Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marina Pointe Healthcare & Subacute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, right-sided hemiplegia/hemiparesis, and total dependence for ADLs was transferred to a GACH for hypotension, desaturation, and other acute symptoms, where imaging revealed a subacute displaced fracture of the right humerus. The hospital social worker reported the fracture to the facility, and the family later questioned the DON and DOR about how the fracture occurred, but facility leadership stated they were unaware of any fall or injury. Despite its policy requiring that unusual occurrences threatening resident welfare be reported to CDPH within 24 hours, the facility did not report the fracture because staff did not know how it happened, resulting in a failure to follow mandated unusual occurrence reporting procedures.
A resident with right-sided hemiplegia, severe cognitive impairment, and total dependence for ADLs repeatedly exhibited pain behaviors when staff moved the right arm during care. CNAs reported the pain to charge nurses, and a family member posted a note above the bed asking staff to be careful with the painful arm. An LVN saw the note, briefly checked the arm for swelling or redness, but did not fully assess range of motion, complete a COC, contact the family, or notify the physician. The resident was later sent to a GACH for a change in condition, where imaging showed a displaced fracture of the right humerus. The DON and DOR reported they were unaware of any fall or injury, and the DON acknowledged only a verbal inquiry was done, without the written investigation and incident reporting required by facility policy. These failures led to the resident’s arm pain not being timely assessed, the MD not being notified, and pain interventions not being provided.
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for multiple ADLs did not have a care plan addressing pain management, mobility deficits, or ADL care, despite PT and OT documentation of poor sitting balance and need for maximal assistance. CNAs reported the resident consistently moaned and said "ouch" when the right arm was moved during dressing and other care, and a family member posted a note above the bed asking staff to treat the weaker, painful side with care. The MDS nurse and DON acknowledged that required care plans for mobility, ADLs, and pain had not been developed, even though facility policy called for comprehensive, person-centered care plans with measurable objectives and timetables.
A resident with right-sided hemiplegia, severe cognitive impairment, and multiple contractures repeatedly showed and voiced pain with movement of the right arm during ADL care, but CNAs did not complete required Stop and Watch forms and only verbally reported concerns to various nurses without clear follow-through. An LPN observed facial grimacing with repositioning but did not treat it as a change in condition, and another LPN saw a family-posted note instructing staff to be careful with the resident’s painful right arm yet did not assess the arm, contact the family, notify the physician, or complete a change of condition report. The facility’s pain assessment and management policy, which required systematic assessment, documentation, and intervention for acute or worsening pain, was not implemented, resulting in delayed assessment, physician notification, and pain management, and the resident was later found at the hospital to have a right shoulder fracture.
Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during high-contact ADL care for two residents on EBP. In both cases, an isolation cart and EBP signage were posted at the room entrances, but CNAs entered and provided care without wearing required isolation gowns. Each resident had severe cognitive impairment, was dependent for ADLs, and had complex medical conditions including chronic respiratory failure and ventilator dependence; one also had COPD and the other had Parkinson disease with GT and trach. Care plans and, for one resident, physician orders directed implementation of EBP for incontinence and other high-contact care, and facility policy required staff to don gowns and gloves before such activities. During interviews, the CNAs acknowledged that the signage meant gowns should be worn for infection control, and an LVN confirmed that EBP includes use of gowns and gloves before providing care.
A resident with respiratory failure, pneumonia, a tracheostomy, and ventilator dependence had incomplete and inaccurate documentation of respiratory assessments and change in condition. An LVN assessed the resident’s breath sounds but left the breath sound section of the Licensed Nurse Record blank and did not chart the findings in progress notes. A respiratory therapist documented a progress note with a time that conflicted with the time recorded on a change-of-condition form and the EMS run sheet, and leadership confirmed the documentation times were inaccurate and the record confusing. These actions and omissions resulted in an inaccurate and incomplete medical record.
Three residents were allowed to go out on pass without proper documentation specifying whether they required accompaniment or the duration of their leave, and staff failed to assess and document their condition before and after leaving, contrary to facility policy. The DON confirmed that required procedures for OOP orders and resident assessments were not followed.
Three residents with significant cognitive and physical impairments were transferred to hospitals without receiving the required written notices about bed-hold policies or transfer/discharge, as mandated by facility policy. The DON confirmed that there was no process in place to provide these notifications, resulting in residents and their representatives not being informed of their rights.
A resident with a tracheostomy and complex care needs was transferred to a hospital for a planned procedure, and although a 7-day bed-hold was requested and ordered, the facility failed to hold the original sub-acute bed. Instead, the bed-hold was moved to a skilled nursing unit room that could not accommodate the resident's medical needs, resulting in the resident not being readmitted within the required period.
Two residents requiring mechanical ventilation did not receive care according to professional standards when one resident's secondary ventilator alarm was left off after a shower, and another resident's primary ventilator alarm was set to low while the secondary alarm was out for repair. Both residents had significant cognitive and physical impairments, and staff interviews confirmed lapses in timely alarm management and communication.
Two residents in the facility had nasal cannulas that were not dated or labeled, contrary to the facility's policy requiring replacement every seven days. One resident with COPD and respiratory failure had a nasal cannula with potential dust accumulation, while another resident with similar conditions had condensation inside the cannula, posing a risk of bacterial growth. Additionally, the facility's laundry room contained opened beverage containers, potentially attracting pests.
A resident with dementia and other health issues was observed smoking unsupervised, contrary to their care plan requiring supervision. Additionally, a facility door and gate were left unlocked, posing a risk of residents leaving unsupervised. Staff acknowledged these lapses, which contravened the facility's safety policies.
