Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marlora Post Acute Rehab Hosp during CMS and state inspections, most recent first.
A resident with impaired cognition and another resident with dementia and schizoaffective disorder had incomplete or inaccurate AD/POLST documentation in the chart. For one resident, the facility did not obtain the resident’s AD after the resident was found capable, and for the other, the POLST showed DNR/comfort-focused care while the OSR still listed CPR, full treatment, and artificial nutrition orders. The SSD and DON stated the AD acknowledgement was incomplete and that the conflicting code status orders were not clarified.
The facility failed to objectively measure and assess ROM for two residents and did not consistently provide ordered ROM services. One resident had a left humerus fracture with post-op clearance for shoulder and elbow ROM, but the facility did not use goniometer measurements for the shoulder, elbow, wrist, or hand and started an RNA PROM program without a licensed therapist assessment. Another resident with dementia and ROM limitations in both legs did not receive ordered PROM to both hips and both ankles, and the PT eval did not objectively measure both knees.
Blood Pressure Taken on Arm With AV Shunt: A resident with ESRD and dependence on HD had an order for no BP on the left upper extremity because of an AV shunt, but bedside observation found no signage indicating the restriction. Record review showed BP readings were taken on the left upper arm on several occasions, and both the LVN and DON stated BP should not be taken from the arm with the AV shunt.
Failure to Coordinate Specialty Appointments and Follow-Up: The facility did not ensure medically-related social services were provided for two residents. One resident with DM and left-eye blindness reported worsening concern about right-eye vision and had no documented ophthalmology visit despite a care plan for eye care consultation. Another resident with quadriplegia and generalized weakness missed an NCS/EMG appointment; the note documented refusal but did not include the reason or any rescheduling, and the SSD and RNS stated follow-up and coordination should have occurred.
The facility failed to keep key clinical documentation readily accessible and accurate for two residents. One resident with a surgically repaired left humerus had a missing ortho follow-up note in the EMR, and the chart still listed the arm as NWB even though the ortho note indicated WBAT with ROM and strengthening. Another resident with dementia had a right-hand splint in use, but staff could not locate the required OT splint assessment in the EMR or rehab records.
The facility failed to document annual flu vaccine status and education for all HCP, including physicians, and failed to show that the 2025 to 2026 flu vaccine was offered. The facility also observed a resident’s foley drainage bag touching the floor; the resident had neurogenic bladder and reported burning and cramping, and an LVN stated the bag should be kept off the floor for infection control.
A resident with acute respiratory failure, oxygen dependence, acute pulmonary edema, and CKD consented to flu and pneumococcal vaccines, but the vaccines were not administered until months later. The IPN confirmed the delay, and the DON stated vaccines should be given within 90 days of consent; the facility policy also required administration within 90 days once consented.
Delayed COVID-19 Vaccination After Consent: A resident with acute respiratory failure, O2 dependence, acute pulmonary edema, and CKD consented to COVID-19 vaccination, but the vaccine was not given within the facility’s 90-day timeframe. The IPN reviewed the record and confirmed the vaccine was administered about 5 months after consent, contrary to the facility’s vaccination policy.
Failure to involve a resident in an IDT meeting after a change in condition. The resident had diagnoses including psychosis, depression, blindness, and diabetes, and developed worsening paranoia and delusions, repeatedly calling 911 and stating staff was poisoning his food and drinks. The care plan called for an IDT meeting and monitoring of paranoia, but the MDS Nurse and DON confirmed no IDT meeting was held after the change in condition, and the resident stated he was not included and wanted to explain his concerns.
Failure to Report Elevated Blood Glucose as a Change in Condition: A resident with Type 2 DM had blood glucose readings above 400 mg/dL on multiple occasions, and the RN supervisor stated these elevated readings were a change in condition. The resident had an order to call the physician when blood glucose exceeded 400 mg/dL, but the facility did not complete SBAR or notify the physician and family as required by its change-of-condition policy and the physician order.
A resident with schizoaffective disorder had an inaccurate PASARR Level I screening that did not indicate the psychiatric diagnosis. The MDS nurse stated the schizophrenia diagnosis should have been marked yes, and the DON stated PASARR accuracy is needed for proper recommendation and appropriate resident placement. The facility policy states it conducts Level I PASARR screening for all admissions and readmissions.
Failure to follow the care plan for a resident refusing Keppra. An alert resident with epilepsy refused levetiracetam, but an LVN offered it only once and did not explain the medication’s purpose, benefits, or the risks of not taking it. The MAR documented multiple refusals, and the RNS and DON stated staff should explain risks and benefits and notify the MD when seizure medication is refused.
A resident with a surgically repaired left humerus fracture did not have the orthopedic follow-up note properly received or acted on by facility staff, and the HMO follow-up was not scheduled as expected. As a result, the resident’s chart continued to show the left arm as NWB even though the ortho note later changed the status to WBAT and allowed ROM and strengthening. Rehab was not informed of the updated ortho instructions, and the resident was observed with significant left arm limitations.
A resident with a nephrostomy tube had an order for nephrostomy care every shift and a care plan calling for monitoring for UTI signs and symptoms, including blood in the urine, sedimentation, dysuria, and flank pain. However, the MDS nurse stated there was no documentation of urine characteristics in the drainage bag, and the DON acknowledged the importance of monitoring urinary drainage. The facility policy required checking urine for unusual appearance and documenting urine characteristics in the medical record.
A resident admitted with intervertebral disc degeneration, acute pulmonary edema, and type 2 DM did not receive the required physician face-to-face assessment within 72 hours of admission. The RNS stated the MD’s in-person visit occurred about 3 weeks later, with no documentation that the medical director evaluated the resident within the required timeframe. The DON confirmed the facility failed to ensure the physician saw the resident in person within 3 days, despite policy requiring a H&P within 72 hours.
Failure to Provide Ordered Psychology Follow-Up: A resident with schizoaffective disorder and moderately impaired cognition did not receive the psychology follow-up ordered by the MD. The care plan called for behavior monitoring and a psych consult as ordered, and staff interviews confirmed the resident needed behavioral services and psychology follow-up due to ongoing behavior concerns and repeated discussion of past traumatic events.
A resident with HTN and atrial fibrillation received amlodipine during a med pass when the pharmacy label’s hold parameters did not match the physician order, and an LPN stated the label and order should align. In a separate med pass, an LPN prepared polyethylene glycol by estimating the water volume before adjusting it to the ordered amount, despite the order and manufacturer guidance for mixing the powder in a specified fluid volume. The DON stated med parameters should match and that polyethylene glycol should be mixed in the ordered volume.
An LVN prepared five meds for a resident with HTN and neuropathy and left them unattended on the resident’s bedside cart while stepping away to get juice, instead of keeping the meds secured. Surveyors also found two medication carts with open red bins containing unidentified discarded tablets and capsules that were retrievable. The DON stated meds should not be left unattended with residents and that discarded meds should be made irretrievable.
Dietary Staff 1 was observed moving from the sanitation area back to the clean dishwashing area with the same gloves on and receiving clean dishes without changing gloves. DS 1 acknowledged that gloves should be changed to prevent contamination, while the DS stated gloves are changed when moving from a dirty to a clean area or starting a new task to prevent cross contamination.
A resident with ESRD, DM, and significant psychiatric and behavioral issues was transferred to another SNF without the facility providing the completed Discharge Summary/Post Discharge Plan of Care to the receiving facility. Although a detailed discharge plan had been initiated, including PCP follow-up, HD schedule and transportation, monitoring of VS, one-on-one supervision, safety needs, blood sugar checks, ADL assistance, and anemia treatment information, the RN Supervisor only sent a face sheet with a transfer report/medication list, along with medications and belongings. The RN Supervisor believed the Discharge Planner had already sent the discharge summary, and no telephone report to licensed staff at the receiving facility was documented, contrary to facility policies requiring transfer/discharge documentation and communication of the discharge summary.
The facility did not notify CDPH within 24 hours after two residents and a staff member tested positive for COVID-19, despite guidance from the PHN and internal policy requiring prompt reporting of such outbreaks. The delay occurred because the IPN believed that reporting to the local public health office was sufficient, resulting in CDPH not being informed in a timely manner.
A resident with CHF, COPD, chronic respiratory failure, and O2 dependence received Norco, Diazepam, Buspirone HCL, and Olanzapine close together after returning from the hospital. The LVN did not recognize the interaction risks or the Buspirone black box warning, and the resident soon became unresponsive, stopped breathing, required CPR and intubation, and later died after recurrent respiratory failure.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Two residents who required assistance with ADLs and had intact cognition were not provided with care plans addressing their assessed needs for smoking safety measures, such as smoking aprons and a cigarette extension. Both were observed smoking without the required equipment, and staff confirmed that no care plans were in place to guide interventions, contrary to facility policy.
Two residents received pain medication outside the prescribed pain level parameters, with staff administering narcotics when pain was documented as 0 or 3, contrary to physician orders specifying administration only for pain levels of 4-10. Staff interviews and record reviews confirmed that these actions did not align with facility policy or prescriber instructions.
A resident with a history of falls, cognitive impairment, and mobility issues was not provided with a comprehensive, individualized fall care plan. The care plan lacked specific interventions for the resident's non-compliance with call light use and did not address ongoing risks, resulting in an unwitnessed fall after the resident attempted to use the restroom independently.
The facility failed to ensure residents were free from significant medication errors, affecting four out of eight sampled residents. A resident did not have their heart rate checked before receiving Amiodarone, and another resident missed doses of Mexiletine, with late doses administered at incorrect intervals. The facility did not monitor for adverse effects or communicate effectively between shifts. Additionally, residents received medications without proper vital sign checks, and the facility's policies on medication administration and error documentation were not followed.
