Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 New Vista Post-acute Care Center during CMS and state inspections, most recent first.
A resident with cancer, muscle weakness, and Type 2 DM had an order for a daily Asperflex lidocaine 4% patch for pain management but repeatedly refused the medication. Despite these refusals, the MAR documented that the patch was applied and removed as scheduled, and nursing staff, including LVNs and the DON, acknowledged that the refusals were not reported to the physician or clinical supervisors as required. Facility policy stated that when a resident refuses care, treatment, medications, or food, the attending physician must be notified within 72 hours, but this notification did not occur.
A resident with cancer, muscle weakness, and Type 2 DM had a daily Asperflex lidocaine 4% patch ordered for pain management, with specific application and removal times. Despite the resident repeatedly refusing the patch because it was believed to be unnecessary or ineffective, an LVN documented on the MAR that the patch was applied on multiple occasions. The ADON and DON confirmed that this documentation implied the medication was given and was inaccurate, and the DON reported not being informed of the refusals, contrary to facility policies requiring accurate medication administration and timely physician notification when care or medications are refused.
Two residents who were cognitively intact but dependent on staff for ADLs reported missing multiple scheduled showers over a one- to two-month period. One resident with spinal stenosis, acute kidney failure, and muscle weakness, and another with lack of coordination, generalized muscle weakness, and hypertension, both stated they were supposed to receive showers twice weekly but did not, and one reported being told by CNAs that staff were unavailable or too busy. A CNA reported being assigned about 12 residents and lacking time to complete all care, while an LVN, RN supervisor, and DON acknowledged that residents have pre-planned shower schedules, are largely dependent on staff for ADLs, and that CNA staffing shortages and sick calls affect the provision of scheduled showers and hygiene.
A resident with spinal stenosis, acute kidney failure, muscle weakness, and significant ADL dependence did not receive ongoing PT/OT services because the facility failed to facilitate use of the resident’s secondary insurance after the primary insurance’s limited coverage ended. PT was discontinued after a short period and the resident was discharged to an RNA program, despite a hospital physician’s recommendation for extended PT/OT and the resident’s expressed desire and potential to benefit from more therapy. The DOR, RN supervisor, and RNA staff acknowledged the resident could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance and that SS might be responsible for securing additional resources, contrary to facility policy requiring provision or arrangement of needed specialized rehabilitative services.
The facility failed to follow its abuse prevention and conduct policies by assigning a CNA to two residents who had requested not to receive care from that CNA and by not honoring a resident’s objection at the time of care. One cognitively intact resident with hemiplegia and multiple comorbidities reported prior negative interactions with the CNA and again objected to her assignment, yet the CNA was still assigned and an altercation occurred during incontinent care, with conflicting accounts about whether the CNA threw a towel at the resident’s face or the resident threw a towel and kicked the CNA. Another resident with severely impaired cognition and significant physical limitations reported that the same CNA roughly grabbed and turned him and was rude, and he requested that the CNA no longer care for him. Staff interviews showed inconsistent awareness and communication about which residents the CNA was restricted from caring for, resulting in assignments that did not respect resident preferences and led to loud arguments and possible physical abuse.
The facility did not maintain adequate nursing and CNA staffing levels as required by its own staffing policy, with documented DHPPD for total nursing and CNAs falling below the facility’s stated minimums on most reviewed days and only five CNAs assigned to 79 residents on one shift. A resident with hemiplegia, epilepsy, and muscle weakness who needs moderate to extensive assistance with ADLs reported that scheduled showers were delayed because there were not enough staff, and a CNA confirmed being unable to provide the shower due to short staffing. The CNA also stated that when residents have private caregivers, the facility allows those caregivers to perform CNA tasks such as feeding, repositioning, changing, and cleaning to reduce staff workload.
A resident with ESRD, toxic encephalopathy, and type II DM had ongoing generalized rash, intense itching, and diffuse excoriations, and was repeatedly treated with permethrin and ivermectin for suspected scabies. Despite clear signs and symptoms and documentation in progress notes and an SBAR, the facility did not perform diagnostic skin scrapings as required by its scabies P&P. The IPN acknowledged the resident had scabies-like symptoms and that scabies is contagious, yet no contact tracing list was developed and no education or in-services on scabies were provided to staff, family members, or visitors, contrary to the facility’s written scabies prevention and control policy.
The facility failed to maintain several resident rooms free of water leaks, resulting in water dripping from ceilings and entering through a window, with towels, blankets, and basins placed on floors to collect the water. One resident with spinal stenosis, polyneuropathy, and type II DM who needed extensive ADL assistance reported feeling water dripping from the ceiling and had their bed moved to avoid getting wet. Another resident with hemiplegia, epilepsy, and muscle weakness was observed with active ceiling leaks and visible ceiling discoloration. The MTD acknowledged ongoing roof and window leak issues despite prior repairs, and the DON stated that such leaks and water on the floor put residents at risk of injury and that residents should have been moved to ensure a safe environment.
A resident with dementia and multiple Stage 4 pressure ulcers, fully dependent for ADLs, had a care plan and physician orders requiring q2h turning, offloading with wedges, frequent incontinence care, and use of an appropriate pressure‑reducing mattress. Facility ADL logs showed the resident was turned only two to three times per day, and interviews with a private caregiver and a CNA confirmed that the private caregiver performed most ADLs while staff documented limited repositioning, contrary to facility policies requiring q2h turning. On readmission, required skin and pressure ulcer risk assessments were not documented, and both the DON and treatment nurse acknowledged that the absence of documentation meant the assessments were not completed. Observation further revealed that the resident’s low air loss mattress was set to a firm 250‑lb setting despite the resident weighing about 156–158 lbs, and staff confirmed that the LAL mattress should be set according to weight, meaning the mattress was not properly configured for pressure ulcer prevention and management.
A resident with hemiplegia, gait abnormalities, a history of falls, and mildly impaired cognition experienced falls associated with wheelchair transfer and being found on the floor. The resident’s fall risk care plan identified multiple fall-related problems and required assistance with transfers, but fall risk evaluations were inaccurately completed, including incorrect scoring for recent fall history and leaving gait/balance items blank despite documented balance and gait issues. Required 72-hour post-fall neuro checks were not consistently performed or documented on all shifts after the fall, and nursing leadership acknowledged incomplete and inconsistent charting that did not follow facility fall and post-fall assessment policies.
A resident with severe dementia, depression, and psychoactive substance abuse was admitted after hospitalization for failure to thrive and psychostimulant use disorder and was documented as lacking decision-making capacity. On admission, the resident scored as high risk for elopement, and staff documented multiple episodes of wandering and exit-seeking behavior, including repeated attempts to leave the building and verbal insistence on going home. Despite facility policy requiring use of the SBAR process and physician notification for significant changes and high elopement risk, the physician was not notified and no wander guard order was obtained. Overnight, after several documented redirections, the resident was later found to be missing from the room and the facility, and was subsequently located by police in another city with bruises and scratches.
A resident with dementia, depression, psychoactive substance abuse, and documented severe cognitive impairment was admitted and assessed as high risk for elopement, but staff did not notify the physician or develop and implement an elopement-focused care plan as required by facility policy. Preadmission records and an elopement risk assessment identified the risk, and visual check logs and nursing notes documented multiple episodes of wandering and exit-seeking behavior throughout the evening and night, with the resident expressing a strong desire to leave and being difficult to redirect. Despite these behaviors, no individualized elopement interventions were care planned, and no wander guard order was obtained. By early morning, staff discovered the resident was no longer in the room or facility, and the resident’s whereabouts were unknown for many hours until police later located the resident in another city with bruises and scratches.
Failure to Follow Orders and SBAR Process: A resident did not receive ordered oral care and water after chlorhexidine treatment, and staff were confused by the transcription of the physician order. Another resident developed abdominal pain, but after an x-ray was refused, staff did not initiate an SBAR/change-of-condition form or document the required 72-hour monitoring of abdominal status before the resident was later transferred to a GACH for lethargy, nausea, and poor appetite.
RNA competency and restorative care were not completed as ordered. Two RNAs’ annual competency evaluations did not include splint application and removal, even though the DSD stated this was part of their duties. In a separate event, an RNA did not follow a resident’s restorative order during treatment: the resident, who had spinal stenosis, polyneuropathy, unsteadiness on feet, and ROM limitations, was supposed to receive UE AAROM and omnicycle therapy, but the RNA substituted LE ROM and said the omnicycle would be done later.
A resident with severe cognitive impairment and ROM restorative orders had an RNA flow sheet entry showing treatment completed even though the RNA was not at the facility that day, and two other residents had PT treatment notes signed by a COTA on behalf of the PT. Staff interviews confirmed the RNA documentation was inaccurate and that a therapist should not sign for another discipline. Facility policy required records to be accurate and entries to be signed only by the person making them.
Infection Control Failures in Resident Room, Therapy Equipment, and Laundry Handling: Staff found that soap and hand sanitizer dispensers in a shared resident room were not working, preventing hand hygiene at the point of care. Therapy staff used a cloth gait belt with multiple residents and cleaned it with disinfectant wipes even though the wipes were intended for non-porous surfaces. In the laundry area, soiled linens and feces-soiled towels were observed overfilled in the chute and exposed to air rather than bagged in a sanitary manner.
Failure to Offer Pneumococcal Vaccination: Two residents did not have documented offers of the pneumococcal vaccine. One resident had severe cognitive impairment and total dependence for multiple ADLs, while the other had intact cognition but required assistance with several ADLs and had an out-of-date pneumococcal vaccination status. The DON stated vaccines are offered at admission and during the active season, but the IP found the consent forms did not show pneumococcal vaccine education or offer for either resident.
Failure to Provide Written Transfer/Discharge Notice: A resident with dementia, dysphagia, and a G-tube was transferred to the hospital, but the notice of transfer/discharge listed only the resident as notified. The RNS stated the facility notifies the resident and/or rep by phone only, while the DON stated the notice is mailed to the rep at the time of transfer. The facility policy required written notice to the resident and, if known, a family member or legal rep, including the reason for the move.
A resident with HTN, acute kidney failure, and depression had an MDS 5-day assessment completed, but the facility did not transmit it to CMS within the required timeframe. During interview and record review, the RN/MDS confirmed the assessment was sent 61 days late, despite the facility’s RAI process stating MDS assessments would be transmitted according to the required dates.
Inaccurate MDS Documentation of Antipsychotic Use: The facility failed to accurately code a resident’s MDS for antipsychotic use. The resident had diagnoses including stroke, respiratory failure, and dementia with moderate cognitive impairment, but the MDS indicated antipsychotic use during the lookback period even though the order summary and MDSC confirmed the resident was not prescribed or taking an antipsychotic at that time. The DON stated the MDS must be accurate because it is the basis for the resident’s plan of care.
Missing PASRR Screening for Admitted Resident: A resident with epilepsy, PTSD, DM2, depression, COPD, HTN, and moderately impaired cognition did not have an initial PASRR completed prior to and/or upon admission. The ADON confirmed the PASRR was not in the paper chart or E-mar, and the DON stated PASRR should be completed within 24 hours of admission/re-admission to evaluate the resident’s need for skilled nursing and ensure appropriate care.
