Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ocean Pointe Healthcare Center during CMS and state inspections, most recent first.
Food was not prepared, stored, and served in a sanitary manner. A prepared protein shake mixture was found past its use-by date, an aide served food while holding a plate with a bandaged thumb, and standing water was observed near the kitchen entrance. Dishes and cups were stored wet or near a trash can, several pitchers and a food prep container were damaged or dirty, plates in the warmer were wet, and multiple items labeled keep refrigerated were stored in dry storage. The food processor bowl attachment also had black residue and cracks.
Failure to maintain privacy and dignity during incontinent care: A resident with dementia, hemiplegia, and HTN who was dependent on staff for ADLs was observed in bed with the room door open and dignity curtains open while CG provided incontinent care, leaving the resident’s private area visible from the hallway. CG said she was closing the curtain for privacy, and the DON stated dignity curtains should be completely closed during ADL care to protect resident privacy.
Failure to assess and authorize self-administration of bedside meds: A resident with intact cognition and diagnoses including cardiomyopathy, DM2, depression, and muscle weakness had lidocaine ointment and multiple supplements at the bedside. Staff were unaware of the items, no physician order for self-administration was found, and the care plan lacked assessment or interventions for self-administration or bedside storage.
Inappropriately Sized Bed for A resident: A resident with right-sided hemiplegia, dysphagia, dysarthria, epilepsy, and moderate cognitive impairment was observed with feet against the footboard and stated feeling uncomfortable in bed. CNA and nursing leadership stated the bed was too small, and that proper bed positioning is important to minimize pain, discomfort, and pressure ulcer risk.
A resident with hemiplegia, dysphagia, epilepsy, muscle weakness, a G-tube, and severely impaired decision-making was observed using a bedside table that was missing one of four wheels. When the resident pushed the table, it tilted and the breakfast tray almost slid off. A CNA confirmed the missing wheel, and another CNA said he had placed the table and tray without noticing the defect. The facility maintenance log did not show a repair request for the table.
Failure to Report Alleged Resident-to-Resident Abuse: The facility did not report an alleged abuse incident involving two residents to CDPH within the required timeframe. One resident with COPD, dementia, and mobility impairment reportedly had a hallucination and hit another resident, who also had intact cognition but needed assistance with ADLs and mobility. The incident was reported to PD and documented in the grievance log, but the Admin stated it was not reported to CDPH because he did not consider it abuse under the facility's AFL interpretation.
Failure to develop a baseline care plan for supplemental O2 therapy. A resident with multiple complex diagnoses had an order for O2 at 2 L/min via NC for desaturation, but was observed receiving 3.5-4 L/min at bedside. The care plan did not address the resident’s O2 needs with measurable goals or interventions, and the DON stated the baseline care plan should be initiated within 24 hours of admission.
A resident’s bedside area contained a medication cup with an unidentified white creamy substance left within view and easy reach. Staff identified it as zinc barrier cream/skin protectant, and an LPN stated it should be discarded after use and not left at bedside. The DON stated bedside medications require assessment and approval for self-administration, and the facility policy addressed discarding ointments and creams in the medication room.
Inadequate Enteral Feeding Delivery: A resident with a GT, dysphagia following CVA, and moderately impaired cognition did not receive enteral feeding as ordered. During a tour, the feeding pump was found turned off and the remaining volume in the feeding bottle indicated the resident had received less formula than prescribed. The physician order specified Jevity 1.5 at 50 mL/hr for 20 hours, and the RNS and DON stated inadequate tube feeding can lead to malnutrition, skin breakdown, weight loss, and open wounds.
Incorrect Oxygen Flow Rate: A resident with a history of stroke-related deficits, dysphagia, Afib, and a heart assist device was ordered oxygen at 2 L/min via NC continuously for desaturation, but was observed receiving 3.5 to 4 L/min at bedside. The RNS confirmed the ordered rate, and the DON stated prolonged oxygen use could cause oxygen toxicity and cell damage. The facility policy required reviewing the physician’s order for oxygen administration.
A private caregiver provided incontinent care and direct care to a cognitively impaired resident with dementia and hemiplegia while no facility staff were assisting. The resident was observed in bed with the room door and privacy curtain open, and the DON stated private duty sitters should not provide direct care because they are not trained; the facility policy also stated they may not administer direct care unless authorized in writing by the attending physician.
No RN on duty for required shifts. Facility records showed that an RN was not on duty for any of the three shifts, and the nursing assignment sheet confirmed there was no RN present for 8 consecutive hours. The DSD and DON both confirmed the staffing gap, and the DON stated the facility did not have a policy and procedure on RN staffing. The Nurse Supervisor job description stated that sufficient LPNs and/or RNs are to be available to maintain quality care.
Open Outside Garbage Bin Lids: Two of three sampled outside garbage and recycling bin lids were observed left open during an observation with the FSD in the alley behind the facility. The FSD stated that garbage bins must be covered to prevent pests, and the FDA Food Code cited in the report requires outside waste receptacles used with food residue to have tight-fitting lids, doors, or covers.
A resident with a fractured mandible, dementia, HTN, and dysphagia had a dental eval and was awaiting dentures, but the SSD did not document social service progress notes or the dental services provided in the EMR. The resident also reported tooth pain while eating, and the SSD and DON confirmed the documentation was missing.
Failure to disinfect shared resident care equipment between residents: An LVN used a BP machine, pulse oximeter, and thermometer for one resident, dropped the BP machine on the floor, wiped it without first cleaning the med cart surface it contacted, and then continued care. The LVN later used the same shared equipment for another resident without cleaning or sanitizing it between residents, despite the facility policy requiring reusable non-critical resident-care items such as BP cuffs to be cleaned and disinfected between residents.
Call buttons were not kept within reach for three residents. Two residents who were seated in reclining wheelchairs had their call lights placed in the center of their beds, and an additional resident’s call button was on a nightstand at the head of the bed and out of reach. The residents had significant cognitive and physical impairments, and care plans and facility policy directed staff to keep call lights within reach.
A resident with CHF, DM, mobility difficulties, and depression, who was cognitively intact, reported being hit in the mouth and head on multiple occasions by another resident with COPD, CKD, dementia, and a documented history of physical and verbal aggression. Staff acknowledged a history of conflict between the two residents and that an incident had occurred days earlier, and progress notes showed prior aggressive behavior by the alleged aggressor. However, no nursing assessment (such as a skin check), change-of-condition evaluation, SBAR communication, or related documentation was completed or recorded after the abuse allegation, despite facility policies requiring assessment, monitoring, physician/responsible party notification, and charting when abuse or physical aggression is reported.
Two residents with significant care needs experienced delays in staff response to their call lights, despite staff being present at the nursing station. One resident, with a history of falls and muscle weakness, waited for assistance with morning medications, while another, totally dependent on staff, also had an active call light ignored for several minutes. Staff interviews confirmed that call lights were not always answered promptly, contrary to facility policy.
A treatment nurse and a CNA did not wear required PPE while performing a suprapubic catheter change for a resident on Enhanced Barrier Precautions. The resident had multiple medical conditions and required significant assistance. Facility policy and physician orders required staff to use PPE for such care, but this protocol was not followed during the observed procedure.
A resident with multiple diagnoses and moderate cognitive impairment had abnormal urinalysis results indicating possible infection, but the facility failed to notify the physician or responsible party and did not document the change in condition as required by policy.
A resident with a history of convulsions, sepsis, and CHF did not receive prescribed Depakote within the required time frames on two occasions, as confirmed by MAAR review and DON interview. The resident reported having a seizure due to delayed anti-seizure medication administration, and the DON acknowledged the deviation from policy requiring medications to be given within one hour of the scheduled time.
A resident with an indwelling urinary catheter who complained of pain and was found to have sediments in the catheter did not have these findings documented or reported to the physician by the treatment nurse. The nurse also did not check or record vital signs, contrary to facility policy, resulting in a deficiency in care to prevent UTIs.
A resident with severe cognitive impairment and multiple diagnoses had a change in dementia medication dosage, but the responsible party or POA was not notified as required by facility policy. Record review and staff interview confirmed the lack of documentation and notification regarding the medication change.
