Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ocean Ridge Post Acute during CMS and state inspections, most recent first.
Failure to Provide Ordered ROM Services: A resident with stroke-related weakness, contractures, and severely impaired cognition did not receive ROM care as ordered. RNA staff changed the right arm program from PROM to AROM even though the resident still could not move through full ROM independently, and during observation the RNA did not physically assist the resident through full ROM of the shoulder, elbow, wrist, or fingers. The RNA also failed to provide ordered AAROM to both legs, stating she did not know what AAROM meant and thought the order was for AROM. Rehab staff confirmed the resident still needed assistance to reach end ROM, and the DOR stated the ordered AAROM required physical assistance through full available ROM.
Missed Podiatry and Ophthalmology Follow-Up The facility failed to ensure medically related social services were provided for two residents by not completing specialty follow-up in a timely manner. One resident with dementia, chronic pain, and a podiatry consult order had thick, long, painful toenails and a callus, while the SSD stated follow-up with podiatry should have occurred more often. Another resident with right eye blindness and fluctuating capacity had a care plan for eye care, but the ophthalmologist’s recommended 3-month follow-up was not completed on time, and the resident reported repeated requests for an appt.
Clean linen carts were accessed by a resident without staff assistance, and the DON and LVN stated carts should only be accessed by facility staff to prevent contamination. In the laundry area, soiled linens and used medical devices, including a wedge, heel protector, and IPC devices, were observed leaning against a wall instead of being placed in a designated covered hamper, which did not follow the facility P&P for handling soiled linen and laundry items.
Missing COVID-19 Vaccination Documentation for Licensed Practitioners: The facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for all licensed practitioners. The IP stated the facility did not document or maintain vaccination status for licensed practitioners, and the DON confirmed records should be maintained for all staff. The facility policy defined staff to include licensed practitioners and stated staff are educated about the benefits, risks, and side effects of the COVID-19 vaccine.
Incorrect Advance Directive and POLST Documentation: Two residents had incomplete or inaccurate surrogate decision-maker documentation. One resident’s POLST showed a DNR and was signed by a family member without chart support proving legal authority, while the admission record listed different family members as RPs and staff could not verify who the legally recognized decisionmaker was. Another resident with dementia, metabolic encephalopathy, palliative care, and moderate cognitive impairment was listed as self-responsible despite documentation showing lack of full medical capacity, and no resident representative was identified in the record.
Failure to report repeated orthopedic appointment refusals. A resident with multiple fractures, severe cognitive impairment, and ongoing mobility limitations refused scheduled ortho follow-up and later refused additional attempts to reschedule. The CM did not document the refusals or notify the physician, and the resident remained without documented ortho follow-up while still using a FWW and not consistently following ordered precautions.
Two residents were given psychotropic meds without documented supporting diagnoses before treatment began. One resident received Xanax for anxiety even though the chart, H&P, and psych notes did not show an anxiety dx, and another resident received Depakote for bipolar disorder even though bipolar disorder was not documented until later. RN and ADON interviews confirmed the missing diagnosis support, and the facility policy required sufficient documentation for psychotropic use.
MDS assessments were not accurately completed for three residents. One resident’s MDS omitted anxiety despite an active Xanax order, another resident’s MDS omitted bipolar disorder despite an active Depakote order, and a third resident’s oral/dental status was coded as normal even though missing upper front teeth and dental problems were observed and documented. The MDS Nurse and DON stated the assessments should have reflected the residents’ actual diagnoses and condition.
PASARR screening and reassessment were not properly completed for four residents with mental health diagnoses and related treatment needs. One resident’s Level II evaluation was not followed through after a hospital transfer and readmission, two residents had new diagnoses/medication orders without a new PASARR Level I review, and one resident had a positive Level I for SMI but no documented Level II evaluation. Staff and the DON stated the missing PASARR follow-up meant the residents’ mental health needs might not be fully assessed.
A resident with multiple fractures and orthopedic restrictions repeatedly refused follow-up ortho appointments, but the record lacked a comprehensive care plan and IDT documentation addressing the refusals, despite staff noting the resident was walking without the CAM boot and using the affected arm. Another resident with dementia, dysphagia, missing upper front teeth, and lost partial dentures had no care plan addressing dental status, even though he reported painful chewing and staff confirmed the issue was omitted from the CP.
A resident with right eye blindness, fluctuating capacity, and functional assistance needs had ophthalmology consults recommending artificial tears for dry eyes and monocular precautions including IOP control, avoiding eye rubbing, and medication monitoring. The care plan addressed impaired visual function but did not include interventions for dry eyes or IOP control, and the MDS nurse and DON stated the ophthalmologist’s recommendations were not reflected in the care plan.
A resident with a left humerus fracture and multiple left leg fractures did not receive the ordered ortho follow-up after refusing the appointment because she did not want to leave her husband unattended. The CM did not document the refusal, repeated rescheduling attempts, or physician notification, and therapy remained limited by NWB and CAM boot precautions without updated ortho guidance.
A resident with a left humerus fracture and left ankle fractures was observed walking with an FWW without the ordered CAM boot and while pushing through the left arm despite NWB precautions. OT and PT documented that a walker was not issued because the resident refused to wear the CAM boot and could not safely maintain the ordered restrictions. The resident stated she had been walking in the room without the boot and had not heard about any changes to her weightbearing status, while the DON confirmed therapy determined the safe device and assistance level for transfers and ambulation.
RNA 1 was found not competent to provide ordered AAROM to a resident with CVA, muscle weakness, contractures, and severely impaired cognition. During an observed restorative session, the RNA instructed the resident to move both legs, knees, ankles, and toes but did not assist the resident through full ROM when the resident could only partially move or could not move the joints.
Missing Annual Performance Evaluations for Nurse Aides: The facility failed to complete required APRs for multiple nurse aides, including a CNA and an RNA. Record review and interviews with the DSD and DON showed that annual evaluations were not completed as required by facility policy, which calls for a review after the 90-day probationary period and at least annually thereafter.
A facility failed to clarify medication orders for two residents. One resident’s artificial tears order lacked a PRN frequency, and another resident with liver disease and alcohol dependence had multiple acetaminophen orders that were not clearly written to prevent duplicate therapy or overdose risk. Staff interviews confirmed the orders were unclear and could be interpreted differently.
Improper Medication Labeling and Contaminated Storage: Surveyors found insulin pens in a med cart without required open dates, including one resident’s Lantus and another resident’s Lantus plus an expired Humalog KwikPen still stored in the cart. In a separate med room, three vitamin C liquid bottles were observed leaking and contaminated with brown spillage on the shelf. The DON and ADON acknowledged the insulin labeling and storage issues and that the vitamin C bottles appeared dirty and possibly contaminated.
A resident with CVA, dementia, and dysphagia was found missing upper front teeth after his partial denture was lost before admission. The resident and RP reported asking nursing staff for help, but the SSD was unaware of the lost denture and did not follow through after a dental visit where broken teeth were noted and extraction was refused due to a misunderstanding. The resident reported pain when chewing hard foods, and the care plan did not address the dental issue.
Two residents signed arbitration agreements without the facility verifying that they understood the terms. One resident had ESRD, HF, and AFib, and the other had NPH, respiratory disorders, and immunodeficiency; both had moderately impaired cognition on MDS and later stated they did not know what arbitration was. The AC said she relied on yes-or-no responses before obtaining signatures, despite the facility policy requiring a verbal acknowledgment of understanding before signing.
A resident with dementia, polyosteoarthritis, muscle weakness, and moderate cognitive impairment, who was dependent on staff for all ADLs and had bilateral upper and lower extremity impairments, developed swelling and ecchymosis of the left arm that was reported by a CNA to an LVN. An X-ray later showed a displaced fracture of the left humeral neck, and the resident was transferred to a hospital. The LVN acknowledged not notifying the DON of this change in condition. The DON and administrator stated that such an unexplained fracture constitutes an injury of unknown origin and an unusual occurrence that, under facility policy, must be reported promptly to the DON, administrator, CDPH, the ombudsman, and other agencies within specified time frames. Review of the abuse and unusual occurrence P&Ps confirmed these reporting requirements, but the incident was not reported as required, resulting in a deficiency.
The facility failed to maintain the quality and freshness of stored produce, impacting the nutritional status of 83 residents. Observations revealed that strawberries, grapes, limes, and lettuce were not stored properly, appearing mushy, discolored, and wilted. The Dietary Supervisor and Registered Dietician confirmed that these items did not meet quality standards, and the facility's policy on food storage and monitoring was not adhered to.
The facility failed to store food properly, risking foodborne illnesses for 83 residents. Observations revealed unlabeled and undated food items, including burritos, donuts, and produce, with improperly sealed bacon. The dietary supervisor and registered dietician acknowledged these issues, emphasizing the need for labeling and proper storage to prevent spoilage. The facility's policy required all foods to be covered, labeled, and dated, which was not adhered to.
The facility failed to ensure dumpsters were not overfilled and left with lids open, as observed with the Dietary Supervisor. The left dumpster was overfilled, preventing proper closure, and the right dumpster lid was left open. The maintenance supervisor confirmed the need for lids to be closed to prevent foul smells and pest attraction. Facility policy requires dumpsters to be kept closed and food waste stored to prevent vermin access.
A resident with muscle weakness and dementia was unable to access her call light, which was found on the floor or tangled behind the bed frame during observations. This failure to ensure accessibility, despite her high fall risk, was confirmed by staff interviews and contradicted the facility's policy requiring call lights to be within easy reach.
The facility failed to accurately complete Level 1 PASRR screenings for several residents, including those with schizophrenia and bipolar disorder, leading to potential delays in necessary care and services. The admissions staff did not verify the accuracy of the screenings, resulting in missed Level 2 evaluations and improper placement of residents.
A resident with a gastrostomy tube experienced progressive weight loss due to the facility's failure to adjust the enteral feeding rate from 65 ml/hr to 70 ml/hr as ordered by the physician. Despite the RD's recommendation and the physician's order, observations showed the feeding rate remained unchanged, leading to unmet nutritional goals.
The facility failed to provide proper respiratory care for four residents by not adhering to physician orders for oxygen administration and monitoring. One resident received higher oxygen levels than prescribed, while another's oxygen saturation was not consistently monitored, risking unrecognized respiratory distress.