The facility's QAA and QAPI committees failed to identify significant medication errors, such as missed doses and late administration, due to a lack of focus on these issues in their current QAPI plan. The DON was unaware of these errors until surveyors identified deficiencies. The facility's policies required medication errors to be documented and reviewed by the QAPI committee, but this was not effectively implemented, placing residents at risk.
The facility failed to provide mandatory training in effective communication for two LVNs upon hire. A review of their personnel records showed no evidence of such training, and the DSD confirmed its absence from orientation. The DON acknowledged the need for mandatory training, as the facility's policy requires nursing staff to meet competency requirements, including communication skills.
The facility failed to provide mandatory QAPI training to two newly hired LVNs, as revealed during a review of their personnel records. The Director of Staff Development confirmed that QAPI training was not part of the orientation services, and the Director of Nursing acknowledged the need for such training. The facility's policy requires all nursing staff to meet competency requirements defined by state law.
The facility failed to update the Advance Directives (AD) for two residents, leading to potential conflicts with their healthcare wishes. One resident, with mental health diagnoses, signed an invalid AD form due to cognitive impairment. Another resident had an AD but the facility lacked a copy. The facility's policy requires AD information upon admission, which was not followed.
Two residents experienced significant medical events that were not promptly communicated to their physicians. A resident with diabetes had a critically high blood sugar level, and another resident missed or received late doses of a critical heart medication. The facility failed to notify the physicians as required by policy, leading to potential delays in medical intervention.
The facility failed to protect residents from abuse and neglect, resulting in significant deficiencies. A resident with end-stage renal disease was allegedly sexually assaulted by another resident, and the facility did not take adequate measures to ensure safety or monitor the situation. In another incident, an agitated resident with dementia was placed near others, leading to a physical altercation with another resident. The facility's failure to follow policies and procedures contributed to these deficiencies.
The facility failed to report a physical altercation between two residents to the CDPH within the required two-hour timeframe. One resident, with dementia and major depressive disorder, hit another resident, with major depressive disorder and PTSD, using a quad cane. Although the incident was reported to local authorities, it was not reported to CDPH as mandated by the facility's policy.
The facility failed to report allegations of physical abuse involving two residents to CDPH within the required timeframe. An altercation occurred when a resident with moderately impaired cognitive skills hit another resident with a quad cane. The incident was reported to local authorities but not to CDPH, violating the facility's policy on abuse investigation and reporting.
The facility failed to provide trauma-informed care for two residents with PTSD, as they did not assess triggers or develop care plans to prevent re-traumatization. Despite having policies in place, the facility did not implement guidelines to address the residents' trauma histories, leading to a deficiency in care.
The facility failed to ensure competent medication administration by nurses, resulting in significant errors for several residents. A resident with severe cognitive impairment received medication without proper pulse checks, while another with cardiac issues had medications administered at incorrect times and without necessary vital sign documentation. Additionally, a resident with hypotension received medication despite high blood pressure readings, and another with heart failure had medications given without proper monitoring. Interviews revealed that nurses were not adhering to facility policies, leading to these errors.
A facility failed to conduct an IDT meeting for a resident after multiple eye doctor appointments, resulting in a lack of awareness about the outcomes and necessary care adjustments. The resident, with conditions like ESRD and diabetes, experienced vision decline but had no IDT meeting since June, despite policy requirements for meetings upon significant changes. Staff interviews confirmed the oversight, acknowledging the need for a meeting to address the resident's care plan.
A resident with multiple health issues, including declining vision, did not have a care plan addressing his vision concerns, despite ongoing eye doctor visits and the resident's awareness of needing surgery. The facility's staff, including an LVN and the MDS Nurse, confirmed the absence of a care plan, which was against the facility's policy requiring timely and comprehensive care planning.
A resident received diclofenac sodium gel without a specified dose for over two weeks, posing a risk of incorrect dosing. The resident had serious heart conditions and impaired cognitive skills. The LVN and DON acknowledged the need for dose specification, which was not included in the medication order, contrary to the facility's policy.
A resident with a history of urinary issues and frequent UTIs did not receive consistent foley catheter care as per the facility's orders, leading to potential recurrent UTIs. The Treatment Administration Record showed missing documentation for catheter care on several dates, and interviews with staff confirmed that undocumented care was likely not provided. The facility's policy required regular catheter care and monitoring to prevent infections, but gaps in documentation indicated non-compliance.
A resident with chronic lung conditions was found to be receiving 2.5 liters per minute of oxygen instead of the prescribed 2 liters per minute. This discrepancy was confirmed by the ADON, who acknowledged the importance of following the physician's order for safe oxygen administration. The DON reiterated the need for staff to adhere to prescribed orders to ensure resident safety.
A facility failed to monitor a resident's behaviors while on psychotropic medications, risking unnecessary medication use. The resident, with dementia and other conditions, was on Escitalopram and Mirtazapine, but there was no documentation of monitoring for hopelessness, anxiety, or sleep. Staff interviews confirmed the facility did not adhere to its policy for behavioral assessment and monitoring.
A medication security lapse occurred when an LVN left a resident's Amiodarone unattended on a medication cart. The resident, with severe cognitive impairment and serious cardiac conditions, was at risk due to this oversight. The facility's policy mandates that medications be accessible only to authorized personnel.
A facility failed to sanitize a mechanical lift between uses for two residents, potentially spreading infections. CNA 1 and CNA 2 used the lift for a resident with end-stage renal disease and then for another resident with chronic kidney disease without cleaning it. CNA 1 admitted to forgetting the cleaning step, and the Director of Staff Development emphasized the importance of sanitizing equipment to prevent infection spread.
A resident at an LTC facility fell and sustained a right shoulder fracture due to a CNA's failure to follow the facility's policy requiring two-person assistance during a Mechanical Lift transfer. The resident, who was high risk for falls and dependent on staff for transfers, was injured when the CNA attempted the transfer alone. Staff interviews confirmed the policy requirement for two-person assistance, which was not followed, leading to the incident.
Two residents experienced violations of their rights and dignity in a LTC facility. One resident, with anxiety and depression, was disrespected by the ADM and BOM during a financial discussion in his room without permission. Another resident, with anxiety and schizophrenia, was moved to a new room against her wishes to accommodate new admissions. The ADM's actions did not align with facility policies on resident rights and dignity.
A resident with dysphagia experienced a choking incident, and the facility staff delayed calling 911 by 14 minutes while checking the resident's code status. The staff also failed to use a non-rebreather mask and did not retrieve the crash cart, leading to inadequate emergency care. Interviews revealed poor communication and delegation among staff during the incident.
A resident with dysphagia choked on noodles during dinner, requiring an LVN to perform the Heimlich maneuver. The LVN failed to document the incident and care provided, resulting in an incomplete medical record. This oversight hindered communication between healthcare professionals and the facility's ability to investigate the incident.
A resident's grievance about missing personal belongings, including a cellphone, was not resolved to their satisfaction. Despite the cellphone being inventoried, the facility did not replace or reimburse it, and the resident's representative was dissatisfied with the response. The facility's policy required prompt resolution of grievances, but this was not achieved.
Incomplete Advance Directive and Conflicting POLST Documentation
Penalty
Summary
The facility failed to ensure that two residents had current and accurate advance directive documentation in their medical records. For one resident, the admission record showed family members listed as emergency contacts but no power of attorney. The history and physical stated the resident had capacity to understand and make decisions, while the MDS described moderately impaired cognition and need for assistance with several activities of daily living. During interview and record review, the Social Service Director stated the facility had not obtained a copy of the resident’s advance directive after the acknowledgement and had not obtained it from the resident after the physician determined the resident was capable. The Director of Nursing stated the advance directive should have been completed sooner and that completion was essential to honor the resident’s wishes and guide care and treatment decisions during emergencies. For the second resident, the admission record showed diagnoses including dementia and schizoaffective disorder. The history and physical stated the resident could make needs known but could not make medical decisions, and the MDS showed the resident required dependent assistance for multiple areas of care. The POLST reviewed for this resident showed DNR and comfort-focused treatment only, and indicated the resident representative elected no advance directive. However, the Order Summary Report still listed orders for CPR, full treatment, and long-term artificial nutrition. A nurse supervisor stated there were two conflicting orders regarding code status and that the staff should have followed up with the primary care physician to reflect the recent hospice-related POLST changes. The record also showed the resident’s advance directive acknowledgement was incomplete. The Social Service Director stated there was no evidence that written materials regarding the right to accept or refuse medical treatment were provided to the resident representative and resident, and that the acknowledgement was invalid and incomplete if information was missing. The Director of Nursing stated verbal or telephone consent should be signed by two witnesses to be valid and that staff should have followed up with hospice and the primary care physician to clarify the order. The care plan referenced keeping the POLST in the chart and providing educational material regarding advance directives as needed, while the facility policy required written information about the right to refuse or accept treatment and to formulate an advance directive.
