Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowood Nursing Center during CMS and state inspections, most recent first.
A resident with a hx of falls, unsteadiness, difficulty walking, chronic pain, and MDD had a BIMS of 14 and was able to participate in care planning. After a fall, the care plan’s fall interventions were not meaningfully revised; the same transfer pole, non-skid mat, and Call, Don't Fall reminders continued, with the Call, Don't Fall intervention duplicated but no additional individualized measures added. The DON acknowledged the interventions were not escalated, and the resident later fell again while transferring to the bedside commode, sustaining an acute L hip fx and requiring hospitalization.
Failure to protect a resident from abuse occurred when another resident hit him on the arm after becoming annoyed with him. The injured resident had a dx of generalized anxiety and a BIMS score of 13, while the other resident had dx including depression and intermittent explosive disorder and also had a BIMS score of 13. Both residents confirmed the altercation during interviews, and the facility policy defined abuse to include resident-to-resident altercation.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
Two cognitively intact residents engaged in repeated verbal and physical abuse at the nurse’s station and in a hallway, including one resident pushing her wheelchair into another, using profanity, and the other intentionally kicking her in the knee and later making obscene gestures and derogatory remarks. Staff, including CNAs, witnessed the initial altercation and a later hostile exchange near a resident’s doorway but did not promptly intervene or separate the residents, despite facility policies defining kicking and disparaging language as abuse and job descriptions requiring CNAs and RNs to protect residents from abuse.
A resident with a history of traumatic subdural hemorrhage, rib fractures, and repeated falls experienced an unwitnessed fall with head strike. CNAs reported finding the resident on the floor by his bed, assisting him back to bed with an RN, and later observing facial discoloration and complaints of head pain, which were noted by the resident’s spouse. Hospital records documented that the resident reported an unwitnessed fall with head strike at the SNF and was admitted with an enlarging subdural hematoma. However, the facility’s records for that day contained no fall entry, no post-fall assessment, no MD or emergency contact notification, no alert charting, and no care plan update, despite policies requiring evaluation, documentation, change-in-condition notification, and care plan revision after falls and incidents.
A resident with cervical radiculopathy and depression lived in a room where the privacy curtain and the ceiling above the bed remained visibly soiled for many months, including brown smears, dark gray splatter-like spots, a white crusty substance on the curtain, and a brown splatter identified as chocolate pudding on the ceiling. The resident reported the curtain had not been washed for over a year and expressed frustration that staff were not maintaining a clean living space. The Environmental Services Supervisor confirmed the stains, acknowledged they needed cleaning, and stated that while spot checks were performed, neither she nor the housekeeper typically looked up to notice ceiling or upper-surface soiling. She also reported that a deep clean routine, which includes washing privacy curtains, had only recently been implemented and that there had previously been no set schedule for curtain washing or deep cleaning, despite facility policy requiring a clean, sanitary, homelike environment.
A resident with substance dependence and no memory impairment had a physician’s order for Suboxone sublingual film three times daily for opioid dependence. Over two days, three ordered doses were not administered because the medication was unavailable, with documentation indicating the drug was pending pharmacy delivery and the order was awaiting physician signature. The resident reported not receiving Suboxone for about a week and experiencing shaking and anxiety, and the ADON confirmed the missed doses and lack of medication availability, acknowledging this as a significant medication error in light of facility policies requiring timely provision of medications and an environment free of significant medication errors.
A resident with HTN and Type II DM, who had a physician order indicating capacity to understand rights and make decisions, requested to leave the facility one evening but was not allowed to discharge. Nursing staff told the resident it was too late, cited safety concerns, and did not know the discharge procedure, and no administrative staff were contacted. The resident was not offered a release of responsibility form as required by facility policy for discharges without physician approval. Multiple staff, including the SSD, ADON, and DSD, later confirmed the resident was responsible for his own decisions and should have been allowed to leave, and the resident reported feeling very upset and frustrated when his request to go home was denied.
A resident with HTN and Type II DM was suspected by multiple staff and the resident’s son to be experiencing financial exploitation by a caregiver who held and possibly used the resident’s credit card. The SSD, ADON, and an LN each acknowledged that the situation constituted suspected financial abuse that warranted reporting, but no report was made to law enforcement, the LTC ombudsman, or CDPH. This inaction conflicted with the facility’s abuse and exploitation policy and state mandated reporting requirements, which require identification, investigation, and timely reporting of suspected abuse or exploitation by any individual.
A resident admitted with unsteadiness in feet and dysphagia had an active physician order for an alternating pressure pad (APP) mattress, but surveyors observed the resident on a regular mattress. Nursing staff acknowledged that physician orders must be followed, confirmed the resident had fragile skin and was at risk for pressure ulcers, and the ADON verified the APP order had not been implemented despite a Braden score indicating risk. Facility policies required use of appropriate support surfaces based on risk factors and adherence to prescribers’ orders, but no specific policy on physician orders was provided when requested.
A medication security deficiency occurred when an LN left a hall medication cart unlocked and unattended while inside a resident’s room, with no other staff present to monitor the cart. The LN later confirmed the cart had been left unlocked, despite facility policy requiring carts to remain closed and locked whenever out of the nurse’s sight. The ADON also confirmed that policy mandates locking unattended carts to prevent unauthorized access to medications, and the written medication administration P&P specifies that the cart must be kept closed and locked when not in direct view of the medication nurse or aide.
Two residents experienced lapses in infection control when staff failed to follow facility policies. For one resident with unsteadiness and dysphagia, an LN picked up three pillows from the floor and placed them back on the bed, despite leadership acknowledging that items on the floor are considered contaminated. For another resident with COPD and emphysema receiving scheduled nebulizer treatments, the nebulizer mouthpiece was left on a bedside dresser near beverages and a used cup instead of being rinsed, disinfected, and stored in a labeled plastic bag as required by facility policy. These actions did not comply with the facility’s infection prevention and nebulizer equipment procedures.
A resident with a PICC line and orders for daily heparin flushes and shift-based monitoring for infection did not have these treatments and assessments consistently documented on the MAR over multiple days. A non-RN licensed staff member reported he could not perform the flushes himself and only reminded RNs, with no confirmation they completed the tasks, and PICC site monitoring was not consistently charted. The resident stated that PICC care occurred less than half as often as ordered despite repeated reminders, and the DON confirmed that missing documentation meant the ordered PICC line care was not completed.
A resident grievance process was not clearly available, and an appointed grievance officer was not in place. Eight residents in a council meeting could not describe how to file grievances and reported repeated complaints about cold food and CNA behavior with no documented response. The AD said there was no clear grievance process, and the ADON said the facility could not provide tracking or response documentation for complaints.
PASRR Level II evaluations were not completed for three residents with documented psychiatric diagnoses and behavioral concerns. One resident had depression, anxiety, bipolar disorder, and cognitive decline; another had depression, bipolar disorder, and schizoaffective disorder with hostile and dangerous behaviors; and a third had schizoaffective disorder, bipolar type, with psychotropic use, aggression, and conflict with roommates and staff. Level I screenings identified each resident as positive for SMI and requiring Level II review, but DHCS notices showed the evaluations were not scheduled or were closed without completion.
Failure to Provide Required Face-to-Face Physician Visits: Multiple residents had only virtual MD visits instead of required in-person assessments at least every 60 days. Residents with serious conditions such as cellulitis, sepsis, paraplegia, HF, DM, osteomyelitis, schizoaffective disorder, ESRD, CAD, and neurologic decline were documented as having virtual-only visits, and requested proof of in-person visits was not provided. The ADM and MD stated the MD was in the building on Mondays and saw residents either in person or virtually, but the records reviewed did not show the required face-to-face visits.
A resident council complaint and tray line observation showed that food served to residents on the last hall was repeatedly cold. Residents reported that meals were always cold because they were served last, and the RD confirmed test trays of pureed and regular texture foods were cooler than they should be, with temperatures around 100 to 110 degrees.
Unlabeled and outdated resident food was found in refrigerators at the nurses’ stations, including milk past its use-by date, sour cream with an old delivery date, and multiple other items with no resident name or date. Staff identified housekeeping and nursing as responsible for monitoring the refrigerators, and an LPN also found a resident-labeled cold pack stored in the freezer with food.
