Below average — CMS composite of the measures below.
A standard survey is most likely before around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Novato Healthcare Center during CMS and state inspections, most recent first.
Failure to Report Allegation of Misappropriation of Resident Property: A resident with severe major depressive disorder with psychotic symptoms and a cognitive communication deficit had an allegation that money was taken from the resident’s bank account. The SSD said she was told of the allegation and reported it to APS, but could not state when; the DON said she and the ADON learned of it from the resident’s EC and the ADM called police, while the ADM did not know who notified CDPH. The record contained no documentation that the SSD reported the allegation to the DON, ADM, or CDPH as required by facility policy.
Failure to Investigate Allegation of Resident Property Misappropriation: A resident with severe major depressive disorder with psychotic symptoms and a cognitive communication deficit had money taken from a bank account, which was reported by the EC to the DON. The DON notified the ADM and police investigated, but the facility did not conduct its own abuse investigation, and the ADM confirmed no written investigation summary was completed or submitted to CDPH.
Failure to Post Required Daily Staffing Information: The facility did not post the required daily census and actual DHPPD information for the prior day, even though only the next day’s estimated staffing form was displayed in the posting area. The ADM said the Scheduler posted the forms before leaving, but the Scheduler stated she had only been instructed to post the next day’s estimated form, not the prior day’s actual census and DHPPD data. The DON confirmed the required prior-day form was not posted, despite the facility policy requiring daily staffing postings in a prominent location accessible to residents and visitors.
A resident with DM, bladder dysfunction, and a history of UTIs had a physician-ordered nephrology referral for CKD stage 4, but the consult was not arranged within 30 days. The resident said she had not seen a kidney doctor or urologist in over a year, was worried about needing a catheter, and felt her condition was worsening. The SSD said she was responsible for scheduling outside appointments and that non-urgent referrals were usually made within 30 days, often identified during quarterly IDT meetings.
Failure to Protect Resident from Physical Abuse During Care: A CNA ignored a resident’s cries of pain, requests to stop, and tears while providing transfer and incontinence care. The resident, who had a femur fracture, thoracic vertebral collapse, and weakness, reported the CNA grabbed her arm, yanked her up, and was rough and dismissive. A roommate heard the resident repeatedly say she was being hurt, and nursing staff confirmed care should have stopped when the resident verbalized pain.
Failure to Provide Ordered PT Services: The facility did not provide ordered PT to multiple residents with active therapy orders and recent PT evaluations showing need for skilled intervention to improve walking, strength, ROM, balance, and safety. Residents with amputations, fractures, hip surgery, neuropathy, back pain, and gait problems reported that PT stopped when the facility had no current DOR, PT, or PTA, and staff confirmed OT was being used for some residents instead of PT. Two residents had OT orders added while PT remained unavailable, and staff acknowledged residents were not receiving PT as ordered.
Pest control program was not maintained when flies were observed in resident areas, including a doorway, a resident’s room, and a dining room. A resident reported flies came into his room and bothered him, while another resident had flies land on his oxygen concentrator and bedsheets while sleeping. Staff and the ADM confirmed flies were present, and observations showed torn or missing screens and an open sliding door to the garden area.
Incomplete informed consent for lorazepam administration: A resident with severe dementia, encephalopathy, and other cognitive impairments received repeated doses of lorazepam even though the consent form on file was incomplete and listed an incorrect 25 mg dose instead of the actual 1 mg order. The DON stated the consent was invalid, no separate consent for the 1 mg order was produced, and an LPN acknowledged he did not check for consent before administering the medication. The resident’s physician later documented that the resident lacked decision-making capacity and that the daughter was the surrogate decision maker.
An LPN failed to notify a resident’s RP/conservator after the resident had an assisted fall and was found sitting on the floor. CNAs and a floor monitor assisted the resident up, and the DON stated an assisted fall is a fall and expected notification of the family and physician. The RP later stated he was not informed of the fall, despite facility policy requiring the RN/LPN to notify the RP as soon as possible after any fall.
A resident with encephalopathy, CVA, cognitive communication deficit, MDD, severe dementia with behavioral disturbance, and insomnia was prescribed lorazepam 1 mg PRN for anxiety/irritability for 90 days. An LN contacted the physician by text to restart the medication, and the physician approved the extended PRN order without a documented rationale. The MAR showed the medication was administered at least once daily on multiple days, and the facility policy required PRN psychoactive meds to be limited to 14 days unless continued use was documented.
Failure to supervise a resident at fall risk occurred when staff did not ensure she used her walker while walking from her room to the nurse's station. The resident, who had dementia, muscle weakness, lack of coordination, and anticoagulant use, was observed walking without an assistive device and then found sitting on the floor. Staff later described the event as an assisted fall, and the nurse's documentation did not show the expected post-fall assessment, evaluation, care plan update, or required notifications.
Failure to Report Abuse Allegation Within Required Timeframe: The facility did not ensure an allegation of abuse involving a resident with a fractured finger was reported to the Department within the required 2-hour timeframe. The SOC 341 documented the family’s allegation of abuse and impropriety related to an injury of unknown origin, and the DON confirmed the report was not faxed within the expected timeframe. LN stated abuse allegations are expected to be reported promptly, and the facility policy required notification by phone and in writing within 2 hours.
Delayed Postmortem Coordination and Communication: A resident with dxs including thoracic vertebral collapse and Alzheimer’s died after staff could not reach the RP. A mortuary repeatedly requested an Indigent application so postmortem and cremation arrangements could proceed, but the request was not promptly routed between Admissions and SS, the PA was not contacted until later, and the application was returned incomplete after multiple follow-ups.
Failure to Protect Resident from Physical and Verbal Abuse: A resident with severe cognitive impairment and another resident with intact cognition were involved in an incident where the second resident struck the first resident's arm and yelled insults after an accidental contact. Staff observed the fist motion and heard the verbal abuse, and the abused resident apologized and left the area.
Nursing staff failed to provide scheduled showers or bed baths for a dependent resident with severe sepsis and severe memory impairment who relied entirely on staff for ADLs, including bathing. Facility records and shower sheets showed that over multiple months the resident received significantly fewer showers than scheduled, with only one documented refusal, while some shower documentation was missing. A CNA reported difficulty completing shower assignments due to workload, and the DON stated the expectation was twice-weekly showers or bed baths in accordance with facility policy on bathing and hygiene.
Medical records staff were unable to promptly locate and provide a resident’s shower sheets covering several consecutive months, despite the resident having severe sepsis and severe memory impairment documented on the MDS. When the surveyor requested these records, the MRD, DON, and ADMIN all acknowledged that shower sheets are part of the medical record and should be readily available. Only some months’ shower sheets were later found and emailed by the MRA after searching overflow storage, and one month’s documentation remained missing, contrary to facility policy requiring accurate and complete medical records for each resident.
A resident with paralysis, joint contractures, and lower extremity stiffness was discharged from OT with a recommendation for referral to the Restorative Nursing Program (RNP) for passive ROM to all extremities and use of hand splints and a palm protector. The OT documented the need for RNP three times per week and reported giving the referral to the DOR, but no RNP order was obtained, and no RNP services or tasks were documented in the EMR. The DOR and DON described differing expectations about who initiates and confirms RNP orders, and LNs stated that an order should exist for RNP but did not. Review of the facility’s RNP policy showed it assigned Nursing responsibility for the RNP plan of care but did not define the process for converting Rehab referrals into RNP orders or clarify roles between Rehab and Nursing, resulting in the resident not receiving the recommended restorative services.
Two residents experienced physical and emotional abuse from other residents, including being struck with a pillow and hit in the face with a bottle, despite documented behavioral risks and care plans. Staff witnessed the incidents, and both cases resulted in physical harm and emotional distress, with the facility's policies requiring protection from such abuse.
A resident with a history of wandering and falls, who required close supervision and a wandering device, exited the facility unnoticed. Staff failed to consistently monitor and document the resident's wandering device, did not follow required procedures for elopement response, and did not immediately alert leadership or make a facility-wide announcement. The resident was found outside the facility and returned without injury.
A CNA did not immediately report a fall incident involving a resident with Alzheimer's Dementia, leading to incomplete information being given to an LN. As a result, a change of condition assessment was not promptly performed, causing a two-day delay in diagnosing and treating a left arm fracture. Facility policies requiring immediate reporting and assessment after accidents were not followed.
A resident with severe memory impairment and a history of aggressive behaviors struck another resident, causing pain and swelling to the left eyebrow. The incident followed previous documented episodes of hitting, kicking, and scratching by the same resident. Staff were not present at the time of the assault, and the injured resident reported ongoing pain and blurry vision.
The facility did not report an allegation of verbal abuse between two residents to the appropriate authorities within the required two-hour timeframe. Nursing staff and CNAs witnessed the incident, and although it was documented and discussed by the IDT, the written report was not submitted until the following day, contrary to facility policy.
Dietary staff were observed and interviewed with multiple competency gaps, including an employee working in the kitchen without a hair net, another not following the manufacturer's instructions for red bucket test strips, and a staff member unable to verbalize the correct hot food cool-down process. The Dietary supervisor could not provide last quarter's cool-down logs for hot food or ambient foods, and RD confirmed there were no competency records for infection control, quaternary ammonia use, cool-down procedures, or related temperature logging.
Improper Temperature of Pureed Cold Fruit: A pureed cold fruit item on a test tray was measured at 71.8 F and tasted warm, while the RD stated it should have been served cold at 40 F. Other pureed items on the tray were also observed and temperature-checked during the survey, and the FDA Food Code cited a 41 F or less initial temperature for cold food with a maximum of 70 F.
Food storage, sanitation, and cooling practices were not maintained according to standards. A DA was observed without a hair net, clean sheet pans and lids were stored wet and with food debris, and the walk-in refrigerator and freezer had issues including an extremely wet floor, expired carrots, unlabeled tortillas, and opened fish nuggets with freezer burn. The oven was dirty, a DA could not properly test the sanitizer red bucket, a cook could not state the correct hot food cool-down process, and the facility had no cooling logbook for hot or ambient food for the prior 3 months.