Failure to Objectively Assess and Provide Ordered ROM Services
Penalty
Summary
The facility failed to provide appropriate ROM services for two residents with ROM concerns. Resident 6 was admitted and re-admitted with diagnoses including a left humeral shaft fracture, muscle weakness, and polyneuropathy after a fall at the facility and surgery to the left humerus. The orthopedic follow-up note stated Resident 6 was cleared to participate in ROM exercises to the left shoulder and left elbow with PT and OT. However, the facility did not objectively measure and assess Resident 6’s left shoulder and left elbow after that clearance, and the Joint Mobility Screening later documented minimal loss at the left elbow and severe loss at the left shoulder without goniometer measurements. The Director of Rehabilitation confirmed the baseline ROM for the left shoulder and left elbow was not determined because the limitations were not measured objectively. Resident 6’s OT evaluation also documented impaired ROM in the left wrist and left hand with minimal loss of motion, but those limitations were not objectively measured with a goniometer. The Director of Rehabilitation confirmed the left wrist and left hand should have been measured because they were impaired, but were not. In addition, the facility established an RNA program for left shoulder and left elbow PROM exercises after orthopedic clearance, but PT and/or OT did not formally assess Resident 6’s left shoulder and left elbow before the RNA program was established. The Director of Rehabilitation and DON both stated a licensed therapist should assess a resident before an RNA program is started. Resident 8 was admitted and re-admitted with diagnoses including senile degeneration of the brain, dementia, and peripheral vascular disease, and had functional limitations in ROM in both legs. The physician ordered RNA PROM exercises to both legs, but during observation the RNA did not provide PROM to both hips and both ankles as ordered, and only partially attempted knee PROM before stopping. The RNA stated she forgot to provide the hip and ankle exercises and confirmed the order meant the entire leg, including hips, knees, and ankles. Resident 8’s PT evaluation documented impaired ROM in both knees, but the limitations were not objectively measured with a goniometer. The Director of Rehabilitation confirmed the knees should have been measured objectively and that the lack of objective measurements affected the ability to monitor and detect changes in ROM.
Blood Pressure Taken on Arm With AV Shunt
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident receiving hemodialysis. The resident had diagnoses including end stage renal disease and dependence on renal dialysis, and the resident's record included an order, starting 11/10/2025, for no blood pressure on the left upper extremity with an AV shunt. The resident's MDS dated 2/19/2026 indicated cognition was intact and that the resident required set up assistance with eating and oral hygiene and substantial assistance with toileting hygiene. During a bedside observation and interview on 3/10/2026, there was no signage indicating not to measure the resident's blood pressure on the left upper extremity, and the LVN stated the resident did not have signage at the bedside. During a concurrent interview and record review, the resident's blood pressure readings from 2/1/2026 to 3/9/2026 were reviewed, and the LVN confirmed that blood pressure was taken on the left upper arm on several occasions. The LVN stated blood pressure should not be measured on the left upper arm because it can cause a clot. The DON also stated blood pressure should not be taken from the arm with the AV shunt because it can cause a clot. The facility policy titled End-Stage Renal Disease, Care of a Resident with revised 9/2010 stated not to use the access arm to take blood pressure.
Failure to Coordinate Specialty Appointments and Follow-Up
Penalty
Summary
Medically-related social services were not provided for two residents when the facility failed to ensure specialty appointments were completed or followed up as documented in the record. Resident 27 was admitted with diagnoses including dementia, diabetes mellitus, and blindness in the left eye. The history and physical indicated the resident had capacity to understand and make decisions, and the MDS showed the resident required assistance with multiple activities of daily living. During interview, Resident 27 stated she was blind in her left eye and worried about her right eye vision, and said no one helped her see an ophthalmologist after admission. Record review showed no documentation that Resident 27 was seen by an ophthalmologist between admission and the time of review. The resident’s care plan included impaired visual function related to blindness in the left eye and an intervention to arrange consultation with eye care practitioners as required. The order summary also showed an annual eye exam with follow-up as needed. The RNS stated she was not aware of the resident’s concern and agreed the resident should have been seen by a specialist because diabetes and poor blood sugar control could lead to blindness. The SSD stated she was not aware of the concern and would have arranged the appointment if she had known. Resident 49 was admitted and readmitted with diagnoses including quadriplegia and generalized muscle weakness, and the history and physical indicated the resident had capacity to understand and make decisions. The MDS showed the resident required dependent or maximal assistance with many activities of daily living. Resident 49 stated she missed important appointments because nursing staff did not prepare the required documentation and no one rescheduled them. The progress note for the missed NCS and EMG appointment documented that the resident refused to go, but it did not include a reason for refusal or any rescheduling information. The RNS stated staff should have notified the PCP, followed up on the reason for refusal, and rescheduled, and the SSD stated it was important to determine why the resident refused and encourage attendance because the resident missed an opportunity to get treatment.
Missing Ortho and Splint Documentation
Penalty
Summary
The facility failed to ensure medical records for two sampled residents were accurately documented and readily accessible. For one resident with a left humeral shaft fracture after surgery, the record showed an orthopedic follow-up note was missing from the EMR, even though staff stated consultation notes were supposed to be scanned in and available for review. The resident’s chart also contained an order that still listed the left arm as non-weight bearing, despite the orthopedic follow-up note indicating the status had been changed to weight bearing as tolerated. The resident’s record showed an initial orthopedic follow-up after surgery with non-weight-bearing and ROM instructions, followed by a later orthopedic visit in which the left arm was documented as weight bearing as tolerated and ROM and strengthening exercises were recommended. However, the facility could not locate that later orthopedic note in the EMR when staff reviewed the chart. Multiple staff members, including an LVN, ADON, CM, DOR, and DON, stated the note should have been in the record and that the missing note prevented staff from knowing the updated recommendations and from accurately updating the physician’s order to reflect the current weight-bearing status. For the second resident, who had dementia, severe cognitive impairment, and functional limitations, the record showed an RNA order for a hand roll to the right hand, and the resident was observed wearing a right-hand splint during an RNA session. The DOR stated a licensed therapist must assess the need for splints, determine wear tolerance, and document the assessment in the EMR or rehab screening records. The DOR and OT reviewed the clinical record, therapy notes, the rehab screening binder, and the OT’s personal binder but could not find the assessment for the right-hand splint. The DON stated all assessments and services provided should be readily accessible and in the EMR, and the facility policy required documentation to be objective, complete, and accurate.
Infection Control Failures With Flu Vaccine Documentation and Foley Bag Placement
Penalty
Summary
The facility failed to implement its infection prevention and control program by not maintaining documented evidence of annual influenza vaccine status for all employees, including physicians, and by not documenting education on the benefits and potential side effects of the 2025 to 2026 flu vaccine or that it was offered. During record review, the Infection Prevention Nurse stated there was no documented evidence for physician or licensed practitioner education on benefits and side effects or the offering of the current flu vaccine, and that the roster did not include physicians even though it should include everyone with direct access to residents. The DON stated staff need to be educated and offered the current annual flu vaccine because it is mandated. The facility policy titled Influenza Vaccine stated all healthcare providers would be provided information regarding the requirement to receive the flu vaccine and that IP would document the status of flu vaccination of all HCP. The facility also failed to keep a resident’s foley catheter drainage bag off the floor. Resident 39 was admitted with diagnoses including neurogenic bladder, GERD, and fusion of spine, and had intact cognition and capacity to understand and make decisions. The resident had an order for an 18 French foley catheter to drainage bag for non-patency as needed one time a day related to neuromuscular dysfunction of bladder. During observation, the resident’s foley catheter drainage bag was touching the floor, and the resident stated she had been experiencing burning and cramping sensations in her abdominal area for the previous couple of days and was waiting for specimen results. An LVN stated the drainage bag was touching the floor and that this placed the resident at higher risk for a UTI. The DON stated the drainage bag should always be maintained off the floor, and the facility’s Catheter Care policy stated staff must be sure the catheter tubing and drainage bag are kept off the floor for infection control.
Delayed Flu and Pneumococcal Vaccination After Consent
Penalty
Summary
The facility failed to ensure that Resident 81’s influenza and pneumococcal vaccines were administered in a timely manner after the resident consented to receive them. Resident 81 was admitted with diagnoses including acute respiratory failure, dependence on supplemental oxygen, acute pulmonary edema, and chronic kidney disease. The resident’s MDS dated 1/16/2026 indicated cognition was intact, and the consent/declination form showed the resident consented to both vaccinations on 10/15/2025. During a concurrent interview and record review on 3/11/2026, the Infection Prevention Nurse reviewed Resident 81’s immunization records and consents and stated the vaccines were administered on 3/5/2026, despite the resident having consented months earlier. The IPN stated the vaccinations should not have been administered five months later. During an interview on 3/12/2026, the DON stated vaccines should be administered within 90 days once a resident consents, and the facility’s policy titled Vaccination of Residents, revised 12/20/2024, stated that required or recommended vaccines will be administered within ninety days when consented.
Delayed COVID-19 Vaccination After Consent
Penalty
Summary
The facility failed to implement its infection prevention policies and procedures for one resident when it did not ensure the resident’s COVID-19 vaccine was administered within 90 days after the resident agreed to receive it. Resident 81 was admitted with diagnoses including acute respiratory failure, dependence on supplemental oxygen, acute pulmonary edema, and chronic kidney disease. The resident’s MDS dated 1/16/2026 indicated cognition was intact. A review of the resident’s COVID-19 Vaccine Information and Declination Form showed the resident consented to vaccination on 10/15/2025. During a concurrent interview and record review on 3/11/2026, the Infection Prevention Nurse reviewed the immunization records and stated the vaccine was administered on 3/6/2026, about five months after consent, and that it should not have been administered that late. The facility’s policy titled Vaccination of Residents, revised 12/20/2024, stated that if a resident is unvaccinated and needs additional vaccine doses, the required or recommended vaccine will be administered within ninety days when consented.
