Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadow Creek Post-acute during CMS and state inspections, most recent first.
A resident with cord compression, cervical disc disorder with myelopathy, and HTN had four scheduled meds, including Epclusa, Theophylline ER, Baclofen, and Losartan, ordered for 9 a.m. but administered at 10:32 a.m. An LVN stated meds should be given within 1 hour of the scheduled time and that a late medication order should be obtained if a dose cannot be given on time; the DON confirmed the late administration and the facility policy required meds to be given within 1 hour of the prescribed time.
A resident with severe cognitive impairment, aphasia, respiratory failure, and neurogenic bladder had a PRN order for indwelling catheter irrigation with NS for clogging. On one occasion, NS irrigation was noted on a change-of-condition form, but the RN did not document the treatment on the MAR and later could not recall the amount of NS used or the resulting urine and drainage output. Review by the QA nurse and DON confirmed the absence of required documentation, which conflicted with facility policies requiring complete, accurate charting of catheter irrigations, including solution volume, return amounts, and urine output.
A resident with severe cognitive impairment and dependence on staff for ADLs was left with an incomplete and uneven haircut after a beautician stopped the service when the resident moved too much and did not allow the haircut to continue. The beautician cut only one side of the resident’s hair, did not seek assistance from nursing staff, and left without notifying staff that the haircut was unfinished. Days later, a CNA noticed the resident’s hair was significantly shorter on one side and alerted nursing staff, and subsequent assessments by an RN and LVN confirmed the uneven appearance. The Social Services Director later learned from the beautician that the haircut had not been completed, and facility policy required that residents be treated with dignity and have their sense of well-being and self-esteem promoted.
A resident with a history of psychoactive substance abuse, respiratory failure, ventilator dependence, and prior suspected illicit drug exposure from a specific family member experienced an overdose event after an inadequately supervised visit. Despite documented prior episodes of altered mental status linked to this family member, a positive UDS for barbiturates, and prior placement of the visitor on supervised status, facility staff allowed the visit to occur without direct staff supervision and instead relied on another family member to monitor the encounter. Following the visit, the resident was found difficult to arouse with hypoxia, bradypnea, and altered mental status, requiring Narcan administration and transfer to an acute care hospital, demonstrating the facility’s failure to implement its own safety and supervision policy for a known high-risk visitor.
A resident with intact cognition, multiple complex medical conditions, ventilator dependence, and a G-tube did not have an individualized care plan addressing safety concerns related to a specific family member. Respiratory therapy notes and staff interviews showed that this family member had intervened in the resident’s care, displayed aggressive behavior toward staff, and brought beer into the facility. An LVN, an RN supervisor, and the DON all acknowledged that no care plan was developed to address these non-compliant behaviors, despite facility policy requiring comprehensive, person-centered care plans that incorporate identified problem areas and associated risk factors.
A resident with severe cognitive impairment, multiple serious diagnoses, and a documented cortisone allergy developed bilateral groin MASD and was ordered hydrocortisone 2.5% ointment every shift. The hydrocortisone was administered on multiple shifts by several nurses without verifying the resident’s documented allergy, despite facility policy requiring allergy checks prior to medication administration. This resulted in repeated administration of a cortisone-related medication to a resident with a known cortisone allergy.
A resident with quadriplegia, severe cognitive impairment, type 2 DM, and identified risk for pressure injuries developed erythema and moisture-associated maceration of the scrotal and penile area, which was documented on a Change of Condition form. An LVN assessed the skin and completed the COC but did not initiate a care plan to address the new skin condition. The DON reported that all changes of condition must be followed by an appropriate care plan to communicate goals and interventions, and facility policy required the IDT to review and update the care plan when there is a significant change in condition, which did not occur in this case.
A resident with multiple medical conditions, including end-stage renal disease and a tracheostomy, continued to receive docusate sodium and senna despite experiencing ongoing diarrhea, contrary to physician orders to hold these medications for loose stools. Documentation and interviews confirmed that staff were aware of the resident's condition, but the medications were still administered, resulting in a significant medication error.
A resident with a history of loose stools continued to receive bowel management medications despite physician orders to hold them when diarrhea was present. The CNA documented and observed the loose stools but did not effectively communicate this to the LVN, who administered the medications as scheduled. The DON confirmed that the medications should have been held and that staff did not follow established protocols for reporting and medication administration.
A ventilator-dependent resident who was fully dependent on staff for personal hygiene did not receive scheduled showers, bed baths, or oral care due to staffing shortages and high acuity. This led to poor hygiene, a worsening pressure injury, and a maggot infestation around a tracheostomy site. Multiple staff observed and reported the issue, but documentation and timely reporting were lacking, and the resident was ultimately transferred to a hospital for further care.
A ventilator-dependent resident with significant care needs was found with maggots around a tracheostomy site due to missed hygiene care. Staff failed to promptly report the incident to state authorities and did not inform the resident's representative, despite facility policy requiring immediate notification and documentation. The lack of timely reporting and communication delayed regulatory oversight and intervention.
A resident with complex medical needs experienced a significant change in condition when maggots were found around a tracheostomy site. The nurse who discovered the issue did not document the incident in the EHR, complete the required SBAR tool, or submit a change of condition report. The DON and physician were verbally informed, but the event was not accurately reflected in the medical record or transfer order, resulting in incomplete documentation and failure to follow facility policy.
A respiratory therapist provided tracheostomy care to a ventilator-dependent resident while wearing artificial nails, in violation of facility policy prohibiting such nails for direct care staff. Facility leadership and the infection preventionist confirmed that artificial nails are not allowed due to infection risks, but there was no system in place to monitor compliance, resulting in a breach of infection control protocols.
A resident with severe cognitive impairment was found with a left shoulder dislocation and transferred to a hospital for evaluation. The DON and Administrator did not report the injury to authorities, considering it a chronic issue based on past medical history, despite facility policy requiring immediate reporting of injuries of unknown origin.
A resident with severe cognitive and physical impairments, dependent on a ventilator, was injured when a CNA repositioned her alone and placed her on ventilator tubing, contrary to facility policy requiring a two-person assist. This resulted in a skin tear to the resident's face, with staff interviews and records confirming the policy was not followed.
A resident with dementia and mobility issues, requiring supervision for oral hygiene, did not receive or have documented oral care every shift as required by facility policy. An LVN and the DON confirmed that oral care should be provided and documented each shift, but records showed this was not consistently done, placing the resident at risk for poor dental hygiene and oral infections.
Three residents with pressure ulcers did not receive their ordered wound care treatments during a day shift, as confirmed by missing documentation in the TAR and staff interviews. The residents, all dependent on staff and with significant medical conditions, had specific physician orders for topical medications and dressings that were not administered as required.
Three residents with G-tubes did not receive required site care as ordered, including cleansing, dressing changes, and infection assessment, as confirmed by TAR review and staff interviews. The residents, all dependent on staff for care and with significant medical conditions, had their treatments omitted and not documented, contrary to facility policy and physician orders.
A monitoring system with audio features was installed and activated in the rooms of three residents without their informed consent or adequate explanation. The residents were unaware of the device's true purpose and its ability to monitor vital signs and audio, and staff were not properly trained or informed about the system's features. Facility policy required education and consent, but this was not consistently followed, resulting in a violation of residents' rights to dignity, self-determination, and privacy.
Two residents were not accurately assessed in the MDS, with one resident's use of bilateral hand mittens as restraints not documented, and another resident's restorative nursing services not coded, despite physician orders and staff confirmation of these interventions. These omissions in the MDS assessment could affect the identification of care needs and the development of appropriate care plans.
The facility did not complete required PASRR Level II assessments for two residents with diagnoses of schizophrenia and schizoaffective disorder. Despite clear documentation of serious mental illness and use of antipsychotic medications, the PASRR Level I screenings were inaccurately marked, and no further evaluation was conducted, as confirmed by staff interviews and record reviews.
A resident with multiple chronic conditions experienced a medication error rate of 46.67% during a medication pass, as 14 out of 30 medication opportunities were missed or incorrectly administered. The nurse responsible reported running late and administering medications outside the prescribed time frame, contrary to facility policy requiring timely and accurate medication administration.
Two residents at high risk for pressure injuries did not receive consistent skin assessments, scheduled showers, or timely turning and repositioning as required by their care plans. Staff failed to document and report skin changes, leading to the development and progression of pressure injuries, including one associated with a medical device. Facility policy for monitoring and documentation was not followed.
Two residents with the capacity to understand and make decisions were not informed of their rights upon admission, as required by facility policy and regulations. Both reported being unaware of their rights, and staff interviews confirmed that the process for providing this information was not consistently followed.
A resident with a tracheostomy, gastrostomy, and impaired cognition was placed in Peek-A-Boo mittens without a physician order specifying the medical reason for restraint use, as required by facility policy. Staff did not consistently monitor or assess the resident when mittens were removed, and the resident was left unsupervised at times, despite being at risk for interfering with medical devices. The facility's actions did not align with its own restraint policy.
A resident with anxiety, depression, and PTSD was admitted and initially screened negative for PASARR Level 1, but after being prescribed paroxetine and risperidone, no updated PASARR screening was completed as required by facility policy. Staff interviews confirmed that the necessary follow-up screening was not performed.
A resident who was fully dependent on staff for activities of daily living, including oral hygiene, was not treated for a documented case of candidiasis. Despite clear signs of oral thrush and staff awareness of the diagnosis, no treatment order was obtained and the condition went untreated, contrary to facility policy requiring care for residents unable to perform self-care.
