Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Olympia Convalescent Hospital during CMS and state inspections, most recent first.
A resident with dementia, documented lack of decision-making capacity, and recent hospital 1:1 sitter for confusion and exit-seeking was admitted ambulatory, anxious, and repeatedly expressing a desire to leave. The facility’s wandering/elopement assessment inconsistently scored the resident as low risk overall despite observable wandering that was not easily redirected, and the care plan calling for evaluation for increased supervision and close monitoring was not effectively implemented. Staff documented multiple episodes of agitation, wandering, and attempts to exit through various doors, yet 1:1 monitoring was discontinued after a Wanderguard was applied, no CNA was specifically assigned to monitor the resident on the morning of the incident, and no new interventions were added despite escalating behaviors. The sliding door in the resident’s room and other rooms opened to a patio with gates to public streets and lacked alarms or integration with the Wanderguard system; on the morning of the elopement, the resident was last seen in the room, later found missing with the sliding door ajar, and was not captured on CCTV exiting through main doors. The resident was subsequently located offsite by EMS with severe burn and trauma injuries and later died at a hospital, and surveyors cited the facility under F689 for failure to prevent elopement and provide adequate supervision.
Two residents with significant medical and cognitive impairments experienced changes in condition and tested for COVID-19, with one confirmed positive. The DON verified that these cases, occurring within a short timeframe, were not reported to the State Agency as required by the facility's infection control policy.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A deficiency was cited when a nursing home area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, and oversight was insufficient to ensure resident safety.
The facility did not complete required annual performance evaluations, skills competencies, or maintain up-to-date training records for nurses, CNAs, and housekeeping staff. Staff interviews and record reviews revealed missing or expired licenses, training, and documentation, with leadership confirming that employee files were incomplete or not maintained as required.
Surveyors found that food was stored on cracked and rusted shelves in the walk-in refrigerator, with ready-to-cook items placed directly on or under these surfaces. Multiple staff, including the dietary supervisor and administrator, confirmed the racks were rusty and needed replacement, in violation of the facility's food storage policy.
Essential equipment in both patient bathrooms and the kitchen was not maintained in safe operating condition, including broken toilets, running faucets, and damaged or missing kitchen equipment such as the ice maker, food warming trays, and refrigerator racks. Staff confirmed these issues had persisted for days to weeks, with no formal documentation or timely repairs, despite facility policies requiring safe and operable equipment.
Two residents with urinary catheters did not have their catheter bags covered with dignity bags, leaving the bags visible in their rooms. Both residents had significant medical and cognitive impairments and required extensive assistance. Staff interviews and facility policy confirmed that catheter bags should be covered to maintain privacy and dignity, but observations showed this was not done.
A resident with multiple chronic conditions was found with a topical corticosteroid cream at the bedside, which staff had not assessed for self-administration capability nor obtained a physician's order for. The LVN was unaware of the medication, and the DON confirmed that facility policy requires assessment and secure storage for self-administered medications, which was not followed in this case.
A resident with cognitive impairment and multiple chronic conditions experienced a significant change in urinary status, but staff failed to complete and document a required change of condition (COC) assessment as per facility policy. This omission was confirmed through interviews and record review, indicating a lapse in timely monitoring and communication among the care team.
A resident with new diagnoses of dementia, anxiety disorder, and Alzheimer's disease did not receive a required PASRR Level I screening upon readmission, and the mental health agency was not promptly notified. Additionally, care plans addressing these diagnoses were not developed, and staff interviews revealed confusion about responsibility for completing the PASRR process.
A resident with a history of diabetes, TIA, and dysphagia was admitted with a g-tube, but staff did not initiate a care plan for g-tube feeding as required by facility policy. Interviews with nursing staff confirmed that the absence of a care plan left staff without necessary guidelines for monitoring and managing the resident's g-tube care needs.
The facility did not provide the required minimum of 80 square feet per resident in 11 multiple-occupancy rooms, with measurements showing as little as 44.4 square feet per resident. Despite observations indicating sufficient space for movement and care, the documented room sizes did not meet federal standards.
A resident with cognitive impairments sustained multiple rib fractures of unknown origin, and the facility failed to report the injury to the SSA within the required 24-hour period. Despite the resident's severe pain and confirmed fractures, the facility delayed reporting until a second opinion was obtained, contrary to their policy requiring immediate reporting of such incidents.
A resident with a history of aggression physically assaulted another resident, causing injury. Despite documented aggressive behavior and interventions like medication and room changes, the facility failed to prevent the incident, resulting in harm to a resident with severe cognitive impairment and physical dependencies.
A resident with dementia and high elopement risk left the facility unsupervised despite wearing a wander guard bracelet. The alarm was triggered but not properly addressed by staff, leading to the resident's elopement. The resident was later found by police and returned without injury. Staff interviews revealed a lack of immediate response to the alarm, contributing to the incident.
A resident with dementia and high elopement risk left the facility unsupervised despite wearing a wander guard bracelet. The alarm was triggered, but staff did not respond immediately. The resident was found hours later by police. The facility's policy on elopement risk was not effectively implemented, leading to the resident's unsupervised departure.
The facility failed to treat residents with dignity and respect by referring to those needing feeding assistance as 'feeders.' This term was used by multiple staff members, including the CNA, ADSD, and DSD, and a list labeled 'RNA FEEDERS' was posted in the dining area. The DON later acknowledged the issue and removed the list.
