Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Madera Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain its boiler system in safe operating condition, resulting in a prolonged loss of hot water throughout multiple stations. After a staff report that hot water was not working on two stations, the Maintenance Supervisor identified a frozen boiler igniter motor and contacted a vendor, but the part was not immediately available. The Maintenance Supervisor informed the Administrator only about two affected stations, despite later acknowledging that additional stations also lacked hot water, and he assessed water temperatures by touch rather than using a thermometer as expected by facility policy. Over several days, CNAs and an RN reported no hot water in resident rooms, shower rooms, or nurses’ station sinks, and residents reported missed showers and being cleaned with cool water. Facility policies required routine maintenance of heating and plumbing systems and documented water temperature checks, which were not followed, leading to residents being without hot water for hygiene and staff without hot water for handwashing.
The facility failed to maintain complete and accurate EMRs when the IP performed influenza A testing on multiple residents with conditions such as dementia, cancer, Parkinsonism, stroke-related hemiplegia, respiratory failure, and chronic diseases, but did not document several of these tests or their results. Some residents had documented changes in condition, including cough, low O2 saturation, and positive influenza A findings, while others with similar respiratory symptoms were tested according to the IP but had no corresponding EMR entries. The DON and ADON confirmed that undocumented tests are considered not done and that it was the IP’s responsibility to chart all influenza tests in accordance with the facility’s documentation policy.
Surveyors found that 12 of 65 alcohol-based hand rub (ABHR) dispensers in hallways and at nurses’ stations were not dispensing product, including units near multiple resident rooms, a shower room, and the maintenance office. The IP stated housekeeping was responsible for refilling or replacing dispensers and confirmed staff were expected to perform hand hygiene when entering and exiting rooms, before and after glove use, and in other routine care situations. An LVN reported keeping ABHR gel on a med cart because some dispensers did not work, and CNAs described encountering non-functioning dispensers and needing to walk down the hall to find working ones. The DON and ADON emphasized the importance of functioning dispensers and frequent hand hygiene, while the facility’s hand hygiene policy required that hand hygiene products be readily accessible and that ABHR dispensers be placed in visible areas with hand hygiene performed before and after resident contact and after contact with the resident environment.
A slide barrel lock was installed out of reach on an exit door in the memory care unit without a hazard assessment, leaving residents and staff potentially unable to exit in an emergency. Additionally, a resident was struck by a vehicle while crossing a busy parking lot in a wheelchair to access the smoking area, resulting in multiple fractures and increased dependence on staff. Staff and policy reviews confirmed the lack of safe pathways and insufficient supervision for residents traveling to the smoking area.
Failure to Address Significant Weight Loss in Two Residents: The facility did not timely identify or intervene for two residents with unplanned weight loss. One resident had a mechanical soft diet she disliked and lost nearly 8% of body weight without updated care plan interventions, RD notes, or IDT follow-up. Another resident, admitted with protein-calorie malnutrition and variable PO intake, lost over 9% before nutritional interventions were added, with staff interviews showing the RD did not trend weights appropriately and initial interventions were delayed.
A resident’s tramadol order lacked a clear pain indication and pain scale, another resident received oxygen at 4 LPM instead of the ordered 2 LPM, an LPN turned off a wander guard alarm without checking outside for possible elopement, and a resident’s scheduled meds were given late outside the allowed administration window. Staff and the DON confirmed the orders, observations, and medication timing did not match facility expectations or provider orders.
Food temperatures were not checked for several items on the steam table during tray line, including french fries, gravy sauce, a ground burger patty, food in cups, and diced pears. DCs, the CDM/D, CDMA, and RD all stated that hot foods, including desserts, must be temperature-checked and documented before serving, and the facility policy identified the danger zone as 41°F to 135°F.
A facility failed to ensure residents ordered fortified diets received the fortified soup listed on the menu. During tray line observation, dietary staff prepared meals but did not add the fortified soup to trays for residents on the fortified diet. Staff, the CDM/D, CDMA, and RD all stated fortified diets are ordered to provide extra calories and protein for residents at risk for wt loss, and the facility policies required correct meal service and physician-ordered therapeutic diets.
Food service safety practices were not followed when the kitchen ice machine and food prep sink lacked an air gap, opened parmesan cheese and bread were left undated, a dietary staff member did not fully cover her hair with a hair net, and puree food scoops were placed on top of the steam table during tray line. Staff interviews confirmed these practices were not acceptable and involved contamination concerns.
The facility failed to complete a facility-wide assessment that included the physical environment for the memory care unit and resident smoking area. The assessment did not address safety in the smoking area or the locked door in the memory care unit for 26 residents in memory care and 15 smokers. The ADM stated changes after a resident was hit by a vehicle were not documented, and the assessment was not updated to reflect the smoking area or the locked door.
A facility failed to protect resident rights related to communication, privacy, and dignity. Spanish-speaking residents and residents who could not understand English did not have alternate communication methods available, several residents reported staff spoke in a foreign language during care, male and female residents shared a bathroom between rooms, and one resident was left watching others at her table eat while she waited for her meal. The DON, DSD, SSD, and Administrator acknowledged the bathroom-sharing arrangement and the communication and dining issues.
The facility failed to implement care plan interventions for four residents. A resident at high fall risk did not have the ordered floor mats and reacher at bedside, another resident with expressive aphasia and Persian as the primary language did not have effective communication supports in place, a resident on a mechanical soft diet was served a regular plate and hard toast instead of the ordered scoop plate and diet consistency, and another resident’s bed was not kept in the lowest position as directed by the care plan.
A facility failed to ensure prescribed meds were available and given as scheduled for three residents. An LVN reported that polyethylene glycol, oxybutynin, vitamin E, and isosorbide mononitrate ER were not in the med cart, and the MARs showed the doses were not administered. The residents had histories of constipation, overactive bladder, heart failure, and HTN, with BIMS scores ranging from no cognitive impairment to severe cognitive impairment. Staff and the DON stated nurses were responsible for checking medication supply and reordering low medications, and the facility policy required residents to have a sufficient supply of prescribed meds.
A facility failed to provide ordered adaptive dining items and meal presentation for three residents during lunch. One resident with dysphagia and a jaw fracture did not receive a right-handed built-up spoon ordered for self-feeding, another resident with stroke-related weakness and dysphagia did not receive a scoop plate, and a third resident with osteoarthritis, glaucoma, and hearing loss was served food on a plate instead of in bowls as ordered. Staff interviews confirmed the meal tickets and OSR directed these items and that the trays did not match the ordered assistive needs.
Incomplete informed consent for psychotropic medications: Two residents with intact cognition received psychotropic medications without fully completed consent documentation. One resident had sertraline ordered for depression, but the ICPM lacked an electronic provider signature even though the medication was administered. Another resident had aripiprazole ordered for schizophrenia, but the ICPM did not include the licensed nurse’s name who prepared and verified the consent. Staff interviews confirmed the forms were incomplete and that informed consent was required before administration.
Inaccurate MDS Medication Coding: A resident with hemiplegia, hemiparesis, depression, diabetes, and atrial fibrillation had an MDS assessment that did not code prescribed antidepressant and anticoagulant medications. The MDS nurses confirmed the resident was receiving sertraline and apixaban but said both were omitted from Section N, and the DON stated she expected MDS assessments to be accurate.
Failure to provide nail care for a resident with hemiplegia, aphasia, dysarthria, and a contracted right hand. The resident’s fingernails were observed to be long, jagged, and dirty on both hands, with dirt built up underneath the nails and no washcloth or palm protector on the contracted hand. Staff, including a CNA, LVN, ADON, and DON, acknowledged the nails should have been cleaned and trimmed and that CNAs were responsible for nail care.
Failure to Follow Up on Pharmacist Drug Regimen Review: A resident with HF, AFib, HTN, repeated falls, and schizophrenia became dizzy and fell, prompting a pharmacist MRR. The PC recommended changing hold parameters for metoprolol and amlodipine, and the provider signed the review, but the MAR/orders were not updated and no rationale was documented for not implementing the recommendation. Staff, the DON, and medical records all stated the recommendation should have been followed up or explained in the chart.
A resident with cerebral infarction, epilepsy, stiff-man syndrome, and major depressive disorder received scheduled tramadol for pain management even though pain was repeatedly documented as 0 out of 10. The resident stated she did not need daily pain medication and that tramadol made her sleepy, while the LVN, PC, and DON stated the opioid was not appropriate without reported pain and that the resident had been overmedicated.
Medication labeling and storage deficiencies were identified in several medication and treatment carts. Staff found a nicotine patch box without a resident identifier, multiple opened meds and OTC products without open dates, an opened phenylephrine hemorrhoidal ointment and carbamide peroxide ear drops without resident identifiers, and an unopened bottle of lispro insulin stored in a medication cart despite directions to refrigerate until opened. The DON, PC, and nursing staff stated resident-specific meds should be labeled with the resident name and opened items should be dated.
Two residents on mechanical soft diets were served hard toasted bread at lunch, despite orders and care plans requiring softer texture food. One resident had dysphagia and a history of stroke-related weakness, and the other had dementia with severe cognitive impairment and chewing problems. CNA, RNA, SLP, CDM, and DON all stated the bread was not appropriate for the ordered diet texture, and facility policy required tray inspection to ensure the correct meal was provided.
A resident with hemiplegia, aphasia, dysphagia, dysarthria, and contractures had perishable foods from family stored in a bedside table instead of being labeled, dated, and refrigerated. Staff found fresh strawberries with black spots, an opened bottle of orange juice without an open date, and other fruits in the drawer; a CNA, LVN, and DON all stated perishable foods should be refrigerated and labeled.
Failure to replace a resident’s handheld nebulizer tubing weekly. A resident receiving ipratropium-albuterol via nebulizer had tubing observed with an outdated date, and RN, LVN, IP, and DON all stated the tubing should be changed weekly because bacteria can grow in it and be inhaled. The resident had multiple chronic conditions, including hemiplegia, hemiparesis, depression, diabetes, atrial fibrillation, and muscle weakness.
Insufficient Room Square Footage: The facility failed to provide the minimum required square footage in 33 of 74 rooms, including multiple-occupancy and single rooms that did not meet the 80 sq ft per resident and 100 sq ft standards. The survey noted that residents had reasonable privacy, adequate storage, bedside stands, and enough room for nursing care and ambulation, with wheelchairs and toilet facilities accessible.
Two residents' wheelchairs were found covered with black and brown substances, visible to passersby, due to a lapse in scheduled cleaning by housekeeping staff. Facility leadership and staff confirmed that wheelchairs were not cleaned as required, citing staffing issues, and acknowledged that this failure compromised the cleanliness and comfort of the environment, as well as potentially exposing residents to sources of infection.
Two residents' wheelchairs were found covered with black and brown unknown substances due to missed scheduled cleaning by housekeeping staff. Despite facility policies requiring regular cleaning and staff expectations for reporting and follow-up, the wheelchairs remained soiled, and the environment was not maintained as clean or homelike, as confirmed by the ADON, DON, and Administrator.