A resident with severe cognitive impairment and multiple medical conditions experienced a significant change of condition, including low oxygen saturation and chest pain, leading to transfer to a hospital where a pulmonary embolism was diagnosed. Staff failed to document the change of condition, care provided, and physician orders for transfer, contrary to facility policy requiring such documentation for all significant events and changes in resident status.
The facility did not consistently complete, post, or retain required DHPPD forms, resulting in missing or incomplete daily nurse staffing information. This led to misinformation for all residents, families, and visitors about the actual staffing levels, as confirmed by the DSD during interviews and record reviews.
Surveyors found that opened food items in a refrigerator were not labeled with the required information, and the dry storage area lacked a thermometer to monitor temperature. The Dietary Supervisor and DON confirmed these lapses, which did not follow the facility's own food safety policies.
A leaking industrial washing machine was found in the laundry room, with a bucket and towels used to catch water and a puddle forming nearby. The Laundry Supervisor was unsure how long the leak had persisted, while the Maintenance Supervisor was aware but had not yet arranged for repairs. The Administrator was not informed of the issue, and the facility's maintenance policy requires equipment to be kept safe and operable. This failure had the potential to delay clean linen for all medically compromised residents.
Surveyors found that the laundry room floor had cracks and holes in front of the industrial washing machine, and the door leading to the dining hall was not functioning properly, with handles turning in different directions and failing to open or close as intended. Both the Laundry Supervisor and Maintenance Supervisor were unaware of the extent or duration of these issues prior to the survey.
A resident with dementia, muscle weakness, abnormal gait, and atrial fibrillation, who was assessed as high risk for falls, did not have bilateral floor mats in place as ordered by the physician and outlined in the care plan. During observation, the resident was found in bed with a bed pad alarm but without the required floor mats. Staff and the DON confirmed the omission, despite facility policy requiring such interventions for fall prevention.
A resident with a gastrostomy tube did not receive tube feeding as ordered when the feeding pump was left paused and alarming for at least 25 minutes, with the nurse unaware of the issue. Another resident receiving enteral hydration via g-tube had an unlabeled hydration bag, contrary to facility policy requiring labeling with the resident's name, date, time, and rate. These deficiencies involved residents with significant medical needs, including malnutrition and dysphagia, and were confirmed by nursing staff and policy review.
A facility failed to ensure a resident's safety after being notified of an APS case involving the resident's family member. Despite the resident's need for assistance and the family member's attempts to remove the resident without approval, no care plan was developed to address the risk. Staff interviews confirmed awareness of the APS case but revealed a lack of documented follow-up or monitoring plan.
A resident with multiple health conditions was discharged from the facility without necessary pre- and post-dialysis assessments, a discharge plan summary, or an IDT meeting, contrary to facility policy. Staff interviews confirmed the absence of these critical discharge steps, placing the resident at risk for harm.
A facility failed to develop a comprehensive care plan for a resident with an APS case involving a family member. Despite being informed of the case and the family member's attempts to remove the resident without approval, no care plan was created to address these issues. Staff interviews confirmed awareness of the situation but revealed a lack of documentation and planning to ensure the resident's safety.
A resident felt unsafe and uncomfortable due to their roommate's constant screaming and cursing, which was not reported by an LVN to the Facility Administrator. Both residents had severe cognitive impairments and required maximal assistance. The facility's policies emphasize supporting residents' dignity and well-being, but the failure to address the disruptive behavior potentially impacted the affected resident's psychosocial well-being.
A resident's family member reported grievances about the resident's roommate, who allegedly shouted racist slurs and threw coffee. The facility failed to resolve the grievance promptly and did not report or investigate the alleged abuse, as required by policy. The DSS called the police instead of addressing the issue internally, and the FA was not informed of the incidents.
The facility failed to report a suspected abuse incident involving a resident with severe cognitive impairment who was subjected to aggressive behavior by another resident. The Director of Social Services did not investigate or report the incident, and the Facility Administrator was not informed. This failure delayed an onsite inspection by the State Agency.
A facility failed to investigate allegations of abuse when a resident with severe cognitive impairment was reportedly subjected to aggressive behavior by another resident. The Director of Social Services did not investigate the claims, citing a lack of witnesses, and called the police due to the family member's agitation. The Facility Administrator was unaware of the incidents and did not report them, violating the facility's policy to investigate and report all allegations of abuse.
A facility experienced a nonfunctional call system affecting nine out of 62 residents, resulting in significant consequences. Residents experienced severe pain, distress, and delays in receiving assistance for activities of daily living and incontinence care. Some residents resorted to banging on tables, yelling, and using personal means like cell phones to contact staff. One resident's fall went initially unwitnessed, highlighting the lack of an alternate call system during the outage.
The facility failed to ensure the safety of storing, preparing, distributing, and serving food in accordance with professional standards. Multiple food items in the kitchen were found without labels indicating a use-by date or an open date, and some items were expired. The Dietary Supervisor confirmed that all food items must have proper labeling to prevent food-borne illnesses.
A resident readmitted from a GACH with significant weight loss did not have their physician notified, as required by facility policy. The dietician and infection preventionist were aware of the weight loss but did not take action, leading to a failure in communication and documentation.
The facility failed to ensure a safe homelike environment for eight ambulatory residents due to uneven surfaces in the hallways and resident rooms. Despite multiple attempts to address the issue, the floor remained uneven with small to medium-sized bubbles, creating a potential tripping hazard.
A facility failed to develop a comprehensive care plan for a resident prescribed Diazepam for anxiety. The resident, who had multiple diagnoses and required moderate assistance with daily activities, did not have a care plan in place for the medication, violating the facility's policy.
The facility failed to follow the physician's order for oxygen supplementation for a resident with a complex medical history, administering 1 liter per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by an LVN during an observation and interview, highlighting a deficiency in the care provided.
A resident experienced severe pain due to the facility's failure to administer pain medication as prescribed and a malfunctioning call light system. The resident, with multiple diagnoses including hemiplegia, reported a pain level of 9 out of 10 and had to wait two hours for pain relief.
The facility failed to post daily nurse staffing information in a prominent place accessible to residents and visitors. Observations and interviews revealed that the facility only posted Census and Direct Care Service Hours Per Patient Day (DHPPD) and was unaware of the requirement to post detailed nurse staffing data, including the total number of RNs, LVNs, and CNAs along with their actual work hours.
The facility failed to follow up on the consultant pharmacist's recommendations for two residents, leading to a deficiency. One resident did not receive recommended blood tests for Depakote, and another had unclear administration parameters for Midodrine. The DON confirmed that the necessary actions were not taken.
The facility failed to implement a safe water management program to prevent waterborne diseases, including Legionnaire's disease. The Maintenance Supervisor (MS) and Infection Preventionist (IP) conducted water testing and treatment internally without external laboratory support, relying on informal methods such as YouTube videos for guidance. This practice did not align with the facility's policy, which required oversight by a water management team and specific measures to control Legionella.
The facility failed to offer the pneumonia vaccine to a resident with multiple diagnoses and severely impaired cognitive skills, as per their policy. The Infection Preventionist admitted to missing the opportunity to offer the vaccine, which was required by the facility's policy.
Food Stored, Handled, and Served Unsafely
Penalty
Summary
The facility failed to prepare, store, and serve food in a sanitary manner and environment. During a concurrent observation and interview in the kitchen, a metal pot containing a white liquid identified by the Food Services Director (FSD) as a prepared protein shake mixture was found in the refrigerator with a use-by date of 5/29/2026, and the FSD stated that because the current date was 6/1/2026, the mixture should be thrown away. During another observation, Dietary Aide (DA) 1 was serving food while holding the plate surface with a bandaged thumb, and the FSD stated that DA1 should wear a glove on the injured hand when serving food to minimize the risk of contamination. Additional kitchen observations showed a floor drain near the kitchen entrance with standing water that the FSD said did not drain and was not sanitary. Small serving dishes were stored near a trash can, small serving cups were stacked with moisture trapped between them, a food prep container had adhesive residue, multiple plastic pitchers had chips and cracks, and a metal bowl and plastic pitcher stored under the sink had moisture in them. Plates in the plate warmer were stored wet. In dry storage, a large container of Ken's Bleu Cheese Dressing with a bulging lid and label indicating keep refrigerated, a large container of Ken's Caesar dressing labeled keep refrigerated, and two containers of lemon juice labeled keep refrigerated were found stored improperly. On 6/3/2026, the food processor bowl attachment was observed with black residue in the clear handle and cracks on the bottom, and the FSD stated it was not clean and should have been replaced. The facility policy titled Food Receiving and Storage stated that foods shall be received and stored in a manner that complies with safe food handling practices and that refrigerated foods must be stored below 41 degrees F unless otherwise specified by law.
