Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Overland Terrace Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with DM, CKD, vascular dementia, severe cognitive impairment, and total dependence for care was re-admitted with existing wounds, but the sacrococcyx pressure ulcer was not documented on admission or during several subsequent skin assessments. Staff later identified it as an unstageable pressure injury, but the change of condition was not documented, the RP notification was not documented, and the low air-loss mattress intervention was ordered after the wound had already been identified. The DON and RN acknowledged the documentation gaps, and the facility policy required skin evaluations, change-of-condition documentation, RP notification, and implementation of ordered pressure injury interventions.
Failure to follow EBP during wound care: A resident with DM, anemia, HTN, HLD, PVD, and a right ankle wound requiring daily dressing care was on EBP, with signage and an isolation cart present outside the room. A TXN was observed performing the wound care without wearing a gown, and later acknowledged forgetting the gown and stated cross contamination was a risk.
Kitchen staff failed to properly label multiple frozen food items with required dating and identification information, and an Activities Director contaminated a resident’s meal ticket by picking it up from the floor with a bare hand and placing it on the resident’s food tray. Staff interviews confirmed the labeling requirements and that contaminated items should not be used, and the dietary infection control policy required removal of soil and prevention of cross-contamination.
Staff failed to treat several residents with dignity by referring to them as "feeders" on assignment sheets and in staff communication. The residents needed substantial or maximal assistance with ADLs, including eating, and had diagnoses such as muscle weakness, impaired cognition, HTN, heart failure, depression, and a pressure ulcer. During observation and interviews, CNA, LVN, RNS, DSD, and DON all confirmed the term was used to identify residents needing feeding assistance, even though the DON acknowledged it was not appropriate to use around residents because it affected respect and dignity.
A facility failed to ensure that three residents with cognitive impairment and documented lack of decision-making capacity did not personally sign vaccine consent forms. One resident with dementia and severe impairment signed refusals for flu, pneumococcal, and COVID-19 vaccines, while two other residents with severe or moderate cognitive impairment signed consents for flu, pneumococcal, and/or COVID-19 vaccines. The LVN and DON stated that residents without capacity should have consent obtained from a representative or surrogate, consistent with the facility’s informed consent policy.
Failure to provide TV remote controls for two residents. One resident with moderate cognitive impairment and dependence on staff for multiple ADLs reported not having a remote for several days and said she had to get up or ask staff to change the TV manually, leaving her frustrated and bored. Another resident with severe cognitive impairment and dependence on staff for multiple ADLs reported not having a remote for a long time and being unable to change channels without getting up. Staff stated that lacking a remote can affect mood, entertainment, and feelings of isolation.
An LPN left a laptop on a med cart in the hallway unattended with a resident’s PHI visible on the screen, including name, DOB, physician, code status, allergies, vital signs, and MRN. A second LPN left another med cart laptop unattended with another resident’s PHI displayed, including name, DOB, vital signs, doctor’s name, and medication information. Both LPNs acknowledged the screens were left open and stated this violated HIPAA.
Dirty Toilet Bowl in Resident Bathroom: A resident with DM and no cognitive impairment, who needed set up or clean up assistance with ADLs including toileting hygiene, was observed with brown dried stains around the inside rim of the toilet bowl in the bathroom. The MHSS confirmed the toilet was not clean, and the DON stated the resident would feel dirty and would not feel like the restroom was home-like. The facility policy stated staff aim to maintain a personalized, home-like atmosphere with attention to cleanliness and order.
A resident with severe cognitive and physical impairments had documented behaviors of throwing feces and tearing apart an incontinent brief, but nursing observations and progress notes for those behaviors were not found in PCC. Another resident with multiple chronic conditions had no nursing documentation explaining a hospital transfer, including the reason, transfer time, vital signs, or notifications, and also had no progress notes documenting a request to stop being assigned a specific LVN despite staff awareness of the request.
Failure to develop a baseline care plan for a resident after readmission. The resident had multiple serious diagnoses, including dementia, quadriplegia, epilepsy, and cognitive impairment, and was dependent on staff for ADLs with bowel and bladder incontinence. The LVN and DON both confirmed the baseline care plan was missing from PCC and stated it should have been completed within 48 hours to identify the resident's needs and needed interventions.
Incorrect Low Air Loss Mattress Weight Settings: The facility failed to keep LALM settings aligned with resident weights for three residents who were ordered pressure-relief support. One resident had an unstageable sacral pressure ulcer and the mattress was found set far above the resident’s weight during multiple observations; two other residents’ mattresses were also set at 200 lbs despite weights in the mid-150s to 160 lbs. An LVN and the DON stated the settings should match the resident’s weight and that incorrect settings can affect pressure reduction and skin condition.
A resident with dysphagia, protein-calorie malnutrition, and severe cognitive impairment was receiving Jevity 1.2 via GT/JT, but the enteral feeding tubing was observed without a date or time label when hung. The same unlabeled tubing was still present later that day. An LVN and the DON both stated that tubing should be labeled to show when it was hung, and the facility policy required the bag and tubing to be labeled with the date and time hung.
A resident with ESRD and dialysis dependence did not receive a documented post-dialysis assessment after returning from off-site HD, even though the facility’s policy required pre- and post-dialysis evaluations by an RN/LVN. The resident also had a provider-ordered 1200 cc fluid restriction, but CNA documentation showed repeated shifts where 1200 cc was recorded, and the RNS acknowledged the resident was on fluid restriction and could become overloaded.
The facility failed to follow infection control practices for a resident with an indwelling catheter, a resident whose meal tray was contaminated when an AD picked up a meal ticket from the floor with a bare hand and placed it on the tray, and a resident whose toilet bowl had dried fecal-like stains. Staff and leadership acknowledged the urinal should have been labeled, the meal ticket was dirty and should not have been placed on the tray, and the toilet condition was a sanitation and infection issue.
Missing Mandated Reporter Training Documentation: The facility failed to ensure an LVN completed Elder Abuse Mandated Reporter training and kept proof of that training in the personnel file. The DSD/LVN could not find any abuse training record in the file or electronic system, and the DON stated that without documentation there is no way to verify the training was completed. The facility policy required abuse, neglect, and exploitation training for new staff.
The facility failed to follow its abuse policy when two residents were involved in an incident in which one cognitively impaired, functionally dependent resident reported being yelled at and hit in the face by a roommate who had returned from pass yelling, unsteady, and smelling of alcohol. An LVN later found the allegedly intoxicated resident on top of the other resident and observed a black eye, but the RN documented the event as an accidental elbow contact despite not witnessing it and acknowledged she did not further investigate. The Administrator later observed the injury but the facility did not initiate and complete the required abuse investigation or make the mandated notifications and written reports to authorities within the time frames specified in its policy and applicable law.