The facility failed to provide appropriate IV care for two residents, leading to potential complications. One resident's IV dressing was not changed every 7 days, nor was the IV site changed every 72 hours as ordered. Another resident's IV site was not labeled with the date and time of insertion, hindering proper monitoring. These deficiencies were confirmed by staff and were against the facility's policies.
A facility failed to complete a POLST form for a resident with chronic conditions, leaving part D incomplete and unclear if an advance directive was in place. Despite the resident's capacity to make decisions, their cognition was moderately impaired, requiring assistance with daily activities. A nurse confirmed the oversight, highlighting the importance of documenting the resident's medical wishes.
The facility failed to maintain a comfortable sound level, as frequent alarm noise from an emergency door disturbed two residents. The alarm was triggered multiple times daily as staff used the door for transporting carts and retrieving shower chairs. Both residents, who have clear cognition and require moderate assistance, reported the noise as annoying, with one resident stating it sometimes disrupted their sleep. Staff acknowledged the issue, noting the potential for disturbance.
A resident with COPD, respiratory failure, and diabetes was observed smoking, but their MDS did not indicate tobacco use. The MDS Nurse confirmed the coding error, which could affect the resident's care plan, especially regarding safety while smoking and using oxygen.
A resident with chronic respiratory failure, major depressive disorder, bipolar disorder, and seizures did not have a comprehensive care plan in place, particularly for the use of hand mittens or restraints. Despite the resident's severely impaired cognition and need for dependent assistance, the facility staff, including an LVN and RN, confirmed the absence of a necessary care plan, which was acknowledged by the DON. This oversight contravened the facility's policies on care plans and restraint use.
A resident with COPD, respiratory failure, and diabetes was observed smoking without protective gear, despite a care plan requiring it. The care plan was not updated to reflect the resident's refusal to wear protective gear, posing a risk of burns. The facility's policy mandates ongoing assessments and revisions, which were not followed.
A resident with conditions complicating wound healing was observed without heel protectors while in bed, contrary to physician orders. The resident's MDS indicated a risk of pressure injury, and the facility's policy on pressure relief was not followed, potentially leading to pressure sores.
A resident with multiple health issues, including a risk for pressure injuries, was not provided with heel protectors as ordered by the physician while in bed. Observations revealed the absence of heel protectors, and an LVN confirmed the oversight, highlighting a failure to adhere to physician orders for skin management.
A facility failed to ensure proper storage and labeling of medications, as a bottle of Pro-Stat was found with sticky spillage in a medication cart. An LVN acknowledged that staff should clean such spills to prevent cross contamination. The facility's policy requires nursing staff to maintain clean and sanitary storage areas.
A resident with a history of seizures did not receive a scheduled Depakote level test as ordered by the physician. The test, intended to monitor the drug level and adjust dosing, was missed on the scheduled date, potentially affecting the resident's treatment. The facility's policy required such tests to be arranged and monitored by staff.
A facility failed to document the insertion and removal of IV lines for a resident with sepsis, as required by their policy. The resident's medical records lacked details on when and by whom the IV lines were placed or removed, despite the resident being prescribed IV-administered antibiotics. This deficiency was confirmed during a review of the resident's records and an interview with an RN.
The facility did not meet the required minimum living space of 80 square feet per resident in several shared rooms, each measuring only 235 square feet for three beds. This was confirmed through documentation review and observation. The Administrator noted potential negative impacts on residents' psychosocial well-being, safety, and comfort.
A resident with dementia and hemiplegia was observed wearing an ankle-foot orthotic device without a physician's order. Facility staff confirmed the device was necessary for maintaining a neutral ankle position, but the resident's care plan did not include the device, contrary to facility policy. This oversight risked inappropriate care and potential complications.
A resident with a fractured right index finger did not receive the prescribed buddy strap for nine days, as indicated by blank spaces in the Treatment Administration Record. Interviews with staff confirmed the oversight, which could delay healing. The responsibility for applying and documenting the buddy strap fell on the treatment nurse and LVNs, as outlined in their job descriptions.
A resident with a history of unauthorized departures and complex medical conditions was not adequately supervised, leading to multiple instances of elopement. The facility failed to activate exit door alarms, and the resident's elopement risk was not accurately assessed. Despite having a care plan requiring monitoring, staff did not implement necessary interventions, resulting in a deficiency in providing a safe environment.
A resident with cellulitis in both lower limbs did not receive wound care as ordered, and weekly assessments were not documented. The resident refused treatment once, and there was no follow-up documentation. A nurse later found maggots on the gauze, highlighting a severe lapse in care.
A facility failed to install alarms on all exit doors, resulting in a high-risk resident with severe cognitive impairment leaving undetected. Staff did not hear any alarms, and the front door, the only entrance and exit, lacked an alarm. The facility's policy required audible alarms to prevent unsupervised exits.
The facility failed to ensure CNAs had the necessary competencies to document and monitor meal intake percentages for three residents, leading to incomplete records and increased risk of undernourishment. Despite specific dietary orders, meal intake was not consistently documented, especially when food was brought in by families.
Failure to Timely Report Resident Fracture as an Unusual Occurrence
Penalty
Summary
The deficiency involves the facility’s failure to follow its Unusual Occurrence policy requiring that events threatening a resident’s welfare, safety, or health be reported to the California Department of Public Health (CDPH) within 24 hours. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment, and dependence on staff for all ADLs, including transfers and mobility. The resident was transferred to a general acute care hospital for hypotension, desaturation, shortness of breath, fever, and further evaluation. A chest radiology report at the hospital identified a subacute displaced fracture of the surgical neck of the right humerus. The facility’s Unusual Occurrence policy, dated 3/2010, required reporting such events to CDPH within 24 hours. The sequence of events shows that the family member learned of the right shoulder fracture from the hospital x‑ray results and then informed the DON two days after the hospital transfer. The DON and DOR reported being surprised by the fracture and indicated there had been no staff reports of falls or injuries involving the resident. The GACH social worker stated she had called the facility the day after the hospital transfer and informed a facility representative of the right shoulder fracture. Despite this information, the DON acknowledged that the facility did not report the fracture to CDPH because they did not know what had happened, even though the ADM stated that unusual occurrences were required to be reported so CDPH could determine through investigation whether the event constituted an unusual occurrence. This failure to report the fracture as an unusual occurrence within the required timeframe constituted the cited deficiency.