Failure to Maintain Privacy and Dignity During Incontinent Care
Penalty
Summary
The facility failed to ensure that Giver (CG) 1 maintained Resident 77’s privacy and dignity during ADL care by leaving the room door open and the dignity curtains open while providing incontinent care. During observation, Resident 77 was seen in bed with the private area visible from the hallway while CG 1 was providing care, and CG 1 attempted to close the curtain only after noticing the observer. The facility’s policy titled Quality of Life - Dignity, revised 1/2026, states that residents shall be treated with dignity and respect at all times and that staff shall promote, maintain, and protect resident privacy, including bodily privacy during personal care. Resident 77 was admitted on 10/23/2024 and readmitted on 5/26/2026 with diagnoses including dementia, hemiplegia, and HTN. The MDS dated 5/30/2026 indicated the resident was cognitively impaired and dependent on staff for ADL care. During interview, CG 1 stated she was closing the curtain to provide privacy while changing the resident’s incontinent brief and said dignity curtains should be closed during incontinent care. The DON stated that resident dignity curtains should be completely closed during ADL care to provide privacy and that leaving them open during incontinent care may cause residents to feel due to lack of privacy and is not dignifying.
Failure to Assess and Authorize Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to notify a physician that Resident 22 was self-administering medications and storing medications at the bedside, failed to obtain a physician's order for self-administration and bedside storage of medications and/or supplements, and failed to conduct an assessment of the resident's ability to self-administer medications and/or supplements and store them at the bedside. Resident 22 was admitted on 3/16/2021 and readmitted on 3/19/2025 with diagnoses including obstructive hypertrophic cardiomyopathy, type 2 DM, depression, and muscle weakness. The MDS dated 4/14/2026 indicated the resident's cognition was intact and that she required substantial assistance with dressing, toileting, bed mobility, and bed-to-chair transfers, and was dependent on staff for showering. During a concurrent observation and interview on 6/1/2026, Resident 22 was observed sitting in bed with ointment and supplements on the bedside table, including lidocaine ointment, biotin 25000 mcg, vitamin B7, collagen peptides, ginger herbal tea with vitamin C, probiotics, and sinus calm meltaway tablets. Resident 22 stated she takes ginger herbal tea because of nausea caused by the medications she was taking, and said she usually informs facility staff about the medications and/or supplements she is taking so staff can write them down. She also stated a staff member took pictures of the medications and/or supplements, but she could not recall the staff member's name. On 6/3/2026, LVN 4 reviewed the bedside supplements and stated she was not aware of the listed items at the bedside. The Order Summary Report showed no physician's order for self-administration for the supplements found at the bedside, and the Care Plan Report did not include assessments or care plan interventions for self-administration of medications and/or supplements. The facility policy titled Self-Administration of Medications stated staff and the practitioner will document findings and resident choices, self-administered medications must be stored in a safe and secure place, and staff will identify and give the Charge Nurse any medications found at the bedside that are not authorized for self-administration.
Inappropriately Sized Bed for Resident
Penalty
Summary
The facility failed to provide an appropriately sized bed for one sampled resident, Resident 26. Resident 26 was admitted with diagnoses including right-sided hemiplegia, dysphagia, dysarthria, and epilepsy. The H&P stated the resident could make needs known but could not make medical decisions. The MDS indicated the resident required total physical assistance with toileting, dressing below the waist, and putting on and removing socks and shoes, and that cognitive patterns were moderately impaired. During observation, Resident 26 was seen with legs bent and feet positioned against the footboard of the bed, and the resident stated they felt uncomfortable in bed. A later observation again showed the resident's feet positioned against the footboard. CNA 3 stated the bed was too small and that residents should be comfortable in bed to minimize pain and discomfort and reduce pressure ulcer risk. RNS 1 stated longer beds are available for taller residents and that proper bed positioning is important to reduce pain, discomfort, and pressure ulcer risk. The DON also stated proper bed positioning is important to decrease risk of pressure ulcers and to minimize pain and discomfort, and that residents should be comfortable in bed to meet physical and psychosocial needs.
Bedside Table Missing Wheel Used by Resident
Penalty
Summary
The facility failed to ensure that Resident 6 had a safe bedside table in use when the resident was observed sitting in bed with a bedside table and breakfast tray in front of her, and the table tilted when the resident pushed it. The breakfast tray almost slid off the table, and inspection showed the bedside table was missing one of its four wheels. Resident 6 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, essential hypertension, type 2 diabetes mellitus, epilepsy, muscle weakness, and a gastrostomy tube. Resident 6's MDS indicated severely impaired cognitive skills for daily decision making, absence of spoken words, and dependence on two or more staff for ADLs. During the observation, a CNA confirmed the bedside table was missing a wheel and removed it from the room. The CNA stated broken equipment should be removed from residents to prevent injuries and that maintenance should be called for repairs. Another CNA stated he had placed the bedside table and breakfast tray for Resident 6 and did not notice the missing wheel. The facility's Maintenance Log did not show any bedside table repairs between the observation and the record review, and the facility policies required reporting needed repairs and removing malfunctioning equipment from service.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of abuse to the California Department of Public Health within 24 hours for two residents involved in a resident-to-resident altercation. Resident 79 was admitted with diagnoses including COPD, mild cognitive impairment, dementia, and abnormalities of gait and mobility. Resident 79's MDS dated 4/3/2026 indicated cognitive skills were intact, with supervision needed for ADLs, touch assistance for transfers and walking, and partial/moderate assistance for toileting and showering. Resident 80 was admitted for aftercare following joint replacement surgery and had diagnoses including presence of a left artificial knee joint, abnormalities of gait and mobility, atrial fibrillation, and hypertension. Resident 80's MDS indicated cognitive skills were intact, with supervision/touching assistance for transfers, toileting, and walking, and substantial/moderate assistance for lower body dressing and showering. The facility's SOC 341 dated 3/23/2026 stated that Resident 79 appeared to have a hallucination and displayed hitting behavior toward Resident 80. The grievance log showed that Resident 80 reported concerns about a recent physical altercation with Resident 79, the local Police Department was called and filed a report, a room change was initiated, and trauma screening was completed. During interviews, the Administrator stated the incident was reported to police but not to CDPH because he did not consider the resident-to-resident altercation to be abuse under the facility's AFL interpretation, stating that one resident had dementia and did not cause harm. The facility policy titled Alleged or Suspected Abuse and Crime Reporting stated that covered individuals must report a reasonable suspicion of a crime to the Department within the designated time frame, but the Administrator stated he did not report the incident to CDPH.
Failure to Develop Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan addressing supplemental oxygen therapy for Resident 75 within the required timeframe after admission. Resident 75 was admitted with diagnoses including sequelae of cerebral infarction, gastrostomy, dysphagia following cerebral infarction, atrial fibrillation, presence of a heart assist device, depression, and malignant neoplasm of the prostate. The Minimum Data Set dated 6/2/2026 indicated the resident had moderately impaired cognition, required assistance with eating and oral hygiene, needed substantial to maximal assistance with upper body dressing, and was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and footwear, and was non-ambulatory. The resident had a physician order for oxygen at 2 liters per minute via nasal cannula continuously every shift for desaturation. During an initial tour, the resident was observed in bed with an oxygen concentrator at bedside flowing at 3.5-4 liters per minute via nasal cannula. Registered Nurse Supervisor 1 stated the oxygen order was 2 L/min. The care plan dated 6/3/2026 did not address the resident’s supplemental oxygen needs with measurable goals, time of recovery or improvement, or interventions to safely correct hypoxemia. The DON stated a baseline care plan should be initiated within 24 hours of admission and that the resident’s needs may not be met if a baseline care plan is not initiated. The facility policy stated a baseline care plan must be developed within the first 48 hours of admission and include the minimum healthcare information necessary to properly care for the resident, including initial goals based on admission orders and physician orders.