The facility failed to maintain proper records and documentation for pharmaceutical services, including the usage and inventory of emergency medication supplies and the automated dispensing cabinet (STATSAFE). Additionally, the administration of a controlled substance to a resident was not documented in the electronic medication administration record (eMAR).
The facility failed to provide effective dietetic service oversight due to the dietary manager not meeting state and federal requirements and the registered dietitian working on a consulting basis. This led to issues with staff competency, food safety, and therapeutic diet accuracy.
The facility failed to ensure kitchen staff were trained and evaluated for competency, leading to the use of incorrect sanitizer test strips and improper preparation of pureed diets. The Dietary Manager confirmed the lack of recent training and documentation.
The facility failed to follow standardized recipes and portion sizes for lunch, resulting in residents receiving incorrect meals and portions. This discrepancy was observed during lunch preparation and tray line service, and both cooks admitted to not following the menu due to a lack of ingredients. The dietary manager and registered dietitian confirmed the deviations and emphasized the potential impact on residents' nutritional intake.
The facility failed to provide the correct food textures for residents on finely chopped, minced, and pureed diets, serving inconsistent and large pieces of meat and soupy rice instead of the required textures. This was confirmed by the Registered Dietitian, Speech Therapist, and Dietary Manager, posing a risk for residents with chewing and swallowing difficulties.
The facility failed to ensure safe and sanitary food storage and preparation practices, including expired food items in the refrigerator, unsanitary ice machine conditions, improper storage of scoops in bulk food containers, and a banana left on top of a resident's closet. These deficiencies pose risks of foodborne illness and contamination.
The facility failed to monitor signs and symptoms of a UTI and did not irrigate an indwelling catheter as required for a resident with bladder neck obstruction and other diagnoses. Staff did not notify the MD when the resident developed cloudy urine with sediment, leading to a potential UTI and blocked catheter.
A facility failed to date a resident's Isosource bag used for G-tube feeding, despite multiple observations and the resident's significant weight loss and swallowing disorder. The LVN admitted to not dating the bag, contrary to facility policy and manufacturer's guidelines.
The facility failed to document the range of motion treatment for a resident on multiple occasions, despite the resident's need for assistance with self-care, mobility, and cognition. Staff interviews and record reviews revealed missing documentation and inconsistencies with the facility's policies and procedures.
The facility failed to implement its hand hygiene policy, with a CNA and an LVN not sanitizing hands between resident interactions. Additionally, a urinal in a resident's room was not labeled, risking cross-contamination. Both staff members acknowledged their lapses, and the DON and IPN emphasized the importance of these protocols.
A resident with severe cognitive impairment and hemiparesis had their call light out of reach, contrary to facility policy. The CNA responsible admitted to not checking the call light's placement, and the DON emphasized the importance of call light accessibility for resident safety.
The facility failed to provide at least 80 square feet per resident in 24 out of 35 resident rooms, with measurements ranging from 73.0 to 78.9 square feet per resident. Despite claims that the room sizes would not interfere with care or safety, the facility was in violation of federal regulations.
Failure to Assess, Supervise, and Secure Environment Leads to Fatal Elopement
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and manage an elopement risk for a newly admitted resident with dementia, confusion, and documented lack of decision-making capacity. The resident had been admitted from an acute hospital where psychiatry documented that the resident was oriented only to self, required constant redirection, and had a 1:1 sitter due to frequent attempts to get out of bed. On admission to the facility, the resident was ambulatory, anxious, frequently expressed a desire to leave, and was identified on a Change of Condition form as an elopement risk. A Wandering & Elopement Risk Assessment completed that morning documented recent observable wandering that was not easily redirected and classified the resident as a moderate elopement risk in one section, but the overall risk score section indicated a Low Probable Risk. RN 2 later stated this assessment was inaccurate and should have reflected a Moderate Actual Risk. The facility developed an Elopement Risk/Wanderer care plan that identified the resident as at risk for wandering due to exit-seeking behavior, new admission status, and verbalizations of wanting to leave. The care plan included goals that the resident would not leave unattended and that safety would be maintained, with interventions such as walking with the resident, redirecting inappropriate behaviors, evaluating the need for additional supervision, and providing close monitoring. Despite this, the facility did not implement continuous or close supervision in response to the resident’s escalating behaviors. Nursing documentation and interviews showed that during the day and evening shifts, the resident had multiple episodes of wandering, agitation, and attempts to exit the facility, including attempts to leave through the front lobby, laundry room, kitchen exit doors, and at least one prior exit to the back patio and another exit from the facility where staff had to bring the resident back inside. Staff reported that 1:1 monitoring used earlier was discontinued once a Wanderguard device was applied, and no CNA was specifically assigned to monitor the resident for safety on the morning of the elopement. The facility also failed to identify and control environmental exit routes associated with the resident’s room and the back patio. The sliding door in the resident’s room, as well as sliding doors in several other rooms, opened onto an outside patio and did not have alarms or devices connected to the Wanderguard system. Maintenance staff confirmed that these sliding doors lacked alarms and that the patio had two gates leading to public streets that could be opened from the inside. On the morning of the elopement, the resident was last seen in the room around breakfast time, ambulatory and changing clothes, and was left unattended while staff attended a huddle. When the nurse entered the room later to administer medications, the resident was missing and the balcony sliding door and screen were found slightly open. A facility-wide search and review of CCTV did not show the resident exiting through the main entrance or other doors, indicating the resident likely exited through the unsecured sliding door and patio area. The resident was later found offsite by emergency responders with severe burn and trauma injuries, and subsequently died at an acute care hospital. The facility did not revise or strengthen elopement interventions despite repeated and escalating exit-seeking behaviors documented across multiple shifts. Nursing notes, MAR entries, and SBAR documentation showed numerous episodes of anxiety, agitation, wandering, and attempts to elope, with staff notifying supervisors and the physician but receiving no new orders and documenting no additional interventions beyond the Wanderguard. The facility did not reassess the resident’s elopement risk classification to reflect the actual behaviors, did not implement continuous visual observation or enhanced supervision as outlined in the care plan, and did not recognize or mitigate the risk posed by the unalarmed sliding door and patio gates. These combined assessment, care planning, supervision, and environmental safety failures resulted in the resident eloping from the facility without staff knowledge and being found later in the community with fatal injuries. State surveyors determined that these failures constituted noncompliance with F689 at an Immediate Jeopardy level when identified, based on the facility’s failure to properly supervise the resident and to have effective interventions in place to prevent elopement. The Immediate Jeopardy was later removed after submission and verification of an Immediate Jeopardy Removal Plan, but the facility remained out of compliance at a scope and severity level G, indicating actual harm had occurred.