A resident with multiple behavioral health diagnoses, including PTSD and major depressive disorder, repeatedly exhibited extreme agitation, verbal and physical aggression, and used racial slurs toward a roommate and the roommate’s family. Despite documented incidents and ongoing complaints, the facility’s interventions were limited and did not effectively address the resident’s behavioral health needs, resulting in continued risk and negative psychosocial impact on others.
Two residents with multiple medical and cognitive conditions experienced disrespectful and non-person-centered care during an overnight shift, including delayed responses to call lights, lack of staff introductions, and rude interactions when requesting incontinence care. Staff interviews denied inappropriate conduct, but facility policy and the DON confirmed expectations for respectful and dignified care.
The facility did not maintain required room temperatures, with several rooms found below the federally mandated range, resulting in a resident feeling cold and uncomfortable. Additionally, a shared bathroom was observed to have chipped paint, holes, and dried fecal matter on the walls and bedside commode, with staff confirming inadequate cleaning and risk of contamination.
A resident with dementia and a history of falls experienced multiple unwitnessed falls, including one resulting in a laceration requiring hospital transfer. Despite repeated incidents, fall risk assessments were incomplete, care plan interventions were delayed, and recommended increased supervision was not implemented. Staff interviews revealed gaps in injury reporting and understanding of policy requirements.
A resident's expired medication was found stored in a food bag inside the residents' refrigerator, an area not designated for medication storage. The Dietary Supervisor and LVN confirmed that licensed nurses are responsible for checking all food and bags stored in the refrigerator, and facility policy requires medications to be stored in locked or designated areas accessible only to authorized personnel. Other medication storage areas were found compliant.
A dietary staff member was observed preparing a meal without following the prescribed recipe, specifically by not measuring black pepper as required. The staff member admitted to not using measuring utensils, and the dietary supervisor confirmed that all cooks are expected to follow recipes. The facility's menu and recipe documentation supported that the meal in question was served to all residents.
Surveyors found that the facility did not properly store, label, or date various food items in the kitchen and residents' food storage areas, with several containers missing expiration or use-by dates. Additionally, the residents' refrigerator and freezer temperatures were not maintained or recorded as required, and the Dietary Supervisor was unaware of their responsibility for these tasks, contrary to facility policy.
Staff failed to use required PPE while providing care to a resident on enhanced barrier precautions, and a shared bathroom used by two residents was found with dried fecal matter on the wall and bedside commode. Despite facility policies and available supplies, these lapses in infection control and environmental cleanliness were confirmed by staff interviews and direct observation.
Two residents with cognitive impairment and a history of falls experienced unwitnessed falls resulting in injuries that required transfer to a general acute care hospital. Despite facility policy requiring reporting of such incidents to CDPH within 24 hours, staff did not report the events due to misinterpretation of injury severity and lack of understanding of reporting requirements.
A resident with PTSD and hypertension was admitted without a baseline care plan being developed or implemented within 48 hours, as required by facility policy. Staff interviews and record reviews confirmed that no care plan addressing PTSD was created at admission, despite the diagnosis being documented. Facility policy mandates timely care planning to address residents' needs, which was not followed in this case.
A resident with an indwelling urinary catheter and multiple urological conditions was observed with the catheter drainage bag positioned above the bladder, contrary to care plan and physician orders. Staff confirmed the improper placement was due to the wheelchair lacking an appropriate attachment, and acknowledged the risk for infection. Facility policy required the drainage bag to be below the bladder, but this was not followed, resulting in a deficiency related to UTI prevention.
A resident with cognitive impairment and multiple medical conditions was found with an unlabeled tube feeding syringe and tubing set, and a water bag labeled with a date several days old. Staff confirmed that tube feeding equipment should be changed and labeled daily, in accordance with facility policy and physician orders, but this was not done.
A resident with dementia, generalized weakness, and diabetes was admitted without natural teeth or dentures and had a physician order for a dental consultation as needed. Despite facility policy requiring prompt referral to outside services, the resident was not referred to a dentist, and staff confirmed the dental consultation was not completed.
A review of facility records and observations revealed that 28 resident rooms did not meet the required minimum square footage per resident, with several multi-occupancy rooms falling below federal standards. Despite this, both residents and staff were observed to have sufficient space to move and provide care safely.
A facility failed to conduct a personal property inventory for a resident upon admission, as required by its policy. The resident, admitted with diabetes, heart failure, and insomnia, reported not receiving an inventory list during her stay. The DON confirmed the oversight, acknowledging that the inventory list was not completed, leaving personal property unaccounted for.
A resident with multiple health issues, including neoplasm of bone and morbid obesity, did not receive adequate care for mobility and incontinence needs. The resident required significant assistance for ADLs, but the care plan did not reflect current limitations, and staff struggled to meet the resident's frequent requests for repositioning and diaper changes. The facility's policies on care planning and incontinence management were not effectively implemented.
A resident with multiple medical conditions, including neoplasm of bone and morbid obesity, did not receive timely assistance for repositioning and diaper changes, leading to discomfort and potential risk of pressure injuries. The care plan failed to address the resident's mobility limitations and preferences, resulting in unmet physical and psychosocial needs. Staff interviews confirmed delays in providing necessary care due to the requirement of multiple staff members for repositioning.
A resident with Parkinson's disease, anoxic brain damage, and a history of falls was inaccurately assessed as low risk for falls upon admission. The facility's fall risk assessment failed to account for the resident's predisposing conditions and medications, leading to a deficiency in providing necessary preventive care. The DON acknowledged the assessment was not correctly coded, which could have resulted in inadequate fall prevention measures.
Delayed Documentation and Intervention for Sacrococcyx Pressure Ulcer
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident who was re-admitted with multiple comorbidities including DM, anemia, HTN, vascular dementia, CKD, metabolic encephalopathy, dysphagia, and muscle weakness. The resident’s MDS indicated severe cognitive impairment, total dependence on staff for bed mobility, transfers, and ADLs, and risk for pressure ulcers. Hospital transfer notes on re-admission documented wounds to the right 4th toe and left leg, but the facility’s admission, skin check, LTC evaluation, skin issues, and IDT skin notes did not document a sacrococcyx pressure ulcer until several days later, when it was first recorded as unstageable. During interview, the TXN stated she did not document the pressure ulcer on admission because she does not stage wounds and said the wound care specialist identified it as unstageable on a later date. The RN stated the resident came from the hospital without a documented or endorsed pressure ulcer, and the DON acknowledged there was no documentation of a sacrococcyx pressure ulcer upon admission, making it impossible to know when it was identified. The DON also agreed the treatment nurse should have documented and described the pressure ulcer in the chart before the wound care specialist’s consult note. The record also showed a failure to document a change of condition when the new pressure ulcer was identified and a failure to document notification of the responsible party. The care plan was revised to include the unstageable sacrococcyx wound and low air-loss mattress intervention, but the order for the low air-loss mattress was entered after the wound had already been identified. The RN stated staff had spoken with the responsible party about the resident’s care but had not documented it, and the facility policy required skin evaluations on admission/re-admission, when there is a change in skin integrity, notification of the physician and responsible party for changes in pressure injury or skin integrity, and implementation of interventions identified in the plan of care.