Medication Cream Left at Bedside
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards when staff left a medication cup containing an unidentified white creamy substance at the bedside of one resident. During a facility tour, the cup was observed on a wall caddy within view and easy reach inside the resident’s room. The resident’s admission record showed diagnoses including diabetes mellitus, COPD, dysphagia, and CHF, and the MDS indicated the resident had intact cognition but required assistance with several activities of daily living, including eating, oral hygiene, toileting hygiene, dressing, and walking 10 feet. During interviews, a CNA identified the substance as zinc used for skin rashes, and an LVN stated it was zinc barrier cream/skin protectant that should be discarded after use and not left at bedside. The LVN also stated that a confused or wandering resident could ingest the substance because it could resemble ice cream or cream cheese. The DON stated residents may only have medication at bedside after assessment and demonstrated ability to self-administer, and that a doctor’s order/approval is required for self-administration. The facility policy on discarding and destroying medication stated ointments and creams may be discarded into the trash receptacle in the medication room.
Inadequate Enteral Feeding Delivery
Penalty
Summary
Facility failed to ensure Resident 75 received enteral feeding as ordered. Resident 75 was admitted with diagnoses including sequelae of cerebral infarction, gastrostomy, dysphagia following cerebral infarction, atrial fibrillation, presence of a heart assist device, depression, and malignant neoplasm of the prostate. The MDS dated 6/2/2026 indicated the resident had moderately impaired cognition, required partial to moderate assistance with eating and oral hygiene, substantial maximal assistance with upper body dressing, and was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear; the resident was also non-ambulatory. During a facility tour on 6/2/2026 at 8:28 a.m., the resident's enteral feeding pump was observed turned off at the bedside. The feeding was labeled as initiated on 6/1/2026 at 12:30 p.m. at a rate of 80 mL/hr, and a residual of 900 mL was observed left in an enteral feeding bottle labeled 1500 mL, indicating the resident had received 400 mL less enteral feeding than ordered. The physician order summary dated 6/4/2026 directed GT feeding of Jevity 1.5 at 50 mL/hr for 20 hours to provide 1000 mL/1500 kcal per 24 hours via enteral from 2 p.m. to 10 a.m. or until dose limit was met. RNS 1 stated that failure to provide adequate enteral feeding could lead to malnutrition, skin breakdown, and poor patient outcomes, and the DON stated inadequate enteral feeding could lead to significant weight loss, skin breakdown, and open wounds.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure Resident 75 received oxygen therapy as prescribed by the physician. Resident 75 was admitted with diagnoses including sequelae of cerebral infarction, gastrostomy, dysphagia following cerebral infarction, atrial fibrillation following cerebral infarction, presence of a heart assist device, depression, and malignant neoplasm of the prostate. The MDS dated 6/2/2026 indicated the resident had moderately impaired cognition, required partial to moderate assistance with eating and oral hygiene, substantial maximal assistance with upper body dressing, and was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. The resident was also non-ambulatory. The Order Summary Report dated 6/4/2026 showed a physician order for oxygen at 2 liters per minute via nasal cannula continuously every shift for desaturation. During an initial tour on 6/2/2026 at 8:28 a.m., the resident was observed lying in bed on the right lateral side with an oxygen concentrator at bedside flowing at 3.5 to 4 liters per minute via nasal cannula. During interview, the RNS stated the resident's oxygen order was 2 L/min. The DON stated prolonged use of oxygen could cause oxygen toxicity and cell damage. The facility policy on Oxygen Administration stated to review the physician's orders for oxygen administration and, unless otherwise ordered, start the flow of oxygen at 2 to 3 liters per minute.
Private caregiver provided incontinent care without authorization
Penalty
Summary
The facility failed to ensure that a private caregiver did not provide incontinent care and direct care to Resident 77 in accordance with the facility's policy and procedures titled Private Duty Sitter. Resident 77 was admitted on 10/23/2024 and readmitted on 5/26/2026 with diagnoses including dementia, hemiplegia, and hypertension. The resident's MDS dated 5/30/2026 indicated cognitive impairment and dependence on staff for ADL care. During an observation on 6/1/2026 at 9:41 A.M., Resident 77 was observed in bed with the room door open and the dignity curtain open, leaving the resident's private area visible from the hallway while CG 1 was providing care. When interviewed immediately afterward, CG 1 stated she was closing the curtain to provide privacy while changing Resident 77's incontinent brief, and no facility staff were assisting with the incontinent care. The DON later stated that private duty sitters should not provide direct care because they are not trained, and that providing incontinent care could potentially lead to a UTI. The facility policy stated that private duty nursing personnel may not administer direct care unless authorized in writing by the attending physician.
No RN on Duty for Required Shifts
Penalty
Summary
The facility failed to ensure that an RN was on duty for the 7am-3pm, 3pm-11pm, and 11pm-7am shifts on 7/20/2025. A review of the Licensed Nursing Schedule dated July 2025 showed that there was no RN on duty for that date, and a concurrent review of the nursing assignment sheet confirmed that there was no RN on duty for 8 consecutive hours on any of the three shifts. The facility had 64 residents in house at the time of the finding. During interview, the DSD confirmed that no RN was on duty for 8 consecutive hours on 7/20/2025 and stated that without an RN the facility cannot perform resident assessments and certain medications will not be administered. The DON also stated that if no RN is on duty, residents' clinical needs will not be met, including antibiotic medication and TPN, and stated that the facility did not have a policy and procedure on RN staffing. A review of the Nurse Supervisor job description dated 2023 stated that sufficient licensed practical and/or registered nurses are to be available for the tour of duty to ensure quality care is maintained.
Open Outside Garbage Bin Lids
Penalty
Summary
The facility failed to ensure that the lids of two of three sampled outside garbage bins were closed. During a concurrent observation and interview with the Food Services Director in the alley behind the facility, two outside garbage and recycling bin lids were observed left open. The Food Services Director stated that garbage bins must be covered to prevent pests. A review of the U.S. Food and Drug Administration's Food Code, dated 2022, indicated that receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.
Missing Documentation for Dental Services
Penalty
Summary
The facility failed to ensure staff completed documentation on dental ancillary services for one sampled resident, Resident 63, in accordance with the Social Service Designee job description and the facility's Dental Services policy. Resident 63 was admitted with diagnoses including fracture of the left mandible, dementia, hypertension, and dysphagia. The MDS dated 4/4/2026 indicated the resident was cognitively intact, and dental records dated 4/18/2026 showed a dentist evaluated the resident and that he was awaiting approval for dentures. During interview, Resident 63 stated he recently had tooth pain while eating a banana. A concurrent record review with the Social Services Director showed no social service progress notes were documented from admission through 6/3/2026, and no documentation was entered for the dental services provided on 4/18/2026. The SSD confirmed the lack of documentation and stated incomplete documentation could have the potential to not meet the resident's needs. The DON also stated that if the SSD had not documented the dental services provided to Resident 63, this would have the potential to not meet the resident's needs.
Failure to Disinfect Shared Resident Care Equipment Between Residents
Penalty
Summary
The facility failed to ensure complete implementation of infection control practices when an LVN did not clean and disinfect shared resident care equipment before and after use for two residents. During observation, the LVN used a portable BP machine, temporal thermometer, and pulse oximeter while preparing to provide care to a resident with metabolic encephalopathy, decreased white blood cell count, paraplegia, dysphagia, and essential hypertension, and who was dependent for ADLs and had severely impaired cognitive skills for daily decision making. During the same observation, the LVN dropped the BP machine on the floor, picked it up, and wiped it with a germicidal disposable wipe at the med cart. The LVN did not first wipe the top of the med cart where the soiled BP machine had contacted the surface. The LVN then changed gloves and proceeded with checking the resident's BP, and later placed the used BP machine back on top of the med cart without cleaning the equipment before moving on with medication administration. When the LVN then went to another resident, who had diagnoses including fracture around an internal prosthetic joint, osteoarthritis, type 2 DM, dysphagia, heart failure, and thyrotoxicosis, the LVN did not clean or sanitize the shared patient care equipment between the two residents. During interview, the LVN stated the germicidal wipe should be used for equipment cleaning and sanitizing, acknowledged the manufacturer's instructions indicated a disinfecting contact time, and stated he did not recall wiping the equipment between residents. The facility policy stated reusable non-critical resident-care items, including BP cuffs, are to be cleaned and disinfected between residents.