Failure to Involve Resident in IDT Meeting After Change in Condition
Penalty
Summary
The facility failed to ensure Resident 28 participated in an IDT meeting after a change of condition was identified for increasing delusions and paranoia. Resident 28 was admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia, legal blindness, unspecified glaucoma, major depressive disorder, and unspecified psychosis. The H&P indicated he was alert, oriented, and had the capacity to understand and make decisions, and the MDS indicated he was able to understand others, make himself understood, participate in assessment and goal setting, and had delusions. The record showed that on 2/25/26 the facility documented new or worsening behavioral symptoms, including paranoia, delusions, and repeated calls to 911 after Resident 28 reported that staff and/or others were poisoning his food and drinks. Progress notes later documented that the facility was informed of his paranoia and statements that staff was poisoning his food. The care plan included interventions for an IDT meeting with the resident and monitoring of paranoia and delusions, but interviews on 3/11/26 and 3/12/26 confirmed the facility did not hold an IDT meeting after the second change of condition. Resident 28 stated he was not involved in the second IDT meeting and wanted to explain that he had to buy his own food because he believed he was being poisoned, while the MDS Nurse and DON acknowledged the IDT meeting was not done after the change in condition.
Failure to Report Elevated Blood Glucose as a Change in Condition
Penalty
Summary
The facility failed to implement its policy and procedure titled Change in a Resident's Condition or Status for reporting a significant change in condition to the physician for one resident with diabetes. The resident was admitted with diagnoses including intervertebral disc degeneration, acute pulmonary edema, and Type 2 DM. The admission H&P dated 2/4/2026 indicated the resident had the ability to understand and make decisions, while the MDS dated 1/22/2026 indicated moderately impaired cognition and need for assistance with eating, oral hygiene, toileting hygiene, and showering. The resident had a physician order, initiated on 1/15/2026 and discontinued on 2/24/2026, for Lispro injection and to call the physician when blood glucose was above 400 mg/dL. During record review and interview, the RN supervisor stated the resident's blood glucose readings were 430 mg/dL, 419 mg/dL, and 437 mg/dL, and that these elevated readings represented a change in condition. The RN supervisor stated the facility did not follow its change of condition policy, including completing SBAR and notifying the physician and the resident's family regarding the elevated blood glucose readings. The DON stated staff were required to follow physician orders and the facility's change of condition protocol, including notifying the physician when blood sugars were above 400 mg/dL per the order.
Inaccurate PASARR Screening for Resident with Psychiatric Diagnosis
Penalty
Summary
The facility failed to ensure that one of one resident's PASARR Level I screening was completed accurately to reflect an existing psychiatric condition. Resident 6's admission record showed diagnoses including schizoaffective disorder, and the resident's MDS dated 1/26/2026 indicated moderately impaired cognition and dependence on staff for all ADLs. During interview and record review, the MDS Nurse reviewed Resident 6's admission record and PASARR Level I Screening dated 11/12/2025 and stated the diagnosis of schizophrenia should have been checked as yes on the PASARR screening. The MDS Nurse stated completing the PASARR Level I screening correctly was important to meet the resident's needs. The DON also stated PASARR should be accurate for proper recommendation and appropriate resident placement. The facility policy stated it conducts Level I PASARR screening for all admissions and readmissions and screens all residents for mental disorders per the PASARR process.
Failure to Follow Care Plan for Refused Seizure Medication
Penalty
Summary
The facility failed to follow Resident 89’s care plan when the resident refused levetiracetam (Keppra), a medication ordered for epilepsy and seizure prevention. Resident 89’s record showed a history of epilepsy, intact cognition, and capacity to understand and make decisions. The care plan dated 3/10/2026 included a focus on refusal of Keppra with interventions to educate the resident on the importance of taking the medication for seizure prevention and to monitor for seizure activity. Another care plan dated 2/13/2026 stated the resident was at risk for clinical or social decline due to refusal of medications and that the resident should be informed of the risks and consequences of choices made daily. During observation, an LVN prepared four medications for Resident 89 and handed the resident levetiracetam 1000 mg, which the resident refused by stating, “not today.” The LVN then administered the other medications and explained only glycopyrrolate as being for drooling symptoms. The LVN offered levetiracetam only one time and did not explain the benefits and purpose of the medication or the risk for seizures if it was not taken as prescribed. In a later interview, the LVN stated she should have offered the medication again before the end of the shift and documented it as refused and informed the physician, but acknowledged she did not offer levetiracetam three times as she should have and did not explain the risks and benefits. The MAR showed levetiracetam was documented as refused three times between 3/1/2026 and 3/11/2026. The order summary included Keppra 1000 mg twice daily and an order to monitor for seizure activity and notify the MD if noted. The RNS and DON both stated that when a resident who is alert refuses seizure medication, staff should explain the risks and benefits, document the refusal, and notify the physician. The facility policy on care plans stated that a comprehensive, person-centered care plan with measurable objectives is developed and implemented for each resident, and the medication administration guideline stated that if two consecutive doses of a vital medication are withheld or refused, the physician is notified.
Failure to Follow Up on Orthopedic Consultation and Update Left Arm Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with a left humeral shaft fracture after surgery. Resident 6 was admitted and re-admitted with diagnoses including a left humeral shaft fracture, muscle weakness, and polyneuropathy. The resident’s history and physical noted the resident had surgery on the left humerus after a fall at the facility and returned for skilled care, PT, and OT. OT evaluation documented impaired ROM in the wrist and hand, with the left shoulder and elbow not assessed because of the surgery. An orthopedic consultation note dated 10/6/2025 showed the resident’s first post-surgical orthopedic follow-up, with the left arm still NWB and permission to begin ROM with PT and OT, and a follow-up appointment was ordered for 11/3/2025. The record later contained an orthopedic note dated 11/3/2025 indicating the resident presented three months after surgery, the left arm status had changed to WBAT, ROM and strengthening exercises were allowed for the left shoulder, elbow, wrist, and fingers, and follow-up through the resident’s HMO was instructed. However, facility staff could not locate this note in the EMR at the time of review, and the resident’s physician order remained inaccurate and continued to list the left arm as NWB. During interviews, the LVN, ADON, CM, DOR, and DON each described that nursing staff were responsible for receiving consultation paperwork, implementing new orders, and ensuring follow-up appointments were scheduled when recommended. The CM stated she never received the 11/3/2025 orthopedic note and was not notified of the follow-up instructions, so the appointment was not scheduled through the HMO as expected. The DOR stated rehab was never informed that the resident’s weight-bearing status changed to WBAT or that ROM and strengthening were allowed. At the time of observation, the resident remained limited in movement of the left arm, with the left elbow bent, the wrist and hand resting on the stomach, inability to fully straighten the arm, inability to lift the wrist upward, and inability to close the fingers into a fist.
Failure to Document Urine Assessment for Resident With Nephrostomy Tube
Penalty
Summary
The facility failed to ensure appropriate assessment and monitoring of urine for signs and symptoms of infection for one sampled resident with a nephrostomy tube. Resident 11 was admitted with diagnoses including artificial openings of the urinary tract status and obstructive and reflux uropathy. The resident’s MDS dated 2/19/2026 indicated cognition was intact, and the resident required set up assistance with eating and oral hygiene and substantial assistance with toileting hygiene. Resident 11’s order summary dated 11/10/2025 directed nephrostomy care every shift. The care plan, initiated 7/5/2025, included monitoring for signs and symptoms of UTI, blood in the urine, sedimentation, dysuria, and flank pain. During interview and record review, the MDS nurse stated the care plan should have been implemented and that there was no documentation of any assessment of urine characteristics in the drainage bag in the resident’s medical record. The DON stated it was important to monitor the urinary drainage to detect any problems. The facility policy on urinary catheter care stated urine should be checked for unusual appearance and urine characteristics documented in the resident’s medical record.
Delayed Physician Assessment After Admission
Penalty
Summary
The facility failed to ensure that a physician assessed one of three sampled residents within 72 hours after admission. Resident 1 was admitted on 1/15/2026 with diagnoses including intervertebral disc degeneration, acute pulmonary edema, and type 2 diabetes mellitus. The resident’s H&P, dated 2/4/2026, indicated the resident had the ability to understand and make decisions, while the MDS, dated 1/22/2026, indicated moderately impaired cognition and need for assistance with eating, oral hygiene, toileting hygiene, and showering. During record review and interviews, the RNS stated that the physician conducted an in-person visit on 2/4/2026, approximately three weeks after admission, and that there was no documentation the medical director evaluated the resident within the required time frame. The RNS stated the physician was expected to see the resident within three days after admission to complete an assessment and evaluation. The DON also stated the facility failed to ensure the physician saw the resident in person within 3 days after admission. The facility policy titled Physician Documentation stated that a history and physical examination shall be provided by the attending physician within 72 hours following admission.
Failure to Provide Ordered Psychology Follow-Up
Penalty
Summary
The facility failed to ensure that Resident 6, who had diagnoses including schizoaffective disorder and moderately impaired cognition, received follow-up by psychology as ordered by the primary physician. Resident 6’s record showed a physician order dated 9/12/2025 for a psychological evaluation and follow-up treatment, and the behavior care plan dated 1/30/2026 directed staff to monitor behavior, notify the MD if it interfered with functioning, and provide a psych consult as ordered. During interviews and record review, the MDS nurse stated Resident 6 needed behavioral services and possibly a psychology follow-up, and an LVN stated the resident required follow-up with psychology based on behavior and ongoing verbal repetition of past traumatic events. The DON stated that residents with psychiatric symptoms should be referred to psych, require an interdisciplinary team meeting, have the care plan updated, and have behavior monitored. The facility policy stated residents would receive behavioral health services as needed to attain or maintain the highest practicable mental, physical, and psychosocial well-being.