Staff failed to maintain resident dignity during mealtime care and medication administration. A CNA stood while feeding a resident who said she felt rushed, another CNA placed cloth protectors on several residents without asking permission and one resident removed it in protest, and a resident with feeding assistance needs was referred to as a "feeder" instead of by name. An LPN also administered medications to a resident with CHF and dementia in a common area without privacy, exposing her knee while other residents were present.
A resident with dementia, COPD, chronic respiratory failure, and a DNR/hospice status did not have a completed POLST in the chart, and five other residents had no documented AD in either the EHR or paper record. Staff confirmed the missing documentation during record review and interviews, and the facility records did not show completed AD forms or refusals for those residents.
Medication administration errors exceeded the allowed rate after surveyors observed multiple missed, late, and improperly given meds. An LPN did not give an ordered prostate medication, gave the wrong vitamin, crushed medications without an order, failed to give several ordered meds including BP and pain meds, and administered scheduled pain medication late while a resident reported severe pain. The DON acknowledged missed and late doses and that physician notification was required.
Improper Medication Storage and Labeling: A resident who could not self-administer had medication items left at the bedside, and medications were also found unattended at a nurse station. Multiple medication carts contained expired, discontinued, and unlabeled items, loose pills, sticky residue on bottles, and non-medication items. Discontinued narcotics were found in the narcotic box, and the PC stated controlled meds should remain counted until transfer of custody and medication carts should be kept clean.
The facility failed to follow infection control practices during resident care and outbreak conditions. Staff did not perform hand hygiene between resident contacts, a shared BP cuff was not sanitized between uses, an LPN wore an N95 improperly during med pass, and staff entered isolation rooms without required face shields. A resident with a suprapubic catheter was not placed on EBP, while other issues included an open COVID-19 isolation room door, uncovered CPAP equipment, unlabeled oxygen tubing, and missing screening, line listing, and PPE competency documentation during the outbreak.
A resident with L hemiplegia had his bed control remote hanging under the bed and out of reach, while another resident with stroke, dementia, and muscle weakness had her call light on the floor behind the nightstand. In both cases, CNA staff confirmed the devices were not accessible, and the DON stated that residents’ bed remotes and call lights should be within reach and on the functional side when needed.
Failure to provide activity services consistent with a resident's preferences. A resident with dementia was observed multiple times sitting in her room on the bed with no activity. Her care plan and activity notes showed she enjoyed reading, conversation, and music, but the AD found no documented activity plan of care for the prior 16 days and no evidence that activities were provided. The DON stated residents should still receive activities, including 1:1 room visits, and the facility policy required room visits and documentation for residents who did not leave their rooms.
A resident with severe cognitive impairment and dependence for bed mobility developed facility-acquired unstageable pressure injuries to both heels after being admitted without skin breakdown. The care plan called for q2h turning, but staff interviews described inconsistent turning, use of pillows before the wounds were identified, and delayed use of a LAL mattress and offloading boots. The DON and wound MD stated the injuries were related to immobility and pressure on the heels.
Failure to Follow RD Supplement Orders Led to Weight Loss A resident with DM, dementia, and GERD experienced significant weight loss while the RD’s therapeutic diet recommendations were not entered into the orders and were not followed. The resident’s nutritional assessments documented repeated, significant weight loss and recommended changing from a house supplement to a NAS supplement with intake monitoring, but the order record still showed the older supplement order. The RD stated the recommendations had not been entered into the orders.
A resident with a BKA, chronic pain syndrome, and phantom limb pain did not receive scheduled Norco on time, and one dose was omitted without documentation explaining why. Staff also did not complete pain assessments every shift as ordered, did not document medication effectiveness, and did not show monitoring for Norco side effects. The resident reported severe uncontrolled pain, frustration, and delays in relief when doses were late.
A registry LPN was not competency-checked before providing care, and two residents received medications late as a result. One resident with Parkinson's disease received carbidopa-levodopa late and reported worsened speech and movement, while another resident with chronic pain received hydrocodone-acetaminophen hours late and reported severe pain. The DON stated registry nurses are expected to be signed off on competencies before working, but no competency checklist was found for the nurse.
The facility failed to ensure two residents were free from unnecessary psychotropic medication use. One resident with MS, depression, chronic pain syndrome, and moderate cognitive impairment received fluoxetine for depression without documented monitoring for depressive behaviors or adverse effects, and the record lacked valid informed consent. Another resident with schizoaffective disorder and Alzheimer’s disease had citalopram ordered for depression despite no depression diagnosis in the chart, and a BH provider’s dose reduction was not implemented or documented as denied.
Medication administration errors occurred when an LPN gave a resident's scheduled pain medication late while the resident was visibly in pain and did not administer the resident's ordered metoprolol for HTN. The resident, who had chronic pain syndrome and HTN, reported waiting too long for the pain medication and rated the pain 8/10. The DON acknowledged the late dose, and the facility policy required medications to be given according to physician orders and held doses to be documented with provider notification.
A resident with stroke, dementia, and muscle weakness was observed with a bed control remote that had a ripped cord and exposed wires, with tape wrapped around the damaged area but not holding. The resident said the remote had been broken for a long time and was scared to use it. A CNA picked up the remote and tried to place it on the bed, while an LPN and the VP both confirmed it was not safe for use.
Call lights were not kept within reach for two residents with moderate cognitive impairment and high fall risk. One resident’s call light was shut in a nightstand drawer, and another resident’s call light was on the floor behind the nightstand because the clip was missing. Staff confirmed both call lights were inaccessible, despite care plans calling for the devices to remain within reach and the facility policy requiring residents to be able to alert nursing staff from their rooms and bathing areas.
A resident with dementia and DM had long, thick toenails and no record of podiatry care despite a care plan for nail monitoring and trimming. Another resident with dementia and dysphagia required 1:1 feeding and personal care, but was left dirty, wet, and still eating breakfast hours later; the LN, CNA, RMDS, and DON confirmed the resident did not receive the needed assistance and hygiene care.
A resident with Type 1 diabetes received a double dose of insulin lispro, along with an additional sliding scale dose, due to a transcription error that left duplicate orders active. Two nurses administered separate scheduled doses within a short interval, and an extra sliding scale dose was also given. This resulted in the resident experiencing a hypoglycemic episode and becoming unresponsive, with staff confirming the error was due to failure to discontinue the previous insulin order.
A resident with Type 1 diabetes received a double dose of insulin lispro from two nurses within a short time frame, along with an additional sliding scale dose, resulting in a hypoglycemic episode. Despite facility policy requiring prompt notification, the resident was not informed of the medication error or the cause of her condition change.
A resident with heart failure and chronic kidney disease was not assisted in obtaining timely dental care after a local oral surgery clinic determined that full mouth extractions should be performed in a hospital. Despite care plan requirements and multiple contacts with dental providers, there was no documentation of a formal hospital referral, and the facility did not document extenuating circumstances for the delay.
A resident with vascular dementia and intact cognitive skills struck another resident with moderately impaired cognition after a dispute involving spilled hot chocolate. The assaulted resident, who also had anxiety and depression, reported distress following the incident. Both residents confirmed the altercation, and the DON noted the need for improved assessment and care planning to prevent such events.
A resident with schizophrenia, hallucinations, and moderate cognitive impairment did not receive a required PASRR Level 2 evaluation after a Level 1 screening identified serious mental illness and psychotropic medication use. DHCS correspondence stated the Level 2 was not completed because facility staff were unresponsive to repeated attempts to communicate within 48 hours. The MDSN was unsure when a PASSR needed correction or whether new symptoms would trigger a new PASSR process, and the DON stated Level 1 PASSRs were often not correctly completed by acute care hospitals.
The facility did not report an allegation of abuse between two residents to the Department of Public Health within the required two-hour timeframe. Although staff stated they attempted to fax a report and leave a voicemail, there was no confirmation these were received, and the official report was not submitted until four days after the incident, contrary to facility policy.
A resident with a recent spinal infection and complex medical history did not receive a prescribed IV antibiotic as ordered after admission. Staff were aware of the medication order and pharmacy delay but did not notify the physician about the missed doses, and documentation confirmed the medication was not administered as scheduled.
A resident's MAR was inaccurately documented to show that a prescribed antibiotic dose was not given due to hospitalization, even though the resident was still present in the facility at the time the medication was due. The DON confirmed the error and acknowledged that the entry did not meet facility policy for accurate medical record documentation.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These failures resulted in a deficiency related to resident care.
Failure to Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident when the resident’s Emergency Contact notified the Social Service Director that money had been taken from the resident’s bank account. The resident’s face sheet showed admission with a history of severe major depressive disorder with psychotic symptoms and cognitive communication deficit, and the Minimum Data Set dated 6/24/26 showed a Brief Interview for Mental Status score of 13, indicating the resident was able to make and understand decisions independently. During interviews, the Social Services Director acknowledged being informed of the allegation and stated she reported it to APS, but could not state when that report was made. The Director of Nursing stated she and the Assistant Director of Nursing learned of the allegation from the resident’s Emergency Contact and that the Administrator was notified, who then called police. The Administrator stated he did not know who notified CDPH of the allegation. Review of the resident’s progress notes found no documented evidence that the Social Services Director reported the allegation to the DON, Administrator, or CDPH. The facility policy required allegations of abuse or reasonable suspicion of a crime to be reported immediately to the Administrator or designated representative, with law enforcement and written reports to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within 2 hours.