Call Buttons Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that resident call buttons were within reach for three residents in their rooms and bathing areas, as required by the facility’s policy on call light accessibility. During observation, Residents 8 and 58 were seated in reclining wheelchairs beside their beds, and their call light buttons were placed in the center of their beds and were not within reach. Resident 8’s record showed diagnoses including atrial fibrillation and Alzheimer’s disease, with impaired hearing, speech, vision, decision-making, and memory, and dependence on others for bathing, toileting, dressing, and transfers. Resident 8’s care plan for communication deficit directed staff to keep the call light within reach. Resident 58’s record showed diagnoses including epilepsy, muscle weakness, and Alzheimer’s disease, with impaired memory and decision-making and dependence on others for all daily activities. Resident 58’s care plan also directed staff to keep the call light within reach. Resident 47’s call button was observed on a nightstand at the head of the bed against the wall and not within reach of the resident. Resident 47’s record showed diagnoses including dementia, COPD, and hypertension, and the MDS indicated cognitive impairment and dependence on staff for ADL care. During interview, an LVN stated that resident call buttons need to be within reach so residents can call for help and that if not within reach, residents may try to get up on their own and end up falling or having an injury. The DON stated that resident call buttons should be within the reach of the resident so they may call for assistance, and if not within reach they may end up soiling themselves or potentially fall. The facility policy stated that the call system should be accessible to residents while in bed or other sleeping accommodations and that staff should facilitate call light placement within reach and secure it as needed.
Failure to Assess and Document After Resident-on-Resident Physical Altercation Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its policies and procedures for alleged or suspected abuse, change in condition, and charting and documentation after a resident reported being physically assaulted by another resident. One resident, with diagnoses including congestive heart failure, difficulty in walking, Type II diabetes mellitus, and depression, and with intact cognitive skills for daily decision-making, reported that another resident had hit him in the mouth and on the head on multiple occasions over several days and that he had called the police about the most recent incident. The resident required moderate assistance to supervision for ADLs. The alleged aggressor resident had diagnoses including COPD, chronic kidney disease, and dementia, with moderately impaired cognitive skills for daily decisions and a need for moderate to maximal assistance with ADLs. Progress notes for this resident documented ongoing monitoring for repeated physical and verbal aggression toward others and a prior incident of physical aggression in which the resident attempted to hit others with a walker in the hallway. Staff interviews confirmed there was a history of arguments and that the two residents did not get along, and that an incident had occurred a few days prior to the survey. Despite the report of physical aggression, the DON acknowledged that no nursing assessments, such as a skin assessment, were completed for the resident who reported being hit, and that she did not perform a nursing assessment herself. Review of the medical record by the Medical Records Director confirmed there was no nursing documentation related to the allegation, including no change of condition or SBAR documentation to reflect any assessment or monitoring after the report. The Administrator stated that complete documentation with nursing assessment, such as change of condition and/or SBAR, is required when a resident reports any type of abuse or physical aggression. These findings show the facility did not follow its own policies requiring assessment, monitoring, physician and responsible party notification, and documentation when a resident reports alleged abuse or physical altercation.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that residents' call lights were answered promptly for two of three sampled residents. For one resident with a history of falls, muscle weakness, fibromyalgia, and difficulty walking, observations showed that the call light was activated and audible for seven minutes while three staff members were present at the nursing station but did not respond. The resident later reported that she had pressed the call light about 20 minutes prior because she needed her morning medications, and that staff sometimes did not answer the call light at all. Her care plan required that the call light and personal items be kept within reach due to her high risk for falls and injury. Another resident, who was totally dependent on staff for activities of daily living and had a history of metabolic encephalopathy and falls, also experienced delayed response to the call light. The call light was observed to be active for eight minutes while two staff members were present at the nursing station but did not respond. Interviews with staff revealed that some were occupied with other tasks or were from the registry and did not respond to the call lights. Facility policy required all staff to promptly respond to activated call lights, regardless of their assignment or employment status.
Failure to Use PPE During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention protocols when a treatment nurse and a certified nurse assistant did not wear the required personal protective equipment (PPE) during a suprapubic catheter change for a resident on Enhanced Barrier Precautions (EBP). Observation revealed that neither staff member donned complete PPE, despite signage indicating EBP outside the resident's room and a physician's order specifying the need for enhanced precautions due to the presence of a suprapubic catheter. The facility's policies and procedures require staff to perform hand hygiene and wear gowns and gloves for high-contact care activities, including catheter care, but these protocols were not followed during the observed procedure. The resident involved had multiple diagnoses, including hypertension, type 2 diabetes mellitus, Alzheimer's disease, and obstructive uropathy, and was assessed as having severe cognitive impairment and requiring moderate to maximum assistance with activities of daily living. Interviews with the treatment nurse and the infection preventionist confirmed that the facility's EBP protocol was not observed during the catheter change, and both acknowledged the expectation for staff to use proper PPE to prevent the spread of multidrug-resistant organisms. Review of facility policies further confirmed the requirement for PPE use during such procedures.
Failure to Notify Physician and Document Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician after a significant change in condition for a resident who exhibited abnormal laboratory results. The resident, who had diagnoses including metabolic encephalopathy, hypertension, and dementia, was dependent on staff for activities of daily living and had moderate cognitive impairment. A urinalysis revealed several abnormal findings, including turbid urine, moderate blood, positive protein, large leukoesterase, elevated white blood cells, and moderate bacteria, all of which were flagged as abnormal. Despite receiving these abnormal lab results, the Registered Nurse Supervisor confirmed that there was no documented evidence that the physician or the resident's responsible party was notified. Additionally, there was no documentation of an SBAR (Situation, Background, Assessment, Recommendation) or progress notes indicating that the physician had been informed, even though the nurse had received the results. The Director of Nursing also confirmed that abnormal urinalysis results are considered a significant change in condition and require prompt notification of the physician and responsible party, as well as proper documentation, none of which occurred in this case. A review of the facility's policies and procedures indicated that staff are required to promptly notify the attending physician and the resident's representative of any significant changes in the resident's condition, including abnormal lab results. The policies also require documentation of how, when, and to whom the information was provided. In this instance, the required notifications and documentation were not completed, resulting in a deficiency.
Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when the facility failed to administer medications to a resident in accordance with physician orders and the facility's policy and procedure for medication administration. The resident, who had diagnoses including unspecified convulsions, sepsis, and congestive heart failure, was prescribed Depakote in specific dosages and at scheduled times. Review of the Medication Administration Audit Record (MAAR) showed that on two occasions, the resident's Depakote was not administered within the required one-hour window of the scheduled time. Specifically, the 125 mg Depakote tablets scheduled for 5 p.m. were given at 9:42 p.m., and the 250 mg Depakote tablet scheduled for 9 a.m. was administered at 11:24 a.m. During interviews, the resident reported experiencing a seizure while in the facility, attributing it to not receiving anti-seizure medication on time. The Director of Nursing (DON) confirmed the medication administration times did not comply with the facility's policy, which requires medications to be given within one hour of the scheduled time unless otherwise specified. The facility's policy and the DON both acknowledged that failure to administer Depakote on time could result in convulsions.