Two residents at high risk for falls, one with right-sided paralysis and another with dementia and impaired mobility, were not provided with adequate supervision or individualized interventions despite staff awareness of their specific risks and behaviors. Both experienced unwitnessed falls resulting in injuries, including fractures and lacerations, after care plans failed to address their needs for supervision and positioning. Staff interviews and record reviews confirmed that known hazards were not incorporated into care planning or daily practices, leading to avoidable accidents.
The facility did not ensure that the IP provided ongoing in-service training and education to all staff during Norovirus and Influenza outbreaks. Many staff members, including dietary, nursing, and CNAs, did not recall receiving refresher or make-up infection control training after the outbreaks began, and there was no evidence of reminders or posted schedules. The IP did not communicate low attendance or coordinate with leadership to ensure all staff were trained, resulting in inadequate preparation to manage and prevent the spread of infection.
The facility did not report allegations of abuse involving two residents to CDPH and the Ombudsman within the required two-hour timeframe. In one case, a CNA delayed reporting an observed incident of alleged physical abuse, and in another, staff failed to report abuse allegations made by a family member to the police. Both residents had severe cognitive impairment and required significant care. Staff interviews and policy reviews confirmed knowledge of mandated reporting requirements, but these were not followed, resulting in delayed investigations and notifications.
Multiple high-risk residents with cognitive and physical impairments experienced unwitnessed falls resulting in serious injuries due to the facility's failure to provide adequate supervision and implement individualized fall prevention interventions. Staff did not follow care plan instructions or address known behaviors, leading to repeated incidents and harm.
The administrator did not provide adequate oversight or resources to address a high number of resident falls, resulting in several unwitnessed falls with injuries requiring hospitalization. Despite being aware of the issue, the administrator did not participate in fall prevention efforts, leaving clinical staff to address the problem without effective leadership or follow-up on interventions.
Two residents with significant fall risks and complex medical histories experienced multiple falls and injuries due to the facility's failure to develop and implement individualized, person-centered care plans. Despite assessments indicating the need for substantial assistance and supervision, care plans included only generic interventions and did not address specific behaviors or needs, resulting in falls, injuries, and hospitalizations.
Nursing staff did not have their fall prevention competencies checked within the past year, despite a high number of falls. A resident with mobility issues suffered an unwitnessed bathroom fall, resulting in a hip fracture and hospitalization. Not all staff attended a recent fall prevention in-service, and there was no evidence of competency testing or a policy for staff competency assessment.
Two residents received hospice services without a valid, signed agreement between the facility and the hospice agencies, as required by facility policy. The Administrator acknowledged that hospice agreements must be signed by both parties before starting care, but this was not done for either resident, both of whom had significant medical conditions and were under hospice care.
The facility did not implement an effective QAPI program to address a high number of resident falls, resulting in multiple falls with significant injuries requiring hospital care. Despite awareness of the issue, leadership failed to systematically track, analyze, or document interventions, and there was no integrated approach to performance improvement or staff competency assessment.
A resident with severe cognitive impairment and physical disabilities was moved to a new room and experienced a fall without the required notification to his responsible party (RP). Facility staff and documentation confirmed that the RP was not informed of these significant events, and the new room's bathroom setup was not suitable for the resident's needs, making safe transfers difficult. The facility's policies requiring advance notice and documentation of such changes were not followed.
A resident with severe cognitive impairment and multiple medical conditions was found with a hospital bed footboard that was loose and detached, creating an environmental hazard. CNAs were aware of the issue but did not report it through proper channels, and the maintenance log did not reflect the problem. Facility leadership confirmed the hazard and noted that required maintenance and reporting procedures were not followed.
A resident with severe cognitive impairment and a history of repeated falls experienced two unwitnessed falls from bed, resulting in head injuries that required emergency room treatment. The facility documented the incidents and notified the physician but failed to report the falls to CDPH as required by policy. Staff interviews confirmed the events were not reported, and the administrator was unaware of the multiple falls during the period.
A resident with a history of pressure ulcers was provided a low air loss (LAL) mattress that was incorrectly set at 320 lbs instead of the resident's actual weight of 72 lbs, contrary to physician orders and manufacturer guidelines. The MDSC and DON confirmed the improper setting, which was not in line with facility policy or the user manual, and linked it to the resident's discomfort and a recent fall.
A resident with multiple chronic conditions was found to have an oxygen concentrator filter covered in dust and lint. The ADON and DON confirmed this was unacceptable and not in line with facility policy, which requires licensed nurses to maintain equipment cleanliness. Facility policies and the manufacturer's manual both specify regular inspection and cleaning of such equipment, but this was not followed in this instance.
Two residents with severe cognitive and physical impairments experienced multiple falls, including one unwitnessed fall resulting in injury, due to lack of adequate supervision and failure to update care plans or conduct fall risk assessments. Another resident with known exit-seeking behavior eloped from the facility when a malfunctioning wander guard device was not properly tested, and staff did not provide direct supervision, resulting in the resident being found outside by police.
A CNA assisted a resident on contact precautions for norovirus without wearing the required gown and gloves, despite facility policy and posted instructions. Additionally, 11 rooms under isolation precautions lacked biohazard receptacles, leading staff to remove and dispose of contaminated PPE outside resident rooms or in hallways. These actions were observed and confirmed by interviews with staff and leadership, and were not in compliance with facility procedures or CDC guidelines.
Two residents with severe cognitive and functional impairments experienced repeated falls and injuries due to the facility's failure to develop and implement individualized, person-centered care plans. Despite staff awareness of each resident's decline and specific fall risks, care plans were not updated with effective interventions or appropriate supervision levels, resulting in preventable falls and injuries.
Nursing staff did not conduct required fall risk assessments for several residents with severe cognitive impairment and a history of falls, relying only on post-fall summaries that did not evaluate risk factors or provide scores. Additionally, staff failed to follow manufacturer guidelines for testing wander guard devices, using improper methods instead of the recommended handheld tester. These failures led to multiple falls, injuries, and an elopement event, placing residents at increased risk.
A resident with dementia, muscle weakness, and an unsteady gait was inaccurately assessed as independent in ambulation on the MDS, despite staff and care plan documentation indicating a need for supervision. The resident was left unsupervised on a patio, resulting in a fall and injury. Staff interviews and record reviews confirmed the MDS did not reflect the resident's true functional status.
A resident with COPD, CHF, Major Depressive Disorder, and Anxiety Disorder was left in her room during a loud verbal altercation between visitors, causing her emotional distress. The staff failed to assess her emotional status or offer relocation for safety, violating her rights to be free from abuse.
The facility failed to implement its water management plan, crucial for preventing Legionella growth. Testing revealed Legionella in the kitchen sink, and the Maintenance Supervisor did not assess or monitor for it. Additionally, a leaking pipe in the laundry room caused wet, stained, and warped floor tiles, with staff mopping frequently to prevent standing water.
The facility failed to inform and provide six residents with written information to formulate an advance directive upon admission. A review of EMRs showed no evidence of such information being offered, indicating a systemic issue. Interviews with the SSD and DON revealed discrepancies in the process for handling advance directives, contrary to the facility's policy.
The facility failed to provide written notifications of transfers to residents, their representatives, and the Ombudsman for several residents. Despite the policy requiring written notices, the facility did not adhere to this, as evidenced by the lack of written notices for multiple transfers. Interviews with staff revealed a lack of awareness regarding the requirement for written notifications, indicating a systemic issue in the facility's transfer processes.
The facility failed to provide written bed hold notices to residents or their representatives during hospital transfers, as required by policy. This deficiency was identified for four residents, where the facility's electronic medical records and interviews revealed that written notices were not provided, and staff were unaware of the requirement to include reserve bed payment information. The facility administrator confirmed that written notices were not issued.
Failure to Maintain Boiler System Resulting in Prolonged Loss of Hot Water
Penalty
Summary
The deficiency involves the facility’s failure to maintain essential equipment, specifically one of two boiler systems responsible for heating water, in safe operating condition. According to the Administrator, the Maintenance Supervisor reported on the morning of 2/21/26 that the boiler supplying hot water to stations 1 and 2 was not working. The Maintenance Supervisor identified that the fan motor to the boiler igniter was frozen and contacted the outside vendor, who came that day but did not have the necessary replacement part. The Maintenance Supervisor stated he informed the Administrator that stations 1 and 2 had no hot water but did not report that other stations were also affected, despite later acknowledging that stations 3, 4, 5, and 6 did not have hot water in their shower rooms, resident rooms, or nurses’ station sinks. The boiler did not receive routine service from an outside vendor and was only serviced when issues arose. Multiple staff interviews confirmed that there was no hot water throughout the facility from 2/21/26 until 2/24/26. Certified Nursing Assistants reported that there was no hot water in resident rooms, shower rooms, or nurses’ station sinks on several stations over the weekend and into Monday, and that residents were offered cold showers or bed baths with cold water. A Registered Nurse also stated that there had been no hot water on her station since 2/21/26. The Director of Nursing reported receiving a text on 2/21/26 that stations 1 and 2 did not have hot water and stated that staff were told the laundry room, which was on a separate boiler, had hot water that could be used for bed baths. The Director of Nursing and Administrator both stated that their expectation was that water temperatures be checked with a thermometer for accurate readings, but the Maintenance Supervisor reported he only used his hand to assess water temperature and did not use a thermometer. Residents confirmed the impact of the lack of hot water. One resident stated that there had been no hot water since Saturday and that she did not receive her scheduled shower on 2/23/26 because of this. Another resident stated he was told there had been no hot water since Saturday and that a CNA used cool water to clean him over the weekend. Facility policies and procedures for Maintenance Service and Water Temperatures, Safety of, required the maintenance department to maintain equipment in safe and operable condition, maintain heating and plumbing systems in good working order, and conduct and record periodic tap water temperature checks using thermostats and temperature controls. The Maintenance Supervisor acknowledged that the boiler did not receive routine service and that he did not follow the policy expectation of using a thermometer to check water temperatures, contributing to the prolonged period without hot water throughout the facility. The facility’s failure to maintain the boiler system in safe operating condition resulted in a non-functioning boiler from 2/21/26 to 2/24/26, during which residents were unable to shower and nursing staff were unable to wash their hands in hot water, placing residents at risk for poor hygiene, infectious disease, and discomfort.