Failure to Investigate Allegation of Resident Property Misappropriation
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of resident property involving one resident who was admitted with severe major depressive disorder with psychotic symptoms and a cognitive communication deficit. The resident’s Emergency Contact notified the DON that money had been taken from the resident’s bank account, and the DON reported the event to the Administrator, who called the police. The DON stated that police came to the facility to investigate the allegation, but the facility did not conduct its own investigation of the abuse allegation. During interview, the Administrator confirmed he was the facility’s Abuse Coordinator and stated the investigation was conducted by police. He also confirmed that an investigation summary was not written and was not submitted to CDPH. The facility’s policy required the Administrator or designated representative to initiate an investigation immediately, interview individuals with relevant information, and provide a written report of the results of all abuse investigations to CDPH within five working days; however, no facility investigation summary was provided.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the required daily patient census and actual direct care service hours per patient day information was posted for 7/29/26 for a facility census of 178. On 7/30/26 at 1:19 p.m., observation of the designated staffing information posting location in a hallway near the front lobby showed only the DHPPD form dated 7/30/26 with estimated direct care service hours per patient day; the form reflecting the average daily census and actual direct care service hours calculations for 7/29/26 was not displayed. During interviews, the Administrator stated the Scheduler posted the required census and DHPPD forms in the evening before leaving the facility and confirmed the Scheduler was directly supervised by the Administrator. The Scheduler stated the Administrator instructed her to post the next day’s daily census and estimated direct care service hours form daily, but she had not been instructed to post the previous day’s DHPPD form showing the average daily census and actual direct care service hours calculations, so she did not post it. The DON also confirmed the required DHPPD form for 7/29/26 was not posted and acknowledged that the previous day’s average daily census and actual direct care service hours calculations must be posted daily. The facility policy required daily posting of staffing data, including resident census, in a prominent place readily accessible to residents and visitors.
Failure to Arrange Ordered Nephrology Consult
Penalty
Summary
The facility failed to provide or obtain a physician-ordered nephrology consult for one resident after an order was entered for a nephrology referral secondary to CKD stage 4. The resident’s record showed diagnoses including diabetes, neuromuscular dysfunction of the bladder, and a history of urinary tract infections, and the MDS indicated renal insufficiency, renal failure, or end-stage renal disease with intact cognitive function. The resident stated she had requested appointments with a kidney doctor and a urologist but had not seen either in a year or more. She reported concern about needing a catheter to urinate and said her overall condition was getting worse, which caused anxiety about leaving the facility and managing her health independently. When evidence of a nephrology appointment was requested, none was provided. The Social Services Director stated she was responsible for arranging outside appointments when ordered by the physician and that non-urgent referrals were typically made within 30 days, with awareness of referrals usually occurring during quarterly IDT meetings. The facility policy stated the Social Services Director or designee is responsible for making referrals for community-based medical appointments and that referrals require a provider order.
Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
The facility failed to protect a resident from physical abuse when a CNA ignored the resident’s verbalizations of pain, requests to stop, and crying during transfer and incontinence care. The resident had been admitted with a displaced right femur fracture, collapsed thoracic vertebrae, and generalized muscle weakness, and her MDS showed a BIMS score of 11. During the incident, the CNA reportedly grabbed the resident by the right arm, yanked her up to sitting and then standing, and continued cleaning her despite the resident crying out in pain and asking the CNA to stop. The resident stated the CNA did not explain what she was going to do, was rough and dismissive, and treated her more like an object than a person. The resident reported feeling scared and said there was no reason to hurt her. A roommate who was present heard the resident repeatedly say, “stop you are hurting me,” and intervened by pulling back the curtain and telling the CNA to be gentle. The roommate stated it was basic decency to stop if care was causing pain. Facility staff interviews and records confirmed the resident later reported she never wanted the CNA to care for her again and that she felt unable to protect herself because the CNA was a big woman. Nursing staff stated that if a resident cried out in pain, care should have stopped and the nurse should have been notified. Social services notes documented that the resident cried after the incident, described the CNA as rough with a curt and dismissive tone, and remained emotionally distressed afterward. The facility’s investigative report and staff interviews reflected that the CNA’s actions caused the resident pain, fear, and emotional distress.
Failure to Provide Ordered PT Services
Penalty
Summary
The facility failed to provide ordered PT services for seven of eleven sampled residents who had active PT orders and recent PT evaluations documenting the need for skilled therapy to improve or maintain mobility, strength, range of motion, gait, balance, and safety awareness. A census report dated 7/2/26 showed no residents listed under PT, while an order listing report dated 7/3/26 showed 11 residents with active PT orders. Interviews with the SLP, DON, OT, and Administrator confirmed the facility had no current DOR, PT, or PTA, and that residents were not receiving PT services as ordered. Resident 3 was admitted with bilateral below-the-knee amputations and gait and mobility abnormalities, had a BIMS of 15, and had an active PT order for 5 times per week for 4 weeks. The PT evaluation stated skilled PT was needed to increase independence with walking, lower extremity ROM and strength, minimize falls, and promote safety awareness. During interview, the resident stated PT had been renewed but no sessions had been received since the last PT quit, and the resident needed therapy to practice stairs and strengthen use of new prosthetics. Resident 4 was admitted with a displaced comminuted fracture of the left patella, difficulty walking, and osteoarthritis, had a BIMS of 15, and had an active PT order for 5 times per week for 4 weeks. The PT evaluation documented balance deficits, decreased functional capacity, pain, strength impairments, and need for skilled PT to increase gait independence, LE ROM and strength, and reduce falls. The resident stated PT had stopped for at least a few weeks and no staff had discussed the interruption, and the resident was spending more time in bed because of continued trouble walking. Resident 5 was admitted with peripheral neuropathy, muscle weakness, and difficulty walking, had a BIMS of 12, and had an active PT order for 3 times per week for 4 weeks. The PT evaluation stated skilled PT was needed to increase walking independence, LE ROM and strength, and reduce falls. The resident stated PT had not been received for 1.5 weeks, wanted to go home, and said there was no current PT to reassess safety for discharge. Resident 6 was admitted after left hip replacement with gait and mobility abnormalities, had a BIMS of 15, and had an active PT order for 3 times per week for 4 weeks. The PT evaluation stated skilled PT was needed to increase walking independence, LE ROM and strength, and reduce falls. The record showed OT orders were added on 7/3/26 in addition to the PT order. The resident stated OT had just started, but PT was needed to stabilize, decrease fall risk, and increase strength, and that OT could not replace PT. Resident 7 was admitted with low back pain, muscle weakness, and abnormal gait and mobility, had a BIMS of 13, and had an active PT order for 3 times per week for 4 weeks. The PT evaluation stated continued PT was needed to increase LE ROM and strength, minimize falls, and promote safety awareness. The resident stated PT had not been received for a couple of weeks because the facility did not have any PT, and the resident felt he was not progressing. Resident 8 was admitted with bilateral above-the-knee amputations, had a BIMS of 13, and had a PT evaluation recommending 3 times per week for 4 weeks to increase functional activity tolerance, LE ROM and strength, reduce falls, and develop a restorative nursing program. The order listing and order summary reports showed active PT orders. The resident stated she had not received PT or OT in weeks, was waiting on physician review for prosthetics, and felt she was becoming much weaker. Resident 9 was admitted with a left femur fracture, degenerative disc disease with back and extremity pain, and osteoporosis, had a BIMS of 15, and had an active PT order for 3 times per week for 4 weeks. The PT evaluation stated continued PT was needed to increase functional activity tolerance, LE ROM and strength, and reduce falls. OT orders were revised as a late entry on 7/3/26. The resident stated PT stopped after only 2 to 3 sessions and said she could not walk and was upset that progress had stopped. Facility staff confirmed the rehab department had no current DOR, PT, or PTA, that OT was being used for residents who needed PT, and that there had been no discussion of transferring residents who required complex PT. The Administrator stated the facility had found a telehealth PT but did not have PTA staff to complete exercises with residents, and confirmed residents had not received PT. The facility also did not provide requested policies on rehabilitative services, following physician orders, or maintaining resident mobility.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an effective pest control program when flies were observed in the residential areas. During an observation at the secured unit doorway, a fly flew into the surveyor’s face and continued to buzz around the doorway area. In Resident 1’s room, the resident was sitting up in bed eating a cold breakfast tray, and the window screen was torn, leaving a wide opening to the outside grounds. Resident 1 stated flies came into the room and bothered him when they buzzed around his head. In Resident 2’s room, two flies were observed flying around the room and temporarily landing on the resident’s oxygen concentrator and bedsheets while the resident was sleeping in bed. An LN confirmed the flies were present and stated the sliding door to the outside garden area was usually open and difficult to keep closed. Additional observations found the dining room sliding glass door slightly open with no screen in place, and a nearby resident room window open with a screen not properly seated in the frame. The Administrator confirmed flies were present and noted torn and missing screens on windows and sliding doors. The facility policy stated the facility is free of insects that could compromise the health, safety, and comfort of residents and that windows are screened at all times.
Incomplete informed consent for lorazepam administration
Penalty
Summary
The physician and licensed nurses failed to ensure informed consent was properly obtained and verified before administering lorazepam to a resident with encephalopathy, cerebral infarction, cognitive communication deficit, major depressive disorder, severe dementia with behavioral disturbance, and insomnia. The resident was admitted with a responsible party identified as the daughter, and the hospital discharge summary recommended avoiding sedatives and deliriogenic medications when possible. The facility’s informed consent documentation on file was incomplete and listed lorazepam 25 mg, even though the resident’s actual medication orders were for lorazepam 1 mg. The informed consent form signed by the physician on 3/16/26 had blank fields for the medical provider’s name, the date of review, and the name of the resident or responsible party who allegedly gave consent. The form also had no boxes checked to show whether consent was obtained from the resident or the responsible party, and no box checked to show whether the physician had verified informed consent. The nurse verification section contained inconsistent dates, and the DON stated the consent documentation for lorazepam 25 mg was invalid because the resident’s lorazepam orders were for 1 mg. No separate informed consent for the 1 mg order was provided to the surveyor. Despite the missing valid consent documentation, licensed nurses administered lorazepam to the resident repeatedly in March, April, and May 2026. The resident’s physician later documented that the resident lacked medical decision-making capacity and that the daughter was the appropriate surrogate decision maker. During interview, an LPN stated he was sure a signed informed consent existed for the 1 mg order but acknowledged he had not checked the consent before administering lorazepam. The facility’s policy required the healthcare practitioner to obtain informed consent and the licensed nurse to confirm that consent was obtained before giving the first dose of psychoactive medication.