Failure to Follow EBP During Wound Care
Penalty
Summary
The facility failed to ensure staff followed infection prevention policies and procedures for Enhanced Barrier Precautions when providing wound care to one resident. The resident was admitted with diagnoses including DM, anemia, HTN, muscle weakness, HLD, and PVD. The resident’s H&P indicated capacity for medical decision making, and the MDS showed the resident was independent to requiring supervision for most ADLs. The resident had an order for daily wound care to the right anterior ankle, including cleansing with NS, applying Santyl ointment, covering with dressing, and wrapping with ACE wrap. During observation, signage outside the resident’s room indicated the resident was on EBP and an isolation cart stocked with gloves, gowns, and surgical masks was present. While the treatment nurse was observed providing wound care at the bedside, the nurse did not don a gown. During a later observation and interview, the EBP sign stated that staff must wear gloves and a gown for wound care involving any skin opening requiring a dressing. The nurse acknowledged forgetting to don the gown before the wound care and stated that cross contamination was a risk.
Food Labeling and Tray Contamination
Penalty
Summary
Kitchen staff failed to ensure several frozen food items were properly labeled with the required information. During a kitchen tour, diced ham, chicken patties, beef steak, and BBQ pork were observed with incomplete labels, including missing or unclear food names, delivery dates, opened dates, and expiration or best-by dates. The Dietary Services Supervisor stated that frozen chicken patties are good for five days after opening and that BBQ pork and beef steak are good for one month from the date opened. Dietary staff stated that food received at the facility must be labeled with the food name, date of delivery, date opened, and expiration information, and that food with incomplete labeling should be thrown away. The facility’s dietary staff also acknowledged that labeling is necessary to know when food is safe to use and when it expires. The Dietary Services Supervisor stated that some staff may have forgotten to label items and that labeling is important because staff do not know how long meat has been stored. Facility records showed dietary staff had been in-serviced on labeling requirements, including dating items when received, used by date, and date opened. The facility’s policies for food storage, handling, and receiving food and supplies also required raw meat and frozen meat to be labeled and dated, and items received to be dated. During a dining observation, the Activities Director picked up a meal ticket that had fallen on the floor with her bare hand and placed the contaminated ticket on Resident 12’s food tray before walking toward the dining room to serve it. The surveyor stopped her before she entered the dining room. The Activities Director stated she was going to give the tray to Resident 12 and acknowledged that the resident might get sick if the food were eaten because she contaminated the tray. The Activities Assistant stated that a meal ticket that falls on the floor is dirty and should not be placed on a food tray. Staff interviews also confirmed that breaking infection control can cause residents to become ill, and the facility’s infection control policy required removal of soil and contamination and prevention of cross-contamination during food preparation.
Staff Used Degrading Term for Residents Needing Feeding Assistance
Penalty
Summary
The facility failed to ensure that staff treated residents with respect and dignity by using the term "feeders" for seven sampled residents who needed assistance with eating. The deficiency involved Residents 2, 3, 20, 56, 57, 58, and 84, all of whom were identified in the facility’s feeder list and required substantial or maximal assistance with all activities of daily living, including eating. Their records showed diagnoses such as muscle weakness, diabetes, heart failure, hypertension, depression, pressure ulcer, and impaired cognition ranging from intact to severely impaired. During observation and interviews, staff repeatedly referred to these residents as "feeders." During a lunch observation, CNA 3 stated she was helping Resident 2 with lunch because the resident was a feeder. The DSD/LVN stated she maintained a list of feeders and assigned two RNAs to care for them. The RNS stated the facility had a list of all feeders and that CNAs also fed them so they would not lose weight. The DON stated the residents on the feeder list were the seven sampled residents and acknowledged that while the term was used among staff, it was not appropriate to use it around residents because it was a matter of respect and dignity. Additional staff interviews confirmed the practice. CNA 3 stated the residents on the FEEDERS list were correct and that the charge nurse wrote the word FEEDERS so CNAs would know how many feeders they had. LVN 6 stated she wrote the residents that were feeders on the assignment so CNAs would know how many feeders they had, and that the RNA helped with at least one feeder. Record review showed a document titled FEEDERS listing residents who needed feeding assistance along with room and bed numbers. The facility’s Residents Rights - Quality of Life policy stated each resident shall be cared for in a manner that promotes dignity, respect, individuality, and person-centered services, and that staff speak respectfully to residents at all times, including addressing the resident by name of choice.
Improper Vaccine Consent for Residents Lacking Capacity
Penalty
Summary
The facility failed to ensure that three residents with cognitive impairment did not sign vaccine consent forms when they lacked the capacity to make informed medical decisions. Resident 1 was admitted with quadriplegia, muscle weakness, and dysphagia, and the MDS showed severe cognitive impairment and dependence on staff for ADLs. The physician’s H&P stated the resident had waxing and waning capacity for medical decision making due to dementia, yet the resident signed forms to refuse influenza, pneumococcal, and COVID-19 vaccines. Resident 43 was admitted with dysphagia and protein-calorie malnutrition, and the MDS indicated severe cognitive impairment with dependence on staff for all or most ADLs. The H&P stated the resident did not have capacity for medical decision making due to CVA and encephalopathy, yet the resident signed consent forms to receive influenza and COVID-19 vaccines. Resident 61 was admitted with dysphagia, hemiplegia, and hemiparesis, and the MDS showed moderate cognitive impairment with varying levels of staff assistance needed for ADLs. Despite this, the resident signed consent forms to receive influenza, pneumococcal, and COVID-19 vaccines. During interview, the Infection Prevention Nurse/LVN stated informed consent requires that the resident understand the vaccine, side effects, and make the decision, and that if a resident cannot make decisions, the representative should sign on the resident’s behalf. The DON stated that Resident 1, Resident 43, and Resident 61 did not have the capacity to make decisions and sign consent forms for vaccines, and that when a resident is not able to make decisions, the facility needs to call the resident’s representative to give consent. The facility’s policy stated that if the resident lacks capacity to provide informed consent, the surrogate decision maker will provide informed consent, or if none exists, the facility will convene a surrogate interdisciplinary team.
Failure to Provide TV Remote Controls
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not providing television remote controls in their rooms. Resident 7 was admitted with diagnoses including muscle weakness, Type 2 DM without complications, and dependence on renal dialysis, and the MDS indicated moderate cognitive impairment and dependence on staff for multiple ADLs. During observation and interview, Resident 7 stated there was no TV remote in the room, that she had to get up or ask staff to turn the TV on or change the channel and volume manually, and that she had not had a remote for several days. Resident 62 was admitted with diagnoses including Type 2 DM without complications, HTN, and insomnia, and the MDS indicated severe cognitive impairment and dependence on staff for multiple ADLs. During observation and interview, Resident 62 stated there was no TV remote in the room and that she had not had one for a long time, could only watch one channel, and could not keep getting up to change the channel. Staff interviews confirmed that lack of a TV remote could affect residents’ mood, make them feel like they are not at home, and leave them without entertainment or stimulation, and the DON stated residents without a remote could feel lonely, isolated, and sad.
