the medical record for one resident contained documentation that she refused to provide a urine sample for a urine toxicology test ordered by her physician. The resident had diagnoses including anxiety disorder, opioid dependence, and COPD. Her MDS indicated she was able to make reasonable and consistent decisions and required one-person assistance with ADLs. After a change in condition on 6/9/2026, she was assessed with altered level of consciousness, pinpoint pupils, and responsiveness only to painful stimuli, and paramedics were called. She received Narcan and became alert and verbally responsive. Later that evening, nursing progress notes documented that she was lethargic, had visual hallucinations, jerking movements, and loss of bowels, and she was transferred by paramedics to GACH for further evaluation and treatment. After readmission, CBC, CMP, UA, and a urine toxicology test were ordered. The urine toxicology specimen was reported as unable to be completed because it was collected using the wrong media, and the specimen needed to be recollected with a new order. An RNS stated that the resident refused to give a urine sample during the day shift, but he did not document the refusal in the clinical record or on the communication board and did not endorse it to the oncoming shift because he got busy and forgot. The DON stated the refusal and need for follow-up should have been documented in the resident's clinical record.
Delayed Return Transportation After Outside Appointment
Penalty
Summary
The facility failed to ensure transportation back to the facility for a resident who had an outside medical appointment and was scheduled for return transportation. Resident 2 was admitted with diagnoses including a left above-knee amputation, difficulty walking, hypertension, and type 2 diabetes with other circulatory complications. Her MDS indicated she was cognitively intact, required partial/moderate assistance with several activities of daily living, and used a wheelchair for mobility. The transportation request showed she was to be taken to the appointment by a transportation company and picked up for return to the facility later that day. Resident 2 stated that after her appointment ended, she and CNA 3 waited in the medical facility lobby for transportation that did not arrive. She reported calling the transportation company and being told she was a no show, then calling the facility multiple times between mid-afternoon and early evening without reaching anyone at the nursing station. She stated that around 6 p.m. a security guard asked her and CNA 3 to leave because the facility was closing, but allowed them to remain in the lobby because the doors would lock if they left. She remained there without food, water, or restroom access until transportation arrived after 7 p.m. The transportation company supervisor stated the van attempted pickup at 3:41 p.m., but Resident 2 was not there and no one answered when they called her phone, so the driver left. The facility’s SSS and SSD stated they were notified after the missed pickup and attempted to arrange another ride, but transportation was not available until 7 p.m. CNA 3 stated she called the facility and was told to wait while the ride was rescheduled, and later her phone battery died. The DON stated the facility should have had a system in place to get the resident back when she was not picked up at the expected time. The facility policy stated it would help with transportation for residents as needed.
Failure to Document Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse was documented in Resident 1’s clinical record. Resident 1 was admitted with diagnoses including osteomyelitis of the cervical vertebrae, lack of coordination, and alcohol use, and the MDS dated 5/14/2026 indicated moderately impaired cognition and need for supervision or touch assistance with several transfers and bed mobility tasks. A Change of Condition evaluation dated 5/17/2026 documented that on 5/16/2026 at 6:40 a.m., Resident 1 called a CNA for help while trying to stand from the edge of the bed, and the CNA allegedly handled the resident roughly by striking the resident’s right knee three times with her right elbow. During interview, Resident 1 stated that around 1 a.m. on 5/17/2026, while trying to get to the restroom, the CNA cursed at her, shoved her with an elbow into her right knee, and pushed her shoulder to make her sit on the bed, causing pain in her back. RN 2 stated the resident told him what the CNA did and demonstrated the elbow-jabbing motion, and he acknowledged he should have documented the allegation of abuse so others reviewing the record would know what happened. The DON stated RN 2 called her around 2 a.m. to report the allegation and that RN 2 should have created a COC per policy. The facility policy required documentation of changes in condition and events or incidents involving the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure one resident was free from physical abuse when that resident swung his hands backward and struck another resident on the nose after the other resident asked him to pick up tissue paper from the floor. The injured resident was found in a common area after the altercation with active bleeding from the right naris, and the incident was documented as a punch to the nose with a nosebleed. The injured resident stated she did not want to be around the other resident anymore and said he needed assistance and supervision. The resident who struck the other resident had diagnoses including paranoid schizophrenia, violent behavior, and type 2 diabetes, and his MDS showed moderate impairment in cognitive skills for daily decision-making and need for partial/moderate assistance with ADLs and transfers. His care plan for physical aggression, initiated for striking out, included 1:1 supervision by staff, psychiatry consult as ordered, medication administration per physician order, and monitoring for side effects. A COC dated 4/29/2026 documented aggression and unprovoked aggression toward others. During interviews, staff described the resident as unpredictable and aggressive, with one LVN stating he had struck two CNAs and said, 'I hate nurses.' The DON stated the resident had previously been on 1:1 supervision for safety and behavioral concerns, but it had been discontinued because he had remained calm and had not exhibited behavioral issues unless provoked. Staff stated they continued hourly monitoring, but no staff witnessed the incident; they only heard a loud noise in the hallway and responded after the altercation occurred.