Failure to Notify RP After Resident Fall
Penalty
Summary
Licensed nurses failed to notify Resident 1’s responsible party of a change in condition after Resident 1 had a fall on 6/16/26. Resident 1’s face sheet showed that her responsible party was also her conservator. During a concurrent observation and interview on 6/16/26 at 1:27 p.m. in the memory care unit, Resident 1 was seen sitting on the floor while two CNAs and a floor monitor assisted her up and placed her in a chair, and an LN checked her vital signs while she was seated. LN 1 later stated on 6/17/26 that Resident 1 had not fallen, while CNA 1 and CNA 2 both stated they witnessed an assisted fall and that Resident 1 was lowered to the floor and then assisted back up. The DON stated that an assisted fall was a fall and that if Resident 1 was found sitting on the floor, Resident 1 had a fall. The DON also stated she expected the LN to complete a change of condition report, initiate a fall care plan, and notify the family and physician. However, Resident 1’s RP stated he was not informed of the fall. The facility’s Fall Management Program required the licensed nurse to notify the resident’s responsible party as soon as possible after any fall, and the Change in Condition policy required notification of the legal representative or appropriate family member when there was an incident or accident involving the resident. Resident 1’s progress note documented that she became unsteady while walking with staff assistance, was safely prevented from falling, and had no impact with the floor, with vital signs within normal limits.
Unnecessary PRN lorazepam order extended beyond policy limits
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary psychotropic medication use when lorazepam was prescribed as needed for 90 days. The resident was admitted with diagnoses including encephalopathy, cerebral infarction, cognitive communication deficit, major depressive disorder, severe dementia with other behavioral disturbance, and insomnia. The resident’s order details showed that the physician was contacted by phone and the lorazepam order was changed from as needed for 14 days to as needed for 90 days. The resident’s order summary listed lorazepam 1 mg by mouth every 12 hours as needed for anxiety for 90 days, with irritability documented as the manifestation. During interview and record review, an LN stated he texted the physician to restart the lorazepam order and that the physician replied that the resident could receive lorazepam PRN for 90 days, without providing a rationale. The MAR showed that licensed nurses administered 1 mg of lorazepam at least once daily on multiple days in April and May 2026. The facility policy stated that any psychoactive medication ordered PRN must not exceed 14 days unless the physician documents the reason for continued use and writes the order for a time frame not to exceed 90 days.
Failure to Supervise Resident Using Walker
Penalty
Summary
Nurses failed to prevent an avoidable accident for a resident with toxic encephalopathy, muscle weakness, lack of coordination, dementia, and current anticoagulant use when staff supervision did not ensure she used her walker while walking from her room to the nurse's station. Her care plan identified a fall risk related to deconditioning, psychoactive drug use, dementia, poor impulse control, and muscle weakness, and noted that staff were to anticipate her needs and place her close to bed as a visual reminder to use her walker because she was not likely to remember due to dementia. During observation, the resident was seen walking independently without an assistive device and then was found sitting on the floor. Staff assisted her from the floor to a chair, and a nurse checked her vital signs. The nurse documented that the resident was ambulating with staff assistance when she became unsteady and was about to fall, but other documentation did not show that a post-fall assessment, staff interview, post-fall evaluation, care plan update, or notification to the physician, DON, or Administrator was completed. Staff interviews later confirmed that the event was an assisted fall and that an assisted fall was considered a fall.
Failure to Report Abuse Allegation Within Required Timeframe
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the Department within the required two-hour timeframe for one of three sampled residents, Resident 1. A facility document titled Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 5/25/26, indicated that Resident 1 was the victim of physical abuse that resulted in a fracture to the second digit of the left hand. The document also stated that the resident's family was alleging abuse and impropriety related to an unknown occurrence/injury of unknown origin. The SOC 341 showed the incident date and time as 5/26/26 at 8:40 a.m., while a separate facility document indicated the form was faxed to the Department on 5/25/26 at 6:02 p.m. During interview, LN 1 stated allegations of abuse are expected to be reported to the Department within two hours. The DON confirmed the SOC 341 documented the family allegation of abuse and stated that if abuse was suspected it should have been reported within the two-hour timeframe. The facility policy titled Abuse- Reporting Investigations stated the Administrator or designated representative will notify the Department by telephone and in writing within two hours of the initial report.
Delayed Postmortem Coordination and Communication
Penalty
Summary
The facility failed to communicate postmortem care requirements for one resident when staff did not coordinate the resident’s postmortem and cremation needs efficiently and in a timely manner between internal departments and external entities. The resident had been admitted with diagnoses including a collapsed thoracic vertebra and Alzheimer’s disease, and his family member was listed as the responsible party. After the resident was found unresponsive and pronounced dead, staff attempted to notify the responsible party but the phone number was no longer in service. Facility records and email correspondence showed that a mortuary contacted the facility and requested completion of an Indigent application so the resident’s postmortem and cremation procedures could proceed. The mortuary sent the application to the facility and followed up multiple times with the Administrator and Admissions staff, but no reply was received from facility staff until several days later. When Social Services finally responded, an incomplete Indigent application was attached. The email thread also indicated that the Public Administrator was to be contacted, but facility staff did not do so until after the application was submitted. During interviews, Admissions stated she had no responsibilities following a resident’s death, but also confirmed she received the application and forwarded it to Social Services ten days later, acknowledging a delay in communication between departments. Social Services stated she received the application from Admissions and did not know why there was a delay. The Administrator confirmed the delay in getting the application to the correct department and having it completed, and stated there should have been better communication to get the necessary application completed in a timely manner. The facility’s policies referenced a 24-hour communication system and contacting the Public Administrator when there is no family or resident representative.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect one of five sampled residents from physical and verbal abuse when Resident 2 struck Resident 1's left arm and yelled insults at him after an incident involving both residents. Resident 1's face sheet showed diagnoses including respiratory failure, dementia, and depression, and his MDS dated 4/26/26 indicated a BIMS score of 3 out of 15, reflecting severe cognitive impairment. Resident 2's face sheet listed diagnoses including hemiplegia/hemiparesis, auditory hallucinations, and dementia, and her MDS indicated a BIMS score of 13 out of 15, reflecting intact cognitive functioning. Facility documentation stated that on 5/1/26, Resident 2 was in close proximity to Resident 1 and was observed pulling her fist back toward Resident 1's arm, suggesting physical contact had just occurred. Immediately afterward, Resident 2 raised her voice and called Resident 1 an insulting name, and Resident 1 apologized, stating he did not mean to. A CSS later reported seeing Resident 2 hit Resident 1's upper outer arm with her fist while yelling at him, after which Resident 1 apologized and left the area. Resident 2 later expressed remorse and acknowledged her reaction was not appropriate. The facility's abuse policy defined physical abuse and verbal abuse and stated the facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property, and/or mistreatment is more likely to occur.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
Facility nursing staff failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing, for one resident who was totally dependent on staff for personal hygiene. The resident was admitted with severe sepsis and had severe memory impairment, with an ADL care plan indicating dependence on staff for personal hygiene and bathing. The MDS documented that the resident was totally dependent on staff for bathing. The facility’s shower schedule showed the resident was to receive showers twice weekly on the evening shift, with an expectation that any refused shower would be offered the following day. A CNA reported being responsible for giving residents showers daily but stated it was difficult to complete all assigned tasks and that staff were busy. Review of shower documentation revealed that over several months the resident did not receive showers as scheduled. In November, the resident received five of eight scheduled showers; in December, two of nine; in January, one of nine; and in March, one of two during the first week. February records were not provided, but it was determined that, during the days the resident was in the facility that month, two shower opportunities were missed. Across the reviewed period, documentation showed only one shower refusal by the resident. The Medical Records Director initially could not locate shower sheets for several months and later provided partial records, with some documentation still missing. The DON stated her expectation was that residents receive showers or bed baths twice weekly and acknowledged that failure to do so could put residents at risk for skin issues, urinary tract infections, and skin infections. The facility’s policy on showering and bathing required tub or shower baths to provide cleanliness, comfort, and prevention of body odors, and directed that the care plan be updated as needed.
Incomplete and Unavailable Shower Documentation in Resident Medical Record
Penalty
Summary
Medical records staff failed to maintain complete, readily accessible, and systematically organized medical records for one resident when they were unable to locate the resident’s shower sheets for a specified time period. The resident had been admitted with severe sepsis and had severe memory impairment per the MDS assessment. On a specific date, the surveyor requested the resident’s shower sheets covering several months, and the Medical Records Director stated she was unable to locate them. The Medical Records Director acknowledged that shower sheets were part of the resident’s medical record and should be available upon request, and that it was the facility’s practice to have records readily available. The DON and Administrator also confirmed that shower sheets were medical records and were expected to be available. Subsequently, partial records were located and provided in stages via email by the Medical Records Assistant, including shower sheets for some, but not all, of the requested months. The Medical Records Assistant reported that staff were continuing to check overflow records in the storage room, and later provided additional months’ shower sheets, but the shower sheets for one month remained missing. The facility’s policy on storage and destruction of the designated record set stated that the facility would maintain accurate and complete medical records for each resident, but the missing and delayed shower sheets for this resident demonstrated that the facility did not maintain a complete and readily accessible medical record as required.