Failure to Assess and Investigate Resident’s Right Arm Pain and Shoulder Fracture
Penalty
Summary
The deficiency involves the facility’s failure to assess and investigate a resident’s right arm pain and a subsequent right shoulder fracture. The resident had a history of hemiplegia and hemiparesis affecting the right dominant side, severe cognitive impairment, and dependence on staff for ADLs. A CNA reported that during ADL care and dressing, the resident consistently reacted to movement of the right arm with moaning and saying “ouch,” and stated that charge nurses had been informed of this pain, though she could not recall specific dates or names. Another CNA stated that such complaints of right arm pain could indicate a possible fracture that staff were unaware of and needed to be assessed, addressed, and investigated. A family member observed that the resident had pain in the right arm when it was touched or moved and posted a note above the bed instructing staff to be mindful when caring for and repositioning the right arm because of the pain. An LVN acknowledged seeing this posted note, briefly touching the arm to check for swelling or redness, but did not further assess range of motion or pain with movement, did not contact the family member about the note, did not complete a change of condition assessment, and did not notify the physician. The DON later stated that the posted sign referred to the resident’s contracted right arm and that nurses were required to address concerns about the resident’s right arm pain, with charge nurses responsible for completing change of condition documentation and RNs to assess and notify the physician as needed. The resident was transferred to an acute hospital for hypotension and elevated pulse, and a chest x-ray performed there revealed a subacute displaced fracture of the surgical neck of the right humerus. The family member reported returning to the facility two days later to ask how the fracture occurred and was told by the DOR and DON that the facility was unaware of it and had no reports of falls or injuries. The DON stated that when she became aware of the fracture, she conducted only a verbal investigation with nurses and could not provide evidence of a written investigation, despite facility policy requiring prompt initiation and documentation of incident investigations and completion of an incident report within 24 hours. These actions and inactions resulted in the resident’s right arm pain not being timely assessed, the physician not being notified, and interventions to manage and treat the pain not being provided.
Failure to Develop Resident-Centered Care Plan for Pain, Mobility, and ADLs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-centered care plan addressing pain management, mobility deficits, and ADL care for a resident with significant functional and cognitive impairments. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, musculoskeletal symptoms, and neurologic symptoms such as motor dysfunction. A History and Physical documented that the resident lacked capacity to understand and make decisions, and an MDS assessment showed severe cognitive impairment and dependence on staff for multiple ADLs, including dressing, toileting, transfers, mobility, oral hygiene, bathing, and dressing tasks. Therapy documentation further identified extensive functional limitations. A PT progress note indicated the resident required maximal assistance for bed mobility and sitting balance, with a need for upper extremity support. An OT progress note documented poor sitting balance during ADLs, also requiring maximal assistance and upper extremity support. Despite these findings, review of the resident’s care plans showed there were no care plans developed for pain management, mobility deficits, or ADL care, even though the facility’s policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet physical, psychosocial, and functional needs. Staff interviews confirmed ongoing pain complaints and the absence of appropriate care planning. CNAs reported that during ADL care, particularly when putting on the resident’s shirt or moving the right arm, the resident would moan, say “ouch,” and complain of pain, and that charge nurses had been informed, though dates and names could not be recalled. A family member stated they observed the resident having pain when the right arm was touched or moved and had posted a note above the bed reminding staff to be mindful of the painful, weaker side. Another CNA stated the resident’s complaints of right arm pain with movement could indicate a possible fracture needing assessment. The MDS nurse and DON both acknowledged that there were no care plans for mobility, ADLs, or pain, and stated that such care plans should have been developed and that nurses were responsible for creating and using these plans to guide care.