Failure to Report COVID-19 Cases to State Agency
Penalty
Summary
The facility failed to follow its infection control policy and procedure by not reporting positive COVID-19 cases to the State Agency for two of three sampled residents. One resident, with diagnoses including diabetes mellitus, hypertension, hyperlipidemia, and major depressive disorder, had severe cognitive impairment and required significant assistance with daily activities. This resident experienced a change in condition with a fever, was tested for COVID-19 (result negative), transferred to the hospital, and later readmitted and tested for COVID-19 upon return. Another resident, with abnormalities of gait and mobility, hypertension, hyperlipidemia, and anemia, and moderate cognitive impairment, also required substantial assistance and was found to be COVID-19 positive after a change in condition. The Director of Nursing confirmed that these cases occurred within seven days of each other and acknowledged that they should have been reported to the State Agency, as required by the facility's infection prevention and control program policy. The policy specifically states the duty to notify appropriate government agencies of reportable contagious or infectious diseases. The failure to report these cases constituted a breach of the facility's established infection control procedures.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision measures were insufficient to prevent potential accidents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of appropriate oversight in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Complete Annual Staff Evaluations, Competencies, and Trainings
Penalty
Summary
The facility failed to ensure that nurses, nurse aides, and housekeeping staff had completed required annual performance evaluations, skills competencies, and trainings. Interviews with staff members revealed that several could not recall the last time they completed annual evaluations, skills competencies, or specific trainings such as sexual harassment, abuse prevention, fire safety, or CPR. Record reviews confirmed that employee files were missing documentation of current licenses, annual evaluations, skills competencies, training records, vaccination records, and background checks for multiple staff members, including both nursing and housekeeping personnel. The Director of Staff Development and the Administrator acknowledged that all employee files should be kept up to date and maintained on site, but files for both facility-employed and contracted staff were incomplete or missing required documentation. The facility's own policy indicated that performance evaluations should be conducted annually or as needed, but this was not consistently followed. The lack of up-to-date employee files and missing documentation for required trainings and competencies affected all reviewed staff, including nurses, CNAs, and housekeeping staff. This deficiency was identified through interviews, record reviews, and policy review, with staff and leadership confirming the importance of maintaining current records to ensure staff competency and compliance with facility requirements.
Unsanitary Food Storage Due to Rusted Refrigerator Shelves
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices in the kitchen, specifically in the walk-in refrigerator where four shelves were found to be cracked and rusted. Ready-to-cook foods were stored on or directly under these rusted shelves. Multiple staff members, including the dietary supervisor and the administrator, acknowledged that the racks in the refrigerator were rusty and needed replacement. The facility's policy and procedures for food storage, reviewed earlier in the year, required food items to be stored, thawed, and prepared in accordance with good sanitary practice, which was not followed in this instance.
Failure to Maintain Safe Operating Condition of Resident and Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition in both patient care areas and the kitchen. Observations revealed that two sampled patient bathrooms had significant issues: one bathroom had a toilet that ran constantly after flushing and a very loose, broken toilet seat, while another had a hot water faucet that would not turn off and a discolored, broken toilet seat. The maintenance aide, who had been employed for one month, confirmed these issues during rounds but did not have documentation or records of repairs or daily rounds. Maintenance repair logs at the nurses' stations did not contain any repair requests for these issues. Both the maintenance aide and a housekeeper acknowledged the danger posed by broken toilet seats, including the risk of resident falls and injury. In the kitchen, multiple pieces of equipment were found to be in disrepair. All four racks in the main refrigerator were rusty, the ice maker was not working, one of four food warming trays was broken and had been nonfunctional for four weeks, and one of three food preparation tables was unsteady and appeared weak. Additionally, one food preparation table was missing, and there was no light in the walk-in freezer. Staff interviews confirmed that the ice maker had been broken for several days without ice being purchased, and the broken food warmer and missing table had not been addressed for weeks. The maintenance aide was aware of these issues but did not keep formal records, relying instead on informal notes and awaiting approval for replacements. Facility policies reviewed indicated that the maintenance department is responsible for keeping all areas, equipment, and grounds in safe and operable condition at all times. The policies also require the development and maintenance of a schedule for maintenance services and the prompt repair or replacement of equipment to ensure safety. Despite these policies, the lack of documentation, delayed repairs, and ongoing equipment failures in both resident and dietary areas contributed to the deficiencies identified during the survey.