Unattended laptop screens exposed resident PHI
Penalty
Summary
The facility failed to protect residents’ rights to privacy and confidentiality of records when two LVNs left two residents’ personal and medical information displayed on laptop computer screens on medication carts in the hallway and unattended. Resident 8 was admitted with multiple diagnoses including type 2 diabetes mellitus, acute kidney failure, myocardial infarction type 2, tachycardia, depression, hypertension, dysphagia, cognitive communication deficit, generalized muscle weakness, long-term insulin use, and osteoarthritis. Resident 8’s H&P indicated the resident was at significant risk of worsening medical status and re-admission to the hospital and had capacity for medical decision making; the MDS indicated moderately impaired cognition, use of a walker and wheelchair, and need for supervision or touching assistance with ADLs. During the facility tour, a laptop on top of Medication Cart A was observed unattended in the hallway, and Resident 8’s name, date of birth, physician’s name, code status, allergies, vital signs, and medical record number were visible on the screen. LVN 1 arrived and confirmed the screen displayed Resident 8’s information and stated the screen had been left open, acknowledging that HIPAA law was violated when the information was left visible unattended. LVN 1 stated the resident’s information could be used for identity theft, impersonation, and stolen financial information, and that the resident may experience loss of trust, hurt, and anger. A similar event occurred with Medication Cart B, where a laptop was observed unattended in the hallway and Resident 11’s personal and medical information appeared on the screen when the mouse pad was touched. Resident 11 was admitted with diagnoses including atherosclerotic heart disease, presence of coronary angioplasty implant and graft, hypertensive chronic kidney disease, generalized muscle weakness, dysphagia, cognitive communication deficit, anxiety disorder, major depressive disorder, and essential hypertension. Resident 11’s H&P indicated significant risk of worsening medical status and re-admission to the hospital, and the MDS indicated intact cognition. LVN 5 confirmed the screen displayed Resident 11’s name, date of birth, vital signs, doctor’s name, and acetaminophen, and stated the screen had been left open after being called away by another resident, acknowledging a HIPAA violation.
Dirty Toilet Bowl in Resident Bathroom
Penalty
Summary
The facility failed to ensure the toilet bowl was clean and sanitary for one of three sampled residents, Resident 79. Resident 79 was admitted on 1/16/2026 with diagnoses including Diabetes Mellitus and muscle spasm. The resident's MDS dated 4/25/2026 indicated no cognitive impairment and that the resident needed set up or clean up assistance with ADLs, including personal hygiene and toileting hygiene, while being independent with transfers and walking 150 feet. During an observation on 06/02/2026 at 10:31 am, the toilet commode in Resident 79's bathroom had brown dried uneven stains around the inside rim of the toilet bowl. A concurrent observation and interview with the MHSS in the resident's room confirmed the toilet was not clean, and the MHSS stated the resident would not be comfortable using the restroom and would not feel like it was their home. During an interview on 6/4/2026, the DON stated the resident would feel dirty, would not want to use the restroom, and would not feel like it was home when having to use a dirty toilet. The facility policy titled Residents Room and Environment, revised in 3/2026, stated staff aim to create a personalized, home like atmosphere with attention to cleanliness and order.
Missing Nursing Documentation for Resident Behaviors, Hospital Transfer, and Nurse Assignment Request
Penalty
Summary
The facility failed to document nursing assessments, observations, and progress notes for two residents. For one resident, the record showed multiple diagnoses including dementia, schizophrenia, epilepsy, quadriplegia, anoxic brain damage, and total dependence on staff for ADLs, with urinary and bowel incontinence. The care plan identified behavioral problems including throwing feces on the floor and tearing apart the incontinent brief, with interventions to monitor behavior, determine underlying causes, and provide frequent care and hygiene. During interview, the resident could not answer simple orientation questions, and nursing staff and the DON stated they could not find any nursing observation or progress note documentation in PCC for the resident’s feces-throwing or brief-tearing behaviors during May and June 2026. For the second resident, the record showed diagnoses including multiple sclerosis, paraplegia, polyneuropathy, chronic pain syndrome, depression, anxiety, muscular dystrophy, cognitive communication deficit, and dependence on staff for emotional, intellectual, physical, and social needs. The nursing progress notes did not contain licensed staff documentation explaining why the resident was transferred to a general acute care hospital, including the reason for transfer, the date and time of transfer, vital signs before transfer, or the date and time the physician and family/responsible party were notified. Staff interviewed stated they could not find documentation in PCC regarding the hospital transfer. The second resident also reported telling the SSD that a specific LVN was unprofessional, disrespectful, and should no longer be assigned to the resident’s care. The resident stated this request was made more than once, but nursing progress notes from May and June 2026 did not contain documentation of the request. The DON stated the request was known to staff and that the resident had the right to choose another nurse, but there was no documentation in PCC showing the request or the follow-up. The assignment sheets showed the same LVN continued to be assigned on some shifts after the request was made.
Failure to Develop Baseline Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop a baseline care plan for a resident after readmission, and the plan was not initiated within 48 hours as required by the facility policy and procedures titled Person-Centered Care Planning. The resident was readmitted on [DATE], and the record review showed no baseline care plan in the electronic health record. During interviews, the LVN and DON both stated they could not find the baseline care plan in PCC and confirmed it should have been completed within 48 hours of readmission. Resident 1 had multiple significant diagnoses, including muscle weakness, cognitive communication deficit, epilepsy, atherosclerotic heart disease, unspecified dementia, contracture, quadriplegia, anoxic brain damage, TIA, schizophrenia, and major depressive disorder. The H&P dated 4/15/2026 stated the resident was at significant risk of worsening medical status and readmission to the hospital and had waxing and waning capacity for medical decision making due to dementia. The MDS dated 4/20/2026 indicated the resident was cognitively impaired, used a manual wheelchair, had functional limitations in range of motion in both upper and lower extremities, was completely dependent on staff for ADLs, and was incontinent of bowel and bladder. During the concurrent interview and record review, the LVN stated the baseline care plan would identify the resident's needs and the interventions needed, and that without it staff would not know the resident's needs and might miss something important. The DON stated the baseline care plan tells staff what help the resident will need and what interventions are needed, and that without it immediate interventions would be missed and care would be delayed. The facility policy stated the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon admission and address resident-specific health and safety concerns, and that it must be developed within 48 hours of admission.