A resident with spinal stenosis, polyneuropathy, unsteadiness on feet, and limited ROM in both UEs and LEs did not receive ordered RNA treatments for AAROM and omnicycle exercise. The RNA flowsheets showed missed treatments over multiple months, and the resident stated staff did not provide exercises, while the DSD confirmed the missed treatments and the DON stated RNA was intended to maintain current functional status.
A resident with a gastrostomy tube and orders for nightly enteral nutrition was observed receiving tube feeding with a label that was missing the date it was hung. The LVN stated the label was incomplete because it should show when the feeding was started and when it needs to be changed, and the DON stated the date is required because the formula has an expected run time per manufacturer guidance. The facility policy required the feeding container to be labeled with the date hung, time hung, and staff initials.
Failure to Administer Ordered Medications: A resident with hypothyroidism, chronic pain, and osteoarthritis did not receive ordered routine Hydrocodone-Acetaminophen and Levothyroxine doses as documented on the MAR. The resident reported missed pain and thyroid medication doses, and the RN supervisor confirmed blank MAR entries meant the meds were not given. The DON stated the pain med was intended to prevent pain from the resident's chronic condition and the thyroid med was used to balance thyroid levels.
Medication Order Missing Indication for Use: A resident with lymphedema, DM, HTN, and cognitive impairment had a Ketoconazole cream order for the lower extremities that did not include the diagnosis or reason for use. An LVN stated the order was missing the diagnosis, and the DON confirmed that medication orders must include an indication so staff know what the medication is being given for, consistent with the facility P&P.
Unlabeled Food Stored in Resident Refrigerator A resident refrigerator next to the nurse's station contained food items that were not properly labeled or dated, including a tied bag with only a room number and a dessert container with no name, room number, or date. The ADON confirmed the missing labels, found a plate with ham and cooked greens inside one bag, and stated the unlabeled dessert could not be confirmed as belonging to a resident or staff. The posted refrigerator instructions and facility policy required food to be labeled with the resident's name and date.
Insufficient Bed Curtains for Resident Privacy: Two residents sharing a room did not have full-length bed curtains that could fully close for privacy. One resident stated both curtains did not pull all the way and one was falling off, while the MTD and MS confirmed the curtains were too short to cover the full room. The DON stated room curtains are for privacy and should be long enough to provide full privacy, and the facility policy addressed resident dignity and privacy.
A resident with spinal stenosis, polyneuropathy, and unsteadiness on feet was found in a room with a closet missing a door and a top drawer, with clothes stored in plastic bags inside the open closet. The resident, CNA, MTD, and DON all confirmed the closet lacked the expected doors and drawers, and the resident stated the room had been without a closet door since moving in and felt like a slum.
A resident with muscle weakness, dementia, and depression was found in bed with the call light hanging nearly to the floor and out of reach. The resident said he did not know where the call light was, and a CNA and the DON stated the call light should be within reach so the resident can call for help when needed. The facility policy also required the call light to be within easy reach when the resident is in bed or in a chair.
Peeling Paint and Ceiling Stains in Resident Room: A resident’s room had a large patch of peeling paint by the window, brown stains on the ceiling, and bubbling paint after a roof leak. The resident, CNA, MTD, and DON all acknowledged the damaged condition of the room, and the resident stated he felt like he lived in a slum while paying hundreds of dollars a day.
Two residents did not receive physician-ordered wound and catheter treatments as required, and treatment documentation was incomplete or inaccurate. One resident, with a suprapubic catheter and pressure-related wounds, had an IDT assessment indicating it was not safe for self-administration of drugs, yet a nurse charted daily catheter flushes as completed while relying on the resident’s report that he did them himself, without observing or assessing this and without documenting refusals or missed treatments on the TAR. The same resident reported not receiving daily skin treatments on at least one day due to lack of a treatment nurse, and the TAR showed blank entries for ordered catheter care and wound care without explanation. A second resident with sacrococcyx and skin conditions had physician orders for daily sacral wound care and topical ketoconazole, but the TAR contained multiple blank entries for these treatments with no documentation of completion, refusal, or reason for omission, contrary to facility policies requiring IDT determination for self-administration and detailed skin care documentation.
Staff did not obtain informed consent from the appropriate representative for a resident with cognitive impairment and lacking decision-making capacity, instead documenting the resident's own verbal declination for COVID-19 and influenza vaccines, contrary to facility policy and procedures.
The facility did not ensure that several residents received required COVID-19, pneumonia, and influenza vaccines despite consent, and failed to document vaccine administration. Staff members, including CNAs and an LVN, were observed not following hand hygiene and PPE protocols, and had not been properly fit tested for N95 masks. High-touch surface disinfection was not consistently documented, and contaminated linen was improperly handled, all in violation of facility policies.
A CNA dropped a clean towel on the floor, mixed it with other clean linens, and intended to use it on a resident with complex medical needs, including a tracheostomy and acute respiratory failure. The incident was observed by a surveyor, and staff interviews confirmed this action violated infection control protocols, as facility policy requires any linen that touches the floor to be treated as contaminated.
A resident with diabetes and cognitive impairment experienced untreated bilateral itchy and discolored eyes for an extended period. Despite observations by staff and reports from a family member, symptoms were not communicated to medical staff, and no ophthalmology referral or evaluation occurred. Record review confirmed the absence of eye doctor visits or orders, and facility leadership acknowledged the lack of adherence to eye care policy and documentation.
A resident with severe cognitive impairment and total dependence on staff was moved to different rooms on two occasions without notifying the family member, as required by facility policy. The family member was not consulted about the changes, which resulted in the resident being placed in a crowded room with limited space for care and personal belongings. Interviews and record reviews confirmed the lack of required notification and documentation.
A resident with severe cognitive impairment and bilateral hearing loss was not protected from misappropriation of personal property when their cochlear hearing aid went missing. Despite the family reporting the loss and the item being listed in the resident's inventory, staff did not document a required theft and loss report or complete the investigation steps outlined in facility policy, resulting in the resident's continued inability to hear.
A resident with severe cognitive impairment and dependence on staff for ADLs exhibited repeated behaviors of removing hand mittens and pulling on their tracheostomy and g-tube, resulting in a dislodged g-tube. Despite staff interventions and documentation of these behaviors, the care plan did not address these specific risks, contrary to facility policy requiring comprehensive, individualized care planning.
A resident with diabetes and ventilator dependence did not receive blood sugar monitoring according to physician orders, as a nurse performed the check at an unscheduled time and did not administer insulin as ordered. Additionally, after the resident's death, required documentation—including the death certificate and physician's note on cause of death—was not completed per facility policy.
A resident with multiple fractures and recent surgery experienced prolonged, uncontrolled pain due to delays in administering prescribed hydromorphone, lack of timely access to the emergency medication kit, and incomplete pain assessment documentation. Staff interviews and record reviews confirmed that pain management protocols were not consistently followed, resulting in the resident requiring hospital transfer for severe pain.
A CNA was observed changing a dependent resident's incontinence brief in a shared room with the privacy curtain open, leaving the resident exposed and failing to maintain dignity and privacy. The CNA could not explain the importance of privacy and responded confrontationally when questioned, while an LVN confirmed the incident. Facility policy requires residents to be treated with dignity and respect at all times.
A LVN crushed and administered multiple medications together without a physician's order and failed to verify a resident's identity or review orders prior to administration. Additionally, a CNA provided incontinence care to another resident without ensuring privacy, leaving the resident exposed in a shared room. Both incidents demonstrate a lack of staff competency in medication management and resident rights.
A nurse failed to properly identify a resident before preparing and administering morning medications, crushed multiple medications together without a physician's order, and was unable to verify which medications were being given. The medications were mixed in applesauce and administered without following required procedures for resident identification or medication verification, contrary to facility policy.
Licensed nursing staff did not consistently document their initials and signatures on the MARs for three residents receiving medications for conditions such as hypertension, ESRD, diabetes, and glaucoma. This resulted in incomplete medical records, as required by professional standards, with multiple staff acknowledging the deficiency during interviews and record reviews.
A facility failed to maintain a clean and homelike environment in a resident's room due to a ceiling leak that had persisted for months. The room, occupied by a resident with complex medical conditions, was cluttered with blankets and basins used to absorb water, creating potential hazards for falls and accidents. Staff and administration acknowledged the issue, and subsequent inspections confirmed the leak had been repaired.
The facility failed to ensure the CM had the necessary skills for a seamless admission process, as outlined in their policy. The CM, working remotely, was unreachable due to a full voicemail, delaying resident admissions. This impacted the residents' care plans and service delivery.
A facility failed to report an alleged abuse incident involving a cognitively impaired resident to the California Department of Public Health. The incident involved inappropriate touching by another resident, which was observed by an LVN and considered sexual abuse. The Facility Administrator acknowledged the failure to report to the Department of Public Health, although the police were contacted. This failure delayed the State Agency's investigation, potentially exposing the resident to further abuse.
Two residents reported missing and damaged clothing after using the facility's laundry services. Despite clothes being labeled, one resident did not receive his clothes back, and another found her T-shirt bleached and worn by another resident. Staff interviews revealed a lack of awareness and inadequate response to the grievances, highlighting a failure in the facility's grievance policy implementation.
The facility failed to maintain the dignity of two residents during meal assistance. A CNA stood over a resident with dementia while feeding her, contrary to policy requiring staff to be seated at eye level. Another resident, who is visually impaired, was not informed about the food items and their placement on the tray, as required by facility policy.
A CNA failed to maintain a resident's privacy by not closing the privacy curtain during personal care, exposing the resident to roommates and an outside view. The resident, with severely impaired cognition and total dependence on staff, was left without privacy despite facility policies emphasizing the importance of maintaining privacy during personal care activities.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring timely physician notification when a resident refuses ordered treatment. A resident with malignant neoplasm of the breast, secondary malignant neoplasm of the lung, muscle weakness, and Type 2 diabetes was admitted with an order for a daily Asperflex lidocaine 4% patch for pain management, to be applied to the back at 9 AM and removed at 9 PM. The resident’s MDS showed moderately impaired cognitive skills for daily decision-making, while the H&P documented that the resident had capacity for medical decision-making. The resident reported repeatedly refusing the lidocaine patch when it was offered, yet the MAR for early April showed documentation that the patch had been applied and removed as scheduled, which did not reflect the resident’s expressed refusals and actual care. During interviews, multiple LVNs and the DON confirmed that the resident had declined the lidocaine patch several times and that refusals should be investigated and reported to the attending physician and clinical supervisors. LVN1 acknowledged being unaware whether the refusals had been reported to the physician. LVN3 stated the resident refused the patch because it was not needed and indicated that the physician should be notified so the physician could assess the resident and consider alternative medication or discontinuation of the order. LVN7 stated that medication refusals occurring more than two or three times must be reported to the physician and clinical supervisors but acknowledged not reporting this resident’s refusals and was unaware if anyone else had done so. The DON stated that licensed staff did not bring the resident’s repeated refusals of the lidocaine patch to the DON’s or the physician’s attention. Review of the facility’s “Resident Rights–Refusal of Care” policy showed that when a resident refuses care, treatment, medications, or food, the attending physician must be notified within 72 hours, which did not occur in this case.