Failure to Cover Urinary Catheter Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents by not ensuring that their urinary catheter bags were covered with privacy (dignity) bags. For one resident, who was admitted with acute kidney failure, encephalopathy, and hypertension, and was cognitively impaired and required extensive assistance with activities of daily living, observations revealed that the urinary catheter bag was hanging from the bed frame without a dignity cover. Both a CNA and a treatment nurse confirmed during interviews that the catheter bag should have been covered to maintain the resident's privacy and dignity, and the DON acknowledged that the lack of a dignity bag could affect the resident's psychosocial wellbeing. For another resident, who had a pressure ulcer, depression, and severely impaired cognition, the care plan specifically indicated that the indwelling Foley catheter should remain in a privacy bag at all times. However, observation showed the catheter bag was full and visible to anyone entering or passing by the room. The resident's CNA, the Director of Staff Development, and the DON all stated in interviews that the catheter bag should have been covered for privacy and dignity. A review of facility policies and in-service training materials confirmed that staff were instructed on the importance of providing privacy and dignity to residents, including the use of dignity bags for catheter care. Despite these policies and training, the facility did not ensure that the dignity bags were in place for the two residents, resulting in a failure to provide care in a manner that maintained or enhanced their dignity and respect.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident was properly assessed and determined capable of self-administering medication that was left at the bedside, and did not obtain a physician's order for self-administration. The resident, who had diagnoses including atrial fibrillation, hypertension, congestive heart failure, type 2 diabetes, and peripheral vascular disease, was found to have a tube of triamcinolone acetonide cream at the bedside. The resident reported using the cream for itching and stated it was prescribed by a physician, but later indicated that a family member had brought the cream to the facility. Staff interviews revealed that the LVN was unaware of the medication at the bedside and confirmed there was no physician's order for self-administration. The DON stated that medications should only be kept at the bedside if the resident has been assessed as capable and has a physician's order, and that such medications should be stored in a locked container. Facility policy requires assessment by the IDT and a physician's order before allowing self-administration, with medications to be kept securely. These procedures were not followed in this instance.
Failure to Complete Change of Condition Assessment and Documentation
Penalty
Summary
The facility failed to complete a change of condition (COC) assessment in accordance with its policy and procedures for one resident. Specifically, a cognitively impaired resident with diagnoses including diabetes, dementia, and hypertension was observed to have urine with sediments and clumps, which was identified as a significant change from baseline. Despite this observation, there was no documented evidence that a COC assessment was completed at the time the change was noticed, as required by facility policy. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that a COC should have been completed immediately upon identification of the change to ensure timely monitoring and intervention. The facility's policy requires prompt reporting and documentation of signs and symptoms that may represent an acute change of condition, as well as timely notification of the resident, physician, and legal representative. The failure to complete the COC assessment and documentation as outlined in the policy had the potential to delay necessary care for the resident. The deficiency was identified through interviews and record reviews, which confirmed the lack of required documentation and adherence to established procedures.
Failure to Complete PASRR Screening and Develop Care Plans for Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level I assessment for a resident upon readmission, despite the resident having new diagnoses of dementia, anxiety disorder, and Alzheimer's disease. The facility also did not promptly notify the mental health agency after these diagnoses were made, nor did it develop care plans addressing the resident's dementia, anxiety disorder, or Alzheimer's disease. These actions were identified through interviews and record reviews, which showed that the PASRR Level I screening was not completed as required by facility policy, and that there was confusion among staff regarding responsibility for completing the PASRR process. The resident in question had a history of Alzheimer's disease, unspecified dementia, major depressive disorder, and anxiety disorder, and was noted to have severely impaired cognition and lacked capacity to make decisions. Despite these significant mental health diagnoses and cognitive impairments, the facility's documentation did not reflect the completion of required assessments or the development of care plans tailored to the resident's needs. Interviews with the MDS Coordinator, MDSC Assistant, and DON confirmed that the PASRR Level I was not completed and that care plans for the new diagnoses were not created.
Failure to Initiate G-Tube Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a gastrostomy tube (g-tube) in accordance with its own care planning policy and procedures. Upon admission, the resident, who had a history of diabetes, transient ischemic attack, and dysphagia, was identified as having a g-tube for feeding due to swallowing difficulties. Record reviews showed that the resident was cognitively impaired, required moderate to total assistance with activities of daily living, and was incontinent of bowel and bladder. Despite these complex needs, there was no care plan initiated for the g-tube feeding upon admission. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed that a care plan for the g-tube should have been created at the time of admission to guide staff in providing appropriate care, such as monitoring for patency, aspiration precautions, infection prevention, and managing bloating. The absence of a care plan meant that staff lacked clear guidelines for the resident's g-tube care, which was not in accordance with the facility's policy requiring a comprehensive, person-centered care plan for each resident based on their assessed needs.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms for 11 out of 39 rooms, each containing three beds. Record review and room measurements confirmed that these rooms ranged from 44.4 to 78.9 square feet per resident, all below the federal requirement. The deficiency was identified through observation, interviews, and review of facility documentation, including a waiver request letter and a client accommodations analysis submitted by the administrator. The waiver letter stated that the room sizes would not interfere with daily nursing care, safety, or residents' dignity and privacy, and that there was sufficient space for care and equipment. During general observations, it was noted that residents had ample space to move freely within the rooms, and there was enough space for beds, side tables, and care equipment. However, the documented square footage per resident in these rooms did not meet the federal minimum standard for multiple occupancy rooms, which is 80 square feet per resident. The report does not mention any specific adverse effects on residents' health or safety at the time of the survey.