A resident with multiple complex medical conditions did not receive the ordered active assisted range of motion (AAROM) exercises as prescribed by their physician. Instead, only passive range of motion (PROM) was provided, and the restorative nursing assistant did not inform licensed nursing staff of the resident's inability to perform AAROM. This lack of communication and failure to follow the physician's order led to a deficiency in care.
A resident with a tracheostomy, ventilator dependence, and severe cognitive impairment was observed with dried secretions on the mouth, despite orders for regular suctioning and oral care. Staff interviews confirmed that oral care and suctioning were necessary and required by facility policy, but these were not performed as needed, resulting in a deficiency.
The facility failed to maintain an active and approved Nurse Assistant Training Program after the program expired, as the DSD did not complete the renewal application correctly or seek help, resulting in the program's denial by CDPH. The administrator became aware of the issue only after the expiration, and CNAs were unable to renew their certificates through the facility's program.
The facility did not complete required annual performance evaluations for two CNAs, as confirmed by both the Director of Staff Development Consultant and the Administrator during record reviews. This omission was contrary to facility policy, which mandates annual written evaluations to assess staff performance and identify training needs.
Licensed nursing staff failed to document the administration of narcotic medications on the Narcotic and Hypnotic Record for two residents with heart and respiratory failure. The responsible LVN did not initial the record after administering Tramadol and Hydrocodone, as required by facility policy, and the DON confirmed that immediate documentation is necessary to prevent medication errors.
Surveyors observed that fresh fruit, including cantaloupe and honeydew melon, was not properly labeled with open and use-by dates in the walk-in refrigerator. Staff interviews and facility policy confirmed that such labeling is required to ensure food safety and prevent serving expired food.
The facility did not provide effective QAPI oversight or ensure implementation of its plan of correction for deficiencies related to timely assessment and treatment of pressure injuries and proper oral care as ordered by a physician. Repeat deficiencies were identified in both areas during consecutive surveys, and interviews with the DON and Administrator confirmed ongoing issues despite regular wound meetings and staff education.
Staff did not assess or change a resident's midline catheter dressing that was visibly soiled and blood-soaked for several days, despite physician orders and facility policy requiring regular monitoring and immediate dressing changes when compromised. Nursing and infection prevention staff confirmed the dressing should have been changed to prevent infection.
A resident with multiple complex medical conditions was prescribed antibiotics for a UTI without meeting McGeer Criteria or showing documented symptoms of infection. The facility did not follow its own Antibiotic Stewardship policy, which requires specific clinical information to be collected and communicated before antibiotics are prescribed.
The facility did not provide approved training for CNAs after its Nurse Assistant Training Program expired. The DSD was aware of the expiration but did not complete the application process correctly or seek help, resulting in a lapse in CNA education and certificate renewal. The administrator only learned of the issue months later, and facility policies requiring ongoing staff development were not followed.
A resident with multiple serious medical conditions and lacking decision-making capacity was admitted without known identity. The facility's social worker did not contact law enforcement to assist with identification, instead waiting for information from the hospital, and was unaware of the need to involve police. The DON confirmed that proper steps to identify the resident were not taken, and facility policy requiring collaboration with community agencies was not followed, resulting in the resident remaining unidentified.
A resident with a history of respiratory and cardiac conditions experienced shortness of breath, low blood pressure, and other symptoms, but staff failed to notify the physician and monitor the resident as ordered. Despite clear physician orders and facility policy requiring notification and assessment for changes in condition, these actions were not taken until the resident's condition worsened and required hospital transfer.
A facility failed to notify a physician when a resident exhibited low blood pressure and temperature readings, potentially leading to hypotension and hypothermia. The resident, with complex medical conditions, was being monitored for sepsis prevention. Despite documented low readings in the EMAR, there was no record of physician notification, as required by care orders. Interviews with LVNs and the DON confirmed the oversight, which violated facility policies on change in condition and vital sign monitoring.
A resident with a suprapubic catheter and recurrent UTIs did not receive necessary urology consultation, despite frequent antibiotic treatments. The facility's staff acknowledged the need for specialist consultation to ensure proper catheter function and infection monitoring, but it was not arranged, leading to a deficiency in care.
A resident with a suprapubic catheter experienced an infection control deficiency when the catheter bag was observed touching the floor, posing a high risk for infection. Despite being on antibiotics for a UTI, the facility failed to document timely changes of the catheter bag, as required by their policy. Interviews with staff confirmed the importance of preventing catheter bags from touching the floor and ensuring regular checks, which were not adequately performed.
A resident at high risk for pressure injuries developed a Stage II ulcer due to the facility's failure to adhere to a turning and repositioning schedule. Despite being dependent on assistance for all activities and having multiple medical conditions, the resident was not repositioned every two hours as required. Documentation gaps and staff interviews confirmed the deficiency, with the Treatment Nurse stating the ulcer was preventable.
A resident in a subacute unit was not turned and repositioned every two hours as required, leading to a Stage II pressure injury. CNAs were overburdened with high acuity residents, each caring for ten or more individuals. Staffing decisions were based on census rather than acuity, contributing to the deficiency.
A resident with a history of cerebral infarction and left side hemiplegia was left unattended after activating the call light for assistance with a bedpan. Despite the call light being activated and audible alarms sounding, multiple nursing staff members did not respond, resulting in the resident urinating on herself. This incident caused the resident to feel uncomfortable and undignified, highlighting a deficiency in the facility's adherence to its policies on prompt response to residents' needs.
A facility failed to provide necessary ROM exercises and splint application for two residents, leading to a deficiency in care. One resident with hemiplegia and dementia did not receive ordered PROM and AAROM exercises or knee splint application, while another resident with knee contractures did not receive PROM exercises. RNA 1 admitted to not performing these services due to workload constraints, and documentation inaccurately reflected that services were provided. Interviews highlighted the risk of further decline in residents' ROM and mobility.
A facility failed to ensure accurate documentation by an RNA, who falsely recorded providing PROM exercises and applying a knee splint to a resident with hemiplegia and dementia. Observations and interviews revealed that the resident did not receive the documented care, and the RNA admitted to mistakenly documenting the services. The facility's policy required accurate charting, which was not followed.
A CNA in an LTC facility was reported for speaking rudely and handling residents roughly, violating their rights to dignity and respect. Multiple residents, including one with cognitive impairment and another with anxiety and depression, experienced disrespectful treatment. The facility's staff confirmed a pattern of complaints against the CNA, highlighting a failure to adhere to the policy of treating residents with kindness and respect.
A resident with dementia was assaulted by another resident with anxiety disorder in the dining room when left unsupervised. The incident occurred after a confrontation over clothing, resulting in hair-pulling. The Activities Director admitted to leaving the room unattended, violating the facility's policy on resident supervision and rights.
A resident at high risk for falls sustained injuries after a CNA attempted a transfer from a shower chair to a bed using a mechanical lift without assistance. The resident, dependent on staff for all ADLs and requiring two-person assistance, fell and suffered lacerations and a skin tear, leading to hospitalization. The care plan lacked specific instructions for mechanical lift use, contributing to the incident.
Late Administration of Scheduled Medications
Penalty
Summary
The facility failed to administer medications as prescribed for one resident who was cognitively intact and had diagnoses including cord compression, cervical disc disorder with myelopathy, and hypertension. The physician’s orders required Epclusa 400-100 mg, Theophylline ER 200 mg, Baclofen 10 mg, and Losartan Potassium 50 mg to be given at 9 a.m., but the Medication Administration Audit Report showed all four medications were administered at 10:32 a.m. instead of the ordered time. During interview, an LVN stated medications were to be administered within one hour before or after the scheduled time and that if a medication could not be given on time, the physician should be notified for a late administration order. The DON reviewed the record and confirmed the medications were given late by an LVN, and stated a physician must be called for a late medication order if a dose is anticipated to be late. The facility policy on administering medications stated medications are to be administered within 1 hour of their prescribed time.
Failure to Accurately Document PRN Catheter Irrigation
Penalty
Summary
The facility failed to ensure accurate documentation of a prescribed catheter irrigation treatment for Resident 1. Resident 1, who had diagnoses including aphasia, respiratory failure, and neuromuscular dysfunction of the bladder, was severely cognitively impaired and dependent on staff for all ADLs. A physician’s PRN order dated 2/1/2026 directed irrigation of the resident’s indwelling catheter with 60 mL NS for catheter clogging. On 2/15/2026, a Change of Condition document noted that cold NS irrigation was performed on the indwelling catheter with clear to amber return. However, a review of the MAR for that date showed no documentation that the catheter irrigation was administered. During interviews, the QA Nurse confirmed there was no record indicating NS irrigation was given on that date and stated that all treatments and medications should be documented timely and accurately so the care team knows exactly what has been done. RN 1 reported she could not remember how much NS she used to irrigate the catheter on 2/15/2026 or the amount of drainage or urine that resulted, and acknowledged the importance of accurate, contemporaneous charting. The DON stated that all licensed nurses must document medications and treatments immediately after administration and that incomplete documentation can lead to medication errors and inaccurate communication, resulting in an incomplete assessment of the resident’s condition. Review of facility policies on catheter irrigation and charting showed requirements to document the date and time of the procedure, the person performing it, the amount of solution used, the amount returned as drainage, the amount of urine drained, and that documentation be objective, complete, and accurate, which was not done in this case.