Failure to Assess, Document, and Manage Ongoing Right Arm Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with its own pain policy and professional standards for one resident with significant neurologic and musculoskeletal impairments. The resident had a history of hemiplegia and hemiparesis affecting the right dominant side following a cerebral infarction, multiple joint contractures, severe cognitive impairment, and dependence on staff for all ADLs. Despite these conditions and the facility’s written Pain Assessment and Management policy requiring staff to assess for pain, recognize its presence, identify characteristics, address underlying causes, and develop and monitor pain interventions, staff did not consistently assess, document, or act upon ongoing signs and reports of right arm pain. Multiple CNAs reported that whenever they provided ADL care, including dressing and putting on the resident’s shirt, the resident would complain of right arm pain, moan, say “ouch,” or otherwise show signs of pain when the right arm was moved or touched. CNAs stated they informed various charge nurses/LVNs of the pain but could not recall specific names or dates, and they did not complete Stop and Watch forms to document these changes in condition as required. One CNA believed the pain complaints were “normal” due to the contracture and did not recognize the need for further assessment, while another CNA acknowledged that such pain could indicate a serious underlying issue. A nurse (LVN 1) reported observing facial grimacing during repositioning but did not document this as a change in condition because there were “no observed changes” in the resident’s pain. A family member posted a written note above the resident’s bed instructing staff to be mindful when touching, moving, or repositioning the resident’s right arm because of pain. LVN 2 acknowledged seeing this note but did not move or extend the arm to assess for pain, did not contact the family member to clarify the concern, did not notify the physician, and did not complete a change of condition report. The DON stated that charge nurses were responsible for completing change of condition reports when CNAs reported pain and that RNs were to assess the arm and notify the physician, but this process was not carried out. As a result of these failures to assess, document, and report the resident’s ongoing right arm pain and the posted family instruction, there was a delay in assessment, physician notification, and pain management interventions. The resident was later sent to a hospital for a change in condition, where imaging revealed a right shoulder fracture.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure CNAs implemented Enhanced Barrier Precautions (EBP) as required when providing activities of daily living (ADL) care to two residents on EBP. For Resident 2, surveyors observed an isolation cart and an EBP sign posted at the room entrance, but CNA 1 entered the room without donning an isolation gown and proceeded to assist the resident with ADL care. Resident 2’s records showed diagnoses of chronic respiratory failure, COPD, and ventilator dependence, with documentation that the resident lacked decision-making capacity and had severe cognitive impairment. The MDS indicated the resident was dependent on staff for ADLs, and the care plan for altered bladder elimination due to incontinence directed staff to implement EBP. For Resident 3, surveyors observed an isolation cart and an EBP sign at the room entrance, yet CNA 2 was in the room providing ADL care without wearing an isolation gown. Resident 3’s records documented chronic respiratory failure, Parkinson disease, and ventilator dependence, with an H&P indicating the resident lacked capacity to understand and make decisions and an MDS showing severe cognitive impairment and dependence for ADLs. Physician orders specified EBP related to the resident’s gastrostomy tube and tracheostomy, including applying EBP to prevent spread of infection during specific care activities such as toileting and changing incontinent briefs, and the care plan for bowel and bladder incontinence also directed implementation of EBP. During interviews, CNA 1 and CNA 2 each acknowledged that the posted EBP sign meant a gown should be worn for infection control, and an LVN confirmed that EBP includes donning gown and gloves before high-contact resident care. The facility’s EBP policy required staff to don gowns and gloves before performing high-contact resident activities such as bathing, providing hygiene, changing briefs, or assisting with toileting.
Inaccurate and Incomplete Documentation of Respiratory Status and Change in Condition
Penalty
Summary
The deficiency involves failures in accurate and complete documentation of a resident’s respiratory status and change in condition. The resident was admitted with acute and chronic respiratory failure, pneumonia, a tracheostomy, and ventilator dependence, and had documented moderate cognitive impairment and dependence on staff for most activities of daily living. The resident’s History and Physical noted coarse breath sounds, and the facility’s policies on Charting and Documentation and Change in a Resident’s Condition or Status required that all services, assessments, and changes in condition be documented objectively, completely, and accurately in the medical record. On the date of the incident, the Licensed Nurse Record for the resident showed a blank section where the breath sound assessment should have been documented. During interview, the LVN assigned to the resident stated that he had assessed the resident’s breath sounds but did not document his findings in either the Licensed Nurse Record or the Progress Notes, leaving the breath sound section blank. He acknowledged that, per facility policy, all observations and services provided, including breath sound assessments, should have been documented to facilitate communication among the care team and that inaccurate documentation prevents the team from knowing the resident’s condition. The resident’s Progress Notes and Change of Condition (COC) form for the same date contained conflicting times for the onset of respiratory distress and unresponsiveness. The Progress Notes, written by a respiratory therapist, indicated that the resident experienced respiratory distress and required emergency transport at 4:15 p.m., while the COC indicated the resident was found unresponsive and pulseless at 4:23 p.m., and the paramedic run sheet showed dispatch at 4:26 p.m. The Respiratory Manager stated that the respiratory therapist likely wrote the Progress Note later in the evening but inaccurately timed it as 4:15 p.m. instead of the actual time it was written, and the DON confirmed that the records were confusing and unclear, with the Progress Note time being inaccurate. These discrepancies and omissions resulted in an inaccurate and incomplete medical record for the resident.
Failure to Follow Out-on-Pass Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to follow its own policy and procedure regarding residents going out on pass (OOP) for three sampled residents. Specifically, OOP orders for these residents did not indicate whether the residents could leave unaccompanied by a responsible person or specify the length of time they were permitted to be out. For example, one resident with moderate cognitive impairment and physical assistance needs had an OOP order that did not clarify if accompaniment was required or the duration of the pass. Another resident's OOP order allowed them to go out with a family member but did not specify the length of time for the pass. A third resident's OOP order also lacked information on accompaniment and duration. Additionally, the facility did not ensure that residents were assessed before and after going out on pass, as required by policy. For one resident, there was no documentation of an assessment to determine stability prior to leaving or upon return. Staff interviews confirmed that assessments should be conducted to establish a baseline and ensure safety, but these steps were not documented or performed as required. The Director of Nursing acknowledged that the facility's policy was not followed, noting that OOP orders were missing critical information such as accompaniment requirements and duration, and that assessments before and after OOP were not documented. The facility's policy clearly states that in the absence of a specific order allowing unaccompanied leave, a responsible person must accompany the resident, and that licensed nurses must assess and document the resident's condition before and after OOP. These procedures were not adhered to for the residents in question.
Failure to Provide Required Written Notices for Bed-Hold and Transfer/Discharge
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the provision of written notices for bed-hold and transfer/discharge to residents or their representatives upon transfer to a general acute care hospital. Specifically, three residents with significant cognitive and physical impairments were transferred to hospitals, but neither they nor their responsible parties received the required written notifications about bed-hold options or transfer/discharge, as mandated by facility policy. The Director of Nursing (DON) confirmed during interviews that there was no process in place to generate and deliver these written notices within the required timeframe. For one resident with a history of tracheostomy, gastrostomy, hemiplegia, and major depressive disorder, the records showed she was dependent for most activities of daily living and unable to make medical decisions. Although a bed-hold was ordered and a family member requested it, there was no documentation that a written notice of bed-hold or transfer/discharge was provided to the resident or her representative. The family member also confirmed not receiving any written notification or information about the resident's rights or room change at the time of transfer. Two additional residents, one with severe dementia and another with tracheostomy, gastrostomy, and ventilator dependence, were also transferred to hospitals without receiving the required written notices. Both residents had significant cognitive impairments and required substantial or total assistance with daily activities. The DON acknowledged that the facility's policies on bed-hold and transfer/discharge documentation were not followed for these residents, and that the lack of written notification resulted in the residents and their representatives not being informed of their rights.