Failure to Timely Report Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its Unusual Occurrence Reporting policy by not reporting a resident's injury of unknown cause to the State Survey Agency (SSA) within the required 24-hour timeframe. The resident, who was confused and had a history of Alzheimer's Disease, dementia, glaucoma, and osteoporosis, sustained multiple left rib fractures. The injury was discovered after the resident complained of severe pain, and an x-ray confirmed the fractures. Despite the policy requiring immediate reporting of such injuries, the facility delayed reporting until they received a second opinion on the x-ray results. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Staff Development, revealed that the staff was unaware of how the injury occurred, and the resident was unable to communicate the cause due to cognitive impairments. The Administrator acknowledged the delay in reporting, stating that the injury was considered of unknown origin and should have been reported within 24 hours. The facility's policy mandates that unusual occurrences be reported to the appropriate agency by telephone within 24 hours and confirmed in writing, which was not followed in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, who had a known history of aggressive behavior. Resident 2, who had been previously aggressive towards other residents and staff, physically assaulted Resident 1 by hitting him several times on the left side of the face, resulting in a scratch on the chin and bleeding. Despite Resident 2's documented history of aggression, including attempts to strike others and verbal aggression, the facility did not adequately prevent the incident from occurring. Resident 1, who was admitted with severe cognitive impairment and physical dependencies due to conditions such as hemiplegia and atrial fibrillation, was unable to defend himself against the attack. The facility's records indicated that Resident 1 was dependent on staff for basic activities and had a care plan addressing the risk of emotional distress, but this was only initiated after the incident. The facility's failure to anticipate and mitigate the risk posed by Resident 2's behavior resulted in harm to Resident 1. Resident 2's aggressive behavior was documented in care plans and psychiatric evaluations, which noted episodes of mood disorder and aggression. Despite this, the facility's interventions, such as medication and room changes, were insufficient to prevent the assault on Resident 1. The facility's policy on abuse prevention emphasized the right of residents to be free from abuse, yet the measures in place did not effectively protect Resident 1 from harm.
Failure to Prevent Resident Elopement Due to Inadequate Response to Alarm
Penalty
Summary
The facility failed to prevent the elopement of a resident who was assessed as high risk for elopement and had a wander guard bracelet. On the specified date, the resident left the facility unsupervised and unnoticed by staff, despite the wander guard alarm being triggered. The alarm emitted an audible sound for 43 seconds, but no staff responded to it. The resident was later found by the police and returned to the facility without injury. The resident had been admitted with diagnoses including dementia, delusional disorders, and psychosis, and was assessed as having severely impaired cognitive skills. The care plan for the resident included the application of a wander guard bracelet and monitoring for wandering behavior every shift. However, on the day of the incident, the alarm was not properly addressed by the staff, leading to the resident's elopement. Interviews with staff revealed that the licensed vocational nurse was on a lunch break when the incident occurred, and the medical record director, who was covering the front desk, did not inform anyone about the triggered alarm. The director of nursing confirmed that the alarm should have prompted an immediate response from all staff, but this did not happen, resulting in the resident leaving the facility unsupervised.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was assessed as high risk for wandering and elopement. The resident, diagnosed with dementia, delusional disorders, and psychosis, was wearing a wander guard bracelet designed to emit an audible alarm if the resident attempted to leave the facility. On the day of the incident, the resident managed to exit the facility through the front door, triggering the wander guard alarm. However, the staff did not respond immediately to the alarm, allowing the resident to leave the premises unsupervised. The incident occurred while the licensed vocational nurse (LVN) was on a lunch break, and the medical record director (MRD) was covering the front desk. The MRD, who was on a phone call at the time, did not see the resident leave and mistakenly thought the alarm was triggered by a different door. Despite resetting the alarm, the MRD did not inform other staff members about the alarm or take immediate action to investigate the cause. As a result, the resident was not found until the police were notified and located the resident several hours later. The facility's policy on wandering and elopement, which emphasizes the importance of identifying residents at risk and minimizing injury, was not effectively implemented. The director of nursing (DON) confirmed that staff should have responded promptly to the alarm and communicated with each other to ensure the resident's safety. The lack of immediate response and communication among staff members contributed to the resident's unsupervised departure from the facility.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that seven sampled residents were treated with dignity and respect, as staff referred to them as 'feeders.' This term was used to describe residents who required assistance with eating, including Residents 28, 61, 3, and 7. Resident 28, who had severe cognitive impairment and required significant assistance with daily activities, was observed being referred to as a 'feeder' by a Certified Nurse Assistant (CNA). Similarly, during a dining observation, Residents 61, 3, and 7 were also referred to as 'feeders' by the Assistant Director of Staff Development (ADSD) and the Director of Staff Development (DSD). The DSD even maintained a list labeled 'RNA FEEDERS' in the dining area to identify residents needing feeding assistance. The Director of Nursing (DON) later acknowledged that residents should not be called 'feeders' under any circumstance and stated that staff would be trained to respect residents and avoid using derogatory terms. The DON removed the list of residents labeled as 'feeders' from the dining hall. However, the initial use of the term and the posting of the list demonstrated a failure to treat residents with the dignity and respect they deserve, potentially causing them humiliation and embarrassment.