Failure to Document Influenza Testing in Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records when the Infection Preventionist (IP) performed influenza testing on several residents and did not document these tests in the electronic medical record (EMR). The facility’s policy on Charting and Documentation requires that all services provided to residents, including treatments or services performed, be documented in the medical record with complete and accurate details such as date, time, provider, and how the resident tolerated the procedure. The IP’s job description states that the IP is accountable for surveillance of healthcare-acquired and community-acquired infections. Despite these requirements, the IP acknowledged that multiple influenza tests she performed were not documented in the EMR, resulting in incomplete medical records. Record reviews showed that several residents had documented changes in condition and positive influenza A results, but not all tests performed by the IP were recorded. One resident with dementia and anxiety had a change in condition note indicating a positive influenza A test, nasal congestion, and a nonproductive cough. Another resident with malignant neoplasm of the lung and secondary neoplasm of the brain had a change in condition with shaking, weakness, altered responsiveness, and low oxygen saturation, and the IP stated she tested this resident for influenza before transfer to an acute care hospital but did not document the test. The IP also stated she tested this resident’s roommate, who had diagnoses including Type 2 diabetes mellitus, hypertension, and muscle weakness, but could not find documentation of that influenza test in the EMR. Additional residents were involved in the undocumented testing. One resident with Parkinsonism, Type 2 diabetes mellitus, and anxiety developed respiratory symptoms with a nonproductive cough, and the IP stated she tested this resident for influenza but confirmed there was no documentation of the test in the EMR. Another resident with hemiplegia and hemiparesis following intracerebral hemorrhage, respiratory failure, and hypoxia developed a nonproductive cough, and the IP recalled testing this resident but found no documentation of the test or results in the EMR. During an interview, the DON and ADON confirmed they were present when the IP tested residents for influenza and stated that if tests were not documented, they were considered not done, and that the medical record was not complete without documentation of the influenza tests. They further stated it was the IP’s responsibility, not the charge nurse’s, to document the tests she performed.
Non-Functioning ABHR Dispensers Undermine Hand Hygiene Accessibility
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when 12 of 65 alcohol-based hand rub (ABHR) dispensers located in hallways and nurses’ stations failed to dispense product during testing with the Infection Preventionist (IP). The non-functioning dispensers were located near multiple resident rooms (Rooms 2, 6, 17, 20, 30, 39, 52, 54, 56, 61), next to the Station 3 shower room, and next to the maintenance office. The IP stated that housekeeping was responsible for refilling or replacing ABHR dispensers and acknowledged that it was important for dispensers to work properly to prevent the spread of germs and infections. The IP also stated that staff were expected to perform hand hygiene when entering and exiting resident rooms, before and after glove use, after using the restroom, before eating, and when hands were soiled. Staff interviews further demonstrated awareness of non-functioning ABHR dispensers and the impact on hand hygiene practices. An LVN reported knowing that some dispensers did not work and therefore kept ABHR gel on the medication cart for hand cleaning. A CNA reported that some hallway dispensers did not work and explained that when encountering a non-functioning dispenser after leaving a resident room, she had to walk down the hall to find another working dispenser to clean her hands. Another CNA stated that ABHR was needed when going in and out of resident rooms, before and after resident care, and before and after passing meal trays. The DON and ADON both stated it was very important for hand sanitizer dispensers to function properly and described expectations for staff hand hygiene, including at the start and end of shifts, in and out of resident rooms, between resident care, after bathroom use, and before and after meals. Review of the facility’s hand hygiene policy indicated that hand hygiene products and supplies were to be readily accessible and convenient for staff use, with ABHR dispensers placed in areas of high visibility and hand hygiene required before and after resident contact and after contact with the resident environment.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and did not provide adequate supervision to prevent accidents in two significant instances. In the memory care unit, a slide barrel lock was installed at the top right corner of an exit door leading to a patio. This lock was positioned out of reach for most individuals, including staff and residents, and required fine motor skills and cognitive understanding to operate. No environmental hazard risk assessment was conducted for this lock, and some staff were unaware of its placement. The lock's presence created a situation where residents and staff could be unable to exit in an emergency, potentially leading to entrapment. The facility's policy required exit doors to remain unlocked, and the Life Safety Code mandates that doors be readily operable from the egress side without special knowledge or effort. Additionally, the facility did not address the hazard posed by the path of travel to the designated smoking area, which required residents to cross a busy parking lot. One resident, who was assessed as cognitively intact and an independent smoker, was struck by a vehicle while returning from the smoking area in his wheelchair. The incident resulted in multiple fractures and hospitalization, with the resident experiencing increased pain and dependence on staff for activities of daily living. Staff interviews confirmed that there was no safe pathway or sidewalk from the facility to the smoking area, and residents had to navigate behind parked cars in a busy parking lot. Multiple staff members acknowledged the lack of safety and the absence of staff assistance for residents traveling to the smoking area. Facility policies required ongoing identification of safety risks and environmental hazards, as well as the development of strategies to mitigate or remove hazards when identified. However, the facility did not conduct a risk assessment for the exit door lock or the route to the smoking area, nor did it implement measures to ensure resident safety in these areas. The deficiencies affected all residents in the memory care unit and placed residents who smoked at risk of serious harm.
Failure to Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional monitoring and interventions for two residents who experienced significant unplanned weight loss. For Resident 2, the record showed a weight decrease from 105.4 lbs on 6/2/25 to 97 lbs on 7/28/25, a 7.95% loss in 56 days. The care plan was not updated to reflect the weight loss, and there were no IDT notes, RD notes, or documented interventions addressing the decline. Interviews with the resident’s daughter, the LVN, the SLP, the RD, and the DON confirmed that the weight loss was not identified or addressed in a timely manner, and the resident remained on a mechanical soft diet that the daughter reported the resident disliked and ate poorly. Resident 2’s record also showed no documented physician notification or SBAR communication related to the weight loss. The SLP stated Resident 2 was not on his patient load and that a fortified/high protein diet should have been started immediately once the weight loss was identified. The RD stated she was unaware of the 7.95% loss and relied on current weights rather than looking back at prior weights. The DON stated the RD should have identified the weight loss and that nursing was not responsible for looking for interventions, while also confirming that no RD notes or IDT notes regarding weight loss were found in the chart. Resident 4 was admitted with diagnoses including protein-calorie malnutrition, type 2 diabetes, CKD, dementia, and altered mental status. The resident’s weights showed a downward trend from 167 lbs on 5/30/25 to 151 lbs on 6/27/25, a 9.58% loss, and to 143 lbs on 7/17/25, a 14.37% loss. The record showed that nutritional interventions were delayed and initially limited to snacks, with diabetic snacks added on 7/1/25 and fortified/high protein diet interventions not added until 7/18/25, after the resident had already sustained substantial weight loss. The record also showed that the resident had variable oral intake, with intake documented at 51-75% on nutrition assessment and 25-50% in later IDT documentation. Interviews and record review showed that the RD did not trend weights back to admission and relied on weekly weights without comparing them to prior weeks, while the DON stated weights should have been trended to identify changes before they became significant. The SLP stated Resident 4 had no current swallowing or chewing issues and that a fortified/high protein diet should have been started immediately on admission or when weight loss was first noted. The DON stated Resident 4 should have been admitted on high protein shakes and a fortified high protein diet because of the admitting diagnosis of protein-calorie malnutrition, and stated that the facility’s policy and procedures regarding weight loss and weight management had not been followed.
Medication Orders, Oxygen Administration, Wander Guard Response, and Late Medication Pass
Penalty
Summary
Resident 95’s tramadol order was written as 50 mg by mouth every 8 hours for pain management, but the order did not include an appropriate indication or an associated pain scale within the administration instructions. Resident 95 was admitted with diagnoses including cerebral infarction, epilepsy, stiff-man syndrome, and major depressive disorder, and had a BIMS score of 15. During interview, the resident stated nursing staff administered tramadol every day without assessing pain first, that she did not need pain medication every day, and that tramadol made her sleepy. The resident’s RP, CNA, LVN, pharmacist consultant, and DON all stated the order lacked the specific pain indication and pain scale needed for appropriate administration. Resident 96 had orders for oxygen at 2 LPM via nasal cannula as needed for shortness of breath and 2 LPM via nasal cannula at bedtime, with diagnoses including COPD, acute and chronic respiratory failure, Alzheimer’s disease, and dementia. On observation, the resident was using a nasal cannula connected to an oxygen concentrator that was turned on at 4 LPM. The same condition was observed again the next day, and the LVN stated the concentrator should not have been on 4 LPM and that the oxygen had not been administered correctly per the physician order. The DON confirmed the resident received 4 LPM oxygen on both days and stated provider orders were not followed. A wander guard alarm was activated at the nursing stations, and LVN 10 turned off the alarm without checking outside the facility for residents who may have left. LVN 10 stated she was not sure of the protocol and did not know how many residents on her station had wander guards. Staff interviews, including CNA, LVN, RN, ADON, DON, and the Administrator, described the expected practice as checking outside and accounting for residents before turning off the alarm. The residents identified as having wander guards included residents with dementia, severe cognitive impairment, or moderate cognitive impairment, including diagnoses such as dementia, Parkinsonism, psychosis, depression, anxiety, and muscle weakness. Resident 144’s scheduled 8:00 a.m. medications, including 81 mg aspirin, 100 mg extended-release metoprolol succinate, and 10 mg amlodipine, were administered at 9:12 a.m. during medication pass observation. The LVN documented the medications as completed after the late administration, and the MAR screen was red/pink at the time of documentation. The pharmacy consultant, LVNs, and DON stated medications were to be administered within one hour before or after the scheduled time, and that administration outside that window was late and considered a medication error.
Food Temperatures Not Checked on Tray Line
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature during tray line on 8/6/25. During observation in the kitchen between 11:30 a.m. and 12:45 p.m., dietary staff checked temperatures of items on the steam table, but temperatures for french fries, gravy sauce, grounded burger patty, food in cups, and diced pears were not checked. During interviews, DC 1 stated food temperatures, including desserts, were to be checked prior to serving and documented in the logbook every meal, and DC 2 stated it was the cook’s responsibility to ensure food reached a safe temperature before serving. The CDM/D, CDMA, and RD each stated all food on the hot table needed to have temperatures checked and recorded, and that unsafe temperatures could result in residents becoming ill. The facility policy titled Food Preparation and Service stated the danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit, where harmful microorganisms can grow rapidly.
Fortified Diet Not Served as Ordered
Penalty
Summary
The facility failed to ensure that residents ordered fortified diets received the fortified food prescribed by the MD. The report states that on 8/6/25, during tray line observation between 11:48 a.m. and 12:45 p.m., dietary staff scooped food onto resident plates and prepared different diet types, but did not add fortified soup to the trays for residents ordered a fortified diet. The menu document for that meal indicated lunch should include "FORTIFIED HIGH PROTEIN" and "SUPER SOUP 6 oz" for the fortified diet. During interviews, Dietary staff, the Certified Dietary Manager/Driver, the Certified Dietary Manager Assistant, and the RD all stated that residents on fortified diets should receive the diet as ordered because it provides extra calories and protein and is intended for residents at risk for weight loss. The facility's Food and Nutrition Services policy stated food trays should be inspected to ensure the correct meal is provided, and the Therapeutic Diets policy stated therapeutic diets must be prescribed by the attending physician or delegated to a registered dietitian as allowed by state law.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety when the kitchen ice machine and food preparation sink were observed without an air gap. During a concurrent observation and interview, the Certified Dietary Manager/Driver and Certified Dietary Manager Assistant confirmed that the ice machine and food prep sink did not have an air gap. The CDMA stated an air gap was needed to prevent backflow of contaminated water, and the CDM/D stated he would notify the administrator and later reported that he had contacted a company to inspect and install an air gap. The facility also had opened food items that were not dated. During the initial kitchen tour, two opened bags of parmesan cheese and one and one-half loaves of bread were found without an opened date or used-by date. The bread was found under the food preparation sink. A dietary staff member stated the bread should not have been stored under the sink and should have been labeled with the date it was opened and used by date. The CDM/D stated all opened food was expected to be labeled with the date opened and used by date. In addition, a dietary staff member was observed in the kitchen with hair not fully covered by a hair net, and food scoops used for puree diet were placed on top of the steam table during tray line. Staff interviews stated hair restraints were expected to fully cover hair to prevent contamination, and the CDM/D stated placing scoops on top of the steam table was not acceptable because the scoops had leftover food on them and this created a contamination issue. The Registered Dietitian stated staff working in the kitchen should wear hairnets and beard covers as soon as they enter the kitchen and ensure all hair is covered.