Failure to Notify Physician and Document Catheter Complications
Penalty
Summary
A resident with a history of urinary tract infection (UTI), sepsis, and congestive heart failure was admitted with an indwelling urinary catheter and identified as high risk for developing complications, including UTI. The resident's care plan included interventions to assess for and record any changes in bladder status and to notify the physician of signs and symptoms of UTI. On review, it was found that the resident complained of pain, and a treatment nurse observed sediments in the resident's catheter after removal. However, the nurse did not notify the physician of the observed sediments, did not document the finding, and did not check or record the resident's vital signs, including temperature. The Director of Nursing confirmed that the resident's complaints and the observation of sediments should have been documented and reported to the physician, as per facility policy. The facility's policy required staff to observe for complications associated with urinary catheters, report any complaints of pain, and notify the physician or supervisor of any unusual findings. The failure to document and communicate these findings constituted a deficiency in providing appropriate care and services to prevent urinary tract infections.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to follow its policy and procedures regarding resident rights by not informing the responsible party (RP) or power of attorney (POA) about a change in a resident's medication dosage. The resident in question had severe cognitive impairment and multiple diagnoses, including dementia, muscle weakness, dysphagia, hyperlipidemia, and hypothyroidism. The resident was admitted with a designated RP/POA due to their inability to make decisions independently. A review of the resident's records showed that the dosage of Donepezil, a medication used to treat dementia symptoms, was decreased from 15 mg to 10 mg per day by the physician. Despite this significant change in medication, there was no documentation in the nursing or physician progress notes indicating that the RP/POA was notified of the change. The Director of Staff Development confirmed during an interview and record review that there was no evidence of notification and acknowledged that such changes should be reported to the responsible party, as it is their right to know. The facility's policy on resident rights, revised in January 2025, states that residents and their legal representatives must be informed of any changes in medical condition or treatment, which was not followed in this instance.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who experienced a significant change of condition (COC) that resulted in transfer to a general acute care hospital. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was observed by staff to be crying, complaining of chest pain, and had an oxygen saturation of 82%. Paramedics were called, and the resident was subsequently transferred to the hospital, where she was diagnosed with bilateral extensive pulmonary embolism and admitted for treatment. Despite these events, there was no documented evidence in the resident's medical record of the COC, progress notes, or physician orders for the transfer to the hospital. Interviews with nursing staff and a review of facility policies confirmed that documentation of such events is required, including completion of a COC form, progress notes, and notification of the physician and family. The lack of documentation meant that the resident's condition and the care provided were not accurately reflected in the medical record. Facility policies reviewed indicated that all changes in a resident's condition, services provided, and significant events must be documented to facilitate communication among the interdisciplinary team and ensure continuity of care. The failure to document the resident's COC and related interventions was not in accordance with accepted professional standards and the facility's own policies and procedures.
Failure to Accurately Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, specifically the Direct Hours Patient Day (DHPPD) forms, was accurately completed, posted in a prominent and accessible location, and retained for the required minimum of 18 months. During interviews and record reviews, it was found that DHPPD forms for several dates were missing, and some forms that were available lacked essential information such as beginning census, admissions, discharges, transfers, deaths, and actual direct care service hours. The Director of Staff Development (DSD) acknowledged responsibility for completing and posting these forms and confirmed the missing and incomplete records. The DSD also stated that the forms should be reviewed and signed by the DON or designee and be available for public review upon request. The facility's policy and procedure required posting the number of nursing personnel providing direct care for each shift and retaining these records for at least 18 months. However, the review revealed that these requirements were not consistently met, resulting in misinformation for all 63 residents, their families, and visitors regarding daily nurse staffing data. The deficiencies were identified through concurrent interviews and record reviews, with the DSD confirming the lapses in documentation and posting practices.
Failure to Label Opened Food and Monitor Dry Storage Temperature
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food storage and preparation practices. Specifically, in one of the reach-in refrigerators, three halved avocados were found wrapped in saran wrap without any labeling to indicate the name of the food item, the date it was opened, or its expiration date. The Dietary Supervisor confirmed that opened avocados should be labeled and dated, and acknowledged that this was not done. The facility's policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated with a use-by date. Additionally, the kitchen's dry storage room was found to be lacking a room thermometer. The Dietary Supervisor confirmed the absence of a thermometer and stated that it is necessary to monitor the ambient temperature to prevent food spoilage. The facility's policy indicates that non-refrigerated foods should be stored in a temperature and humidity-controlled environment. The Director of Nursing also stated that staff are expected to follow safe food practices to prevent the spread of foodborne illness among residents.
Leaking Industrial Washing Machine Not Repaired
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the industrial washing machine used for laundering both facility linen and residents' clothing was not leaking. During an observation, a red bucket with towels was found placed under the washing machine to catch leaking water, resulting in a medium to large puddle in the immediate area. The Laundry Supervisor was unsure how long the machine had been leaking and deferred to the Maintenance Supervisor, who confirmed awareness of the leak and stated that a part was needed for repair. The Maintenance Supervisor indicated that the repair person would be informed about the issue. The Administrator was not aware of the leaking washing machine or the condition of the laundry room floor and stated that the damaged machine had not been reported. A review of the facility's maintenance policy revealed that the maintenance department is responsible for keeping all equipment in a safe and operable manner at all times, including maintaining the building in good repair and free from hazards. The failure to address the leaking washing machine had the potential to delay the provision of clean and sanitary linen for all 63 medically compromised residents who rely on staff for a homelike environment.
Unsafe Laundry Room Floor and Malfunctioning Dining Hall Door
Penalty
Summary
The facility failed to maintain a safe and operable environment in two key areas. In the laundry room, the floor in front of the industrial washing machine was observed to be cracked with medium to large holes in the concrete, creating an unsafe walkway. The Laundry Supervisor was unaware of the duration of the disrepair, as all repairs are managed by the Maintenance Supervisor. The Maintenance Supervisor acknowledged the floor had been in disrepair for some time and had discussed the need for repairs with the administrator, who was also unaware of the current condition of the floor. Additionally, the door leading from the hallway to the resident dining hall was found to be malfunctioning. The door did not remain shut when closed, would not open properly, and the handles on either side of the door turned in different directions. The Maintenance Supervisor was not aware of the malfunctioning door handle prior to the observation. Facility policy requires the maintenance department to keep the building and equipment in a safe and operable manner at all times, but these deficiencies were present at the time of the survey.
Failure to Provide Ordered Fall Prevention Equipment for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls and injury had bilateral floor mats in place as ordered by the physician and as specified in the resident's care plan. The resident, who had diagnoses including dementia, muscle weakness, abnormal gait and mobility, and atrial fibrillation, was admitted with a physician order for bilateral floor mats to be used for fall management. The resident's care plan and fall risk assessment both indicated the need for these mats due to the resident's high risk for falls and injury. During an observation, the resident was found lying in bed with a bed pad alarm, but no floor mats were present on either side of the bed. Staff interviews confirmed that the floor mats were not in place and that the resident should have had them according to the physician's order and care plan. The DON acknowledged that the resident had a history of overestimating their ability to walk and transfer, had experienced a previous fall, and was at increased risk for injury without the mats. The facility's policy on falls management required providing a hazard-free environment and adequate supervision, including the use of assistive devices such as floor mats, but this was not followed in the resident's case.
Failure to Administer and Label Enteral Nutrition and Hydration as Ordered
Penalty
Summary
A resident with a gastrostomy tube (GT) and diagnoses including dysphagia, protein-calorie malnutrition, and dementia was admitted and readmitted to the facility. The resident's physician ordered Nutren 2.0 to be administered via enteral pump at a specific rate and duration. During observation, the resident's feeding pump was found paused and alarming, displaying a message that it had been idle for 10 minutes. The pump had not been restarted for at least 25 minutes, and the nurse present was unaware of the alarm or the reason for the pause. The Director of Nursing confirmed that staff may pause tube feedings for care or medication administration but are expected to restart them promptly to ensure adequate nutrition. Another resident with a gastrostomy tube and multiple diagnoses, including moderate protein-calorie malnutrition, adult failure to thrive, MRSA infection, dysphagia, and chronic kidney disease, was observed receiving enteral hydration. The hydration bag in use was not labeled with the resident's name, date, time of initiation, or rate, as required by facility policy. The Registered Nurse Supervisor acknowledged that the lack of labeling could result in the hydration not being changed as needed, and the DON emphasized the importance of labeling to prevent gastrointestinal issues. Facility policies reviewed indicated that enteral nutrition and hydration should be administered as ordered and that containers must be labeled with specific information to ensure safe and appropriate care. The observed failures included not restarting a resident's tube feeding pump in a timely manner and not labeling another resident's enteral hydration, both of which did not comply with established protocols and orders.