Failure to Initiate Restorative Nursing Program After Therapy Referral
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate restorative nursing services to maintain or improve range of motion (ROM) for a resident who had significant mobility impairments. The resident was admitted with paralysis from the neck down, contractures of the left hand, and stiffness of the left hip, both knees, and both ankles. An Occupational Therapy (OT) discharge summary documented that the resident should be referred to the Restorative Nursing Program (RNP) for passive ROM to both arms and legs three times per week, and for application and removal of a right-hand splint and a left-hand palm protector by a restorative nursing assistant. Review of the resident’s medical record showed no documentation of any RNP activities, and the Medical Records Assistant confirmed there was no order for the recommended RNP or evidence that RNP services had been initiated. Interviews with facility staff confirmed that the RNP referral and order process was not completed. The Director of Rehabilitation acknowledged that the RNP referral/order for the resident was not completed and described a new process in which she would initiate the RNP order and the Director of Nursing (DON) would confirm and obtain the physician’s order. The DON stated she expected the Rehabilitation Department to write the RNP order, and Nursing to confirm the order, create the plan of care, and add RNP tasks into the electronic medical record. Licensed nurses interviewed stated that there should be an order in place if a resident is to be on RNP, but one was not present. Review of the facility’s Restorative Nursing Program policy showed that it assigned responsibility to Nursing for initiating and updating the RNP plan of care but did not specify how an RNP order is generated from a Rehabilitation referral or clearly define the roles of Rehabilitation and Nursing in initiating RNP services, contributing to the failure to implement the ordered restorative care for this resident.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
The facility failed to protect two residents from physical and emotional abuse by other residents. In the first incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident, who was wheelchair-bound and totally dependent on staff, with a pillow multiple times. This occurred after the aggressor believed the other resident was interfering with his belongings. Staff, including a licensed nurse and a CNA, witnessed the incident and confirmed that the resident being struck attempted to protect himself. The administrator substantiated the occurrence as resident-to-resident abuse. In the second incident, a resident with no cognitive impairment but a history of behavioral issues and fabricating stories engaged in a physical altercation with her roommate, who was also physically dependent due to medical conditions. The altercation began after a dispute over personal items and the use of a television. During the incident, a full bottle of nutritional supplement was thrown, resulting in a bruise to the dependent resident's lower lip. Both residents provided conflicting accounts, but staff observations and interviews indicated a pattern of negative interactions and previous behavioral concerns. The administrator substantiated this event as resident-to-resident abuse as well. The facility's own policies define abuse as the willful infliction of injury and require the protection of residents from all forms of abuse and neglect. Despite documented behavioral risks and care plans addressing these issues, the facility did not prevent these incidents, resulting in physical harm and emotional distress to the affected residents. The findings were based on interviews, record reviews, and direct observations by staff and surveyors.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with a history of aphasia, muscle weakness, unsteadiness, falls, and prior elopement was admitted to the facility and assessed as being at risk for wandering and elopement. The resident's care plan included interventions such as engaging the resident in purposeful activity, placing a wandering device and checking its presence every shift, monitoring the resident's whereabouts every 15 minutes, and identifying de-escalation behaviors. However, documentation revealed that staff did not consistently monitor or document the presence and functionality of the resident's wandering device as required. On the day of the incident, the resident was observed by the receptionist walking out the front doors, which triggered an alarm. The receptionist turned off the alarm, checked on the resident, and saw the resident walking toward a lounge area. When the resident's CNA arrived, the receptionist returned to her duties. The CNA attempted to persuade the resident to return inside, but the resident refused. The CNA then informed the nurse and resumed his work. Subsequently, the nurse and another staff member searched for the resident, who was eventually found walking down the street approximately 0.8 miles from the facility. The resident was returned to the facility without injury. Interviews and record reviews indicated that staff were unaware the resident had eloped until after the fact, and the required facility-wide announcement and immediate notification of the DON or Administrator were not made. The facility's policy required staff to accompany or follow a resident who exits the facility and to alert other staff and organize a search if a resident is missing. These procedures were not followed, and documentation of monitoring the wandering device was lacking.
Failure to Report Fall Results in Delayed Fracture Diagnosis and Treatment
Penalty
Summary
Certified Nursing Assistant 1 (CNA 1) failed to immediately report a fall incident involving a resident with Alzheimer's Dementia, who had moderately impaired decision-making abilities and memory problems. During an episode in the shower room, the resident began to fall, grabbed a metal bar, and lowered himself to the floor, resulting in yelling, kicking, and swinging his arms. CNA 1 and another staff member observed a skin tear and scratch on the resident's left arm after the incident and informed the Licensed Nurse (LN 1) only of the injuries, not the fall itself. LN 1, believing the wounds to be superficial and unaware of the fall, did not conduct a change of condition assessment at that time, as required by facility policy. This lack of immediate and complete communication led to a two-day delay in diagnosing a left arm fracture, as the resident continued to display pain and swelling before an X-ray was ordered and the fracture was identified. The facility's policies required prompt reporting of incidents and changes in condition, as well as immediate assessment and notification of the physician and family in the event of an accident. The failure to follow these protocols resulted in a delay in appropriate treatment and pain management for the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with fully intact cognition and a history of pressure ulcers and heart failure was struck in the face by another resident diagnosed with Alzheimer's disease and severe memory impairment. The incident occurred after the resident with Alzheimer's complained about television noise, prompting the first resident to turn off the TV. When staff left the room, the resident with Alzheimer's returned, grabbed the other resident's arm, and punched him in the left eye area. The injured resident reported pain and blurry vision, and a licensed nurse documented mild redness and swelling to the left eyebrow. Prior to this incident, the resident with Alzheimer's had documented behavioral issues, including hitting, kicking, and scratching others on multiple occasions. The facility's policy defined physical abuse as hitting and required identification and intervention in situations where abuse is more likely to occur. Despite these documented behaviors, the facility failed to prevent the assault, resulting in injury to the resident.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse between two residents within the required two-hour timeframe. Documentation showed that a verbal altercation occurred between the residents, and the incident was witnessed by nursing staff and certified nurse assistants. The event was documented in the facility's SBAR Communication Forms and discussed by the Interdisciplinary Team the following day. However, the written report of suspected dependent adult/elder abuse was not submitted to the California Department of Public Health until the day after the incident occurred. Interviews with the Administrator, DON, and ADON confirmed that the report was not sent within the mandated timeframe, as required by the facility's Abuse Prevention and Management policy. The policy specifies that all allegations of abuse must be reported to CDPH Licensing and Certification within two hours. The delay in reporting was acknowledged by facility leadership during interviews.
Dietary Staff Competency and Documentation Deficiencies
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service was not met when dietary staff were found to lack documented competencies and skills checks. During observation, DA 1 was seen working inside the kitchen without a hair net, DA 2 did not follow the manufacturer's instructions for using red bucket test strips, and the [NAME] could not verbalize the correct cool-down process for hot food. In addition, the Dietary supervisor was unable to provide last quarter's cool-down logs for both the hot food cool-down process and the ambient food cool-down process. During a concurrent interview and record review, RD 1 confirmed there were no records of competencies or documentation for dietary staff related to infection control hairnet use, quaternary ammonia, the cool-down process for hot food, or food temperature logging related to the cool-down process for hot food and ambient foods. The facility policy titled Staff Competency or Skills checks stated competency evaluations or skills checks would be performed annually, through written testing and observation, and retained in the employee file.
Improper Temperature of Pureed Cold Fruit
Penalty
Summary
The facility failed to ensure pureed food was prepared correctly for a census of 162 when a cold pureed fruit item tested at 71.8 F and was warm to taste. During an observation in the conference room, two test trays were delivered by the Dietary Supervisor and RD 2 on a food cart, including one regular meal tray and one pureed meal tray. Temperature checks performed by RD 2 and the Nurse Surveyor showed the pureed tacos casserole at 124 F, pureed zucchini at 118.8 F, and pureed tangy glazed fruit at 71.8 F. The survey team sampled the pureed food and found the tangy glazed fruit, which was expected to be served cold, tasted warm. During interview, RD 1 stated the tangy glazed fruit should be served cold and needed to be at 40 F. A review of the FDA Food Code 2022 indicated cold food should have an initial temperature of 41 F or less and may not exceed 70 F.
Food Storage, Sanitation, and Cooling Deficiencies
Penalty
Summary
Food was not stored, prepared, and distributed in accordance with professional standards in the kitchen serving a census of 162. During an initial kitchen tour with the Dietary Supervisor, a Dietary Aide was observed inside the kitchen without a hair net, and the supervisor confirmed the deficiency. The facility policy required hair restraints to cover hair, beard, and mustache while in kitchen and food storage areas, and the Registered Dietician stated that hair restraints are an important part of the kitchen uniform for infection control. Multiple food storage and sanitation issues were observed in clean and ready-to-use areas. Several metal sheet pans and lids were stacked wet, and one pan had food debris inside. In the walk-in refrigerator, the floor was extremely wet, one bag of carrot strips was expired, and one opened bag of corn tortillas was not labeled with an open or use-by date. In the walk-in freezer, one opened package of fish nuggets in a large zipped bag had freezer burn and was not tightly sealed. The Registered Dietician stated the refrigerator, freezer, and kitchen floor must be kept clean, and that the fish nuggets should have been discarded. The oven was also observed with black residue at the bottom and was confirmed to be dirty. Staff knowledge and documentation related to sanitation and cooling were also deficient. A Dietary Aide could not demonstrate the proper process for testing the sanitizer red bucket and dipped the test strip for less than 5 seconds before reading it, while the supervisor stated it must remain in the solution for 10 seconds. A cook was unable to state the correct cool down process for hot food, and the Dietary Supervisor confirmed the facility did not have a cool down logbook for hot food and ambient food for the last 3 months. The Registered Dietician confirmed there was no cooling logbook available for the last quarter, and the facility policy required recording food temperatures every hour on a cooling monitor log.
Failure to Maintain Resident Dignity During Feeding, Mealtime Care, and Medication Administration
Penalty
Summary
The facility failed to ensure residents were treated with dignity during mealtime and care interactions. During dining observations, CNA 11 was standing while assisting Resident 58 with lunch, and when asked how she felt, Resident 58 said she felt rushed. CNA 10 was also observed placing towels around the necks of Resident 42, Resident 58, Resident 116, and Resident 135 without asking permission first. Resident 135 became upset, removed the towel, threw it on the table, and said, "I don't need this." Resident 116 stated staff should ask first if she wanted the towel, and Resident 42 stated she did not like the white towel as a cloth covering and thought they should use something nicer. Resident 64, who was admitted with multiple sclerosis, depression, chronic pain syndrome, multiple contractures including the right hand, and moderate cognitive impairment, required feeding assistance per the care plan. During observation, Resident 64's lunch tray was placed about three feet away from reach. CNA 2 stated the resident was a "feeder" because he could not eat by himself and depended on staff for feeding assistance. CNA 2 later acknowledged that he should not have called the resident a feeder and should have said the resident needed assistance with feeding. During interview, Resident 64 stated he preferred to be called by his name rather than "feeder." Resident 124, who was admitted with CHF and dementia and was rarely/never understood, was observed receiving medications in a common area across from the nurses station while other residents were present. LN 4 administered and explained the medications out loud, pulled up Resident 124's pants to expose her left knee, and applied arthritis medication without offering privacy. The DON stated the expectation was to bring the resident back to her room for privacy and dignity during medication administration.