A facility failed to manage severe pain for a resident by not notifying the physician of pain levels, not following medication parameters, and not updating care plans. The resident, with a history of chronic pain, received inappropriate medication for severe pain. Another resident's pain was not accurately assessed per the physician's order, as staff documented an 'X' instead of a numeric value on the MAR. The DON confirmed the importance of following the pain assessment policy to ensure proper pain management.
A resident with hypertension and renal dialysis dependence received amlodipine against physician orders, which specified holding the medication on dialysis days and when certain blood pressure and heart rate parameters were not met. The DON confirmed the medication was administered incorrectly, constituting a significant medication error.
A LTC facility failed to follow infection control practices for three residents. A resident's Foley catheter bag was found touching the floor, contrary to policy. Another resident's nasal cannula, after falling on the floor, was not replaced but cleaned improperly. Additionally, a CNA did not wear an isolation gown while caring for a resident on Enhanced Barrier Precautions. These actions were against the facility's infection control policies, as confirmed by the DON and other staff.
The facility failed to report changes in the conditions of two residents, leading to deficiencies in care. One resident consistently refused RNA services for PROM exercises, but the facility did not notify the physician or initiate a timely COC evaluation. Another resident experienced critically high blood sugar levels, but the facility failed to notify the physician promptly. These lapses in following protocols resulted in inadequate care for the residents.
The facility failed to accurately document the medical diagnoses and pain frequency for two residents in their MDS assessments. One resident's bipolar disorder was not reflected in the MDS, despite being treated for it, while another resident's frequent pain was documented as occasional, affecting their pain management. These inaccuracies were confirmed by the DON and MDSC, highlighting a failure to adhere to documentation standards.
The facility failed to create and implement person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with nausea had no care plan for Zofran use, another on temazepam lacked a plan to monitor its effectiveness, and a third resident required assistance with fingernail care but had no care plan in place. The absence of these care plans hindered individualized care and monitoring.
The facility failed to update care plans for two residents, leading to inadequate care. One resident consistently refused RNA services for left leg ROM limitations, but the care plan was not revised. Another resident experienced severe pain without appropriate medication adjustments. The facility did not follow its policies for care plan updates and pain management, resulting in deficiencies in care.
A resident was found with long fingernails and black material underneath, indicating a failure in personal hygiene care. The resident expressed concerns about previous nail cutting experiences and stated that staff had not offered to clean or cut her nails. Interviews with staff revealed a lack of documentation and adherence to facility policy regarding nail care, resulting in unmet care needs.
A facility failed to follow a dietician's recommendation to obtain a physician's order for mid-arm circumference measurements for a resident who refused to be weighed. The resident, with severe cognitive impairment and poor oral intake, was at risk of malnourishment. The order was delayed for several months, and staff were unaware of the measurement's importance, contrary to the facility's nutritional assessment policy.
A resident with left leg ROM limitations and high risk for contracture development repeatedly refused RNA services for ROM exercises over nearly a year. Despite these refusals, the facility did not implement necessary evaluations or modify the RNA program to ensure appropriate care, leading to a potential decline in the resident's ROM and physical functioning.
A facility failed to assess the need for continued use of an indwelling urinary catheter for a resident admitted with fractures. Despite being cognitively intact and requiring assistance with toileting, the resident had a Foley catheter due to urinary retention, which is not a valid reason for long-term use. The facility did not document clinical indications or assess the ongoing need for the catheter, increasing the risk of infection.
The facility failed to administer medications as per physician orders and maintain accurate documentation, affecting multiple residents. Issues included improper administration of Advair Diskus and aspirin, late administration of hydralazine, and discrepancies in controlled medication records. Additionally, a resident was transferred to a hospital due to the unavailability of methadone.
A facility failed to act on a consultant pharmacist's recommendations to reduce the doses of quetiapine and sertraline for a resident with schizoaffective disorder and major depressive disorder. The Psychiatry NP disagreed with the recommendations without providing a clinical rationale, contrary to facility policy. The resident continued to receive the same medication doses, and the facility did not follow up with the medical director as required.
A resident receiving apixaban for DVT prophylaxis was not monitored for side effects, despite being at high risk for bleeding. The resident, with multiple health conditions and moderate cognitive impairment, was not monitored from the start date of the medication. Facility staff confirmed the lack of monitoring, which was against the facility's policy requiring continual monitoring for side effects.
A facility failed to obtain informed consent before administering temazepam, a controlled medication, to a resident with multiple diagnoses, including bipolar disorder and anxiety. Despite the resident's capacity to understand and make decisions, the facility did not secure consent for the medication's dosage and frequency. Interviews with staff confirmed the oversight, acknowledging the need for informed consent due to changes in medication administration.
The facility failed to maintain a medication error rate below 5%, resulting in a 17.86% error rate. Errors included incorrect administration of ClearLax and Advair Diskus, failure to instruct a resident to chew aspirin, and late administration of hydralazine. These errors were due to non-compliance with physician orders and facility policies.
A facility failed to properly label and store medications, affecting several residents. A resident's lorazepam was found without an open date, making it impossible to determine its expiration. In a medication cart, another resident's latanoprost was expired, and both latanoprost and fluticasone-salmeterol inhalers lacked open dates. An Advair Diskus for a third resident was also improperly labeled. These deficiencies were acknowledged by staff, highlighting risks of administering expired or ineffective medications.
A resident with left leg ROM limitations and at high risk for contracture development repeatedly refused RNA services for left leg exercises over a year. Despite documented refusals, the facility failed to ensure the resident received skilled therapy services to maintain joint ROM and functional abilities. The Rehabilitation Department was not informed of the refusals until six months later, and no timely interventions or PT consultations were initiated.
A resident with muscle wasting and COPD had incomplete physician orders for splint application, lacking details on the responsible staff and wear time. The resident reported that splints were not applied as expected, and observations confirmed improper limb positioning. Interviews with the DOR and DON highlighted the risk of unqualified staff applying splints due to unclear orders, contrary to facility policy requiring clear documentation and assessment by therapy.
A facility failed to implement its Infection Prevention and Control Program for a resident on enhanced barrier precautions. A CNA did not wear an isolation gown during high-contact care, failed to provide proper perineal care, and improperly discarded contaminated items, risking cross-contamination. The facility's policies required gowns and proper handling of soiled items to prevent infection spread.
A resident with severe cognitive impairment received Levaquin for UTI prophylaxis without meeting the McGeer criteria for infection surveillance. The order was made by an NP without consulting the physician, who had advised waiting for culture results. The resident received the antibiotic twice before lab results showed resistance, contrary to the facility's antibiotic stewardship policy.
A resident in an LTC facility was found to have a firearm in their belongings after their death, despite the facility's policy prohibiting weapons. The resident, who had mental health and substance dependence issues, was admitted with the capacity to make medical decisions but required supervision for daily activities. The firearm was discovered during postmortem care, revealing a lapse in the facility's procedures for checking residents' belongings.
A facility failed to create an individualized care plan for a resident with suicidal ideations and an OOP order. Despite the resident's diagnoses of major depressive disorder and opioid dependence, the care plan lacked specific interventions for suicidal ideations and guidance for staff when the resident returned from OOP. Interviews with staff revealed that the care plan should have included monitoring for suicidal ideation and mood changes, as well as increased supervision, in accordance with the facility's policy for comprehensive, person-centered care plans.
Failure to Provide Ordered ROM Services
Penalty
Summary
The facility failed to provide appropriate care to maintain and/or improve range of motion for a resident with significant neurologic and musculoskeletal impairment. Resident 61 had diagnoses including cerebral infarction, muscle weakness, and contractures of the right shoulder, both hips, both knees, and both ankles. The resident’s MDS indicated severely impaired cognition and functional limitations in ROM in one arm and one leg. OT documentation showed the resident had impaired ROM and 0/5 strength in the right arm, and an RNA referral initially called for PROM to the right arm five times a week or as tolerated. The resident’s RNA program was later changed to AROM for the right arm, and a physician’s order also directed AROM to the right arm five times a week. During observation of an RNA session, RNA 1 instructed the resident to move the right shoulder, elbow, wrist, and fingers, but the resident could only move the arm minimally and could not achieve full ROM. RNA 1 did not assist the resident through full ROM. In interviews, RNA 1 stated she did not assist because she believed the order had been changed to AROM, meaning the resident was to move independently without physical assistance. Rehab staff reviewed the resident’s therapy history and confirmed the resident still had significant weakness and could not move through full ROM on his own, and OT 2 stated the RNA program should have been modified to AAROM rather than AROM because the resident still needed assistance to move through end ROM. The facility also failed to provide ordered AAROM to both legs. A physician’s order directed RNA to provide AAROM exercises to both legs five times a week. During the same observed RNA session, RNA 1 instructed the resident to move both legs, knees, ankles, and toes, but the resident could only partially move the legs and could not complete full ROM. RNA 1 did not physically assist the resident through full ROM. RNA 1 stated she did not know what AAROM meant and thought the order was for AROM. The DOR confirmed that AAROM required physical assistance through full available ROM and stated that failing to provide it could result in ROM decline and contracture development. The facility’s policies stated residents with limited ROM should receive treatment and services to increase and/or prevent further decrease in ROM, and that maintenance programs would be implemented to assure the resident maintains functional and physical status.
Missed Podiatry and Ophthalmology Follow-Up
Penalty
Summary
The facility failed to provide medically related social services for two sampled residents by not ensuring specialty appointments were completed as ordered or recommended. Resident 19 was admitted with diagnoses including cerebral infarction, dementia, muscle weakness, and chronic pain syndrome, and the H&P stated he had no capacity to understand and make decisions. His OSR showed a podiatry consult order for mycotic/hypertrophic nails and keratotic lesions, and during observation his right toenails were thick, long, dark yellow, partly black, and growing toward the right side. He also had a callus on the top of the big toe and stated the toenails hurt when he stood to transfer or do therapy. Resident 19 stated it had been a long time since he was seen by a podiatrist and that he and his RP had asked multiple times for a podiatry visit without success. The SSD reviewed a podiatry evaluation showing tinea unguium, toe pain, corns, and callosities, with debridement and trimming performed. The SSD stated she should have followed up with the podiatrist office for more frequent visits and stated she was not aware of the resident’s long, painful toenails. Resident 45 was admitted with diagnoses including right eye blindness, muscle weakness, and AKI, and his H&P stated he had fluctuating capacity to understand and make decisions. His care plan addressed impaired visual function and included arranging consultation with an eye care practitioner as required. During observation, his right eye cornea was cloudy and opaque, and he stated he had lost vision in the right eye due to possible glaucoma, was worried about his left eye, and had asked staff multiple times to arrange ophthalmology appointments. The ophthalmology report recommended follow-up in three months, but the SSD stated the follow-up did not occur within that timeframe and the last visit was over three months later.