Failure to Hold Appropriate Bed for Resident with Tracheostomy During Hospital Transfer
Penalty
Summary
The facility failed to follow its own policy and procedure regarding bed-holds and resident returns when a resident with complex medical needs, including a tracheostomy, was transferred to a general acute care hospital for a planned cardiology clearance. The resident, who was dependent for all activities of daily living and unable to make medical decisions or communicate, had a responsible party who requested a 7-day bed-hold at the time of transfer. Documentation confirmed that the resident and family were informed of the right to a 7-day bed-hold, and a physician's order for the bed-hold was in place. Despite these measures, the facility did not hold the resident's original sub-acute bed, which was equipped to meet the resident's specialized care needs. Instead, the facility transferred the bed-hold to a room in the skilled nursing unit that was not equipped for residents with tracheostomies. The daily census records showed the resident's name was moved from the sub-acute unit to the skilled nursing unit during the bed-hold period, and the sub-acute bed was not kept vacant for the resident's potential return. Interviews with facility staff, including the DON, confirmed that the bed-hold was not appropriately maintained in the sub-acute unit, and the new room assignment could not accommodate the resident's medical requirements. As a result, the resident was not readmitted to the facility within the 7-day bed-hold period, contrary to facility policy and the resident's rights as outlined in the bed-hold notification and informed consent documentation.
Failure to Ensure Proper Ventilator Alarm Function and Settings for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required mechanical ventilation. For one resident with anoxic brain damage, tracheostomy, and respiratory failure, the secondary ventilator alarm located outside the room was observed to be turned off for approximately 25 minutes after the resident returned from a shower. The respiratory therapist responsible for the resident stated that the alarm was turned off during the shower and was not turned back on in a timely manner upon the resident's return. The resident was cognitively impaired and totally dependent on staff for activities of daily living, including respiratory care. For another resident with chronic respiratory failure, COPD, and dependence on a ventilator, the secondary ventilator alarm outside the room was not present because it was broken and had been sent to maintenance for repair. Additionally, the primary ventilator alarm at the bedside was set to a low volume, making it difficult for both the resident and staff to hear when the room door was closed. The respiratory therapist confirmed that the alarm should have been set to medium or high and acknowledged the increased risk due to the absence of the secondary alarm and the low setting of the primary alarm. The resident had moderate cognitive impairment and required substantial to maximal assistance with daily activities. Interviews with staff revealed a lack of timely communication and follow-up regarding the repair and reinstallation of the ventilator alarm. The maintenance supervisor was not informed about the broken alarm until he discovered it in his office, and the director of nursing confirmed that both primary and secondary ventilator alarms should be operational and set to high volume to ensure prompt care. Facility policies required immediate response to ventilator alarms and corrective action within the scope of practice, but these procedures were not followed in the cases observed.
Infection Control Deficiencies in Nasal Cannula Management
Penalty
Summary
The facility failed to ensure that nasal cannulas for two residents, identified as Resident 67 and Resident 147, were properly dated and labeled. This oversight was observed during inspections in the residents' rooms, where the nasal cannulas were attached to oxygen tanks but lacked any indication of when they were last replaced. The facility's policy requires oxygen tubing to be replaced every seven days, but the absence of dating and labeling made it impossible to verify compliance with this policy. Licensed Vocational Nurse (LVN) 3 confirmed the lack of labeling and acknowledged the risk of infection due to potential dust or dirt accumulation. Resident 67, who has chronic obstructive pulmonary disease (COPD), respiratory failure, and diabetes mellitus, was found with a nasal cannula that was not dated or labeled. The resident's cognitive abilities were moderately impaired, requiring moderate assistance for personal care and oxygen therapy. LVN 3 noted that the undated nasal cannula could lead to respiratory infections due to inhalation of dust or dirt. Resident 147, diagnosed with COPD, respiratory failure, and pneumonia, also had a nasal cannula that was not dated or labeled. This resident's cognitive abilities were severely impaired, making them dependent on staff for personal care and oxygen therapy. LVN 3 observed condensation inside the nasal cannula, which could harbor bacteria and increase the risk of respiratory infection. Additionally, the facility failed to maintain cleanliness in the laundry room, where opened and emptied beverage containers were found, potentially attracting pests.
Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who required supervision while smoking. Resident 9, who has diagnoses including hypertension, dementia, and congestive heart failure, was observed smoking unsupervised on the facility's smoking patio. The resident's care plan and smoking safety evaluation indicated that supervision was necessary during designated smoking times. However, during an observation, the resident was seen smoking without staff supervision, as the assigned Activity Assistant was on a break and not present to monitor the resident. This lack of supervision could have resulted in the resident injuring themselves while smoking. Additionally, the facility did not adequately monitor entrance and exit doors to prevent residents from leaving the premises unattended. An observation revealed that a door and an outside gate, which should have been locked, were left unlocked, allowing potential unsupervised egress. Staff interviews confirmed that the door was kept unlocked for staff convenience, despite a notice indicating it should remain locked. The unlocked gate was also acknowledged as a safety concern, as it could allow residents to leave the facility and potentially sustain injuries. The facility's policy emphasized the importance of maintaining a safe environment free from accident hazards, yet these practices were not adhered to, posing a risk to resident safety.
