Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mid-wilshire Health Care Cntr during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and overactive bladder had severe cognitive impairment and needed help with bathing and toileting. After loose stools were documented and the stool sample was positive for C. diff, the chart did not contain a separate C. diff care plan; instead, it was incorporated into a constipation and SBO care plan. The RNS and DON stated that C. diff required a specific care plan with unique goals and interventions, and the facility’s policy required a comprehensive plan of care that addressed the resident’s individual needs.
Medication Given Despite Hold Order for Loose Stool: A resident with dementia, dysphagia, and severe cognitive impairment had multiple episodes of watery loose stool, and the physician ordered lactulose and senna to be held if diarrhea continued. Despite this, the MAR showed lactulose was still administered after the loose stools began. The RNS and DON stated laxatives should be held during diarrhea and that giving lactulose when ordered to be held means the physician order was not followed.
Failure to Follow Up on Advance Directive Requests: Three residents had AD acknowledgement forms showing a desire to execute an AD, but the record did not show follow-up assistance. One resident had atherosclerotic heart disease, hemiplegia, and HTN and stated he wanted an AD but had not completed one; another had ESRD, DM2, and bladder dysfunction; and a third had DM, vascular dementia, and CKD, with the representative requesting an AD. The MDSs showed no executed ADs, and the SSD stated the facility completes AD forms on admission and described a lengthy process if a resident later wants to execute one.
A resident with multiple fractures, hyperlipidemia, and OA had skin tears on the back of the knee and ankle treated with triple antibiotic ointment and dry dressings. The TXN said the ointment was being used without a physician order because it was supplied by the DSD, and the initial skin assessment had not yet been documented. The DON stated the ointment is an antibiotic that requires a provider order, and that treatment nurses should assess, measure, document, and monitor wounds and notify the physician of new or worsening skin issues.
Nursing staffing information was not posted or updated daily at two nurse's stations. During observation, the required staffing details were missing from the bulletin boards, and the DSD stated the census and DHPPD form was kept in a binder at the nurse's station while a blank form was posted directing people to the binder.
Unsafe Food Storage Practices: The facility failed to maintain safe food storage when bananas were observed next to an open sanitizer disinfectant container under the sink, a container of barley in dry storage had no date label, and a bag of chopped cabbage mixed with red pepper flakes in the walk-in refrigerator had no label or date. The DS stated that improperly labeled food or food stored near sanitation chemicals can put residents at risk of getting sick, and the facility P&P required food labels with date information and cleaning supplies stored away from food.
Hand hygiene and PPE were not consistently used during resident care and med passes, including in rooms on EBP for residents with MDRO history. An RN also carried an uncleaned basket with supplies between multiple rooms, creating cross-contamination during medication administration. The facility’s IPCP was not effectively implemented because staff did not attend annual IPC training and the IPN did not know how to report communicable diseases, and the water management plan was not followed or accurately maintained.
The facility failed to monitor antibiotic use for a resident with a hx of UTI, ESBL, DM2, and CKD. The resident had orders for Macrobid for UTI treatment and then Macrodantin for UTI prophylaxis, while the care plan still reflected a long-term ESBL/UTI history with no updated interventions. The Pharmacy Consultant stated the 30-day Macrodantin order was unclear and would normally be questioned.
Failure to maintain Flu and PNA vaccine policies and procedures and current consent forms for multiple residents. One resident had documented refusals for both vaccines, while four other residents had no current Flu and PNA consent forms found during review. The DSD and IPN stated the forms are needed so staff and residents are on the same page, and noted the importance of having P&P aligned with national standards of practice.
Failure to Provide COVID-19 Vaccine Education and Staff Declination Forms: The facility did not provide education on COVID-19 vaccine risks and potential side effects for five sampled residents, including residents with diagnoses such as heart disease, dementia, CKD, DM2, dysphagia, and hemiplegia. The DSD stated the facility used a COVID-19 info sheet that did not list side effects and only provided printed education in English. Staff vaccination records also did not include declination forms for employees who declined COVID-19 booster vaccines.
Failure to maintain resident dignity occurred when staff did not follow a Foley catheter dignity care plan for one resident and a CNA fed another resident while standing rather than seated at eye level. The resident being fed had severe cognitive impairment, dysphagia, and required extensive ADL assistance; during the meal, the CNA pushed pureed food into the resident’s mouth as the resident kept the lips tightly closed and food dripped onto a paper towel on the chest. The DSD stated the CNA missed the feeding in-service and no additional feeding assistance training had been provided.
Failure to Protect Resident from Resident-on-Resident Physical Abuse: A resident with dementia and other diagnoses was hit on the face by another resident who also had dementia, fluctuating decision-making capacity, and a history of aggressive behaviors including trying to hit others. The injured resident was lying in bed when the other resident stood up, lost balance, and struck the resident’s face; staff later reported the event, and the DON stated the residents should have been separated immediately.
Failure to implement the abuse prevention policy occurred after two roommates had a physical altercation. One resident with epilepsy, dementia, and depression was struck in the face by another resident with dementia, DM, and a history of falling while the first resident was lying in bed. HK 1 reported the residents were not separated immediately, and the DON stated there was no documentation of a room change and only one nursing note about the incident.
Failure to Timely Report Alleged Resident-to-Resident Physical Abuse: The facility did not timely report an allegation of physical abuse between two roommates to CDPH. One resident reported that the other resident struck the right side of the face while the resident was lying in bed. The injured resident had epilepsy, dementia, and depression with moderately impaired cognition, and the other resident had DM, dementia, and fluctuating capacity. The DON stated the incident was not reported for an unknown reason, while the DSD and Admin acknowledged that resident-to-resident hitting is abuse and must be reported to the appropriate agencies.
Failure to initiate a baseline care plan for a resident with pelvic fractures. A resident admitted with multiple fractures, hyperlipidemia, and osteoarthritis reported ongoing pain in the L leg and heel and requested PT to help strengthen her legs. The OSR included PRN hydrocodone-acetaminophen orders for moderate and severe pain related to the pelvic fracture, but the DOR and DON confirmed that the baseline care plan had not been started to include pain management and therapy services, despite the facility policy requiring baseline care plans within 48 hours of admission.
Care plans were not revised for two residents when medication orders changed. One resident with dementia and major depressive disorder still had Remeron listed as an active care plan item even though it was no longer active on the MAR. Another resident with HF, CKD, and AFib had a care plan that listed Eliquis 2.5 mg BID, while the physician order reflected 2.5 mg once daily in the afternoon; an RN confirmed the order discrepancy and noted the MD had reduced the dose.
Failure to follow pain med orders and reassess pain: A resident with pelvic fractures, OA, and other diagnoses received Hydrocodone-Acetaminophen 10-325 mg when pain was rated 5/10, even though the order called for the 5-325 mg dose for moderate pain. An LPN also administered the higher dose for 7/10 pain and did not reassess the resident within the required timeframe after giving the medication.