Clean Linen Access and Soiled Laundry Handling
Penalty
Summary
The facility failed to ensure clean linen carts were accessed only by facility staff. During an observation on 3/23/2026 at 10:09 a.m., a resident was observed accessing the clean linen cart located in front of room [ROOM NUMBER] without staff assistance. During an interview on 3/24/2026 at 1:13 p.m., LVN 1 stated clean linen carts should only be accessed by facility staff to prevent the spread of bacteria, and that resident access without staff assistance would increase the risk for the spread of infection to other residents. During an interview on 3/25/2026 at 2:14 p.m., the DON stated clean linen carts should only be accessed by facility staff to ensure the linens were not contaminated and that resident access without staff assistance could increase the risk for cross contamination. The facility also failed to implement its P&P titled Departmental (Environmental Services) - Laundry and Linen. During a concurrent observation and interview on 3/26/2026 at 3:07 p.m. in the laundry area, multiple items were observed leaning against a wall above the hamper next to the washing machine rather than being placed in a designated hamper or laundry chute. LA 1 identified the items as a resident's hat, soiled clothing, a shower blanket, medical devices, a wedge, a heel protector, intermittent pneumatic compression devices, and used linens, and stated the items were used and that it was not acceptable to store medical devices in the laundry area or leave soiled linens outside a designated covered container. During an interview on 03/26/2026 at 4:06 p.m., the DON stated soiled linens and soiled medical devices must be kept in a designated container to prevent contamination and infection. The facility's January 2026 P&P stated all soiled linen must be placed directly into a covered laundry hamper which can contain moisture, and that loose items will not be placed in the laundry chute.
Missing COVID-19 Vaccination Documentation for Licensed Practitioners
Penalty
Summary
The facility failed to maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status for all licensed practitioners. During a concurrent interview and record review with the Infection Preventionist, updated 2025-2026 COVID-19 vaccine acceptance/declination forms were reviewed and found to be undated. The Infection Preventionist stated that all individuals who provide care or have contact with residents, including licensed practitioners, are considered staff, and that the facility should encourage staff to receive COVID-19 immunization by providing screening, education, offering vaccination, and maintaining documentation of vaccination status. The Infection Preventionist stated she did not document or maintain COVID-19 vaccination status for licensed practitioners, including screening, education, and offering. During an interview, the DON stated the facility should maintain COVID-19 vaccination records for all staff, including licensed practitioners, to monitor vaccination status and reduce the risk of illness for residents. The facility's policy titled Coronavirus Disease (COVID-19)-Vaccination of Staff, dated January 2026, stated staff are educated about the benefits, risks, and potential side effects of the COVID-19 vaccine and defined staff to include employees, licensed practitioners, students, trainees, and volunteers.
Incorrect Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to correctly formulate Advance Directives and POLST documentation for two sampled residents. For one resident, the admission record showed diagnoses including dysarthria, alcoholic cirrhosis of the liver with ascites, and generalized anxiety disorder. The resident’s H&P and SOAP note indicated the resident was capable of making medical decisions, and the MDS showed dependence for multiple activities of daily living. During record review, the resident’s POLST showed a DNR order and stated that the AD was discussed with a legally recognized decisionmaker, with the POLST signed by a family member as that decisionmaker. During interview, the RNS stated there was no documentation proving the family member was the legally recognized decisionmaker or RP in the chart, and stated the POLST was not completed because it was signed by an unauthorized person. The RNS stated that if the POLST was not complete and accurate, the resident would be treated as full code and all life-sustaining measures would be done during an emergency per policy. The SSD reviewed the admission record and stated the resident and one family member were documented as RPs, while another family member was listed only as an emergency contact. The SSD stated the RP and legally recognized decisionmaker were different and that neither family member had legal documents proving authority. For the second resident, the admission record identified the resident as self-responsible, while the H&P for a hospice face-to-face encounter indicated the resident did not have full medical capacity to make decisions. The MDS showed moderate cognitive impairment and extensive dependence for bathing, dressing, transfers, toileting hygiene, personal hygiene, and other care needs. During interview, the SSD stated the resident did not have the capacity to be self-responsible and that there were no notes specifying who the decisionmaker was, yet the IDT had listed the resident as self-responsible. The SSD also stated a family member was involved in care because the resident had periods of confusion, but the admission record did not specify that family member as the resident’s representative.
Failure to Report Repeated Orthopedic Appointment Refusals
Penalty
Summary
The facility failed to ensure the Case Manager reported one resident’s repeated refusals of orthopedic follow-up appointments to the physician. Resident 51 was admitted after being struck by a car and sustained multiple fractures, including a left humerus fracture, left distal fibula fracture, left tibia dislocation, and left medial malleolus fracture. The resident also had diagnoses including systemic involvement of connective tissue, muscle weakness, and polyneuropathy, and the MDS later documented severe cognitive impairment and functional limitations in range of motion in one arm and one leg. An orthopedic consultation and physician order directed follow-up with orthopedics and continued precautions for the left arm and left leg. The resident’s IDT note documented refusal to wear the left leg CAM boot when walking and stated therapy would limit activity until orthopedic clarification was obtained. During later observation and interview, the resident stated she had been walking with a FWW without the CAM boot and was putting weight through the left arm. She also stated she refused the scheduled orthopedic appointment because she did not want to leave her husband unattended and said she had not heard anything about the status of her left arm and ankle for over two months. The CM stated she was responsible for scheduling follow-up consultations and confirmed the resident was supposed to follow up with orthopedics but did not attend. The CM stated the resident refused the appointment and that she did not document the refusal in the clinical record. She also stated she attempted to schedule additional orthopedic appointments multiple times, but the resident refused each time, and those attempts were not documented. The CM further stated she did not notify nursing or the physician of the repeated refusals. The DON stated refusals for follow-up appointments should be documented, care planned, discussed in an IDT meeting, and reported to the physician, nursing, and the resident’s family. The facility policy also stated the resident, attending physician, and resident representative are to be promptly notified of changes in condition or status, and the nurse is to notify the physician when there is a refusal of treatment or medications two or more consecutive times and when medical treatment needs to be altered significantly.
Unnecessary Psychotropic Medications Without Supporting Diagnoses
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medications by starting Xanax for one resident and Depakote for another without supporting diagnoses documented before treatment began. For Resident 10, the admission record listed bipolar disorder, schizophrenia, and depression, and the MDS showed moderate cognitive impairment and active diagnoses of depression, bipolar disorder, and schizophrenia, but it did not show an active diagnosis of anxiety. The order summary report showed Xanax 0.25 mg twice daily for anxiety manifested by inability to relax, with side effect monitoring ordered, and the medication was started on 11/6/2025. During the concurrent review, the RN supervisor stated Resident 10’s diagnosis list, H&P, and psychiatrist note did not indicate anxiety, even though Xanax had been prescribed for anxiety. The RN supervisor stated the importance of having a diagnosis before starting medication was to ensure the resident needed the medication to control or treat the diagnosis. The ADON also stated that prescribing an antianxiety medication without an anxiety diagnosis could result in negative effects or the opposite effect of the medication. For Resident 12, the admission record listed anxiety disorder, depression, and schizophrenia, and the MDS showed moderate cognitive impairment with active diagnoses of anxiety, depression, and schizophrenia, but it did not show bipolar disorder. The order summary report showed Depakote 500 mg twice daily for bipolar disorder manifested by mood changes and sudden angry outbursts, with the medication started on 1/6/2026. The RN supervisor stated the diagnosis list, H&P, and psychiatrist notes did not indicate bipolar disorder, while the ADON stated the bipolar diagnosis was added later and that Depakote had been prescribed before the diagnosis was documented. The facility policy stated that diagnosis alone does not necessarily warrant psychotropic medication use and that supporting documentation must show the resident meets the criteria for the diagnosis.
MDS assessments did not reflect residents’ diagnoses and dental status
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three sampled residents by not reflecting all relevant diagnoses and dental status in the assessments. The deficient practice involved Resident 10, Resident 12, and Resident 19, and resulted in incorrect data being transmitted to CMS. The report states this had the potential to negatively affect the plan of care and delivery of care and services for these residents. For Resident 10, the admission record listed diagnoses including bipolar disorder, schizophrenia, and depression. The MDS dated 3/4/2026 identified moderate cognitive impairment and documented active diagnoses of depression, bipolar disorder, and schizophrenia, but did not indicate anxiety. The order summary report dated 3/25/2026 showed an active physician order for Xanax 0.25 mg twice daily for anxiety. During interview, the MDS Nurse stated the MDS did not indicate anxiety and that another assessment should have been completed when the new anxiety medication started so the resident’s new diagnosis would be reflected accurately. For Resident 12, the admission record listed anxiety disorder, depression, and schizophrenia. The MDS dated 1/13/2026 identified moderate cognitive impairment and documented active diagnoses of anxiety, depression, and schizophrenia, but did not indicate bipolar disorder. The order summary report dated 3/25/2026 showed Depakote 500 mg twice daily for bipolar disorder. The MDS Nurse stated the bipolar diagnosis should have been included in the assessment and that failing to include it could lead to inappropriate or lack of treatment and services. For Resident 19, the admission record listed cerebral infarction, dementia, and dysphagia. During observation, missing upper front teeth were noted, and the resident stated he had lost his partial dentures in the hospital and that chewing hard foods was painful. The MDS oral/dental status sections dated 11/17/2025 and 12/16/2026 indicated no broken or loosely fitting dentures and no mouth or facial pain or difficulty chewing. The MDS Nurse stated she was not aware of the missing upper front teeth and should have assessed the resident thoroughly before documenting the MDS. The DON also reviewed a dental progress note indicating broken teeth and stated the MDS should have been coded correctly based on the resident’s dental status.