Failure to protect resident PHI occurred when lunch tray tickets with residents' names and diet orders were found in a trash can in the dining hall. An ADON stated that tray tickets should not be discarded in the trash because they contain protected health information, and the facility policy stated that resident personal and medical records would be safeguarded.
The facility failed to notify the ombudsman's office of a resident's transfer to the hospital. The resident had multiple serious diagnoses, was sent to the ER for abnormal drowsiness and left chest swelling, was later transferred for a higher level of care, and died in the ICU. The Administrator verified no documentation could be found showing the Ombudsman was notified, despite facility policy requiring a copy of the transfer or discharge notice be sent to the State LTC Ombudsman.
PASRR screening was not coordinated correctly for a resident with schizoaffective disorder and schizophrenia. The resident’s Level I PASRR stated there was no diagnosed or suspected mental illness and no psychotropic meds, even though the MDS showed moderate cognitive impairment and an active schizophrenia dx, and the MAR/order summary showed Seroquel for schizophrenia with auditory hallucinations. The resident was not referred for a Level II PASRR evaluation.
Failure to develop a care plan for depression. A resident with hemiplegia, hemiparesis, major depressive disorder, and moderate cognitive impairment had an MDS showing little or no interest or pleasure nearly every day and an active depression diagnosis. The resident was minimally verbal during interview, and the ADON stated there should have been a nursing care plan to monitor the condition and set goals and interventions, but none was in place.
A resident with rheumatoid arthritis, muscle wasting, and severe mobility impairment was not transferred out of bed into his wheelchair for an extended period after his wheelchair went missing. The resident said he had not been up in a wheelchair or taken outside in months, a nurse confirmed there was no wheelchair in the room, and a CNA and the ADON acknowledged the resident needed assistance and should not have been left in bed.
A resident with a diagnosis of left eye keratitis did not receive several prescribed doses of an ophthalmic solution, and there was no documentation in the MAR or medical record explaining why the medication was not administered. Interviews with the DON and Administrator confirmed that this lack of documentation did not meet facility policy, which requires reasons for missed medications to be recorded.
A resident with a history of cellulitis and venous insufficiency had acetaminophen left at her bedside without a physician's order for self-administration, resulting in the medication not being taken and her condition worsening. Additionally, staff were found to have pre-prepared medications for multiple residents, leaving unidentified medications in the medication cart, with the DON aware and instructing staff to supervise administration of these pre-prepared doses. These actions were not in accordance with facility policy and increased the risk of medication errors.
A resident with a history of cellulitis and venous insufficiency experienced a significant change in condition, including high fever, altered mental status, and worsening leg redness. Despite these symptoms being recognized by staff during the morning shift, the physician was not notified until several hours later. The delay in notification and lack of documentation led to delayed care and hospitalization for fever, altered consciousness, and sepsis, constituting neglect as defined by facility policy.
A nurse failed to maintain a resident's dignity and privacy during the administration of a rectal suppository by not stopping the procedure when the resident expressed pain and requested it be stopped, not ensuring privacy by leaving the curtain and door open, and not providing an adequate explanation of the procedure beforehand. The resident experienced pain, embarrassment, and psychological trauma as a result.
A registered nurse performed a digital stool dis-impaction on a resident without a physician's order during the administration of a rectal suppository, resulting in the resident experiencing pain, distress, and ongoing psychological trauma. The facility lacked adequate staff training, competency documentation, and policies regarding rectal medication administration and digital dis-impaction, leading to inconsistent practices among nursing staff.
A resident with a history of post laminectomy syndrome and constipation reported feeling violated after a nurse administered a rectal suppository in a manner the resident found inappropriate. Although facility policy required immediate reporting of abuse allegations within two hours, there was no evidence that the incident was reported to the Department within the required timeframe, and the Department did not receive notification until the following day.
A CNA solicited and received a debit card and PIN from a resident with multiple medical conditions, using the card to withdraw money after expressing financial hardship. The resident, who had no memory impairment, expected repayment but did not hear from the CNA afterward and reported feeling taken advantage of. Facility policy prohibits staff from accepting gifts, loans, or financial dealings with residents, and staff interviews confirmed awareness of these rules.
The facility failed to issue Notices of Medicare Non-Coverage (NOMNC) to two residents prior to their discharge, despite receiving Medicare Part A services. Staff interviews revealed a lack of clarity and accountability regarding the issuance of these notices, with key personnel unable to explain the oversight.
A resident with a history of pulmonary issues was using an Acapella device without a physician's order, contrary to facility policy. Staff interviews revealed a lack of awareness and oversight, as the device was not documented or ordered until noted by a surveyor. The facility's protocol required a physician's order for such devices, which was not initially obtained.
A resident sustained a left femoral fracture after a fall during a transfer using a mechanical lift, as only one staff member assisted instead of the required two. The staff member involved had not completed the necessary competency test for using the lift. The facility's policy, which mandates two staff for such transfers, was not followed, leading to the resident's injury.
Two residents in an LTC facility experienced injuries due to inadequate supervision and delayed response to call lights. One resident, requiring assistance for mobility, fell and fractured his arm after waiting over twenty minutes for help to use the toilet. Another resident, allowed to smoke unsupervised, sustained burns when his pants caught fire. Staff interviews revealed inconsistencies in following facility policies for call light response and smoking supervision.
A resident with chronic pain and a recent hip replacement experienced unmanaged pain due to the facility's failure to administer pain medication on time. The resident's medications, including Oxycodone and Norco, were frequently given late, contrary to the facility's policy of administering within one hour of the scheduled time. Interviews with staff confirmed the policy but revealed inconsistencies in its implementation, leading to the resident's significant discomfort.
The facility failed to provide scheduled showers to three residents, compromising their hygiene needs. A resident admitted for physical therapy after hip replacement did not receive showers for weeks, despite requiring partial assistance. Another resident with Alzheimer's and Parkinson's diseases, dependent on staff for showers, had no shower logs for two months. A third resident, needing setup assistance, reported not receiving showers for two weeks, leading to discomfort. Staff interviews revealed inconsistencies in providing showers outside scheduled days, and the facility lacked proper documentation, violating its hygiene policy.
Two residents experienced significant negative outcomes due to delayed call light responses in an LTC facility. One resident, requiring moderate assistance, fell and fractured an arm after waiting over twenty minutes for help. Another resident, needing substantial assistance, developed moisture-associated skin damage from prolonged exposure to moisture due to similar delays. Staff interviews confirmed the facility's policy of responding within five minutes was not consistently followed.
A resident in an LTC facility received pain medications Oxycodone and Oxycontin more frequently than prescribed, despite facility policies requiring verification of the right medication and dosage. The resident, with a history of chronic pain and recent hip surgery, was at risk due to these significant medication errors.
A resident's call light system was found to be non-functional, posing a risk of unmet needs. Despite daily checks, the issue was not reported or addressed until observed by staff. The resident, with cognitive intactness and requiring assistance, relied on another resident to signal for help. The malfunction was due to dirt obstructing the connection, which was resolved after cleaning.
A facility failed to accurately complete the MDS for a resident, resulting in incomplete information necessary for a resident-centered care plan. The resident, admitted with mobility issues, had an MDS indicating a BIMS score of 14, but key areas like eating and hygiene were not assessed. The MDS Coordinator acknowledged the inaccuracies, which contradicted the facility's policy on comprehensive assessments.