Incomplete Haircut Left Resident With Uneven Appearance
Penalty
Summary
The facility failed to ensure a resident’s right to dignity and proper grooming when the contracted beautician did not complete a haircut and left the resident with uneven hair. The resident, who had diagnoses including unspecified hypotension, anemia, and schizoaffective disorder, had severely impaired cognition per an MDS dated 3/7/2026 and was dependent on staff for ADLs. On 2/16/2026, the beautician attempted to cut the resident’s hair but, according to her written statement and later interview, stopped after cutting only one side because the resident was moving too much and did not allow her to continue. She did not request assistance from nursing staff, did not notify staff that the haircut was incomplete, and left the facility without completing the service, resulting in the resident having short hair on the right side and significantly longer hair on the left side. On 3/6/2026, a CNA noticed the resident’s hair was short and uneven and notified nursing staff. An SBAR and change of condition documentation were completed, noting the discovery of the short, uneven hair on the right side of the resident’s head and the resident’s inability to clearly report when the haircut occurred. RN and LVN staff who assessed the resident confirmed the hair was uneven, with the right side much shorter than the left, and stated that it is important for residents to look their best as a matter of dignity. The Social Services Director reported that the beautician acknowledged she had been unable to complete the haircut on 2/16/2026 and had not charged for the service because it was not completed. The facility’s dignity policy stated that each resident shall be cared for in a manner that promotes well-being, self-worth, and self-esteem, and that residents are to be treated with dignity at all times.
Failure to Supervise High-Risk Visitor Resulting in Resident Overdose Event
Penalty
Summary
The deficiency involves the facility’s failure to follow its own “Safety and Supervision of Residents” policy regarding a visitor known to pose a safety risk. Resident 1, who had diagnoses including psychoactive substance abuse, respiratory failure, chronic kidney disease, ventilator dependence, and a gastrostomy tube, had a documented history at a previous facility of suspected illicit substance provision by Family Member (FM) 2. Progress notes from the prior facility dated 10/15/2025, 11/2/2025, and 11/3/2025 documented episodes of altered mental status occurring only during FM 2’s visits, suspected drugs provided by FM 2, and a positive urine drug screen for barbiturates suspected to have been provided by FM 2. An IDT note dated 11/7/2025 indicated FM 2 had been placed on supervised visits at the previous facility due to these concerns. At the current facility, concerns about FM 2 continued. A respiratory therapy note dated 1/30/2026 documented that FM 1 expressed not trusting FM 2 and believed FM 2 was giving Resident 1 something that could affect breathing. Another RT note dated 2/5/2026 described that after FM 2 left, Resident 1’s ventilator alarmed, Resident 1 had an altered level of consciousness, and was breathing at a rate of four breaths per minute, later becoming more arousable after aggressive stimulation. A physician progress note dated 2/26/2026 indicated suspicion that Resident 1 may have been using drugs other than those prescribed due to altered mental status. LVN 1 reported that FM 2 had been placed on supervised visits because he brought drinks to Resident 1 despite NPO status, and on 1/14/2026 LVN 1 observed a beer in a clear bag brought in by FM 2. LVN 1 stated FM 2’s visits were to be supervised only by facility staff to prevent unauthorized items being provided. Despite this history and the facility’s policy emphasizing resident safety and supervision as core components of accident prevention, the facility failed to ensure that FM 2 was not allowed to visit Resident 1 without staff supervision on 2/27/2026 and failed to ensure that facility staff, rather than FM 1, supervised FM 2’s visit. On that date, RT 1 responded to Resident 1’s ventilator alarm and found Resident 1 difficult to arouse, with suspected consumption of alcohol or drugs, and FM 1 told RT 1 that Resident 1 had consumed something. Resident 1 became unresponsive with hypoxia, bradypnea, and altered mental status, requiring emergency administration of Narcan and transfer to a general acute care hospital for evaluation and treatment. The DON acknowledged that facility staff, not FM 1, should have supervised FM 2’s bedside visit and that the incident could have been avoided if visitors had been supervised by staff, particularly given FM 2’s suspicious, agitated, and restless behavior at the time.
Failure to Care Plan for Family Member Interference and Alcohol in Resident’s Environment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized care plan addressing a resident’s safety needs related to a specific family member whose behavior interfered with care. The resident was admitted and later readmitted with diagnoses including psychoactive substance abuse, respiratory failure, chronic kidney disease, ventilator dependence, and a gastrostomy tube, and had intact cognition with a need for moderate assistance with ADLs per the MDS. Respiratory therapy notes documented a meeting with social services regarding the resident’s family member intervening in the resident’s care and exhibiting aggressive behavior toward staff. A nurse reported that the family member acted suspiciously during visits and had brought beer into the facility on at least one occasion. During interviews, an LVN, an RN supervisor, and the DON each confirmed there was no care plan addressing the family member’s non-compliant behaviors, such as bringing beer into the facility or interrupting the resident’s care, despite awareness of these issues. They each stated that a care plan should have been developed to outline goals and interventions to ensure the resident’s safety and to guide staff in safely and appropriately caring for the resident. Review of the facility’s comprehensive, person-centered care plan policy showed it required measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs, incorporating identified problem areas and associated risk factors, but this was not carried out for this resident’s situation involving the family member.
Failure to Verify Allergy Before Administering Hydrocortisone
Penalty
Summary
The facility failed to ensure that a resident with a documented cortisone allergy was protected from significant medication errors when hydrocortisone ointment was ordered and administered without verification of allergies. The resident’s face sheet showed admission with multiple serious diagnoses, including nontraumatic intracerebral hemorrhage, acute respiratory failure, quadriplegia, and type 2 diabetes. An allergy list dated 11/15/2024 documented a cortisone allergy with unknown severity. An MDS dated 11/24/2025 indicated the resident had severe cognitive impairment, was rarely or never understood by others, was dependent on staff for activities of daily living, and was at risk for pressure injuries. On 2/13/2026, a change of condition note documented bilateral groin moisture-associated skin damage, and the physician was notified and ordered hydrocortisone ointment to the affected area every shift. The order recap report showed hydrocortisone 2.5% ointment was ordered on 2/13/2026 and the MAR documented that the resident received hydrocortisone every shift on five occasions between 2/13/2026 and 2/15/2026. Email communication between an RN and the DON on 2/17/2026 indicated the RN failed to check the resident’s allergies when the hydrocortisone cream was ordered. In a telephone interview, an LVN stated she administered hydrocortisone as ordered but did not check the resident’s allergies prior to administration. The DON stated that, based on her review, three nurses administered hydrocortisone ointment without checking the documented allergies. The facility’s medication administration policy, revised 4/2019, required that resident allergies be checked and verified prior to administering medications.
Failure to Develop Care Plan for Resident’s Genital Skin Breakdown
Penalty
Summary
The facility failed to develop and implement a care plan to address a documented change in condition for one resident who developed erythema and moisture-associated maceration of the scrotal and penile area. The resident had been admitted with diagnoses including nontraumatic intracerebral hemorrhage, acute respiratory failure, quadriplegia, and type 2 diabetes, and was identified on the MDS as having severe cognitive impairment, being rarely or never understood by others, and being dependent on staff for oral hygiene, toileting hygiene, showering, and dressing. The MDS also indicated the resident was at risk for developing pressure injuries. On a specified date, a Change of Condition (COC) note documented redness and moisture-associated maceration to the resident’s scrotal area and penis. During interview, the LVN who assessed the resident’s skin and created the COC acknowledged that she did not create a corresponding care plan to reflect the resident’s skin changes. She stated that failing to develop a care plan for the skin changes could cause a delay in the resident receiving timely assessments and consistent treatments. The DON stated that the resident was at risk for skin breakdown and that all COCs must be followed up with an appropriate care plan to address goals and interventions, and described the care plan as a tool used to communicate the resident’s plan of care to staff to ensure consistent care. Review of the facility’s policy on comprehensive person-centered care plans indicated that the IDT is to review and update the care plan when there has been a significant change in the resident’s condition, but this was not done for the documented skin condition.
Failure to Hold Laxatives and Stool Softeners for Resident with Diarrhea
Penalty
Summary
A facility failed to ensure that a resident did not receive docusate sodium and senna while experiencing loose, watery stools, contrary to physician orders that specified these medications should be held in such circumstances. The resident, who was cognitively intact and had diagnoses including end-stage renal disease requiring dialysis, generalized anxiety disorder, depression, and a tracheostomy, was at risk for pressure injuries and moisture-associated skin damage. Despite clear orders to hold the medications for loose stools, medication administration records showed that both docusate sodium and senna were administered on multiple days when the resident was documented as having diarrhea. Certified nursing assistants (CNAs) and family members reported that the resident was experiencing ongoing diarrhea, with associated skin irritation and discomfort. Documentation confirmed multiple episodes of loose stools, and interviews revealed that CNAs informed charge nurses about the resident's condition. However, at least one LVN stated they were not made aware of the loose stools and continued to administer the medications as ordered, without holding them as required by the physician's instructions. The Director of Nursing confirmed upon review that the medications should have been held on days when the resident had loose stools, in accordance with the physician's order and facility policy. The facility's policy on medication administration required medications to be given as prescribed and for staff to contact the prescriber if a dosage was believed to be inappropriate. The failure to hold the medications as ordered constituted a significant medication error, as the medications were administered despite clear documentation and communication regarding the resident's loose stools.