PASARR reassessments not completed for residents with mental health needs
Penalty
Summary
The facility failed to ensure PASARR assessments were appropriately coordinated and followed through for four sampled residents with mental health diagnoses and related treatment needs. The deficiency involved Resident 3, Resident 10, Resident 11, and Resident 12, whose records showed PASARR screening or reassessment issues tied to readmission, new diagnoses, or new medication orders. Resident 3 was originally admitted with diagnoses including dementia, schizoaffective disorder, and depression, and later readmitted to the facility. A Notice of Attempted Evaluation showed the Level II evaluation for serious mental illness was not completed because the resident was temporarily transferred to the hospital. During interview, the RNS stated that after readmission there should have been a follow-up to complete the second evaluation, but the attempt to reassess Resident 3 was missed. The DON stated PASARR is used to ensure the facility can meet residents’ mental health needs and that if residents are not reassessed, they will not get the follow-up needed. Resident 10 had diagnoses including bipolar disorder, schizophrenia, and depression, and the record showed an order for Xanax for anxiety. The PASARR Level I screening dated 9/2/2025 did not indicate anxiety, and staff stated no new PASARR Level I screening was submitted after the anxiety diagnosis and medication order. Resident 12 had diagnoses including anxiety disorder, depression, and schizophrenia, and later had an order for Depakote for bipolar disorder. The PASARR Level I screening dated 8/6/2025 did not indicate bipolar disorder, and staff stated no resident review PASARR Level I screening was submitted for the new diagnosis. Resident 11 was admitted with dementia, anxiety disorder, major depressive disorder, and psychotic disorder; the PASARR Level I screening was positive for SMI and indicated a Level II follow-up, but staff could not find documentation of a Level II evaluation. The DON stated a new PASARR Level I should have been submitted on the 31st day because the resident was expected to stay longer than 30 days, and that staff should have followed up with the Level II evaluation. The facility policy stated that when Level I indicates possible mental illness criteria, the resident is referred for Level II evaluation and determination.
Failure to Care Plan Orthopedic Follow-Up Refusals and Dental Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident who had multiple fractures after being struck by a car and later refused repeated orthopedic follow-up appointments. The resident was admitted for rehabilitation after sustaining a left humerus fracture, left distal fibula fracture, left tibia dislocation, and left medial malleolus fracture, with surgery performed to realign the ankle dislocation and repair the fractures. Orthopedic orders required the left arm to remain non-weightbearing and the left leg to be weightbearing as tolerated while wearing a CAM boot, with follow-up scheduled with orthopedics. The record showed the resident refused the orthopedic appointment in January 2026 because she did not want to leave her husband unattended, and the case manager stated additional rescheduling attempts were made but were not documented. The resident’s clinical record did not contain a care plan or IDT meeting addressing the repeated refusals to follow up with orthopedics. The case manager stated she should have documented the refusals, notified the physician, developed a care plan, conducted an IDT meeting, and continued to follow up with the resident to investigate the reason for refusal and offer accommodations, but did not. The MDS nurse confirmed the facility did not develop a comprehensive care plan or conduct an IDT meeting for the orthopedic follow-up refusals. At the time of observation, the resident was sitting at the edge of the bed wearing slippers on both feet, stated she walked with a FWW in the room without the CAM boot, and said she put weight through her left arm. She also stated she had not heard anything about the status of her left arm and ankle for over two months. The facility also failed to develop a person-centered care plan for another resident’s dental health status. That resident had diagnoses including cerebral infarction, dementia, and dysphagia, and the H&P stated he had no capacity to understand and make decisions. During observation, he was missing upper front teeth and stated he had lost his partial dentures while in the hospital before admission. He reported that he told nursing staff but no one helped him retrieve or replace the dentures, and he said it was painful to chew hard foods such as chopped chicken or diced unripe melon. The MDS nurse reviewed the care plan and confirmed it did not address the resident’s missing partial denture or broken upper front teeth, and the DON stated the dental issues should have been identified and included in the care plan.
Care Plan Not Updated for Ophthalmology Recommendations
Penalty
Summary
The facility failed to ensure the comprehensive person-centered care plan for Resident 45 was revised, updated, and reflected ophthalmologist recommendations. Resident 45 was admitted with diagnoses including right eye blindness, muscle weakness, and dysphagia, and the history and physical noted fluctuating capacity to understand and make decisions. The resident’s MDS showed the need for assistance with transfers, dressing, oral hygiene, showering, personal hygiene, toilet hygiene, and eating. The resident’s order summary included artificial tears for dry eyes, and ophthalmology consults dated 10/14/2025 and 2/12/2026 recommended an artificial tears regimen for dry eye treatment and monocular precautions such as control of IOP, avoiding eye rubbing, and monitoring for medications. During record review, the care plan for impaired visual function related to right eye blindness included goals to maintain optimal quality of life and interventions to identify factors affecting visual function and monitor for acute eye problems, but it did not include interventions for dry eyes or IOP control. The MDS nurse stated the ophthalmologist’s recommendations were not reflected in the care plan, and the DON stated the recommendations should have been carried out and reflected in the care plan after the ophthalmology visits.
Missed orthopedic follow-up for resident with fractures
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for one resident by not following up with an orthopedic consultation appointment related to left humerus and left ankle fractures. The resident had been admitted after being struck by a car and had multiple injuries, including a left humerus fracture, left distal fibula fracture, left tibia dislocation, and left medial malleolus fracture. The resident also had diagnoses including systemic involvement of connective tissue, muscle weakness, and polyneuropathy, and the MDS indicated severe cognitive impairment and functional limitations in range of motion in one arm and one leg. The resident’s therapy evaluations documented precautions of toe-touch weightbearing to the left leg while wearing a CAM boot and non-weightbearing to the left arm with the arm in a sling when out of bed. An orthopedic consultation note later changed the left leg status to weightbearing as tolerated while wearing a CAM boot and directed follow-up with orthopedics. The physician’s order summary reflected the follow-up appointment and continued non-weightbearing precautions to the left arm and weightbearing as tolerated to the left leg in the CAM boot. An IDT note later documented that the resident was refusing to wear the CAM boot when walking and that therapy would limit treatment to transfers until orthopedic clarification was obtained. The resident stated she refused the scheduled orthopedic appointment because she did not want to leave her husband unattended and said staff never followed up to schedule another appointment. The case manager stated the resident refused the appointment, but the refusal was not documented, and additional attempts to reschedule were not documented either. The case manager also stated the physician was not notified, and no care plan or IDT follow-up was completed for the repeated refusals. Nursing leadership and rehabilitation leadership confirmed there was no documentation showing the orthopedic follow-up occurred, and the facility policy required case management to coordinate referrals and follow-up appointments and document them in the medical record.
Unsafe ambulation with walker and noncompliance with fracture precautions
Penalty
Summary
The facility failed to ensure that Resident 51 followed ordered mobility precautions after sustaining multiple fractures, including a left humerus fracture, a left distal fibula fracture, a left tibia dislocation, and a left medial malleolus fracture. The resident was admitted for rehabilitation after being struck by a car while crossing the street and had surgery to realign the left ankle dislocation and repair the left ankle and left humerus fractures. Therapy evaluations documented precautions for the left leg to be toe-touch weightbearing while wearing a CAM boot and for the left arm to be non-weightbearing and positioned in a sling when out of bed. Later orthopedic orders changed the left leg status to weightbearing as tolerated while wearing a CAM boot and continued the left arm non-weightbearing restriction. On 1/21/2026, OT documented that staff saw the resident walking to the restroom without assistance and without the CAM boot, and OT told the resident that a front-wheeled walker would not be issued because she refused to wear the boot during transfers and walking. The resident was instructed to use a bedside commode with assistance, but she refused. At an IDT meeting the next day, OT again educated the resident that a walker would not be provided if she did not wear the CAM boot, and therapy was limited to transfers only until clarification from orthopedics. During later observations, the resident was seen sitting at the edge of the bed and stated she walked with a FWW in the room without the CAM boot and put weight through her left arm. On another observation, she was walking in the room with an FWW, not wearing the CAM boot, and pushing through the left arm while walking. The resident stated she did not like wearing the CAM boot because it was too heavy and rubbed against her skin, and she reported she had not heard anything from staff about changes to her weightbearing restrictions. OT and PT both confirmed they had not issued a walker because it was unsafe due to the resident's refusal to wear the CAM boot and inability or refusal to maintain left arm non-weightbearing precautions. The DON stated PT and OT determined the level of assistance and device needed for safe transfers and walking, and that walking with a walker against therapy and physician orders could result in worsening fractures, harm, injury, and accidents.
RNA Not Competent to Provide Ordered AAROM
Penalty
Summary
The facility failed to ensure Restorative Nursing Aide 1 was competent to provide active assistive range of motion exercises to a resident's both legs in accordance with physician orders. Resident 61 was admitted and re-admitted with diagnoses including cerebral infarction, muscle weakness, and contractures of the right shoulder, both hips, both knees, and both ankles. The resident's MDS dated 1/15/2026 indicated severely impaired cognition, dependence or substantial assistance with multiple activities of daily living, and functional limitations in range of motion in one arm and one leg. A physician's order dated 3/16/2026 directed RNA to provide AAROM exercises to both legs five times a week. During an observation on 3/24/2026, RNA 1 performed the session in the resident's room while the resident was lying in bed. After assisting with right arm ROM, RNA 1 instructed the resident to move the left leg, left knee, left ankle, and left toes, but the resident could only partially move the leg and could not move through full ROM; RNA 1 did not assist the resident through full ROM. RNA 1 then repeated the same approach on the right leg, with the resident again only partially moving and RNA 1 not assisting the resident through full ROM.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for CNA 1, CNA 2, and RNA 1. During a concurrent interview and record review, the Director of Staff Development reviewed the Anniversary Performance Reviews for 2024 and 2025 and stated that the evaluations were essential to assess staff performance, identify training needs, and communicate facility expectations. The records showed that CNA 1, hired 7/18/2023, was missing APRs for 2024 and 2025; CNA 2, hired 1/8/2024, was missing an APR for 2025; and RNA 1, hired 3/13/2023, was missing APRs for 2024 and 2025. The DON stated performance evaluations should be completed at least annually and as needed to ensure nurse aides are providing appropriate care, meeting expected performance, and identifying strengths and areas for improvement. The facility policy titled Performance Evaluation, revised January 2026, stated that a performance evaluation will be completed at the conclusion of the 90-day probationary period and at least annually thereafter.