Failure to Update Fall Care Plan After Significant Change
Penalty
Summary
The facility failed to revise and implement a comprehensive, person-centered care plan after a significant change in condition for one resident who had a history of falls, unsteadiness on feet, difficulty walking and moving safely, chronic pain, and major depressive disorder. The resident’s BIMS score in May 2026 was 14, indicating cognitive intactness and ability to participate in care planning. Before the April 2026 fall, the care plan included a transfer pole, a non-skid floor mat, a Call, Don't Fall reminder, and PT evaluation as indicated. After the fall on 4/09/26, the fall prevention interventions remained substantially unchanged, and the Call, Don't Fall intervention was duplicated in the care plan, but no additional individualized interventions were added to address the resident’s increased fall risk. During interview, the PT stated that after the April fall the resident declined restorative nursing services and continued to express the goal of transferring independently rather than walking, and that interventions included a non-skid floor mat and Call, Don't Fall reminders. The DON reviewed the September 2025, April 2026, and June 2026 care plans and acknowledged the fall prevention interventions were not escalated after the resident’s April fall and remained essentially the same after both falls. The resident later sustained a second fall while attempting to transfer to the bedside commode using the transfer pole, resulting in an acute left hip fracture and hospitalization.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure one resident was free from abuse when another resident hit him on the left arm. Resident 1 was admitted with a diagnosis of generalized anxiety and had an MDS BIMS score of 13, indicating no significant issues with memory, thinking, or reasoning. In an SBAR dated 4/22/26 at 3:15 p.m., Resident 1 alleged that another resident hit him on the arm on 4/22/26. Resident 2 was admitted with diagnoses including depression and intermittent explosive disorder, and her MDS also showed a BIMS score of 13. In an SBAR dated 4/22/26 at 7:48 p.m., Resident 2 allegedly hit another resident on 4/22/26. During interviews, Resident 1 stated that Resident 2 hit his left arm after he did not touch or approach her, and Resident 2 stated she remembered the incident and hit Resident 1 because he annoyed her. The facility policy on Abuse, Neglect and Exploitation defined abuse as the willful infliction of injury, including resident-to-resident altercation.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Prevent and Intervene in Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse during and after a resident‑to‑resident altercation that included profanity and physical contact. One resident with COPD and major depressive disorder, who had an intact BIMS score of 13, was involved in an incident at the nurse’s station with another cognitively intact resident who had hemiplegia/hemiparesis following a cerebral infarction and heart failure. According to the facility’s own post‑event note and SBAR forms, the first resident wheeled up to the nurse’s station where the second resident was already seated, pushed her wheelchair into the second resident, and told her to “fuck off” when asked to stop. The second resident then kicked the first resident in the left knee. Staff, including two CNAs, witnessed the incident, and documentation identified the second resident as the aggressor who intentionally kicked the other resident’s knee. Interviews with both residents confirmed the verbal and physical nature of the altercation and that it occurred in front of staff. The first resident reported that the second resident was in her way at the nurse’s station, that she was kicked in the left knee, that it hurt, and that staff did not respond immediately to the incident. The second resident stated that the first resident told her to “get the fuck out of my way” and continued yelling, and that she kicked toward the first resident to get her away, striking her knee. The second resident also reported that, after the incident, she would give the first resident the middle finger when she passed by, and that the first resident would sit outside her room and call her a “fucking bitch.” Surveyor observation showed that the antagonistic interactions between the two residents continued without staff intervention. On one occasion, the first resident stopped in front of the second resident’s doorway, the second resident yelled “Keep going!”, and the first resident responded “Oh yea!” and continued down the hallway while a staff member seated about 10 feet away paid no attention to the interaction. Staff interviews, including with a CNA, confirmed that the kick was intentional and that the second resident could verbalize her needs instead of kicking. The Social Service Director and ADON both characterized the incident as verbal and physical abuse under the facility’s abuse policy, which defines physical abuse to include kicking and verbal abuse to include disparaging and derogatory terms, and job descriptions for CNAs and RNs require them to protect residents from abuse. Despite these definitions and responsibilities, staff did not promptly intervene to separate the residents or prevent ongoing verbal and gestured abuse.
Failure to Document and Respond to Resident Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to document and respond to a resident fall and associated change in condition in accordance with its policies and fall protocol. Resident 4, who had a history of traumatic subdural hemorrhage, multiple rib fractures, and repeated falls, was cognitively intact with a BIMS score of 13. On a prior date in March, he had a witnessed fall with head strike, was sent to a general acute care hospital (GACH), and imaging showed an acute on chronic subdural hematoma with a 4 mm shift; he was later returned to the SNF in stable condition. These clinical details established that the resident was at high risk for serious injury from any subsequent head trauma. On a later date in April, hospital records from the GACH emergency department documented that the resident reported an unwitnessed fall at the SNF with a positive head strike. A critical care consult note from the same hospitalization stated that he had previously fallen in March with a subdural hematoma and that he presented again after an unwitnessed fall in the SNF in which he hit his head, and was transferred for a new, enlarging left-sided subdural hematoma with mass effect, brain compression, and shift. Despite this, the SNF’s electronic medical record for that April date contained no evidence that a fall had occurred, and no documentation of a status-post-fall assessment, MD notification, emergency contact notification, alert charting, or an updated care plan. Interviews with facility staff further described the events of the day of the unwitnessed fall. One CNA stated that another CNA requested help to pick the resident up from the floor and that the assigned nurse, identified as LN 1, also responded; they assisted the resident from a crouched position by his bed back into bed. The same CNA later accompanied the resident to a doctor’s appointment, where the resident’s wife noticed one side of his face was discolored and red; the CNA observed reddish-pinkish discoloration on one side of the resident’s face and heard the resident tell his wife that his head hurt, after which the wife wanted him to go to the hospital. Another CNA reported that when she responded to the resident calling for help, she found him on the floor next to his bed, and he told her he had fallen; she then retrieved his nurse, who assessed him, and the CNA left the room. The administrator confirmed that LN 1 was the resident’s nurse on that day and that there was no documentation in the resident’s record of a fall or related assessments or notifications, despite facility policies requiring evaluation, documentation, physician and representative notification, and care plan revision for falls and changes in condition. The facility’s written policies required staff to evaluate and document all falls, including when and where they occurred and observations of events, and to identify interventions to prevent subsequent falls and address risks of serious consequences. Policies on change in condition required notifying the attending physician and resident representative of accidents or incidents involving the resident and documenting information related to changes in condition or status. Documentation policies required that the medical record contain an accurate representation of the resident’s actual experiences, including events, incidents, or accidents, and that assessments be ongoing with care plans revised as conditions change. The RN job description required ensuring compliance with policies, assessing for changes in status, notifying the physician and family or representative, documenting accordingly, and reporting incidents or unusual occurrences to nursing leadership. The lack of any fall documentation, post-fall assessment, notifications, or care plan update for the April unwitnessed fall, despite staff accounts and subsequent hospital records, constituted the failure to provide quality of care and to follow the facility’s fall, change-in-condition, documentation, and care planning protocols for this resident.
Failure to Maintain Clean, Homelike Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean, homelike environment for one resident when a privacy curtain and the ceiling above the resident’s bed remained visibly soiled for an extended period. The resident, admitted with cervical radiculopathy and depression among other diagnoses, reported that the privacy curtain between his and his roommate’s beds had not been washed for over a year. Surveyor observation confirmed two brown smears, a cluster of dark gray splatter-like spots, and an area of white crusty substance on the curtain. The resident also identified a brown splatter on the ceiling above his bed, which he stated was chocolate pudding that had been present for about nine to ten months. The resident expressed feeling frustrated that staff were not doing their jobs to keep his living environment clean. During an observation and interview, the Environmental Services Supervisor (ESS) verified the stains on the privacy curtain and the brown splatter on the ceiling and agreed they needed to be cleaned. ESS stated she conducted spot checks of rooms to ensure EVS staff were cleaning to her standards but acknowledged she had not noticed the soiled curtain or ceiling and that she and the housekeeper likely did not look up during daily cleaning and checks. ESS reported that a deep clean routine, including washing privacy curtains, had only recently been started in March 2026 and that the resident’s room had not yet received a deep clean due to a Covid outbreak that halted the process. ESS further stated that prior to March 2026 there was no set routine for washing privacy curtains or deep cleaning rooms. The Administrator stated that soiled privacy curtains absolutely needed to be changed and were expected to be washed on a routine schedule. The facility’s Homelike Environment policy indicated residents are to be provided with a safe, comfortable, homelike, clean, and sanitary environment.