A resident with ESRD, DM2, and dialysis dependence had an AV fistula in the left arm, with orders to monitor the fistula every shift. Despite this, staff documented BP readings on the left arm on multiple occasions, and no sign was posted in the room to indicate that BP or blood draws were not to be taken on that arm. RN stated BP should be taken on the opposite arm because cuff pressure can damage the fistula, and the facility policy said not to take BP on the arm with the dialysis shunt.
Bed rail dimensions were not inspected for appropriate size and weight for a resident with epilepsy, dementia, and depression who had moderately impaired cognition and needed assistance with ADLs. The resident was observed in bed with two side rails up, while RN and maintenance staff stated the rails were not measured or inspected and the DON confirmed the facility did not measure them to ensure the bed dimensions were appropriate for the resident’s size and weight.
A resident with multiple chronic conditions and intact cognition had home medications brought into the facility, but staff could not identify or account for the medications in the bag, and the belongings record did not document them. In addition, the pharmaceutical waste container was observed full with visible tablets and capsules not covered by liquid, and the lid was not secured as required; the medication disposition log also lacked resident names for disposed medications.
Failure to act on a PharmC-identified Eliquis dosing irregularity for a resident with HF, CKD, and AFib. The resident’s chart showed Eliquis 2.5 mg PO daily in the afternoon, while the PharmC noted the recommended dose was 2.5 mg PO BID and asked for review to make the medication therapeutic. RN stated the MD knew of the recommendation but disagreed, and the resident’s cardiologist had prescribed Eliquis 2.5 mg BID.
A resident with major depressive disorder, Alzheimer's disease, and diabetes mellitus was receiving Remeron, but the facility did not document monitoring for signs and symptoms of depression. Although the care plan directed staff to observe for depression and the resident's MDS showed an active depression diagnosis, the physician's orders and MAR did not include monitoring, and the DSD stated there was no behavioral monitoring documentation. The facility policy required psychotropic medication monitoring every shift with nurse documentation of behaviors and observations.
Improperly Covered Garbage Dumpster: A garbage dumpster in the parking garage was observed filled with trash bags to the point that the lid could not fully close. The DS stated that insects or animals could enter if the lid remained open, and facility policy required waste containers to be closable.
Call Light Not Within Reach: A resident with severe cognitive impairment and extensive ADL dependence was observed with the call light cable and button on the floor under the nightstand and not within reach. The resident's care plan directed staff to place the call light within reach, and facility policy required the call light to be within reach at all times, including when the resident was in the room or on the toilet.
Failure to Provide Required Abuse and Neglect Training: The facility failed to ensure an LVN and a housekeeper received ongoing abuse, neglect, and exploitation training. The DSD stated the facility had not provided this training, the LVN said no abuse or neglect training was given, and the housekeeper said abuse training was only provided at hire and they did not know how to report suspected abuse. The facility policy required orientation and annual training for all employees.
A resident who was cognitively intact and required assistance with daily activities was not provided the opportunity for their next of kin to participate in a care plan conference, despite facility policy and the resident's care plan indicating a preference for family involvement. Documentation did not show that the next of kin was invited or notified, resulting in the resident and their next of kin not being given their right to participate in care planning.
A resident with dementia and anxiety disorder was moved to different rooms multiple times without advance written notice or proper documentation, and the responsible party was not notified as required. Staff interviews revealed that notifications were made informally and not documented in the medical record, contrary to facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Two residents were involved in an incident where an allegation of employee-to-resident abuse was not reported to authorities or investigated in a timely manner, despite facility policy requiring immediate action. One resident, with intact cognition, filed a grievance on behalf of another with severe cognitive impairment, describing forceful care by a CNA that led to distress. The DON and Administrator did not report the incident as required, citing lack of physical harm and incomplete communication of the incident details.
The facility did not complete annual performance evaluations for two LVNs and three CNAs, including a Restorative Nursing Assistant, as required by policy. The DSD was unaware of the requirement and had not reviewed the policy, and the DON confirmed that evaluations were not performed or documented in the employee files.
The facility did not follow standardized recipes or portion sizes for pureed diets, resulting in multiple residents receiving alternative foods of incorrect texture and consistency instead of the planned menu items. The menu lacked inclusion of therapeutic and texture-modified diets, and staff did not have guidance on appropriate portions or recipes, as confirmed by dietary staff and the registered dietitian.
Surveyors found that kitchen staff failed to follow safe food storage and preparation practices, including thawing meat on the counter, not maintaining the ice machine in a sanitary condition, and storing multiple food items without proper labeling or dating. These actions were contrary to facility policy and staff knowledge, and were confirmed by interviews and record reviews.
A resident with severe cognitive impairment and multiple chronic conditions was found in bed with the call light out of reach, despite care plan and facility policy requiring it to be accessible. Staff confirmed the call light was not within reach and acknowledged the importance of proper placement for timely assistance.
A resident with a history of DKA and uncontrolled diabetes experienced repeated episodes of extremely high blood glucose, with readings exceeding the glucometer's measurable range. Nursing staff did not notify the physician or document these events as required by facility policy and professional standards, and inaccurately recorded 'HI' readings. The lack of communication and documentation resulted in a failure to provide care according to orders and standards of practice.
A resident with severe cognitive impairment and a g-tube for nutrition did not have their enteral feeding bag changed every 24 hours as required by facility policy. Staff confirmed the bag had been in use for two days, acknowledging the risk of infection and GI complications due to this lapse.
A resident with dementia and a high risk for falls was admitted without a comprehensive fall prevention care plan, contrary to facility policy. Despite a high Morse Fall Score, the resident was not adequately monitored, leading to a fall and a left femur fracture. Facility staff acknowledged the absence of a necessary care plan, which contributed to the incident.
A facility failed to prevent falls for a high-risk resident with dementia and a history of falls. Despite having a care plan, the resident experienced multiple falls due to ineffective interventions and lack of proper monitoring. The facility did not revise the care plan after each fall, leading to repeated incidents and injuries.
A resident reported that a CNA touched her private parts and forced her to touch his private area, causing significant psychological distress. The incident was confirmed by surveillance video, and the CNA was asked to leave the facility. The resident's account remained consistent when reported to staff and police.
The facility failed to ensure that a CNA had the appropriate abuse training, leading to an alleged sexual abuse incident involving a resident. The CNA did not attend any abuse training sessions, and there was no employee file to verify competencies. The resident reported inappropriate touching by the CNA, and surveillance footage corroborated the timeline. Facility staff confirmed that registry staff were not provided with formal abuse training, violating the facility's policy.
Failure to Develop a Specific Care Plan for C. diff
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident 1, who was readmitted with diagnoses including dementia, dysphagia, and overactive bladder. The resident’s MDS dated 4/23/2026 showed a BIMS score of 2, indicating severe problems with thinking and memory, and the resident required nursing assistance with bathing and toileting. The H&P dated 5/4/2026 stated the resident did not have the capacity to understand and make decisions and had a surrogate decision maker. Nursing progress notes dated 1/1/2026 documented three episodes of watery, yellowish, loose stool, and the physician was notified that day. The care plan dated 4/3/2026 identified a long-term problem of risk for constipation with a goal that the resident would pass a soft formed stool, and it included revisions related to loose bowel movements and lactulose being held for loose stool. The resident’s stool sample was positive for C. diff on 4/4/2026, but the DON stated there was no separate care plan for C. diff in the resident’s chart and that it had been incorporated into the constipation and small bowel obstruction care plan. The RNS stated that a new diagnosis such as C. diff required a specific care plan with goals and interventions unique to that diagnosis, and the facility’s policy stated the comprehensive plan of care should address the resident’s individual needs.