Medication label mismatch and improper polyethylene glycol preparation
Penalty
Summary
The facility failed to ensure that the instructions on Resident 36’s amlodipine bubble pack matched the physician’s order before administration during medication pass observation. Resident 36 was admitted with diagnoses including essential hypertension and paroxysmal atrial fibrillation, and the record noted the resident had capacity to understand and make decisions, although the MDS described cognition as moderately impaired. During the observed medication pass, the LVN administered amlodipine 5 mg along with other medications after checking the resident’s blood pressure and pulse. The pharmacy label on the amlodipine bubble pack instructed staff to hold the medication if systolic blood pressure was less than 110 or pulse was less than 60. The physician order in the order summary report instructed to give amlodipine 5 mg daily and hold only if systolic blood pressure was less than 110. During interview, the LVN stated the pharmacy label and the physician order should always match and align, and the DON stated nurses should verify the right medication parameters before administration and that the physician order and pharmacy label should match. The DON also stated there was a risk that amlodipine could have been inadvertently held because of the pharmacy label instructions. The facility also failed to ensure that Resident 62’s polyethylene glycol powder was dissolved in the correct volume of water in accordance with the physician’s order and manufacturer’s specifications during medication pass observation. Resident 62 had diagnoses including recurrent C. difficile enterocolitis, unspecified noninfective gastroenteritis, and colitis, and the record indicated the resident had capacity to understand and make decisions with intact cognition. During the observed medication pass, the LVN prepared polyethylene glycol by measuring water in a cup, initially estimating the volume, then using a medicine cup and adding water until the total reached 120 mL after the surveyor questioned the amount. The physician order for polyethylene glycol directed 17 grams mixed in 4 to 8 ounces of fluid, and the LVN stated the medication should have been dissolved in the volume specified by the manufacturer and physician’s order. The DON stated polyethylene glycol usually should be mixed with eight ounces of water or juice and that if the order indicated four to eight ounces, that volume would be acceptable. The facility policy stated medications are administered as prescribed and that if the label and MAR are different, the physician’s orders are checked for the correct dosage schedule.
Unsecured Medications Left With Resident and Discarded Drugs Stored Improperly
Penalty
Summary
Medication storage and administration practices were not followed when an LVN prepared five medications for a resident with diagnoses including unspecified polyneuropathy, essential hypertension, and paroxysmal atrial fibrillation, and then placed the medications on the resident’s bedside cart in front of her. The resident’s record showed she had capacity to understand and make decisions in the H&P, while the MDS described moderately impaired cognition and need for assistance with multiple ADLs. During the observation, the resident asked for juice instead of water, and the LVN turned away, left the medications unattended and unsecured with the resident, and went to the medication cart to get juice. The medications left unattended were one tablet of amlodipine 5 mg, two capsules of gabapentin 300 mg, one tablet of carvedilol 25 mg, one lidocaine 5% patch, and one capsule of docusate sodium 100 mg. The LVN later stated she left the medications unattended when the resident requested juice and acknowledged this increased the risk that the resident could have pocketed or taken the medications incorrectly. The DON stated medications should not be left unattended with residents and that if medications go out of sight without supervision, staff do not know what the resident will do with them or whether they will be taken correctly. The survey also found discarded medications stored unsafely in two medication carts. One cart contained an open red container with unidentified white tablets in the bottom drawer, and another cart contained an open red container with unidentified tablets and capsules of varied shapes, sizes, and colors that were retrievable. Staff stated the tablets were likely refused or dropped medications, and one LVN stated the container was not safe because anyone could retrieve medications for misuse. The DON stated the red bins were used for discarded medications or capsule shells and that discarded medications should be made irretrievable, but the observed containers were open and accessible.
Failure to Change Gloves Between Dirty and Clean Tasks
Penalty
Summary
Dietary Staff 1 failed to change gloves when moving between the sanitation area and the clean dishwashing area, and was observed going back to the clean dishwashing area with the same gloves on and receiving clean dishes without changing gloves. During the observation, DS 1 stated that gloves must be changed to prevent contamination, but also stated he did not have to change his gloves after leaving the sanitation area because they were still clean. The Dietary Supervisor later stated that gloves are changed when moving from a dirty to a clean area or when starting a new task to prevent cross contamination and that residents can get sick from cross contamination.
Failure to Send Complete Discharge Summary to Receiving SNF
Penalty
Summary
The deficiency involves the facility’s failure to provide a complete Discharge Summary/Post Discharge Plan of Care to the receiving SNF when a resident was transferred. The resident had multiple significant diagnoses, including ESRD, DM, schizophrenia, depression, and anxiety disorder, and had been assessed as unable to make reasonable and consistent decisions or understand and make medical decisions. Prior documentation showed the resident had exhibited severe behavioral issues, including banging hands on the wall and attempting to grab staff members’ private parts, which led to a psychiatric hold and subsequent readmission. An IDT care conference documented that discharge options to a more appropriate SNF capable of managing the resident’s behavioral needs were discussed with the responsible party. On the day of transfer, a physician’s order directed that the resident be transferred to another SNF with all remaining medications, and that a representative from the receiving facility would pick up the resident’s medications, belongings, and discharge paperwork. Nursing progress notes documented that the RN Supervisor was unable to reach licensed staff at the receiving facility despite multiple calls, but that a representative from the receiving facility would pick up the resident’s medications, cigarettes, and belongings. The facility had initiated a Discharge Summary/Post Discharge Plan of Care the day before transfer, which included instructions to follow up with the primary care physician, details of the hemodialysis facility, treatment schedule and transportation, monitoring of vital signs and overall well-being, one-on-one supervision and safety needs, blood sugar checks, assistance with ADLs, and the latest hemoglobin result with associated anemia treatment. Despite this, the RN Supervisor provided only the face sheet with the transfer discharge report/transfer medication list, along with the resident’s belongings and medications, to the receiving facility’s representative and did not print or send the Discharge Summary Instructions. The RN Supervisor stated he believed the Discharge Planner had already sent the discharge summary to the receiving facility and that he was told only to send the transfer medication list, medications, and belongings. The responsible party later reported that the receiving SNF could not provide discharge instructions from the sending facility. Review of facility policies titled “Transfer or Discharge Documentation” and “Discharging the Resident” showed that the facility’s procedures required that a copy of the resident’s discharge summary and other appropriate documentation be communicated to the receiving facility and that a transfer summary and telephone report be completed, which did not occur in this case.
Failure to Timely Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH) within 24 hours after identifying a COVID-19 outbreak involving two residents and one staff member. Record reviews showed that one resident, admitted with Parkinson's disease and failure to thrive, exhibited symptoms such as dizziness, sore throat, and runny nose and tested positive for COVID-19. Another resident, admitted with hypothyroidism, tested positive for COVID-19 but was asymptomatic. Both cases were identified on the same day, and a staff member also tested positive the following day. Despite receiving guidance from the Public Health Nurse (PHN) to report the outbreak to CDPH, the facility's Infection Preventionist Nurse (IPN) delayed reporting, believing that notifying the local public health office would suffice. Interviews with facility leadership confirmed awareness of the reporting requirement and the PHN's guidance. The IPN and Administrator acknowledged that the outbreak met the criteria for an unusual occurrence and should have been reported to CDPH within 24 hours, as outlined in the facility's policy. The delay in reporting resulted in CDPH not being informed in a timely manner, which prevented oversight and monitoring of the facility's infection control practices during the outbreak.
Concurrent CNS-Depressant Medications Given Without Recognizing Black Box Warning
Penalty
Summary
The facility failed to ensure a resident with CHF, COPD, chronic respiratory failure, dependence on supplemental O2, and moderate cognitive impairment was not given multiple CNS-depressing medications together without appropriate recognition of their combined effects. After returning from the hospital, the resident had orders for Buspirone HCL with a black box warning to monitor for concomitant use with benzodiazepines and narcotics, Diazepam 7.5 mg three times daily, Norco 7.5 mg/325 mg every 6 hours as needed, and Olanzapine 10 mg twice daily plus 15 mg at bedtime. On the morning of the event, an LVN administered Norco at 8:30 a.m. and then administered Buspirone HCL, Diazepam, and Olanzapine at about 9:00 a.m. Shortly after those medications were given, CNA 1 alerted the LVN that the resident was unresponsive. The LVN found the resident sitting up in bed, unresponsive to verbal commands, diaphoretic, and still breathing. A code blue was called, and the resident then stopped breathing. CPR was started, 911 was called, and paramedics took over resuscitation before transferring the resident to a GACH. The paramedic report documented altered level of consciousness, pinpoint pupils, a GCS of 3, and administration of Narcan without improvement. The ED record documented agonal respirations at six breaths per minute and intubation for airway protection. The resident’s hospital course included acute hypoxic hypercapnic respiratory failure, ICU care, bronchoscopy, and later recurrent respiratory failure with worsening somnolence, labored breathing, absent gag reflex, and hypercapnic respiratory failure. Comfort measures were pursued and the resident died later that day. Interviews showed the LVN was not aware of the interactions between Diazepam, Norco, and Buspirone, did not know what Olanzapine was indicated for, and monitored side effects toward the end of the shift. The DON stated the black box warning for Buspirone was on the MAR but was not signed off by the LVN, and the DSD stated she had not trained staff on black box warnings or on using narcotics concurrently with psychotropic medications.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Develop and Implement Smoking-Related Care Plans
Penalty
Summary
The facility failed to develop and implement care plans addressing the smoking needs of two residents who required substantial or maximal assistance with activities of daily living and had intact cognition. Both residents had documented assessments indicating the need for specific safety measures while smoking, such as the use of a smoking apron and, for one resident, a cigarette extension. Despite these documented needs, there were no care plans created to guide staff in providing the necessary interventions to ensure the residents' safety during smoking activities. Observations revealed that both residents were seen smoking without the required safety equipment, and staff confirmed that no care plans were in place for smoking-related risks. Interviews with nursing staff and the DON confirmed the absence of care plans and acknowledged that care plans are intended to guide staff in maintaining resident safety. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not followed for the two residents in question.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed by the physician for two out of four sampled residents. For one resident with diagnoses including metabolic encephalopathy and mood disorder, the physician's order specified that Oxycodone-Acetaminophen should be given only for breakthrough pain rated 4-10 out of 10. However, the Medication Administration Record (MAR) showed that the medication was administered when the resident's pain level was documented as 0 and 3, which did not meet the criteria outlined in the physician's order. Interviews with nursing staff confirmed that the medication was given outside the prescribed parameters, and staff acknowledged that this was not in accordance with the order. Another resident, admitted with diagnoses such as encephalopathy, sciatica, and dementia, had a physician's order for Hydrocodone-Acetaminophen to be administered for moderate to severe pain (pain level 4-10). The MAR indicated that this resident also received pain medication when their pain level was documented as 0. Staff interviews confirmed that the medication should not have been administered at a pain level of 0, and that the documentation was inaccurate. The facility's policy on administering medications requires that medications be given in accordance with prescriber orders, including any specified parameters. The observed practice of administering pain medication outside the prescribed pain levels for both residents was not consistent with these requirements, as confirmed by staff interviews and record reviews.