Missed Suboxone Doses Due to Untimely Reordering and Unavailability
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when prescribed Suboxone for opioid dependence was not available and not administered as ordered. The resident was admitted with a diagnosis of substance dependence and had no documented memory impairment. A physician’s order dated 2/4/26 directed Suboxone sublingual film 8-2 mg, one film three times daily for opioid dependence. Review of the medication administration record for 2/26 showed that the resident did not receive Suboxone on three occasions: one evening dose on 2/23/26 and two doses on 2/24/26, with the MAR coded as “other/see Nurse Notes.” Progress notes documented that on 2/23/26 the Suboxone was pending pharmacy delivery, and on 2/24/26 it was not given and was unavailable due to the order pending the physician’s signature, and later still pending delivery. During interview, the resident reported not receiving Suboxone for a week, stated he did not know why, and reported experiencing shaking and anxiety, noting he was a recovering heroin addict. The ADON, upon review of the MAR and progress notes, confirmed the three missed doses and that the medication had not been available for administration, and stated it was her expectation that medications be ordered timely and available so doses were not missed. She further agreed that, given the resident’s use of Suboxone for opioid dependence and his complaints of anxiety and shakiness due to missed doses, this constituted a significant medication error. Facility policies on Medication Reordering and Medication Errors stated that the facility would provide medications in a timely manner to meet each resident’s needs and ensure residents receive care in an environment free of significant medication errors.
Failure to Honor Resident’s Request for Discharge and Right to Self-Determination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination when the resident’s request to be discharged was not granted. The resident was admitted in 11/2025 with diagnoses of essential HTN and Type II DM, and a physician order dated 11/11/25 indicated the resident was capable of understanding rights, responsibilities, and informed consent. On the evening of 1/28/26, the resident told the Social Services Director that he wanted to discharge from the facility. An Alert Note dated 1/29/26 at 12:46 a.m. documented that at approximately 8:30 p.m. on 1/28/26, the resident and a visitor requested an explanation as to why the resident could not leave the facility at that time. The nurse explained that per facility protocol and due to safety concerns, the resident was not cleared to leave and that a discharge care meeting could be arranged during normal business hours, and informed the visitor that leaving would be unsafe and against medical advice. Interviews and record reviews confirmed that, despite the physician’s order deeming the resident responsible for himself, staff did not allow him to discharge and did not offer a release of responsibility form as required by facility policy for discharges without physician approval. The Social Services Director, Assistant DON, and Director of Staff Development each verified that the resident was responsible for himself and had the right to leave the facility, and the Assistant DON confirmed that staff should have offered a release of responsibility form but did not. The nurse on duty stated she told the resident it was late, that nothing could be figured out at night, there was no administrative staff available, and she did not know the procedure or what to do, believing that allowing discharge at night would compromise safety. The resident later stated by telephone that he had wanted to go home at that time but was not allowed to do so and that he was really upset and frustrated. Facility policies on “Discharging a resident without Physician’s Approval” and “Resident’s Rights” indicated that residents requesting discharge without physician approval should be asked to sign a release of responsibility form and that residents have the right to self-determination.
Failure to Report Suspected Financial Abuse to Required Agencies
Penalty
Summary
The facility failed to report suspected financial abuse of a resident by the resident’s caregiver to law enforcement, the LTC ombudsman, or the State Agency (CDPH), despite multiple staff members forming suspicions of exploitation. The resident was admitted in November 2025 with diagnoses of essential HTN and Type II DM. The Social Services Director (SSD) reported that both she and the resident’s son believed the caregiver was taking advantage of the resident’s finances and expressed concern that the caregiver was holding the resident’s credit card. The SSD acknowledged she suspected financial abuse and agreed it should have been reported as such, but she did not report it because she believed the resident had an emotional attachment to the caregiver and the resident did not complain. The Assistant Director of Nursing (ADON) stated that concerns raised by the resident’s son about the caregiver keeping the resident’s credit card and being paid while the resident remained in the facility warranted further investigation and reporting to appropriate agencies. A licensed nurse (LN B) also stated she suspected financial abuse when she learned the caregiver had the resident’s credit card and believed the caregiver used it, and acknowledged these suspicions should have been reported to CDPH and the police. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and CDPH All Facilities Letter 21-26 showed that the facility was required to identify, investigate, and report all possible incidents of abuse, neglect, exploitation, or misappropriation of property, including suspected abuse by family, friends, or other individuals, to law enforcement, the LTC ombudsman, and CDPH. These required reports were not made in this case.
Failure to Implement Physician Order for APP Mattress for At-Risk Resident
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a physician’s order for an alternating pressure pad (APP) mattress was not implemented for one resident. The resident was admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia. A physician’s order dated 1/16/26 directed that an APP mattress be placed on the resident’s bed. On 2/20/26, a licensed nurse stated that physician orders should be followed and that if an APP mattress was ordered, the facility should provide it; the nurse acknowledged that failure to follow the order meant facility policy was not followed and that residents would be at risk for further skin issues. During an observation in the resident’s room that same day, another licensed nurse confirmed the resident was on a regular mattress and not on an APP mattress, and stated the resident had fragile skin and was at risk for developing pressure ulcers. In a concurrent interview and record review with the ADON on 2/20/26, the ADON verified that the resident was not on an APP mattress despite the active physician order from 1/16/26. The ADON also confirmed the resident’s Braden score was 15, indicating the resident was at risk for pressure ulcers, and stated that using an APP mattress was a preventive measure to help prevent development of pressure ulcers. The facility’s policies indicated that appropriate support surfaces should be selected based on residents’ risk factors in accordance with current clinical practice, that medications are administered in accordance with prescribers’ orders, and that staff must demonstrate skills necessary to care for residents’ needs including skin and wound care. A policy specific to physician orders was requested but not provided.
Unattended Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves failure to keep medications secured in locked compartments as required by facility policy and professional standards. During an observation and interview on 2/20/26 at 5:14 p.m., a licensed nurse left the hall 1 medication cart unlocked while inside a resident’s room, and there were no other licensed or unlicensed staff present to monitor the cart. Upon returning, the nurse confirmed that the cart had been left unlocked and unattended and acknowledged that facility policy requires medication carts to be locked when unattended for resident safety. In a subsequent interview at 5:20 p.m., the assistant DON confirmed that medication carts are required by facility policy to be locked when unattended to prevent unauthorized access to medications, and review of the written medication administration policy dated 12/2025 showed it directs that the medication cart be kept closed and locked when out of sight of the medication nurse or aide. The report states that this failure could result in access to medications by unauthorized people, leading to medication theft and unauthorized medication ingestion with a risk of overdose, drug interactions, or severe adverse effects.
Failure to Follow Infection Control Practices for Bed Linens and Nebulizer Equipment
Penalty
Summary
The facility failed to maintain infection control measures for two residents when staff did not follow established policies and procedures. For one resident admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia, a licensed nurse was observed picking up three pillows from the floor and placing them at the foot of the resident’s bed. The Assistant Director of Nursing confirmed seeing the three pillows on the bed and stated that anything that fell on the floor was considered contaminated and should not have been placed back on the bed, describing such items as soiled or dirty. The facility’s Infection Prevention and Control Committee policy indicated that the committee was to assist in the development and implementation of written policies and procedures for the prevention and control of infections among residents, provide guidelines for a safe and sanitary environment, and review, establish, and monitor environmental infection prevention and control practices in accordance with CDC, HICPAC, OSHA, and local and state requirements. For another resident admitted in December 2022 with COPD and emphysema and an order for nebulized medication every eight hours, the nebulizer mouthpiece was observed resting on top of the bedside dresser, not stored in a container or bag to protect it from cross contamination, and placed near a soda and a used drinking cup. The resident stated that staff administered the nebulizer medication but rarely kept the mouthpiece inside the provided plastic bag. A licensed nurse verified that the mouthpiece was not kept inside the plastic bag as required by facility policy and stated that after use, the mouthpiece should be stored in the bag. The Director of Nursing also verified that the mouthpiece was not in the plastic bag and was on the bedside dresser, and stated this practice was not acceptable. The facility’s policy on administering medications through a small volume handheld nebulizer required that the nebulizer equipment be rinsed and disinfected according to facility protocol and stored in a plastic bag labeled with the resident’s name and date.