Medication Given Despite Hold Order for Loose Stool
Penalty
Summary
The facility failed to administer and hold medications according to physician orders for one resident. The resident had diagnoses including dementia, dysphagia, and overactive bladder, and the MDS showed a BIMS score of 2 with the resident requiring assistance from nursing staff with bathing and toileting. The H&P stated the resident did not have the capacity to understand and make decisions and had an assigned surrogate decision maker. Nursing progress notes documented that the resident had three episodes of watery, yellowish, loose stool, and the physician was notified with an order to hold lactulose and senna if diarrhea continued and to monitor closely. However, the MAR showed lactulose was administered after the loose stools began, including on 1/1/2026 and 1/2/2026, and the RNS stated that if a resident is having diarrhea, laxatives or stool softeners cannot be given and all laxatives must be held until the loose stool stops. The DON stated that lactulose should not be given when a resident has loose stool because it will make the stool worse, and that giving medications when the physician ordered them to be held means the physician orders are not being followed. The facility policy stated medications shall be administered per physician orders and concerns about administration due to a resident's condition should be clarified with pharmacy.
Failure to Follow Up on Advance Directive Requests
Penalty
Summary
The facility failed to follow up on assisting three residents with executing advance directives after each resident or representative indicated a desire to do so. Resident 2 was admitted with diagnoses including atherosclerotic heart disease, hemiplegia, and high blood pressure; the H&P dated 12/4/2025 stated the resident had the mental capacity to make their own decisions, while the MDS indicated moderately impaired mental status and no executed AD. The AD acknowledgement form dated 12/2/2025 indicated Resident 2 wanted to execute an AD, but the medical record did not show any follow-up assistance. During interview, Resident 2 stated he wanted to execute an advance directive but had not done so. Resident 5 was readmitted with diagnoses including end stage renal disease, type 2 DM, and neuromuscular dysfunction of the bladder; the H&P dated 6/28/2025 stated the resident had the mental capacity to understand and make decisions, while the MDS indicated moderately impaired mental status and no executed AD. The AD acknowledgement form dated 11/7/2025 indicated Resident 5 wanted to execute an AD, but the record did not show follow-up assistance. Resident 19 was readmitted with diagnoses including DM, vascular dementia, and chronic kidney disease; the H&P dated 9/2/2025 stated the resident did not have the mental capacity to understand and make decisions, the MDS indicated no executed AD, and the AD acknowledgement form dated 8/31/2024 indicated the resident's representative wanted to execute an AD. The medical record did not indicate any follow-up regarding assisting Resident 19 with an AD. The Social Services Director stated AD acknowledgement forms are completed on admission and that if a resident has not executed an AD and wishes to do so, there is a lengthy process involving the resident's family, a notary, and the Ombudsman.
Unordered topical antibiotic used for skin tears without required monitoring
Penalty
Summary
The facility failed to provide treatment in accordance with professional standards of practice and established facility protocol for Resident 77, who was admitted with diagnoses of multiple pelvic fractures, hyperlipidemia, and osteoarthritis and was documented in the H&P as having the capacity to understand and make decisions. During observation, Resident 77 was seen walking with a walker from the bed to the door with a clean and dry dressing on the back of the left knee and stated that she had a few skin tears being treated at the facility. The resident’s OSR listed orders for skin tears on the back of the left knee and right ankle to be cleansed with normal saline, patted dry, treated with triple antibiotic ointment, and covered with dry dressing. During interview and record review, the TXN stated Resident 77 had been receiving triple antibiotic ointment for the skin tears, but no physician order had been placed for the ointment and the order was not required because the DSD supplied it. The TXN also stated an initial assessment had been performed but not yet documented, and that treatment staff focused on wound care only and were not responsible for documenting wound progress. The DON stated treatment nurses should assess skin on admission, weekly, and with significant changes, measure and document wounds, follow physician-ordered treatments, and inform physicians of new or worsening wounds. The DON further stated triple antibiotic ointment is an antibiotic and requires a physician’s order and ongoing monitoring, but Resident 77 did not have an order for it.
Nursing Staffing Information Not Posted Daily
Penalty
Summary
The facility failed to ensure that nursing staffing information was posted and updated daily. During observations on 3/10/2026 at 9:30 a.m. at nurse's station one and at 9:31 a.m. at nurse's station two, the nursing staffing information was not posted on the bulletin board. During an interview on 3/11/2026 at 10:00 a.m., the DSD stated the required staffing information was not posted on a bulletin board for residents, staff, and visitors to view. The DSD stated the census and direct care service hours per patient day (DHPPD) form was kept in a binder at the nurse's station, and a blank form was posted directing individuals to the binder.
Unsafe Food Storage Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen. During an observation on 3/9/2026 at 7:30 a.m. under the kitchen sink, a box of bananas was sitting next to a small, open red container labeled sanitizer disinfectant that was halfway filled with clear liquid. During another observation on 3/9/2026 at 7:35 a.m. in the dry food storage area, a container of barley had no date label. During an observation on 3/9/2026 at 7:40 a.m. in the walk-in refrigerator, a large clear plastic bag filled with chopped cabbage mixed with red pepper flakes had no label or date. During an interview on 3/10/2026 at 12:45 p.m., the Dietary Supervisor stated that if food stored in the kitchen is not labeled properly or is placed near sanitation chemicals, residents are at risk of getting sick. The facility policy titled Food Storage Principles, dated April 2020, stated that food must have a label with the expiration date, date of receipt, or when the item was stored after preparation, and that cleaning supplies should be stored away from food storage.
Infection Control Failures in Hand Hygiene, PPE Use, Cross-Contamination, IPCP, and Water Management
Penalty
Summary
The facility failed to perform hand hygiene and use PPE during resident care and medication administration for multiple sampled residents. Resident 70 was on enhanced barrier precautions for a history of MDRO, yet a CNA entered and exited the room without performing hand hygiene or putting on PPE. During other observations, an RN went in and out of rooms for Residents 8, 22, and 19 to administer medications without performing hand hygiene. A CNA exited the enhanced barrier precaution rooms for Residents 5, 9, and 59 without hand hygiene and then entered other residents’ rooms without hand hygiene. An LVN administered medications in the enhanced barrier precaution room for Residents 5, 9, and 59 without wearing a gown and without performing hand hygiene before putting on gloves, and later a CNA and RNA provided care in that same room without gowns. The facility also failed to prevent cross-contamination during medication administration when an RN carried a plastic basket containing tissues, medicine cups, and cups with tea from the medication cart to multiple residents’ rooms, placed it on several bedside tables including enhanced barrier precaution rooms, and returned it to the cart without disinfecting it between uses. In addition, the facility’s infection prevention and control program was not effectively implemented: staff did not attend the annual IPC training, the infection preventionist stated she did not know how to report infectious diseases to local or state public health authorities, and the antibiotic stewardship surveillance record showed five of ten resident infections were urinary tract infections. The facility also failed to implement its water management plan, as the administrator stated the water plan map was not accurate and the facility did not know where water entered the building, and the maintenance supervisor stated the facility did not follow the water management plan for chlorine water testing.