Failure to Follow EBP PPE Requirements During Resident Care
Penalty
Summary
The facility failed to enforce its infection prevention and control policy for residents on enhanced barrier precautions (EBP) when staff did not follow required PPE procedures during care. Resident 2 was admitted and readmitted to the facility with diagnoses including unspecified anxiety disorder, PTSD, and type 2 diabetes with a foot ulcer. The resident’s MDS indicated intact cognitive skills for daily decision-making and that the resident required partial/moderate assistance with ADLs. During an observation on 05/06/2026 at 10:29 a.m., CNA 1 and CNA 2 were observed providing post-shower care to Resident 2 in the resident’s room without donning the required PPE, even though the resident was on EBP for left foot ulcers. In interviews, CNA 1 stated she was in a rush and did not put on PPE, and CNA 2 stated she knew PPE and hand hygiene were required before entering rooms with isolation precautions but acknowledged she should have put on PPE before assisting. The DON stated signage was posted and EBP in-service training had been conducted, while the IP stated she had recently started and would provide more infection-control training. The facility policy revised 12/2024 stated EBP requires gown and gloves for high-contact care activities including bathing/showering and providing hygiene or grooming.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible and within reach as required by the resident’s care plan and facility policy. The resident, who had diagnoses including unspecified dementia, hypertension, and lack of coordination, was wheelchair bound and required partial to total assistance with activities of daily living such as oral hygiene, toileting, bathing, and lower-body dressing. The resident’s care plan, initiated due to fall risk associated with dementia, hypertension, and lack of coordination, specifically directed staff to make sure the call light was within reach and to encourage the resident to use it for assistance as needed. During observation in the resident’s room, the resident was found lying in bed with the call light hanging against the wall and touching the floor, out of reach. The resident stated she needed her nurse but could not call for assistance because she could not locate the call light. Later, a CNA located the call light and placed it on the resident’s bed, stating it was her first day working in the facility and she had not checked all call lights to ensure they were within reach, although she typically does so when making rounds. An LVN reported that the resident had not used her call light that day and that the roommate usually activated the call light to obtain help for the resident, and acknowledged she had not realized the resident did not have her call light. The DON stated that call lights must be kept within easy reach of residents and that all staff are responsible for ensuring accessibility, consistent with the facility’s policy requiring staff to ensure call lights are accessible from the bed, toilet, shower/bathing area, and floor.