Inaccurate MAR Documentation of Repeatedly Refused Lidocaine Patch
Penalty
Summary
Facility staff failed to accurately document the administration and refusal of an ordered Asperflex lidocaine 4% patch for pain management for one resident. The resident, admitted with diagnoses including malignant neoplasm of the breast, secondary malignant neoplasm of the lung, muscle weakness, and Type 2 diabetes mellitus, had an MDS indicating moderately impaired cognitive skills but an H&P stating capacity for medical decision-making. The physician’s order directed application of a lidocaine 4% patch to the back once daily at 9 a.m. and removal at 9 p.m. Review of the resident’s MAR for early April showed entries by an LVN documenting that the patch was applied on multiple dates and times. However, the resident reported repeatedly refusing the lidocaine patch when offered, and stated that the MAR still showed it as applied and removed as scheduled despite these refusals. During interviews, LVN staff acknowledged that the resident had been declining the lidocaine patch because the resident did not believe it was needed or effective, and one LVN stated that the last couple of MAR entries must be documentation errors because the resident had refused the medication. The ADON and DON both confirmed that the MAR documentation implied the medication was given, and the DON stated that inaccurate documentation is misleading, inappropriate, and constitutes a medication error. The DON also reported not being informed by licensed staff that the resident had been refusing the ordered lidocaine patch, despite facility policies requiring medications to be administered per physician orders and requiring notification of the attending physician when a resident refuses care or treatment, including medications, within a specified time frame. Other LVNs interviewed stated that staff were aware the resident had declined the medication more than two or three times and that documentation errors could lead to medication errors and provide wrong information during medication regimen review.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled showers in accordance with its Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services policy, which requires monitoring and provision of bathing/showering and personal hygiene. Two residents who were cognitively intact but dependent on staff for ADLs reported missing scheduled showers. One resident, admitted with spinal stenosis, acute kidney failure, and muscle weakness, used a wheelchair for mobility and was dependent on staff for all ADLs; this resident stated he was supposed to receive showers twice a week but had missed some. Another resident, admitted with lack of coordination, generalized muscle weakness, and hypertension, required staff assistance for transfers to the shower/tub and for bathing tasks, and reported missing a couple of showers in the last month. The second resident further stated that in the last month or two he had missed two or more showers and was told by CNAs that staff were not available, that there was construction, and that they did not have enough staff. This resident reported feeling frustrated by missing showers and services and did not want to complain to leadership because staff were busy. A CNA reported being assigned an average of 12 residents on the morning shift and not having enough time to complete all tasks, spending 10 to 45 minutes per resident depending on care needs. An LVN stated that most residents receive showers twice a week and that it is important residents receive showers on their scheduled days as it is their right. The RN supervisor and DON both acknowledged that residents have pre-planned shower schedules, that most residents are dependent on staff for ADLs, and that frequent CNA staffing shortages and sick calls affect residents’ ADL care, contributing to missed scheduled showers for the sampled residents.
Failure to Facilitate Insurance Coverage Resulting in Interrupted PT/OT Services
Penalty
Summary
The facility failed to ensure that a resident received necessary PT/OT services by not facilitating the use of the resident’s secondary insurance coverage, contrary to its Specialized Rehabilitative Services policy. The resident was admitted with diagnoses including spinal stenosis, acute kidney failure, and muscle weakness, and the MDS showed intact cognition, bilateral upper and lower extremity impairment, wheelchair dependence, and dependence on staff for ADLs. A PT evaluation and plan of treatment documented lower extremity strength deficits and the resident’s goal to walk again. PT services were provided for a limited period and then the resident was discharged to an RNA program in December, with the MDS later indicating no special treatments, procedures, or programs in the prior seven days. The resident reported that a hospital physician had recommended at least 90 days of PT/OT, but therapy was discontinued after about a month because the primary insurance only covered 32 days, despite the resident having provided secondary insurance information to the facility. The DOR confirmed that the resident could have benefited from more PT/OT and that therapy did not continue due to limitations of the primary insurance and a technical issue between the business office and the secondary insurer. The resident, RNA staff, RN supervisor, and SS director all indicated that the resident wanted more therapy and could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance coverage issues or that SS was responsible for obtaining additional resources. The facility’s policy required it to provide or obtain specialized rehabilitative services when required by the comprehensive care plan, but this was not carried out for this resident.
Failure to Honor Resident Care Preferences and Prevent Alleged Staff Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and rules of conduct policies by assigning a CNA to provide care to residents who had requested not to receive care from that CNA, and by not honoring a resident’s expressed objection at the time of care. Resident 4, who has intact cognition and decision-making capacity and requires assistance with multiple ADLs due to hemiplegia, lack of coordination, and other medical conditions, had previously reported negative interactions with CNA4, including an incident where CNA4 forced a glove into the resident’s hand, applied A&D ointment to the glove, and told the resident to apply it herself. Resident 4 also reported that on a later night shift, CNA4 gave her a towel to clean herself, and when the towel fell to the floor and was picked up, CNA4 told her that next time it would be worse for her and stated, “I am from [NAME]; we do not play that in [NAME],” making the resident feel less than the staff. On the night in question, Resident 4 told LVN2 at the beginning of the 11 p.m.–7 a.m. shift that she did not want CNA4 assigned to her. Despite this, LVN2 completed the staff assignment including CNA4, stating her understanding was that the only resident CNA4 could not be assigned to was Resident 5, who had previously requested not to have CNA4. RN1 confirmed that one staff member had called in sick and that CNA4 was assigned to Resident 4; RN1 acknowledged that Resident 4 did not want CNA4, but he asked Resident 4 to give CNA4 a chance, and both agreed to work together. CNA4 stated that LVN2 knew she could not work with Resident 4 but told her the assignment could not be changed, and that RN2, who usually made assignments and did not assign CNA4 to Resident 4, was on vacation. During incontinent care for Resident 4 on that shift, an altercation occurred between Resident 4 and CNA4. CNA4 reported that Resident 4 requested another CNA, but LVN3 told the resident that due to short staffing she must allow CNA4 to change her. CNA4 stated that Resident 4 dried herself and then threw the dirty washcloth at CNA4, hitting her in the abdomen, and that Resident 4 kicked her in the stomach without provocation. Resident 4, however, told LVN3 and the Social Services Director that after she dried herself and gave the towel to CNA4, CNA4 became upset, accused her of throwing the towel, and then grabbed the same towel and threw it at Resident 4’s face, causing Resident 4 to feel abused and to kick CNA4 in self-defense. LVN3 corroborated that when she entered the room, Resident 4 and CNA4 were arguing, Resident 4 alleged that CNA4 hit her in the face with a towel, and CNA4 denied throwing the towel but stated that Resident 4 had hit her. The Administrator and SSD both acknowledged that Resident 4 reported CNA4 throwing the towel at her face and that there was a prior history between them. The deficiency also involves the facility’s handling of Resident 5’s complaints about CNA4. Resident 5, who has severely impaired cognition and multiple medical conditions including non-Hodgkin lymphoma, osteoarthritis, and polyneuropathy, requires extensive assistance with ADLs and mobility. Resident 5 told CNA5 that he wanted to speak to a supervisor to report abuse, and CNA5 reported this to the charge nurse, supervisor, and Administrator. Resident 5 later stated that CNA4 grabbed his left arm, swung him to the left side, and was rude, and that he did not like how CNA4 turned him and that CNA4 did not communicate what she was going to do. The Administrator confirmed that Resident 5 stated he did not like the care he received from CNA4 and requested that CNA4 no longer be assigned to him, and that CNA4 was barred from caring for Resident 5 based on his preference. Despite this, LVN2 and other staff referenced confusion or incomplete awareness about which residents CNA4 could not be assigned to, and CNA4 herself stated that Resident 5 did not want her to care for him and that she was aware she was not allowed to have Resident 5. These events demonstrate that the facility did not consistently ensure that staff assignments and care practices honored residents’ expressed preferences and protected them from alleged abusive or disrespectful interactions, as required by the facility’s abuse prevention and rules of conduct policies. In addition, multiple staff interviews revealed inconsistent understanding and communication regarding restrictions on CNA4’s assignments. LVN2 believed only Resident 5 could not be assigned to CNA4, while RN1 later learned from CNA4 that she was not supposed to be assigned to Resident 4. LVN3 stated she was unaware that CNA4 could not be assigned to Resident 4 until after the altercation, and also stated that CNA4 was not allowed to have Resident 5. The Social Services Director knew that CNA4 had been removed from caring for Resident 5 but did not know the reason or how Resident 5 developed bruising on his arm and fingers. The Administrator stated that if a resident does not want a staff member to care for them, staff should honor the resident’s request, and expressed concern about CNA4’s code of conduct and its effect on other residents. These facts collectively show that the facility failed to ensure that CNA4 was not assigned to residents who had requested not to receive care from her and failed to prevent situations that escalated into loud arguments and possible physical altercations, contrary to the facility’s abuse prevention and conduct policies.
Failure to Maintain Adequate Nursing and CNA Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents' needs in accordance with its own staffing policy on multiple sampled days. Review of the facility’s Direct Care Services Hours Per Patient Day (DHPPD) records showed that on seven of ten sampled days, total nursing and CNA hours fell below the facility’s stated minimums of 3.5 total nursing DHPPD and 2.4 CNA DHPPD, absent any waiver. On one morning shift, the DON confirmed there were only five CNAs assigned to care for 79 residents on the skilled unit. The DON acknowledged the facility was experiencing staffing shortages and that adequate staffing is needed to ensure staff can provide care and services to residents. A resident admitted with hemiplegia and hemiparesis affecting the right dominant side, epilepsy, and muscle weakness, and assessed as cognitively intact and requiring moderate to extensive assistance with ADLs, reported that when he requested showers on his scheduled shower days, staff told him his shower would be delayed until the afternoon because the facility did not have enough staff. A CNA interviewed on the same day stated she was unable to provide this resident’s shower due to short staffing. The CNA also reported that when residents have private caregivers, the facility allows those caregivers to perform CNA responsibilities such as feeding, repositioning, changing, and cleaning residents to ease staff workload.