Missing POLST and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure residents’ wishes regarding treatment and advance directives were accurately documented for six sampled residents. For Resident 10, the record showed admission in July 2025 with diagnoses including left femur fracture, chronic respiratory failure, COPD, and dementia. The MDS dated 7/13/25 showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. The record also showed a DNR order dated 7/18/25, hospice care ordered on 8/5/25, and the profile listed code status as DNR, but the case manager confirmed on 9/17/25 that there was no completed POLST in the medical record. During follow-up interviews, the case manager stated she tried to locate the POLST, contacted the hospice agency and physician, and later obtained the POLST from the resident’s family. She stated the expectation was that the POLST would be in the medical record and match the electronic health record. The facility’s POLST policy stated the form is intended to be a portable, authoritative, immediately actionable physician order consistent with the resident’s wishes and medical condition, and that a valid POLST is to be honored across treatment settings. For Residents 13, 15, 18, 110, and 122, review of the electronic and paper records found no documented evidence that an advance directive had been completed. Nursing staff, medical records staff, social services, and the DON all confirmed the absence of completed advance directive forms in the paper chart, EHR, and overflow records. Staff described the admission process as asking residents or responsible parties whether an advance directive exists, requesting a copy if one is available, and referring residents without one to social services; however, the records for these five residents did not contain completed advance directives or documentation that they had refused to complete one.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below five percent after surveyors found 22 medication errors out of 47 observed opportunities, resulting in a 46.81 percent error rate. The errors were observed during medication administration for three residents and included medications not given, medications given late, medications given in a manner not ordered, and a wrong vitamin administered. The report states these failures occurred during direct observation, interview, and record review. For one resident with an order for finasteride 5 mg daily and vitamin B complex daily, the nurse administered medications without asking the resident’s name or explaining each medication, did not give finasteride because it was not available in the cart, and gave the wrong vitamin. For another resident, the nurse prepared 12 medications, crushed all medications together without a physician order to crush them, mixed them with applesauce, and did not give ordered medications including metoprolol, lidocaine patch, omeprazole, diclofenac gel, and metoclopramide as ordered. The pharmacy consultant stated that omeprazole and metoclopramide should not be crushed. For a third resident, the nurse prepared 13 medications while the resident was waiting in pain and reported a pain score of 8/10. The resident stated the scheduled pain medication was due at 9 a.m. but was given late, and the nurse acknowledged that all medications were administered late and that metoprolol was not given. The medication administration audit showed the medications were administered at 10:47 a.m., and the DON acknowledged the pain medication was late and that the physician should have been notified of the missed dose.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were properly stored and labeled. During observations, a medication cup with cream and a wound cleanser bottle were found on a resident’s bedside table, and LN 9 confirmed the resident could not self-administer medications. Medications were also observed unattended at the station 3 nurse’s station, and LN 12 acknowledged the medications were left there to be given to the nursing supervisor for discontinuation. The pharmacist consultant stated discontinued medications should be stored in a separated location. At Medication Cart C in Station 1, LN 13 identified a discontinued and expired Humulin vial, an unlabeled Paxlovid medication, five discontinued pain medication cards in the narcotic box, two discontinued narcotic patches in the narcotic box, and an expired morphine bottle in the narcotic box. LN 13 stated the Paxlovid should have had a pharmacy label and that the discontinued medications should have been removed from the cart. The DON stated expired medications were to be removed from facility supply and placed in the locked medication destruction cabinet, and the pharmacist consultant stated narcotics should remain in their separated storage area and still be counted until transfer of custody to the DON or ADON. Additional cart inspections found expired artificial tears opened on 12/31/24, sticky liquid residue on multiple bottles, loose pills in medication carts, a discontinued lidocaine vial, Ensure stored in a medication cart, and glucometer control solution without tops or an open date. LN 14 confirmed the eyedrops should have been discarded and LN 10 and LN 8 confirmed loose pills and discontinued medications should have been removed. The manufacturer’s labeling for the control solution required use within 90 days of opening, and the pharmacist consultant stated medication carts are expected to be kept clean and glucometer solution should be dated upon opening. Facility policies stated bedside medication storage is only for residents approved to self-administer, controlled medications are to be counted at each shift change by two licensed nurses, and outdated or discontinued medications are to be removed or stored separately.
Infection Control Failures During Resident Care and COVID-19 Precautions
Penalty
Summary
The facility failed to implement infection prevention and control practices during resident care and in shared areas. During dining observations, CNA 11 assisted a resident with lunch and then moved away without performing hand hygiene before or after the meal assistance. CNA 10 assisted one resident with lunch while wearing gloves, then went to another resident and continued care without removing the gloves or performing hand hygiene in between residents. The Activity Director also changed gloves between residents but did not perform hand hygiene before putting on the new pair. The Infection Prevention Nurse stated hand hygiene was expected before and after each resident care activity and before and after removing gloves. Resident 150, who had toxic encephalopathy, quadriplegia, and a suprapubic catheter connected to a urinary drainage bag, was not placed on Enhanced Barrier Precautions. At the room entrance, there were no EBP signs posted and no PPE set up for staff use. CNA 1, LN 1, and the Infection Preventionist each confirmed that the resident should have been on EBP because of the catheter and that the precautions were not in place. The facility’s EBP policy identified urinary catheter care as a high-contact activity requiring EBP and required posting the EBP sign on the resident’s room door. The facility also failed to clean a shared blood pressure cuff between resident uses, and LN 4 used the same cuff on two residents without sanitizing it in between. LN 4 also wore an N95 mask under the nose and over only the mouth while administering medications to multiple residents. In addition, staff entered isolation rooms without the required face shields, including nurses and CNAs caring for residents on droplet, contact, and airborne precautions. The report also documented that the facility had no active COVID-19 screening of visitors and staff at entry, no documented contact tracing or line listing, no documented current PPE competency, and no documented surveillance monitoring or in-services for PPE donning and doffing during the outbreak. Other infection control failures included Resident 89 being in COVID-19 isolation with the room door open and the PPE trash can placed outside the room, Resident 157’s CPAP mask left uncovered on the nightstand, and Resident 10’s oxygen tubing not labeled and dated. Housekeeping staff were observed entering an isolation room without hand hygiene or a gown, and the housekeeping staff interviewed were not familiar with the disinfecting chemical used or its dwell time. Observations also noted no high-contact surface disinfection, residents in hallways without masks for source control, and no screening for signs and symptoms of COVID-19 at the front lobby.
Bed Remote and Call Light Not Within Residents’ Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents when Resident 120’s bed control remote was not within reach and Resident 140’s call light was not within reach. Resident 120 was admitted in 2017 with multiple diagnoses including left hemiplegia, and the medical record indicated the left side was his dominant side. His care plan showed he was dependent on staff for bed mobility, turning, transfer, and personal hygiene. During observation, Resident 120 was lying flat on his back and stated he needed to raise his head because he could not see well when flat and could not find his remote. The bed control remote was observed hanging down under the bed near his feet on the left side, and the resident was unable to see or reach it. A CNA later found the remote and confirmed it had not been within the resident’s reach. The CNA stated the resident could use the remote if it was on the right side of the bed and within reach, and that it should be clipped to the right side bed rail to accommodate his paralysis on the left. Resident 140 was admitted earlier in the year with diagnoses including stroke, dementia, and muscle weakness. Her care plan for risk for falls directed staff to anticipate and meet her needs and ensure her call light was within reach. During observation, she was sitting on the edge of the bed and stated she did not have the call bell and instead went to look for staff. Her call light was observed on the floor behind the nightstand about three feet from the bed. A CNA later found both residents’ call lights behind the nightstand and placed them on the beds, and confirmed Resident 140 would not have been able to use the call light when needed or in an emergency.
Failure to Provide Activity Services Consistent With Resident Preferences
Penalty
Summary
Provide activities to meet all resident's needs. Based on observation, interview, and record review, the facility failed to ensure one of 40 sampled residents, Resident 14, was offered activities that met her interests and preferences. Resident 14 was admitted with multiple diagnoses, including dementia. Her Activity Progress Note indicated preferences for independently reading books, newspapers, and magazines and listening to music in a group setting. Her Care Plan Report stated that she enjoyed reading and conversation, that staff should engage her in conversation daily, provide reading material, and inquire about what she was reading, and that activities should accommodate her impaired cognitive function. During multiple observations, Resident 14 was in her room sitting on the bed with no activity. On two separate observation dates, she was observed at several times in the morning, afternoon, and later afternoon with no activity. During a concurrent interview and record review, the Activities Director reviewed the resident's Activity Lookback Report and found no plan of care for activities documented in the clinical record for the last 16 days. The Activities Director stated the plan of care was where staff documented activities completed by residents each day and confirmed there was no documented evidence of activities done by Resident 14. The DON stated that despite the outbreak, activities should still be provided for residents, such as 1:1 room visits, and that if activities were not provided, it could result in a decline in psychosocial wellbeing. The facility policy stated residents who are not physically able or choose not to leave their room would receive regularly scheduled room visits, supplies or equipment for activities specified in the Activities Care Plan, and documentation of the activity, participation, and response.