Failure to Provide Appropriate IV Care
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) care for two residents, leading to potential complications. For one resident, the facility did not change the IV dressing every 7 days and did not change the IV site every 72 hours as ordered. This resident was readmitted with diagnoses including sepsis and a urinary tract infection and was prescribed Zosyn to be administered via IV. Despite the order to change the IV site every 72 hours, documentation showed that the IV site was not changed, and the dressing was not replaced every 7 days, as confirmed by a registered nurse. The facility's policy required transparent dressings to be changed with each site rotation or at least every 7 days. For another resident, the facility failed to label the IV site with the date and time of insertion. This resident had diagnoses including hypertension, dementia, and diabetes and required substantial assistance with daily activities. During an observation, it was noted that the IV dressing lacked an insertion date and time, which is necessary for monitoring and timely changing of the IV to prevent infection. The facility's policy stated that nurses should write the date, time, and initials on the dressing label after IV insertion.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) form was completed for one of the sampled residents, identified as Resident 69. This oversight was discovered during a review of the resident's records, which showed that part D of the POLST form was incomplete. The resident, who had been admitted and readmitted to the facility, had a medical history that included chronic obstructive pulmonary disease, respiratory failure, and diabetes mellitus. Despite having the capacity to understand and make decisions as indicated in the resident's History and Physical, the Minimum Data Set assessment noted that the resident's cognition was moderately impaired, requiring partial assistance for daily activities. During an interview with a registered nurse, it was confirmed that the POLST form was incomplete, and it was unclear whether the resident had an advance directive. The nurse acknowledged that it was the responsibility of all nurses to ensure the POLST was filled out and emphasized the importance of completing part D to understand the resident's medical wishes in the event of a change in condition. The facility's policy on advance directives stated that residents have the right to formulate such directives, and information regarding their existence should be clearly documented in the medical record.
Frequent Alarm Noise Disturbs Residents
Penalty
Summary
The facility failed to ensure a comfortable sound level for residents, specifically affecting two residents, Resident 33 and Resident 56. The deficiency was observed when staff frequently set off an alarm while exiting the emergency door, causing disturbances throughout the day and night. Resident 33, who has clear cognition and requires moderate assistance for activities of daily living, reported that the alarm was constantly going off, causing annoyance and sometimes waking them up. Similarly, Resident 56, who also has clear cognition and requires moderate assistance, expressed that the alarm noise was very annoying. Observations and interviews revealed that the alarm was triggered multiple times as staff used the door to transport carts and retrieve shower chairs, with the alarm sounding at various times throughout the day. Licensed Vocational Nurse 1 and the Director of Nursing acknowledged the frequent alarm noise, noting that it was annoying and could potentially disturb residents' rest. The facility's policy on providing a homelike environment emphasizes maintaining comfortable noise levels, which was not adhered to in this instance.
Inaccurate Assessment of Resident's Smoking Habits
Penalty
Summary
The facility failed to accurately assess a resident for smoking, which led to a deficiency in the resident's care plan. The resident, who was diagnosed with chronic obstructive pulmonary disease (COPD), respiratory failure, and diabetes mellitus, was observed smoking on the patio. However, the Minimum Data Set (MDS) for the resident did not indicate tobacco use, despite the resident's smoking behavior. This discrepancy was confirmed during an interview with the MDS Nurse, who acknowledged that the MDS was incorrectly coded and needed to be updated to reflect the resident's current tobacco use. The inaccurate assessment of the resident's smoking habits had the potential to impact the development and implementation of an individualized care plan, particularly concerning the resident's safety while smoking and using oxygen. The facility's policy and procedure on the Resident Assessment Instrument (RAI) emphasized the importance of accurate assessments to prevent harm and ensure compliance with care planning requirements. The MDS Nurse stated that the MDS is updated annually, quarterly, and can be modified, highlighting the need for accurate coding to prevent potential harm to the resident.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was formulated for a resident, identified as Resident 76, who was part of a sample of 19 residents. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 76 had multiple diagnoses, including chronic respiratory failure with hypoxia, major depressive disorder, bipolar disorder, and seizures, and was assessed to have severely impaired cognition, requiring dependent assistance for activities of daily living. Despite these needs, there was no care plan in place for the use of hand mittens or restraints, which are critical for the resident's care and safety. Interviews with the facility's Licensed Vocational Nurse (LVN) and Registered Nurse (RN) revealed that care plans are supposed to be initiated upon admission and updated with any change in the resident's condition. However, both the LVN and RN confirmed that a care plan for the use of hand mittens or restraints was not created for Resident 76. The Director of Nursing (DON) also acknowledged that care plans are necessary to meet the resident's needs and that the absence of such a plan could result in unmet needs. The facility's policies on care plans and restraint use emphasize the importance of developing comprehensive, person-centered care plans with measurable objectives, which were not adhered to in this case.
Failure to Revise Care Plan for Smoking Safety
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 69, had a revised care plan to include wearing protective gear while smoking. Resident 69, who has chronic obstructive pulmonary disease, respiratory failure, and diabetes mellitus, was observed smoking without protective gear on the patio. The resident's care plan, dated March 6, 2024, indicated the need for observation, constant supervision, and protective gear while smoking, but did not list wearing protective gear as an intervention. This oversight had the potential to place the resident at risk of burns. During a review, it was noted that Resident 69's cognition was moderately impaired, requiring partial assistance for personal care. Despite the care plan's requirements, the resident refused to wear the protective gear, which was identified as an apron to prevent burns. The Registered Nurse (RN) acknowledged that the care plan should have been revised to reflect the resident's refusal to comply with wearing protective gear. The facility's policy on care plans emphasized the need for ongoing assessments and revisions as resident conditions change, which was not adhered to in this case.