Failure to Follow Two‑Person Transfer Requirements Resulting in Fall and Bilateral Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required a two‑person assist with a full body lift for transfers was provided that level of assistance, resulting in an unassisted transfer attempt and a fall. The resident had multiple diagnoses including diabetes mellitus, morbid obesity, extrapyramidal movement disorder, hypotension, neuropathy, generalized weakness, and a history of falls. Her MDS dated 3/1/2026 showed intact cognition and a need for maximal assistance for sit‑to‑stand transfers, and a fall risk evaluation identified her as at moderate risk for falls. A care plan initiated on 6/2/2023, and confirmed as current by the MDS specialist, specified that due to obesity and poor lower extremity strength, the resident was at risk for falls and required safe handling with a full body lift and a two‑person assist for transfers. On the day of the incident, after the resident was showered, CNA 1 returned her to her room in a shower chair. CNA 1 reported that the resident stood up using a walker next to her bed, holding onto the bed rail, and that the resident would normally pivot to get onto the bed. Instead, the resident suddenly screamed for help and stated her legs felt weak. CNA 1 stated she got behind the resident, called for help, and eased her to the floor, where the resident landed on her bottom with her knees and feet bent. CNA 1 acknowledged that she had been working with this resident for four years and usually assisted her alone during transfers because the resident was often able to walk and help with transfers. CNA 1 also stated she was not aware that the resident’s care plan required a two‑person assist with transfers. Following the fall, an SBAR documented that after the transfer from chair to bed, both of the resident’s legs became weak and she was eased to the floor. Later that day, the resident complained of bilateral leg pain and had swelling and bluish discoloration of the right ankle. She was transferred to a general acute care hospital, where ED documentation indicated she reported falling when getting out of her shower chair that morning and was found to have significant swelling and ecchymosis of the right ankle and likely swelling of the left ankle. Radiology and orthopedic notes confirmed displaced distal fibular fractures and bilateral bimalleolar fractures of both ankles. The DON stated CNA 1 should have requested assistance for the transfer and that licensed nurses should have communicated the resident’s need for a two‑person assist during transfers. The facility’s falls and fall risk policy required staff to identify and implement resident‑centered interventions based on risk factors such as lower extremity weakness and functional impairments, which were present in this resident.
Failure to Report Alleged Theft of Resident Wallet and Unauthorized $800 Charge to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of suspected theft of a resident’s wallet and an associated unauthorized $800 credit card charge to the California Department of Public Health (CDPH) as required. The resident, who had diagnoses including metabolic encephalopathy, pneumonia, acute chronic respiratory failure with hypoxia, and diabetes mellitus, was initially admitted and later readmitted after a transfer to a general acute care hospital (GACH). The resident’s Minimum Data Set indicated intact cognition. The resident’s Inventory of Personal Effects documented a billfold/wallet, two credit cards, and four check booklets. On the date of readmission, the facility’s Theft and Loss Log recorded that the resident reported his wallet missing, and several days later the log showed the wallet was replaced. A Theft/Loss Report documented the missing brown leather wallet but left blank the sections for estimated value and whether the item was listed on the inventory form. During interviews, the resident stated that when he was transferred to the GACH he was too sick to remember to take his wallet, which he usually kept in the drawer next to his bed. While still hospitalized, he asked a family member to look for the wallet, and it could not be found in its usual place, leading him to believe it had been stolen. The resident reported that someone charged $800 to his credit card, that the bank detected the unauthorized charge, and that the bank reimbursed the money. He stated he informed a social services staff member about both the theft of his wallet and the unauthorized $800 withdrawal, and that his wallet was replaced but not the contents, which he said included his credit card, Medicare card, Medi-Cal card, social security card, family pictures, and the card used for the $800 charge. The Social Services Director stated that, after the resident returned from the GACH, the resident reported that $800 had been taken from his bank account but reimbursed by the bank, and acknowledged that the theft of the wallet and missing money should have been reported to the police because the amount exceeded $100. The Social Services Director also stated that the allegation of $800 missing after the report of the missing wallet suggested someone could have taken and used the resident’s credit card. Another social services staff member confirmed that the resident reported $800 missing from his bank account and that, because the bank was going to return the money, he did not think to report the missing money to CDPH, though he acknowledged the allegation could imply someone from the facility took the wallet. The Administrator stated he was not aware of the resident’s report of the missing $800 and that, if such a report had been made following the report of the lost wallet, it should have been reported to CDPH per regulations. Facility policies required notification of state licensing and certification and other agencies within specified time frames when alleged or suspected misappropriation of resident property is reported, and required staff to report suspected exploitation, theft, or misappropriation of resident property, which did not occur in this case with respect to CDPH notification.