Unclear PRN Medication Orders and Duplicate Acetaminophen Therapy
Penalty
Summary
The facility failed to clarify physician orders for two residents during medication review and administration. For one resident with diagnoses including type 2 DM and immune mechanism disorder, the active order for artificial tears ophthalmic solution initially read as 1 drop in both eyes as needed for dry eyes, but it did not include a frequency for the PRN use. The resident’s record also showed moderately impaired cognition and need for varying levels of assistance with ADLs. During interview, an LVN stated the missing frequency could lead different nurses to interpret the order differently, and the DON stated the order should have included medication name, dosage, strength, frequency, time, and special instructions. For the second resident, who was admitted with hepatomegaly, uncomplicated alcohol dependence, fatty liver, muscle weakness, and chronic encephalopathy with no capacity for medical decision making, the medication record contained multiple acetaminophen orders. These included acetaminophen 500 mg, 2 tablets as needed for moderate to severe pain, acetaminophen 325 mg, 2 tablets every 4 hours as needed for fever, and acetaminophen 325 mg, 2 tablets every 6 hours as needed for mild pain. The order for acetaminophen 500 mg did not clearly indicate a frequency in the main order wording, and an LVN stated the order could increase the risk for acetaminophen overdose because it was unclear whether the daily notation was scheduled or PRN. The resident received acetaminophen from separate orders on multiple occasions, including administration of 500 mg tablets and 325 mg tablets on the same and different days. The DON stated the acetaminophen 500 mg order was corrected to indicate every 24 hours as needed, and stated the resident’s fatty liver disease and alcohol dependence placed the resident at risk for liver toxicity if acetaminophen was not administered appropriately. The facility policy required medication orders to specify type, route, dosage, frequency, and strength, and PRN orders to specify type, route, dosage, frequency, strength, and reason for administration.
Improper Medication Labeling and Contaminated Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications in Station 2 Medication Cart 2 and Station 1 Medication Room. During observation and interview, a Lantus Solostar pen for Resident 52 was found without an open date. Resident 52’s record showed admission with a diagnosis including cerebral infarction and Type 2 DM, and the H&P stated the resident could make medical decisions. The resident had an active order for Lantus Solostar 100 units/mL, 16 units subcutaneously daily for DM 2. A second resident’s medications in Station 2 Medication Cart 2 were also not properly labeled or removed when expired. Resident 42’s Lantus Solostar pen had no open date, and a Humalog Kwikpen had an open date but was expired and still stored in the cart. Resident 42’s record showed admission with a diagnosis including Type 2 DM with hyperglycemia, and the H&P stated the resident could make own medical decisions. The resident had active orders for Humalog KwikPen sliding scale insulin before meals and at bedtime, and Lantus SoloStar 10 units subcutaneously daily after dinner. In Station 1 Medication Room, surveyors observed three vitamin C liquid bottles that were leaking, looked contaminated and/or deteriorated, with brown colored spillage on and around the bottles on a medicine cabinet shelf. The bottles were labeled with sealed clear plastic around their lids. The ADON stated the bottles did not look good to be administered, and the DON stated they looked dirty and could have been contaminated. The facility policy stated medications and biologicals are to be stored in locked compartments and maintained in a clean, safe, and sanitary manner, with opened multi-dose items dated and discarded within 28 days unless the manufacturer specifies otherwise.
Failure to Replace Lost Partial Denture and Follow Through With Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for Resident 19 when the resident’s partial denture was lost and dental follow-through was not completed. Resident 19 was admitted with diagnoses including cerebral infarction, dementia, and dysphagia, and the H&P indicated the resident had no capacity to understand and make decisions. The MDS showed the resident required assistance with toileting, showering, dressing, personal hygiene, transfer, bed mobility, oral hygiene, and eating. During observation, Resident 19 was seen missing upper front teeth and stated the partial denture had been lost while in a GACH before admission. The resident stated the RP and he told nursing staff, but no one helped him. Resident 19 also stated it was painful to chew hard foods such as chopped chicken or diced unripe melon. The RP stated the resident had asked nursing staff about denture replacement but had not received a response, and the resident no longer wanted to smile around others because of the missing teeth and complained of dental pain while eating hard food. Record review showed a dental progress note documented broken teeth and that the resident refused extraction after the dental visit, but the SSD stated she did not know the partial upper denture had been lost before admission and had not followed through regarding the reason for refusal after the dental visit. The resident’s inventory of personal items showed no personal belongings, and the care plan did not include dental issues related to broken teeth or the missing partial denture. The facility policy stated residents with lost or damaged dentures should be referred for dental services within 3 days, with documentation if delayed, but this did not occur for Resident 19.
Failure to Verify Resident Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that two residents understood the Binding Arbitration Agreement before their signatures were obtained. Resident 46 was admitted with end stage renal disease, heart failure, and arterial fibrillation; the H&P stated the resident had the ability to understand and make decisions, while the MDS later indicated moderately impaired cognition. Resident 46 signed an Arbitration Agreement on 3/18/2026, but during interview on 3/25/2026 stated not knowing what arbitration was. Resident 91 was admitted and later readmitted with normal pressure hydrocephalus, respiratory disorders, and immunodeficiency; the H&P indicated whether the resident had the ability to understand and make decisions, and the MDS indicated moderately impaired cognition. Resident 91 signed an Arbitration Agreement on 12/7/2025, but during interview on 3/25/2026 stated not knowing what arbitration was. The AC stated she asked both residents if they understood the arbitration agreement and, after they answered yes, proceeded with signing without verifying understanding. The DON stated arbitration resolves disputes outside of court and signing gives up the right to proceed in court, and that understanding should be verified more thoroughly than by yes-or-no questions. The facility policy stated the resident or representative must verbally acknowledge understanding before signing, and that a signature alone is not sufficient.
Failure to Report Injury of Unknown Origin as Required by Abuse and Unusual Occurrence Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting and prevention policies by not reporting an injury of unknown origin for one resident to required external agencies. The resident had diagnoses including polyosteoarthritis, dementia, and muscle weakness, and an H&P documented that the resident did not have capacity to understand and make decisions. An MDS assessment showed moderate cognitive impairment, dependence on staff for all ADLs, need for assistance with rolling, and impairments in both upper and lower extremities. A change in condition note documented swelling and ecchymosis of the resident’s left arm, and a subsequent X-ray identified a displaced fracture at the surgical neck of the left humerus, with the resident later transferred to a general acute care hospital for treatment. Staff interviews revealed that a CNA notified an LVN about discoloration of the resident’s left arm, and the LVN observed discoloration in the upper and lower parts of the arm. The LVN acknowledged that, in the event of a change in condition, she should have notified the DON but did not do so. The DON stated that an unusual occurrence includes suspected abuse such as an injury of unknown origin, and that the facility’s protocol required the LVN to report such events to the DON, the administrator, CDPH, the ombudsman, and, if needed, law enforcement and APS within specified time frames. The DON stated that serious injuries such as accidents and fractures are unusual occurrences that must be reported to appropriate officials and CDPH within two hours, and that when the LVN learned of the fracture, she should have informed the DON. The administrator stated that an unusual occurrence is an event that cannot be explained or have its root cause identified, and that for unusual occurrences and abuse allegations, the facility is to report the incident and notify the ombudsman, police, and CDPH within two hours, followed by an investigation within five days. The administrator stated they did not know how the resident’s left arm was broken, that this was an injury of unknown origin, and that it would have been reportable. Review of the facility’s written policies confirmed that all reports of resident abuse, including injuries of unknown origin, must be reported immediately to the administrator and to state licensing/certification and other required agencies within defined time frames, and that unusual occurrences affecting health, safety, or welfare must be reported by telephone within 24 hours and in writing within 48 hours. Despite these policies, the injury of unknown origin and resulting fracture were not reported as required, leading to the cited deficiency.
Deficiency in Produce Quality and Freshness
Penalty
Summary
The facility failed to ensure the quality and freshness of fruits and vegetables stored in the refrigerator, which had the potential to impact the nutritional status and quality of life of 83 out of 88 residents. During an observation, it was noted that strawberries, grapes, limes, and lettuce were stored in a manner that did not maintain their quality. The strawberries and grapes appeared mushy and dark in color, the limes had brown spots, and the lettuce was wilted. The Dietary Supervisor acknowledged that these items did not meet the quality and freshness standards and needed to be discarded. Interviews with the Dietary Supervisor and Registered Dietician revealed that the facility's staff were expected to check the produce for firmness, color, and absence of bruising or discoloration to ensure they were not old or spoiling. The Registered Dietician emphasized that poor appearance of produce could lead to decreased intake by residents. The facility's policy indicated that food should be stored to minimize nutrient loss and maintain safety, with regular monitoring and rotation to ensure freshness. However, these practices were not followed, leading to the deficiency.
Deficient Food Storage Practices in Facility
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of microorganisms and potential foodborne illnesses for 83 out of 88 residents. During an observation and interview, it was found that the facility's refrigerator contained three bean burritos, a box of donuts, and a package of bacon that were not labeled or dated. Additionally, the bacon was not properly sealed and was open to air. Another refrigerator contained a cut onion and two bell peppers that were also not labeled or dated. The dietary supervisor acknowledged these issues, noting that the donuts should have been dated with the date received and thawed, and that the cook had forgotten to label and date the leftover produce. The registered dietician confirmed that all food stored in the kitchen needed to have a delivery date, date opened, and/or a use-by date to prevent serving spoiled or poor-quality food to residents. The dietician emphasized the importance of properly sealing and covering food to prevent oxidation and faster spoilage. The facility's policy and procedure on food receiving, labeling, and storage, dated November 2022, indicated that all foods stored in the refrigerator or freezer were to be covered, labeled, and dated with a use-by date. These practices were not followed, placing residents at risk for developing foodborne illnesses.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two out of two facility dumpsters were not overfilled and left with the lid open. During an observation and interview with the Dietary Supervisor in the facility parking lot, it was noted that the left dumpster was overfilled, preventing the lid from shutting properly, and the right dumpster lid was left open. The Dietary Supervisor indicated that facility staff might have forgotten to close the lid when disposing of trash. In a subsequent interview, the maintenance supervisor confirmed that the dumpster lids needed to be completely closed to prevent foul smells and the attraction of pests such as flies. A review of the facility's policy and procedure titled Food-Related Garbage and Rubbish Disposal indicated that outside dumpsters provided by garbage pick-up services should be kept closed, and garbage containing food waste should be stored in a manner that is inaccessible to vermin. This deficient practice had the potential to harbor and feed pests, including rodents and flies.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 73, had access to her call light, which is essential for requesting assistance from nursing staff. Resident 73 was admitted with diagnoses of muscle weakness, dementia, and major depressive disorder, and was assessed as a high risk for falls due to general weakness. Her care plan included the intervention of keeping her call light within reach to prevent falls. However, during multiple observations, the call light was found out of her reach, either on the floor or tangled behind the bed frame, which prevented her from calling for help when she felt unwell. Staff interviews confirmed the importance of having the call light within reach, as it is the primary means for residents to communicate their need for assistance. The Director of Nursing acknowledged the potential safety risks if residents cannot access their call lights. The facility's policy also stipulated that call lights should be within easy reach when residents are in bed, highlighting a failure to adhere to established procedures, thereby placing Resident 73 at risk for accidents.