Failure to Monitor Antibiotic Use for a Resident with UTI History
Penalty
Summary
The facility failed to ensure that one of four sampled residents, Resident 31, was monitored for antibiotic use. Resident 31 was readmitted with diagnoses including type 2 diabetes mellitus and chronic kidney disease. The resident’s H&P documented a history of UTIs and a hospitalization for a UTI in February 2025. The care plan dated 12/7/2025 identified a long-term care plan for history of ESBL/UTI but had no updated interventions. Physician orders dated 2/6/2026 included Macrobid 100 mg by mouth twice daily for UTI for seven days, and an order dated 2/9/2026 included Macrodantin 100 mg by mouth each morning for UTI prophylaxis for 30 continuous days. During interview, the Pharmacy Consultant stated he was unsure why Resident 31 was ordered Macrodantin for 30 days and that this type of order would normally be questioned.
Failure to Maintain Flu and PNA Vaccine Policies and Consent Forms
Penalty
Summary
The facility failed to develop and implement policies and procedures for influenza and pneumococcal vaccinations for five sampled residents. During record review, Resident 2’s admission record showed diagnoses including atherosclerotic heart disease, hemiplegia, and hypertension, and the resident’s vaccine consent form dated 12/3/2025 indicated that both Flu and PNA vaccines were declined. During interview, the DSD and Infection Preventionist Nurse stated Resident 2 had declined all vaccines and was not interested in receiving any vaccinations. For Residents 14, 31, 36, and 58, the admission records showed diagnoses including encephalopathy, pneumonitis, dysphagia, type 2 DM, CKD, dementia, hyponatremia, anemia, UTI, and hemiplegia. During interview, the DSD and Infection Preventionist Nurse did not find current Flu and PNA vaccine consent forms for these residents. The DSD stated that consent forms are important so staff and residents are on the same page with resident care, and later stated the importance of maintaining Flu and PNA policies and procedures in accordance with national standards of practice so staff know what to do and how to handle situations according to standards of practice.
Failure to Provide COVID-19 Vaccine Education and Staff Declination Forms
Penalty
Summary
The facility failed to provide education regarding the risk and potential side effects of the COVID-19 vaccine for five sampled residents: Resident 2, Resident 14, Resident 31, Resident 36, and Resident 58. Resident 2 was admitted with diagnoses including atherosclerotic heart disease, hemiplegia, and high blood pressure, and his COVID-19 booster consent form indicated he did not consent to receive the booster. Resident 14 was admitted with diagnoses including encephalopathy, pneumonitis, and dysphagia, and his COVID-19 consent form indicated he consented to receive the booster. Resident 31 was readmitted with diagnoses including type 2 diabetes mellitus and chronic kidney disease, and her COVID-19 consent form indicated she consented to receive the booster. Resident 36 was admitted with diagnoses including dementia, hyponatremia, and anemia, and her COVID-19 consent form indicated she consented to receive the booster. Resident 58 was admitted with diagnoses including UTI, dysphagia, and hemiplegia, and his COVID-19 consent form indicated he consented to receive the booster. During interview, the DSD stated vaccine consent forms are completed at admission by Social Services, nursing staff follow up if residents have questions, and the facility provides a COVID-19 information sheet that does not specify side effects; the DSD also stated the facility only provides printed vaccination education in English. In addition, review of staff vaccination records showed the facility did not maintain declination forms for employees who declined COVID-19 vaccine boosters, and the DSD stated the facility does not collect those forms.
Failure to Maintain Resident Dignity During Catheter Care and Feeding
Penalty
Summary
The facility failed to implement a Foley catheter dignity care plan for Resident 5 and failed to ensure CNA 2 was seated at eye level while feeding Resident 16. Resident 16’s admission record showed diagnoses including Alzheimer’s disease, depression, glaucoma, hearing loss, right shoulder osteoarthritis, lack of coordination, and dysphagia. The MDS dated 01/06/2026 indicated a BIMS score of 1, reflecting severe cognitive impairment, and showed the resident required partial to substantial assistance with multiple ADLs and maximum assistance or dependence for transfers, toileting, and showering. During a dining observation, CNA 2 was feeding Resident 16 while standing in front and toward the resident’s right side rather than seated at eye level. CNA 2 was pushing spoonfuls of liquidized pureed food into the resident’s mouth as the resident kept the jaw clenched and lips tightly closed, opening only slightly for the spoon tip. Food dripped onto a paper towel placed on the resident’s chest while CNA 2 alternated between soup and vanilla pudding. The tray ticket showed a pureed, fortified lunch diet. The DSD stated CNA 2 missed the feeding in-service and that no additional feeding assistance training had been provided to nursing staff. The facility policy on Resident Dignity and Personal Privacy stated that dignity means staff carry out activities that assist residents in maintaining and enhancing self-esteem and self-worth.
Failure to Protect Resident from Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect Resident 47 from physical abuse when Resident 78 hit Resident 47 on the right side of the face. Resident 47 was admitted and later readmitted with diagnoses including epilepsy, dementia, and depression, and the MDS indicated moderately impaired cognition and need for assistance with eating, toileting, bathing, dressing, and footwear. Resident 78 had diagnoses including DM, dementia, and a history of falling, and the H&P noted fluctuating capacity to understand and make decisions. Resident 78’s care plan also identified behaviors of screaming, cursing, throwing things, and trying to hit others. According to Resident 47’s interview and SBAR/progress note, Resident 47 was lying in bed when Resident 78’s hand suddenly hit the right side of the face. The DON stated the incident was reported by HK 1 to LVN 4, and that LVN 4 interviewed both residents. HK 1 reported that Resident 78 stood up from the bed, lost balance, and hit Resident 47’s face with his hand, then remained next to Resident 47 until a nurse entered the room. The DON stated staff should have immediately separated the residents and that the incident could have been prevented if HK 1 had called for assistance when Resident 78 attempted to get up. The DSD stated resident-on-resident hitting is considered abuse and should be reported to law enforcement, the ombudsman, and CDPH.
Failure to Separate Roommates After Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to implement its written Abuse and Neglect Prohibition Policy after a physical altercation between two roommates. One resident with epilepsy, dementia, and depression was observed lying on the bed when the other resident, who had dementia, diabetes mellitus, and a history of falling, struck the right side of the resident’s face with a hand. The first resident later reported that the other resident hit the right side of the face while the resident was lying on the bed. The facility’s policy stated that if resident-to-resident abuse is suspected, the resident who threatened or attacked another must be removed from the setting or situation. During interview and record review, the DON stated there was no documentation of a room change and that nursing staff only documented the incident in nursing progress notes on the day it occurred. The DON also stated nursing staff on each shift should have monitored the resident for 72 hours after the incident. HK 1 reported that after the incident, the two residents were not separated immediately and remained in the room until a nurse entered. HK 1 further stated that when returning later, both residents were lying in bed and appeared calm.