Failure to Ensure Staff Competency in Bowel Management and Communication
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) and a licensed vocational nurse (LVN) demonstrated appropriate competency in caring for and reporting episodes of diarrhea in a resident. The resident, who was cognitively intact and at risk for pressure injuries and moisture-associated skin damage (MASD), had physician orders for docusate sodium and senna for bowel management, with explicit instructions to hold these medications if the resident experienced loose stools. Despite these orders, the resident continued to receive both medications on multiple days when documentation and interviews confirmed the presence of loose or watery stools. Record reviews showed that the resident had several episodes of loose stools documented throughout the month, yet the medication administration record indicated that the bowel management medications were administered on those same days. Interviews revealed that the CNA observed and documented the loose stools and reported them to an unknown charge nurse, but the LVN assigned to the resident was not informed and proceeded to administer the medications as scheduled. The LVN stated that he would have held the medications if he had been aware of the loose stools and would have reported a change of condition if there were multiple episodes. The Director of Nursing (DON) confirmed that the facility's protocol required CNAs to notify nurses of changes such as loose stools and that nurses should hold bowel management medications per physician orders in such cases. The DON also verified that the resident received the medications on days when loose stools were documented, contrary to the physician's instructions. Facility job descriptions for both CNAs and LVNs outlined the responsibility to report changes of condition and administer medications as prescribed, but these protocols were not followed in this instance.
Failure to Provide Scheduled Hygiene Care Resulting in Maggot Infestation and Pressure Injury
Penalty
Summary
A ventilator-dependent resident with multiple complex medical conditions, including acute respiratory failure, chronic kidney disease, and dysphagia, was found to have not received regularly scheduled showers and bed baths as required by facility policy. The resident was completely dependent on staff for all activities of daily living, including personal hygiene and oral care. Documentation and interviews revealed that scheduled showers and bed baths were frequently missed due to high resident acuity and inadequate staffing, resulting in lapses in hygiene care. The resident's oral cavity was observed to be unclean, with thick yellowish coating and dried secretions, and the lips were dry and cracked. Oral care was not documented as provided on multiple shifts, and staff interviews confirmed that oral care and hygiene were often not completed due to workload demands. The resident developed a Stage III pressure injury on the left lateral side of the neck, which was attributed to tracheostomy ties and worsened over time. Moisture-associated skin damage was initially noted, and the wound deteriorated to a full-thickness skin loss. On one occasion, approximately 20 maggots were discovered around the resident's tracheostomy site and within the pressure injury wound. Staff interviews confirmed that the presence of maggots was observed by multiple staff members, including CNAs and respiratory therapists, during routine care. However, the incident was not properly documented in the resident's electronic health record, and required communication tools such as SBAR forms and progress notes were not completed. The physician and family were eventually notified, and the resident was transferred to an acute care hospital for further evaluation and treatment. Facility records and staff interviews indicated that the failure to provide scheduled hygiene care, including showers, bed baths, and oral care, was a recurring issue due to staffing shortages and high resident acuity. The lack of regular hygiene care contributed to poor skin condition, the development and worsening of pressure injuries, and ultimately, the maggot infestation. The facility's own policies on infection prevention, bathing, and tracheostomy care were not followed, and there was a lack of proper documentation and timely reporting of significant changes in the resident's condition.
Failure to Timely Report Neglect and Notify Authorities Following Maggot Infestation
Penalty
Summary
A ventilator-dependent resident with multiple complex medical conditions, including acute respiratory failure, chronic kidney disease, and dysphagia, was found to have maggots present around the tracheostomy site. The resident was non-verbal, unresponsive, and fully dependent on staff for personal and oral hygiene. Observations revealed poor oral hygiene, with a thick yellowish coating on the tongue, dried secretions, and cracked lips. The care plan required oral care every shift, but staff interviews indicated that scheduled hygiene care, including showers and bed baths, was often missed or delayed due to high resident acuity and inadequate staffing levels. On the morning the maggots were discovered, a respiratory therapist identified approximately 20 maggots around the resident's tracheostomy site. This finding was communicated to nursing staff, including the outgoing and incoming registered nurse supervisors, and subsequently to the Director of Nursing and the facility administrator via group text. Despite this, there was no immediate documentation of the incident in the resident's electronic health record, no completion of required communication tools, and no timely notification to the California Department of Public Health (CDPH) as mandated by state regulations. The resident's representative was also not informed of the specific reason for the hospital transfer, as staff were instructed not to disclose the presence of maggots. Staff interviews revealed that the administrator, upon learning of the incident, did not notify CDPH or initiate an internal investigation as required by facility policy. Nursing staff acknowledged that the presence of maggots was not reported or documented appropriately, and that the incident was not communicated to the resident's family. Facility policies reviewed indicated the requirement for immediate reporting of suspected abuse, neglect, or injury of unknown source to the administrator and appropriate authorities. The failure to promptly report the incident and notify the resident's representative resulted in a delay in regulatory oversight and impeded timely intervention.
Failure to Document Change in Condition and Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was dependent on staff for all activities of daily living and had significant medical conditions, including acute respiratory failure, chronic kidney disease, and a tracheostomy. On a specific date, maggots were discovered around the resident's tracheostomy site, but this significant change in condition was not documented in the resident's electronic health record (EHR). The nurse who identified the issue did not complete the required SBAR communication tool, did not document the incident in the nursing progress notes, and did not submit a change of condition report as required by facility policy. Interviews with facility staff confirmed that the presence of maggots was verbally reported to the physician and the Director of Nursing (DON), but there was no written documentation in the EHR or in the physician's order summary to accurately reflect the resident's condition. The DON acknowledged that the omission of this information from the medical record and transfer order was inappropriate and that an incident report, progress notes, and care plan update should have been completed. The nurse involved also admitted to not informing the resident's family of the specific reason for the hospital transfer and stated that her actions were not consistent with facility policy or nursing standards of practice. A review of facility policies and job descriptions confirmed that nurses are required to document changes in a resident's condition and ensure timely and appropriate documentation of care activities. The lack of documentation regarding the discovery of maggots and the resident's change in condition resulted in incomplete clinical records and a failure to follow established protocols for reporting and escalating significant health concerns.
Failure to Enforce Infection Control Policy During Tracheostomy Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during tracheostomy care for a resident who was ventilator-dependent and had multiple complex medical conditions, including acute respiratory failure and dependence on renal dialysis. The resident was fully dependent on staff for personal hygiene, including oral care and bathing. During an observation, a respiratory therapist was seen performing tracheostomy care and suctioning while wearing artificial (acrylic) nails, which is against facility policy for staff providing direct care, especially to severely ill or immunocompromised residents. Interviews with facility leadership, including the DON and Infection Preventionist, confirmed that artificial nails are prohibited for staff providing direct care due to the risk of harboring bacteria and increasing the potential for cross-contamination and infection. The respiratory therapist acknowledged wearing artificial nails during care and recognized this as a violation of facility policy. The Infection Preventionist further stated that there was no current system in place to ensure staff compliance with the artificial nail policy, and that artificial nails pose a significant infection control risk, particularly for residents with open wounds, tracheostomies, or ventilators. A review of the facility's hand hygiene policy indicated that artificial fingernails are strongly discouraged for all direct care staff and explicitly prohibited for those caring for severely ill or immunocompromised residents. The policy also grants the infection preventionist the authority to request removal of artificial nails if they are deemed an infection control risk. Despite these policies, the lack of enforcement and monitoring led to a breach in infection control practices during the provision of tracheostomy care.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report, or report within 24 hours, an injury of unknown origin for a resident with severe cognitive impairment and no capacity to make decisions. The resident was found with swelling, redness, and warmth in the left elbow, and an X-ray confirmed a left shoulder dislocation. The resident was subsequently transferred to a general acute care hospital for further evaluation. Despite these findings, the incident was not reported to the California Department of Public Health (CDPH) as required. Interviews with the DON and Administrator revealed that the injury was not reported because they considered the shoulder dislocation to be a chronic issue based on the resident's previous medical history, rather than an acute event. The facility's policy required immediate reporting of injuries of unknown origin, but this was not followed. As a result, CDPH was unable to investigate the injury in a timely manner, and there was potential for facts related to the injury to be lost or forgotten.
Failure to Provide Adequate Supervision and Safe Repositioning Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to follow established facility policies and procedures regarding the safe repositioning of a resident who was dependent on a ventilator and required a two-person assist for bed mobility. The CNA repositioned the resident alone, without assistance, and placed the resident on top of the ventilator circuit tubing. This action was contrary to the facility's policy, which specifically required two staff members to assist with turning or moving residents in bed, especially those with significant functional limitations. The resident involved had a history of cerebrovascular accident, diabetes mellitus, and was dependent on a ventilator, residing in the facility's sub-acute unit. The resident was documented as having severe cognitive impairment and functional limitations in both upper and lower extremities, making her totally dependent on staff for all aspects of self-care and bed mobility. The care plan and assessment tools clearly indicated the need for a two-person assist for any repositioning or bed mobility tasks. As a result of the CNA's actions, the resident sustained a skin tear with minimal bleeding to her left upper lip, which was discovered by a nurse during routine wound care. Interviews with staff and review of records confirmed that the CNA did not seek assistance as required, and the resident was found lying on the ventilator circuit, which contributed to the injury. Facility policies emphasized the importance of resident safety, supervision, and targeted interventions to reduce individual risks, but these were not followed in this instance.