Facility Assessment Did Not Address Memory Care Door Lock or Smoking Area Safety
Penalty
Summary
The facility failed to conduct a facility-wide assessment specific to resident needs because the assessment did not include an evaluation of the physical environment for the memory care unit or the resident smoking area. Based on interview and record review, the facility assessment did not address safety in resident smoking areas or environmental concerns related to locks on doors in the memory care unit for 26 of 26 residents in the memory care unit and 15 of 15 smokers in the facility. During interview, the Administrator stated changes had been implemented after a resident was hit by a vehicle, but those changes were not documented in the facility assessment. The Administrator also stated the assessment was not updated for the lock placed on the memory care unit door, and the DON stated she had toured the unit with another evaluator nurse and no issues with the lock were identified. The Administrator stated the last update to the facility assessment was on May 2, 2025, but it was not updated to reflect the smoking area or the locked door in the memory care unit.
Communication, Privacy, and Dignity Failures
Penalty
Summary
The facility failed to protect and promote resident rights related to communication, privacy, and dignity for multiple residents. Resident 2, who spoke Spanish and understood very limited English, and Resident 14, who stated he could not speak English, did not have alternate communication methods observed in their rooms. Resident 2’s responsible party stated the resident relied heavily on pointing and that it was difficult when no Spanish-speaking staff were assigned. Resident 14 told CNA 2 that a picture board would help him communicate his needs, and CNA 2 stated she was not proficient in Spanish medical terminology and would not understand him if he verbalized a medical need. Several residents reported that staff spoke in a foreign language while providing care. Resident 30 stated he had difficulty verbalizing his needs and understanding some staff because they were talking in a foreign language during care. Resident 148 stated staff were speaking in a foreign language during care. Resident 38 stated staff were speaking in a foreign language while providing care to her and her roommate. Resident 50 stated she had the same complaint and found it frustrating not to understand what staff were saying while they provided care. The DON reviewed staffing schedules and stated staff were expected not to speak in a foreign language while providing care and should speak in a language understood by residents so their needs could be met. The facility also allowed three female residents and three male residents to share a bathroom between their rooms. The DSD, CNA 8, CNA 7, the SSD, the DON, and the Administrator all acknowledged the bathroom-sharing arrangement and stated that male and female residents should not share a bathroom and that privacy was a resident right. Family members of affected residents stated they had not been informed of the arrangement. In addition, Resident 4 was observed sitting at a dining table while other residents at the same table were served and began eating, and Resident 4 waited more than five minutes for her food. CNA 10 stated it was not right for Resident 4 to watch other residents eat while waiting for her tray, and the DON stated staff should have notified the kitchen to avoid residents watching others eat while they waited.
Failure to Implement Person-Centered Care Plans for Falls, Communication, and Diet Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four sampled residents. For Resident 6, the care plan identified a fall risk related to limited mobility, antihypertensive medication use, and altered mental status, with interventions for floor mats on both sides of the bed and a reacher at bedside. During observation, Resident 6 had only one floor mat in the room and no reacher at bedside. The resident was sitting in a wheelchair, alert and oriented to familiar names and faces, and stated he had fallen from bed. The resident’s wife and daughter were present, and the responsible person reported that he had been falling from bed and had confusion related to a UTI. Staff interviews confirmed the resident was a high fall risk and that the care plan interventions should have been followed. For Resident 49, the care plan addressed expressive aphasia and identified Persian as the resident’s primary language, with interventions for a communication book and communication poster. During observation, the resident was awake in bed with slurred speech, could respond only with yes/no nods, and repeatedly said unintelligible words. Staff reported using gestures and pointing to communicate and stated they had not seen a communication board or communication book at the bedside. A communication board was later found in a bedside drawer under food items and was dirty and sticky. Staff also stated the resident’s language was difficult to identify, that the resident became frustrated when unable to communicate, and that family was called to interpret. The social services director stated the facility did not have staff who could understand Persian and would need translator or interpreter services for residents who could not speak or understand English. For Resident 68, the resident had diagnoses including cerebral infarction sequelae, muscle weakness, contracture of the left shoulder, and dysphagia. The meal ticket and order summary indicated a mechanical soft diet and use of a scoop plate for all meals. During lunch observation, the resident was served on a regular plate instead of a scoop plate and was given a hard piece of toast. Staff, including a CNA, SLP, CDM, LVN, and ADON, stated the resident should have received a scoop plate and should not have been served hard toast because of the ordered mechanical soft diet and dysphagia. For Resident 185, the care plan identified fall risk related to limited mobility, muscle weakness, and gait abnormalities, and included keeping the bed in the lowest position. During observation, the bed was not in the lowest position, and a CNA later lowered it. Staff interviews confirmed that the bed should have remained in the lowest position as specified in the care plan.
Missed Scheduled Medications Due to Unavailable Supply
Penalty
Summary
The facility failed to ensure prescribed medications were available and administered as scheduled for three residents. During medication administration observations, an LVN stated that Resident 53 did not receive polyethylene glycol because it was not available in the medication cart, Resident 82 did not receive oxybutynin 10 mg and vitamin E because they were not available in the medication cart, and Resident 144 did not receive isosorbide mononitrate ER 60 mg because it was not available in the medication cart. The MARs for August 2025 showed each of these medications was not administered at the scheduled times. Resident 53 had a history of constipation and a BIMS score of 15, indicating no cognitive impairment. Resident 82 had a history of overactive bladder and a BIMS score of 3, indicating severe cognitive impairment. Resident 144 had a history of heart failure and hypertension and a BIMS score of 11, indicating moderate cognitive impairment. For Resident 144, the blood pressure obtained before the missed dose was 122/68. During interviews, an LVN stated nurses were responsible for checking that residents' medications were available and for reordering medications or notifying the charge nurse if supplies were getting low. Another LVN stated all nurses were responsible for checking that residents' medications were available. The DON stated it was the nurse's responsibility to reorder medications that were running low and to ensure residents did not run out of regularly scheduled medications. The facility's Charge Nurse job description and Pharmacy Services Overview policy both stated that prescribed medications should be maintained in adequate supply and available in a timely manner.
Failure to Provide Ordered Adaptive Dining Equipment and Meal Presentation
Penalty
Summary
The facility failed to provide special eating equipment and utensils for three residents during lunch service. Resident 44, who had diagnoses including a right mandible fracture, dysphagia, type 2 DM, and HTN, was observed eating lunch in a wheelchair with assistance from the SLP. His meal ticket directed staff to provide a scoop plate and a right-handed built-up spoon, but the SLP stated the right-handed built-up spoon was not in the tray and that the kitchen had forgotten to include it. The resident had a scoop plate at the time of observation, but the adaptive spoon ordered for self-feeding was missing. Resident 68, who had diagnoses including sequela of cerebral infarction, muscle weakness, left shoulder contracture, and dysphagia, had a meal ticket and OSR directing staff to provide a scoop plate for all meals. During lunch observation, his tray contained a regular plate instead of a scoop plate. CNA 6 stated the resident was not provided with a scoop plate and needed it because of muscle weakness. The IP later stated she checked trays against meal tickets before they were sent out and did not notice that Resident 68 was not provided the ordered scoop plate. Resident 67, who had diagnoses including generalized osteoarthritis, glaucoma, and hearing loss, had a meal ticket and OSR directing that food be served in bowls. During lunch observation, her meal tray had food served on a plate rather than in bowls. CNA 10 stated the ticket called for food in bowls and that the resident should have had her food served that way to make it easier to pick up and feed herself safely. Dietary staff and the CDM/D stated the tray line and nursing staff were responsible for following the meal ticket instructions, and the RD stated the order for food to be placed in bowls should have been followed.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure completed physician informed consent was obtained for psychotropic medication use for two sampled residents. Resident 95 had diagnoses including cerebral infarction, epilepsy, stiff-man syndrome, major depressive disorder, and anxiety disorder, and had a BIMS score of 15, indicating cognitive intactness. The resident had an active order for sertraline 50 mg, 0.5 tablet by mouth daily for major depressive disorder, with administration beginning on 7/5/25. The informed consent form for this medication did not show an electronic provider signature, yet the medication was administered daily per the order. Resident 108 had diagnoses including heart failure, atrial fibrillation, hypertension, repeated falls, and schizophrenia, and also had a BIMS score of 15. The resident had an active order for aripiprazole 15 mg by mouth daily for schizophrenia, with the order dated 3/19/25 and the medication started on 3/20/25. The informed consent form for aripiprazole did not include the name of the licensed nurse who prepared the consent form and verified that informed consent had been obtained. During interviews, the LVN stated the provider was responsible for contacting the resident or responsible party and obtaining informed consent, while licensed nursing staff were responsible for ensuring the consent was obtained and documenting the ICPM. The MRA stated the forms were reviewed for completeness, including the licensed nurse name and provider electronic signature, and both residents' forms were incomplete. The DON stated sertraline and aripiprazole required informed consent before administration, that informed consents were legal documents that could not be replaced by a progress note, and that all required elements had to be completed for the document to be valid. Facility policies stated residents must be informed in advance of treatment, including risks, benefits, and alternatives, and that written informed consent with required signatures must be in the record before psychotherapeutic drugs are initiated.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of one sampled resident, Resident 13. Resident 13 was admitted with diagnoses including hemiplegia, hemiparesis, depression, diabetes, and unspecified atrial fibrillation. The admission record and order summary showed that Resident 13 was receiving Apixaban 5 mg by mouth twice daily, started 4/18/25, and Sertraline HCl 25 mg by mouth daily, started 4/22/25, along with empagliflozin 10 mg daily. During interview and record review, the MDS Nurse and another MDS Nurse reviewed Resident 13's MDS Section N dated 7/15/25 and stated that the resident received antidepressant medication and anticoagulant medication, but these medications were not coded on the assessment. They stated Resident 13 should have been coded as receiving both antidepressant and anticoagulant medications. The DON stated her expectation was that MDS assessments be accurate and completed on time, and that she was not responsible for checking for accurateness because the MDS nurses were new and she submits or transmits the assessments.