Failure to Timely Report Alleged Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two roommates to the California Department of Public Health within the required time frame of two hours. The incident occurred when one resident struck the other resident on the right side of the face while the second resident was lying in bed. The injured resident had diagnoses of epilepsy, dementia, and depression, and the MDS dated 2/2/26 indicated moderately impaired cognition and the need for supervision with some ADLs. The resident involved in the alleged abuse had diagnoses of diabetes mellitus, dementia, and a history of falling, and a history and physical dated 11/14/2025 indicated fluctuating capacity to understand and make decisions. The incident report documented the injured resident’s statement that the other resident’s hand hit the right side of the face. During interviews, the DON stated the incident was not reported for an unknown reason, and the DSD and Administrator acknowledged that resident-to-resident hitting is considered abuse and must be reported to the appropriate agencies. The facility policy stated that suspected or alleged abuse must be reported immediately, and no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury.
Failure to Initiate Baseline Care Plan for Pain Management and Therapy
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for Resident 77 that addressed physician orders for pain management and physical therapy. Resident 77 was admitted with diagnoses of multiple pelvic fractures, hyperlipidemia, and osteoarthritis, and the history and physical dated 3/3/2026 indicated that the resident had the capacity to understand and make decisions. During an observation and interview on 3/9/3036, Resident 77 was sitting in bed brushing her teeth and stated that she had pain in her left leg and left heel. The resident said she had received pain medication early that morning, but the pain was not relieved, and she also stated that she wanted physical therapy to help her legs get stronger. A review of the order summary report showed physician orders entered on 3/4/2026 for Hydrocodone-Acetaminophen 5-325 mg every 4 hours as needed for moderate pain related to pelvic fracture and Hydrocodone-Acetaminophen 10-325 mg every 6 hours as needed for severe pain related to pelvic fracture. During interview and record review, the DOR stated that after PT/OT evaluation, goals and interventions should be documented in the care plan so staff remain informed and consistent, and also stated that staff had not initiated a care plan addressing physical therapy and pain management. The DON stated that baseline care plans should include physician orders, dietary orders, and therapy services and should be initiated within 48 hours of admission. The facility policy titled Baseline (Initial) Care Plan stated that baseline care plans should address, at a minimum, initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASSR recommendations.
Care Plans Not Updated to Match Medication Orders
Penalty
Summary
The facility failed to revise the care plans for two residents when their medication orders no longer matched the documented plans. One resident was admitted with diagnoses of dementia and major depressive disorder. The MDS indicated moderate mental impairment, use of glasses and hearing aids, and no symptoms of depression other than occasional loneliness. The physician orders showed that Remeron was no longer an active medication on the MAR, but the resident’s care plan still listed Remeron as an active plan with interventions and outcomes related to its use. A second resident was admitted with heart failure, chronic kidney disease, and atrial fibrillation. The MDS indicated no mental function or memory issues, no walking devices needed, and that the resident was taking Eliquis. The care plan for atrial fibrillation stated to administer Eliquis 2.5 mg twice daily, but the physician order dated 01/22/2026 stated Eliquis 2.5 mg by mouth in the afternoon once daily. During interview, RN 1 stated that MD 1 disagreed with the pharmacy consultant recommendation, that the original dose had been 2.5 mg twice daily, and that MD 1 decreased the dose to 2.5 mg daily in the afternoon. The facility policy stated that care plans should be re-evaluated and modified to reflect changes in care service and treatment as necessary, quarterly, and with a significant change in status assessment.
Failure to Follow Pain Medication Orders and Reassess Effectiveness
Penalty
Summary
The facility failed to follow the physician’s order for pain management for Resident 77, who was admitted with multiple pelvic fractures, hyperlipidemia, and osteoarthritis. The resident’s H&P dated 3/3/2026 indicated the resident had the capacity to understand and make decisions. The OSR dated 3/12/2026 showed orders for Hydrocodone-Acetaminophen 5-325 mg, one tablet by mouth every 4 hours as needed for moderate pain rated 4-6 related to pelvic fracture, and Hydrocodone-Acetaminophen 10-325 mg, one tablet by mouth every 6 hours as needed for severe pain rated 7-10 related to pelvic fracture. During observation on 3/11/2026, an LVN entered the resident’s room with a medication cup and stated, “I have your pain medication,” and the resident took the pills. During interview and MAR review, the LVN stated the resident received Hydrocodone-Acetaminophen 10-325 mg for right shoulder pain rated 7/10 at 8:47 a.m. and was not reassessed within the required timeframe. The MAR also showed that on 3/9/2026 at 2:34 a.m., the resident reported pain level 5/10 and received Hydrocodone-Acetaminophen 10-325 mg instead of the ordered 5-325 mg dose for pain level 4-6. RN 1 stated the resident received an incorrect dose, should have received the lower dose, and that staff did not follow the physician’s order for pain by matching the resident’s pain level with the corresponding medication order.
Improper BP Measurement on AV Fistula Arm
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with end-stage renal disease, type 2 diabetes, and dependence on dialysis who had an AV fistula in the left middle arm. The physician’s order dated 11/22/25 directed staff to monitor the fistula every shift. However, vital sign documentation showed that blood pressure was taken on the left arm on multiple dates in March 2026, despite the fistula being located on that arm. During an observation in the resident’s room, there was no sign present indicating that blood pressure and blood draws were not to be taken on the left arm because of the AV fistula. During interview and record review, RN 1 stated that blood pressure should be taken on the right arm when a fistula is on the left arm, and that cuff pressure can damage the fistula and cause bleeding. RN 1 also stated that staff who documented blood pressure on the left arm should have known better. The facility policy titled Hemodialysis, Care of Residents stated not to take blood pressure on the arm with the dialysis shunt.
Bed rail dimensions were not inspected for appropriate size and weight
Penalty
Summary
The facility failed to ensure bed dimensions were inspected for appropriate size and weight for one of five sampled residents, Resident 47. Resident 47 was admitted and readmitted with diagnoses of epilepsy, dementia, and depression. The MDS dated 2/2/26 indicated the resident had moderately impaired cognition, required supervision with eating, substantial to maximal assistance with toileting, showering, and lower body dressing, and partial assistance to roll from side to side. On 3/09/2026, Resident 47 was observed lying in bed facing the doorway with two bedside rails up, and the rails were not padded. The resident’s OSR included an order dated 9/20/2025 for bilateral 1/3 side rails as an enabler for bed mobility and ADL care. During interview and record review, RN 1 stated the bedside rails were assessed quarterly and that no one in the facility measured or inspected the bed rails; the last Rail/Restraint/Device Assessment did not include measurements. The MC stated he did not measure the bed rails and only checked the bed monthly to ensure the motor and brakes were working. The DON stated the bedside rails were not measured to ensure the bed dimensions were appropriate for the resident’s size and weight, and that the facility only completed rail/restraint/device assessments every quarter and monitored for entrapment each shift. The facility policy stated the resident should be assessed before bedside rail use to ensure bed dimensions are appropriate for the resident’s size and weight.