Failure to Follow PICC Line Flushing and Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policy for PICC line care for one resident. The resident was admitted with metabolic encephalopathy and bacteremia and had a physician order for the PICC line to be monitored every shift on the day shift for signs and symptoms of infection. Review of the Medication Administration Record (MAR) for February showed that this monitoring order was not documented as completed on multiple specified day shifts. The resident also had a physician order for a daily heparin lock flush solution to maintain PICC line patency, which was not documented as administered on several ordered dates and times. The facility’s policy required flushing catheters at regular intervals to maintain patency, monitoring for IV complications, and recording the date and time medications were administered in the medical record. During interviews, the licensed staff member who worked several of the shifts in question confirmed that documentation of PICC line care was missing from the MAR and stated that, as he was not an RN, he could not flush the line himself and instead reminded RNs to perform the task, but could not verify it was done without documentation. He also stated he monitored the PICC site daily, although this was not consistently documented. The resident reported that staff flushed and monitored the PICC line less than half of the required times and not daily, despite his repeated reminders, and stated he felt neglected and feared infection. The DON acknowledged that a PICC line not flushed consistently could become clogged, that lack of monitoring could miss a reaction or infection, and that if a task was not documented, it meant it was not completed, confirming the missing documentation on the resident’s MAR.
Grievance Process Not Available or Tracked
Penalty
Summary
The facility failed to ensure eight sampled residents were aware of how to file a grievance and had their complaints resolved when there was no current grievance process or appointed grievance officer. During a Resident Council Meeting, the eight residents present could not describe the current grievance process and expressed frustration that concerns had been repeatedly raised without response. One resident stated that since the last Social Services Director left, there had been no follow-up on complaints or grievances. Resident council notes from 11/25 and 12/25 documented multiple complaints about cold food and CNA behavior in the dining hall, but no facility or department response was documented. During interviews, the Activities Director stated there was no clear grievance process, and the ADON stated the Social Services Director was the grievance officer but the facility did not currently have one and could not provide documentation showing grievances were tracked or facility responses were recorded. The facility policy stated the grievance officer was responsible for investigating complaints, informing the resident of findings and actions taken, and maintaining the results of all grievances on file.
PASRR Level II Evaluations Not Completed for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure PASRR Level II evaluations were completed for three sampled residents with documented psychiatric diagnoses and related functional concerns. Resident 23 was admitted with diagnoses including major depressive disorder, anxiety disorder, bipolar disorder, diabetes, and age-related cognitive decline. The record showed a PASRR Level I screening dated 9/18/24 identified Resident 23 as positive for SMI and required a Level II screening, but DHCS correspondence stated a Level II evaluation was not scheduled because the individual had no SMI and no functional limitations in the last 6 months. Resident 41 was admitted with diagnoses including hemiplegia and hemiparesis, depression, and schizoaffective disorder. The MDS also listed active diagnoses of depression and bipolar disorder. A PASRR Level I screening dated 9/18/24 indicated Resident 41 required a Level II screening due to positive SMI, but DHCS correspondence stated a Level II examination was not scheduled because the individual had no SMI and no functional limitations in the last 6 months. The record also included progress notes describing behavioral concerns, including hostile verbal altercations with another resident and behaviors presenting danger to self and/or others, and the care plan identified a psychosocial well-being problem related to schizophrenic disorder bipolar type. Resident 68 was admitted with schizoaffective disorder, bipolar type. The MDS indicated the resident was not considered by the state Level II PASRR process to have SMI or ID, yet the MDS psychiatric diagnosis section listed schizophrenia. A PASRR Level I screening dated 8/01/25 indicated Resident 68 required a Level II screening due to positive SMI, and DHCS correspondence stated a Level II mental health evaluation was required. A later DHCS notice stated the Level II evaluation was not scheduled because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening and the case was closed. The resident’s care plan identified psychotropic medication use for schizoaffective disorder and a psychosocial well-being problem, and staff observed and reported conflict, aggressive interactions, room changes, and swearing at staff during meal delivery. Interviews with the MDS Coordinator and ADON confirmed the facility was responsible for ensuring PASRR was completed accurately and that a new screening should be initiated if needed, but they did not know why Resident 68’s Level II screening had not been completed after the positive Level I result.
Failure to Provide Required Face-to-Face Physician Visits
Penalty
Summary
The facility failed to provide face-to-face and in-person physician visits at least once every 60 days for 6 of 12 sampled residents, including Residents 5, 19, 23, 41, 98, and 99. The deficiency was identified through observation, interview, and record review, and the records reviewed showed that these residents had only virtual physician visits during the relevant period. Documentation of in-person physician visits was requested from both the facility physician and the facility for Residents 5, 19, 23, 41, 98, and 99, but it was not provided. Resident 19 was admitted with cellulitis, hypertension, acute respiratory failure, and spinal stenosis, and her physician notes showed only virtual visits with Physician A in the past 90 days. During interview, she stated she had not seen a doctor except on the screen and said she was unsatisfied with her medical care and wished to go home. Resident 5 was admitted with rhabdomyolysis, sepsis, and paraplegia, and his physician notes showed he had only seen the facility physician once, virtually, since admission. Resident 23 was admitted with heart failure and diabetes mellitus, and his physician notes also showed only virtual visits with Physician A. Resident 41 was admitted with osteomyelitis, schizoaffective disorder, and syncope and collapse, and his physician notes likewise showed only virtual visits with Physician A. Resident 98 was admitted with heart failure, coronary artery disease, end-stage kidney disease, diabetes mellitus, left above-the-knee amputation, and an implanted defibrillator, and his physician notes showed only virtual visits with Physician A before he later died in an ICU at a nearby hospital. Resident 99 was admitted with metabolic encephalopathy, left-sided paralysis following cerebral infarct, intractable epilepsy, coronary artery disease, and a heart attack; after readmission from the hospital, he was placed on comfort care and later died. His physician notes showed only virtual visits with Physician A since admission. The Administrator stated Physician A was in the building every Monday for about an hour, did rounds, and also did virtual visits, seeing one hall each week because there were four halls and over 20 residents on each hall. Physician A stated he saw patients every Monday, either in person or virtually, and that the number seen varied depending on concerns and could include a whole wing.
Cold Food Served on Last Hall
Penalty
Summary
The facility failed to provide food at a palatable temperature for three sampled residents, identified in the report as Resident 90, Resident 7, and Resident 53, during a resident council interview. At the resident council meeting, the three residents who lived on Hall 4 stated that the food was always cold because they were served last. Resident council notes also showed that cold food had been reported in 08/25, again in 11/25, and in 12/25. During a tray line observation, the cook began plating lunch at 12:05 p.m., and staff did not begin passing lunch trays to residents on Hall 4 until 1:14 p.m. During a test tray observation with the Registered Dietitian, temperatures were taken from a pureed tray and a regular texture tray. The pureed tray measured carrots at 100 degrees, potatoes at 110 degrees, and fish at 110 degrees, and the survey team agreed the carrots were too cold. The regular texture tray measured tater tots at 105 degrees, carrots at 105 degrees, and fish at 100 degrees, and the survey team agreed all of the foods were too cold. The RD stated the food was cooler than it should be and said, "It could be warmer." The RD also stated she usually heard people say the food was cold with the last hall, and thought the test tray was cool because it was a longer tray line due to fish day and increased demand for alternatives.
Unlabeled and Outdated Resident Food Stored in Nurses’ Station Refrigerators
Penalty
Summary
The facility failed to safely store residents’ personal food brought in from outside the facility in the two refrigerators at the nurses’ stations. During observation, one refrigerator at Nurses’ Station 2 contained multiple items that were not labeled or were outdated, including a gallon of milk with a use-by date of 12/1/25, sour cream with a delivery date of 11/16/25, a frozen ice cream milkshake with no date or name, vegetable spring rolls with no name or date, two half-gallons of ice cream with no name or date, several ice cream sandwiches with no name or date, and a pina colada-flavored fruit drink with a use-by date of 12/2025 and no name or date. The Housekeeping Supervisor stated she was responsible for monitoring the food in the refrigerators and said items should be labeled with the resident’s name, room number, and the date and time placed in the refrigerator. At Nurses’ Station 1, the refrigerator contained a tub of whipped topping and a container of take-out food, both without a name or date. The freezer also contained a black and white cloth ice pack with a resident’s name written on it, and the Licensed Nurse stated it was a cold pack for pain relief and should not be stored there with food. The Registered Dietitian stated nursing had a checklist for checking the refrigerators and that expired food should be thrown away, and the Assistant Director of Nursing stated nursing or housekeeping were responsible for monitoring the refrigerators. Facility policy required perishable foods to be stored in sealed containers, labeled with the resident’s name, item, and use-by date, and for staff to discard foods showing signs of foodborne danger or past-due expiration dates.