Failure to Provide Nail Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure nail care was provided for Resident 49, whose fingernails were observed to be long, jagged, and dirty with brownish to blackish dirt built up underneath the nails. During a concurrent observation and interview, Resident 49 was found lying in bed, awake, with slurred speech, unable to move the right upper and lower extremities, and with the right hand elevated on a pillow in a closed fist position with minimal swelling. Resident 49 was unable to open the right hand and had no washcloth or palm protector on the right hand. Resident 49’s record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, dysphagia, dysarthria, and contracture of the right hand and an unspecified joint. The MDS indicated the BIMS was not conducted and the resident was rarely or never understood. During a later observation, a CNA checked both hands and stated the right hand was contracted like a fist, the fingernails were long with dirt underneath, and there was no washcloth or palm protector applied to the right hand. The CNA also observed the left hand fingernails were long, jagged, and dirty, with the left thumb stained. Staff interviews confirmed that nail care was expected to be provided and that CNAs were responsible for nail clipping and nail care. The ADON stated licensed nurses conduct weekly checks of residents’ fingernails to ensure they are trimmed and cleaned to prevent infection and self-inflicting scratches and injury, and that Resident 49’s right-hand contracture required a washcloth to be applied and fingernails kept trimmed. An LVN also observed the fingernails were long and dirty and stated they should be cleaned and trimmed to prevent infection. The facility policy stated nail care includes daily cleaning and regular trimming, and that trimmed and smooth nails prevent accidental scratching.
Failure to Follow Up on Pharmacist Drug Regimen Review
Penalty
Summary
The facility failed to act on a consultant pharmacist’s monthly drug regimen review irregularity for a resident who was admitted with heart failure, atrial fibrillation, hypertension, repeated falls, and schizophrenia. The resident had a BIMS score of 15, indicating cognitive intactness. After the resident sustained a fall and reported feeling dizzy, a drug regimen review was completed because of the change in condition. The consultant pharmacist identified irregularities and recommended changing the hold parameters for metoprolol and amlodipine to hold for SBP less than 110 instead of 100. The provider signed and dated the review as reviewed, but the resident’s medication orders were not updated to reflect the recommendation. There was no documentation in the medical record explaining why the recommendation was not implemented. During interviews, the LVN, MRS, PC, and DON each stated that licensed nursing staff, the provider, the DON, and medical records staff were responsible for ensuring the drug regimen review recommendations were implemented or that a rationale was documented if they were not. They also stated the resident’s orders did not reflect the pharmacist’s recommendations and that no rationale could be located. The facility’s policy stated that the attending physician documents in the medical record that the irregularity has been reviewed and what action, if any, was taken to address it.
Unnecessary opioid pain medication given despite no reported pain
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary drugs when tramadol was administered for pain management despite repeated documentation of no pain. The resident was admitted with diagnoses including cerebral infarction, epilepsy, stiff-man syndrome, and major depressive disorder, and had a BIMS score of 15, indicating cognitive intactness. The resident’s order summary showed an active order for tramadol 50 mg by mouth every 8 hours for pain management. The medication administration record showed tramadol was given 74 times in June, 85 times in July, and 29 times in August, with each administration documented for a pain rating of 0 out of 10. During interview, the resident stated she received tramadol every day since admission, did not need pain medication every day, preferred not to take pain medication when not in pain, and reported that tramadol made her sleepy after administration. The resident also stated her pain was controlled with other medications and acetaminophen was available as needed for breakthrough pain. Licensed nursing staff, the pharmacist consultant, and the DON all stated that tramadol was an opioid pain medication and that pain should be assessed before administration. The LVN stated tramadol was not appropriate when the resident had no pain and acknowledged it had been administered inappropriately for pain scores of 0 out of 10. The DON stated moderate to severe pain was considered 4 and above, that it was not appropriate to administer opioids when there was no reported pain, and that the resident was overmedicated. The DON also stated the facility’s pain management policy and in-services had not been followed when tramadol was administered for pain ratings of 0 out of 10.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals used in the facility were found not to be labeled and stored in accordance with facility policy and accepted practice during observations, interviews, and record review. In the Station 5 Medication Cart, a box of Nicotine Transdermal Patches was found without a resident identifier, and an opened foil packet of Budesonide inhalation suspension was found without the date of opening written on the packet. Staff interviews confirmed that resident medications were expected to be labeled with a resident identifier and that opened medications were expected to have an open date recorded so their use could be tracked. In the treatment carts, multiple opened items were found without open dates or resident identifiers. An opened bottle of iodine in the Station 5/6 Treatment Cart had no open date. In the Station 3 Treatment Cart, two opened tubes of 20% Zinc Oxide, an opened tube of Hydrocortisone Acetate 1%, an opened tube of Muscle Rub Cream 10% menthol and 15% methyl salicylate, an opened tube of Diphenhydramine topical cream, and two opened tubes of 100% Medical Grade Manuka Honey were all found without open dates. An opened tube of Phenylephrine Hemorrhoidal Ointment was found without a resident identifier. Staff, including LVNs, the PC, and the DON, stated that items should be dated when opened and labeled with a resident identifier when they were resident-specific. Storage issues were also identified. An unopened bottle of Lispro insulin was found in the Station 1 Medication Cart even though the packaging indicated it should be refrigerated until opened. An opened bottle of carbamide peroxide 6.5% ear drops was found in the Station 2 Medication Cart without a resident identifier. During interviews, RN staff stated the insulin should have been refrigerated because it had not yet been used, and the DON stated unused insulin should be stored in the refrigerator. The facility policies reviewed stated that when opening a multi-dose container, the date opened is recorded on the container, medications requiring refrigeration are stored in a secured refrigerator, and medication labels include the resident name and expiration date.
Incorrect Diet Texture Served to Residents on Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food in the prescribed texture for two sampled residents who were ordered mechanical soft diets. Resident 68 had diagnoses including sequela of cerebral infarction, muscle weakness, left shoulder contracture, and dysphagia. His meal ticket and order summary indicated a mechanical soft texture diet, but during lunch on 8/5/25 he was observed with a slice of hard toast on his tray. CNA 6 stated the toast was burnt and should not have been given because Resident 68 was on a mechanical soft diet, and the SLP stated the hard toast should not have been provided because he had not progressed enough to adequately eat and swallow it. Resident 143, who had diagnoses including dementia, polyneuropathy, type 2 DM, and HTN, had an MDS BIMS score of 7, indicating severe cognitive impairment. Her order summary and care plan indicated a mechanical soft/chopped meat texture diet. During lunch on 8/5/25, she was observed in the dining room touching toasted bread and stating it was hard. RNA 1 stated the bread was hard as a rock, was not mechanical soft bread, and requested the kitchen replace it multiple times before the appropriate texture bread was served. RNA 1 and the SLP stated Resident 143 was on mechanical soft texture due to chewing problems and was at higher risk for choking if served food she could not chew. Facility staff acknowledged that the hard toast did not meet the ordered diet texture for either resident. The DON stated residents should receive their prescribed diet to prevent choking and to ensure proper nutrition and hydration. The CDM stated a person on a mechanical soft diet should not have received hard toast and that kitchen staff should have caught it during trayline. The facility policy stated food and nutrition services staff will inspect food trays to ensure the correct meal is provided to each resident.
Improper Storage of Perishable Foods Brought by Family
Penalty
Summary
The facility failed to follow its policy and procedure for foods brought by family and visitors when perishable food was stored in a resident’s bedside table instead of being labeled, dated, and stored in a refrigerator. During observation, a container of fresh strawberries with multiple scattered black spots was found in the resident’s bedside table, along with an opened bottle of orange juice that had no open date. The resident was lying in bed, awake, with slurred speech, right-sided paralysis and weakness, and was unable to move the right upper and lower extremities. His admission record showed diagnoses including hemiplegia, hemiparesis following cerebral infarction, aphasia, dysphagia, dysarthria, and contractures of the right hand and an unspecified joint. Staff interviews confirmed that the resident’s family brought food on a weekly basis and that the food had been stored in the bedside table. A CNA stated she discarded the rotten strawberries and said fresh strawberries should be stored in the refrigerator, not at the bedside table. Later observation found additional perishable foods in the bedside table drawer, including three oranges, one apple, and a bag of grapes, and the drawer was dirty with bread crumbs and sticky paste-like juice. An LVN stated perishable foods should be stored in a refrigerator and labeled and dated, and the DON stated perishable items brought by family should be stored in the refrigerator, labeled, and dated to prevent food-borne illnesses.
Failure to Replace Nebulizer Tubing Weekly
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when Resident 13’s handheld nebulizer tubing was observed dated 7/17/25 during an initial tour on 8/5/25. Resident 13 was not in the room at the time of the observation, and the nebulizer was found at bedside inside a plastic bag. Resident 13’s admission record showed diagnoses including hemiplegia, hemiparesis, depression, diabetes, unspecified atrial fibrillation, and muscle weakness. The order summary showed ipratropium-albuterol inhalation solution 3 ml to be inhaled orally three times a day, with a start date of 4/18/25. During a concurrent observation and interview, RN 5 stated the handheld nebulizer tubing had a date of 7/17/25 and that the practice was to change the tubing every week. RN 5 stated the tubing should have been changed when oxygen tubing was changed and identified it as an infection control issue because bacteria could grow inside the tubing and be carried directly to the lungs. LVN 9 also reviewed the medication orders and stated the nebulizer tubing should have been changed weekly and that bacteria could grow in the tubing and be inhaled. The IP stated oxygen tubing and handheld nebulizer tubing are changed every week on Thursdays and as needed, and that Resident 13’s tubing should have been changed on 7/24/25 and 7/31/25 but was not. The DON stated licensed nurses were expected to ensure oxygen and handheld nebulizer tubing are changed weekly and as needed. The facility policy titled Oxygen Administration addressed documentation of the procedure, including date and time performed, frequency and duration, and resident tolerance.
Insufficient Room Square Footage
Penalty
Summary
The facility failed to provide and maintain the minimum required square footage for residents in 33 of 74 rooms, including Rooms 16 through 35 and 38 through 50, during the survey period. The report states that these rooms did not meet the regulation requiring at least 80 square feet per resident in multiple-occupancy rooms and 100 square feet for single resident rooms. The survey also noted that residents had a reasonable amount of privacy, closets and storage spaces were adequate, bedside stands were available, there was sufficient room for nursing care and resident ambulation, and wheelchairs and toilet facilities were accessible. The report identifies the issue as a waiver request to continue in effect for the rooms that did not meet the minimum square footage requirement.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for two residents when their wheelchairs were observed to be covered with black and brown unknown substances. Both residents were found lying in bed asleep during the observation, and their wheelchairs, which were visibly soiled, were accessible and visible to passersby. The Assistant Director of Nursing (ADON) confirmed that housekeeping staff were responsible for cleaning the wheelchairs weekly, but this was not done. The ADON also acknowledged that the substances on the wheelchairs could be a source of bacterial growth and potentially cause illness. Housekeeping staff confirmed that the wheelchairs had not been cleaned the previous week due to staffing problems and agreed that unclean equipment could lead to illness. The Director of Nursing (DON) and the Administrator both stated that wheelchairs were expected to be cleaned weekly and as needed, and that all staff were responsible for ensuring a clean and homelike environment. Review of facility policy and job descriptions confirmed the expectation for maintaining cleanliness and a homelike environment. The failure to clean the wheelchairs as scheduled resulted in a violation of the residents' rights to a comfortable and homelike environment, as well as a potential source of infection.