Failure to Investigate Alleged Theft and Unauthorized Bank Charge
Penalty
Summary
The deficiency involves the facility’s failure to investigate a resident’s allegation that his wallet was missing and that an unauthorized $800.00 charge was made to his bank account after his wallet was reported lost. The resident, who had intact cognition per a recent MDS and diagnoses including metabolic encephalopathy, pneumonia, acute chronic respiratory failure with hypoxia, and diabetes mellitus, was initially admitted and then transferred to a general acute care hospital (GACH) for drowsiness and refusal to eat. His Inventory of Personal Effects documented a billfold/wallet, two credit cards, and four check booklets. While he was at the GACH, he realized his wallet was missing when a family member could not locate it in its usual drawer next to his bed. Upon readmission, the facility’s Theft and Loss Log recorded that he reported his wallet missing and that it was later replaced, but the Theft/Loss Report left blank the sections for estimated value and whether the item was on the inventory form. The resident reported to a social services staff member that $800.00 was missing from his bank account and that the bank would reimburse the money. He also stated that his wallet had contained his credit card, Medicare card, Medi-Cal card, social security card, family pictures, and cash, and that someone had charged $800.00 to his credit card before the bank reversed the charge. The resident reported that he informed a social services specialist of both the theft of his wallet and the unauthorized withdrawal, and that although the wallet itself was replaced, the contents were not. A family member later contacted another social services staff member to report that the wallet and its contents, including identification and financial cards, were still missing and expressed concern that no investigation had been conducted into the theft while the resident was at the GACH. Despite these reports, the facility did not initiate an investigation into the allegation of the unauthorized $800.00 charge until nearly two months after the wallet was reported missing, as reflected in the Five Day Report. The social services specialist acknowledged that the allegation of missing funds could imply that someone from the facility took the wallet but stated he did not report or investigate the matter because the bank was handling the reimbursement. The administrator reported he was unaware of the resident’s report of the missing $800.00 and stated that such an allegation should have been investigated. The facility’s policy on investigating incidents of theft and/or misappropriation of resident property requires that all reports of theft or misappropriation be promptly and thoroughly investigated and that the administrator appoint a staff member to investigate, which did not occur in this case.
Failure to Maintain Functional Suction Equipment on Crash Cart
Penalty
Summary
The facility failed to ensure that an oxygen nut and stem adaptor, commonly referred to as a 'Christmas tree' connector, was readily available and connected to the portable suction machine on the south station crash cart. This deficiency was identified when staff were unable to provide suctioning to a resident during an emergency situation because the necessary plastic connector piece was missing from the suction machine. Multiple staff interviews confirmed that, during the incident, the suction machine could not be used as intended due to the absence of this critical component, and staff were unaware of where to locate a replacement. The incident involved a resident with a history of heart failure and type 2 diabetes mellitus, who was found unresponsive, without a pulse, and not breathing while sitting on the toilet. Staff initiated CPR and attempted to clear the resident's airway, noting the presence of food and secretions in the mouth. Despite efforts to remove the obstruction manually, the inability to use the suction machine due to the missing connector impeded the staff's ability to clear the airway effectively during the emergency. Interviews with various staff members, including CNAs, respiratory therapists, and nursing leadership, revealed that it was the responsibility of the night shift to check and ensure the crash cart was fully stocked and that all equipment, including the suction machine, was operational. The facility's policy required that all critical supplies for basic life support be available and replaced promptly after use. However, the missing connector on the suction machine was not identified or replaced prior to the emergency, resulting in the equipment being nonfunctional when urgently needed.