Failure to Provide and Document Required Oral Care
Penalty
Summary
The facility failed to ensure that a resident received oral care as required. The resident, who had diagnoses including muscle weakness, abnormalities of gait and mobility, and dementia with moderately impaired cognition, required supervision for oral hygiene and personal hygiene according to their Minimum Data Set (MDS) assessment. Facility records indicated that oral care was to be provided every shift and as needed. However, a review of the resident's Point of Care Response History showed that from 4/21/2025 to 5/19/2025, oral care was not provided every shift as required. During interviews, an LVN confirmed that staff were responsible for ensuring the resident performed or received oral care every shift. The DON stated that if oral care was not documented, it was considered not done, and emphasized that oral care should be provided at least every shift. The facility's policy on mouth care required documentation of the date, time, and staff member providing care. The lack of documented oral care placed the resident at risk for poor dental hygiene and increased risk for oral infections.
Failure to Administer and Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure that wound treatments were administered as ordered for three out of six sampled residents with pressure ulcers. On the specified date, the Treatment Administration Records (TARs) for these residents showed that multiple physician-ordered wound care treatments, including topical medications and dressings, were not administered during the day shift. This was confirmed through both record review and interviews with the treatment nurse and the Director of Nursing, who stated that if treatments were not documented, they were not performed. The residents involved had significant medical histories and were dependent on staff for activities of daily living. One resident had metabolic encephalopathy and required a gastrostomy tube, with several pressure ulcers present upon admission. Another resident had hemiplegia and hemiparesis following a cerebral infarction, was severely cognitively impaired, and also had a pressure ulcer on admission. The third resident had similar neurological deficits and was admitted with a left heel scab. All three residents had specific wound care orders, such as Betadine, Santyl, zinc oxide, Vitamin A&D ointment, and Medi honey dressings, which were not administered as scheduled. Facility policies and job descriptions reviewed indicated that medications and wound care treatments were to be administered as prescribed and documented in the medical record. The failure to provide and document these treatments as ordered was acknowledged by both the treatment nurse and the Director of Nursing during interviews. The deficiency was limited to the lack of administration and documentation of wound care treatments for the affected residents on the specified date.
Failure to Provide Ordered G-Tube Site Care
Penalty
Summary
The facility failed to provide appropriate gastrostomy (G-tube) site care for three residents on a specified date, as required by physician orders and facility policy. For each of the three residents, the Treatment Administration Record (TAR) indicated that the order to cleanse the G-tube site with normal saline, pat dry, apply a dry dressing, secure with tape daily, and assess for signs and symptoms of infection was not completed. This omission was confirmed through review of the TARs and interviews with nursing staff, who acknowledged that if the TAR was not signed, the treatment was not administered. The residents involved had significant medical conditions necessitating G-tube care. One resident had metabolic encephalopathy and was dependent on staff for oral hygiene, toileting, and showering, with intact cognition. The other two residents had hemiplegia and hemiparesis following cerebral infarction, severely impaired cognition, and were dependent on staff for all activities of daily living. All three residents had orders for daily G-tube site care, which were not carried out or documented on the specified date. Interviews with the treatment nurse and the Director of Nursing confirmed that the required treatments were not completed as ordered and that documentation was lacking. Facility policy required that the procedure be performed and documented to promote cleanliness and protect the gastrostomy site from irritation, breakdown, and infection. The job description for the treatment nurse also specified responsibility for administering treatments as ordered by the physician.
Failure to Obtain Proper Consent and Inform Residents of Monitoring System Features
Penalty
Summary
The facility failed to ensure the rights of three residents to self-determination and informed consent were upheld when a contactless cardiorespiratory monitoring system with a microphone and speaker was installed and activated in their rooms without proper consent or adequate explanation. Residents were unaware of the device's true function, believing it to be a night light, and did not know it was monitoring their heart rate and respirations or that it contained a speaker. One resident's consent was signed by a family member, but the resident herself was not aware of the consent or the device's capabilities. Another resident had not signed any admission papers, and a third had denied consent, yet the monitoring system was still activated in their rooms. Interviews with staff revealed a lack of training and awareness regarding the monitoring system. The Director of Staff Development had not provided in-service education to staff about the system, and both the Director of Nursing and the admissions coordinator were unaware that the device included a speaker. Staff members, including LVNs and CNAs, expressed concerns about privacy and agreed that residents should be informed about the monitoring system and its features. The admissions coordinator confirmed that the informed consent form did not mention the presence of a speaker, and the system was activated in residents' rooms without their full understanding or agreement. Facility policy required that residents or their representatives be educated about the monitoring system and that consent be obtained prior to activation. However, the process for obtaining and documenting consent was inconsistent, and the information provided to residents was incomplete. The monitoring system was used to collect and transmit residents' vital sign data, but residents were not adequately informed about the nature of the monitoring or the presence of audio features, resulting in a violation of their rights to dignity, self-determination, and privacy.
Failure to Accurately Assess and Document Restraints and Restorative Nursing Services in MDS
Penalty
Summary
The facility failed to accurately assess and document the use of restraints and restorative nursing services for two residents, as required by the Minimum Data Set (MDS) assessment tool. For one resident with a history of tracheostomy, gastrostomy, and acute respiratory failure, the MDS did not reflect the use of bilateral hand mittens, which were ordered and applied to prevent the resident from removing life-saving devices. Observations and staff interviews confirmed that the mittens were in use and considered restraints, but the MDS did not document them as such. The MDS Assistant acknowledged that the mittens met the definition of a restraint according to the Resident Assessment Instrument (RAI) but were not coded appropriately, which could affect the accuracy of data submitted to CMS and the resident's care assessment. For another resident with multiple complex medical conditions, including dependence on a respirator and renal dialysis, the MDS failed to document participation in a Restorative Nursing Program (RNP), despite a physician's order for active assisted range of motion (AAROM) exercises to be performed by a Restorative Nursing Assistant (RNA) three times a week. Review of records and interviews with the MDS Assistant confirmed that the RNA services were not coded in the MDS, even though the services were ordered and intended to maintain or restore the resident's physical function. The Director of Nursing confirmed that both the hand mittens should have been coded as restraints and the RNA services should have been included in the MDS assessments. Facility policy and the MDS Coordinator's job description require comprehensive and accurate assessments to develop person-centered care plans and ensure compliance with regulations. The failure to accurately assess and document these interventions in the MDS had the potential to impact the identification of care needs and the development of appropriate care plans for the affected residents.
Failure to Complete PASRR Level II Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a required Preadmission Screening and Resident Review (PASRR) Level II assessment was completed for two residents diagnosed with serious mental illnesses, specifically schizophrenia and schizoaffective disorder. For one resident, the admission record and medical documentation indicated a diagnosis of schizophrenia and the use of antipsychotic medication, yet the PASRR Level I screening incorrectly marked 'No' for serious mental illness, and no Level II assessment was conducted. For the second resident, records showed diagnoses of schizoaffective disorder and bipolar disorder, with the PASRR Level I screening also failing to identify a serious mental disorder, despite the resident's active psychiatric diagnoses and dependence on staff for daily care. Interviews with facility staff, including the MDS Assistant and Social Worker, confirmed that the PASRR Level I screenings were not accurately completed, and the necessary Level II assessments were not initiated. Staff acknowledged that the screenings are essential for identifying residents who require specialized psychiatric care and services. The facility's policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders per the PASRR process, but this protocol was not followed for the two residents in question.
High Medication Error Rate During Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a medication error rate of 46.67% during a medication pass for one resident. Fourteen medication errors were identified out of thirty opportunities for a resident with multiple diagnoses, including chronic kidney disease, hypertension, diabetes mellitus, and osteomyelitis. The errors were observed during a medication administration round, where the nurse administering the medications stated she was running late and had notified the physician that the medications would be administered late. Record review showed that the resident was prescribed a complex medication regimen, including antihypertensives, insulin, anticoagulants, and other medications. Facility policy required medications to be administered within one hour of the scheduled time unless otherwise specified, and in accordance with prescriber orders. The observed practice did not align with these policies, as medications were not administered as ordered, contributing to the high error rate.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for two residents. For one resident with anoxic brain damage and multiple contractures, staff did not consistently perform skin assessments during scheduled shower days or on days when bed baths were provided. Documentation showed missed showers and incomplete skin inspections. Additionally, the resident's care plan required turning and repositioning at least every two hours, but records indicated this was not done consistently, with significant gaps between documented repositioning times. Observations confirmed the resident was often found lying on his back for extended periods, and staff interviews acknowledged the importance of these interventions but revealed lapses in their execution and documentation. Another resident, who was dependent on staff for all activities of daily living and had a history of diabetes, gastrostomy, tracheostomy, and ventilator dependence, was at high risk for pressure injuries. This resident developed a Stage II pressure injury on the right shin, which was not promptly identified or reported by staff. Interviews with CNAs and restorative nursing aides revealed uncertainty about the onset of skin changes and inconsistent use of the facility's early warning documentation tools. The treatment nurse confirmed that the injury was discovered during physician rounds rather than through routine staff monitoring, and that earlier intervention could have prevented the progression of the wound. Facility policy required regular evaluation, reporting, and documentation of skin changes, as well as frequent monitoring of device-related pressure areas. However, staff did not consistently assess or report skin conditions under medical devices such as knee splints, and there was a lack of communication and documentation regarding abnormal findings. These failures in following care plans, performing scheduled assessments, and documenting and reporting skin changes contributed to the development and progression of pressure injuries in both residents.