Failure to Implement Scabies Prevention and Control Measures
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy and procedures for scabies when a resident exhibited signs and symptoms consistent with scabies. The resident, who had diagnoses including toxic encephalopathy, ESRD, and type II DM, was cognitively intact and required only setup or clean-up assistance for ADLs. Physician progress notes documented that the resident had significant itching and had been treated multiple times with permethrin and ivermectin for suspected scabies, including during a recent hospitalization. An SBAR dated 1/30/2026 described an unknown generalized skin condition with generalized redness and rash on the body and complaints of itching, with a recommendation for permethrin 5% weekly for four weeks. Despite these ongoing symptoms and repeated treatments for suspected scabies, the facility did not perform diagnostic testing as outlined in its policy. The infection preventionist stated that scabies diagnosis requires skin scrapings sent to a lab, but confirmed that no skin scraping had been done on this resident to diagnose and identify scabies. The resident continued to have diffuse scattered excoriations and generalized rash, with staff describing numerous scratches on the trunk and extremities, red scattered skin rash, and constant scratching. These findings were documented in the medical record and confirmed in staff interviews. The facility also failed to carry out required contact identification and education measures specified in its scabies prevention and control policy. The policy required that as soon as a possible case of scabies is identified, the infection control practitioner develop a contact identification list for all residents, staff, visitors, and volunteers who may have had direct physical contact with the case within the previous month, and to notify and educate employees, family members, and visitors. The infection preventionist acknowledged that no contact list had been started or developed for this resident and that no education or in-services regarding scabies had been provided to staff. These omissions occurred despite the infection preventionist’s acknowledgment that the resident had signs and symptoms of scabies and that scabies is contagious and passed through contact.
Failure to Maintain Resident Rooms Free of Ongoing Water Leaks
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment by not ensuring that multiple resident rooms were free of water leaks, contrary to its Physical Environment and General Maintenance policies. In one room, a resident with spinal stenosis, polyneuropathy, and type II DM, who had mildly impaired cognition and required moderate to maximal assistance with ADLs, reported feeling water dripping from the ceiling beginning the previous day. Surveyors observed a concentric ring and water bubble on the ceiling, with the resident’s bed moved to the middle of the room to avoid getting wet, and towels, blankets, and a basin placed on the floor to collect water from the ceiling. In another room, a resident with hemiplegia and hemiparesis affecting the right dominant side, epilepsy, and muscle weakness, who required moderate to clean-up assistance with ADLs, was observed with water actively dripping from the ceiling. The ceiling showed rusty brown discoloration, and a basin, blankets, and towels were on the floor to catch the water. The Maintenance Director acknowledged that the roof had been repaired previously but that water leaks persisted, especially after rain, and described a bubble dent and water stains on one room’s ceiling and water intrusion through a window that required towels and blankets to block incoming water. The DON stated that water leaks and water on the floor put residents at risk of injury and acknowledged that residents should have been moved to provide a safe environment.
Failure to Reposition Resident, Complete Skin Assessment, and Correctly Set LAL Mattress for Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards and its own policies for a resident with multiple Stage 4 pressure ulcers. The resident had diagnoses including malignant melanoma of the left upper limb and shoulder, Stage 4 pressure ulcers of the left buttock and sacral region, metabolic encephalopathy, and dementia, and required total dependence for ADLs per the MDS. A wound care provider documented physician instructions for offloading and repositioning throughout 24 hours, including at night, using wedges for support and frequent incontinence garment changes to prevent moisture-associated skin damage. The resident’s care plan for risk of impaired skin integrity specified goals to prevent further skin breakdown with interventions including turning and repositioning every two hours and more frequently if needed, use of an appropriate pressure-reducing mattress, and frequent incontinence pad changes. An IDT meeting with the resident’s POA documented that the plan of care included ensuring the resident would be turned and repositioned as scheduled and as needed, side to side only, to keep pressure off the sacral open area. Despite these documented plans and orders, the facility’s own records showed that the resident was not repositioned according to the every-two-hour schedule. Review of the ADL turn and repositioning log for nearly a one‑month period showed the resident was turned only two to three times per day, rather than every two hours as required by the care plan and IDT decisions. Interviews with the resident’s private caregiver and a CNA confirmed that the private caregiver was performing most of the resident’s ADLs, including turning, repositioning, feeding, and changing incontinent briefs, with CNAs assisting only at times. The DON acknowledged that CNAs and staff are responsible for ADL care and confirmed that the log documented turning only two to three times per day instead of every two hours. Facility policies on Prevention of Pressure Ulcers/Injuries and Activities of Daily Living required residents in bed to be repositioned at least every two hours and CNAs to turn and reposition residents at least every two hours, which was not reflected in the documentation for this resident. The facility also failed to complete and document required skin and pressure ulcer risk assessments upon the resident’s readmission, contrary to its Admission Assessment – Nursing policy and its Pressure Ulcer/Injury Management policy. The DON and treatment nurse both stated that residents’ skin must be assessed, evaluated, and documented on admission and readmission, and that the absence of documentation meant the assessment was not done. Additionally, the facility did not ensure the low air loss (LAL) mattress was set according to the resident’s weight, as required by the physician’s order for an alternating pressure mattress and the facility’s Low Air Loss Mattress policy. The resident’s weight was documented as 158 lbs and later 156 lbs, but observation showed the LAL mattress control set to firm at 250 lbs. The treatment nurse and DON both stated that the LAL mattress setting should correspond to the resident’s weight and that an incorrect setting would not assist with wound prevention and management. These failures in repositioning, admission skin assessment, and proper LAL mattress setup constituted the deficient practices identified by the surveyors.
Failure to Accurately Assess Fall Risk and Complete Post-Fall Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for falls was properly assessed and monitored after fall events, in accordance with its own fall-related policies and procedures. Resident 8 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, abnormalities of gait and mobility, and a history of falling. An MDS dated 1/15/2026 documented mildly impaired cognitive skills for daily decisions and a need for moderate to supervision assistance with ADLs, as well as use of a manual wheelchair. The resident’s fall risk care plan, initiated on 7/17/2025, identified problems and concerns related to falls and potential for injury due to balance issues, cognitive and physical impairment, generalized weakness, lack of coordination, and hemiparesis/hemiplegia, with interventions such as maintaining a hazard-free environment, keeping the call light and frequently used items within reach, and providing assistance with transfers. The facility’s fall risk evaluations for Resident 8 showed inconsistent and inaccurate scoring relative to the resident’s condition and history. A fall risk evaluation dated 10/22/2019 showed a high fall risk score of 11, while the evaluation dated 1/16/2026 showed a moderate fall risk score of 8, and the evaluation dated 2/17/2026 again showed a high fall risk score of 13. During interview and record review, RN 1 acknowledged that the 1/16/2026 fall risk evaluation was not accurately documented: the item for history of falls in the past three months was scored as 0 (no falls), despite facility records indicating a history of falls, and the gait/balance section was left blank instead of reflecting multiple balance and gait problems and the need for assistive devices. These inaccuracies meant the documented fall risk score did not accurately reflect the resident’s true fall risk status. The facility also failed to complete and document required 72-hour post-fall neurological checks after Resident 8 slipped out of the wheelchair during a transfer on 1/16/2026 and was later found on the floor on 2/17/2026. Review of the 72-hour neuro check documentation showed that post-fall neuro assessments were only recorded on 1/17/2026 during the 7 a.m.–3 p.m. shift and on 1/19/2026 during the 11 p.m.–7 a.m. shift, with no neuro checks documented on the evening and night shifts of 1/16/2026, the evening and night shifts of 1/17/2026, or on any shift on 1/18/2026. RN 1 stated that, per facility practice, residents must be checked by licensed nurses on all three shifts for 72 hours after a fall, and the DON confirmed there were inconsistencies and incomplete documentation of the post-fall assessments and fall risk evaluations. These actions and omissions constituted a failure to follow the facility’s policies titled “Falls by a Resident” and “Fall Risk & Prevention of Injury to include pathological Fractures,” which require complete post-fall assessments, incident investigations, and accurate fall risk assessments to guide care planning.
Failure to Notify Physician and Implement Elopement Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Change of Condition – SBAR policy and its Wandering/Exit Seeking Behavior policy for a newly admitted resident with severe dementia, depression, and psychoactive substance abuse. The resident had been hospitalized for failure to thrive, significant weight loss, and psychostimulant use disorder, and was documented as lacking capacity to make decisions. On admission, an elopement risk assessment scored the resident at 24, which the facility defined as high risk for elopement. Facility policy and the Registered Nurse Supervisor’s interview indicated that such abnormal findings required physician notification to obtain orders for a wander guard, but the physician was not informed and no wander guard order was obtained. On the day of admission, staff documented and observed multiple episodes of exit-seeking behavior. The visual hourly check log, initiated that afternoon, recorded that the resident attempted to exit the building several times in the evening and overnight, and that staff redirected and returned the resident to his room on at least three occasions. Nursing progress notes described the resident walking the hallway looking for an exit, expressing a desire to leave because he wanted to “live his life to the fullest,” and being difficult to redirect. Despite these repeated behaviors and the high elopement risk score, there is no documentation that the physician was notified or that elopement precautions requiring a physician order, such as a wander guard, were implemented. In the early morning hours following these events, the visual check log showed that at 4 a.m. the resident was no longer in his room. A CNA reported that the resident had been asleep around 1 a.m. and was still asleep when the CNA left for break at 3:30 a.m., but when the CNA checked again at approximately 4:20 a.m., the resident could not be found in his room or elsewhere in the facility. The resident’s family member reported having previously asked during a facility tour about residents’ ability to get out and was told there would be door monitoring and alarms. The family member later received a call from the facility stating the resident was missing, and then a call from police that the resident had been located in another city with bruises and scratches, with the resident stating he had fallen. The DON confirmed that once a resident is identified as an elopement risk, protocol including staff alerting and wander guard placement with a physician order should be initiated as soon as possible, which did not occur in this case.
Failure to Care Plan for High Elopement Risk Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized, comprehensive care plan addressing elopement risk for a newly admitted resident who had been clearly identified as high risk for elopement. The resident was admitted with diagnoses including dementia with behavioral disturbance, depression, and psychoactive substance abuse, and preadmission information from a general acute care hospital documented severe dementia, lack of decision-making capacity, failure to thrive, significant weight loss, and psychostimulant use disorder. An elopement risk assessment completed at admission scored the resident at 24, which the facility defined as high risk (17 or higher), and the facility’s policies required that such findings be incorporated into a baseline and comprehensive care plan with measurable objectives and interventions, including care plan interventions for wandering/exit-seeking behavior. Despite this high-risk assessment and the facility’s written policies, no elopement risk care plan was developed for the resident, and the physician was not notified to obtain an order for a wander guard. Nursing documentation and visual hourly check logs from the evening and night of admission showed multiple episodes of exit-seeking behavior: the resident attempted to exit the building several times in the west hallway and was redirected back to the room at 7 p.m., 9 p.m., and 1 a.m. A nursing progress note described the resident walking the hallway looking for an exit, expressing a desire to leave because he wanted to “live his life to the fullest,” and being difficult to redirect. CNA interview confirmed that exit-seeking behavior began after dinner, that the resident became upset when redirected back to his room, and that the resident was last observed asleep around 1 a.m. By 4 a.m., staff discovered the resident was no longer in the room or anywhere in the facility, and the resident’s whereabouts were unknown for an extended period. The resident’s family member reported having previously asked during a facility tour whether residents could get out and was told there was someone at the door during the day and that the door was locked and alarmed at night. The family member stated that on admission day, the resident had repeatedly asked to go home and needed reminders to stay. The family member later received notification from the facility that the resident was missing and subsequently from police that the resident had been located in another city with bruises and scratches, and the resident reported having fallen. Facility leadership and the RN supervisor acknowledged in interviews that the resident had been assessed as a high elopement risk, that the physician was not informed, and that an elopement care plan and related interventions were not initiated as required by facility policy, which could have prevented the resident from leaving the facility without staff knowledge.