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who stated that his roommate pulled his right arm and touched his right leg multiple times. The resident, who expressed fear and discomfort during the incident, reported the event to his assigned CNA, who then informed the RN. The RN subsequently reported the incident to the abuse coordinator, and a meeting was held where the complaint was treated as a grievance rather than an abuse allegation. The administrator decided not to investigate the complaint as possible abuse and did not report it to the California Department of Public Health (CDPH), as he did not believe it constituted abuse. The resident accused of the touching had a history of Pick's disease and schizophrenia, with documented moderate cognitive impairment. Facility records, including the face sheet and MDS, confirmed these diagnoses. The facility's policy required timely reporting of suspected or identified abuse to appropriate agencies, but this protocol was not followed in this case. As a result, the incident was not reported to CDPH, preventing timely investigation and potentially leading to loss of information or recollection of the event.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess Resident Following Chest Pain Complaint
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic kidney disease (CKD) and diabetes mellitus (DM), reported experiencing chest pain on the left side that had persisted for several weeks. The resident's cognition was noted to be intact. Following the complaint, the physician ordered a 12-lead EKG to assess the resident's chest discomfort. However, there was no documentation or evidence that the resident was assessed for chest pain or discomfort by the registered nurse (RN) who received and carried out the EKG order. The RN acknowledged that an assessment should have been performed, especially since the EKG was ordered due to chest discomfort, which could be related to serious conditions such as a heart attack. Further review revealed that facility policy required nurses to make detailed observations and gather pertinent information prior to notifying the physician or healthcare provider about a change in a resident's condition. The RN supervisor's job description also included the responsibility to identify changes in residents' physical or psychological conditions. Despite these requirements, there was no documentation of an assessment or monitoring of the resident's status following the complaint of chest pain, resulting in a lack of knowledge regarding the resident's medical status at the time.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent and Address Severe Unplanned Weight Loss
Penalty
Summary
A resident experienced severe unplanned weight loss totaling 29 pounds (18.59% of body weight) over a six-month period. The facility failed to implement multiple recommendations made by the Registered Dietician (RD), including weekly weight monitoring, administration of protein supplements, provision of double portions at breakfast, initiation of an appetite stimulant, and completion of blood tests for a complete metabolic panel and prealbumin. The resident's care plan, which required monitoring and reporting of weight loss and poor oral intake to the physician, was not followed. Additionally, the facility did not conduct weekly interdisciplinary team (IDT) weight variance meetings or develop a comprehensive care plan with interventions to prevent further weight loss. The resident had a complex medical history, including diabetes mellitus, kidney transplant, legal blindness, and gastro-esophageal reflux. Despite documented weight losses of 10 lbs., 8 lbs., 9 lbs., and 2 lbs. across several months, the facility did not complete required Change of Condition (COC) assessments or notify the physician and family as outlined in facility policy. The RD and nursing staff did not communicate or act on significant weight changes in a timely manner, and the resident's declining food intake and refusal of meals were not adequately addressed. The resident's family reported concerns about the facility's food and the lack of communication regarding the resident's weight loss. Interviews with facility staff, including the Assistant Director of Nurses (ADON), RD, and Director of Nurses (DON), confirmed that there were missed opportunities to identify and intervene in the resident's weight loss. The RD was unaware of the resident's weight loss until several months after it began, and recommended interventions were not implemented. Facility policies required prompt notification and multidisciplinary care planning for significant weight changes, but these procedures were not followed, resulting in the resident's continued and preventable weight loss.