Failure to Provide Heel Protectors for Resident at Risk of Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 6, had heel protectors on while lying in bed, as required by the physician's orders. Resident 6 was admitted with diagnoses including metabolic encephalopathy, respiratory failure, and diabetes mellitus, which are conditions that can complicate wound healing. The resident's Minimum Data Set (MDS) indicated a risk of pressure injury and a dependency on staff for personal care. Despite these risks, observations on two separate occasions revealed that Resident 6 was not wearing heel protectors while in bed, and there were no heel protectors available in the resident's room. During an interview with a Licensed Vocational Nurse (LVN), it was confirmed that the heel protectors were intended to prevent pressure sores on the resident's heels by reducing friction and pressure. The facility's policy on Support Surface Guidelines, which aims to prevent skin breakdown and promote circulation, was not adhered to in this instance. This oversight had the potential to result in pressure sores for Resident 6, highlighting a failure in providing the necessary care and services as per the resident's care plan.
Failure to Follow Physician Orders for Skin Management
Penalty
Summary
The facility failed to ensure that staff followed physician orders for one of the sampled residents, identified as Resident 6. Resident 6 was admitted with diagnoses including metabolic encephalopathy, respiratory failure, and diabetes mellitus, and was at risk for pressure injuries. The physician's orders, dated December 26, 2023, specified that Resident 6 should wear heel protectors while in bed for skin management. However, during observations on February 18 and February 20, 2025, Resident 6 was found lying in bed without heel protectors. Licensed Vocational Nurse (LVN) 4 confirmed during an interview and record review that the physician's orders required heel protectors to be worn while Resident 6 was in bed. LVN 4 acknowledged the importance of following physician orders to prevent skin breakdown. The facility's policy and procedure on physician orders, dated January 2020, indicated that all physician orders should be reviewed for accuracy on a monthly basis. Despite this policy, the failure to adhere to the physician's orders for Resident 6's skin management was observed, indicating a lapse in following established procedures.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as evidenced by a bottle of Pro-Stat, a liquid protein supplement, found with a large amount of sticky spillage on the container and inside a medication drawer in medication cart #4. During an observation and interview with an LVN, it was noted that a plastic bag with another medication was stuck to the Pro-Stat bottle, and the LVN acknowledged that the staff are responsible for cleaning such spills to prevent cross contamination. The facility's policy and procedure on the storage of medications, dated April 2007, requires nursing staff to maintain storage and preparation areas in a clean and sanitary manner.
Failure to Conduct Scheduled Depakote Level Test
Penalty
Summary
The facility failed to ensure that a Depakote level test was completed for a resident as per the physician's order. The resident, who was admitted with diagnoses including hypertension, diabetes, and seizures, had a physician's order for a Depakote level to be checked on the first Monday of every month. However, the test was not conducted on the scheduled date of February 3, 2025, following the last test on January 6, 2025. This oversight was identified during a review of the resident's medical records and confirmed by a registered nurse, who acknowledged the missed test. The resident's care plan included the completion of lab work as ordered to monitor and manage recurrent seizures. The facility's policy required staff to arrange for necessary tests and for nurses to ensure these tests were conducted to monitor drug levels. The failure to perform the Depakote level test as ordered could potentially result in inappropriate dosing, which might lead to seizures if the drug level is too low or other negative outcomes if the level is too high.
Failure to Document IV Line Management
Penalty
Summary
The facility failed to ensure proper documentation related to the insertion and discontinuation of intravenous (IV) lines for a resident who was readmitted with sepsis and a urinary tract infection. The resident was prescribed Zosyn to be administered via IV every 8 hours for 10 days. However, the medical records lacked documentation of when and by whom the IV lines were inserted or removed. Specifically, there was no record of the IV line placement in the right hand on 9/9/2024, nor was there documentation of its removal. Additionally, there was a lack of documentation regarding the removal of an IV line from the left arm between 9/11/2024 at 7:08 a.m. and 9/11/2024 at 2:02 p.m. The facility's policy requires that all services provided to residents be documented in their medical records, including treatments or services performed. The absence of documentation regarding the IV lines for this resident indicates a failure to adhere to this policy. This deficiency was identified during a review of the resident's medical records and an interview with a registered nurse, who confirmed the lack of documentation and emphasized the importance of recording such information to communicate effectively with other nursing staff.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents in multiple rooms had the required minimum living space of 80 square feet per resident in shared rooms. Specifically, rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 23, 34, 35, 36, 38, and 40, which each contained three beds, measured only 235 square feet, falling short of the required 240 square feet. This deficiency was identified through a review of the Client Accommodation Analysis and a Room Variance Waiver request letter, as well as direct observation by surveyors. During an interview, the Administrator acknowledged that the smaller room size could negatively impact residents' psychosocial well-being, safety, and comfort.
Failure to Obtain Physician's Order for Orthotic Device
Penalty
Summary
The facility failed to obtain a physician's order for an ankle-foot orthotic device for Resident 1 before its implementation. Resident 1, who has a history of dementia, osteoarthritis, and hemiplegia affecting the left side, was observed wearing the orthotic device without a corresponding physician's order. The lack of a physician's order for the device was confirmed during a review of Resident 1's active physician orders and care plans, which did not include any mention of the orthotic device. Interviews with facility staff, including an LVN and the Director of Rehabilitation, revealed that the orthotic device was used to maintain a neutral ankle position and prevent injury when Resident 1 was out of bed. However, the Director of Nursing confirmed that the facility's policy and procedure required care plans to describe all services provided to a resident, and Resident 1's care plan did not include the orthotic device. This oversight placed Resident 1 at risk of receiving inappropriate care, potentially leading to skin breakdown and joint complications.