Failure to Protect Resident PHI in Dining Room
Penalty
Summary
The facility failed to protect residents' private health information when lunch tray tickets containing residents' names and diet orders were found thrown in the garbage in the dining room. During an observation on 1/05/26 at 12:46 p.m. in the RNA Dining Hall, resident tray tickets were seen in the trash can. During an interview on 1/08/26 at 2:45 p.m., the ADON stated that no tray tickets should be in the trash because they contain protected health information. A review of the facility policy titled, Confidentiality of Information and Personal Privacy, revised 10/25, indicated that the facility would safeguard the personal privacy and confidentiality of all resident personal and medical records.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the ombudsman's office of Resident 98's transfer to the hospital. Resident 98's face sheet showed admission to the facility with multiple diagnoses including heart failure, coronary artery disease, end-stage kidney disease, diabetes mellitus, and an implanted defibrillator. A nurse progress note documented that Resident 98 was sent to the local hospital emergency room when he was abnormally drowsy and had swelling to his left chest. Hospital records showed he was then transferred to another nearby hospital for a higher level of care and died in the intensive care unit. During interview, the Administrator verified that documentation could not be found showing the ombudsman's office had been notified of the transfer, and facility policy stated that a copy of the transfer or discharge notice would be sent to the Office of the State Long-Term Care Ombudsman.
PASRR Screening Did Not Reflect Resident’s Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for one sampled resident when the resident’s Level I PASRR did not accurately reflect a serious mental disorder and the resident was not referred for a Level II PASRR screening. Resident 5 was admitted with diagnoses including paraplegia, generalized muscle weakness, acute kidney failure, and schizoaffective disorder. The resident’s MDS dated 11/26/25 indicated moderate cognitive impairment on the BIMS and an active diagnosis of schizophrenia. A review of the resident’s order summary dated 1/07/26 showed Seroquel was being given at bedtime for schizophrenia manifested by auditory hallucinations. However, the DHCS PASRR Level I Screening dated 11/18/25 indicated the resident did not have a diagnosed or suspected mental illness and was not receiving psychotropic medications, and the DHCS Notice of PASRR Level I Screening Results stated the resident did not require a Level II Mental Illness Evaluation Referral due to being negative for SMI. During interview, the ADON stated nursing was responsible for ensuring the PASRR was correctly completed and for initiating a new evaluation if there was a change in condition. The facility policy stated that if the Level I screen indicates a possible mental disorder, intellectual disability, or related disorder, the individual is referred for Level II screening.
Failure to Develop Care Plan for Depression
Penalty
Summary
The facility failed to initiate and implement a resident-centered nursing care plan for depression for one of six sampled residents. Resident 32 was admitted with diagnoses including hemiplegia, hemiparesis, and major depressive disorder. The resident’s MDS dated 12/07/25 showed a BIMS score of 12, indicating moderate cognitive impairment, and also documented that in the past two weeks the resident had little or no interest or pleasure in doing things nearly every day and had an active diagnosis of depression. A review of the physician progress notes dated 11/06/25 indicated Resident 32 was assessed with depression. During an interview on 1/05/26, Resident 32 would not speak and answered simple questions only by shaking her head up and down or side to side. During an interview on 1/08/26, the ADON stated there should have been a nursing care plan in place for Resident 32’s depression diagnosis to monitor disease progression and set goals and interventions for management of the condition, but there was none. The facility’s undated Care Planning policy stated that a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS).
Failure to Provide Mobility Assistance After Wheelchair Was Missing
Penalty
Summary
The facility failed to ensure one of three sampled residents, a resident admitted with rheumatoid arthritis, muscle wasting and atrophy, and gait and mobility abnormalities, received services to maintain functional abilities when staff did not transfer him out of bed and into his wheelchair for an undetermined length of time. His MDS indicated he required a wheelchair for mobility and was completely dependent for bed-to-chair transfers, and his care plan identified contractures, limited mobility, and the need for assistance from two staff with a Hoyer lift and a wheelchair with a non-skid, pressure-relieving surface for mobility. The resident stated that the facility had misplaced his wheelchair and that he had not been up in a wheelchair or taken outside in five months, with no follow-up about it. A nurse confirmed there was no wheelchair in the resident’s room, and a CNA stated the wheelchair had gone missing and that the resident needed a comfortable wheelchair to get up because of contractures in his legs and had not been out of bed in a long time. The ADON stated she would have expected staff to address a missing wheelchair rather than leave the resident in bed, and the facility’s ADL policy stated residents should be provided care and services to enable them to carry out ADLs, including mobility and transferring in and out of bed.
Failure to Document Reasons for Missed Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation regarding the administration of medication for one resident diagnosed with left eye keratitis. The resident's Medication Administration Record (MAR) showed that several doses of a prescribed ophthalmic solution were not administered on specific dates and times. However, there was no corresponding nursing documentation explaining the reason for the missed doses. The resident's medical record lacked any notes indicating why the medication was withheld, whether the physician was notified, or what follow-up actions were taken regarding the missed medication. Interviews with the Director of Nursing (DON) and the facility Administrator confirmed that the absence of documentation did not meet the facility's expectations or policy requirements. The facility's policy on medication administration documentation requires that reasons for withholding or not administering medication be recorded, along with any related follow-up. The deficiency was identified through record review and staff interviews, which verified that the required documentation was missing for the resident in question.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed in several instances involving medication administration. In one case, a resident with a history of cellulitis and peripheral venous insufficiency, who was cognitively intact according to her assessment, had acetaminophen left at her bedside by a licensed nurse without a physician's order for self-administration. The resident did not take the medication as intended, and her fever escalated, leading to her being found slumped and shivering, and subsequently transferred to the hospital with a diagnosis of fever and sepsis. The facility's policies required that self-administration be documented and approved by the care team, and that medications not be left unattended at the bedside, which was not followed in this instance. Additionally, the facility was found to have allowed the pre-preparation of medications for multiple residents. Staff interviews and record reviews revealed that medications were removed from their original packaging and placed in medication cups ahead of administration, with several cups containing unidentified medications left in the medication cart. Staff, including the Director of Staff Development and other licensed nurses, confirmed that this practice was not standard and posed a risk for medication errors, as it was unclear which medications belonged to which residents. The Director of Nursing was aware of these practices and, on at least two occasions, instructed staff to supervise the administration of these pre-prepared medications rather than discarding them and preparing new doses as per policy. Facility policies reviewed indicated that medications should be prepared and administered one resident at a time, with verification of the right resident, medication, dosage, time, and route. Medications were also required to be stored in their original containers until administration. The observed practices of leaving medications at the bedside without proper authorization and pre-preparing medications for multiple residents directly contravened these policies and increased the potential for medication errors and delays in care.
Delayed Physician Notification and Neglect of Change in Condition
Penalty
Summary
The facility failed to protect a resident from neglect by not promptly notifying the physician of a significant change in condition. The resident, who had a history of cellulitis and peripheral venous insufficiency, was admitted with minimal cognitive impairment. On the day of the incident, the resident exhibited a resting heart rate of 117 bpm, was shaking, and complained of being cold. Later, the resident developed an elevated temperature of 100.2°F, which progressed to a fever of 103.6°F and then 104.6°F, along with an altered level of consciousness and decreased oxygen saturation. Despite these symptoms, the physician was not notified until several hours after the initial signs of deterioration were observed. Multiple staff interviews confirmed that the resident's change in condition, including worsening redness in the leg and the development of a high fever, was recognized during the morning shift. However, the assigned nurse did not appear concerned and did not escalate the situation or notify the physician in a timely manner. The Director of Staff Development and the Director of Nursing both acknowledged that a fever is considered a change in condition that requires immediate physician notification, and that the delay in reporting constituted neglect. Documentation of the resident's symptoms, particularly the redness in the leg, was also lacking in the medical record. The facility's own policies require prompt notification of the physician and documentation of significant changes in a resident's condition. In this case, the delay in physician notification and inadequate documentation resulted in the resident experiencing delays in care, ultimately requiring hospitalization for fever, altered mental status, and sepsis. Staff interviews and record reviews confirmed that the facility did not follow its protocols, leading to the identified deficiency.