Failure to Prevent Facility-Acquired Heel Pressure Injuries
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment and dependence for bed mobility from developing facility-acquired pressure injuries to both heels. The resident was admitted without pressure injuries and was identified as being at risk for pressure injury development. The care plan called for turning and repositioning at least every 2 hours, pressure injury prevention measures, and monitoring for skin changes, and later orders included a low air loss mattress, heel offloading, and offloading boots. The resident’s records showed that pressure injuries were first identified on the right and left heels on 8/2/25. A SBAR communication form noted a CNA observed a pressure injury sore on the bottom of the right foot with heel discoloration. A wound assessment later documented unstageable pressure injuries on both heels, with the right heel measuring 5 cm by 6 cm and the left heel measuring 1.5 cm by 2 cm. Staff interviews indicated that before the wounds developed, pillows were used to elevate the heels, and a low air loss mattress and offloading boots were ordered only after the pressure injuries occurred. Interviews with staff described inconsistent prevention and communication. One nurse stated the resident should have had a turning schedule and that CNAs were still not turning him every 2 hours, while another CNA stated she had not been informed about the heel wounds or received instruction regarding pressure relief. The DON stated the resident rubbed his heels on the mattress and pushed down on his heels in the wheelchair. The wound MD stated the wounds were pressure injuries caused by immobility and that pillows under the calves and a low air loss mattress may have helped prevent the injuries.
Failure to Follow RD Supplement Recommendations Led to Significant Weight Loss
Penalty
Summary
The facility failed to ensure Resident 9’s weight was maintained when the RD’s therapeutic diet recommendations were not entered into the orders and were not followed. Resident 9 was admitted with diagnoses including type 2 DM, dementia, and GERD. The Nutritional Risk Assessment dated 6/2/25 documented that the resident had lost 9.9% or 20.6 lbs in three months and noted that the resident liked supplements and was agreeable to increasing them. The assessment recommended discontinuing the house supplement 4 oz daily and 4 oz twice daily and adding a NAS house supplement 4 oz twice daily with percentage intake recorded. A later Nutrition/Dietary Note dated 8/15/25 documented further significant weight loss, including 7.7% in 1 month, 12% in 3 months, and 19.6% in 6 months, and the RD recommended discontinuing the 4 oz house supplement once daily and adding NAS house supplement 4 oz three times daily with percentage intake recorded. However, the Order Summary Report printed on 9/19/25 still showed an order for a 4 oz house supplement/milk shake in the afternoon with an order date of 5/22/25. During interview, the RD stated that when she reviewed the care plan she realized nobody had entered her recommendations into the orders, and that once she made a recommendation in her dietary note it did not require physician approval to be carried out. The facility policy stated that weight loss should be identified and appropriate interventions implemented and the care plan updated and revised.
Pain Medication Delays and Incomplete Pain Monitoring
Penalty
Summary
Adequate pain management was not provided for a resident with a left below-knee amputation, chronic pain syndrome, and phantom limb pain. The resident was cognitively intact and had physician orders to assess pain every shift using a numeric scale and to receive Hydrocodone-Acetaminophen 10-325 mg three times daily for pain, with the medication held only if respirations were below 12. The resident stated that pain medication was often delayed, that he had to wait for scheduled doses, and that when he did not receive Norco on time his pain increased to 10 out of 10 and it took a long time to get relief. The record showed that the resident’s scheduled Norco was not administered at the ordered time on at least two occasions. On one day, the noon dose was not given and there was no progress note explaining why it was omitted; the resident reported that he eventually received the medication almost at 5 p.m. instead of 1 p.m. On another day, the 9 a.m. dose was not given by the expected time and was later documented as administered at 10:45 a.m. The resident was observed in bed with a painful expression and moving his stump up and down while reporting severe pain and stating he had not received his Norco. The facility also did not complete pain assessments every shift as ordered and did not document the effectiveness of pain medication or monitoring for side effects. Nursing staff stated they assessed pain only once daily during morning medication administration, and the DON acknowledged that pain assessments were not completed on all shifts, were not done quarterly, and were not addressed at the care conference. The DON also acknowledged there was no documented evidence that the resident was monitored for adverse effects of Norco. The resident’s care plan called for monitoring pain complaints, administering pain medications as ordered, responding immediately to pain complaints, and documenting side effects and effectiveness, but the record did not show these actions were consistently completed.
Registry Nurse Competency Validation Failure Led to Late Medication Administration
Penalty
Summary
The facility failed to ensure a registry Licensed Nurse had the specific skills and competencies needed before providing resident care. The Director of Staff Development stated registry staff should be checked off on skills and competencies before working, but she could not locate a competency checklist for the nurse in question. The Director of Nursing also stated registry nurses are expected to be signed off on competencies before providing resident care, and that there was a risk for medication errors and resident complaints when registry nurses' skills and competencies were not validated. This failure was associated with late medication administration for two residents. One resident with Parkinson's disease was ordered carbidopa-levodopa every 4 hours and stated her morning dose was given 1 1/2 hours late; she also stated her speech and movement were affected when her Parkinson's medications were delayed, and the OT confirmed she occasionally received these medications late when registry nurses were working. Another resident with chronic pain was ordered hydrocodone-acetaminophen three times daily and stated he did not receive his noon dose and had severe pain when his medication was delayed. The MAR showed the registry nurse administered the resident's 1:00 p.m. dose at 4:07 p.m., and the nurse acknowledged administering the Parkinson's medication 1 1/2 hours late.
Unnecessary Psychotropic Medication Use and Missing Consent/Order Follow-Through
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication use. For Resident 64, the record showed an order for fluoxetine 20 mg daily for depression for 7 days, then 40 mg daily for depression. Resident 64 had multiple sclerosis, depression, chronic pain syndrome, and moderate cognitive impairment based on a BIMS score of 12 out of 15. The clinical record did not contain documented evidence that the resident was monitored for manifested behaviors of depression or for adverse effects of fluoxetine. Resident 64’s record also contained an unsigned and undated informed consent document for a psychotropic drug, but it did not identify specific manifested behaviors of depression and did not show that the physician reviewed and discussed the reason for treatment, side effects, risks, or alternatives with the resident or responsible party. During interview, Resident 64 stated he was told he had depression but did not know whether he had it, and said he took antidepressant medications because they helped him sleep. The DON acknowledged that informed consent had not been obtained, that the order did not specify the exact behavior manifestation of depression, and that the resident was not monitored for adverse effects. For Resident 3, the admission record listed schizoaffective disorder and Alzheimer’s disease, but did not include depression. The OSR showed an active order for citalopram 40 mg daily for depression manifested by increased irritability. A BHN later documented a plan to decrease citalopram from 40 mg daily to 20 mg daily, but there was no documented evidence that the medication change was implemented. The DON stated the attending physician needed to be informed of behavioral health medication changes and that if the physician refused, the reason had to be documented, but the chart did not show that the physician was notified or that any denial was documented.
Medication Administration Errors
Penalty
Summary
Resident 46, who was admitted with diagnoses including acquired absence of the left leg below the knee, HTN, and chronic pain syndrome, was observed during medication administration with intact cognition noted on the MDS. During the observation, the resident was waiting next to the medication cart, moaning and tearful, and stated he had been waiting too long for his pain medication and rated his pain as 8/10. LN 4 administered hydrocodone/acetaminophen 10-325 mg at 10:47 a.m., although the scheduled time was 9:00 a.m., and acknowledged that the pain medication was given late while the resident was in pain. During the same observation, LN 4 told the resident that metoprolol was not available to be administered, and the blood pressure medication was not given. The medication administration audit report confirmed that hydrocodone was administered at 10:47 a.m. and metoprolol was not administered. The DON acknowledged the pain medication was administered late and stated the LN should have called the doctor to notify of the missed dose and obtain new orders. The facility policy stated medications must be administered according to physician orders and within one hour before or after the scheduled time, and that when a medication is held, it must be documented and the prescribing provider notified.
Bed Control Remote Left with Exposed Wires
Penalty
Summary
The facility failed to keep a bed control remote in a safe operating condition for one resident. The resident was admitted earlier this year with multiple diagnoses, including stroke, dementia, and muscle weakness. During an observation, the resident was sitting on the edge of the bed and was alert and able to carry on a small conversation. The resident picked up the bed control remote from the floor and pointed out that the cord near the remote was ripped with wires exposed, with tape wrapped around the damaged area but not holding. The resident stated the remote had been broken for a long time and said, "I'm scared to use it." During a concurrent observation and interview, a CNA entered the room, picked up the remote from the floor, and attempted to place it on the resident's bed. When asked if it was safe for use, the CNA did not provide an answer before leaving the room. A licensed nurse later acknowledged that the insulation was broken and wires were exposed, and stated the remote was not safe to use and should be replaced. The VP also observed the remote with exposed wires and stated it was not safe for the resident's use, validating that exposed wires created risks for injury and had the potential to cause fire. The facility policy stated that the Maintenance Department is responsible for maintaining equipment in a safe and operable manner at all times.
Call Lights Not Accessible to Two Residents
Penalty
Summary
The facility failed to ensure call lights were accessible for two residents who had care plans directing that their call lights be kept within reach and that requests for assistance receive prompt response. Resident 138 was admitted with diagnoses including left wrist fracture, right hand metacarpal fracture, diabetes, cognitive impairment, and generalized muscle weakness. The resident’s MDS indicated moderate cognitive impairment with a BIMS score of 8 out of 15, and the care plan identified high fall risk related to confusion, deconditioning, and psychoactive drug use. During observation, Resident 138 was found lying in bed with the call light shut in the nightstand drawer and unable to reach it; a CNA later confirmed the call light was not accessible and stated it should be in the bed with the resident. Resident 10 was admitted with diagnoses including left femur fracture, chronic respiratory failure, COPD, and dementia. The resident’s MDS also showed moderate cognitive impairment with a BIMS score of 8 out of 15, and the care plan identified high fall risk related to deconditioning, incontinence, and psychoactive drug use. During observation, Resident 10 was in bed with the call light on the floor behind the nightstand and stated he could not find it; an LN later confirmed the call light was inaccessible and stated it should be clipped to the bed, noting the clip was missing. The facility policy stated the call system should allow residents to alert nursing staff from their rooms and toilet/bathing facilities, and that call cords would be placed within the resident’s reach.