Failure to Maintain Proper Pharmaceutical Records and Documentation
Penalty
Summary
The facility failed to maintain proper records and documentation for pharmaceutical services, specifically regarding the usage and inventory of emergency medication supplies and the automated dispensing cabinet (STATSAFE). The STATSAFE was used for accessing emergency medication supplies and first doses, but the facility did not keep a logbook of its activity. The Director of Nursing (DON) confirmed that the STATSAFE did not have a printer attached and that the facility did not keep a record of its activities. Additionally, the DON stated that any controlled substances activity at the STATSAFE required a call to the pharmacy to verify the order and obtain a code, but it was observed that access could be gained without this prompt. The DON also admitted to not receiving any STATSAFE reports from the pharmacy and not keeping records of resolved discrepancies. For Resident 70, there was a failure to document the administration of a controlled substance (Ativan) in the electronic medication administration record (eMAR). The lorazepam count sheet indicated a dose was removed, but the eMAR did not reflect this administration. The nurse responsible for administering the medication confirmed that she forgot to document it. The facility's policies and procedures for medication administration and STATSAFE activities were not followed, as evidenced by the lack of documentation and record-keeping. The facility's emergency pharmacy service and emergency kits policy did not align with the observed practices, further contributing to the deficiencies noted in the report.
Deficient Dietetic Service Oversight
Penalty
Summary
The facility failed to provide effective dietetic service oversight when the dietary manager did not meet the state and federal requirements for the position, and the registered dietitian worked on a consulting basis. This resulted in lapses in the delivery of food services associated with staff competency, safe and sanitary food storage and food preparation practices, and therapeutic diet texture accuracy, wrong portion sizes, and not following the menu. During the annual recertification survey, multiple issues were identified, including the oversight of food safety, sanitation, and storage of food in the kitchen, the evaluation of dietary staff competency, and the overall evaluation of food production in relation to therapeutic diets, puree diets, portion control, and following the menu. The dietary manager, who had a certification from an accredited certified dietary manager program, did not receive the required six hours of in-service training on the specific California dietary service requirements. The registered dietitian, who was new to the facility and worked once a week, was not aware of the identified concerns in the kitchen. The dietary manager admitted to not knowing about the need for the six-hour training and acknowledged issues with missing ingredients and incorrect menu items for pureed diets. The facility's job description for the Supervisor of Food Service indicated responsibilities that were not being met, contributing to the deficiencies observed during the survey.
Deficiencies in Kitchen Staff Training and Food Preparation
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties. Dishwasher 1 (DW1) and Dietary Aide 1 (DA1) were observed using the wrong sanitizer test strip for the dish machine sanitizer. Both staff members were using a QUAT sanitizer test strip instead of the required chlorine test strip. The Dietary Manager (DM) confirmed that there had been no recent training or in-services on checking dish machine sanitizer effectiveness and test strips. Additionally, the dish machine sanitizer log lacked documentation of checks, indicating a lapse in proper sanitation practices. Cook 1 did not follow the menu and standardized recipes when preparing a pureed diet. During an observation, Cook 1 was found to be boiling tofu and rice instead of following the prescribed menu, which included Bean Dregs Stew with blanched zucchini and steamed rice. Cook 1 also did not add thickener to the pureed rice, resulting in a soupy and thin liquid consistency. The Registered Dietitian (RD) and Speech Therapist (ST) confirmed that the pureed rice did not meet the required texture standards, which should be smooth and pudding-like. The Dietary Manager (DM) admitted that there were no recent training sessions or in-services on puree diet preparation or following the menu and recipe. The facility's in-service records for 2024 showed no documentation of training on these topics. The DM acknowledged the deficiencies and stated that in-service training would be provided to address these issues. However, the lack of routine staff competency evaluations and proper training led to these deficiencies in food safety and diet preparation.
Failure to Follow Standardized Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure that standardized recipes and portion sizes for the lunch menu were followed on 4/29/24. Specifically, 15 residents on a pureed diet did not receive the prescribed pureed pork and kimchi stew and pureed zucchini; instead, they were served pureed tofu and pureed peas. Additionally, 24 residents on a regular diet and 18 residents on a mechanical soft diet received only 3 ounces of pork and kimchi stew instead of the 6 ounces specified in the menu. This discrepancy was observed during lunch preparation and tray line observation, and it was confirmed through interviews with the cooks and the dietary manager (DM). The DM acknowledged that the pureed food did not match the regular menu and that the portion sizes were incorrect, which could lead to decreased nutritional intake and potential weight loss among residents. During an observation in the kitchen, Cook 1 was seen preparing pureed tofu with vegetables and pureed peas instead of the prescribed menu items. Cook 1 admitted to not following the recipe for the Korean food menu because she did not have the necessary ingredients and was not responsible for the Korean food menu. Cook 2, who was responsible for the regular and mechanical soft diet on the Korean food menu, also admitted to not following the recipe due to a lack of ingredients. Both cooks stated that the DM was aware of these deviations from the menu. The registered dietitian (RD) confirmed that the lunch menu and ingredients were changed without her approval and emphasized that cooks should always follow the menu. During the tray line service, it was observed that residents on a pureed diet received 4 ounces of pureed tofu instead of the 5 1/3 ounces specified in the menu, and residents on regular and mechanical soft diets received only 3 ounces of pork and kimchi stew instead of 6 ounces. The DM confirmed that the portion sizes were incorrect and acknowledged that serving less food could lead to reduced nutritional intake and weight loss. Both Cook 1 and Cook 2 admitted to using incorrect portion sizes, and the RD reiterated that serving smaller portions could result in weight loss among residents.