Inaccurate PASRR Screenings Lead to Potential Delays in Care
Penalty
Summary
The facility failed to ensure accurate completion of the Level 1 Preadmission Screening and Resident Review (PASRR) for five out of nine sampled residents, which is a federal requirement to prevent inappropriate placement in nursing homes. This deficiency was identified through interviews and record reviews, revealing that the PASRR screenings for Residents 6, 24, 17, 28, and 79 were inaccurately marked as negative for serious mental illness, despite their diagnoses of conditions such as schizophrenia and bipolar disorder. This oversight had the potential to delay necessary care and services for these residents. Resident 24 was admitted with diagnoses of schizophrenia and anxiety, yet their PASRR Level 1 screening was marked negative, indicating no need for a Level 2 screening. Similarly, Resident 6, diagnosed with bipolar disorder and schizophrenia, also had a negative PASRR Level 1 screening. The Director of Nursing (DON) acknowledged that the admissions staff, who were not nurses, only ensured the completion of the PASRR without verifying its accuracy. This led to missed opportunities for appropriate psychiatric evaluations and treatments. Resident 17's PASRR Level 1 screening was positive for serious mental illness, but a Level 2 evaluation was not conducted due to a duplicate PASRR on file. The facility failed to resubmit a new Level 1 screening, potentially resulting in improper placement. Residents 28 and 79, both with serious mental illness diagnoses, also had incorrect PASRR Level 1 screenings, which did not trigger the necessary Level 2 evaluations. The facility's policy required accurate PASRR completion prior to admission, but this was not adhered to, impacting the residents' access to appropriate mental health services.
Failure to Adjust Enteral Feeding Rate as Ordered
Penalty
Summary
The facility failed to follow physician's orders for enteral feeding for a resident with a traumatic brain injury, aphasia, and a gastrostomy tube. The resident was experiencing slow progressive weight loss, and the registered dietician recommended increasing the tube feeding rate from 65 ml/hr to 70 ml/hr. The physician's order to increase the feeding rate was placed on January 16, 2025. However, observations on January 21 and January 23, 2025, revealed that the tube feeding was still running at the previous rate of 65 ml/hr, contrary to the updated physician's order. Interviews with the LVN and the RD confirmed that the feeding rate had not been adjusted as per the physician's order, which was necessary to address the resident's weight loss. The Director of Nursing also acknowledged that the feeding rate was not set to the correct rate, which meant the resident was not meeting their nutritional goals. The facility's policy and procedure for enteral tube feeding required checking the rate of administration against the order, which was not adhered to in this case.
Failure to Provide Proper Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide proper respiratory care for four residents by not adhering to physician orders for oxygen administration and monitoring. Resident 69, who was admitted with respiratory failure and COPD, was observed receiving oxygen at 4L/min and 4.25L/min instead of the prescribed 2L/min. Similarly, Resident 496, admitted with COPD and shortness of breath, was found to be receiving oxygen at levels between 3L/min and 4L/min, contrary to the physician's order of 2L/min. Resident 492, diagnosed with leukemia and requiring continuous oxygen for shortness of breath, was also observed receiving oxygen at 3.5L/min instead of the ordered 2L/min. Additionally, the facility failed to adequately monitor oxygen saturation for Resident 53, who was on continuous high-concentration oxygen due to chronic respiratory failure and COPD. The resident's medical records indicated that oxygen saturation should be checked every shift, yet there were numerous instances where this was not documented. The lack of monitoring could lead to unrecognized changes in the resident's condition, such as respiratory distress due to insufficient oxygen levels. Interviews with the Director of Nursing and Licensed Vocational Nurse confirmed these deficiencies, acknowledging that the residents did not receive the prescribed level of care. The facility's policies on oxygen administration and documentation were not followed, resulting in a failure to provide appropriate respiratory care and monitoring for the affected residents.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to manage severe pain appropriately for Resident 79, who experienced pain levels of 7-10 out of 10. The staff did not notify the physician of these severe pain levels from August 2024 to January 2025, nor did they follow the physician's ordered pain medication parameters. Resident 79's pain was not accurately documented in the Minimum Data Set (MDS), and care plans were not updated to address the continued pain. Additionally, the location of the pain was not consistently documented, which contributed to a delay in obtaining appropriate consults and providing a suitable pain management regimen. Resident 79, who had a history of nontraumatic subdural hemorrhage, type 2 diabetes mellitus, and chronic pain from a left hip replacement, was admitted to the facility in August 2024. Despite the resident's complaints of severe pain, the facility administered Tramadol for moderate pain and Acetaminophen for mild pain, without contacting the physician for a more appropriate medication. The Licensed Vocational Nurse (LVN) acknowledged that there was no documentation indicating that the physician was contacted about the severe pain levels, and the Director of Nursing (DON) confirmed that medications should be administered within the ordered pain scale parameters. For Resident 32, the facility failed to accurately assess pain per the physician's order. Resident 32, who had severe cognitive impairment and a history of traumatic brain injury, was to be monitored for pain using a numeric scale every shift. However, the Medication Administration Report (MAR) showed that an 'X' was documented instead of a numeric value, which was not in accordance with the physician's order. The DON stated that the numeric pain scale was appropriate for Resident 32 and emphasized the importance of monitoring pain to ensure proper management. The facility's policy on pain assessment and management was not followed, leading to a potential for Resident 32 to experience unnecessary pain.
Failure to Prevent Significant Medication Error
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was receiving medication for high blood pressure. The resident, who had been admitted with diagnoses of hypertension and dependence on renal dialysis, had specific physician orders for the administration of amlodipine, a medication to treat high blood pressure. The orders specified that the medication should be held if the resident's systolic blood pressure was below 110 or heart rate was less than 60, and also on dialysis days (Monday, Wednesday, and Friday) to prevent hypotension during dialysis. Despite these orders, the resident received amlodipine on several occasions when it should have been withheld. The Director of Nursing (DON) confirmed that the resident received the medication on dialysis days and when the blood pressure and heart rate were below the specified parameters. This was not in accordance with the physician's orders, constituting a medication error. The facility's policy indicated that medications were to be administered according to the prescriber's written orders, which was not followed in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices in three separate instances involving three residents. In the first instance, a resident with a Foley catheter had their drainage bag touching the floor, which was observed during a room visit. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that this was against the facility's policy and increased the risk of infection. The facility's policy clearly stated that the catheter drainage bag should be kept off the floor to prevent infections. In the second instance, a resident's nasal cannula fell on the floor and was not replaced as required. Instead, a Certified Nurse Assistant (CNA) attempted to clean it with hand sanitizer, which was not an appropriate method of sanitization. The LVN and DON confirmed that the nasal cannula should have been replaced immediately to prevent potential contamination and infection, as per the facility's policy. The third instance involved a resident on Enhanced Barrier Precautions (EBP) due to a tracheostomy stoma and Candida auris infection. A CNA provided direct care to this resident without wearing an isolation gown, which was required to prevent the spread of multi-drug-resistant organisms. The Infection Preventionist Nurse and the DON emphasized the importance of following infection control protocols, including the use of personal protective equipment, to reduce the transmission of infections.
Failure to Report Changes in Resident Conditions
Penalty
Summary
The facility failed to report changes in the condition of two residents, leading to deficiencies in care. Resident 32, who was admitted with diagnoses including left hemiplegia and traumatic brain injury, consistently refused Restorative Nursing Aide (RNA) services for passive range of motion (PROM) exercises from February 2024 to January 2025. Despite these refusals being documented, the facility did not notify the resident's physician or initiate a change of condition (COC) evaluation in a timely manner. The first COC was only initiated in August 2024, six months after the refusals began, and no further COCs were initiated despite continued refusals. This lack of timely notification and intervention put Resident 32 at risk for a decline in mobility and the development of contractures. Resident 58, who was admitted with diabetes mellitus, experienced multiple instances where blood sugar levels exceeded 400 mg/dL, a critical level for diabetic patients. On three occasions in November and December 2024, the facility failed to notify the physician when Resident 58's blood sugar levels were critically high. Additionally, a blood test result showing a critically high Hemoglobin A1C level of 9.7% was not reported to the physician until eight days after the results were available. This delay in notification could have led to adverse health outcomes for Resident 58, as timely intervention is crucial in managing diabetes effectively. The facility's policy and procedure require immediate notification of the physician when there is a significant change in a resident's condition, such as refusal of treatment or critically high blood sugar levels. However, in both cases, the facility did not adhere to these protocols, resulting in a failure to provide appropriate and timely care to the residents. The Director of Nursing and other staff members acknowledged the lapses in following the facility's procedures, which contributed to the deficiencies identified in the care of Residents 32 and 58.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document the medical diagnosis of two residents in their Minimum Data Set (MDS) assessments, which are crucial for ensuring appropriate care. Resident 21 was admitted with diagnoses of Parkinson's disease and anxiety disorder, but was later assessed to have bipolar affective disorder, for which they were receiving Depakote. However, the MDS did not reflect this diagnosis, as confirmed by the Director of Nursing (DON) during an interview. The DON acknowledged the importance of accurate MDS coding to ensure residents receive the correct care and treatment. Resident 79's MDS inaccurately documented their pain frequency as occasional, despite records showing they experienced pain almost constantly and required daily Tramadol for relief. The MDS Coordinator (MDSC) confirmed that the MDS should have reflected the resident's frequent pain to ensure proper care and treatment. An interview with Resident 79 revealed that their pain was not adequately managed with the current medication regimen, and they had requested stronger pain medication without receiving it. The facility's MDS Nurse Job Description and the policy on Charting and Documentation emphasize the need for accurate and complete documentation. However, the discrepancies in the MDS assessments for Residents 21 and 79 indicate a failure to adhere to these standards, potentially impacting the residents' care plans and treatment outcomes.