Failure to Provide Needed ADL Care
Penalty
Summary
The facility failed to provide needed ADL care for two residents. One resident with frontotemporal neurocognitive disorder, dementia with psychotic disturbances, and type 2 DM was observed walking in the hallway without socks, and the resident’s toenails were long, thick, and pointy. The resident’s care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, and the order summary included podiatry service as clinically indicated. The DON stated that residents with long toenails, especially those with DM, were expected to be referred to podiatry as soon as possible, and that long, thick toenails could result in skin issues of the foot and pain. The SSD stated there was no evidence in the clinical record that the resident had been seen by podiatry. A second resident with dementia, communication deficit, and dysphagia had a decline in function and was documented by the physician as having hand tremors and left facial jaw movements and as being unable to feed herself, requiring one-on-one help with meals. The resident’s care plan directed staff to provide personal hygiene, sponge baths as needed, oral care, and cleanup assistance after meals, and to check the resident every two hours and more often as needed for incontinence care. Nursing progress notes showed the resident was given breakfast and was still eating it more than an hour later when medication was administered, and later that morning the resident’s daughter reported the resident was dirty and wet, had a crusted eye, dirty hands, a foul-smelling room, and breakfast still present. The assigned CNA was sent to lunch and did not return for two hours, and the LN documented that the IDT was notified about the resident’s hygiene and feeding concerns. During interviews, the LN, CNA, RMDS, and DON confirmed that the resident required one-on-one feeding assistance and regular personal care, and that the resident was not cleaned or assisted as expected on the day in question. Facility policies for grooming, dining, and incontinence care stated that residents who need assistance are to receive help with meals, remain clean and dry, and have nail care addressed according to need.
Double Insulin Dose Leads to Hypoglycemic Episode
Penalty
Summary
A significant medication error occurred when a resident with Type 1 diabetes received a double dose of insulin lispro, along with an additional sliding scale dose, resulting in a total of 27 units of fast-acting insulin administered within a short period. The error was caused by a transcription mistake during the entry of new insulin orders into the computer system, where the previous insulin order was not discontinued. As a result, two licensed nurses administered separate doses of 12 units each, and one nurse also gave an additional 3 units based on a sliding scale order. This led to the resident receiving two scheduled doses only 1 hour and 24 minutes apart, in addition to the sliding scale dose. Following the administration of these insulin doses, the resident experienced a hypoglycemic episode, becoming unresponsive with a blood sugar reading of 43 mg/dl, which was significantly lower than her average blood glucose level. Staff interviews confirmed that the resident was not acting normally and was found to be shaking and unresponsive. The facility's documentation and interviews with the Director of Nursing and other staff acknowledged the medication error, attributing it to a failure to discontinue the prior insulin order, resulting in duplicate administration.
Failure to Notify Resident of Significant Medication Error
Penalty
Summary
The facility failed to notify a resident of a significant medication error involving the administration of a double dose of insulin lispro, which resulted in a hypoglycemic episode. The resident, who has Type 1 diabetes and is her own healthcare decision maker, was scheduled to receive 12 units of insulin lispro at two separate times in the morning. However, two licensed nurses administered the doses only 1 hour and 24 minutes apart, and an additional sliding scale dose was also given, totaling 27 units of fast-acting insulin. This led to the resident experiencing a dangerously low blood sugar level of 43 mg/dl, as documented in the medical record and confirmed by staff interviews. Despite the occurrence of this medication error and the resulting change in the resident's condition, the facility did not inform the resident about the error. Interviews revealed that the resident was not told about the double dosing incident and expressed a desire to have been notified. The facility's own policies require prompt notification of residents and their representatives regarding significant changes in condition or medication errors, but this was not followed in this case. Staff interviews further confirmed that the resident was not made aware of the medication error at the time it occurred.
Failure to Arrange Timely Hospital Referral for Dental Extractions
Penalty
Summary
The facility failed to assist a resident in obtaining timely dental care after receiving a letter from a local oral surgery clinic indicating that the resident required referral to a hospital for full mouth extractions. The resident, who had diagnoses including heart failure and chronic kidney disease, was identified as having oral/dental problems related to poor oral hygiene and likely cavities. The care plan specified that licensed nurses or a social worker were responsible for coordinating dental care and transportation as needed. Despite a referral to a local oral surgery clinic and subsequent consultation, the clinic determined that the procedure should be performed in a hospital setting. However, there was no documentation that a formal referral to the hospital was ever made. Record reviews and interviews revealed that the social services staff contacted Denti-Cal and learned that both Denti-Cal and the local oral surgery clinic, as well as the hospital, declined services. The social services director stated that it became the nurse's responsibility to find a location for the procedure, but no progress note or documentation was found to confirm that a hospital referral was completed. The administrator also confirmed the absence of documentation for a formal hospital referral. The facility's policy required social services to arrange necessary dental appointments and document any extenuating circumstances for delays, but this was not done in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical abuse when one resident struck another on the back of the head. Resident 1, who had diagnoses including end stage renal disease and vascular dementia but was assessed as having intact cognitive skills for daily decision making, hit Resident 2 after Resident 2 spilled hot chocolate on her. Resident 2, who had peripheral vascular disease, dementia with moderately impaired cognitive skills, anxiety disorder, and depression, reported feeling distressed as a result of the altercation. Resident 1 admitted to hitting Resident 2 and stated it was in response to being called names. The incident was reported by Resident 2 to staff, and both residents confirmed the details during interviews. The Director of Nursing acknowledged recent changes in facility leadership and management, and emphasized the importance of improved resident assessment and care planning to prevent such altercations. A review of the facility's abuse prevention policy indicated that the facility is responsible for identifying, correcting, and intervening in situations where abuse is more likely to occur.
Failure to Complete Required PASRR Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Resident 3 received a federally required PASRR evaluation. Resident 3 was admitted with diagnoses including metabolic encephalopathy, cognitive communication deficit, and schizoaffective disorder. The resident’s MDS dated 7/22/25 showed a BIMS score of 12, indicating moderate cognitive impairment, and the MDS dated 7/17/25 listed schizophrenia as an active diagnosis. An Order Summary Report dated 8/28/25 showed the resident was receiving Zyprexa 5 mg daily for schizophrenia with hallucinations. A California DHCS PASSR Level 1 Screening dated 7/28/25 identified Resident 3 as having a serious mental illness and receiving psychotropic medication, and stated that a PASSR Level 2 screening was required. DHCS correspondence to the facility dated 8/02/25 stated that a PASSR Level 2 was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 screening. During interviews, the MDS Nurse stated he was unsure when a PASSR would need to be corrected or whether a new PASSR process would be started if a resident presented with symptoms of mental illness not reflected in the PASSR. The DON stated the facility had recent administrative changes and that Level 1 PASSRs were often not correctly completed by acute care hospitals, which could leave residents without appropriate oversight from DDS.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving two residents was reported to the Department of Public Health within the required two-hour timeframe. Documentation shows that a verbal altercation occurred between the two residents, with one making verbal threats toward the other. Although staff members stated they attempted to report the incident by faxing a SOC 341 form and leaving a voicemail, there was no confirmation or evidence that these reports were successfully received by the Department. The written investigation summary and five-day follow-up report were not received by the Department until four days after the incident. Interviews with the administrator and licensed nurses confirmed that facility policy required reporting allegations of abuse to the Department within two hours. However, there was no fax confirmation or voicemail log to verify that the initial report was made as required. The administrator acknowledged that, even if a phone call had been made at the time stated by staff, it would not have met the two-hour reporting requirement. The facility's policy specifically mandated that a written SOC 341 report be sent to the Department within two hours of the incident.
Failure to Administer Prescribed Antibiotic and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received a prescribed antibiotic, Ceflozane Sulfate Tazobactram Sodium (CSTS), as ordered by the physician following admission from the hospital. The resident, who had a complicated medical history including a recent spinal infection and abscess treated for lumbosacral-spine-osteomyelitis, was admitted with orders for CSTS to be administered intravenously every eight hours until a specified date. Despite these orders, the medication was not acquired or administered as scheduled, with the medication administration record showing missed doses on the day of admission and the following morning and afternoon. Interviews and record reviews confirmed that staff were aware of the medication order and the delay in pharmacy delivery, but there was no documentation that the physician was notified about the inability to administer the antibiotic as prescribed. The Director of Nursing confirmed that it was expected for the physician to be notified in such situations, and the facility's policy required medications to be administered as ordered to ensure compliance with dosing guidelines. The lack of timely acquisition and administration of the antibiotic, as well as the failure to notify the physician, led to the identified deficiency.
Inaccurate MAR Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for one resident when the Medication Administration Record (MAR) incorrectly indicated that a prescribed dose of Ceflozane Sulfate Tazobactram Sodium (CSTS) was not administered because the resident was hospitalized. A review of the resident's transfer form showed that the resident was not transferred to the hospital until 7:15 p.m., but the MAR entry at 4:00 p.m. on the same day stated the medication was withheld due to hospitalization. The Director of Nursing (DON) confirmed that the resident was still present in the facility at the time the medication should have been administered and that the MAR entry was inaccurate. Facility policy titled 'Completion and Correction' requires that all entries in the medical record be complete, legible, and accurate. The DON acknowledged that the MAR entry did not meet these standards, as it did not accurately reflect the resident's status or the administration of the prescribed medication. This resulted in an inaccurate medical record for the resident.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
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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 Novato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Smith Ranch Skilled Nursing & Rehabilitation Cente | 6 mi | ★★★★★ | 19 | 0 |
| Professional Post Acute Center | 6.3 mi | ★★★★★ | 17 | 0 |
| Pine Ridge Care Center | 6.3 mi | ★★★★★ | 23 | 0 |
| Northgate Postacute Care | 6.3 mi | ★★★★★ | 4 | 0 |
| Villa Marin | 6.7 mi | ★★★★★ | 8 | 0 |
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