Failure to Provide Correct Food Textures for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure that 12 residents on a finely chopped diet and 14 residents on a minced diet received meat in the appropriate texture as per their dietary needs. During meal preparation, the cook served regular diet meat with inconsistent sizes and large chunks instead of the required finely chopped or minced forms. This was observed during a meal preparation and tray line service, where residents on modified diets received pork and kimchi stew with large pieces of pork and kimchi, contrary to the menu specifications. The Registered Dietitian and Speech Therapist confirmed that the served food did not meet the required texture, posing a risk for residents who have difficulty chewing or swallowing. The Dietary Manager acknowledged the error and noted that the kitchen did not serve the correct texture diet for these residents, which could lead to choking hazards. Additionally, 15 residents on a pureed diet received rice that was thin and soupy instead of having a smooth, pudding-like consistency. During the tray line service, it was observed that the cook added liquid to the rice because it did not blend well, resulting in a thin consistency. The Registered Dietitian and Speech Therapist confirmed that the pureed rice was not served at the correct texture, which could pose a risk for residents who require thicker pureed food to prevent aspiration. The Dietary Manager admitted that the pureed rice was not prepared correctly and stated that an in-service would be provided to the cooks on diet textures. The facility's policies on mechanical or dental soft, finely chopped, and pureed diets were reviewed and indicated specific requirements for food textures that were not met. The policies outlined that finely chopped foods should be the consistency of coleslaw, minced foods should be ground, and pureed foods should be smooth and pudding-like. The facility's portion and serving guide also specified the correct textures for different diets, which were not adhered to during the meal preparation and service observed on the specified date.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices. During an observation in the kitchen, a small container of previously cooked rice and a small container of cooked meat with an expired use-by date were found in the reach-in refrigerator. Additionally, a container of milk with an open date exceeding the storage period was also stored in the refrigerator. Nutritional supplements labeled to be used within 14 days of thawing were not monitored for their thaw dates, leading to the potential for expired products being used. The Dietary Manager confirmed that these items should have been dated and discarded before their use-by dates but were not, posing a risk of foodborne illness to residents on nutritional supplements in the facility. The U.S. Food and Drug Administration Food Code requires ready-to-eat, time/temperature control for safety food to be clearly marked with the date by which the food shall be consumed, sold, or discarded if held for more than 24 hours, which was not adhered to in this case. The facility's ice machine was also found to be unsanitary. A clean paper towel swipe of the ice storage bin ceiling and sides produced a pink residue, indicating a buildup of contaminants. The Maintenance Supervisor, responsible for cleaning the ice machine, admitted that he did not remove the baffle before cleaning and acknowledged that the residue should not be present as it could contaminate the ice. The U.S. Food and Drug Administration Food Code mandates that surfaces of utensils and equipment contacting food must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms, which was not followed in this instance. Additionally, improper storage practices were observed in the kitchen dry storage area, where scoops were stored inside bulk food containers with the handles in contact with the food. The Dietary Manager acknowledged that this could result in contamination of the food. Furthermore, during a tour of a resident's room, a banana was found on top of the resident's closet, which could lead to gnat or bug infestation and pose a food safety issue. The Director of Nursing confirmed that food should not be left on top of residents' closets as it could cause infection and environmental safety issues. The facility's policy on food brought in by visitors states that perishable food requiring refrigeration should be discarded after two hours at the bedside, which was not adhered to in this case.
Failure to Monitor and Manage Indwelling Catheter Leading to Potential UTI
Penalty
Summary
The facility failed to monitor signs and symptoms of a urinary tract infection (UTI) and did not irrigate the indwelling catheter as per the treatment administration record (TAR) for one resident. Resident 48, who was admitted with diagnoses including bladder neck obstruction, UTI, and benign prostatic hyperplasia (BPH), had fluctuating capacity to understand and make decisions and was dependent on staff for daily activities. The care plan indicated that the resident should show no signs and symptoms of urinary infection, but the progress notes did not indicate that a medical doctor (MD) was notified when the resident developed cloudy urine with sediment. Additionally, the TAR showed that the foley catheter was not irrigated as needed on specific dates, leading to the resident developing cloudy urine with sediment and a potential UTI and blocked catheter. Observations and interviews with staff revealed that the indwelling catheter was not properly monitored. Licensed Vocational Nurse 3 (LVN 3) and Licensed Vocational Nurse 4 (LVN 4) both acknowledged the presence of cloudy urine with sediment and the need to notify the MD, but this was not done. The Director of Nursing (DON) confirmed that the facility's policy required reporting signs and symptoms of infection to the MD, which was not followed in this case. The facility's policy and procedures for catheter care emphasized the importance of preventing infections and reporting any signs or symptoms of UTI, which were not adhered to, resulting in the deficiency.