Failure to Implement Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to create and implement person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident 73, who was admitted with diagnoses including muscle weakness, dementia, and major depressive disorder, had an order for Zofran to manage nausea. However, there was no care plan in place to address the use of this medication, despite the resident frequently experiencing nausea. The Director of Nursing acknowledged the absence of a care plan, emphasizing its importance for continuity of care and individualized interventions. Resident 17, diagnosed with bipolar disorder, major depressive disorder, anxiety disorder, and hemiplegia, was prescribed temazepam for insomnia. Despite receiving the medication consistently, there was no care plan to monitor its effectiveness or to outline goals and interventions if the medication was ineffective. The MDS Coordinator confirmed the lack of a care plan, which hindered the facility's ability to monitor the medication's impact on the resident's sleep. Resident 28, with diagnoses including schizophrenia, COPD, CHF, and diabetes mellitus, required assistance with self-care and grooming, particularly concerning fingernail care. The resident expressed concerns about previous nail trimming experiences and had not been offered assistance with nail care. The absence of a care plan for grooming and self-care was noted by a Licensed Vocational Nurse, who stated that even if the resident refused care, a plan should have been in place to document the offer and explore alternative interventions. The Director of Nursing highlighted the necessity of care plans for ensuring resident-centered care and guiding staff in providing appropriate services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents, leading to deficiencies in their care. Resident 32, who was identified as having left leg range of motion (ROM) limitations and was at high risk for contracture development, consistently refused Restorative Nursing Aide (RNA) services from August 2024 to January 2025. Despite these refusals, the care plan was not updated since August 2024, and the interventions listed were ineffective. The Minimum Data Set Nurse Coordinator (MDSC) and the Director of Nursing (DON) confirmed that the care plan should have been revised to include effective interventions to maintain the resident's ROM, mobility, and activities of daily living (ADLs). Resident 79 experienced severe pain that required increased use of as-needed (PRN) pain medications from August 2024 to January 2025. The resident complained of pain levels of 7/10 and 8/10, but there was no PRN medication ordered for severe pain, and the nursing staff did not contact the physician to clarify and order an appropriate medication. The care plan for pain management was not revised during this period, and the facility's policy indicated that pain management interventions should be consistent with the resident's goals for treatment and should be revised as necessary. The facility's policies and procedures for care plans and pain management were not followed, leading to inadequate care for both residents. The care plans were not updated quarterly or as needed, and the interventions were not adjusted to meet the residents' changing conditions. This failure to update and revise care plans resulted in a lack of appropriate care and services for the residents, as confirmed by the MDSC and the DON.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to maintain good grooming and personal hygiene for a resident, identified as Resident 28, who was observed to have long fingernails with black material underneath. This deficiency was noted during an observation and interview with the resident, who expressed that the last time her fingernails were cut, it resulted in a cut to her skin, and she did not want that to happen again. The resident also mentioned that staff had not offered to clean or cut her fingernails, although she would like them to try again. Interviews with facility staff, including an LVN and the DON, revealed that CNAs are responsible for daily grooming and ADLs, including nail care. The DON acknowledged that there was no documentation of services being offered or refused by the resident, indicating that the services were not provided. The facility's policy on nail care emphasizes the importance of cleaning and trimming nails to prevent infections and requires documentation of any difficulties or refusals, which was not adhered to in this case.
Failure to Follow Dietician's Recommendations for Nutritional Assessment
Penalty
Summary
The facility failed to follow the dietician's recommendations and obtain a physician's order for mid-arm circumference measurements for a resident, which could delay care and identification of potential malnourishment. The resident, who was admitted with diagnoses including blindness, traumatic brain injury, and hemiplegia, refused to be weighed and had poor oral intake. The registered dietician recommended mid-arm circumference measurements in August 2024 as an alternative to assess the resident's nutritional status, but the order was not placed until January 2025. Interviews revealed that the licensed vocational nurse was unaware of what a mid-arm circumference measurement was, and the dietician expressed concern that her recommendations were not followed up promptly. The Director of Nursing confirmed that there was no indication the physician was informed of the dietician's recommendation until months later. The facility's policy on nutritional assessment emphasizes the importance of timely and multidisciplinary interventions, which were not adhered to in this case.
Failure to Address Resident's ROM Decline Due to RNA Refusals
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent a decline in range of motion (ROM) for a resident identified as having left leg ROM limitations and at high risk for contracture development. The resident, who had diagnoses including left hemiplegia and traumatic brain injury, repeatedly refused Restorative Nursing Aide (RNA) services for left leg ROM exercises from February 2024 to January 2025. Despite these refusals, the facility did not implement multiple Change of Condition (COC) evaluations, investigate the reasons for refusals, or modify the RNA program to ensure the resident received appropriate care. The resident's RNA Flowsheets consistently indicated refusals of RNA services, yet there was a lack of follow-up actions from the facility. The Director of Staff Development (DSD) confirmed that the resident refused or did not receive RNA services almost every day, five times a week, during the specified period. The facility's policy required that residents with limited ROM receive treatment and services to prevent further decline, but this was not adhered to in the case of this resident. Interviews with facility staff, including the Director of Rehabilitation (DOR) and the Director of Nursing (DON), revealed that the facility's RNA program was not reassessed or modified despite the resident's continuous refusals. The DOR stated that the Rehabilitation Department was unaware of the resident's multiple refusals until a COC evaluation was initiated in August 2024. The DON confirmed that the RNA program was not provided as ordered, and no follow-up assessments were conducted to check the effectiveness of any interventions. This lack of action contributed to the resident's potential decline in ROM and physical functioning.
Failure to Assess Continued Need for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to assess the need for the continued use of an indwelling urinary catheter for a resident, identified as Resident 22, who was admitted with a periprosthetic fracture and multiple rib fractures. The resident was cognitively intact and required assistance with toileting hygiene. Despite having an order for a Foley catheter due to urinary retention, there was no documentation supporting the necessity of the catheter for long-term use, as urinary retention is not an approved diagnosis for prolonged catheterization in a nursing home setting. Observations and interviews revealed that the resident still had the Foley catheter due to limited mobility, but the Director of Nursing confirmed that this was not a valid reason for continued catheter use. The facility's policy required documentation of clinical indications for catheter use and regular assessments for its necessity, which were not conducted. This oversight increased the risk of catheter-induced infections due to unnecessary prolonged use.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and manufacturer specifications, affecting multiple residents. For instance, a resident was not instructed to rinse their mouth after using Advair Diskus, increasing the risk of oral thrush. Another resident was observed swallowing an aspirin chewable tablet instead of chewing it, as required. Additionally, the facility did not ensure that polyethylene glycol was dissolved in the correct amount of water, as per physician orders, for two residents, potentially leading to gastrointestinal issues. The facility also failed to administer medications within the scheduled time frame. A resident's hydralazine, prescribed for hypertension, was administered almost two hours late, contrary to the facility's policy of administering medications within 60 minutes of the scheduled time. This delay occurred despite the nurse's awareness of running late and the potential risks associated with late administration, such as high blood pressure and stroke. Furthermore, the facility did not maintain accurate documentation of controlled medications. Discrepancies were found between the medication count sheets and the actual medication cards for several residents, indicating a failure to document the administration of controlled substances immediately. This lack of documentation could lead to medication errors, misuse, overdose, and drug diversion. Additionally, a resident did not receive their scheduled methadone dose due to the facility's failure to reorder the medication in a timely manner, resulting in the resident being transferred to a hospital for uncontrolled pain.