Inaccurate and Unclear Documentation of Restorative Nursing Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aide (RNA) services were accurately documented for three residents. For each of these residents, the RNA daily documentation did not clearly reflect whether services were provided, missed, or not applicable, due to the use of unclear notations such as 'n, n, n' or 'n, n' in the electronic medical record. Staff interviews revealed that these notations were used inconsistently to indicate either that prompts did not pertain to the RNA task or that the resident was not seen for RNA treatment, but there was no standardized understanding or guidance on their use. This led to confusion among staff, including the Assistant Director of Nursing (ADON), Medical Records Director (MRD), and Director of Nursing (DON), all of whom were unable to determine from the documentation whether RNA services had actually been provided on specific dates. For one resident with a history of left femur fracture and gout, the RNA flowsheets indicated scheduled walking exercises and range of motion (ROM) activities, but the documentation was unclear as to whether these services were performed. The resident was observed to have significant physical limitations and required substantial assistance with daily activities. Staff interviews confirmed that the documentation process was confusing, and it was not possible to determine from the records if the resident received or missed RNA sessions on several dates. Another resident with right-sided hemiplegia, legal blindness, and sepsis had RNA documentation for walking exercises that also used the unclear 'n, n, n' notation. The resident reported inconsistent assistance with exercises, and staff again could not confirm from the documentation whether services were provided on certain dates. A third resident, who required a splint applied to the right elbow, had RNA documentation prompts that did not match the actual RNA task, leading to further confusion. The facility's policy required that all services provided be documented objectively, completely, and accurately, but the observed documentation practices did not meet these standards.
Infection Control Lapses in Equipment Cleaning, Hand Hygiene, and Environmental Cleanliness
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were identified during the survey. Staff failed to ensure that shared resident-care equipment, specifically cloth gait belts used in therapy, were disinfected according to manufacturer instructions. The cloth gait belts, made of porous material, were wiped with Super Sani-Cloth disinfectant wipes, which are only effective on non-porous, hard surfaces. Both the Infection Preventionist Nurse and the Director of Nursing confirmed that the wipes were not appropriate for disinfecting cloth gait belts, and that laundering after each use was necessary to prevent cross contamination. Hand hygiene practices were not consistently followed by staff when entering and exiting resident rooms or after providing care. Observations showed that CNAs did not perform hand hygiene before assisting residents with meals or after touching high-contact surfaces in resident rooms, including those on Enhanced Barrier Precautions due to the presence of medical devices and risk of MDRO infection. Staff interviews confirmed awareness of the hand hygiene policy, but lapses in practice were observed, including failure to use hand sanitizer or wash hands as required by facility policy and CDC recommendations. Environmental cleanliness was also found lacking, as evidenced by stained and soiled curtains in a resident's room. The resident expressed discomfort with the unclean curtains, and both nursing and housekeeping staff acknowledged that curtains should be clean and free of stains for both infection control and resident dignity. Facility policy requires a clean, sanitary, and homelike environment, but observations and staff interviews confirmed that this standard was not met in this instance.
Failure to Maintain and Inspect Electrical Therapy Equipment
Penalty
Summary
The facility failed to maintain and perform preventative maintenance on three types of electrical therapy equipment used in the therapy gym: a motorized electrical bicycle for arms and legs, a recumbent cross trainer, and a recumbent stepper. Observations and interviews with the Director of Rehabilitation (DOR) revealed that no inspections or maintenance had been conducted on any of these devices, despite instructions in the user manuals requiring regular checks and maintenance. The Maintenance Director confirmed that the maintenance department did not perform any routine inspections or preventative maintenance on the therapy equipment, and acknowledged the importance of such actions to ensure proper functioning and safety. Review of the user manuals for each device indicated specific maintenance schedules and safety checks that were not being followed, such as tightening screws, cleaning components, checking batteries, and inspecting drive belts. The facility's own policy and procedure required maintenance services to be provided for all equipment and for maintenance personnel to follow manufacturer-recommended schedules. Interviews with the DOR and Director of Nursing (DON) further confirmed the lack of maintenance and the importance of keeping rehabilitation equipment safe and operable for resident use.