Failure to Inform Residents of Their Rights Upon Admission
Penalty
Summary
The facility failed to ensure that two sampled residents were informed of their rights, as required by federal and state regulations. Resident 60, who was admitted with diagnoses including respiratory failure, osteoarthritis, and atrial fibrillation, was found to have the capacity to understand and make decisions. Resident 75, admitted with conditions such as hemiplegia, hemiparesis, cardiac arrest, and heart failure, was also assessed as able to express ideas and comprehend information. During interviews, both residents stated they were not aware of their rights, with one resident specifically mentioning not knowing her rights and expressing concerns about changes to her shower schedule without her input. Staff interviews revealed that shower days were predetermined and not flexible, with residents not allowed to shower on Sundays unless specially requested. The Social Worker acknowledged that she had not explained resident rights to one of the residents and stated that residents should have received a copy of their rights upon admission. The Director of Nursing confirmed that the Social Worker was responsible for this process and that residents should be informed of their rights at admission and during quarterly meetings. Review of facility policies supported the requirement to inform residents of their rights, but this was not consistently done for the sampled residents.
Failure to Follow Restraint Policy and Monitoring Procedures
Penalty
Summary
The facility failed to follow its policy and procedure regarding the use of physical restraints for one resident by not ensuring that the physician's order for Peek-A-Boo mittens included a specific reason for their use that would benefit the resident's medical symptom. The physician order and documentation indicated the use of mittens and instructions for their release and skin checks, but did not specify the medical symptom necessitating the restraint as required by facility policy. The facility's policy states that restraint orders must include the specific reason for use and how it benefits the resident's medical condition. Additionally, the facility did not consistently monitor and assess the resident's tolerance when the Peek-A-Boo mittens were removed. Observations showed that the resident was left without mittens and without staff present in the room on multiple occasions. Interviews with staff confirmed that mittens were sometimes removed without direct supervision, and that the resident was at risk of pulling out medical devices such as a tracheostomy and gastrostomy tube during these periods. Staff also provided inconsistent information regarding the frequency and process for removing the mittens, and acknowledged that proper assessment and monitoring were not always performed during restraint release. The resident involved had a history of tracheostomy, Tourette's disorder, gastrostomy, and acute respiratory failure, and was dependent on staff for all activities of daily living. The Minimum Data Set indicated moderately impaired cognitive skills and no documented use of restraints, despite the ongoing use of mittens. The facility's failure to ensure proper physician orders and monitoring during restraint use did not align with its own policy and placed the resident at risk during periods when the mittens were removed.
Failure to Update PASARR Screening After Initiation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was accurately documented for one resident. The resident was admitted with diagnoses of anxiety, depression, and post-traumatic stress disorder (PTSD). Initial PASARR Level 1 screening was completed and found negative, indicating that a Level II assessment was not required at that time. However, subsequent records showed that the resident was later prescribed paroxetine (an antidepressant) and risperidone (an antipsychotic) for their mental health conditions. Despite these new prescriptions and ongoing diagnoses, no updated PASARR Level 1 screening was completed after the initiation of these psychotropic medications. Interviews with the MDS Assistant and the DON confirmed that a new PASARR Level 1 should have been conducted when the resident began these medications. Facility policy required screening for mental disorders and referral to the appropriate authority when such conditions were identified, but this process was not followed, resulting in a deficiency.
Failure to Treat Oral Candidiasis in Dependent Resident
Penalty
Summary
The facility failed to provide necessary treatment for a resident diagnosed with candidiasis, resulting in the resident having an untreated oral fungal infection since 3/29/2025. The resident, who was dependent on nursing staff for all activities of daily living including oral hygiene, was observed to have a dry mouth and a white tongue. Despite the resident's documented diagnosis of candidiasis and complete dependence on staff for care, there was no order in the resident's chart for treatment of the infection. Nursing staff and supervisors acknowledged the presence of candidiasis and the lack of a treatment order, with the Director of Nursing confirming that licensed staff should have contacted the physician for appropriate medication. Interviews with staff revealed that while nursing staff were responsible for oral care and respiratory therapists for oral suction, there was a lack of communication and follow-through regarding the resident's condition. The respiratory therapist supervisor noticed signs of oral thrush but did not report it, and the nursing staff did not initiate treatment or notify the physician. Facility policy required provision of care and services to maintain personal and oral hygiene for residents unable to perform these tasks independently, but this was not followed in the case of this resident.
Failure to Implement and Communicate Restorative Nursing Orders for Range of Motion
Penalty
Summary
A deficiency occurred when the facility failed to implement and follow the physician's order for restorative nursing services for one resident with significant medical needs. The resident, who had diagnoses including pneumonia, candidiasis, dependence on a respirator and renal dialysis, gastrostomy, and tracheostomy, was dependent on staff for most activities of daily living. The physician's order required a restorative nursing assistant (RNA) to perform active assisted range of motion (AAROM) exercises to both upper and lower extremities while the resident was sitting at the edge of the bed, three times a week as tolerated. Despite this order, documentation and interviews revealed that the resident was only receiving passive range of motion (PROM) exercises, not the ordered AAROM. The RNA confirmed that PROM was being documented and admitted to not following the specific order for AAROM. The RNA also did not inform the licensed nurse that the resident was unable to perform the AAROM exercises as ordered. The Director of Rehabilitation confirmed that the resident had been discharged from physical therapy and was under RNA services, and that the RNAs were expected to notify nursing staff if the resident could not tolerate the ordered exercises. The facility's job description for RNAs required them to communicate any significant changes in the resident's condition or ability to appropriate staff and to document and report any problems or reassessment needs. However, this communication did not occur, and the licensed nurses were not made aware that the resident was only receiving PROM instead of the ordered AAROM. This failure to follow the physician's order and to communicate changes in the resident's ability to perform exercises constituted the deficiency.
Failure to Provide Timely Oral Care and Suctioning for Ventilator-Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary oral care and oral suctioning for a resident with a tracheostomy, ventilator dependence, and severe cognitive impairment. The resident was observed with dried secretions covering the entire mouth, despite physician orders for suctioning every two hours as needed and the use of Chlorhexidine Gluconate Solution for oral care every shift. The resident was completely dependent on staff for all activities of daily living, including oral hygiene, and lacked the capacity to make decisions or communicate needs. Interviews with facility staff, including a respiratory therapist, LVN, respiratory therapy supervisor, and RN, confirmed that oral care and suctioning were required to prevent infection and maintain the resident's dignity. Facility policy required daily oral care for all patients to maintain hygiene and prevent complications. Despite these requirements and staff awareness, oral care and suctioning were not performed in a timely manner, as evidenced by the presence of dried secretions during observation.
Nurse Assistant Training Program Expired and Not Renewed
Penalty
Summary
The facility failed to ensure that its Nurse Assistant Training Program was renewed and approved by the California Department of Public Health (CDPH). The Director of Staff Development (DSD) was aware that the program had expired and had submitted a new application, but admitted to not knowing how to properly complete the application and did not seek assistance. Communication from CDPH indicated that additional documentation, such as a resume with verifiable qualifications and proof of experience in teaching adults, was required to complete the application. The DSD confirmed that these requirements were not met in a timely manner, resulting in the program's expiration and denial. The administrator stated that he only became aware of the program's expiration months after it had lapsed and acknowledged that the facility was still awaiting a response from CDPH regarding the new application. The administrator also noted that, due to the denial of the training program, Certified Nursing Assistants (CNAs) would be unable to renew their certificates through the facility's program. The facility's policies and the DSD's job description both outlined responsibilities for maintaining and coordinating educational programs, which were not fulfilled, leading to the deficiency.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for two Certified Nursing Assistants (CNAs), as confirmed during interviews and record reviews with the Director of Staff Development Consultant and the Administrator. Both staff members acknowledged that there were no performance evaluations found in the employee files for the two CNAs, despite facility policy requiring such evaluations at least annually and after a 90-day probationary period. The policy also specifies that written evaluations should include remarks, suggestions, and any necessary actions such as further training. The lack of documented performance reviews meant that areas of weakness and skills necessary for providing nursing services were not assessed for these CNAs.
Failure to Document Narcotic Administration by Licensed Staff
Penalty
Summary
The facility failed to ensure that the Narcotic and Hypnotic Record included the required signatures of licensed nursing staff to document the administration of controlled medications for one of seven medication carts. Specifically, on the date reviewed, there were no licensed staff initials in the designated signature boxes for the administration of Tramadol to one resident and Hydrocodone to another resident. The responsible LVN confirmed that she had not documented the administration of these medications immediately after giving them, as required by facility policy. Both residents involved had significant medical conditions, including heart failure and respiratory failure, and were dependent on staff for personal care and hygiene. The Director of Nursing confirmed that licensed staff are responsible for immediate documentation after medication administration to prevent errors. Review of the facility's policy indicated that the administering staff must record their signature and title in the resident's medical record as required.
Improper Storage and Labeling of Fresh Fruit in Dietary Services
Penalty
Summary
The facility failed to ensure that fresh fruits were stored properly in accordance with professional standards and facility policy. During an observation in the walk-in refrigerator, surveyors found an open container with half a cantaloupe and half a honeydew melon. The cantaloupe had a date written on its skin, and the honeydew melon was in a plastic bag with a date, but the container was only labeled with a general 'fresh fruit' date and an expiration date. The cook confirmed that each fruit should have both an open date and a use-by date to ensure freshness and prevent serving expired food. Interviews with the dietary supervisor, infection preventionist nurse, and administrator all confirmed that open and use-by dates are required for perishable food items to prevent foodborne illness and gastrointestinal infections. A review of the facility's policy indicated that all newly opened food items must be labeled with an open date and use-by date, and all prepared foods must be covered, labeled, and dated. The observed failure to properly label and store the fresh fruit was not in compliance with these requirements.