Failure to Develop and Implement Comprehensive Fall Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, resident-centered fall care plan for a resident with a history of falls, encephalopathy, sciatica, and dementia. The resident was assessed as having mildly impaired cognitive skills and required moderate assistance with several activities of daily living, including transfers and toileting. Despite being identified as a fall risk due to balance problems, history of multiple falls, and other medical conditions, the care plan only included an intervention to place the resident in a room near the nursing station for better visibility. The resident experienced an unwitnessed fall after not using the call light to request assistance with a restroom transfer. Interviews with staff revealed that the resident often attempted to go to the bathroom independently and did not consistently use the call light, despite reminders and reeducation. Staff also noted the resident's desire for independence, forgetfulness, unsteady gait, and occasional non-compliance with safety interventions. The care plan did not address the resident's non-compliance with call light use or include additional interventions tailored to the resident's specific risks and behaviors. Further review and interviews confirmed that the facility's interdisciplinary team was aware of the resident's fall risk and history but did not update the care plan to reflect the resident's ongoing needs and behaviors. The facility's policies required comprehensive, person-centered care plans based on thorough assessments and ongoing revisions as resident conditions changed. However, the care plan for this resident lacked specific, measurable interventions to address the identified risks, leading to a deficiency in care planning.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that four out of eight sampled residents were free from significant medication errors. Specifically, the licensed nurses did not check Resident 6's heart rate prior to administering Amiodarone as ordered, resulting in 26 instances of non-compliance over two months. Additionally, Resident 26 did not receive Mexiletine as prescribed, with missed and late doses documented, and the facility failed to ensure the medication was available for administration. The Quality Assurance Performance Improvement (QAPI) team did not identify or act to correct these errors, and the facility's policy on adverse consequences and medication errors was not followed. Resident 26 experienced significant issues with the administration of Mexiletine, a medication critical for treating life-threatening ventricular arrhythmias. The resident missed a dose on one occasion and received doses at intervals shorter than the prescribed eight hours on multiple occasions. The facility also failed to monitor Resident 26 for adverse effects when doses were missed or administered late. Furthermore, the communication between shifts regarding late administration was inadequate, leading to potential risks for the resident. The facility also failed to adhere to physician's orders for other residents. Resident 29 received Midodrine despite having a systolic blood pressure greater than the prescribed threshold, and Resident 30's blood pressure and pulse rate were not checked before administering Amiodarone. These deficiencies were compounded by the facility's failure to document vital signs accurately, with 'Not Applicable' being recorded instead of actual readings. The facility's policies on medication administration and error documentation were not followed, contributing to the risk of adverse consequences for the residents involved.
Removal Plan
- Resident 26 was seen by MD 2. The DON spoke to MD 2 and informed him Resident 26 missed a dose of Mexiletine and was given a late dose.
- The DON provided one on one training to the Licensed Vocational Nurses (LVNs) who documented Mexiletine's late and missed administration. The DON discussed the importance of making sure medications are available, the process of when to reorder medications, and process if dose was late or missed, physician notification, monitoring of residents for adverse effect for missing medications and development of change of condition Situation, Background, Assessment, Recommendation (SBAR) and care plan.
- The DON provided one on one counseling and in-service with LVN 2 in failing to administer the Mexiletine dose as scheduled and as ordered by the physician, the possible adverse effects of late administration and notification to the physician and monitoring of resident and/or responsible party if the schedule of the medication dose needs to be altered or changed.
- The DON provided a phone one on one counseling and in-service with involved LVN 3 in failing to administer the Mexiletine dose as scheduled and as ordered by the physician, and about the adverse effects of late administration including the process if the medication dose schedule needs to be altered or change such as notification to the physician. The DON will provide in-person counseling and in-service upon return to work of LVN 3 who failed to administer Mexiletine dose.
- The facility's contracted Pharmacy Consultant initiated an in-service with thirteen LVNs regarding administration of medications, the adverse effects of missing the dose and/or late medication administration. In-services will continue until all twenty-five LVNs have participated.
- The facility contracted Pharmacy Consultant is scheduled to do a Medication Regimen Review (MRR) for Residents receiving antiarrhythmic medications including Residents 6, 11, 20, 26, 30, 43, 51 and 70.
- The facility's Medical Director will initiate an in-service training with the seven LVNs on the importance of administering antiarrhythmic medications as ordered and at the specified time; the adverse effects of not administering medications or late administration, and adverse effects of overdosing on medications when administered medication too close between doses. The Medical Director will continue to conduct the in-service until the remaining eighteen LVNs have participated.
Failure to Address Medication Errors in QAPI Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address significant medication errors within the facility. During an interview, the Director of Nursing (DON) revealed that the current QAPI plan was focused on falls and discharges against medical advice, and medication administration errors were not included in their program. The DON admitted that they were unaware of the medication errors, which included missed doses, late administration, and not following physician's orders, until deficiencies were identified by surveyors. A review of the facility's policies and procedures indicated that medication errors were supposed to be documented, reported, and reviewed by the QAPI committee to inform necessary process changes or additional staff training. However, the QAPI program, as revised in February 2020, was not effectively implemented to monitor and evaluate these errors. This oversight placed all residents at risk for adverse effects due to the mismanagement of their medication regimen.
Failure to Provide Mandatory Communication Training for LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 2 and 3) received mandatory training in effective communication upon hire. During an interview and record review with the Director of Staff Development (DSD), it was found that the personnel records of LVN 2 and 3 lacked documented evidence of training in effective communication. The DSD confirmed that effective communication was not included in the orientation services for newly hired staff. In a subsequent interview with the Director of Nursing (DON), it was acknowledged that mandatory training needed to be implemented in the facility. The facility's policy and procedure, titled 'Competency of Nursing Staff' from May 2019, indicated that all nursing staff must meet specific competency requirements, including communication skills, as defined by state law. This oversight had the potential to result in staff with poor communication skills, which could negatively affect the residents' quality of care.
Failure to Provide QAPI Training to New LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 2 and 3) received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program upon hire. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was found that the personnel records of LVN 2 and 3 lacked documented evidence of QAPI training. The DSD confirmed that QAPI training was not included in the orientation services for new staff. Additionally, the Director of Nursing (DON) acknowledged the need for mandatory training to be implemented in the facility. The facility's policy and procedure on the competency of nursing staff, dated May 2019, indicated that all nursing staff must meet specific competency requirements as defined by state law.
Failure to Update Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records of two residents were up to date concerning their Advance Directives (AD), as per the facility's policy. Resident 38 was admitted with several mental health diagnoses and was moderately impaired in cognitive skills. Upon admission, the AD Acknowledgement form was not discussed with Resident 38 due to their lack of alertness. The form was eventually signed on 12/5/2024, but it was deemed invalid as the resident was not capable of making medical decisions at that time. The Social Service Director and Director of Nursing acknowledged that the form should have been completed within 72 hours of admission during a care conference meeting. Resident 86 was admitted with conditions including atrial fibrillation and anxiety disorder, and was also moderately impaired in cognitive skills. The AD Acknowledgement form indicated that Resident 86 had an Advance Healthcare Directive (AHCD), but the facility did not have a copy of it. The resident did not recall discussing the AD Acknowledgement form, although they had spoken with their doctor about their wishes. The Director of Nursing noted that the form should have been completed during the admission process to ensure the facility had a copy of the AD. The facility's policy, revised in December 2016, requires that residents be provided with information about their right to formulate an AD upon admission. If a resident is incapacitated, the information should be given to their legal representative, and the resident should receive the information later if they become able to understand it. The policy also mandates that information about the existence of any AD be prominently displayed in the medical record. The failure to adhere to this policy resulted in the facility not being fully informed of the residents' wishes regarding their healthcare decisions.