Incorrect Low Air Loss Mattress Weight Settings
Penalty
Summary
The facility failed to maintain proper weight settings for low air loss mattresses for three residents who were identified as needing pressure ulcer prevention and skin management. Resident 3 was admitted with an unstageable sacral pressure ulcer, diabetes, and chronic kidney disease, and the care plan identified the resident as at risk for pressure ulcer development due to decreased mobility and anticoagulant use. The care plan directed that the low air loss mattress be calibrated to the resident’s weight and monitored for accurate settings every shift. Resident 3’s records showed a weight of 152 to 153 pounds in April and May 2026, but the mattress was observed on 6/2/2026 and 6/3/2026 set at 200 to 250 pounds. During wound care on 6/4/2026, the sacral wound was described as having 70% slough and 30% granulation tissue. An LVN stated the mattress had been set at 250 pounds earlier that day and was changed after calling the mattress company and being told to reduce it to the resident’s weight of 152 pounds. The DON stated the mattress setting is based on the resident’s weight and that the wound may not improve if the mattress is on the wrong setting. Resident 19 and Resident 57 also had orders for low air loss mattresses to be calibrated by resident weight and monitored every shift. Resident 19’s weight was 156 pounds, but the mattress was observed set at 200 pounds, and an LVN stated it should have been set at 150 pounds to be closest to the resident’s actual weight. Resident 57’s weight was 160 pounds, but the mattress was also observed set at 200 pounds, and an LVN stated it should have been set at 150 pounds. The DON and LVN stated that incorrect settings could affect mobility in bed and create more pressure on the skin, and the facility policy stated that mattresses were to provide pressure reduction and evenly distribute body weight.
Unlabeled Enteral Feeding Tubing
Penalty
Summary
The facility failed to ensure that enteral feeding tubing was labeled with the date and time when hung for Resident 43. Resident 43 was admitted with diagnoses including dysphagia and unspecified protein-calorie malnutrition, and the MDS dated 4/20/2026 indicated severe cognitive impairment and dependence on staff for all ADLs, including eating and personal care. The order summary dated 5/20/2026 directed Jevity 1.2 enteral feeding at 75 ml/hr via Kangaroo Pump with G-tube flushing before and after medication administration. During an observation on 6/2/2026 at 9:15 AM, Resident 43 was observed in bed receiving Jevity 1.2 through a GT/JT, and the feeding bottle was attached to a pump. The enteral feeding tubing was not labeled with a date and/or time when hung up. A later observation the same day at 2:20 PM found the same tubing still unlabeled. LVN 5 stated that not labeling the tubing was not the right practice and that it was impossible to tell whether the tubing had been opened that day or had been in use for several days. The DON also stated that labeling is important so staff know when tubing was changed and whether it was from the same day or previous days. The facility policy titled Nursing Manual - Dietary & Dining - DD16 Enteral Feedings stated that the bag and tubing should be labeled with the date and time hung and that hang time is no more than 24 hours.
Dialysis Assessment and Fluid Restriction Not Followed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with ESRD and dependence on renal dialysis by not completing a post-dialysis assessment after the resident returned from dialysis treatment and by not implementing the physician-ordered fluid restriction of 1200 cc per 24 hours. The resident’s record showed diagnoses including ESRD and heart failure, and the care plan identified dialysis treatment every Tuesday, Thursday, and Saturday with a goal of no signs or symptoms of fluid overload. The care plan also included a 1200 cc daily fluid restriction and instructions to apply pressure to the AV shunt if bleeding occurred after dialysis. The resident’s physician orders directed dialysis at an off-site center three times weekly and ordered staff to observe the left upper arm dialysis access every shift for redness, tenderness, bleeding, and drainage. The facility’s dialysis management policy required a licensed nurse to complete both pre- and post-dialysis evaluations, and the DON stated that the post-dialysis assessment should be completed within 30 minutes of the resident’s return from dialysis. During interview and record review, the LVN stated that a post-dialysis form was not completed and that the assessment was needed to evaluate vital signs and access-site bleeding. The resident’s CNA documentation showed multiple instances in May and June when 1200 cc of fluid was documented during the evening shift, and the RNS acknowledged that the resident was on a fluid restriction but still received 1200 cc on those shifts. The RNS stated the resident could become overloaded due to too much fluid. The facility’s fluid restriction policy required a provider order and plan of care for the restriction, along with intake and output documentation and resident education regarding the restriction.
Infection Control Failures With Unlabeled Urinal, Contaminated Meal Ticket, and Dirty Toilet
Penalty
Summary
The facility failed to maintain infection control practices for three residents. Resident 3 had diagnoses including an unstageable sacral pressure ulcer, type 2 diabetes mellitus with foot ulcer, and chronic kidney disease, and the MDS indicated severely impaired cognition and an indwelling urinary catheter. During observation, a urinal hanging in Resident 3’s bathroom contained a small amount of urine and was not labeled with the resident’s name, room number, or date. CNA 2 stated the urinal should be marked for infection control and to prevent cross contamination, and the DON stated the urinal must have the resident’s name, room number, and a date so staff know when to replace it and because it is an infection control issue. During a dining observation, the Activities Director picked up a meal ticket that had fallen on the floor with a bare hand and placed the contaminated ticket on Resident 12’s food tray before walking toward the dining room to serve the tray. The AD stated the resident might get sick if the food on the contaminated tray was eaten and described possible stomach pain, vomiting, and frequent bathroom use. The Activities Assistant stated a meal ticket that falls on the floor is dirty and should not be placed on a food tray because food is clean. Other staff interviewed stated that breaking infection control measures can lead to diarrhea, infection, vomiting, and possible emergency room transfer, and that residents are vulnerable and can become very sick from contaminated food. Resident 79’s record showed diagnoses including diabetes mellitus and muscle spasm, and the MDS indicated no cognitive impairment and need for set up or clean up assistance with several ADLs, including toileting hygiene. During observation in the resident’s bathroom, the toilet commode had solid brown dried uneven stains and feces-like substance around the inside rim of the bowl. The DON stated the resident would not want to use the restroom and that it was a sanitation and infection issue, and the Infection Prevention Nurse stated the resident could get an infection from using the dirty toilet bowl and might need treatment or hospitalization. The facility policy stated infection control procedures are intended to maintain a safe, sanitary, and comfortable environment and help prevent transmission of diseases and infections.
Missing Mandated Reporter Training Documentation
Penalty
Summary
The facility failed to ensure that one of one staff member, LVN 7, completed Elder Abuse Mandated Reporter training in accordance with the facility's policy and procedures titled Training Requirements. During a concurrent interview and record review of LVN 7's personnel file, the file did not contain evidence of Elder Abuse Mandated Reporter training upon hire. The Director of Staff Development/LVN 2 stated there was no Elder Abuse Mandated Reporter training in the staff member's file and, after checking the facility's electronic system, was unable to provide any additional information regarding abuse training for LVN 7. During interview, the DON stated that if the abuse training is not in the file, there is no way to verify that the training was completed. The DON further stated that the abuse training provided to new employees should remain in the file to prove they received the training needed to safely perform their duties for residents, and that without it, staff may not know what to do when working with residents. The facility's policy required training on abuse, neglect, and exploitation, including the types of actions that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property.
Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention and management policy regarding timely reporting and investigation of a resident-to-resident allegation of physical abuse. Resident 1, who had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, dysphagia, and heart failure, was cognitively moderately impaired and required maximal assistance to dependent for ADLs. On the date of the incident, an SBAR documented that another resident (Resident 2) accidentally bumped into Resident 1’s right face, hitting the right upper cheek, and that Resident 2 was apologetic. However, during an interview, Resident 1 reported that Resident 2 was yelling and arguing, then hit Resident 1 in the face with both fists, and ended up on top of Resident 1’s bed after Resident 1 tried to push the bedside table to push Resident 2 away. Resident 1 stated there were no staff present when this occurred and that he later explained the incident to staff. LVN 1 reported that Resident 2 returned from an out pass yelling, walking wobbly, and smelling of alcohol, and that he assumed Resident 2 had been drinking based on a brown paper bag with a can inside. LVN 1 stated he directed Resident 2 back to his room, where Resident 1 was also present, and then heard a loud crashing sound. Upon entering the room, LVN 1 found Resident 2 on top of Resident 1 and observed that Resident 1 subsequently had a black eye. When questioned, Resident 1 told LVN 1 that Resident 2 fell on top of him and asked that Resident 2 not be allowed to return to the room. LVN 1 stated he did not witness the actual contact and that Resident 2, who was intoxicated, could not clearly explain what had happened. LVN 1 reported the incident to RN 1. RN 1 documented in Resident 2’s progress notes that Resident 2 returned from pass, was yelling and cursing, and that while walking toward his bed, Resident 2 grabbed the bedside table for support and his elbow accidentally touched Resident 1’s right cheek, with staff supporting Resident 2 to prevent a fall. During interview, RN 1 acknowledged she had not witnessed this and that she should not have documented the event as an accidental elbow contact without further investigation. The Administrator later stated he was not in the facility when the incident occurred and that he had just seen Resident 1 with a black eye and needed to further investigate and interview staff and residents. Despite the facility’s written policy requiring the Administrator or designee to immediately initiate an investigation upon receiving an abuse allegation and to notify law enforcement and submit written SOC341 reports to the Ombudsman, law enforcement, and CDPH within two hours, the facility did not implement these reporting and investigative requirements for this resident-to-resident allegation of physical abuse and did not submit a conclusion report of investigation within five days or in accordance with state or federal law.
Failure to Provide Necessary Behavioral Health Services for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident with significant behavioral health diagnoses received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including diabetes, hypertension, stroke, PTSD, major depressive disorder, and Cluster B personality disorder, exhibited repeated episodes of extreme agitation, verbal and physical aggression, and use of racial slurs and derogatory language towards a roommate and the roommate’s family members. These behaviors were documented on multiple occasions, including incidents of yelling, screaming, hitting, spitting, and making threatening or abusive remarks, particularly when the resident felt his personal space was encroached upon or when interacting with the roommate’s visitors. Despite the ongoing and escalating behavioral issues, the facility’s interventions were limited to offering room changes, which the resident refused, and implementing care plan interventions such as discussing behaviors with the resident, removing the resident from situations, and arranging for psychiatric and psychological consults as indicated. The care plan was updated to reflect the resident’s behavioral problems and included goals to reduce agitation, but the interventions did not effectively address or mitigate the resident’s aggressive and abusive behaviors. Staff interviews revealed that the resident’s behaviors were well-known, and there was reluctance to move the resident due to anticipated issues with other roommates. The roommate’s family expressed concerns for safety and documented their experiences in a letter to the facility, but the underlying behavioral health needs of the resident were not adequately addressed. The facility’s policy on behavior management required appropriate treatment for residents displaying mental disorders or psychosocial adjustment difficulties, including the use of non-pharmacological interventions before psychoactive medications. However, the documentation and interviews indicate that the facility did not ensure the resident received comprehensive behavioral health care and services as required, resulting in ongoing risk and negative psychosocial impact on the roommate, the roommate’s family, other residents, and staff.
Failure to Provide Respectful, Person-Centered Care to Two Residents
Penalty
Summary
Two residents were not treated with respect, dignity, or person-centered care, as evidenced by their experiences during the overnight shift. One resident, with diagnoses including muscle weakness, depression, and anxiety, reported that a CNA assigned to her care expressed reluctance to provide incontinence care and did not respond when asked if there was an issue. The resident also noted that staff on the overnight shift appeared angry, did not introduce themselves, and failed to greet her when called for assistance with activities of daily living, leading her to feel scared and fear abandonment. Another resident, who had spinal stenosis, muscle weakness, COPD, cognitive impairment, and anxiety disorder, stated that he waited two hours for a call light response during the same shift. When a female nurse finally arrived, she did not introduce herself, addressed him rudely, and stated she had other residents to attend to before leaving the room without providing the requested incontinence care. The resident was unable to identify the staff member because staff wore their badges in a way that obscured their names. Facility records confirmed the staff assignments for the shift in question. Interviews with the involved CNAs denied any inappropriate behavior, but the Director of Nursing confirmed that staff are required to be polite, introduce themselves, and treat residents with dignity and respect. Facility policies reviewed also emphasized the importance of treating residents with kindness, respect, and dignity, and providing care in a person-centered manner.
Failure to Maintain Safe Room Temperatures and Sanitary Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, sanitary, and homelike environment for its residents in two key areas. First, the facility did not keep resident room temperatures within the federally required range of 71 to 81 degrees Fahrenheit. During observations, five resident rooms, including one occupied by a resident with Parkinson's disease, anemia, and high blood pressure, were found to have temperatures ranging from 62 to 68 degrees Fahrenheit. The resident reported feeling cold and uncomfortable, which made it difficult to sleep. The DON was unaware of the specific temperature requirements, and facility policy emphasized the importance of comfortable temperatures for residents. Second, the facility did not provide a clean and sanitary environment in a shared bathroom between two resident rooms. Observations revealed chipped paint, holes, and dried brown smears identified as fecal matter on the walls and bedside commode. A resident confirmed the presence of fecal matter and stated that housekeeping only cleaned the toilet and floor daily. The Director of Staff Development acknowledged that the fecal matter placed residents at risk of contamination and did not reflect good hygiene. Facility policies required cleanliness and infection control to maintain a safe and comfortable environment.