Failure to Implement Effective QAPI Oversight for Pressure Injury and Quality of Care Deficiencies
Penalty
Summary
The facility failed to maintain and develop an effective Quality Assurance Performance Improvement (QAPI) plan to correct identified and potential problems related to pressure injuries and quality of care. Specifically, the facility did not provide effective oversight or ensure implementation of its plan of correction for deficiencies regarding timely assessment and treatment of pressure injuries, as well as proper oral care as ordered by a physician. The CMS 2567 survey report documented that the facility failed to assess a resident's pressure injury and initiate wound care treatment in a timely manner, and also failed to assess a resident's tongue and administer prescribed mouthwash for dry mouth and throat. These deficiencies were identified during both the previous and most recent recertification surveys. Interviews with the DON and Administrator confirmed that, despite conducting regular wound meetings and implementing skin sweeps, the facility continued to experience repeat deficiencies in these areas. The DON acknowledged that the current plan of correction was not effective in addressing the issues, and the facility's QAPI committee was not successful in coordinating, monitoring, and evaluating performance improvement projects to achieve the intended quality of care outcomes.
Failure to Change Soiled Midline Catheter Dressing
Penalty
Summary
Staff failed to observe proper infection control practices by not assessing and monitoring a resident's midline catheter dressing as required. The resident, who had multiple complex medical conditions including pneumonia, candidiasis, dependence on a respirator and renal dialysis, gastrostomy, and tracheostomy, was dependent on staff for all activities of daily living. Physician orders specified that the midline site should be assessed for signs and symptoms of infection every shift, with any concerns reported to the physician. Despite these orders and facility policy, observations revealed that the resident's midline catheter dressing was soiled and soaked with blood for several days, with the dressing dated several days prior to the observation. Interviews with nursing staff and the infection preventionist confirmed that the dressing should have been changed immediately when it became soiled or bloody, in accordance with facility policy. The failure to change the dressing as required was directly observed and acknowledged by staff.
Failure to Follow Antibiotic Stewardship Protocol for UTI
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol for a resident who was prescribed an antibiotic for a suspected urinary tract infection (UTI) without meeting the McGeer Criteria. The resident, who was admitted with multiple diagnoses including nontraumatic intracranial hemorrhage, respiratory failure, hyperlipidemia, and dysphagia, was highly dependent on nursing staff for all activities of daily living and was unable to express wants or understand others. According to the Minimum Data Sheet, the resident did not attempt to move independently due to medical or safety reasons. A review of the Infection Screening Evaluation and interviews with the Infection Preventionist Nurse revealed that there was no documentation of infection symptoms, and the resident did not meet the McGeer Criteria at the time antibiotics were prescribed. Despite this, a physician's order was written for a 10-day course of Augmentin for a UTI. The facility's policy required specific clinical information to be gathered and communicated before prescribing antibiotics, but this protocol was not followed in this case.
Failure to Provide Approved CNA Training After Program Expiration
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received approved training after the expiration of the facility's Nurse Assistant Training Program. The Director of Staff Development (DSD) was aware that the training program had expired and had submitted a new application, but admitted to not knowing how to complete the application and did not seek assistance. Communication notices from the state outlined the required documents and revisions needed for the application, including a resume with verifiable qualifications and experience in teaching adults, but these requirements were not met in a timely manner. The administrator confirmed that the DSD was responsible for CNA education and only became aware of the expired program months after it had lapsed. As a result, CNAs were unable to renew their certificates due to the denial of the education program. The facility's policies and the DSD's job description both emphasized the importance of ongoing staff development and training, but these were not followed, leading to a lapse in required CNA education.
Failure to Attempt Identification of Unidentified Resident
Penalty
Summary
The facility failed to make an adequate attempt to identify a resident who was admitted without known identity. The resident, who had diagnoses including hemiplegia, acute respiratory failure, encephalopathy, and sepsis, lacked the capacity to understand and make decisions. Despite being admitted without identification, the social worker only attempted to contact the hospital for information and did not reach out to law enforcement for assistance in identifying the resident. The social worker was unaware that contacting law enforcement was necessary and stated that the resident could have been a missing person since January, with family potentially searching for him. The Director of Nursing confirmed that an effort should have been made to identify the resident upon admission, specifically by contacting the police. The facility's policy required the social services staff to obtain information about residents' personal and family backgrounds and to collaborate with community agencies when specialized assistance was needed. However, these steps were not followed, resulting in the resident remaining unidentified for an extended period after admission.
Failure to Notify Physician and Monitor Resident Following Change in Condition
Penalty
Summary
The facility failed to ensure that a resident with a history of pneumonia, pleural effusion, heart failure, and systemic lupus erythematosus received appropriate assessment, monitoring, and physician notification in accordance with physician orders and facility policy. The resident experienced shortness of breath at rest, a low systolic blood pressure reading of 98/57 mmHg, and other symptoms such as productive cough, yellow sputum, congestion, and lethargy. Despite physician orders to notify the medical doctor if the systolic blood pressure fell below 110 mmHg and to monitor and report symptoms related to COVID-19, there was no evidence that the physician was notified when these conditions occurred. Interviews with staff confirmed that the resident's change in condition, including shortness of breath and low blood pressure, should have prompted immediate physician notification and further assessment. The LVN acknowledged that the physician should have been notified about the low blood pressure and that the resident should have been monitored for further decline. The RN and DON also stated that changes such as shortness of breath, low blood pressure, and lethargy are considered significant and require prompt reporting and monitoring. Documentation review showed that the resident was eventually tested for COVID-19, found positive, and subsequently transferred to an acute care hospital with diagnoses including acute hypercapnic respiratory failure and bilateral pleural effusion. However, the initial failure to notify the physician and monitor the resident as ordered represented a lapse in following both physician orders and facility policy, as well as county public health guidelines for COVID-19 management.
Failure to Notify Physician of Vital Sign Changes
Penalty
Summary
The facility failed to ensure timely notification of a physician when a resident exhibited blood pressure and temperature readings below the baseline, which could potentially lead to hypotension and hypothermia. The resident, who was being monitored for sepsis prevention, had several instances of low blood pressure and temperature readings documented in their electronic medication administration record (EMAR) for January and February 2025. Despite these readings, there was no documentation indicating that the medical doctor was notified of these changes, as required by the resident's care orders. The resident in question was admitted with multiple complex medical conditions, including acute respiratory failure, a gastrostomy, and a tracheostomy. The resident's Minimum Data Set (MDS) indicated significant dependency on staff for self-care and mobility, and the resident was rarely or never understood. The facility's policy required that the medical doctor be notified of specific changes in the resident's condition, such as blood pressure below 100 mmHg or temperature below 97 degrees Fahrenheit, which were not adhered to in this case. Interviews with Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) confirmed that the medical doctor should have been notified of the changes in the resident's condition. The facility's policies on change in condition and vital sign monitoring were not followed, as there was no documentation of physician notification in the Situation, Background, Assessment, and Recommendation (SBAR)/Change of Condition (COC) assessments or Nurses Notes. This oversight had the potential to delay necessary medical intervention for the resident.
Failure to Provide Urology Consultation for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to ensure that a resident with a suprapubic catheter received necessary consultation care, which is a deficiency in meeting professional standards of quality. The resident, who was admitted with multiple complex medical conditions including quadriplegia and a history of urinary tract infections (UTIs), was dependent on staff for all self-care activities. Despite recurrent UTIs and frequent antibiotic treatments since admission, the facility did not arrange for a consultation with a urology specialist to assess the suprapubic catheter's placement and function. Interviews with the Quality Assurance Nurse and the Director of Nursing revealed that the resident had been receiving antibiotics intermittently for UTIs since admission, and both staff members acknowledged the need for a urology consultation. The facility's policy requires a comprehensive, person-centered care plan, which should have included consultation with a urology specialist to prevent further complications. The lack of such consultation and an updated care plan for the resident's condition contributed to the deficiency identified in the report.
Infection Control Deficiency with Suprapubic Catheter
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for a resident with a suprapubic catheter. The catheter bag was observed hanging on the side of the bed in a privacy bag that was touching the floor, which was identified as an infection control issue by the Registered Nurse Supervisor (RNS). The RNS acknowledged that the catheter bag touching the floor posed a high risk for infection, especially since the resident was already on antibiotics for a urinary tract infection (UTI). The resident, who was admitted with multiple diagnoses including acute respiratory failure, quadriplegia, and a UTI, was dependent on staff for all self-care and mobility activities. The facility's records indicated that the suprapubic catheter drainage bag was to be changed as needed, but there was no documentation of changes in January or February 2025, despite the RNS stating that the catheter bag was changed on specific dates in February. The lack of documentation suggested that the catheter bag was not changed as required, increasing the risk of infection. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that catheter bags should not touch the floor and should be checked during daily rounds to prevent infection. The facility's policy on suprapubic catheter care emphasized the importance of preventing infection and documenting catheter changes, but these procedures were not followed, leading to the deficiency in infection control for the resident.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident who was at a very high risk for developing pressure injuries. The resident, who was dependent on assistance for all activities of daily living and had multiple medical conditions including acute respiratory failure, type 2 diabetes, and dementia, was not turned and repositioned every two hours as required by their care plan. This failure to adhere to the turning and repositioning schedule was documented on multiple occasions, leading to the development of a facility-acquired Stage II pressure injury on the resident's right posterior lower leg. The resident's Minimum Data Set (MDS) and Braden Scale assessments indicated a very high risk for pressure injuries, necessitating a strict turning and repositioning program. Despite this, documentation and interviews revealed that the resident was not consistently repositioned, as evidenced by gaps in the charting of these activities. The Treatment Nurse confirmed that the pressure ulcer was preventable and attributed its development to the staff's failure to reposition the resident as required. Interviews with facility staff, including a Certified Nurse Assistant and the Director of Nursing, highlighted a lack of adherence to the facility's policy and procedure for pressure ulcer prevention. The Director of Nursing acknowledged that if care was not documented, it was not done, emphasizing the importance of documentation in preventing pressure injuries. The facility's policies on pressure ulcer prevention and care planning were not effectively implemented, contributing to the resident's injury.