Failure to Maintain Resident Dignity and Privacy During Rectal Medication Administration
Penalty
Summary
A registered nurse (RN) failed to provide nursing care in a manner that maintained a resident's dignity and respect during the administration of a rectal suppository. The RN did not stop the procedure when the resident complained of pain and requested that the procedure be stopped. Instead, the RN continued to move her finger inside the resident's rectum for several minutes, stating it was necessary for the medication to dissolve, despite the resident's clear expression of discomfort and request to cease. Additionally, the RN did not ensure the resident's privacy during the procedure. The privacy curtain was not drawn, and the door to the hallway was left open, allowing others to see the resident partially unclothed from the waist down. This lack of privacy was confirmed by both certified nursing assistants (CNAs) present during or after the incident, with one CNA noting that the resident's buttocks were visible from the hallway. The RN also failed to adequately explain the procedure to the resident prior to performing the invasive rectal medication insertion. The facility's policy required staff to explain procedures, provide privacy, and respect residents' rights to refuse or discontinue treatment. The resident, who had intact cognitive skills and a history of depression but no other psychiatric diagnoses, reported feeling violated, embarrassed, and traumatized by the incident. The event resulted in the resident experiencing pain, anxiety, and ongoing psychological distress.
Failure to Follow Professional Standards in Rectal Medication Administration
Penalty
Summary
A registered nurse performed a digital stool dis-impaction procedure on a resident without a physician's order, which is not in accordance with professional standards of practice. The nurse inserted a rectal suppository and manipulated her finger inside the resident's rectum for several minutes, despite the resident expressing pain and asking for the procedure to stop. The nurse stated she was attempting to break up stool to allow the suppository to dissolve, and removed some stool during the process. The resident was prescribed a rectal suppository as needed for constipation, but there was no order for digital dis-impaction. The resident, who had a history of post laminectomy syndrome and constipation, reported feeling violated, embarrassed, and traumatized by the procedure. The resident's cognitive skills for daily decision-making were intact at the time of the incident. Witnesses, including a certified nursing assistant, confirmed that the procedure took significantly longer than usual and that the resident was visibly upset afterward. The resident later reported ongoing psychological distress, including nightmares and feeling unsafe in the facility. A review of facility records revealed that there was no documented competency or specific training for licensed nursing staff regarding rectal suppository administration or digital stool dis-impaction. The facility lacked a policy on digital dis-impaction, and staff interviews indicated inconsistent understanding of the correct procedures and requirements for physician orders. The facility's policy on rectal medication administration did not address digital dis-impaction, and the nurse involved believed such procedures did not require a physician's order.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Department for one sampled resident. The resident, who had a history of post laminectomy syndrome and constipation, reported feeling violated after a registered nurse administered a rectal suppository, stating that the procedure took too long and caused discomfort. The incident was documented in the nursing notes, and the resident expressed his concerns during an interview, specifying the time and nature of the event. Despite the facility's policy requiring immediate reporting of abuse allegations within two hours, there was no evidence that the initial report was sent to the Department as required. The administrator was notified of the allegation by a charge nurse, who claimed to have faxed the report, but a review of the fax log showed no such transmission. The Department did not receive notification until the following morning, when the administrator sent the required form after confirming the initial report had not been received.
Misappropriation of Resident Property by Staff
Penalty
Summary
A certified nurse assistant (CNA) solicited and received a debit card and PIN from a resident who had diagnoses including polyneuropathy, intervertebral disc degeneration, arthritis, depressive disorder, chronic pain syndrome, and adult failure to thrive. The resident, who had no memory impairment, gave her card to the CNA after the CNA expressed financial hardship and requested a loan, with the understanding that the money would be repaid. After the transaction, the CNA did not return or communicate with the resident, prompting the resident to report the incident to facility staff. The resident expressed feeling taken advantage of and described emotional distress as a result of the incident. Facility policy, as outlined in the employee handbook and ethical house rules, strictly prohibits staff from accepting gifts, loans, or financial dealings of any kind with residents, including the removal of residents' personal belongings from the facility. Interviews with staff and the administrator confirmed that employees are not allowed to accept cash, bank cards, or any items of value from residents. The CNA involved admitted to taking the card and withdrawing money, which was in direct violation of facility policy and procedures.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to two residents, resulting in a deficiency in beneficiary notification. Resident #244, who had a medical history of paraplegia, was admitted on June 27, 2024, and discharged home on August 19, 2024. The resident received Medicare Part A skilled services from July 11, 2024, to August 18, 2024. Despite the planned discharge and the end of Medicare coverage, the facility did not provide the required NOMNC to the resident. Similarly, Resident #245, with a medical history of rheumatoid arthritis, was admitted on September 20, 2024, and discharged on October 25, 2024. This resident also received Medicare Part A services from the admission date until October 24, 2024, but was not issued a NOMNC prior to discharge. Interviews with facility staff revealed a lack of clarity and accountability regarding the issuance of NOMNCs. The Biller and Business Office Manager were unable to explain why the notices were not provided. The Social Services Supervisor, responsible for issuing beneficiary notices, acknowledged that NOMNCs should be given two to three days before the last covered day of therapy services. The Director of Nursing and the Administrator also confirmed the expectation that NOMNCs be issued 48 hours prior to discharge, yet neither could account for the oversight. This deficiency highlights a breakdown in communication and procedure adherence within the facility's administrative processes.
Failure to Obtain Physician's Order for Respiratory Device
Penalty
Summary
The facility failed to obtain a physician's order for the use of a respiratory device, specifically an Acapella device, for a resident. The resident, who had a medical history of acute pulmonary edema and pulmonary hypertension, was observed using the device independently without a physician's order. The facility's policy required a physician's order for the use of such devices, and the device should be administered by a licensed nurse or respiratory therapist. Despite the resident's care plan indicating potential respiratory issues, the necessary order for the Acapella device was not obtained until after the surveyor's observation. Interviews with facility staff, including a Licensed Vocational Nurse and a Respiratory Therapist, revealed a lack of awareness and oversight regarding the resident's use of the device. The Respiratory Therapist acknowledged that the device was mentioned in a prior assessment but failed to secure a physician's order. The Director of Nursing and the Administrator confirmed that the facility's protocol required a physician's order for medical devices and that staff should have informed the nurse upon discovering the device at the resident's bedside. The deficiency was identified when the surveyor noted the device and prompted the facility to obtain the necessary physician's order.
Failure to Follow Mechanical Lift Policy Results in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent a fall for a resident, identified as Resident 1, who required the use of a mechanical lift for transfers. The facility's policy mandated that at least two staff members assist with mechanical lift transfers to ensure safety. However, on the day of the incident, only one staff member, Unlicensed Staff A, assisted Resident 1 during a transfer from a wheelchair to a bed, which was against the facility's policy. Additionally, Unlicensed Staff A had not completed the required competency test for using the mechanical lift prior to the incident. This lack of training and failure to adhere to the facility's policy resulted in Resident 1 sustaining a fall, leading to a left femoral fracture. The resident, who had intact cognition and required maximal assistance for personal care, was later diagnosed with a left partial hip replacement following the injury. Interviews with various staff members, including the Director of Nursing, Licensed Staff, and other Unlicensed Staff, confirmed that the standard practice was to have two staff members present during mechanical lift transfers to prevent falls and accidents. The Assistant Director of Nursing acknowledged that the policy was not followed during the incident, which contributed to the resident's fall and subsequent injury.