Failure to Maintain Clean Wheelchairs and Effective Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the condition of two residents' wheelchairs, which were observed to be covered with black and brown unknown substances. Both residents were found asleep in their beds during the observation, and their wheelchairs' metal frames and wheels were visibly soiled. The Assistant Director of Nursing (ADON) confirmed that the housekeeping staff were responsible for cleaning the wheelchairs weekly, but this had not been done. The ADON acknowledged that the facility did not provide a comfortable and homelike environment and that the substances on the wheelchairs could be a source of bacterial growth and illness. Housekeeping staff confirmed that the wheelchairs were dirty and should have been kept clean at all times, but due to staffing problems, the scheduled cleaning was missed. The Housekeeper stated that unclean equipment such as wheelchairs could make residents ill and that the facility failed to provide a comfortable homelike environment for the affected residents. The Director of Nursing (DON) also reviewed photos of the wheelchairs and stated that she expected them to be cleaned as scheduled and as needed for soilage. The DON indicated that the housekeeping department was responsible for cleaning wheelchairs weekly and as needed, and that licensed nurses and CNAs were expected to report dirty wheelchairs to housekeeping for follow-up. The Administrator stated that all wheelchairs were expected to be cleaned weekly and as needed, and that providing a clean, comfortable, and homelike environment was the responsibility of all staff. The facility's job description for housekeepers and its policies and procedures for assistive devices and infection control both indicated that maintaining a clean and safe environment was required. However, these policies were not followed, resulting in the deficiency.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective individualized interventions to prevent falls for two residents identified as high risk. One resident, who had right-sided paralysis, severe cognitive impairment, and was dependent on staff for repositioning, was frequently observed leaning to the left against a side rail in bed. Despite staff awareness of this behavior and the resident's inability to reposition himself, the care plan did not address these specific risks. The resident experienced an unwitnessed fall from bed, resulting in a nasal fracture and lacerations requiring emergency department treatment and sutures. Staff interviews confirmed that the resident's positioning issues and use of the electric bed were known, but interventions were not updated to address these hazards. Another resident, with diagnoses including Alzheimer's disease, dementia, and impaired mobility, was assessed as needing staff supervision to ambulate more than 50 feet and had known behaviors of putting herself on the ground. Despite these risks, the resident was allowed to ambulate outside to the memory care unit patio without staff supervision, leading to an unwitnessed fall. The resident sustained a laceration to the back of her head and required emergency department assessment. Staff and care plan reviews revealed that the need for supervision during ambulation and the resident's specific behaviors were not adequately addressed in the care plan prior to the fall. Both incidents demonstrated a lack of individualized, resident-centered interventions and supervision as required by facility policy and assessment findings. Staff interviews and record reviews indicated that known risks and behaviors were not incorporated into care plans or daily supervision practices, directly resulting in avoidable falls and injuries for both residents. The facility's failure to implement and update interventions based on each resident's assessed needs contributed to the deficiencies observed.
Failure to Provide Ongoing Infection Control Training During Outbreaks
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) possessed and demonstrated the necessary competencies and skills to provide ongoing in-service training and education to staff during outbreaks of Norovirus and Influenza. The IP did not conduct refresher or make-up in-service sessions after the initial training, despite confirmed cases and an active outbreak. Interviews with dietary staff, nurses, and certified nursing assistants revealed that many did not recall attending infection control in-services provided by the IP after the outbreak began, and there was no evidence of reminders or posted schedules for such training. The IP acknowledged that in-service training on Norovirus was provided 15 days before the first confirmed case, but no additional sessions were held after the outbreak started. Attendance at subsequent in-services on Influenza and related precautions was low, and the IP did not communicate this to facility leadership or attempt to ensure all staff received the necessary education. The Director of Staff Development (DSD) and Director of Nursing (DON) both stated that they were not informed of the low attendance and did not provide or coordinate additional training, with the DSD indicating she would have assisted if asked. Facility policies required ongoing education and competency evaluation for staff during outbreaks, but these were not followed. The lack of comprehensive and timely in-service training for all staff, especially those providing direct care, resulted in staff being inadequately prepared to manage and prevent the spread of infection among residents, staff, and visitors during the Norovirus and Influenza outbreaks.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the required timeframe for two residents. In the first instance, a Certified Nursing Assistant (CNA) observed another CNA allegedly pushing a resident roughly onto her bed. The incident occurred in the early morning, but the witnessing CNA did not report the event to facility staff until nearly 22 hours later, despite being aware of the requirement to report such incidents within two hours. The resident involved had severe cognitive impairment, a history of falls, and required assistance with personal care. The facility's internal investigation was not initiated until the incident was reported, and the final report was not sent to CDPH until several days after the event. In the second case, a family member of another resident contacted the local police department on two separate occasions, alleging that the resident was being abused by facility staff. The police conducted welfare checks and informed facility staff of the abuse allegations. Despite this, the facility did not report the allegations to CDPH or the Ombudsman as required by both federal regulations and the facility's own policies. The resident in question was severely cognitively impaired, frail, and on hospice care, with a history of skin breakdown and bruising. Staff were aware of the family member's repeated concerns and the police visits but did not escalate the allegations to facility management or external authorities. Interviews with facility staff, including CNAs, LVNs, the Director of Nursing, and the Administrator, confirmed that all were aware of the mandated reporting requirements, which stipulate that all allegations of abuse must be reported within two hours. However, in both cases, staff either delayed reporting or failed to report the allegations altogether, resulting in untimely investigations and notifications to the appropriate authorities. Facility policies and in-service training documents reviewed during the survey reiterated the immediate reporting requirements, which were not followed in these instances.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall prevention interventions for multiple residents identified as high fall risks. One resident with a history of falls, moderate cognitive impairment, Parkinsonism, and muscle weakness was found on the bathroom floor after an unwitnessed fall. Staff interviews revealed that this resident required supervision and touch assistance for ambulation and was known to be forgetful and noncompliant with using the call light. Despite these known risks, the resident did not have individualized fall prevention interventions in place prior to the incident, and was found barefoot, contrary to care plan instructions for appropriate footwear. The care plan interventions were not followed, and the root cause of the fall was not clearly identified by the interdisciplinary team. Another resident with left-sided paralysis, severe cognitive impairment, and a history of repeated falls experienced multiple unwitnessed falls while sitting unsupervised at the edge of the bed. This resident had poor balance and safety awareness, and staff acknowledged that he was impulsive and unable to maintain stability while sitting up. The care plans for this resident were not person-centered, lacked specificity regarding the level of supervision required, and did not address the root causes of his falls. Staff and therapy personnel confirmed that the resident needed assistance to sit safely, but interventions were not effectively implemented, resulting in repeated injuries, including lacerations requiring emergency care. A third resident, assessed as needing supervision during transfers and known to self-transfer between a wheelchair and an armchair, was left unsupervised in a hallway armchair. This resulted in an unwitnessed fall causing significant injuries, including a hip fracture and a forearm fracture, necessitating surgical intervention and hospitalization. The facility's failure to provide adequate supervision and individualized interventions for these residents, despite their assessed needs and known behaviors, led to serious harm and demonstrated a pattern of non-compliance with accident prevention requirements.
Removal Plan
- Facility added 1:1 support and supervision while awake and will remain in sight of Residents 1 and 2.
- Staff will assist Resident 2 with stability and balance while sitting on side of the bed to minimize risk for falling.
- Staff will assist Resident 1 with individual toileting plan including upon waking, before and after meals, before bed and every two hours as needed.
- Resident 6 will be placed on a 1:1 while awake after she returns to the facility, assist with safe transfers, cueing and provide direct care for impulsive attempts to rise or transfer.
- IDT reviewed Root Cause (RC) Analysis of accident hazards, supervision and assistive devices to prevent avoidable accidents and have updated care plans with person-centered interventions which will be reviewed by the IDT.
- Facility increased CNA staffing on stations 5 & 6 as identified during RC analysis for falls.
- The facility assigns monitor staff including each unit supervisor for safety checks on identified residents with falls.
- The activity department added additional snack and crafts cart and staff support for identified high fall risk residents with actual falls.
- Director of Staff Development (DSD) initiated in-service for direct care staff with specific focus on resident interventions to reduce falls and injuries from falls.
Failure to Provide Administrative Oversight and Fall Prevention
Penalty
Summary
The facility administrator failed to provide consistent administrative oversight and resources to ensure residents received adequate supervision and care planning, despite being aware of 63 resident falls over a two-month period. The administrator did not establish an effective fall prevention program, and this lack of action resulted in multiple residents experiencing unwitnessed falls with injuries that required hospitalization. Specifically, one resident suffered a right hip fracture after slipping in the bathroom without staff assistance, was found barefoot and without a brief, and reported significant pain following the incident. Interviews with staff revealed that the unit supervisor and the DON were aware of the high number of falls but were unable to clearly identify the root causes or ensure that effective interventions were implemented. The DON, who was new to the facility, had not yet familiarized herself with the facility's policies and procedures and could not articulate the findings of the interdisciplinary team's review of the fall incidents. The Director of Staff Development acknowledged conducting a fall prevention in-service but did not assess staff competency afterward. The administrator admitted to being aware of the high fall rate but considered falls to be a clinical issue under the DON's responsibility and did not participate in fall-related meetings or reviews. The facility's job description for the administrator and its policies emphasized the administrator's responsibility for accident prevention and oversight, including reviewing incident reports and ensuring effective safety programs. However, these responsibilities were not fulfilled, contributing to the ongoing risk and occurrence of resident falls with injury.
Failure to Develop and Implement Effective, Person-Centered Fall Prevention Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with known fall risks, resulting in multiple falls and injuries. One resident, with a history of falls, Parkinsonism, moderate cognitive impairment, and mobility issues, was admitted with significant risk factors. Despite assessments indicating the need for substantial assistance with transfers and ambulation, the care plan only included generic interventions such as ensuring the call light was within reach and encouraging its use, as well as proper footwear. Staff interviews confirmed that the resident was forgetful and did not consistently use the call light, and that no individualized fall prevention interventions were in place prior to the resident's fall. The resident subsequently experienced an unwitnessed fall in the bathroom, resulting in a hip fracture and hospitalization. Another resident, admitted with left-sided paralysis, a history of falls, and severe cognitive impairment, also did not have effective fall prevention interventions in place. This resident had a behavior of sitting at the edge of the bed unsupervised, which was not addressed in the care plan. The resident experienced four falls, two of which occurred on the same day, resulting in a laceration above the eyebrow that required emergency room treatment and sutures. Staff interviews and record reviews revealed that the care plan interventions were not specific to the resident's needs, did not address the behavior of sitting at the edge of the bed, and did not specify the level of supervision or frequency of checks required. The root cause of the resident's behavior and falls was not identified or addressed in the care plan. Facility policies required comprehensive, person-centered care plans with measurable objectives and individualized interventions based on assessment data. However, the care plans for both residents lacked specificity, did not reflect the assessed needs, and failed to implement effective interventions to prevent falls. Staff were unable to articulate the rationale for the interventions in place or how they addressed the residents' specific risks, and documentation did not demonstrate that the care plans were revised in response to changes in the residents' conditions or after falls occurred.