Failure to Prevent Repeated Falls and Injury Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of falls and dementia from repeated falls, resulting in injury. The resident experienced multiple falls over several months, including incidents on 10/26/2024, 12/1/2024, 12/24/2024, 12/27/2024, and 2/28/2025. Despite these repeated events, fall risk assessments were either incomplete or did not accurately reflect the resident's fall history, and the total risk scores were not documented. The care plans were updated only after several falls had already occurred, and interventions to address the resident's high risk for falls were not clearly documented or implemented in a timely manner. On 2/28/2025, the resident suffered another unwitnessed fall, resulting in a laceration to the left eyebrow that required first aid and transfer to a general acute care hospital for further evaluation and treatment. Documentation indicated that the resident was found in a crouching position in bed, confused and disoriented, with a bleeding cut above the left eye. The injury was managed by nursing staff, and emergency services were called. The resident's family had previously suggested increased supervision, such as moving the resident closer to the nurse's station, but this was not implemented prior to the incident. Interviews with facility staff revealed gaps in communication and understanding of the significance of the injury. The administrator did not report the unwitnessed fall to the state health department, stating he did not consider the laceration and bleeding to be significant, and was unaware of the medical implications due to lack of clinical training. Facility policy required safety risk evaluations and reporting of unwitnessed falls with significant injury, but these procedures were not consistently followed, contributing to the deficiency.
Improper Storage and Labeling of Medication in Resident's Refrigerator
Penalty
Summary
Facility staff failed to ensure that medications were properly labeled and stored in accordance with professional standards for one resident. During an observation of the residents' outside food storage refrigerator, multiple food items were found without expiration dates, along with expired foods and expired medication in a resident's food bag. The Dietary Supervisor stated that it is the responsibility of licensed nurses to check residents' outside food items before storage. Further interviews and observations confirmed that the resident's refrigerator is not a designated area for medication storage, and that only licensed nurses, pharmacy personnel, and those lawfully authorized are permitted access to medications, which should be stored in locked compartments or designated areas. Additional observations of medication carts and storage rooms showed that all other medications and narcotics were properly stored, dated, and accounted for. However, the presence of expired medication in a resident's food bag within the refrigerator indicated a lapse in following facility policy and procedures regarding medication storage. Both the LVN and DON acknowledged that medications should not be stored in the resident's refrigerator and that it is the licensed nurses' responsibility to check all food and bags being stored there.
Failure to Follow Food Recipe During Meal Preparation
Penalty
Summary
During an observation and interview, a dietary staff member was seen preparing lunch and not following the facility's recipe for ground beef, specifically by pouring black pepper without using measuring utensils. The dietary staff member, who has worked at the facility for eight years, admitted to not following the recipe and acknowledged that not measuring seasonings could result in using too much, which could make residents sick. The dietary supervisor confirmed that all dietary cooks are required to follow recipes and stated that staff had been in-serviced on this requirement two weeks prior. A review of the facility's recipe for Southern Style Pattie indicated that only 1/8 teaspoon of black pepper should be used, and the menu for the day confirmed that this dish was served for lunch to all residents.
Failure to Properly Store, Label, and Monitor Food Items and Temperatures
Penalty
Summary
Surveyors observed that the facility failed to properly store, label, and date food items in both the kitchen and the residents' food storage areas. Multiple food containers, including ground spices, sauces, mayonnaise, and salad dressing, were found without original labels, expiration dates, or use-by dates. Additionally, a review of dietary purchase invoices did not show records for several of these food items, and the Dietary Supervisor confirmed that if residents consume expired foods, it could make them very sick. The Registered Dietician also stated that all food items should be labeled and dated to prevent residents from consuming expired foods. Further observations revealed that the residents' outside food refrigerator and freezer were not maintained at appropriate temperatures, with the freezer above zero degrees and the refrigerator at 43 degrees Fahrenheit. There was no documented evidence that temperatures for these storage units were checked or recorded for the required period. The Dietary Supervisor was unaware of their responsibility to maintain and record these temperatures, despite facility policy stating otherwise. Facility policies also required that perishable food brought in by visitors be labeled, dated, and discarded after specific timeframes, but these procedures were not followed.
Failure to Follow Infection Control Protocols and Maintain Sanitary Environment
Penalty
Summary
Facility staff failed to adhere to infection control measures in two key areas. First, a certified nursing assistant (CNA) was observed providing activities of daily living (ADL) care to a resident on enhanced barrier precautions (EBP) without donning the required personal protective equipment (PPE), despite signage indicating the need for PPE and the availability of supplies nearby. The CNA acknowledged awareness of the requirement but stated that PPE was not present in the room at the time. Interviews with the infection prevention nurse and the director of nursing confirmed that staff are expected to use PPE when caring for residents on EBP, and that PPE is accessible for staff use. Second, the facility failed to maintain a clean and sanitary environment in a shared bathroom used by two residents. Observations revealed a dried, hard brown smear by the light switch and fecal matter on a bedside commode (BSC) inside the bathroom. A resident reported that while housekeeping cleans the toilet and floor daily, the fecal matter on the walls remained. The director of staff development confirmed the presence of fecal matter and acknowledged that housekeeping is responsible for cleaning resident bathrooms. Facility policies reviewed indicated the expectation for maintaining a safe, clean, and sanitary environment, as well as adherence to infection control procedures.
Failure to Timely Report Unwitnessed Falls with Injury
Penalty
Summary
The facility failed to report two separate incidents of unwitnessed falls with injury to the Department of Health Services (CDPH), Licensing and Certification, and the local health officer within twenty-four hours as required by facility policy. In the first incident, a resident with a history of falls, osteoporosis, cognitive impairment, and dementia experienced an unwitnessed fall in the hallway, resulting in a skin tear to the right upper eyebrow. The resident was assessed, provided first aid, and transferred to a general acute care hospital (GACH) for further evaluation. Despite the injury and transfer, the event was not reported to the appropriate authorities within the required timeframe. In the second incident, another resident with a history of falls and unspecified dementia was found on the floor with a cut to the left eyebrow after an unwitnessed fall. The resident required moderate to maximum assistance with activities of daily living and did not have the capacity to make medical decisions. The registered nurse supervisor applied pressure and steri-strips to the wound and called 911 for transfer to GACH. Although the incident involved a significant injury and emergency transfer, it was not reported to CDPH within 24 hours, as required by facility policy. Interviews with facility staff, including the DON and Administrator, revealed a lack of understanding and miscommunication regarding what constitutes a significant injury and the reporting requirements. The DON and Administrator both acknowledged that the incidents should have been reported but failed to do so, citing misinterpretation of the severity of the injuries. Facility policy clearly states that unusual occurrences affecting resident welfare, safety, or health must be reported to the appropriate agency within 24 hours by telephone and confirmed in writing, which was not followed in these cases.
Failure to Initiate Baseline Care Plan for Resident with PTSD Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and hypertension. The resident was admitted with a documented history of PTSD, and the diagnosis was entered into the medical record on the day of admission. Despite this, a review of the resident's electronic medical chart revealed that no care plan addressing PTSD was created at the time of admission, as confirmed by a Licensed Vocational Nurse (LVN) during an interview. The LVN acknowledged the absence of a care plan for PTSD and stated that such a plan is necessary to identify triggers and implement interventions to manage the resident's condition. Further interviews with facility staff, including the Director of Nursing (DON), confirmed that the facility's policy requires a care plan to be completed upon admission or the following day, especially for residents with behavioral health diagnoses such as PTSD. The facility's policy on Comprehensive Person-Centered Care Planning specifies that a baseline care plan must be developed and implemented within 48 hours of admission, reflecting the resident's goals and including interventions for identified needs. The lack of a timely care plan for the resident with PTSD constituted a failure to meet these requirements.