Failure to Account for Home Medications and Secure Pharmaceutical Waste
Penalty
Summary
The facility failed to accurately account for a resident’s home medications upon admission and failed to ensure the pharmaceutical waste container was maintained so discarded tablets and capsules were inaccessible. Resident 62 was admitted with diagnoses including hypertensive heart failure, abnormal gait and mobility, thrombocytopenia, anemia, chronic kidney disease, type 2 diabetes, and atrial fibrillation. The MDS indicated a BIMS score of 13, showing intact cognition, and the resident required assistance with activities of daily living and supervision with transfers, walking, and showering. During observation, interview, and record review in the medication room, a bag containing Resident 62’s home medications was observed. RN 1 stated she was unfamiliar with facility policy regarding home medications and did not know which or how many medications were in the bag, and also stated the resident had been in the facility for almost two months. RN 1 later stated resident belongings should be documented by the social worker, while SSD stated the process was to review the belongings list completed by CNA and enter the information into the electronic charting system. SSD also stated that when residents bring home medications, the facility does not keep them and asks family or friends to pick them up. The pharmaceutical waste container was observed full, with visible tablets and capsules not covered by any dissolving liquid or chemical agent, and the lid was loose and not secured as tamper-proof. RN 1 stated the IP was responsible for picking up the waste container and that liquid should be added to dissolve wasted medications so they cannot be retrieved. Review of the medication disposition log showed the last entry dated 2/18/2026 and lacked resident names associated with disposed medications. The DON stated staff are responsible for accounting for and documenting resident belongings, including home medications, and that if home medications were brought in, staff must document the medication names and quantities, seal and label them, and store them securely until they can be sent home.
Failure to Address Eliquis Dosing Irregularity
Penalty
Summary
The facility failed to act upon a medication irregularity identified by the Pharmacy Consultant for one of four sampled residents, Resident 62. Resident 62 was admitted with heart failure, chronic kidney disease, and atrial fibrillation, and the MDS indicated no cognitive losses, no walking devices needed, very little help with daily activities, and use of an anticoagulant, Eliquis. The physician order dated 01/22/2026 indicated Eliquis 2.5 mg by mouth in the afternoon for atrial fibrillation. A Consultant Pharmacist recommendation dated 2/27/26 stated that Resident 62 was receiving Eliquis 2.5 mg once daily in the afternoon, while the recommended dosing was 2.5 mg PO twice daily, and asked that the medication be reviewed and changed as necessary to make it therapeutic. During observation and record review on 03/12/2026, the medication bubble pack for Eliquis was present at the med cart, and RN 1 stated that MD 1 was aware of the pharmacist recommendation and disagreed, explaining that the original dose had been 2.5 mg twice daily but MD 1 decreased it to 2.5 mg daily in the afternoon. The resident’s cardiologist had prescribed Eliquis 2.5 mg twice daily, and progress notes entered on 2/2/26 documented Eliquis 2.5 mg every evening by mouth for atrial fibrillation. During telephone interview, MD 1 stated he usually collaborates with specialists and pharmacists for accurate therapeutic dosing but did not remember whether someone relayed the pharmacy recommendation to him.
Failure to Monitor and Document Depression Symptoms for Resident on Remeron
Penalty
Summary
The facility failed to monitor and document the signs and symptoms of depression for one sampled resident who was receiving Remeron for major depressive disorder. Resident 51 was admitted with diagnoses including major depressive disorder, Alzheimer's disease, and diabetes mellitus. The resident's MDS dated 1/16/2026 indicated an active diagnosis of depression, and the physician's orders dated 7/24/2024 showed Remeron had been started for major depressive disorder, but the orders did not include monitoring for signs and symptoms of depression. The resident's care plan dated 12/8/2025 directed staff to observe the resident for any signs and symptoms of depression, but the MAR dated 3/1/2026 did not indicate monitoring for signs and symptoms of depression. During interview, the DSD stated there was no documentation for behavioral monitoring for Resident 51 and that staff should have been monitoring and documenting signs and symptoms of depression. The DON stated Remeron long-term use is not acceptable. The facility policy titled Psychoactive Medication Management stated residents on psychotropic medication will be monitored for behavior every shift and licensed nurses will document summary of behaviors and observations.
Improperly Covered Garbage Dumpster
Penalty
Summary
The facility failed to ensure a garbage dumpster lid was properly covered. During an observation in the parking garage, a garbage dumpster was found filled with trash bags to the point that the lid could not fully close. During an interview, the Dietary Supervisor stated that insects or animals could travel inside the dumpster if the lid is left open and that this could result in residents becoming sick. The facility policy titled Waste Management stated that waste containers must be closable, and Food Code 2022 stated that garbage receptacles must have tight-fitting lids or covers to prevent scattering of garbage or refuse by birds, breeding of flies, or entry of rodents.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that Resident 53 had the call light within reach. Resident 53 was admitted with diagnoses including Alzheimer's disease, embolism and thrombosis of the deep veins of the right lower extremity, anemia, hypertension, osteoporosis, lack of coordination, dysphagia, and urinary retention. The MDS dated [DATE] indicated a BIMS score of 6, showing severe cognitive impairment, and the resident required partial to substantial assistance with activities of daily living, maximum assistance with transfers, and was dependent for toileting and showering. During a concurrent observation and interview on 3/9/2026 at 4:10 p.m. in Resident 53's room, the resident's call light cable and button were observed on the floor under the nightstand and not within reach. The care plan dated 10/27/2025 directed staff to place the call light within reach, and the facility policy stated that the call light should be within the resident's reach when in the room or on the toilet and that all residents should have a call light in place at all times. Staff interviews indicated that CNA and LVN staff were expected to check that the call light was in place before leaving the room.
Failure to Provide Required Abuse and Neglect Training
Penalty
Summary
The facility failed to ensure that LVN 2 and HK 1 received training on abuse, neglect, and exploitation. During a concurrent interview and record review on 3/11/2026, the DSD stated that the facility had not provided staff with training on abuse, neglect, and exploitation and said this training is important so staff can recognize and protect residents. The DSD also stated that without this training, staff may fail to detect abuse. During interviews, LVN 2 stated that the facility did not provide abuse or neglect training and that staff need proper training before working in the facility so they can provide safe care to residents. HK 1 stated that in the two years they had worked at the facility, abuse training had only been provided at hire and no additional training had been given. HK 1 also stated they did not know which form to complete to report suspected abuse. The facility policy titled Abuse and Neglect Prohibition Policy dated 6/2024 stated that abuse and neglect training would be provided to all employees through orientation and ongoing sessions at a minimum of annually, and would include review of the abuse and neglect policy, interventions for aggressive or catastrophic resident reactions, and how staff should report allegations without fear of reprisal.