Inadequate Staffing Leads to Pressure Injury in Resident
Penalty
Summary
The facility failed to ensure sufficient nurse staffing to provide adequate care for a resident in the subacute unit, leading to a deficiency in care. The resident, who was dependent on assistance for all activities of daily living, was not turned and repositioned every two hours as required by their care plan. This failure increased the resident's risk for developing a facility-acquired Stage II pressure injury, which was documented on the resident's right posterior lower leg. Interviews with Certified Nurse Assistants (CNAs) revealed that each CNA was assigned ten or more residents, making it difficult to provide the necessary care for each resident, especially those with high acuity needs. The Treatment Nurse confirmed that the resident was not turned and repositioned as required on multiple occasions, and the Director of Nursing acknowledged that staffing should be based on acuity rather than census alone. The facility's policy and procedure documents indicated that staffing should be determined by the needs of each resident's plan of care and the facility assessment. The facility's administrator admitted that staffing decisions were based on the number of residents rather than their acuity levels, which contributed to the inadequate care provided. The facility's policies emphasized the importance of having sufficient staff to meet residents' needs, but the practice of sending staff home due to low census without considering acuity levels led to the deficiency in care for the resident.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to ensure timely response to a call light for a resident, leading to a deficiency in care. Resident 6, who was continent and had a history of cerebral infarction with left side hemiplegia, was left unattended after activating the call light for assistance with a bedpan. Despite the call light being activated and audible alarms sounding, multiple nursing staff members at the nursing station did not respond to the resident's request for assistance. This resulted in the resident urinating on herself, causing feelings of discomfort and indignity. Observations revealed that the call light was ignored by several nurses who were present at the nursing station and in the hallway. Interviews with the resident and staff confirmed the lack of response to the call light, with the resident expressing feelings of being ignored and disrespected. The facility's policies on Activities of Daily Living, Quality of Life-Dignity, and Call Lights emphasize the importance of prompt response to residents' needs, which was not adhered to in this instance.
Failure to Provide Required ROM Exercises and Splint Application
Penalty
Summary
The facility failed to ensure that Restorative Nursing Assistant 1 (RNA 1) provided the necessary range of motion (ROM) exercises and splint application for two residents, leading to a deficiency in care. Resident 1, who was admitted with diagnoses including hemiplegia, hemiparesis, and dementia, had orders for passive range of motion (PROM) exercises to her lower extremity, active assistive range of motion (AAROM) exercises to her bilateral upper extremities and left lower extremity, and a splint application to her right knee. However, observations on multiple occasions revealed that Resident 1 was not receiving these services as ordered, and her knee splint was consistently observed not being applied. Resident 8, who had a contracture of the knees and dementia, also did not receive the ordered PROM exercises to his bilateral lower extremities. RNA 1 admitted to not performing the required exercises due to workload constraints, as she was responsible for over 30 residents requiring RNA services. The RNA's documentation inaccurately reflected that services were provided when they were not, further contributing to the deficiency. Interviews with the Director of Rehabilitation and the Director of Staff Development highlighted the risk of further decline in residents' range of motion and mobility due to the lack of RNA services. The facility's policies and procedures emphasized the importance of providing restorative nursing care to maintain or improve residents' physical abilities, which was not adhered to in these cases.
Falsification of Resident Care Records by RNA
Penalty
Summary
The facility failed to ensure that Restorative Nurse Assistant 1 (RNA 1) did not falsify records for Resident 1, who was one of eight sampled residents. RNA 1 documented that Resident 1 received seven minutes of passive range of motion (PROM) exercises to her bilateral lower extremities and had a splint applied to her right knee on a specific date and time, although these services were not provided. This documentation was inaccurate and did not reflect the actual care provided to Resident 1. Resident 1 was admitted to the facility with diagnoses including hemiplegia, hemiparesis, and dementia, and was totally dependent on staff for various activities of daily living. The Minimum Data Set (MDS) indicated that Resident 1 had functional limitations in range of motion and did not walk during the assessment period. The facility's order listing report included orders for RNA to perform PROM exercises and apply a splint to Resident 1's right knee, which were not carried out as documented. Observations on the specified date showed that Resident 1 was not wearing the knee splint and was not receiving RNA therapy at the times documented by RNA 1. Interviews with Resident 1's family member and facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that RNA 1's documentation was inaccurate and that the services were not provided. The facility's policy and procedure on charting and documentation required accuracy, which was not adhered to in this case.
CNA's Rude Behavior Violates Resident Rights
Penalty
Summary
The facility failed to treat three out of four sampled residents with dignity and respect, as evidenced by the behavior of a certified nursing assistant (CNA 1) who spoke rudely to the residents. This behavior was reported by multiple residents and staff members, indicating a pattern of disrespectful conduct. Resident 1, who was moderately cognitively impaired and required substantial assistance with activities of daily living, was left wet for two hours and experienced rough handling by CNA 1, who was described as having a bad attitude and being unfriendly. Resident 2, who was cognitively intact and had a history of anxiety and major depressive disorder, reported that CNA 1 was rude and rough during care, performing tasks abruptly and speaking in a condescending manner. Similarly, Resident 3, also cognitively intact, described CNA 1 as having an attitude and using a bad tone of voice, which did not make him feel good. These interactions were corroborated by Resident 4, who witnessed CNA 1's rude behavior towards Resident 1 and reported that CNA 1 seemed impatient and unfriendly. The facility's social services director and director of staff development confirmed that CNA 1 had a history of complaints regarding her behavior towards residents. The director of nursing emphasized the importance of respecting residents' rights, as the facility is their home, and acknowledged that staff rudeness could negatively impact residents' emotional well-being. The facility's policy on resident rights mandates that employees treat residents with kindness, respect, and dignity, which was not upheld in this case.
Unsupervised Residents Lead to Physical Altercation
Penalty
Summary
The facility failed to protect a resident from abuse when two residents were left unattended in the dining room, resulting in one resident physically assaulting another. Resident 1, who has dementia and uses a wheelchair, was assaulted by Resident 2, who has generalized anxiety disorder and a history of verbal behavioral symptoms. The incident occurred when Resident 1 confronted Resident 2 about wearing her clothes, leading to Resident 2 pulling Resident 1's hair. This incident highlights the facility's failure to ensure supervision and prevent abuse among residents. Interviews and record reviews revealed that the Activities Director left the dining room unattended, which is against the facility's policy that requires staff presence to prevent such incidents. The facility's policy on resident rights, which includes the right to be free from abuse, was not upheld. The lack of supervision allowed the altercation to occur, demonstrating a deficiency in maintaining a safe environment for residents.
Inadequate Supervision During Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during the transfer of a resident, who was at high risk for falls, resulting in the resident sustaining multiple injuries. The incident occurred when a Certified Nurse Assistant (CNA) attempted to transfer the resident from a shower chair to a bed using a mechanical lift without the assistance of another staff member. The resident, who was dependent on staff for all activities of daily living and required two-person assistance for transfers, fell from the bed and sustained lacerations to the scalp and a skin tear on the arm, necessitating hospitalization and suturing. The resident involved had a complex medical history, including hemiplegia, hemiparesis, type 2 diabetes mellitus, unspecified dementia, and a history of falls with injuries. The resident's care plan identified them as being at risk for falls and required extensive staff assistance for transfers. However, the care plan did not specify the use of a mechanical lift or the need for two-person assistance during transfers, which contributed to the incident. The CNA, who was responsible for the resident's care, cited a high workload and the inability to request assistance as reasons for attempting the transfer alone. Interviews with facility staff, including a Licensed Vocational Nurse and an Occupational Therapist, confirmed that the resident required two-person assistance for transfers due to their size and high fall risk. The facility's policies on falls management and safe lifting were not adequately followed, as the resident's care plan lacked specific instructions for mechanical lift use and two-person assistance. The incident was deemed avoidable by the facility's administrator, who acknowledged that proper adherence to the care plan and staffing protocols could have prevented the fall.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,855 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paramount
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Villa Post Acute | 1.5 mi | ★★★★★ | 26 | 0 |
| Paramount Convalescent Hosp. | 2 mi | ★★★★★ | 24 | 0 |
| La Paz Geropsychiatric Center | 2.3 mi | ★★★★★ | 33 | 0 |
| Downey Post Acute | 2.3 mi | ★★★★★ | 20 | 0 |
| North Long Beach Post Acute | 2.5 mi | ★★★★★ | 5 | 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.