Failure to Date Isosource Bag for G-Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident's Isosource bag, used for G-tube feeding, was properly dated. This deficiency was observed multiple times over two days. The resident, who had a documented swallowing disorder and significant weight loss, had an Isosource bag that was not dated to indicate when it was opened. This was first observed in the morning and again later in the day, with the Licensed Vocational Nurse (LVN) confirming that the bag was not dated and acknowledging the importance of dating the bags. The LVN admitted to setting up the bags the previous day but failing to date the Isosource bag. The facility's policy requires that all equipment and products be labeled with the date and time they were first used or opened. The manufacturer's instructions for the Isosource bag also specify that the bag can hang for up to 48 hours once spiked. Despite these guidelines, the Isosource bag in Resident 64's room remained undated, which could lead to the bag being used beyond the recommended time frame, potentially causing harm to the resident.
Failure to Document Range of Motion Treatment
Penalty
Summary
The facility failed to ensure that the range of motion treatment for one resident was properly documented. A review of the resident's Medical Data Set indicated that the resident required assistance with self-care, indoor mobility, and functional cognition. However, the Administrative Restorative Nursing Assistant Log did not show that the resident received range of motion treatment on several dates in April 2024. During interviews, the Director of Staff Development and Restorative Nursing Assistants could not explain the missing documentation, and it was revealed that the RNAs might have forgotten to document or were too busy to do so at the time. Further review of the facility's policies and procedures indicated that daily and weekly documentation of treatment specifics should be maintained, but the staff could not demonstrate where these items were documented. The Medical Records audit also showed missing signatures, and although the audit report was given to the Director of Staff Development, the issue of missing documentation persisted. The failure to document the range of motion treatment as required by the facility's policies and procedures led to this deficiency.
Failure to Implement Hand Hygiene and Labeling Protocols
Penalty
Summary
The facility failed to implement its hand hygiene policy, resulting in multiple instances of non-compliance by staff. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene between assisting Resident 25 and Resident 81. Similarly, Licensed Vocational Nurse 1 (LVN 1) did not use hand sanitizer or wash hands before entering residents' rooms 142 and 143. Both staff members acknowledged their failure to follow hand hygiene protocols during interviews, citing reasons such as being in a hurry or forgetting the procedure. Resident 25, who has dementia, depression, and hypertension, required substantial assistance with daily activities. Resident 81, also diagnosed with dementia and delusional disorders, needed moderate assistance. During an observation, CNA 1 was seen assisting Resident 25 with cutting bread and then immediately handling a glass of milk for Resident 81 without sanitizing hands in between. LVN 1 admitted to not using hand sanitizer before entering the rooms of residents, explaining that he was in a hurry and forgot the procedure. Additionally, the facility failed to label a urinal in Resident 82's room, who has a fractured femur, hyperlipidemia, and hypertension. The urinal lacked any identifying marks such as initials, room number, or bed number, which could lead to cross-contamination. CNA 3 confirmed that the urinal was not labeled and explained that labeling is a standard practice to prevent mix-ups. The Director of Nursing (DON) and the Infection Preventionist Nurse (IPN) both emphasized the importance of hand hygiene and proper labeling to prevent the spread of infections.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of the residents, identified as Resident 28. Resident 28 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for moderate to maximal assistance with activities of daily living (ADLs). During an observation, it was noted that Resident 28's call light was hanging on the wall behind the bed, out of the resident's reach. Certified Nursing Assistant 2 (CNA 2) acknowledged that the call light was not checked and placed within reach when CNA 2 started the shift that morning. CNA 2 admitted it was their responsibility to ensure the call light was accessible to the resident. The Director of Nursing (DON) confirmed that the call light system is crucial for residents to call for help and emphasized that it should always be within reach for safety reasons. The facility's policy, dated 10/24/22, mandates that call cords be placed within the resident's reach in their rooms. The failure to adhere to this policy had the potential to prevent Resident 28 from receiving timely assistance, which could lead to adverse outcomes such as falls or unmet needs.
Failure to Provide Adequate Room Size for Residents
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 24 out of the 35 resident rooms. These rooms, which consisted of 3 beds each, did not meet the federal regulation requirement, with measurements ranging from 73.0 to 78.9 square feet per resident. This deficiency was identified through observation, interview, and record review, and it was noted that the inadequate space had the potential to result in insufficient usable living space for residents and working space for health caregivers. A review of the Request for Room Size Waiver letter submitted by the Administrator indicated that the room sizes would not interfere with daily nursing care or the safety of the residents. The letter claimed that there was enough space to provide for each resident's care, dignity, and privacy, and that the spaces would not adversely affect the residents' health and safety. However, the facility's Client Accommodations Analysis confirmed that the rooms did not meet the required square footage per resident. Despite the observations that residents had ample space to move freely and that there was sufficient space for beds, side tables, and resident care equipment, the facility was still in violation of the federal regulation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alvarado Care Center | 0.1 mi | ★★★★★ | 30 | 1 |
| Alden Terrace Convalescent Hospital | 0.1 mi | ★★★★★ | 14 | 0 |
| California Post Acute | 0.2 mi | ★★★★★ | 9 | 0 |
| Alta View Post Acute | 0.3 mi | ★★★★★ | 31 | 0 |
| Grand Park Convalescent Hospital | 0.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.