Failure to Notify Physicians of Critical Medical Events
Penalty
Summary
The facility failed to notify the primary care physician of two residents regarding significant medical events. Resident 6, diagnosed with Diabetes Mellitus, had a critically high blood sugar level of 508 mg/dL, which was not communicated to the physician as required by the facility's policy. This oversight was confirmed through interviews and record reviews, where it was noted that the physician was not informed of the elevated blood sugar level, which was considered a change in condition necessitating immediate notification. Resident 26, who was on a strict medication regimen for ventricular tachycardia, experienced multiple instances of missed or late doses of mexiletine, a critical heart medication. The facility's records showed that doses were either missed or administered late on several occasions, yet there was no documentation that the physician was notified of these medication errors. Interviews with staff confirmed that these were considered medication errors and should have been reported to the physician for further instructions and monitoring. The facility's policies clearly outlined the need for prompt physician notification in cases of significant changes in a resident's condition or medication errors. However, in both cases, the facility did not adhere to these protocols, resulting in a lack of timely communication with the residents' physicians, which could have led to delays in necessary medical interventions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect three residents from abuse and neglect, leading to significant deficiencies in care. Resident 69, who was diagnosed with end-stage renal disease, generalized muscle weakness, and hypertension, was allegedly sexually assaulted by another resident, Resident 1, in March 2023. Despite the incident being reported to the charge nurse and the Social Service Director (SSD), appropriate measures were not taken to ensure Resident 69's safety. Resident 1 was initially moved to another room but was later placed back near Resident 69, causing distress and fear for Resident 69. The facility did not adequately monitor or document the situation, failing to separate the residents effectively and ensure Resident 69's emotional well-being. In another incident, Resident 146, who had a history of dementia and aggressive behavior, was placed in front of the nursing station despite being agitated and combative. This placement led to a physical altercation with Resident 62, who was struck with a quad cane and punched by Resident 146. The facility did not take appropriate measures to separate Resident 146 from other residents, resulting in preventable abuse. The Director of Staff Development acknowledged that the situation was mishandled and should have been reported as abuse to the California Department of Public Health. The facility's policies and procedures regarding resident rights and abuse prevention were not followed, contributing to the deficiencies. The Social Service Director and other staff members failed to document and monitor the incidents properly, and the facility did not ensure the safety and well-being of the residents involved. These actions and inactions placed the residents at risk for further abuse and neglect, violating their rights to be free from harm.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of physical abuse involving two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. Resident 146, who has diagnoses including dementia and major depressive disorder, was involved in a physical altercation with Resident 62, who has diagnoses including major depressive disorder and PTSD. The incident occurred when Resident 146 grabbed Resident 62's quad cane and hit Resident 62 in the chest and arms. Despite the altercation being reported to the local police department and the ombudsman, it was not reported to CDPH as required by the facility's policy. The facility's policy on abuse investigation and reporting mandates that all reports of resident abuse and neglect be promptly reported to local, state, and federal agencies. The policy specifies that alleged violations involving abuse must be reported within two hours. The failure to report this incident to CDPH within the regulated timeframe resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.
Failure to Report Abuse Allegations to CDPH
Penalty
Summary
The facility failed to report allegations of physical abuse involving two residents to the California Department of Public Health (CDPH) within the required five-day period. Resident 62, who had intact cognitive skills and required assistance with daily activities, was involved in an altercation with Resident 146, who had moderately impaired cognitive skills and required substantial assistance with daily activities. The incident occurred when Resident 146 grabbed Resident 62's quad cane and hit Resident 62 in the chest and arms. The Director of Nursing (DON) confirmed that the altercation was reported to the local police department and the ombudsman but not to CDPH, and no investigative report was sent to CDPH. The facility's policy and procedure on abuse investigation and reporting, revised in April 2017, required the Administrator or designee to provide a written report of the findings to the appropriate agencies within five working days of the incident. This failure to report resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with PTSD, potentially leading to re-traumatization and negative impacts on their psychosocial status. Resident 62, who was admitted with major depressive disorder and PTSD, had intact cognitive skills and required assistance with daily activities. The resident's trauma history included exposure to war-related casualties, natural disasters, and life-threatening situations. Similarly, Resident 146, admitted with dementia, major depressive disorder, and PTSD, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. This resident's trauma history also included exposure to war-related casualties, natural disasters, and life-threatening illnesses. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility did not assess the residents' triggers or develop trauma-informed care plans to address these triggers and prevent re-traumatization. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization for trauma survivors, particularly during the transition to an institutional setting. However, the facility did not implement these guidelines, resulting in a deficiency in providing appropriate care for residents with PTSD.
Medication Administration Errors Due to Incompetent Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses were competent during medication administration for four out of eight sampled residents, leading to significant medication errors. Resident 6, who had severe cognitive impairment and a history of heart disease, was supposed to receive amiodarone hydrochloride with specific instructions to hold the medication if the pulse was less than 60 BPM. However, the Medication Administration Record (MAR) showed that the pulse reading was marked as 'not applicable' multiple times, and the medication was still administered. Resident 26, with a history of ventricular tachycardia and cardiac arrhythmia, was prescribed amiodarone and mexiletine with specific administration times and conditions. The MAR indicated that doses were missed, administered late, or given without the required pulse readings. Additionally, the administration audit report showed that mexiletine was given at incorrect intervals, potentially leading to adverse effects. Resident 29, diagnosed with hypotension and atrial fibrillation, was to receive midodrine with instructions to hold the medication if the systolic blood pressure exceeded 130 BPM. Despite this, the MAR documented that the medication was administered even when the blood pressure was above the specified limit. Similarly, Resident 30, with atrial fibrillation and congestive heart failure, had medications administered without proper documentation of vital signs. Interviews with the Director of Nursing and Director of Staff Development revealed that the nurses were not following the facility's policy, leading to these medication errors.
Failure to Conduct IDT Meeting for Resident's Vision Decline
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) Care Conference meeting was initiated for a resident, identified as Resident 86, after multiple eye doctor appointments. This oversight resulted in neither the staff nor the resident being aware of the outcomes from these appointments. The deficiency violated the resident's right to actively participate in the IDT meeting to discuss his plan of care and services, potentially delaying necessary discussions about needed care and services. Resident 86 was admitted to the facility with diagnoses including end-stage renal disease, type 2 diabetes, anemia, and hypertension. The resident had intact cognitive status and required assistance with various self-care and functional activities. Despite these needs, the last recorded IDT Care Conference Meeting for Resident 86 was on 6/27/2024, with no mention of vision decline. The resident reported seeing an eye doctor two months prior, who recommended surgery, but he was unaware of any arrangements for the procedure, and his vision was deteriorating. Interviews with facility staff, including a Licensed Vocational Nurse, Social Service Director, Assistant Director of Nursing, and MDS Nurse, revealed that there was no IDT meeting held in September 2024, despite the resident's reported vision decline and visits to an outside eye doctor. The facility's policy required IDT meetings for significant changes in a resident's condition, but this was not adhered to in Resident 86's case. The staff acknowledged that an IDT meeting should have been conducted to address the resident's vision issues and update the care plan accordingly.
Failure to Implement Vision Care Plan for Resident
Penalty
Summary
The facility failed to implement a care plan for a resident, identified as Resident 86, who experienced a decline in vision. This deficiency was identified during a survey that included observation, interviews, and record reviews. Resident 86 was admitted with multiple diagnoses, including end-stage renal disease, type 2 diabetes, anemia, and hypertension. Despite having intact cognitive status and the ability to make decisions about his care, there was no care plan addressing his vision decline, which was a concern he had verbalized since September. During the survey, it was observed that Resident 86 was aware of his need for eye surgery due to worsening vision, but there were no updates on the surgery's schedule. Interviews with the Licensed Vocational Nurse (LVN) and the MDS Nurse confirmed that there was no comprehensive care plan for the resident's vision issues, despite his ongoing visits to an eye doctor. The LVN acknowledged that a care plan should have been in place to ensure the healthcare team was aware of the interventions and to assess their effectiveness. The Director of Nursing (DON) also confirmed the absence of a care plan for the resident's vision decline. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the comprehensive assessment and to be revised as the resident's condition changes. However, this was not done for Resident 86, indicating a failure to adhere to the facility's care planning procedures.
Medication Order Lacks Specified Dose
Penalty
Summary
The facility failed to ensure that the medication order for a resident's diclofenac sodium external gel included a specified dose. This oversight resulted in the medication being administered without a documented dose from November 17, 2024, to December 3, 2024. The resident, who was readmitted to the facility with serious heart conditions and had severely impaired cognitive skills, received the medication for pain management without clarity on the amount to be applied. The lack of a specified dose in the medication order posed a risk of overdosing or underdosing the resident. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) acknowledged the absence of a specified dose in the Medication Administration Record (MAR) and recognized the need for clarification on the order. The Director of Nursing (DON) confirmed that medication orders must indicate the dose to ensure correct administration. The facility's policy and procedure for administering medication emphasized the importance of verifying the right dosage, among other factors, before administering medication. However, this policy was not adhered to in this instance, leading to the deficiency.
Deficient Foley Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate foley catheter care for a resident, identified as Resident 25, which led to the potential for recurrent urinary tract infections (UTIs). Resident 25 was admitted with several diagnoses, including obstructive and reflux uropathy, hypertension, benign prostatic hyperplasia, and mechanical complications of an indwelling urethral catheter. The resident required maximal assistance for various self-care activities and had intact cognitive status, allowing him to understand and make decisions about his care. The deficiency was identified through a review of Resident 25's Treatment Administration Record (TAR) for November 2024, which showed missing documentation for foley catheter care on multiple dates. The facility's policy required catheter care every shift, three times a day, and monitoring for signs of infection such as foul odor, hematuria, and sediments in urine. However, there were gaps in documentation, indicating that the care may not have been provided as ordered. During interviews, both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that if care was not documented, it was likely not provided. Observations and interviews with Resident 25 revealed that he had experienced frequent UTIs in the past, although he did not have one at the time of the interview. The facility's policy emphasized the importance of maintaining clean technique and regular monitoring to prevent catheter-associated UTIs. The lack of consistent documentation and adherence to the care plan increased the risk of Resident 25 developing recurrent UTIs, as confirmed by the DON during the interview.