Failure to Implement Physician's Order for Buddy Strap Application
Penalty
Summary
The facility failed to implement a physician's order for a resident to wear a buddy strap on their right index finger for nine days. The resident, who had a history of dementia, osteoarthritis, and hemiplegia affecting the left side, was admitted and readmitted to the facility. The physician's order, dated 1/20/2025, specified that the buddy strap should be worn during the day to aid in the healing of a fractured right index finger. However, a review of the Treatment Administration Record (TAR) from 1/21/2025 to 1/29/2025 showed blank spaces, indicating that the buddy strap was not applied during this period. Interviews with the Director of Rehabilitation and a Licensed Vocational Nurse (LVN) confirmed that the buddy strap was not applied, which could potentially delay the healing process. The Director of Nursing stated that the treatment nurse and LVNs were responsible for ensuring the application and documentation of the buddy strap. The job descriptions for the Treatment Nurse and Charge Nurse LVN, dated 2003, indicated their responsibilities in providing therapeutic services and coordinating nursing services to maintain a resident's treatment regimen.
Failure to Provide Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to provide a safe environment for a resident by not implementing adequate supervision and interventions. The resident, who had a history of leaving the facility without authorization, was not properly monitored despite having a care plan that required staff to monitor behavior symptoms such as wandering and inappropriate responses. The resident had a complex medical history, including encephalopathy, bipolar disorder, and major depressive disorder, which were not adequately considered in the elopement risk assessment. The facility's exit door alarms were not consistently activated, which contributed to the resident's ability to leave the facility unnoticed. On multiple occasions, the resident left the facility without signing out or having the necessary physician's order, despite staff attempts to prevent this. The facility's policy required door alarms to be on at all times, but staff failed to activate them after use, allowing the resident to exit without detection. The facility's elopement screening did not accurately assess the resident's risk, as it failed to account for the resident's diagnoses and history of unauthorized departures. The resident's care plan included interventions for monitoring and supervision, but these were not effectively implemented, leading to the resident's unsupervised departure. The facility's policies on safety and supervision were not followed, resulting in a deficiency in providing a safe environment for the resident.
Failure to Provide Wound Care and Weekly Assessments
Penalty
Summary
The facility failed to provide appropriate wound care and services for a resident admitted with cellulitis in both lower limbs. The resident had a physician's order to cleanse the lower extremities with Dakin's solution, apply Bactroban ointment, and cover with kerlix daily for seven days. However, on one occasion, the resident refused treatment, and there was no documentation indicating that the treatment was completed later. Additionally, the Treatment Administration Record showed that the wound treatment was marked as refused, and there was no evidence of the treatment being administered afterward. Furthermore, the facility did not conduct weekly assessments of the resident's wound as required. The Weekly Non-pressure Ulcer Observation Tool lacked documentation for two consecutive weeks. This oversight was compounded when a nurse discovered maggots on the gauze during a wound treatment, indicating a severe lapse in care. Interviews with staff revealed that the nurse did not complete the wound care on the day of refusal and failed to document the weekly wound progress, which is crucial for monitoring the resident's condition.
Failure to Install Exit Alarms Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that all doors leading to the outside were equipped with alarms, which resulted in a high-risk resident for elopement leaving the facility undetected. The resident, who had severe cognitive impairment and was assessed as a high risk for elopement, was last seen in bed but was later found missing. Staff, including an LVN and RN, did not hear any alarms during their shifts, and the resident did not have any devices to notify staff if she left the facility. Interviews with staff revealed that there was no alarm installed on the front door, which was the only entrance and exit for staff, residents, and visitors. The Director of Nursing and Maintenance Personnel confirmed that the front door lacked an exit alarm, and as a result, there was no sound to alert staff if a resident left through it. The facility's policy on elopement indicated that exit doors should be safeguarded with audible alarms to alert staff when a resident attempts to leave unsupervised. This deficiency had the potential for the resident to be injured while outside the facility without supervision.
Failure to Document and Monitor Meal Intake Percentages
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) had the necessary competencies and skill sets to document and monitor meal intake percentages for three residents. Resident 1, who had diagnoses including hyperlipidemia, unspecified protein-calorie malnutrition, and iron deficiency anemia, refused meals multiple times over several months. Despite having orders for a regular diet with specific consistencies, the documentation showed numerous instances of meal refusal without proper follow-up or documentation of alternative food intake from outside sources. Resident 1's mental capacity was also noted to be impaired, complicating the situation further. Resident 2, diagnosed with hyperlipidemia, unspecified protein-calorie malnutrition, and dysphagia, had cognitive impairments and was dependent on assistance for activities of daily living (ADLs). The documentation for Resident 2 lacked meal intake percentages on specific dates, despite having orders for a regular diet with pureed texture and thin liquids. This lack of documentation was confirmed during interviews with staff, who acknowledged the importance of accurate meal intake records for nutritional assessment and intervention. Resident 3, with diagnoses including iron deficiency anemia, unspecified protein-calorie malnutrition, and dysphagia, also had cognitive impairments and was dependent on assistance for ADLs. Similar to Resident 2, the documentation for Resident 3 did not indicate meal intake percentages on specific dates, despite having orders for a controlled carbohydrate diet with mechanical soft texture and thin liquids. Interviews with CNAs and the Director of Nursing (DON) revealed that the staff were aware of the need to document food intake accurately, especially when food was brought in by families, but failed to do so consistently. This deficiency in documentation increased the risk of undernourishment for the residents involved.
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Illustrative
What surveyors actually found near you
We read the 5,784 citations issued within 25 miles in the last 12 months — including the 42 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Culver City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marycrest Manor | 1.1 mi | ★★★★★ | 24 | 0 |
| Vista Del Sol Care Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Meadowbrook Behavioral Health Center | 1.2 mi | ★★★★★ | 16 | 0 |
| Southern California Hosp At Culver City D/p Snf | 1.7 mi | ★★★★★ | 9 | 0 |
| Culver West Health Center | 1.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.