Failure to Follow Physician Orders and Initiate SBAR Monitoring
Penalty
Summary
The facility failed to follow physician orders for Resident 75’s oral care and water intake. Resident 75 had diagnoses including hypertension, acute kidney failure, and depression, and was assessed as cognitively intact but requiring maximal assistance with multiple activities of daily living. After returning from the VA hospital following surgery, the resident was supposed to receive ice chips and later transition to water after oral care. The chart also contained a physician order for chlorhexidine gluconate mouth/throat solution every shift with water following the solution, but the resident’s representative stated the resident had not received oral care treatments or the ordered water. Staff interviews showed confusion about the order, with the DON stating the transcription and progress note were confusing and could lead to delayed care or orders not being followed. The facility also failed to initiate an SBAR/change-of-condition process and continue monitoring for Resident 115 after abdominal pain was documented. Resident 115 had diagnoses including chronic kidney disease, acute cystitis, and hydronephrosis, and was dependent on staff for several activities of daily living with severely impaired cognition. Nursing notes documented new abdominal pain and an abdominal x-ray was ordered, but the responsible party refused the x-ray. The record did not show that staff initiated a change-of-condition form or SBAR, and there was no documentation that abdominal pain, bowel patterns, or bowel movements were monitored for 72 hours as described by staff during interview. Resident 115 was later transferred to a GACH for lethargy, nausea, and poor appetite. The ADON stated the SBAR form should have been initiated to notify staff to monitor the resident for 72 hours, and the DON stated the SBAR activates staff to continue monitoring every shift for at least 72 hours. The facility policy stated that changes in condition are to be assessed and evaluated using the SBAR process with physician notification for early clinical management to avoid unnecessary readmissions.
RNA Competency and Restorative Program Order Not Followed
Penalty
Summary
The facility failed to complete annual competencies for putting on and taking off splints for two Restorative Nursing Assistants (RNAs). During a concurrent interview and record review, the Director of Staff Development reviewed RNA 1’s annual competency evaluation dated 9/15/2025 and RNA 2’s annual competency evaluation dated 9/2/2025 and stated that neither evaluation included skills for putting on and taking off splints. The Director of Staff Development stated that splint application and removal were part of the RNA duties and skills in the restorative nursing program. The Director of Nursing stated that all staff required annual competencies covering all areas and skills performed in their daily job to ensure they were competent in their roles and assignments. The DON also stated the facility would not know if RNA staff could safely and correctly apply and remove a splint if competency was not assessed, and that incorrect splinting could cause harm or damage to a resident. The facility’s RNA job description stated that RNAs were responsible for ensuring placement of restorative devices and equipment and must demonstrate the knowledge and skills necessary to provide care appropriate to the residents served. The facility also failed to follow Resident 74’s ordered restorative nursing program during an observed treatment session. Resident 74 was admitted with spinal stenosis, polyneuropathy, and unsteadiness on feet, and the MDS indicated cognitive intactness with dependent assistance needed for several activities and functional limitations in ROM of both upper and lower extremities. The resident’s orders included AAROM for both upper extremities and omnicycle therapy. During observation, RNA 1 performed AAROM to both upper and lower extremities and told the resident the omnicycle would be done the next day, stating the resident did not want to get out of bed and that leg ROM was done instead. RNA 1 stated the resident’s treatment orders were for upper extremity AAROM and omnicycle if the resident got up in a wheelchair, and that the resident did not want to get out of bed that day.
Inaccurate RNA Documentation and Improper Therapy Note Signatures
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three sampled residents. For one resident with diagnoses including right femur fracture and atrial fibrillation, the Minimum Data Set showed severe cognitive impairment and dependence for multiple activities of daily living. The resident had restorative nursing assistant orders for passive range of motion exercises to all extremities. On review of the February 2026 RNA treatment flowsheet, an entry showed RNA treatment completed on 2/4/2026, but the Director of Staff Development, the Assistant Director of Nursing, and RNA 2 all stated RNA 2 had not been at the facility to provide that treatment and the documentation was not accurate. For another resident with complete paraplegia and lack of coordination, the record review showed PT treatment encounter notes in which COTA 2 signed on behalf of PT 1. The Director of Rehabilitation/COTA 1 stated the PTA treatment note required supervision and co-signing by the supervising PT, and that it was the responsibility of each therapist to sign their own treatment note. She also stated a COTA was not qualified to verify whether a PTA treatment was valid and within the resident’s plan of treatment and care. OT 1 stated only the PT could co-sign a PTA’s notes, and the DON stated staff could not sign on someone else’s behalf. The same issue was identified again in another resident’s PT treatment encounter note, where DOR/COTA 1 signed on behalf of PT 1. The facility policy on Documentation Principles stated entries must be accurate, timely, objective, specific, concise, legible, clear, and descriptive, and that an entry should never be signed by someone other than the person making the entry. The PT job description stated the PT maintains necessary documentation of services in the medical record and supervises up to two PTAs. These findings showed inaccurate RNA documentation for one resident and improper signing of PT treatment notes for two residents.
Infection Control Failures in Resident Room, Therapy Equipment, and Laundry Handling
Penalty
Summary
The facility failed to provide infection prevention and control measures in a resident room shared by two residents. Resident 74 was admitted with diagnoses including spinal stenosis, polyneuropathy, and unsteadiness on feet, and was cognitively intact but required dependent assistance with oral hygiene, toileting, dressing, and sit-to-lying. Resident 56 had diagnoses including low back pain, metabolic encephalopathy, and unspecified dementia, and was also cognitively intact but required dependent assistance with toileting hygiene and dressing, and maximal assistance with rolling left and right. During observation, staff in the room stated that both the soap dispenser and the hand sanitizer dispenser were not working, and the maintenance director later confirmed that neither dispenser worked and that both should be working at all times so staff could perform hand hygiene. The facility also failed to properly sanitize a cloth gait belt used with multiple residents in therapy. In the therapy gym, Resident 69 was observed using a pink cloth gait belt, and another similar gait belt was hanging on the equipment rack. The Director of Rehabilitation confirmed that therapy staff used pink cloth gait belts with multiple residents throughout the day and cleaned them with disinfectant wipes between uses. The Infection Preventionist stated the disinfectant wipes were intended only for non-porous surfaces, that cloth gait belts were porous, and that the wipes could not properly disinfect the gait belts. The facility further failed to handle soiled linen in a sanitary manner in the laundry area. During observation, the laundry chute was described as completely filled with linens, with linens extending up from the floor into the chute. Feces-soiled towels were observed in the chute area, not bagged and exposed to the air. The laundry worker stated the linens were not stored in a sanitary manner because the washing machine was broken, and the Infection Preventionist stated the chute was overfilled and that linens should be stored inside plastic bags until separated. The DON stated soiled linens are bagged before being sent down the laundry chute.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
Licensed nursing staff failed to offer the pneumococcal vaccine to two sampled residents. Resident 13 was readmitted with diagnoses of cerebral infarction, respiratory failure, and hypertension, and a later MDS showed severely impaired cognition with total dependence on staff for transfer, dressing, eating, toileting, and personal hygiene. Resident 13's immunization record showed the resident had never received the pneumonia vaccine, and the immunization consent form did not indicate education on the pneumococcal vaccine. The medical chart did not show that the vaccine had been offered. Resident 32 was originally admitted and later readmitted with diagnoses including a stage 4 pressure ulcer/injury, atrial fibrillation, and hypertension. The resident's MDS showed intact cognition and need for partial to substantial assistance with toileting hygiene, showering/bathing, lower body dressing, and personal hygiene, and also indicated the pneumococcal vaccination was not up to date. The immunization consent form documented education on the COVID-19 vaccine, but did not indicate education on the pneumococcal vaccine. During interview, the DON stated the facility offers vaccines at admission and during the active season, and the IP stated review of the consent forms showed the pneumococcal vaccination had not been offered to these residents. The facility policy stated all residents are to be evaluated for pneumococcal vaccination status on admission and that education, receipt, refusal, or medical contraindication should be documented.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to ensure that Resident 38 or the resident’s representative was notified in writing in a timely manner of the reason for the transfer/discharge to the hospital. Resident 38 was admitted to the facility with diagnoses including dementia, dysphagia, and a gastrostomy tube, and the Minimum Data Set indicated the resident was cognitively intact and dependent on staff for activities of daily living. A physician order dated 12/14/2025 indicated the resident may transfer to a general acute care hospital, and the notice of transfer/discharge form dated the same day listed the person notified as Resident 38. During interview and record review, the Registered Nurse Supervisor stated that a notice of proposed transfer is completed at the time of transfer to the hospital and is provided to the resident and/or representative, then faxed to the Ombudsman. The Director of Nursing stated that the notice of proposed transfer is mailed to the resident representative at the time of transfer, and if it is not done, the representative may not be aware of the resident’s whereabouts. The facility policy required written notice to the resident and, if known, a family member or legal representative, including the reason for the move, before transfer or discharge when practicable.
Late Transmission of MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident 75’s MDS assessments were transmitted to CMS within 14 days after completion. Resident 75 was admitted with diagnoses including hypertension, acute kidney failure, and depression. The resident’s MDS dated [DATE] indicated cognition was intact and that the resident required maximal assistance from staff for toileting, hygiene, bathing, upper and lower body dressing, and personal hygiene. During interview and record review with the RN/MDS on 2/6/2026 at 10:29 PM, the facility’s Resident 75 MDS Medicare 5-day assessment was reviewed. The RN/MDS stated that the facility completed the 5-day MDS on 12/7/2025 but did not transmit it to CMS until 2/6/2026, which was 61 days late. The facility’s RAI Process stated that the facility would transmit MDS assessments in accordance with the transmission dates outlined.
Inaccurate MDS Documentation of Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected Resident 2’s antipsychotic medication use. Resident 2 was re-admitted with diagnoses including cerebral infarction, respiratory failure, and dementia, and the most recent quarterly MDS indicated moderate cognitive impairment. However, the MDS also documented that the resident had taken an antipsychotic medication during the 7-day lookback period, while the active order summary showed the resident was not prescribed an antipsychotic on the referenced date. During a concurrent interview and record review, the MDS Coordinator reviewed the resident’s MDS and medication administration records and stated the quarterly MDS showed the resident was taking an antipsychotic medication, but the resident was not taking one in December 2025 or during the 7 days before the MDS was coded. The MDS Coordinator stated the MDS was not correct. The DON stated the MDS must be accurate because it is the basis for the resident’s plan of care and that an inaccurate MDS can lead to ineffective patient care. The CMS RAI User’s Manual stated the person completing the MDS is to check whether any antipsychotic medication was taken during the 7-day lookback period, and the facility’s RAI Process policy stated the RAI process is used for accurate assessment of each resident’s functional capacity and health status.