Incorrect Oxygen Administration for Resident
Penalty
Summary
The facility failed to ensure that a resident was receiving the correct concentration of oxygen, which was a deviation from the physician's order. The resident, who was readmitted with diagnoses including interstitial pulmonary disease, pulmonary fibrosis, acute respiratory failure, and dependence on supplemental oxygen, was observed to have their oxygen set at 2.5 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an observation and interview. The ADON acknowledged the importance of adhering to the prescribed oxygen level to maintain proper lung function. The Director of Nursing (DON) also emphasized the necessity for staff to follow physician orders to ensure resident safety. The facility's policy on oxygen administration, revised in 2010, requires verification of the physician's order for safe oxygen administration, which was not followed in this instance.
Failure to Monitor Resident on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident who was prescribed psychotropic medications, which could lead to unnecessary medication use. The resident, who was admitted with diagnoses including dementia, major depressive disorder, PTSD, and limb amputations, was receiving Escitalopram for depression and anxiety, and Mirtazapine for sleep issues. However, there was no documented evidence that the resident's feelings of hopelessness, anxiety, or sleep patterns were monitored to assess the effectiveness of these medications. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility did not follow its policy and procedure for behavioral assessment, intervention, and monitoring. The policy required the interdisciplinary team to document any changes in behavior, mood, and function, and to monitor progress until stable. The lack of monitoring was acknowledged by the staff, indicating a failure to ensure the resident's behaviors were assessed to determine the necessity and effectiveness of the psychotropic medications.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure the secure storage of medications, as evidenced by an incident involving Resident 70's medication. During a medication pass, an LVN placed Resident 70's Amiodarone on top of the medication cart and left it unattended. This action was observed on December 4, 2024, at 9:30 a.m. The unattended medication was later noticed by the Director of Staff Development, who confirmed that medications should not be left unattended to prevent unauthorized access by other residents. Resident 70 had been readmitted to the facility with serious cardiac conditions, including ventricular fibrillation and hypertensive heart disease with heart failure. The resident's cognitive skills for daily decision-making were severely impaired, as indicated by the Minimum Data Set dated November 23, 2024. The facility's policy on medication storage specifies that medication supply should only be accessible to authorized personnel, highlighting the importance of secure medication handling to ensure resident safety.
Failure to Sanitize Mechanical Lift Between Residents
Penalty
Summary
The facility failed to observe proper infection control measures when using a mechanical lift for two residents. Certified Nursing Assistant (CNA 1) and CNA 2 used the mechanical lift to transfer Resident 69, who required substantial assistance due to conditions such as end-stage renal disease and generalized muscle weakness, to a wheelchair. After completing the transfer, CNA 1 did not sanitize the mechanical lift before placing it in the hallway. Subsequently, CNA 1 used the same unsanitized lift to assist Resident 14, who was dependent on assistance for personal hygiene and dressing due to chronic kidney disease and anxiety disorder, into a Geri chair. During an interview, CNA 1 acknowledged forgetting to clean the mechanical lift between uses, recognizing the importance of this practice to prevent infection spread. The Director of Staff Development confirmed that equipment like mechanical lifts must be cleaned before and after use to prevent cross-contamination. The facility's policy on infection prevention and control, dated October 10, 2018, mandates maintaining a sanitary environment to prevent communicable diseases, which was not adhered to in this instance.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Mechanical Lift. The facility's policy requires at least two people to be present during transfers with a Mechanical Lift to ensure safety. However, CNA 1 attempted to transfer the resident alone, resulting in the resident falling from the lift and sustaining a right shoulder nondisplaced fracture. The resident, who was initially admitted to the facility with diagnoses including end-stage renal disease, generalized muscle weakness, and hypertension, was assessed as high risk for falls. The resident required substantial assistance for transfers and was dependent on staff for moving from one surface to another. On the day of the incident, the resident returned from dialysis and requested help to go to bed. CNA 1 attempted the transfer alone, leading to the resident falling and injuring their shoulder. Interviews with staff, including the Licensed Vocational Nurse (LVN), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the facility's policy mandates two-person assistance for transfers using a Mechanical Lift. The Occupational Therapist (OT) noted that the resident's right arm and shoulder range of motion were impaired following the fall, requiring therapy to regain function. The facility's policy, revised in October 2019, clearly states the requirement for two-person assistance during such transfers, which was not adhered to in this case.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to uphold and protect the rights of two residents, resulting in a deficiency related to resident dignity and respect. Resident 2, who has diagnoses including generalized anxiety disorder, major depressive disorder, and hemiplegia, experienced a violation of privacy and dignity when the Administrator (ADM) and Business Office Manager (BOM) entered his room without permission to discuss his outstanding balance. The ADM spoke to Resident 2 in a demeaning manner, questioning his financial decisions in a way that made him feel anxious and disrespected. This interaction was witnessed by Resident 2's roommate, who confirmed the disrespectful tone used by the ADM. Resident 3, diagnosed with anxiety disorder, major depressive disorder, and schizophrenia, was moved to another room against her wishes. Despite expressing her disagreement with the room change due to anxiety concerns, the ADM proceeded with the move to accommodate newly admitted residents near the nurse's station. The Ombudsman was contacted by Resident 3, who felt her rights were violated, and the ADM acknowledged the resident's refusal but decided to move her regardless. The facility's policy on room changes states that resident preferences should be considered, and residents have the right to refuse a move if it is for staff convenience. The facility's policies on resident rights and quality of life emphasize treating residents with dignity, respect, and privacy. However, the actions of the ADM in both cases did not align with these policies, leading to feelings of anxiety, humiliation, and a lack of trust among the affected residents. The ADM admitted to not having permission to discuss financial matters in Resident 2's room and acknowledged leaving the door open during the conversation, further compromising privacy. These actions contributed to the deficiency in maintaining resident dignity and respect.
Delayed Emergency Response for Choking Resident
Penalty
Summary
The facility failed to promptly activate Emergency Medical Services (EMS) and provide appropriate emergency care when a resident was observed choking while eating. The incident involved a resident with a history of dysphagia and severely impaired cognitive skills, who was dependent on staff for eating. During the choking episode, the resident's oxygen saturation fluctuated between 52% and 82%, and the staff administered oxygen at an insufficient rate via a nasal cannula instead of using a non-rebreather mask, which would have been more effective. The delay in calling 911 was due to the actions of RN 1 and LVN 1, who prioritized checking the resident's code status and consulting with the Director of Staff Development (DSD) over immediately contacting emergency services. This resulted in a 14-minute delay before EMS was called. Additionally, the staff failed to retrieve the crash cart and a non-rebreather mask, which were necessary for providing adequate emergency care to the resident. Interviews with staff members revealed a lack of clear communication and delegation during the emergency. CNA 1 and CNA 2 were not instructed to call 911 or retrieve the crash cart, and LVN 1 did not inform RN 1 about performing the Heimlich maneuver. The Director of Nursing (DON) and DSD acknowledged that the facility's response was inadequate, emphasizing that 911 should have been called immediately and the crash cart should have been brought to the resident's room to prevent a delay in care.
Failure to Document Choking Incident and Care
Penalty
Summary
The facility failed to document the care provided to a resident who experienced a choking incident during dinner. The resident, who had a history of dysphagia and severely impaired cognitive skills, was being fed noodles by a CNA when they began to choke. The CNA called for assistance, and an LVN performed the Heimlich maneuver, successfully expelling food particles from the resident's mouth. However, the LVN did not document the incident or the care provided in the resident's medical record, citing being busy as the reason for the oversight. This lack of documentation resulted in an incomplete medical record for the resident, which did not reflect the choking incident or the subsequent care provided. The facility's policy required detailed documentation of such incidents, including the time, assessment data, and the resident's response. The failure to document prevented accurate communication between healthcare professionals and hindered the facility's ability to review and investigate the incident thoroughly.
Failure to Resolve Resident's Grievance Regarding Missing Belongings
Penalty
Summary
The facility failed to resolve a grievance to the satisfaction of a resident and their representative regarding missing personal belongings, specifically a cellphone. The resident, who was admitted with diagnoses including sepsis, depression, and hemiparesis, had intact cognition and required supervision for activities of daily living. The resident's inventory list included a black cellphone, which was reported missing along with other items such as a backpack, checkbook, and social security card. Despite the grievance being filed, the resolution did not address the cellphone, which was inventoried, and the resident's representative expressed dissatisfaction with the lack of replacement or reimbursement. The facility's policy required prompt resolution of grievances to the satisfaction of the resident or their representative, but this was not achieved. The Social Services Director acknowledged that the cellphone should have been replaced or reimbursed, as it was listed in the inventory. The Administrator, however, stated that the resident had the ability to safeguard their belongings and was not satisfied with the resolution. The facility's grievance policy indicated that all grievances should be responded to in writing with a rationale, but this was not adequately fulfilled in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Palms Healthcare | 0.1 mi | ★★★★★ | 41 | 0 |
| Coral Cove Post Acute | 0.4 mi | ★★★★★ | 45 | 0 |
| Ocean Ridge Post Acute | 0.4 mi | ★★★★★ | 23 | 0 |
| Shoreline Healthcare Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Bel Vista Healthcare Center | 0.6 mi | ★★★★★ | 3 | 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 July 2026) and official state health department websites.