Inadequate Supervision and Delayed Response Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure that Resident 1 was free from accidents due to delayed response to call lights. Resident 1, who required moderate assistance for transfers due to unsteadiness and mobility issues, fell twice while attempting to go to the toilet without staff assistance. The call light was not answered promptly, leading Resident 1 to wait over twenty minutes before attempting to transfer independently, resulting in a fall and a fractured right arm. Resident 2 was not adequately supervised while smoking, leading to cigarette burns on his right thigh and scrotum. Despite having a care plan that allowed unsupervised smoking, Resident 2's pants caught fire, and he sustained burns. The facility's smoking policy required supervision for residents with restricted smoking privileges, but Resident 2 was observed smoking without supervision or a smoking apron, contrary to the policy. Interviews with staff revealed inconsistencies in the implementation of the facility's policies regarding call light response and smoking supervision. Staff acknowledged the risks associated with delayed call light responses and unsupervised smoking, yet these policies were not consistently followed, contributing to the incidents involving Resident 1 and Resident 2.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide timely pain management for a resident who had undergone a left hip arthroplasty and suffered from chronic pain due to multiple surgeries. The resident reported experiencing excruciating pain because the nursing staff did not administer her pain medication according to the scheduled times. Specifically, the resident stated that it often took more than two hours to receive her pain medication after requesting it, leading to significant discomfort. A review of the resident's medical records revealed discrepancies in the administration of her prescribed medications. The Medication Administration Record (MAR) indicated that the resident was supposed to receive Oxycodone Hydrochloride ER 30 mg every twelve hours and Norco 10-325 mg every four hours. However, the Medication Administration Audit Report showed that these medications were frequently administered late, sometimes by several hours, which was contrary to the facility's policy of administering medications within one hour of the prescribed time. Interviews with the Director of Nursing (DON) and Licensed Staff D confirmed that the facility's policy allowed for medication administration within one hour of the scheduled time. However, the records indicated that this policy was not consistently followed, resulting in ineffective pain management for the resident. The DON acknowledged that there was a delay in the electronic medication administration record system but stated that it should not take an hour or more to save the nurse's signature. The failure to adhere to the medication schedule led to the resident experiencing unmanaged pain.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that three residents received showers on their scheduled days, which compromised their personal grooming and hygiene needs. Resident 5, who was admitted for physical therapy after a hip replacement, reported not receiving showers for several weeks. The Minimum Data Set (MDS) indicated that Resident 5 required partial assistance with showers, but the facility lacked electronic records to confirm whether showers were provided. The only documentation available showed a refusal on one occasion, with no further records for the month. Resident 7, diagnosed with Alzheimer's and Parkinson's diseases, was dependent on staff for showers. The facility did not provide any shower logs for Resident 7 for January and February 2024, indicating a lack of documentation and potential neglect in meeting the resident's hygiene needs. Similarly, Resident 6, who required setup or clean-up assistance, reported not receiving a shower for two weeks, leading to perineal itching. Despite being scheduled for showers twice a week, there was no documentation to confirm that these were provided, and the resident expressed dissatisfaction with the timing of the showers offered. Interviews with unlicensed staff revealed that showers were scheduled twice a week and as requested, but there was inconsistency in providing showers outside of scheduled days. The facility's policy stated that residents unable to perform activities of daily living independently should receive necessary services to maintain hygiene, yet the lack of documentation and resident reports indicate a failure to adhere to this policy. The absence of electronic records and incomplete shower logs further highlight the facility's deficiency in maintaining adequate hygiene care for its residents.
Delayed Call Light Response Leads to Resident Injuries
Penalty
Summary
The facility failed to adhere to its policy of responding to call lights within five minutes, as evidenced by the experiences of two residents. Resident 1, who required moderate assistance for transfers due to unsteadiness and mobility issues, fell twice while attempting to use the toilet without staff assistance. Despite activating the call light, Resident 1 waited over twenty minutes for assistance, leading to a fall that resulted in a fractured right arm. Observations confirmed that call lights were not answered promptly, with one instance taking eight minutes to respond. Resident 3, who was incontinent and required substantial assistance for transfers and hygiene, also experienced delays in call light response. This resident reported waiting over twenty minutes for assistance, resulting in prolonged exposure to moisture and the development of moisture-associated skin damage in the perirectal area. Interviews with staff confirmed that the facility's policy required call lights to be answered within three to five minutes, yet this standard was not consistently met. Interviews with facility staff, including unlicensed personnel and the Director of Staff Development, highlighted the expectation for call lights to be answered promptly to prevent safety issues. The facility's policy, dated September 2022, mandated that calls for assistance be answered within five minutes, with urgent requests addressed immediately. However, the failure to meet these standards led to significant negative outcomes for the residents involved.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of pain medications Oxycodone and Oxycontin. The resident, who had undergone a left hip arthroplasty and had a history of chronic pain due to multiple surgeries, was prescribed Oxycodone Hydrochloride ER 30 mg to be taken every twelve hours. However, records indicated that the medication was administered more frequently than prescribed, with doses given at 6:00 a.m., 8:00 a.m., and 9:00 p.m. on one occasion. Additionally, a subsequent order for Oxycontin 20 mg to be taken every twelve hours was also not followed correctly, with doses administered at 4:00 a.m., 8:30 a.m., and 9:00 p.m. Interviews with the Director of Nursing and Licensed Staff D revealed that the facility's policy required nurses to verify the right medication and dosage before administration, allowing a one-hour window before or after the scheduled time. Despite this policy, the medication was not administered as prescribed, leading to potential risks for the resident. The facility's policy on administering medications, revised in April 2019, emphasized the importance of checking the medication label three times to ensure the correct resident, medication, dosage, time, and method of administration.
Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that the call light system was in good working condition for one of the residents, identified as Resident 8. This deficiency was observed during a review of the resident's records, interviews, and direct observations. Resident 8, who was admitted with diagnoses including age-related cognitive decline, COPD, and muscle weakness, had a BIMS score indicating cognitive intactness and required assistance with transfers. On a specific date, Resident 8 was found lying on the floor next to her bed, and during subsequent interviews, it was revealed that her call light had not been functioning for a long time. Another resident, Resident 6, confirmed that she would activate her own call light to assist Resident 8 when needed. During an observation, it was confirmed that Resident 8's call light did not activate, while Resident 6's call light was functional. Unlicensed Staff B verified that the call light connector in Resident 8's room was obstructed by dirt or grease, preventing a proper connection. After cleaning the connector, the call light was restored to working order. The Maintenance Director stated that daily room rounds were conducted to test call lights, but he had not received any reports about Resident 8's call light malfunctioning. The facility's policy requires that the resident call system remains functional at all times, which was not adhered to in this case.
Inaccurate MDS Completion for a Resident
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for one of the sampled residents, leading to incomplete information necessary for developing a resident-centered care plan. The resident in question was admitted with diagnoses including unsteadiness on feet and other abnormalities of gait and mobility. The MDS dated for the resident indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, suggesting cognitive intactness. However, during an interview and concurrent record review, it was revealed that the MDS assessment for the resident was inaccurately completed, with several areas such as eating, maintaining oral and personal hygiene, showering/bathing, dressing, and footwear not assessed or lacking information. The MDS Coordinator acknowledged the inaccuracies in the MDS assessment and confirmed her responsibility for ensuring its accuracy. The facility's policy on comprehensive assessments and care delivery, revised in December 2016, outlines the process of collecting and analyzing information, choosing and initiating interventions, and monitoring results. It also specifies that the MDS should be completed within 14 days after admission. The failure to accurately complete the MDS assessment resulted in a lack of complete information necessary to meet the resident's healthcare needs.
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 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Clearlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Point Care Center | 16.9 mi | ★★★★★ | 13 | 0 |
| Lakeport Post Acute | 17 mi | ★★★★★ | 1 | 0 |
| Cloverdale Healthcare Center | 23.8 mi | ★★★★★ | 5 | 0 |
| Healdsburg Hospital D/p Snf | 26 mi | ★★★★★ | 0 | 0 |
| Almond View Care Center | 28.6 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Meadowood Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.