Missing PASRR Screening for Admitted Resident
Penalty
Summary
The facility failed to complete a PASRR for one of 33 sampled residents, Resident 29, who was admitted with diagnoses including epilepsy, PTSD, diabetes type 2, depression, COPD, and hypertension. A review of the resident’s MDS dated 12/8/2025 indicated moderately impaired cognition. During a concurrent interview and record review with the ADON on 2/5/2026 at 12:43 pm, the resident’s paper chart and E-mar were reviewed and showed there was no initial pre-admission screening completed prior to and/or upon admission on [DATE], and the ADON stated the resident’s PASRR was not in the E-mar and/or physical medical chart. During an interview on 2/6/2026 at 4:31 pm, the DON stated PASRR should be completed within 24 hours of admission/re-admission to evaluate the resident’s need for skilled nursing and ensure residents receive appropriate care. The facility’s revised policy and procedures dated 7/11/2025, titled PASRR, stated that each resident applying for admission to, or residing in the facility, regardless of payment source, shall have a PASRR Level 1 Screening completed using the California DHCS Online PASRR 6170 in accordance with the specific timelines.
Missed RNA Treatments for Resident With Limited ROM
Penalty
Summary
The facility failed to provide Restorative Nursing Assistant (RNA) treatments as ordered for one resident with diagnoses including spinal stenosis, polyneuropathy, and unsteadiness on feet. The resident’s MDS indicated cognitive intactness but dependence for oral hygiene, toileting, dressing, and sit-to-lying, along with functional limitations in ROM of both upper and lower extremities. The resident’s orders included RNA program services for AAROM to the left UE four times a week, AAROM to the right UE four times a week, and omnicycle exercise three times a week as tolerated. The restorative nursing care plan identified an increased risk for decline in mobility and set a goal to maintain ROM in both UEs and LEs, with interventions for LE omnicycle exercise and UE AAROM as tolerated. Review of the RNA treatment flowsheets showed missed treatments in November, December, and January. During observation, the resident was in bed, could move the right arm up and down, had difficulty moving the left arm, and stated he did not receive exercises with staff and instead performed his own exercises with resistance bands tied to the side rails. The DSD reviewed the flowsheets and confirmed missing RNA treatments, and the DON stated the RNA program was intended to maintain the resident’s current functional status and that residents should receive RNA treatments as ordered.
Incomplete Labeling of Enteral Feeding
Penalty
Summary
The facility failed to label the gastric tube feeding with the date it was hung for one sampled resident who had a gastrostomy tube and was receiving enteral nutrition. The resident was admitted with diagnoses including dementia and dysphagia, and the physician order directed Glucerna 1.2 to be administered every night shift via pump at 60 mL per hour. During a concurrent observation and interview, the tube feeding formula was connected and running, but the label on the feeding was missing the date it was hung. During the interview, the LVN stated tube feeding labels should include the date it was hung so staff know when it was started and when it needs to be changed, and stated the resident's label was incomplete and inaccurate. The DON stated the date should be included when the feeding is hung because the formula has an expected run time per the manufacturer's directions, and that hanging it past the expected time may lead to adverse effects such as nausea, vomiting, and fever. The facility policy required closed enteral feeding containers to be labeled with the date hung, time hung, and initials of the staff member who initiated the feeding.
Failure to Administer Ordered Medications
Penalty
Summary
The facility failed to ensure that one resident received medications as ordered by the physician and in accordance with the facility's medication administration policy. Resident 45 was admitted with diagnoses including hypothyroidism, lymphedema, and osteoarthritis of the knee, and was documented as cognitively intact and dependent on staff for activities of daily living. Physician orders included Levothyroxine Sodium 100 mcg by mouth for low thyroid hormone and Hydrocodone-Acetaminophen 10-325 mg by mouth every 12 hours for pain management. Review of the MAR showed blank administration boxes for Hydrocodone-Acetaminophen on 12/12/2025 and for Levothyroxine on 1/15/2026, and the resident stated he missed his pain medication twice in 12/2025 and once in 1/2026, as well as his thyroid medication on 1/30/2026, 1/31/2026, and 2/1/2026. During interviews, the RN supervisor stated that a blank box meant the medication was not given, and the DON stated the routine pain medication was intended to prevent pain from the resident's chronic condition and that Levothyroxine was used to balance thyroid levels. The facility's medication administration policy required medications to be given safely, timely, and as prescribed, within one hour before or after the scheduled time unless otherwise specified.
Medication Order Missing Indication for Use
Penalty
Summary
The facility failed to ensure that a resident’s medication order included the indication for use, as required by its policy and procedure titled Physician Services and Orders. Resident 14 was admitted with diagnoses including lymphedema, DM, and HTN, and the physician’s order dated 10/22/2025 directed Ketoconazole External Cream 2% to be applied topically to the lower extremities every day shift for lower extremities. The resident’s MDS dated 10/29/2025 indicated cognitive impairment and extensive staff assistance with ADLs. During a concurrent interview and record review, an LVN stated the resident had hyper ketosis on the bilateral lower extremities and that staff were applying Ketoconazole to the BLE, but also stated the order was missing the diagnosis for which it was being given. The LVN stated the diagnosis is needed so staff know what the resident is being treated for and so the medication is not used without a full order. The DON also stated that a complete medication order needs to include an indication for use so staff know what the medication is being given for, and that without it staff may misjudge why they are giving the medication and may not be able to look out for effects of the medication. The facility policy stated medication orders must include the reason or problem for which the medication is given.
Unlabeled Food Stored in Resident Refrigerator
Penalty
Summary
The facility failed to label and date food items in the resident refrigerator in accordance with facility policy. During an observation, the refrigerator next to the nurse's station contained a paper bag, a tied plastic bag with only a room number written on it and no date, and a container of tiramisu with no name, room number, or date. The Assistant Director of Nursing confirmed that the items were not dated, inspected the bag and found a plate covered with a black plastic dome lid containing a slice of ham and cooked greens, and stated that the unlabeled dessert could not be confirmed as belonging to a resident or staff. The ADON also stated that food items without a name or date should be discarded and that the condition posed a risk for foodborne illness. The posted refrigerator sign required food to be labeled with name, room number, and date, and to discard unlabeled food or food beyond 72 hours of the labeled date. The facility policy titled Refrigerator for Resident Storage of Food stated that food would be labeled with the resident's name and the date it was placed in the refrigerator.
Insufficient Bed Curtains for Resident Privacy
Penalty
Summary
The facility failed to provide full-length curtains around the beds for two residents, which prevented full privacy in their shared room. Resident 74 was admitted with diagnoses including spinal stenosis, polyneuropathy, and unsteadiness on feet, and was cognitively intact but required dependent assistance with oral hygiene, toileting, dressing, and sit to lying. Resident 56 was initially admitted and later readmitted with diagnoses including low back pain, metabolic encephalopathy, and unspecified dementia, and was cognitively intact but required dependent assistance with toileting hygiene and dressing, and maximal assistance with rolling left and right. During observation and interview in the shared room, Resident 74 stated that the curtains around both beds did not pull all the way and that the curtain for the roommate was falling off on one side and did not pull all the way for privacy. The Maintenance Director observed that the curtain around Resident 74's bed was not long enough to cover that half of the room and was too short, and stated that if the curtain was pulled toward the window, the roommate could be seen. The Maintenance Supervisor stated both curtains were too short and needed to be longer to cover the whole part of the bedroom. The DON stated the curtains in each resident's room are for privacy and should be long enough to give a resident full privacy, and the facility policy indicated residents have a right to dignity and privacy.
Missing Closet Door and Drawer in Resident Room
Penalty
Summary
The facility failed to provide one of 22 sampled residents, Resident 74, with an appropriate closet with doors and drawers in the resident's room. Resident 74 was admitted with diagnoses including spinal stenosis, polyneuropathy, and unsteadiness on feet. The MDS dated 1/13/2026 indicated the resident was cognitively intact and required dependent assistance with oral hygiene, toileting, dressing, and sit to lying. During observation in the resident's room, Resident 74 stated the closet had no door, clothes were stored in plastic bags stacked inside the closet, and there was no door to the closet. The resident stated the closet had been without a door since moving into the room about a month earlier and said the room felt like a slum. CNA 2 confirmed the closet did not have a door and was missing the top drawer, stating there should be two drawers and a door for each resident's closet. The MTD also confirmed the closet door was missing and stated a resident should have a closet door to keep things out of the closet and feel comfortable in the room. The DON stated each resident should have a closet with doors and drawers in their room, and the facility policy on Resident's Right to Dignity and Privacy stated each resident shall be cared for in a manner that promotes dignity, respect, individuality, and privacy.
Call Light Out of Reach for Resident Needing Assistance
Penalty
Summary
The facility failed to ensure that a working call system was within reach in a resident’s bathroom and bathing area, and the deficiency was identified for one sampled resident. Resident 11 was admitted with diagnoses including muscle weakness, dementia, and depression. The resident’s MDS dated 12/21/2025 indicated cognition was intact, and the resident required moderate to maximal assistance from staff for toileting, hygiene, bathing, upper and lower body dressing, and personal hygiene. During observation on 02/04/2026 at 12:48 PM, Resident 11 was lying in bed and the call light was observed hanging off the bed nearly touching the floor on the right side of the bed and out of reach. During interview, Resident 11 stated he did not know where the call light was and pointed to the floor on the right side of the bed. CNA 6 stated the call light should not be hanging at the bedside and should be within reach so the resident can call for help if needed. The DON stated the call light must remain within reach of all residents so they can push it to alert staff when assistance is needed. The facility policy titled, Nursing - Call Lights, stated that when the resident is in bed or in a wheelchair or chair in the room, staff should make sure the call light is within easy reach of the resident.
Peeling Paint and Ceiling Stains in Resident Room
Penalty
Summary
The facility failed to provide a safe and comfortable environment for one of 22 sampled residents, Resident 74, whose room had a large patch of peeling paint next to the window, a brown circular stain on the ceiling to the right of the window, and bubbling paint on the ceiling. Resident 74 was admitted with diagnoses including spinal stenosis, polyneuropathy, and unsteadiness on feet, and the MDS indicated he was cognitively intact and required dependent assistance with oral hygiene, toileting, dressing, and sit to lying. During observation and interview, Resident 74 stated there were brown stains on the ceiling from a roof leak and that the facility had not fixed anything, adding that he felt like he lived in a slum while paying hundreds of dollars a day. A CNA observed the brown ceiling stains and peeling paint and stated the ceiling looked like rain had dripped through it. The MTD confirmed the stains were from a roof leak during the last rains, that the ceiling still needed to be fixed, and that the wall and ceiling needed to be patched, sanded, and painted. The DON stated there should not be peeling paint, bubbling paint, or stains because it was not a homelike environment. The facility policy stated it is the policy to maintain a safe, clean, comfortable environment for residents.