Failure to Act on Pharmacist's Recommendations for Medication Adjustment
Penalty
Summary
The facility failed to act on two recommendations from the consultant pharmacist regarding the medication regimen of a resident, identified as Resident 41. The consultant pharmacist had recommended reducing the doses of quetiapine and sertraline for Resident 41, but the recommendations were not acted upon. The Psychiatry Nurse Practitioner (NP) disagreed with the pharmacist's recommendations without providing a clinical rationale, which is against the facility's policy that requires a clinical explanation for any disagreement with pharmacist recommendations. Resident 41 was admitted with diagnoses including schizoaffective disorder and major depressive disorder. The resident's Minimum Data Set (MDS) indicated intact cognition and varying levels of assistance required for Activities of Daily Living (ADLs). Despite the consultant pharmacist's recommendations, the resident continued to receive the same doses of quetiapine and sertraline as documented in the Medication Administration Record (MAR) over several months. The NP stated that the resident felt stable with the current medication regimen and had not experienced episodes of delusions or significant mood changes, which was the reason for not adjusting the medication. The facility's policy on Medication Regimen Review requires that any disagreement with the pharmacist's recommendations be documented with a clinical rationale. The Director of Nursing (DON) emphasized the importance of providing a clinical rationale due to the potential side effects of psychotropic medications. However, in this case, the NP did not provide such a rationale, and the facility did not follow up with the medical director as required by their policy, leading to a deficiency in medication management for Resident 41.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen for side effects, specifically for a resident receiving an anticoagulant medication, apixaban, which was prescribed for deep vein thrombosis prophylaxis. The resident, who had multiple diagnoses including chronic respiratory failure, COPD, hypertension, and hyperlipidemia, was at high risk for bleeding due to the anticoagulant. Despite this risk, there was no monitoring for side effects from the start date of the medication on 12/19/24. This lack of monitoring was confirmed during interviews with facility staff, who acknowledged that residents on anticoagulants should be monitored every shift for signs of bleeding, such as skin discoloration, gum bleeding, and dark stools. The resident, who had moderate cognitive impairment and required varying levels of assistance for daily activities, was not monitored for side effects from 12/20/25 to 1/13/25. This oversight was identified during a review of the Medication Administration Record (MAR) and confirmed by both a Licensed Vocational Nurse and the Director of Nursing. The facility's policy on medication administration emphasized the importance of continual monitoring for side effects, particularly after the administration of new medications. However, this policy was not followed, leading to a potential delay in necessary care and services for the resident.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering a controlled medication, temazepam, to a resident identified as Resident 17. This resident was admitted with multiple diagnoses, including bipolar disorder, major depressive disorder, anxiety disorder, and hemiplegia following a cerebral infarction. Despite having the capacity to understand and make decisions, as indicated in the resident's history and physical, the facility did not secure informed consent for the administration of temazepam, a psychotropic medication prescribed for insomnia. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and varying levels of assistance required for daily activities. The Order Summary Report showed that temazepam was ordered and administered daily from January 10 to January 23, 2025, without any missing doses. However, a review of the resident's informed consent documentation revealed no consent for the medication at the prescribed dosage and frequency. During an interview, the resident acknowledged taking a sleeping pill but was unaware of its name, indicating a lack of informed consent. Interviews with the MDS Coordinator and the Director of Nursing confirmed the absence of informed consent for the temazepam medication. The facility's policy required informed consent for psychotropic medications, which was not obtained in this case. The MDS Coordinator and the Director of Nursing acknowledged the oversight, noting that the change in frequency and dosage necessitated a new informed consent, which was not secured, potentially leaving the resident uninformed about the medication's side effects.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 17.86% error rate. This deficiency was observed in the administration of medications to four residents. For one resident, the nurse did not ensure the resident finished the full dose of ClearLax solution and failed to instruct the resident to rinse their mouth after using Advair Diskus, contrary to the manufacturer's instructions. Additionally, the nurse used an incorrect amount of water to dissolve the ClearLax, which was not in accordance with the physician's order. Another resident was administered an aspirin tablet that was supposed to be chewed, but the nurse failed to instruct the resident to do so, leading to the resident swallowing the tablet whole. The physician's order for this medication was also unclear, as it indicated an oral capsule instead of a chewable tablet. This discrepancy was not clarified, contributing to the medication error. For a third resident, the nurse dissolved ClearLax in an incorrect amount of water, not following the physician's order. The fourth resident received hydralazine two hours late, beyond the facility's policy of administering medications within one hour of the scheduled time. This delay in administration was not in accordance with the facility's policy and could potentially affect the resident's blood pressure management. The Director of Nursing acknowledged these errors and the need for clarification of physician orders to prevent such medication errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential risks for residents. In the Station 1 Medication Room, a bottle of lorazepam oral concentrate for Resident 81 was found without an open date label, contrary to the manufacturer's requirements. The absence of an open date made it impossible to determine the expiration date, which could result in the administration of expired medication. This oversight was acknowledged by both RN 1 and the Director of Nursing (DON), who confirmed that the medication could potentially harm the resident if it was expired or ineffective. In the Station 1 Medication Cart 1, several medications were either expired, improperly stored, or lacked necessary labeling. For Resident 84, an unopened bottle of latanoprost ophthalmic solution was found without an open date, and an opened bottle was past its expiration date. Additionally, a fluticasone-salmeterol inhalation device for Resident 84 and an Advair Diskus inhalation device for Resident 35 were found without open dates. LVN 1 admitted to the oversight and acknowledged the potential risks of administering these medications without proper labeling and storage. The facility's policy and procedure for medication storage, dated May 2022, requires medications to be stored according to manufacturer's recommendations, with open dates clearly labeled to determine expiration. The failure to adhere to these guidelines resulted in the potential for residents to receive expired or ineffective medications, posing risks to their health and safety. The DON confirmed the importance of proper storage and labeling to ensure the therapeutic effectiveness and safety of medications administered to residents.
Failure to Provide Necessary Physical Therapy Services
Penalty
Summary
The facility failed to provide necessary Physical Therapy (PT) services for a resident identified as having left leg range of motion (ROM) limitations and at high risk for contracture development. The resident repeatedly refused Restorative Nursing Aide (RNA) services for left leg ROM exercises from February 2024 to January 2025. Despite these refusals, the facility did not ensure the resident received skilled therapy services to maximize joint ROM and maintain functional abilities. The resident, who was initially admitted in 2019 and readmitted in 2023, had diagnoses including left hemiplegia and traumatic brain injury. A physician's order from August 2023 required RNA to assist the resident with passive range of motion (PROM) exercises to the left hip and ankle five times a week. However, the RNA documentation from February 2024 to January 2025 consistently showed that the resident refused these exercises. Despite the refusals being documented, the facility failed to initiate timely interventions or consult PT for re-assessment and modification of the RNA program. Interviews with facility staff revealed that the Rehabilitation Department was not informed of the resident's continuous refusals until August 2024, six months after the refusals began. The Director of Staff Development confirmed that a Change of Condition (COC) should have been initiated in February 2024, and PT should have been consulted. The facility's failure to address the resident's refusals and provide appropriate skilled therapy services resulted in the resident not receiving the necessary care to prevent a decline in ROM and functional abilities.
Incomplete Physician Orders for Splint Application
Penalty
Summary
The facility failed to ensure that a resident had complete and accurate physician's orders for the application of splints. The orders for the resident's bilateral knee extension splints, left elbow extension splint, and left resting hand splint did not specify the designated staff member responsible for applying the splints or the splint wear time. This omission led to confusion and incomplete documentation regarding the care and services provided to the resident. The resident, who was admitted with diagnoses including muscle wasting, atrophy, and chronic obstructive pulmonary disease, was cognitively intact and required assistance with various activities of daily living. The resident reported that staff had not applied the splints as expected, which was confirmed during an observation where the resident's limbs were not in the correct position. Interviews with the Director of Rehabilitation and the Director of Nursing revealed that the orders were unclear and could lead to unqualified staff applying the splints improperly, potentially causing harm. The facility's policy and procedure for orthotic application required that therapy assess the resident for appropriate splints and establish a wear schedule, which should be documented clearly in the physician's orders. However, the orders for the resident in question did not meet these requirements, leading to a lack of clarity and potential risk for the resident. The facility's documentation guidelines emphasized the need for complete and accurate records to facilitate communication among the interdisciplinary team, which was not achieved in this case.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program for a resident by not ensuring that a Certified Nursing Assistant (CNA) wore an isolation gown when providing high-contact care. The resident was on enhanced barrier precautions (EBP) to prevent the spread of multidrug-resistant organisms. Despite the presence of an EBP sign outside the resident's room, the CNA entered without a disposable gown and proceeded to change the resident's soiled incontinence brief without adhering to the required precautions. Additionally, the CNA did not provide proper perineal care to the resident. The CNA cleaned only the outside of the resident's perineal area and failed to clean the labia minora or urethra, which is essential to prevent urinary tract infections. The CNA also improperly discarded contaminated linens and incontinence briefs by opening the door with contaminated gloves to discard them in the hallway, further risking cross-contamination. The Director of Staff Development and the Director of Nursing confirmed the importance of following proper procedures, including wearing gowns in EBP rooms and correctly discarding soiled items to prevent infection spread. The facility's policies on Enhanced Barrier Precautions, Laundry, and Perineal Care were reviewed, indicating the need for gowns during high-contact care and proper handling of soiled laundry to prevent infection transmission.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for a resident who did not meet the McGeer criteria for infection surveillance. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was ordered Levaquin for UTI prophylaxis despite not exhibiting clinical manifestations of an infection. The order was made by a Nurse Practitioner without clarifying with the physician, who had previously advised waiting for culture results before prescribing antibiotics. The resident's lab results showed a high white blood cell count, but not high enough to meet the criteria for antibiotic treatment. Despite this, the resident received Levaquin on two occasions before culture results indicated resistance to the prescribed antibiotic. The Infection Preventionist and Director of Nursing both stated that antibiotics should only be administered when minimum criteria are met to prevent antibiotic resistance, which was not the case here. The facility's policy on antibiotic stewardship emphasizes the importance of monitoring antibiotic use and ensuring that lab results and clinical situations are communicated to prescribers before starting or continuing antibiotic therapy. However, in this instance, the protocol was not followed, leading to the inappropriate administration of antibiotics to the resident.
Resident Found with Firearm in LTC Facility
Penalty
Summary
The facility failed to ensure the safety of its residents, staff, and visitors by allowing a resident to possess a firearm within the premises. The deficiency was identified when a gun was discovered in the belongings of a resident who had passed away. The resident, who had been admitted with diagnoses including major depressive disorder, opioid dependence, and suicidal ideations, was found to have a firearm in a bag beside the nightstand in their room. The facility's policy prohibits firearms and other weapons, yet there were no signs posted to indicate this prohibition. The resident's admission records and assessments indicated they had the mental capacity to make medical decisions and required supervision for activities of daily living. Despite this, the facility did not detect the presence of the firearm until after the resident's death. Interviews with staff revealed that the gun was found during postmortem care and was subsequently secured by the facility's administration. The incident highlighted a lapse in the facility's procedures for checking residents' belongings, as noted by the medical doctor, who emphasized the danger posed by the firearm to the resident and others in the facility.
Failure to Develop Individualized Care Plan for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who had an Out on Pass (OOP) order and a diagnosis of suicidal ideations. The resident was admitted with major depressive disorder, opioid dependence, and suicidal ideations, and had the mental capacity to make medical decisions. Despite these diagnoses, the care plan did not include specific interventions for the resident's suicidal ideations or a plan for when the resident returned from OOP. This lack of a personalized care plan resulted in staff not knowing what interventions to implement upon the resident's return from OOP. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), revealed that the care plan should have been individualized based on the resident's needs and diagnoses. The staff acknowledged that the care plan should have included monitoring for verbalization of suicidal ideation, mood changes, and increased supervision. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, which were not developed for this resident, potentially affecting the resident's well-being.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,751 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coral Cove Post Acute | 0 mi | ★★★★★ | 45 | 0 |
| Marlora Post Acute Rehab Hosp | 0.4 mi | ★★★★★ | 31 | 1 |
| Pacific Palms Healthcare | 0.5 mi | ★★★★★ | 41 | 0 |
| Shoreline Healthcare Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Bel Vista Healthcare Center | 0.7 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ocean Ridge Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.