Failure to Involve Next of Kin in Care Planning
Penalty
Summary
The facility failed to include a resident's next of kin (NOK) in the care plan conference, despite the resident's care plan indicating a preference for family or significant other involvement. The resident, who was cognitively intact and required varying levels of assistance with daily activities due to diagnoses including heart failure and lack of coordination, attended the care conference. However, there was no documentation that the NOK was invited to participate, as required by the facility's policy and the resident's care plan preferences. Interviews and record reviews confirmed that while the NOK was reportedly invited and unable to attend due to work obligations, this was not documented in the resident's records. The facility's policies require prompt and accurate documentation of such events and emphasize the importance of involving residents' families or representatives in care planning. The lack of documentation and failure to ensure the NOK's participation resulted in the resident and their NOK not being given their right to participate in the care planning process.
Failure to Provide Advance Written Notice and Documentation for Room Changes
Penalty
Summary
The facility failed to honor a resident's right to receive advance written notice and proper documentation before room changes occurred. Specifically, a resident with dementia and anxiety disorder, who required varying levels of assistance with daily activities, was moved to different rooms on four separate occasions. On each occasion, the responsible party (RP) was not notified in advance, and no written notice was provided explaining the reason for the room change. Additionally, there was no documentation in the resident's medical record regarding the room changes or the notification of the RP. Interviews with facility staff revealed inconsistencies in the notification process. The director of staff development confirmed that the RP should have been notified and consent obtained prior to any room change, but could not find documentation to support this. The social worker stated that notifications were made via text messages and that she kept a binder for room changes, but admitted that written notices were not provided and that documentation in the medical record was lacking. The facility's own policy required advance notice and documentation of room changes, which was not followed in these instances.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse policy and procedures for two residents when an allegation of employee-to-resident abuse was not reported to the state licensing/certification office, police, or ombudsman, and the incident was not investigated in a timely manner. Resident 2, who had intact cognition and the capacity to make decisions, filed a grievance on behalf of Resident 3, who had severe cognitive impairment and was dependent on staff for most activities of daily living. The grievance described an incident in which a CNA allegedly proceeded forcefully with care despite the resident's refusal, resulting in the resident yelling and screaming in resistance. Interviews and record reviews revealed that the Director of Nursing acknowledged the grievance contained an allegation of abuse and should have been reported, but it was not, as there was no physical problem observed. The Administrator stated he was aware of the incident but was not informed of the specific details indicating forceful behavior, which would have prompted reporting. The facility's policy required immediate reporting of all alleged violations of abuse to appropriate authorities, but this procedure was not followed in this case.
Failure to Complete Annual Performance Evaluations for Staff
Penalty
Summary
The facility failed to ensure that five employees received annual performance evaluations as required by facility policy. During a review of employee files with the Director of Staff Development (DSD), it was found that performance evaluations for two LVNs and three CNAs, including one Restorative Nursing Assistant, had not been completed. The DSD stated she was unaware of the requirement for annual performance evaluations and had not reviewed the relevant facility policy. The Director of Nursing (DON) confirmed that annual performance evaluations were required and acknowledged that the current DSD had not been instructed to perform them. The facility's policy indicated that each employee should receive an annual performance evaluation, with documentation maintained in the human resources file.
Failure to Follow Standardized Recipes and Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to ensure that standardized recipes and portion sizes for the lunch menu were followed for residents on pureed diets. During observations, it was noted that twenty-three residents on pureed diets did not receive the pureed versions of the menu items listed for the regular diet, such as pureed soybean paste stew and fern salad. Instead, they were served alternative pureed foods like meat, rice, and beans. The pureed foods provided were of a thin, soupy consistency rather than the required homogenous, cohesive, pudding-like texture. Staff interviews revealed that the menu did not include therapeutic or texture-modified diets, nor did it specify standard portions or serving guides for these diets. The dietary supervisor acknowledged difficulties in preparing the Korean menu for pureed diets and admitted to using portion sizes from an old menu as a reference. Further interviews and observations confirmed that the registered dietitian had not reviewed the menu or provided in-service training to staff regarding texture-modified diets. The dietitian stated that residents on pureed diets should receive the same foods as those on regular diets, and that the menu should include all therapeutic and texture-modified diets with appropriate recipes and portion sizes. Facility policy reviews indicated that menus should include standardized recipes, nutrient analysis, and portion control, but these were not being followed for the pureed diet. As a result, residents on pureed diets were not receiving meals consistent with the planned menu or in the correct texture and portion, as required by facility policy.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Surveyors observed frozen sliced pork thawing on the kitchen counter instead of in the refrigerator, contrary to both facility policy and staff knowledge, which require thawing in a refrigerator or by other approved methods. The staff member responsible for this acknowledged the error, stating the meat should not have been left on the counter. Additionally, the kitchen was understaffed at the time, with the Dietary Supervisor and another staff member performing multiple duties, including dishwashing and cooking. Further deficiencies were identified with the facility's ice machine, which was found to have pink residue inside the storage bin and on the baffle, indicating it was not maintained in a sanitary manner. The ice scoop was also overdue for cleaning. The Maintenance Supervisor admitted to not cleaning the ice machine on schedule and failing to use sanitizer as required by facility policy. Review of cleaning logs and policies confirmed that the ice machine should be cleaned regularly with a sanitizer solution, but this was not done as specified. Additional issues were found with the labeling and dating of food items in the refrigerators. Open milk gallons and individual cups of beverages were stored without open or use-by dates, and other items such as sliced cheese, kimchi, and previously cooked rice were also found without proper labeling or dating. Facility policies require all refrigerated, ready-to-eat foods to be labeled and dated, and leftovers to be discarded if not used within specified timeframes. The Dietary Supervisor confirmed that staff failed to follow these procedures, resulting in improper food storage and potential for foodborne illness.
Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, Parkinson's disease, lack of coordination, and polyosteoarthritis, was found in bed with the call light not within reach. The resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene, bathing, and transfers, as documented in the Annual Minimum Data Set. The resident's care plan specifically included an intervention to keep the call light within reach due to the risk of bedside rail entrapment. During an observation, the call light was seen hanging at the end of the bed, out of the resident's reach. A CNA present in the room confirmed the call light was not accessible and acknowledged the importance of its placement. Interviews with an LVN and the Director of Staff Development further confirmed that facility policy requires call lights to be within easy reach of residents to ensure timely assistance. A review of the facility's policy also supported this requirement.
Failure to Notify Physician and Document High Blood Glucose Readings in Diabetic Resident
Penalty
Summary
A resident with a history of diabetic ketoacidosis (DKA) and uncontrolled diabetes was admitted to the facility with diagnoses including unspecified acidosis and Type II diabetes with ketoacidosis. The resident's care plan included monitoring for signs and symptoms of hyperglycemia and hypoglycemia, administering diabetes medications as ordered, and reporting abnormal findings to the physician. Despite these interventions, the resident experienced multiple episodes of extremely high blood sugar, with readings over 500 mg/dL documented on at least 27 occasions over a two-month period. The blood glucose machine used by the facility could only register readings up to 599 mg/dL, displaying 'HI' for higher values, which occurred several times for this resident. Facility staff failed to notify the resident's physician about these consistently high blood sugar readings, and there was no documentation of physician contact or a change in the resident's condition related to these events. Interviews with nursing staff and supervisors confirmed that the physician was not informed of the high readings, and that documentation of communication and interventions was lacking. The facility's policy required staff to contact the provider for glucose values above certain thresholds or when the glucometer reading was too high, but this was not followed in practice. Additionally, staff inaccurately documented 'HI' readings from the glucometer as 599 mg/dL, rather than recording the actual result and following the manufacturer's instructions to contact a healthcare professional immediately. The resident's family was not made aware that the physician had not been contacted regarding the high blood sugar levels. The medical director and other staff acknowledged that the standard of practice was not followed, and that the lack of communication and documentation represented a failure to provide care in accordance with professional standards.