Failure to Follow Self-Administration Determination and Complete Wound/Catheter Treatments and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of quality in medication/treatment administration and documentation for two residents. For Resident 1, the Self-Administration of Drugs Assessment, completed by the IDT, indicated it was not safe for the resident to self-administer drugs. Despite this, Treatment Nurse 1 reported that the resident was performing his own suprapubic catheter flushes, and she documented the ordered daily flushes as completed on the Treatment Administration Record (TAR) even though she did not perform them and had never observed the resident doing them. The TAR for Resident 1 also showed blank entries, without any notation of refusal or other explanation, for ordered treatments including suprapubic catheter care and left ischium wound care on multiple dates. Resident 1’s clinical information showed he had neuromuscular dysfunction of the bladder, HTN, atrial fibrillation, an indwelling suprapubic catheter, and required moderate to maximal assistance with ADLs, while his MDS indicated intact cognitive skills for daily decisions. He reported that on one day he did not receive any of his daily skin treatments because there was no treatment nurse available, and he stated that his suprapubic catheter required daily care. Treatment Nurse 1 acknowledged that on one of the cited dates she did not provide any skin treatment because the resident refused suprapubic catheter care, yet this refusal and the missed treatments were not documented on the TAR. She further acknowledged that she signed for treatments as if she had administered them on multiple dates when she had not. For Resident 2, who had diagnoses including neuromuscular dysfunction of the bladder, HTN, and atrial fibrillation, and required moderate to maximal assistance with ADLs, the physician’s orders included daily sacrococcyx wound care with NS, medihoney, and dry dressing, and daily topical ketoconazole cream to the right lower back. Review of Resident 2’s TAR showed multiple blank entries for these ordered treatments on several dates, with no documentation of completion, refusal, or any reason for the omissions. Registered Nurse 1 confirmed that a blank TAR entry with no notation means the treatment was not done and that the correct process is to document why a treatment was not completed rather than leaving the TAR blank. Facility policies on self-administration of medications and prevention of pressure ulcers/skin care required IDT determination of self-administration safety and detailed documentation of skin care, refusals, and resident condition, which were not followed in these cases.
Failure to Obtain Proper Informed Consent for Vaccinations
Penalty
Summary
Facility staff failed to obtain proper informed consent for COVID-19 and influenza vaccinations for a resident with cognitive impairment. The resident, who had diagnoses including schizophrenia and was documented as lacking capacity for medical decision-making, was recorded as having verbally declined both vaccinations. However, according to the facility's policy and the Director of Nursing, residents without decision-making capacity should not be providing consent or declination themselves; instead, consent or declination should be obtained from the resident's representative or family member. Record reviews showed that the resident's medical history and assessments indicated impaired cognition and mental incapacitation. Despite this, the facility documented the resident's own verbal declination for both vaccines, rather than obtaining the required authorization from a representative. The facility's policy requires that informed consent or declination for vaccinations be obtained from the appropriate decision-maker and properly documented, which was not followed in this case.
Failure to Adhere to Infection Control Practices and Documentation
Penalty
Summary
The facility failed to ensure adherence to infection prevention and control practices in several key areas. Four out of five sampled residents did not receive COVID-19, pneumonia, and influenza vaccines as required, despite some having provided verbal consent for vaccination. Documentation was lacking in the residents' medical records to confirm administration of these vaccines, and there was no evidence of consent or declination for the pneumonia vaccine. The Director of Nursing confirmed that there was no documentation in the electronic or physical charts to show that the vaccines were administered, and was unsure why the vaccinations were not given even when consent was obtained. Staff members, including two CNAs and an LVN, were observed not adhering to proper infection control protocols. One CNA entered a COVID isolation room without performing hand hygiene and without donning the required PPE, aside from an N95 mask. This CNA also improperly handled contaminated linen by carrying it into the hallway instead of placing it in the designated hamper inside the isolation room. Both the CNA and LVN admitted to not being fit tested for the N95 masks they were wearing, and the facility's fit testing binder lacked current documentation for these staff members. The Director of Nursing acknowledged that fit testing should be conducted annually and upon hire, but records were incomplete or outdated. Housekeeping practices were also found deficient, as high-touch surfaces such as handrails were not consistently documented as being disinfected according to the facility's COVID-19 Mitigation Plan, which requires cleaning at least every four hours. The janitor stated that while disinfection occurred twice per shift, there was no log or documented evidence to verify this. The Director of Nursing was unable to confirm the frequency of disinfection or the existence of a tracking log, despite facility policy requiring such documentation. These lapses in infection control practices were observed and confirmed through interviews, record reviews, and direct observation.
Failure to Follow Infection Control Protocols During Linen Handling
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed carrying clean towels, linen, a gown, and chux pads when a towel slipped from their hand and fell onto the floor. The CNA picked up the towel, mixed it with the remaining clean items, and proceeded toward a resident's room with the intention of using the contaminated towel on the resident. The incident was witnessed by a surveyor, and the CNA acknowledged that the towel had been on the floor and was about to be used for resident care, which is a violation of infection prevention protocols and facility policy. The contaminated items were subsequently discarded after the CNA was confronted. The resident involved had a complex medical history, including acute respiratory failure with hypoxia, a benign neoplasm of the meninges, acute kidney failure, and a tracheostomy. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Prevention Nurse, confirmed that using linen that had been on the floor poses a risk of infection, especially for immunocompromised residents. The facility's infection control policy specifies that any linen that comes into contact with the floor should be treated as contaminated and not used for resident care.
Failure to Provide Timely Ophthalmology Services for Resident with Ongoing Eye Symptoms
Penalty
Summary
The facility failed to ensure that a resident with a history of type 2 diabetes and essential hypertension received appropriate ophthalmology services as required by physician orders, resident preferences, and facility policy. The resident, who was moderately cognitively impaired and required maximum assistance with activities of daily living, experienced untreated bilateral itchy and discolored eyes since admission. Multiple staff members, including a CNA and LVN, observed the resident rubbing her eyes and noted discoloration but did not report these symptoms to nursing or medical staff. A family member also reported the resident's ongoing eye issues to a charge nurse, but there was no evidence that this concern was communicated to a physician or resulted in an ophthalmology referral. Record reviews confirmed that there were no active orders for ophthalmology services for the resident, and no documentation indicated that the resident had been seen by an eye doctor since admission. The Director of Social Services and DON both acknowledged that the resident had not been scheduled for or received eye care in accordance with facility policy, which required eye doctor visits every 3-6 months and as needed. The ophthalmologist confirmed that he had not been notified of the resident's symptoms and only conducted annual visits. The administrator stated that residents are seen by the ophthalmologist based on need, but also indicated there was no formal policy for eye or vision care in place.
Failure to Notify Family of Resident Room Changes
Penalty
Summary
The facility failed to notify a resident's family member when the resident was moved to different rooms on two consecutive days. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was transferred without the knowledge or consent of her family member. The family member reported not being informed or consulted about the room changes, which resulted in the resident being placed in a three-bed room with limited space, making it difficult to use necessary equipment such as a Hoyer Lift and leaving the resident without a bedside table for personal belongings. Interviews and record reviews confirmed that there was no documentation of family notification regarding the room changes, as required by the facility's policies and procedures. The Social Services Director acknowledged that the facility is responsible for notifying family members or representatives of room transfers and confirmed that this did not occur in this instance. The facility's policies also require documentation of the room transfer and communication with the resident and their representatives, which was not completed.
Failure to Protect Resident Property Resulting in Loss of Hearing Aid
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal property, specifically a cochlear hearing aid. The resident, who had severe bilateral hearing loss and a history of cochlear implant surgery, was cognitively impaired and fully dependent on staff for activities of daily living. Upon admission, the resident's hearing aid and charger were documented in the inventory list. The resident's family member reported the hearing aid missing after being unable to locate it in the resident's room and notified facility staff and management. Despite this report, the hearing aid was not replaced, and communication with the resident became difficult for the family member. Interviews and record reviews revealed that the Social Services Director was aware of the missing hearing aid and stated that an investigation and replacement process was underway. However, there was no evidence in the medical record that a theft and loss report had been filed as required by facility policy. The policy mandates prompt and thorough investigation of all reports of theft or misappropriation, including interviews and searches, but these steps were not documented as completed for this incident.
Failure to Develop Comprehensive Care Plan for Tube-Pulling Behaviors
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan addressing a resident's behavior of removing hand mittens and pulling on their tracheostomy and gastrostomy (g-tube) tubes. The resident, who had diagnoses including respiratory failure, ventilator dependence, type II diabetes mellitus, and anxiety, was assessed as having severely impaired cognitive skills and was dependent on staff for activities of daily living. Nursing notes documented the use of bilateral hand mittens to prevent the resident from pulling out their tracheostomy and g-tube, and there was a documented incident where the g-tube became dislodged after the resident pulled on it, requiring replacement. Despite these documented behaviors and interventions, a review of the resident's care plan revealed that it did not address the behavior of removing mittens or pulling on the tracheostomy and g-tube. Staff interviews confirmed the ongoing issue, with reports of the resident removing mittens multiple times in a shift and the need for frequent reapplication. The facility's policy required a comprehensive, resident-centered care plan with measurable objectives and timeframes for all identified needs, but this was not implemented for the resident's specific behaviors.
Failure to Follow Physician Orders for Blood Sugar Monitoring and Post-Death Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with multiple complex medical conditions, including respiratory failure, ventilator dependence, and type II diabetes mellitus. Specifically, the resident's physician ordered finger stick blood sugar (FSBS) monitoring every 12 hours at 6 a.m. and 6 p.m., with insulin administration as needed per a sliding scale. However, a nurse performed the blood sugar check at 12 p.m., not at the times specified in the physician's order, and did not administer insulin, citing nursing judgment due to the resident being on tube feeding. This deviation from the prescribed monitoring schedule was confirmed by both the nurse involved and a reviewing RN, who noted that the physician's order was not followed and there was no clinical indication for an unscheduled blood sugar check. Additionally, the facility did not follow its own policy and procedure regarding documentation after a resident's death. When the resident expired, there was no death certificate on file in the medical record, and the attending physician had not documented the cause of death in the progress notes as required. The facility's policy mandates that the attending physician must record the cause of death and complete and file a death certificate within 24 hours or as prescribed by state law, but this was not done.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident who had multiple traumatic injuries, including fractures and recent bladder surgery. The resident was prescribed hydromorphone for moderate to severe pain, with orders to administer the medication as needed and to assess and document pain levels before and after administration. Despite these orders, the resident repeatedly reported severe pain and did not receive timely administration of hydromorphone. On several occasions, the medication was not available, and staff did not access the emergency medication kit promptly or document pain assessments and follow-up evaluations as required by facility policy. Record reviews revealed gaps in pain assessment documentation and medication administration. The resident's pain flow sheets and medication administration records showed missing entries for pain levels and interventions on multiple days, and there was no evidence of reassessment of pain within two hours after medication was given. Interviews with nursing staff indicated confusion about procedures for accessing the emergency medication kit and delays in obtaining pharmacy authorization, resulting in the resident experiencing prolonged periods of uncontrolled pain. The pharmacy confirmed that the emergency kit was stocked and that authorizations were provided when requested, but there were no calls from the facility on certain dates when the resident reported pain. The resident described experiencing significant pain over a weekend, repeatedly requesting pain medication, and being told to wait due to unavailability of hydromorphone. The resident ultimately required transfer to an acute care hospital for severe pain and hematuria. Staff interviews corroborated the resident's account of delayed pain management and lack of timely medication administration. Facility policy required prompt assessment, medication administration, and physician notification for unrelieved pain, but these procedures were not consistently followed, resulting in the resident suffering from uncontrolled pain.