Failure to Monitor Resident's Safety Amid APS Case
Penalty
Summary
The facility failed to ensure the safety and proper supervision of a resident after being notified of an active Adult Protective Services (APS) case involving the resident's family member. The resident, who was diagnosed with end-stage renal disease, chronic obstructive pulmonary disease, and anxiety disorder, required moderate to maximal assistance for daily activities. Despite the facility being informed of the APS case and the family member's attempts to remove the resident without staff approval, there was no documentation or care plan developed to address the potential risk posed by the family member. Interviews with facility staff, including the Director of Nursing and the Social Services Assistant, confirmed awareness of the APS case but revealed a lack of documented follow-up or care plan to monitor the family member's interactions with the resident. The facility's policy on abuse investigation and reporting mandates prompt reporting and thorough investigation of abuse allegations, but this was not adhered to in this case, leaving the resident at risk of abuse and neglect.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with End Stage Renal Disease, chronic obstructive pulmonary disease, and anxiety disorder. The resident, who required moderate to maximal assistance for activities of daily living and used mobility aids, was discharged to home without a pre-dialysis and post-dialysis assessment on the day of discharge. Additionally, there was no documentation of a discharge plan summary or an Interdisciplinary Team meeting for discharge planning, as required by the facility's policy and procedure. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of necessary assessments and documentation. The Social Services Assistant acknowledged discussing discharge planning with the resident but failed to document it or conduct an IDT meeting. The lack of these critical steps in the discharge process placed the resident at risk for harm due to an unsafe discharge, as noted by the Director of Nursing.
Failure to Implement Comprehensive Care Plan for Resident with APS Case
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident after being notified of an Adult Protective Services (APS) case involving the resident's family member. The resident, who was admitted with diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and anxiety disorder, required moderate to maximal assistance for activities of daily living. Despite the facility being informed by a general acute care hospital about the APS case and the family member's attempts to remove the resident from the facility without approval, no care plan was developed to address these concerns. Interviews with facility staff, including a registered nurse, social services assistant, and the director of nursing, confirmed awareness of the APS case but revealed a lack of documentation and care planning to ensure the resident's safety. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not followed, potentially impacting the resident's health and safety.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring a safe and comfortable environment in their room. One resident, who had severe cognitive impairment and required maximal assistance for activities of daily living, expressed feeling unsafe and uncomfortable due to their roommate's constant screaming and cursing. The roommate, who also had severe cognitive impairment and required maximal assistance, was admitted with diagnoses including sepsis, anxiety, depression, and bipolar disorder. The disruptive behavior was noted by a Licensed Vocational Nurse (LVN), who was aware of the issue but did not report it to the Director of Social Services or the Facility Administrator as required. The Facility Administrator confirmed that they were not informed of the resident's concerns and emphasized that staff should report such issues immediately. The facility's policies on accommodation of needs, quality of life, and resident rights were reviewed, indicating that the environment and staff behaviors should support residents' dignity and well-being, and that staff should treat all residents with kindness, respect, and dignity. The failure to address the disruptive behavior of the roommate potentially impacted the psychosocial well-being of the affected resident and delayed necessary care.
Failure to Address Grievance and Report Alleged Abuse
Penalty
Summary
The facility failed to promptly resolve a grievance involving a resident's family member who expressed concerns about the resident's roommate. The family member reported that the roommate was shouting racist slurs and allegedly threw coffee at the resident. Despite these serious allegations, the Director of Social Services (DSS) called the police for intervention instead of addressing the grievance through the facility's established procedures. The DSS claimed there was no documentation or witness to support the family member's claims and deemed police intervention necessary due to the family member's agitation. Additionally, the facility did not report or investigate the alleged violations of neglect and abuse as required by their policy. The Facility Administrator (FA) was not informed of the incidents involving the roommate's disruptive behavior, which included screaming, cursing, and throwing objects at staff and residents. The FA acknowledged that the grievance report lacked a specific resolution and that further investigation should have been conducted. The facility's policy mandates prompt efforts to resolve grievances and requires reporting and investigation of any alleged violations, which were not adhered to in this case.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of abuse in accordance with state and federal law. This involved a resident who was subjected to aggressive behavior by another resident. The affected resident, who had severe cognitive impairment and required significant assistance for activities of daily living, was reportedly yelled at, screamed at, and had a cup of coffee thrown at them by another resident. The family member of the affected resident reported these concerns to the Director of Social Services (DSS), who did not take appropriate action to investigate or report the incident as required by the facility's policy. The DSS, upon being informed of the incident, called the police instead of conducting an internal investigation or reporting the incident to the appropriate authorities. The Facility Administrator was not informed of the incident and therefore did not report it either. The facility's policy, which mandates the prompt reporting of all allegations of abuse to the appropriate agencies, was not followed. This failure resulted in a delay of an onsite inspection by the State Agency to ensure the safety of the residents and had the potential to result in unidentified abuse within the facility.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policies and procedures by not conducting an investigation into a reasonable suspicion of abuse involving a resident. Resident 1, who was severely cognitively impaired and required significant assistance for activities of daily living, was reportedly subjected to aggressive behavior by Resident 2, who also had severe cognitive impairments and a history of behavioral issues. Resident 1's family member reported to the Director of Social Services (DSS) that Resident 2 was yelling, screaming, cursing, and had thrown a cup of coffee at Resident 1, raising concerns for Resident 1's safety. However, the DSS did not investigate these allegations, citing a lack of witnesses or documentation, and instead called the police due to the family member's agitation. The Facility Administrator (FA) was not informed of the incidents involving Resident 2, which included screaming, cursing, and throwing cups at staff and residents, and therefore did not report the incidents as required. The facility's policy mandates thorough investigation and reporting of all allegations of abuse, mistreatment, neglect, or injuries of unknown sources to the appropriate authorities, including the ombudsman, police, and state agency. The failure to investigate and report these incidents resulted in a delay of an onsite inspection by the State Agency, potentially leaving residents unprotected from possible abuse.
Nonfunctional Call System Leads to Resident Distress and Delayed Assistance
Penalty
Summary
The facility failed to provide an alternate call system for nine out of 62 residents when the main call system was nonfunctional from 3/9/2024 to 3/12/2024. This resulted in significant consequences for the residents. Resident 58 experienced severe pain in his left leg, rated at a level 9 out of 10, due to the nonfunctional call system and staff not responding to his calls for help. Other residents, including Residents 26, 49, 51, 64, 119, 120, 218, and 219, resorted to banging on tables, yelling, and screaming for assistance as the call system was not operational. Residents had to wait for extended periods for staff help, with some needing assistance for activities of daily living and incontinence care. The deficiency in the call system led to distress and discomfort among residents. Resident 26 expressed feeling petrified and uncomfortable, fearing an emergency situation due to the nonfunctional call system. Residents 49 and 64 had to use personal means, like a cell phone, to contact staff for assistance, highlighting the lack of alternative communication methods provided by the facility. Resident 218's fall went unwitnessed initially, with Resident 219 having to call for help and expressing a wish for the call system to be functional.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to ensure the safety of storing, preparing, distributing, and serving food in accordance with professional standards and its policies for food service. During an observation and interview with the Dietary Supervisor, multiple food items in the kitchen were found without labels indicating a use-by date or an open date. Specific items included a container of dill weed, beans, green lentils, milk, prunes, peaches, apple sauce, tofu, strawberry sauce, tuna salad, hamburger dill chips, bananas, corn tortillas, lemons, and tomatoes. Some of these items were also found to be expired, such as the dill weed, strawberry sauce, and tuna salad. Additionally, a box containing bananas had a paper with a black substance, which could indicate contamination or spoilage. The Dietary Supervisor confirmed that all food items in the refrigerator and dry food storage area must have a label indicating when the food should be used by, and when food items are opened, there should also be an open date. The facility's policy and procedures titled 'Food Service Management' dated 2017, indicated that practices to maintain safe refrigerated storage include labeling, dating, and monitoring refrigerated food, including leftovers, so it is used by its use-by date, or frozen where applicable or discarded. The failure to adhere to these policies had the potential to result in food-borne illness in medically vulnerable residents who consumed the food prepared by the facility kitchen.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to initiate a change of condition (COC) for a resident who was readmitted from a general acute care hospital (GACH) with significant weight loss. Specifically, the facility did not notify the resident's physician of the weight loss, which placed the resident at risk for further weight loss. The resident, who had multiple diagnoses including end-stage renal disease, chronic respiratory failure, and type 2 diabetes, was readmitted to the facility with a weight of 110 pounds, down from 135 pounds prior to hospitalization. The dietician noted the significant weight loss but stated that it was the nursing department's responsibility to notify the physician and the resident's family, which was not done. During interviews, the dietician and the infection preventionist (IP) both acknowledged awareness of the resident's significant weight loss but indicated that no action was taken to notify the physician because the weight loss occurred in the GACH. The facility's policies and procedures require that any changes in a resident's condition, including significant weight loss, be documented and communicated to the attending physician and responsible party. However, there was no documentation that the physician was notified, leading to a failure in communication and documentation as per the facility's policies.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe homelike environment for eight ambulatory residents due to uneven surfaces in the hallways and resident rooms. During an observation, it was noted that the hallway floor in front of several resident rooms and the Nurses' Station had bulged areas, creating a potential tripping hazard. The Maintenance Supervisor confirmed that the Administrator was aware of the issue and had attempted to address it by cutting the tiles to release air bubbles, but this method was unsuccessful. The floor remained uneven with small to medium-sized bubbles. The Administrator stated that the floor tiles were installed about four years ago, and issues with waves and bubbles appeared later. Despite multiple attempts by the company to reheat and flatten the tiles, the problem persisted. The facility's policies and procedures indicated that floors should be maintained in a clean, safe, and sanitary manner, and that maintenance services should ensure the building is free from hazards. However, the facility did not meet these standards, resulting in a potentially unsafe environment for the residents.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was placed on a psychotropic medication. The resident, who had multiple diagnoses including type 2 diabetes, anxiety disorder, and hypertension, was prescribed Diazepam for anxiety. However, during a review of the resident's care plans, it was found that there was no care plan in place for the use of Diazepam. This was confirmed by the Minimum Data Set Nurse, who acknowledged the absence of a care plan for the medication. The resident's Minimum Data Set indicated that they were cognitively intact and required moderate assistance with daily activities. Despite this, the facility did not have a care plan that included measurable objectives and timetables to meet the resident's needs related to the use of Diazepam. This oversight was in violation of the facility's own policy, which mandates a comprehensive, person-centered care plan for each resident.