Failure to Document, Assess, and Notify Physician for Changes in Resident Condition
Penalty
Summary
Three residents experienced deficiencies in care and services due to failures in documentation, assessment, and timely physician notification. One resident, with a history of diabetes mellitus and hypertension, had a physician order for laboratory tests to be drawn every three months. Despite three consecutive unsuccessful blood draws, there was no documentation of a change in condition (COC) or physician notification, as confirmed by both the LVN and the Director of Nursing. The lack of documentation meant that staff were not formally alerted to the change in the resident's status or the need for monitoring. Another resident, with diagnoses including diabetes mellitus, hemiplegia, anxiety disorder, and hyperlipidemia, reported an incident involving a certified nursing assistant (CNA) during personal care. The resident alleged inappropriate handling and possible abuse. Despite this allegation, a full body skin assessment was not performed immediately after the incident. The Director of Staff Development and the Director of Nursing both acknowledged that the absence of a timely skin assessment delayed the identification and treatment of any potential injuries or changes in the resident's condition. A third resident, diagnosed with vascular dementia, anxiety disorder, depression, and diabetes mellitus, had persistently elevated blood sugar readings over several days, despite being on a sliding scale insulin regimen and the addition of long-acting insulin. Nursing staff did not notify the physician about the continued hyperglycemia, nor did they seek new orders or adjustments to the treatment plan. Both the LVNs and the Director of Nursing confirmed that the lack of physician notification and intervention meant the resident's blood sugar remained uncontrolled for an extended period.
Staff Failed to Feed Residents at Eye Level, Compromising Dignity
Penalty
Summary
Staff did not assist residents at eye level during feeding for two residents, contrary to facility policy and best practices for maintaining dignity. For one resident with dementia, anxiety, cirrhosis, and anemia, who required set up and moderate assistance with eating and other activities of daily living, staff were observed standing in front of the resident while feeding, rather than sitting at eye level. Similarly, another resident with metabolic encephalopathy, anemia, acute respiratory failure, and benign prostatic hyperplasia, who was severely cognitively impaired and required set up and maximal assistance with eating, was also assisted by staff standing over him during feeding. In both cases, staff did not follow the facility's policy, which specifies that residents should be fed with attention to safety, comfort, and dignity, including not standing over them. Interviews with a CNA and the DON confirmed that feeding residents at eye level is important for their comfort and dignity, and that standing over residents can make them feel inferior or babied. The facility's policies on dignity and meal assistance both emphasize the importance of treating residents with respect and providing assistance in a manner that promotes their well-being and self-esteem. The observed actions were inconsistent with these policies and had the potential to impact the residents' sense of dignity and respect.
Failure to Obtain Valid Informed Consent for Psychoactive Medications
Penalty
Summary
Licensed nursing staff failed to ensure that a resident and/or their responsible party were properly informed in advance about the risks and benefits of psychoactive medications. The resident in question was admitted with diagnoses including dementia, mood disorder, and anxiety, and was assessed as having severely impaired cognition, requiring moderate assistance with daily activities. Despite documentation indicating the resident could not make medical decisions, the resident was asked to sign consents for psychoactive medications, including Ativan, Buspirone, and Lamictal, which were prescribed for anxiety and mood disorder. Interviews with nursing staff, including an LVN, RN Supervisor, and the DON, confirmed that the resident was confused, unable to make medical decisions, and should not have been signing consents. The facility's policy required that the risks and benefits of psychotropic medications be reviewed with the resident or their representative prior to obtaining documented consent. However, the consents were signed by the resident, who did not have the capacity to understand or authorize such decisions, resulting in a violation of the resident's right to make an informed decision regarding psychoactive medication use.
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Illustrative
What surveyors actually found near you
We read the 7,342 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Care Nursing Center | 0.1 mi | ★★★★★ | 5 | 0 |
| Pacific Villa, Inc | 0.1 mi | ★★★★★ | 35 | 0 |
| Bixby Towers Post-acute Rehab | 0.7 mi | ★★★★★ | 7 | 2 |
| Catered Manor Care Center | 1 mi | ★★★★★ | 15 | 0 |
| Atlantic Memorial Healthcare Center | 1 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.