Resident Exposed During Incontinence Care Due to Failure to Maintain Privacy
Penalty
Summary
A certified nursing assistant (CNA) failed to maintain a resident's dignity and privacy during incontinence care. The CNA was observed changing the resident's incontinence diaper in a shared room with the privacy curtain open, leaving the resident's private areas completely exposed. The CNA was unable to explain the importance of keeping the privacy curtain closed during personal care and responded in a confrontational manner when questioned by the surveyor. A licensed vocational nurse (LVN) was present and confirmed the observation and interview. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had diagnoses including dementia, hypertension, and dysphagia. Facility policy and procedures reviewed indicated that all residents are to be treated with dignity and respect at all times, and that privacy must be maintained during personal care. The actions observed were not in accordance with these policies.
Failure to Ensure Staff Competency in Medication Administration and Resident Privacy
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to demonstrate the necessary skills and knowledge to safely prepare and administer medications for a resident with schizophrenia, hypertension, and dysphagia. The LVN crushed all of the resident's morning medications and mixed them together in applesauce without a physician's order to do so. The LVN was unable to identify the medications being administered, did not verify the resident's identity, and admitted to not reviewing the physician's orders prior to administration. The Registered Nurse Supervisor confirmed that there was no order to crush the medications and that the LVN did not follow proper procedures for medication administration, including not crushing medications together and not ensuring the resident was present during preparation. A Certified Nursing Assistant (CNA) failed to provide care with dignity and respect to a resident with dementia, hypertension, and dysphagia who was dependent for activities of daily living. The CNA was observed changing the resident's incontinence diaper in a shared room with the privacy curtain open, leaving the resident's private areas exposed. The CNA was unable to explain the importance of maintaining privacy during personal care and responded inappropriately when questioned about the procedure. Another nurse present confirmed that privacy should have been maintained during the care activity. The facility's policies and procedures require that nursing staff participate in competency-based training and demonstrate skills necessary to meet residents' needs, including medication management and respecting resident rights. The observed actions of the LVN and CNA were not consistent with these requirements, as both failed to follow established protocols for safe medication administration and resident privacy.
Failure to Follow Safe Medication Administration Procedures
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow proper medication administration procedures for a resident with schizophrenia, hypertension, and dysphagia, who also had moderate cognitive impairment and lacked capacity for medical decision-making. The LVN prepared the resident's morning medications without properly identifying the resident, as the resident was not present during medication preparation and the LVN was unable to confirm the resident's location or identity at the time. The LVN removed medications from multiple bubble packs, placed them in a cup, and subsequently crushed three tablets and opened a capsule, mixing all the medications together in applesauce. This was done without a physician's order to crush the medications, and the LVN was unable to verbalize which medications were being administered or the reasons for not crushing certain medications together. The LVN admitted to not reviewing physician orders or verifying the medications with the resident prior to administration. The Registered Nurse Supervisor confirmed that there was no physician's order to crush the medications and that the LVN did not follow required procedures for resident identification, medication verification, or safe medication administration. Facility policies reviewed indicated that medications should only be crushed if ordered, residents must be identified before administration, and medications should be administered at the time they are prepared, none of which were followed in this instance.
Failure to Document Staff Identification on Medication Administration Records
Penalty
Summary
Licensed nursing staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of four sampled residents. Specifically, the Medication Administration Records (MARs) for these residents were missing the required initials and signatures of the licensed staff responsible for administering medications. This omission was observed throughout the month of April for multiple medications, with only a few exceptions where staff signatures or initials were present. Resident 1, who was admitted with diagnoses including hypertension and end stage renal disease, had a MAR for Apixaban administration that lacked staff identification for nearly the entire month. Resident 2, admitted with type two diabetes mellitus, hypertension, and benign prostatic hyperplasia, had MARs for Aspirin and Flomax that also lacked staff initials and signatures for the documented administration dates. Resident 3, with a history of transient ischemic attack, peripheral vascular disease, and glaucoma, had MARs for Dorzolamide-Timolol and Losartan Potassium that were missing staff identification for most of the month, except for one date. During interviews and record reviews, multiple nursing staff, including RNs and LVNs, acknowledged the deficiency and confirmed that it is standard practice to document initials and signatures on the MAR after medication administration. The interim DON also confirmed that the MARs were missing identifiable information for the responsible licensed staff, which is not in accordance with standard practice. The facility's policy and procedures require that orders and documentation be consistent with principles of safe and effective order writing, including the use of approved abbreviations and symbols.
Ceiling Leak and Cluttered Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in room [ROOM NUMBER], which was occupied by three beds, with one resident present. Observations during an initial tour revealed that beds and floors were covered with blankets to absorb water leaking from the ceiling. Interviews with the resident and staff confirmed that the ceiling had been leaking for a couple of months, particularly during rain, and that the facility was still in the process of identifying and fixing the issue. The presence of blankets and basins to capture water leaks created a cluttered and disorderly environment, posing potential risks for accidents. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) indicated that the water leak had been ongoing, and staff had been using blankets and buckets to manage the situation. The facility Administrator acknowledged the potential hazards for falls and accidents due to the clutter and water leak. A subsequent record review revealed that the skylight glass frame causing the leak had been repaired, and inspections during recent rainstorms confirmed that the problem had been resolved. However, the facility's policy and procedures emphasized the importance of maintaining a safe, clean, and comfortable environment, which was not upheld in this instance.
Case Manager's Inaccessibility Delays Admissions
Penalty
Summary
The facility failed to ensure that the Case Manager (CM) possessed the necessary competencies and skills to facilitate a seamless and efficient admission process, as outlined in the facility's Nurse Admission Policy. The deficiency was identified through observations, interviews, and record reviews. The Business Office Manager (BOM) explained that referrals for new admissions are sent from hospitals and initially reviewed by the CM, who works remotely out of state. During the surveyor's on-site visit, multiple attempts to contact the CM via telephone were unsuccessful, as the calls went directly to a full voicemail box. The CM acknowledged that when his voicemail box is full, it prevents people from contacting him, which in turn delays the admission process for residents needing to be admitted to the facility. The facility's policy requires the CM to collaborate with hospital case managers and serve as a liaison to ensure all necessary information is obtained for admission approval. The inability to reach the CM and the resulting delays in the admission process negatively impacted the residents' plan of care and the delivery of necessary care and services.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to implement its abuse policy and procedures by not reporting an alleged abuse incident involving a resident to the California Department of Public Health. The incident involved a resident with severe cognitive impairment who was dependent on staff for all activities of daily living. The alleged abuse was observed by a Licensed Vocational Nurse (LVN) who reported that another resident was rubbing the impaired resident's left arm and inner thigh close to the groin, which the LVN considered to be sexual abuse. However, the Registered Nurse Supervisor (RNS) did not classify the incident as sexual abuse but acknowledged that allegations of abuse must be reported to law enforcement, the ombudsman, and the Department of Public Health. The Facility Administrator (FA) admitted that the abuse allegation had not been reported to the Department of Public Health, although the police had been contacted. The facility's policy and procedure on abuse prevention and reporting require that any suspected abuse be reported immediately to the appropriate authorities. The failure to report the incident to the Department of Public Health resulted in a delay of the onsite investigation by the State Agency, potentially exposing the resident to further abuse and causing mental anguish and emotional distress.
Failure to Return and Protect Residents' Clothing
Penalty
Summary
The facility failed to ensure that residents received their clothes back in the correct number and color after laundering, and that residents did not wear other residents' clothes. This deficiency was observed in two residents, Resident 21 and Resident 101. Resident 21 reported that he sent his clothes to the facility's laundry and did not receive them back. His clothes were labeled with his name, but despite asking several staff members, he did not recover them. Resident 101 also reported missing clothes and noted that one of her T-shirts was bleached from black to beige. Additionally, she observed another resident wearing one of her T-shirts. Interviews with staff revealed that clothes are supposed to be labeled and placed in a mesh bag before being sent to the laundry. If clothes are lost, the CNA on duty is expected to search the laundry room and report the loss to the Social Services Director (SSD) if they cannot be found. However, the SSD was not aware of the missing or damaged clothes for Residents 21 and 101 until the issue was brought to her attention. The facility's policy requires a thorough investigation of theft or misappropriation of resident property, but this process was not initiated until after the residents reported their grievances. The facility's administrator stated that an inventory list is maintained for residents' belongings, and any new items brought in after admission should be logged by staff. If items are lost or stolen, the facility is responsible for replacing them after a search. However, the initial response to the residents' grievances was inadequate, as the SSD was unaware of the issue, and the facility's grievance policy was not effectively implemented to address the residents' concerns promptly.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents, Resident 34 and Resident 69, during meal assistance. For Resident 34, who has severe cognitive impairment due to dementia and is g-tube dependent, a Certified Nursing Assistant (CNA) was observed standing over her while assisting with feeding. This required Resident 34 to extend her neck to look up at the CNA, which is against the facility's policy that staff should be seated at eye level with residents during meal assistance to promote dignity. Resident 69, who is visually impaired and has intact cognition, was not provided with a description of the food items or their placement on the tray during meal service. The CNA assisting Resident 69 did not describe the food layout, assuming the resident's independence in eating. The facility's policy requires staff to describe the food items and their location to visually impaired residents to accommodate their needs and maintain their dignity.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to protect a resident's privacy by not closing the privacy curtain while performing personal care. This incident involved a resident who was visually exposed to their roommates during morning care. The resident's room window blinds were also open, allowing a clear view from the outside alley. CNA 1 acknowledged that the privacy curtain should have been closed to maintain the resident's privacy. The resident involved had a severely impaired cognition and was totally dependent on staff for all activities of daily living. The resident had a feeding tube, indwelling catheter, and two stage 4 pressure ulcers. The facility's policy and procedures emphasized the importance of maintaining privacy during personal care activities, which was not adhered to in this instance. The Director of Nursing confirmed that the privacy curtain should be closed during a resident's care to maintain dignity and privacy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Post Acute Care | 0.8 mi | ★★★★★ | 5 | 0 |
| Brentwood Health Care Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Ocean Park Healthcare | 1.7 mi | ★★★★★ | 4 | 0 |
| Sunset Park Healthcare | 1.8 mi | ★★★★★ | 3 | 0 |
| Berkley East Healthcare Center | 2.1 mi | ★★★★★ | 14 | 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.