Failure to Ensure Staff Competency in Fall Prevention Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed and demonstrated the necessary competencies in fall prevention, as evidenced by the lack of documented competency checks for all seven sampled nursing staff within the past year. Despite a high incidence of falls—42 occurring over a six-week period—there was no evidence that staff had been evaluated for their ability to implement fall prevention interventions. An in-service on fall prevention was held, but not all staff attended, and there was no follow-up to assess whether those who attended had achieved competency. The Director of Staff Development acknowledged that competency testing was not conducted after the in-service, and the facility could not provide any policy or procedure for staff competency assessment. This deficiency directly contributed to an incident in which a resident, who had involuntary tremors and required assistance with transfers, experienced an unwitnessed fall in the bathroom. The resident sustained a right intertrochanteric hip fracture, resulting in pain, decreased mobility, and a week-long hospitalization. At the time of the fall, the resident did not have fall prevention interventions in place, and staff were unsure how the resident ended up in the bathroom alone. Interviews confirmed that some staff had not attended the fall prevention in-service, and there was no documentation verifying staff competency in this critical area.
Failure to Obtain Signed Hospice Agreements Prior to Initiating Hospice Services
Penalty
Summary
The facility failed to follow its own hospice policy and procedures for two residents who were receiving hospice services without a valid, signed hospice agreement in place. For both residents, the hospice agreements with the respective hospice agencies were found to be unsigned by the hospice agency's authorized representative. The Administrator confirmed that the agreements must be signed by both parties prior to the initiation of hospice services, and acknowledged that this was not done for either resident. The Administrator also stated that it was his responsibility to ensure contracts with outside service providers, including hospice, were reviewed and signed before care or services began. Resident 8 was admitted with diagnoses including congestive heart failure, type 2 diabetes mellitus, hypertension, and pleural effusion, and was under hospice care from admission. Resident 14 was admitted with diagnoses including Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, hypertension, and anxiety disorder, and was also under hospice care. Facility policy required a written and signed agreement with hospice providers before services were furnished to any resident, but this procedure was not followed for these two residents.
Failure to Implement Effective QAPI Program for Fall Prevention
Penalty
Summary
The facility failed to identify, develop, and implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of an effective fall prevention program. Between January 1 and March 4, 2025, there were 63 resident falls, with three resulting in significant injury that required transportation to an acute care hospital. The facility's documentation showed a high number of falls, including 31 in January and 11 in the first 12 days of February. Despite being aware of the high fall rate, the Director of Staff Development only provided an in-service on fall prevention without testing staff competency afterward. Interviews with the Administrator (ADM) revealed that the QAPI committee, which included department heads and the medical director, met monthly to discuss facility issues. However, the ADM was unable to explain how data collected through QAPI was used to reduce falls or what specific performance improvement plans were implemented. The ADM also stated that each department head took their own minutes, and there was no integrated documentation of QAPI discussions or actions related to falls. The ADM deferred responsibility for fall prevention to the Director of Nursing and was not involved in clinical discussions or daily stand-up meetings where falls were reviewed. A review of the facility's QAPI policy indicated that the program should be data-driven, ongoing, and focused on identifying and correcting quality deficiencies. The policy assigned the administrator responsibility for ensuring compliance and required systematic analysis and corrective action. However, the facility did not follow these procedures, as there was no evidence of systematic tracking, analysis, or implementation of effective interventions to address the high rate of resident falls.
Failure to Notify Responsible Party of Room Change and Fall
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident regarding significant events, including a room change and a fall. The resident, who had a history of repeated falls, fractures, paraplegia, muscle weakness, and severe cognitive impairment, was moved to a different room without prior notification to his RP. The facility's own policy required advance notice to the RP before any room change, but documentation and interviews confirmed that no such notification was made. The resident's RP only learned of the room change after another family member visited and found the resident in a different room. Additionally, the resident experienced a fall, and again, the RP was not notified as required by facility policy. The resident's RP stated she was not informed about the fall and only became aware of it through family discussions. Review of the medical record and interviews with staff, including the MDS Coordinator and LVN, revealed no documentation of RP notification for either the room change or the fall. The facility's policy clearly stated that the RP must be notified of any accident, incident, or significant change in the resident's status, but this was not followed in this case. Observations further revealed that the new room was not suitable for the resident's physical needs, as the grab bars in the bathroom were not accessible to him due to his left-sided paralysis. The resident and his RP both expressed concerns about the safety and appropriateness of the new room, and staff confirmed the difficulty in assisting the resident due to the bathroom setup. The Social Services Director acknowledged that the required process and documentation for room change and RP notification were not completed, and the facility's policy was not followed.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Bed
Penalty
Summary
A deficiency occurred when a resident's hospital bed footboard was found to be loose and detached from the bedframe, making it visible to passersby and creating an environmental hazard. The resident, who had a history of cerebrovascular disease, congestive heart failure, generalized muscle weakness, and hypertension, was observed lying in bed asleep at the time of the incident. The resident's cognitive status was severely impaired, as indicated by a BIMS score of 3 out of 15. Certified Nurse Assistants (CNAs) were aware of the ongoing issue with the bed's footboard, but it had not been properly reported or documented for maintenance. The Assistant Director of Nursing (ADON) and the Maintenance Director both confirmed that the loose footboard was an environmental hazard and required immediate repair. The Maintenance Director stated that the issue had not been reported or logged in the maintenance records, and admitted to not checking the maintenance log daily as required. The Director of Nursing (DON) also acknowledged the hazard and emphasized the expectation that staff report equipment issues promptly. Facility policies reviewed indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, and that regular inspections and maintenance logs are required, but these procedures were not followed in this instance.
Failure to Timely Report Unwitnessed Falls with Injury
Penalty
Summary
The facility failed to report two unwitnessed falls with injury involving a resident to the California Department of Public Health (CDPH) within the required time frame. The resident, who had a history of repeated falls, paraplegia, muscle weakness, and severe cognitive impairment, experienced two separate falls from his bed on the same day. Both incidents were unwitnessed, and in each case, the resident struck his head, resulting in a skin tear and later a laceration to the left eyebrow that required emergency room treatment and sutures. Review of the resident's records indicated that the falls were documented, and the attending physician was notified. However, there was no documentation that CDPH was notified of either incident. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the events were not reported to the state agency. The DON stated that the falls were not considered reportable due to the resident's medical condition and history of falls, and interventions were focused on minimizing injury rather than preventing falls. Further review of facility policy revealed that any injury of unknown source or suspected neglect should be reported immediately to the administrator and appropriate authorities, including the state agency. Despite this policy, the administrator and DON did not report the incidents, and the administrator was unaware of the resident's multiple falls during the period in question. This failure resulted in the falls not being investigated in a timely manner as required.
Failure to Set Low Air Loss Mattress According to Manufacturer Guidelines
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, hypertension, sacral pressure ulcer, and anxiety disorder was admitted to the facility and required a low air loss (LAL) mattress for wound management. The physician's order and care plan specified the use of the LAL mattress, and the manufacturer's guidelines required the mattress setting to be adjusted according to the resident's weight. However, the LAL mattress was set at 320 lbs, while the resident's actual weight was 72 lbs, as confirmed by the Minimum Data Set Coordinator (MDSC) during a review of the resident's records and a photo of the mattress settings. The MDSC and the Director of Nursing (DON) both acknowledged that the mattress setting did not follow the manufacturer's recommendations and that this could have contributed to the resident's discomfort and a recent fall. The facility's policy and procedure, as well as the job description for floor nurses, required adherence to manufacturer guidelines and proper equipment operation. The user manual for the mattress also specified that the pressure should be set according to the patient's weight. The failure to set the LAL mattress correctly represented a lack of compliance with professional standards of quality for the care of this resident.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
A deficiency was identified when a resident's oxygen concentrator filter was observed to be covered with dust and lint. The resident, who had been admitted from an acute care hospital with diagnoses including congestive heart failure, type 2 diabetes mellitus, hypertension, and pleural effusion, was receiving oxygen therapy as ordered. During an observation in the resident's room, the Assistant Director of Nursing (ADON) and a registered nurse confirmed the filter's dirty condition and acknowledged that this was not acceptable. The ADON stated that maintaining the cleanliness of the oxygen concentrator was the responsibility of licensed nurses. Interviews with the Director of Nursing (DON) further confirmed that the use of a dirty oxygen concentrator was not in line with facility expectations and could potentially cause residents to become ill. Review of facility policies and procedures indicated that equipment should be maintained according to manufacturer instructions and infection control standards, and that staff are responsible for ensuring equipment is in good working order. The oxygen concentrator's user manual also emphasized the need for frequent inspection and cleaning of the filter, especially in environments with dust and lint.
Failure to Prevent Accidents Due to Inadequate Supervision and Assistive Measures
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents, including falls and elopement, for multiple residents with known cognitive and physical impairments. In one instance, a resident with dementia, epilepsy, muscle weakness, and a history of unsteady gait was left unsupervised on an outdoor patio. Despite staff awareness of his declining functional status and need for supervision while ambulating, no staff was assigned to supervise him. The resident was found on the ground after an unwitnessed fall, sustaining a laceration above the left eyebrow that required emergency department treatment. Interviews with staff confirmed that the resident's health had been declining, he required close monitoring, and that the fall could have been prevented with proper supervision. The facility did not perform fall risk assessments before or after the incident, and the care plan was not updated to reflect the resident's increased need for supervision. Another resident with severe cognitive impairment, poor safety awareness, and a history of repeated falls was not provided with effective supervision or individualized interventions to prevent falls. This resident experienced multiple falls while in bed, despite staff and care plan recognition of her high fall risk and the ineffectiveness of interventions such as reminders to use the call light. The care plan interventions focused on increased monitoring and keeping the resident in visual areas when not in bed, but did not address the cause of her falls, which occurred while she was unsupervised in bed. Staff interviews confirmed that the resident needed one-on-one supervision while in bed to prevent further falls, but this was not implemented. A third resident, identified as having exit-seeking behavior and a high risk of elopement due to severe cognitive impairment, was able to leave the facility undetected when his elopement detection device failed to function and alarm. Staff were aware of the resident's risk and the need to check the placement and function of the wander guard device every shift, but this was not done. The resident was found outside the facility by police after a neighbor reported him as confused and alone. The facility's method for testing the wander guard device did not follow manufacturer guidelines, as they lacked the appropriate testing equipment and instead took the resident to an alarmed door. The failure to ensure the device was functioning properly and to provide direct supervision resulted in the resident's elopement.