Failure to Change Enteral Feeding Bag Every 24 Hours
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dysphagia, aphasia, dementia, and Parkinson's disease, who was dependent on a gastrostomy tube (g-tube) for nutrition, did not receive proper care in accordance with facility policy. The resident's enteral feeding bag, which was supposed to be changed every 24 hours per the facility's Enteral Feeding Via Pump Administration policy, was observed to have been in use for two days without being changed. The feeding bag was dated two days prior to the observation, and the feeding pump was turned off at the time of inspection. Interviews with facility staff confirmed that the feeding bag and tubing had not been changed as required, and staff acknowledged the risk of infection and gastrointestinal complications associated with this lapse. The facility's policy, as well as statements from the Director of Staff Development and a Licensed Vocational Nurse, indicated that the failure to change the feeding bag and tubing daily placed the resident at risk for adverse outcomes.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of falls and dementia, who was assessed as high risk for falls. Despite the facility's policy requiring a person-centered care plan to manage risk factors, no such plan was created for the resident upon admission. The resident's Morse Fall Score was 75, indicating a high risk for falls, yet there was no documentation of a fall prevention care plan or monitoring for the resident on the day following admission. On the second day after admission, the resident was found on the floor, complaining of pain, and was subsequently diagnosed with a left femur fracture at a General Acute Care Hospital. The facility's failure to frequently monitor the resident and anticipate their needs, as well as the absence of a fall prevention care plan, contributed to the incident. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that a care plan should have been developed and implemented to prevent such an occurrence. The facility's policies, including the Person Centered Plan of Care and Post Fall Management Program, emphasize the importance of developing and updating care plans to prevent falls and accommodate resident needs. However, these policies were not followed in the case of the resident, leading to a preventable fall and subsequent injury. The lack of a fall prevention care plan and inadequate monitoring were identified as deficiencies in the facility's care for the resident.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident with dementia, a history of multiple falls, and a high risk for falls received the necessary care and services to prevent accidents and falls. The facility did not implement its Fall Prevention Program policy and procedure to identify interventions related to the resident's specific risks and causes. Additionally, the facility did not evaluate the effectiveness of interventions and implement new ones to prevent repeated fall incidents after the resident fell on multiple occasions. The resident was not monitored for the behavior of trying to get out of bed without assistance as per the physician's order, leading to repeated falls and a laceration requiring hospital transfer. The resident was admitted with diagnoses including a history of falling, dementia, lack of coordination, and Alzheimer's disease. The resident's care plan included interventions such as monitoring whereabouts, helping with transfers and ambulation, providing proper fitting shoes, maintaining a safe environment, and keeping the call light within reach. Despite these interventions, the resident experienced multiple falls, including incidents where the resident was found on the floor after attempting to go to the bathroom without assistance. The facility's staff did not revise the care plan effectively after each fall, and the same interventions were repeatedly implemented without success. Interviews with facility staff revealed that the resident was forgetful, confused, and unable to walk independently. Staff acknowledged that the resident did not use the call light and often tried to get out of bed without assistance. The facility did not use a bed alarm, which could have alerted staff when the resident attempted to get out of bed. The Director of Nursing and other staff members admitted that the care plan interventions were not person-centered and were ineffective in preventing the resident's falls. The facility's policies and procedures required reassessment and revision of care plan interventions after each fall, but this was not done, leading to recurrent falls and injuries for the resident.
Failure to Protect Resident from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a Certified Nurse Assistant (CNA). The resident, who was cognitively intact and had medical decision-making capacity, reported that the CNA touched her private parts and forced her to touch his private area. This incident caused the resident significant psychological distress, including feelings of fear, shame, anxiety, and guilt. The resident initially reported the incident to a caregiver from home, who then informed the facility staff. The incident occurred during the 7 AM to 3 PM shift when the CNA was assigned to care for the resident. Surveillance video confirmed the CNA's presence in the resident's room during the reported time frame. The resident described the incident in detail, stating that the CNA touched her inappropriately and made her touch him, despite her saying 'no' multiple times. The resident was observed crying and tearful during interviews, expressing fear of seeing the CNA again and concern about potential repercussions for reporting the incident. The facility's staff, including the Social Services Director and Administrator, were informed of the incident and took immediate steps to ensure the resident's safety. The CNA was asked to leave the facility and was not allowed to return. The resident's account of the incident remained consistent when reported to various staff members and the police. The facility's policy on abuse and neglect prohibits such actions, and the incident was thoroughly documented and investigated by the facility staff.
Failure to Provide Abuse Training to CNA Leads to Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) 1 had the appropriate abuse training, which led to an incident of alleged sexual abuse involving a resident. CNA 1, who had been working at the facility for several months, did not attend any of the abuse training sessions provided by the facility. The facility's records confirmed that CNA 1 did not participate in multiple in-service training sessions on abuse prevention and reporting, and there was no employee file for CNA 1 to verify competencies or skill sets. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that registry staff, including CNA 1, were not provided with formal abuse training during their orientation at the facility, relying instead on the registry agency to provide such training. This lack of training was in direct violation of the facility's Abuse and Neglect Prohibition Policy, which mandates that all staff, including those from registry agencies, receive abuse prevention training during orientation and ongoing sessions at least annually. The incident in question involved Resident 1, who was cognitively intact and had medical decision-making capacity. Resident 1 reported that CNA 1 had touched her inappropriately and forced her to touch his private area during a routine change of her incontinent brief. Surveillance video footage corroborated the timeline of CNA 1's presence in Resident 1's room, although it did not capture the alleged abuse directly. Resident 1 was visibly distressed during the interview, describing the incident in detail and expressing fear and confusion about whom to report the incident to. The facility's records indicated that Resident 1's family and physician were notified of the incident. Interviews with facility staff, including the DSD, DON, and the Administrator, revealed a systemic failure to ensure that registry staff received the necessary abuse training. The facility's Master Staffing Agreement with the registry agency placed the responsibility for compliance with health regulations, including abuse prevention training, on the facility. Despite this, the facility did not provide formal abuse training to registry staff, creating a potential risk for abuse. The Administrator, who was also the abuse coordinator, acknowledged that all staff should be trained on abuse prevention and that the lack of training could lead to potential abuse incidents.
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 7,021 citations issued within 25 miles in the last 12 months — including the 38 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pih Health Good Samaritan Hospital D/p Snf | 0.2 mi | ★★★★★ | 3 | 0 |
| Burlington Convalescent Hospital | 0.2 mi | ★★★★★ | 19 | 0 |
| Angels Nursing Health Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Bonnie Brae Skilled Nursing | 0.3 mi | ★★★★★ | 9 | 0 |
| Westlake Convalescent Hospital | 0.4 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.