Failure to Follow Physician's Order for Oxygen Supplementation
Penalty
Summary
The facility failed to follow the physician's order for oxygen supplementation for Resident 118. The resident, who has a complex medical history including chronic obstructive pulmonary disease, chronic respiratory failure, and other significant conditions, was observed receiving oxygen at 1 liter per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by Licensed Vocational Nurse 5 during an observation and interview, who acknowledged that the resident was not receiving the correct oxygen treatment as prescribed. The failure to administer the correct oxygen dosage could lead to increased shortness of breath for the resident. A review of the facility's policies and procedures indicated that there are guidelines for safe oxygen administration, which include verifying and following the physician's orders. Additionally, the facility's policy on physician orders mandates that medications and treatments be administered as ordered and monitored for accuracy. Despite these policies, the facility did not adhere to the physician's order for Resident 118, resulting in a deficiency in the care provided to the resident.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to administer pain medication in accordance with physician's orders and care plans for one resident, resulting in severe pain. Resident 58, who was admitted with diagnoses including toxic encephalopathy, muscle weakness, essential hypertension, and hemiplegia affecting the left side, experienced a pain level of 9 out of 10 in the left leg for two hours. The resident's pain management plan included Tylenol, Gabapentin, and Oxycodone, but the Medication Administration Record (MAR) did not indicate that any pain medication was administered or refused on a specific date. The resident reported that the call light system was not working for three days, making it difficult to receive pain medication on time, and had to wait in severe pain for two hours over a weekend. During an interview, the Director of Nursing confirmed that Resident 58 had a pain management care plan in place. The facility's policy on pain assessment and management emphasized a commitment to appropriate assessment and treatment of pain based on professional standards, the comprehensive care plan, and the resident's choices. However, the facility did not adhere to these guidelines, leading to the resident's prolonged and severe pain. The failure to administer prescribed pain medication and the malfunctioning call light system contributed to the deficiency.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place readily accessible to residents and visitors. During observations on multiple dates, the nurse staffing data was not visible anywhere in the facility. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of the requirement to post daily nurse staffing data, including the total number of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs) along with their actual work hours. The facility only posted Census and Direct Care Service Hours Per Patient Day (DHPPD) daily, which did not meet the regulatory requirements. The facility's policy and procedures, dated August 2022, indicated that nurse staffing data should be posted daily for each shift and maintained for a minimum of 18 months. However, the facility did not comply with this policy. The DON and ADM admitted that the facility had never maintained specific hours for RNs, LVNs, and CNAs. This lack of compliance was confirmed through observations, interviews, and records review, leading to the deficiency noted in the report.
Failure to Follow Up on Pharmacist Recommendations
Penalty
Summary
The facility failed to follow up and communicate with a physician regarding the consultant pharmacist's recommendation to perform blood tests for two residents, leading to a deficiency. Resident 49, who had multiple diagnoses including type 2 diabetes, hypertension, and a mood disorder, was prescribed Depakote. The Pharmacy Consultation Report recommended ordering several blood tests due to potential side effects of Depakote, but these tests were not ordered, and the recommendation was not signed or dated by a physician. The Director of Nursing (DON) confirmed that the lab tests were not done and could not provide documentation indicating otherwise. Similarly, Resident 51, who had a range of diagnoses including toxic encephalopathy, Parkinson's disease, and chronic obstructive pulmonary disease, was prescribed Midodrine for hypotension. The Drug Regimen Review recommended clarifying the administration parameters and frequency of Midodrine with a physician. However, the physician's orders did not include these parameters, and the Drug Regimen Review was neither signed nor dated, indicating it was not completed. The DON confirmed that the review was not done. The facility's policy on Medication Regimen Reviews requires the consultant pharmacist to review each resident's medication regimen monthly and provide a signed and dated report to the DON and medical director. The policy also mandates that physician responses be documented and maintained as part of the permanent medical record. The failure to follow these procedures resulted in the identified deficiency, as the necessary follow-up actions were not taken for Residents 49 and 51.
Failure to Implement Safe Water Management Program
Penalty
Summary
The facility failed to implement a safe water management program to prevent waterborne diseases, including Legionnaire's disease. During an interview, the Maintenance Supervisor (MS) revealed a lack of awareness about any water management program, although MS tested water temperatures and kept a log. The Infection Preventionist (IP) mentioned that maintenance increased water temperature to kill bacteria and that water tests were conducted twice a month using a mini-lab water testing kit. However, the MS admitted to using YouTube videos for guidance on water treatment and disinfection, and the facility did not employ an outside laboratory for water testing. Instead, water testing was conducted internally by the MS, IP, and Administrator (ADM). The ADM confirmed that water testing began at the start of 2024, with IP collecting samples from various facility areas and using a mini-lab test kit for testing. A review of the facility's policy and procedure (P&P) titled
Failure to Offer Pneumonia Vaccine to Resident
Penalty
Summary
The facility failed to ensure that pneumonia vaccines were offered and/or re-offered to a resident, as per their policy. Resident 29, who had multiple diagnoses including elevated white blood cell count, retention of urine, difficulty walking, muscle weakness, bipolar disorder, neuroleptic induced parkinsonism, mild cognitive impairment, tremors, hyperlipidemia, hypertension, allergic rhinitis, edema, and polyneuropathy, was not offered the pneumonia vaccine. The resident's Minimum Data Set indicated severely impaired cognitive skills and required maximal staff assistance for activities of daily living. During an interview and concurrent record review, the Infection Preventionist admitted to not locating any records indicating that Resident 29 had received the pneumonia vaccine. The facility's policy, dated February 2022, mandates that residents be informed about the benefits and risks of immunizations and be given the opportunity to receive the influenza and pneumococcal vaccines unless medically contraindicated, refused, or already immunized. The failure to offer the vaccine to Resident 29 was acknowledged by the Infection Preventionist as an oversight.
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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 Santa Monica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkley West Healthcare Center | 0 mi | ★★★★★ | 14 | 0 |
| Pacific Post Acute | 0 mi | ★★★★★ | 14 | 0 |
| Santa Monica Rehabilitation Center | 0.2 mi | ★★★★★ | 48 | 0 |
| Santa Monica Health Care Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Berkley East Healthcare Center | 0.2 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.