Failure to Adhere to Infection Control Protocols During Norovirus Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in two key areas. First, a Certified Nursing Assistant (CNA) assisted a resident who was on contact precautions for symptoms of norovirus without wearing the required personal protective equipment (PPE), specifically a gown and gloves. The CNA physically supported the resident from the bathroom to the bed, despite signage indicating the need for PPE and the facility’s policy requiring its use for residents with norovirus symptoms. The CNA acknowledged during an interview that she should have donned the appropriate PPE before providing care, and both the Director of Nursing (DON) and Infection Preventionist (IP) confirmed that the correct PPE was not used as required by facility policy and CDC guidelines. Additionally, the facility did not provide biohazard receptacles in 11 out of 22 rooms where residents were under isolation precautions. Staff, including a Licensed Vocational Nurse (LVN) and another CNA, were observed doffing contaminated PPE outside of resident rooms or in the hallway due to the absence of proper disposal containers inside the rooms. In one instance, a yellow biohazard bag was left on the hallway floor for PPE disposal, which the IP and DON stated was inappropriate and could lead to contamination of the hallway environment. Both staff and leadership interviews confirmed that contaminated PPE should be removed and disposed of inside the resident’s room to prevent the spread of infection. The facility’s policies and procedures, as well as CDC guidelines, were reviewed and all indicated the necessity of using PPE for contact precautions and the proper disposal of contaminated materials within the resident’s room. The observed failures to follow these protocols occurred during an outbreak of norovirus, with multiple residents symptomatic and on contact precautions. The lack of adherence to established infection control measures was confirmed through direct observation, staff interviews, and policy review.
Failure to Develop and Implement Person-Centered Fall Prevention Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to prevent falls for two residents with significant cognitive and functional impairments. For one resident with dementia, epilepsy, muscle weakness, and difficulty walking, staff were aware of a decline in functional status and poor safety awareness, yet did not update the care plan to specify the required level of supervision for safe ambulation. Despite multiple falls and a recent injury requiring emergency department care, interventions remained generic, such as encouraging use of the call light and bed rest, which were not appropriate for a resident with severe cognitive impairment. Staff interviews confirmed that the care plan did not reflect the resident's current needs or address the specific risks associated with his condition. Another resident with severe cognitive impairment, encephalopathy, cerebral infarction, and a history of repeated falls also lacked an effective, individualized fall prevention plan. The care plan interventions focused on increased monitoring and keeping the resident in visual areas, but did not address the fact that her falls occurred while she was in bed unsupervised. Staff acknowledged that the interventions were not person-centered and did not specify the frequency or type of supervision needed to prevent falls in bed. The care plan was not updated to reflect the actual circumstances of the resident's falls, and interventions were not tailored to her specific risks. Facility policies required comprehensive, person-centered care plans with measurable objectives and individualized interventions based on ongoing assessments and changes in resident condition. However, the care plans for both residents were not revised to address their changing needs, did not include effective or specific interventions, and failed to prevent repeated falls and injuries. Staff and leadership interviews confirmed that the care plans were not accurate, not updated, and not effective in addressing the residents' fall risks.
Failure to Perform Fall Risk Assessments and Properly Test Wander Guard Devices
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for six of nine sampled residents. Nursing staff did not perform fall risk assessments for four residents with severe cognitive impairment, poor safety awareness, and a history of falls, both after falls and on a quarterly basis. Instead, staff completed only a Post Fall Review, which summarized the fall event but did not assess risk factors or provide a fall risk score. Interviews with LVNs and the DON confirmed that formal fall risk assessments were not conducted, despite the facility's policy requiring such assessments to identify risk factors and guide interventions. Medical records and MDS assessments indicated that these residents had severe cognitive impairment and multiple diagnoses that increased their fall risk, yet no fall risk assessments were found in their records. Additionally, licensed nurses did not follow manufacturer guidelines for checking the function of wander guard devices for two residents at risk of elopement. Staff were expected to check the placement and function of these devices every shift, but instead of using the recommended handheld testing device, they took residents to alarmed doors to see if the alarm would sound. This practice did not comply with the manufacturer's instructions, which required daily testing with a specific device. As a result, one resident was able to elope from the facility when their wander guard malfunctioned, and another was placed at risk for elopement. Interviews with staff, including LVNs, the DON, and the wander guard vendor, confirmed that the facility was not following the correct procedures for testing the wander guard devices. The facility's own policies required identification and monitoring of residents at risk for wandering and elopement, but these were not adequately implemented. Documentation and interviews revealed that staff were aware of the deficiencies in both fall risk assessment and wander guard testing, but failed to carry out the required practices, resulting in adverse events and increased risk for the residents involved.
Inaccurate MDS Assessment Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment accurately reflected the resident's healthcare and functional status. The resident in question had a documented history of dementia, epilepsy, muscle weakness, and difficulty walking, with a care plan noting an unsteady gait and declining health since early November. Despite these documented issues, the MDS completed on 11/23/24 assessed the resident as independent in ambulation, which was inconsistent with the care plan and staff observations. Multiple staff interviews confirmed that the resident required supervision to ambulate safely due to cognitive impairment and physical decline. Certified Nursing Assistants (CNAs) and nursing staff reported that the resident's ability to perform activities of daily living had decreased, and he exhibited a shuffling gait and episodes of leaning forward, increasing his fall risk. The resident was left unsupervised on the patio, where he subsequently fell and sustained a laceration above his left eye. Staff acknowledged that the resident did not have the mental capacity to call for help, further emphasizing the need for supervision. Review of facility records and interviews with the MDS Coordinators revealed that the MDS was completed using CNA documentation, but did not accurately reflect the resident's need for supervision. The Director of Nursing and other staff agreed that the MDS coding was incorrect and did not match the resident's actual condition as described in the care plan and by staff. The facility's policy required accurate and comprehensive assessments, but this was not followed, resulting in an inaccurate assessment and a preventable fall.
Failure to Protect Resident from Emotional Distress During Visitor Altercation
Penalty
Summary
The facility failed to protect and promote the rights of a resident to be free from abuse when a Licensed Vocational Nurse (LVN) and other staff left the resident in her room during a verbal altercation between four visitors. The incident occurred when the resident, her former roommate, and two visitors were present in the room, and two additional visitors entered, causing a loud and inappropriate verbal altercation. The resident reported feeling threatened and fearful, experiencing emotional distress, and an exacerbation of her anxiety following the incident. The resident, who was readmitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Major Depressive Disorder, and Anxiety Disorder, was not checked on by the staff after the incident. The LVN acknowledged not assessing the resident's emotional status or offering to move her to another room for safety. The Director of Nursing (DON) confirmed that the staff should have protected the resident from any form of abuse and assessed her for emotional distress, which was not done, violating the resident's rights as outlined in the facility's policy and procedure on resident rights.
Failure to Implement Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to implement its water management plan effectively, which is crucial for preventing the growth and spread of Legionella and other waterborne pathogens. The facility's policy, dated September 2022, outlined the need to identify areas in the water system where Legionella bacteria could grow and spread, and to take specific measures to control its introduction and spread. However, the facility did not conduct a comprehensive assessment to identify potential growth areas for Legionella. Testing conducted by an outside company in August 2023 revealed a sample from the kitchen sink had Legionella present, although at a non-detectable level. The Maintenance Supervisor admitted to not assessing or monitoring for Legionella, only checking water temperatures, and was unaware of the regulation requiring such assessments. Additionally, during an observation, it was noted that the facility's laundry room had wet, stained, and warped floor tiles due to a leaking pipe under a washing machine. The Account Manager confirmed the leak and stated that staff mopped the floor several times per shift to prevent standing water. The Maintenance Supervisor was unaware of the leak and did not routinely flush or clean drains and pipes to minimize standing water. The facility had previously received a positive Legionella test result from the kitchen's three-compartment sink, which led to the replacement of the sink and faucet after a subsequent negative test.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that six residents out of a sample of 36 were informed and provided with written information to formulate an advance directive upon admission. This deficiency was identified through a review of electronic medical records (EMR), which showed no evidence that the facility offered information or assistance related to advance directives to these residents or their families. The residents involved were admitted at various times, and the lack of documentation spanned several years, indicating a systemic issue in the facility's admission process. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed discrepancies in the facility's process for handling advance directives. The SSD stated that her role was to assess and identify if a resident had an advance healthcare directive, while the DON indicated that the Admission Nurse was responsible for collecting advance directives and offering assistance if needed. The facility's policy, dated September 2023, requires that residents or their representatives be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive, which was not adhered to in these cases.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of facility-initiated transfers to residents, their representatives, and the Ombudsman for five out of six sampled residents. This deficiency was identified during a review of the facility's policy and interviews with staff. The policy required that notices of transfer be provided in a form and manner that residents could understand, taking into account their educational level, language, communication barriers, and physical or mental impairments. However, the facility did not adhere to this policy, as evidenced by the lack of written notices for the transfers of several residents. One resident, who had a Power of Attorney on file, was transferred to the hospital without the responsible party being provided a copy of the transfer notice. Another resident, who was his own responsible person, experienced a change in mental status and was transferred to the hospital from a dialysis center without receiving a written notice of the transfer. Similarly, another resident was transferred to the hospital following a fall, and the facility failed to provide a written notice of the transfer to the resident. Interviews with facility staff revealed a lack of awareness regarding the requirement to provide written notifications of transfers. The Director of Nurses stated that nurses only filled out transfer/discharge notification forms if the resident was sent out directly from the facility, and the Administrator confirmed that the facility did not provide written Transfer/Discharge Notices. This lack of compliance with notification requirements was consistent across multiple cases, indicating a systemic issue within the facility's transfer and discharge processes.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for four residents out of a sample of 36. The facility's policy mandates that written information regarding bed hold policies be provided to residents or their representatives both in advance of any transfer and at the time of transfer. However, the facility did not adhere to this policy, as evidenced by the lack of written notices in the cases reviewed. For Resident R96, the facility's electronic medical record indicated a discharge to a hospital, but the bed hold section of the transfer notice did not include reserve bed payment information. Interviews with the resident and staff revealed that the resident did not receive the required paperwork, and the Director of Nursing was unaware of the need to include reserve bed payment information. Similarly, for Resident R130, who experienced a change in mental status and was transferred to a hospital, there was no indication that a written bed hold notice was provided. Resident R148 was transferred to a hospital following a fall, and the transfer notice did not include a written bed hold notice. The facility administrator confirmed that written notices were not provided. Resident R2 was transferred twice to a hospital, and in both instances, the bed hold section of the transfer notice did not indicate that a written notice was provided. Interviews with medical records staff confirmed that only verbal notices were given to the resident's representative, not written ones.
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Illustrative
What surveyors actually found near you
We read the 221 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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 Madera
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madera Care Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Chowchilla Memorial Healthcare District | 16.4 mi | ★★★★★ | 7 | 0 |
| Palms Care Center | 16.5 mi | ★★★★★ | 1 | 0 |
| Foundation Skilled Nursing | 17.4 mi | ★★★★★ | 38 | 0 |
| North Point Healthcare & Wellness Centre Lp | 17.7 mi | ★★★★★ | 0 | 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.