Improper Placement of Catheter Drainage Bag Increases UTI Risk
Penalty
Summary
Facility staff failed to ensure proper placement of an indwelling urinary catheter drainage bag for a resident with a history of obstructive and reflux uropathy, chronic kidney disease, and benign prostatic hyperplasia. The resident, who was moderately cognitively impaired and required partial assistance with activities of daily living, had a care plan and physician orders specifying that the catheter drainage bag should be positioned below the level of the bladder to prevent urinary tract infections (UTIs). However, during observation, the drainage bag was found attached to the side of the resident's wheelchair at waist level, with the tubing looped and the bag positioned above the bladder, resulting in urine not draining properly. Staff interviews confirmed that the improper placement was due to the lack of an appropriate attachment on the wheelchair, and both the LVN and DON acknowledged that the drainage bag should be below the bladder to prevent infection. Facility policy also required the catheter and tubing to be free from kinking and the collection bag to be kept below the bladder. The failure to maintain the correct position of the catheter drainage bag constituted a deficiency in providing appropriate care to prevent UTIs.
Failure to Label and Change Tube Feeding Equipment as Required
Penalty
Summary
The facility failed to properly label and change tube feeding equipment for a resident with significant medical needs. Specifically, a tube feeding syringe was observed hanging from the resident's feeding pole without a label indicating the date or time, and the tube feeding set also lacked a label to show when it had last been changed. The water bag attached to the feeding pole was labeled with a date several days prior to the observation, suggesting that the tubing set may not have been changed as required. The resident involved had diagnoses including encephalopathy, generalized weakness, and adult failure to thrive, and was dependent on staff for activities of daily living due to cognitive impairment. During interviews, staff confirmed that the tube feeding set, including the tubing, bottle, and water bag, should be changed daily and labeled with the resident's name, date, and time of change. The facility's policy also required that feeding bags and tubing be labeled and changed every 24 hours. The lack of labeling and failure to change the tube feeding set as required constituted a deviation from both facility policy and physician orders.
Failure to Provide Timely Dental Referral per Physician Order
Penalty
Summary
The facility failed to provide a dental referral for a resident as required by physician orders and facility policy. The resident was admitted with diagnoses including dementia, generalized weakness, and diabetes mellitus, and was noted to have no natural teeth or dentures. A physician order for a dental consultation on an as-needed basis was present from the time of admission, but the referral was not made. The Social Services Director confirmed that the resident had not been seen by a dentist, despite the order and the resident's lack of teeth, which was documented in both the admission record and the social services assessment. The facility's policy requires that referrals to outside services, such as dental care, be coordinated by the Director of Social Services in accordance with physician orders or the care plan. Interviews with facility staff, including the DON and Social Services Director, indicated that the process is to initiate the referral the day the order is received. However, this process was not followed for this resident, resulting in the resident not receiving the required dental consultation.
Resident Room Square Footage Below Regulatory Minimums
Penalty
Summary
The facility failed to ensure that 28 out of 39 resident rooms met the required minimum square footage per resident, as specified by federal regulations. Specifically, rooms designed for two, three, and four residents did not provide at least 80 square feet per resident, with several rooms falling short of the 160, 240, and 320 square foot minimums for 2-, 3-, and 4-person rooms, respectively. This deficiency was identified through observation, interview, and record review, including a Client Accommodation Analysis and a facility letter requesting a room waiver. Despite these findings, observations indicated that both residents and staff had enough space to move about freely and that nursing staff could safely provide care with adequate space for beds, side tables, dressers, and care equipment.
Failure to Conduct Personal Property Inventory
Penalty
Summary
The facility failed to adhere to its own Policy and Procedure (P&P) by not conducting and completing a personal property inventory for a resident upon admission. This oversight was identified during a review of the resident's admission records and confirmed through interviews. The resident, who was admitted with conditions including diabetes mellitus, heart failure, and insomnia, reported that the facility staff did not offer a personal property inventory list during her stay. The Director of Nursing (DON) acknowledged that the inventory list was not completed as required by the facility's policy, which mandates that a personal property inventory be conducted upon admission. The facility's P&P on personal property, reviewed in January 2024, outlines the procedures for safeguarding residents' belongings. It specifies that the Admissions Staff should inform residents or their representatives about marking belongings and updating the inventory list as items are added or removed. Additionally, a Certified Nursing Assistant (CNA) or designee is responsible for conducting the inventory and placing it in the medical record. The failure to complete this process for the resident left personal property unaccounted for, as confirmed by the DON during an interview.
Deficient Care for Resident's Mobility and Incontinence Needs
Penalty
Summary
The facility failed to provide necessary care and assistance for a resident, resulting in a lack of mobility and inadequate incontinent care. The resident, who was readmitted with multiple diagnoses including neoplasm of bone, morbid obesity, and muscle weakness, required maximal assistance for lower body dressing and moderate assistance for activities of daily living (ADLs). Despite these needs, the resident's care plan did not reflect current mobility limitations, and interventions were not adequately implemented to prevent episodes of incontinence. Interviews with the resident and staff revealed that the resident frequently requested to be repositioned and have their diaper changed, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which hindered their ability to perform tasks independently. Staff acknowledged the challenges in meeting the resident's needs due to the requirement of multiple staff members to assist with repositioning. The facility's policies on person-centered care planning and bowel and bladder training were not effectively followed, contributing to the deficiency in care provided to the resident.
Deficiency in Resident Care and Mobility Support
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, identified as Resident 1, to maintain or improve their range of motion and mobility. Resident 1 was readmitted to the facility with multiple diagnoses, including neoplasm of bone, morbid obesity, muscle weakness, and anxiety disorder. The resident required maximal assistance for lower body dressing and moderate assistance for toileting hygiene. Despite these needs, the care plan did not adequately address the resident's current mobility limitations, and the interventions were not effectively implemented to meet the resident's physical and psychosocial needs. Observations and interviews revealed that Resident 1 frequently requested assistance to be repositioned in bed and for diaper changes, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which made it difficult to access personal items, and reported delays in receiving assistance. Staff interviews confirmed that repositioning the resident required at least four people, which sometimes led to delays in providing the necessary care. Additionally, the resident's care plan did not reflect the resident's preferences and needs, such as having personal items on the right side of the bed. The facility's policies and procedures for person-centered care planning and bowel and bladder training were not effectively followed, resulting in neglect of the resident's needs. The failure to provide timely and adequate care had the potential to increase the resident's discomfort and risk of developing pressure injuries, as well as contribute to psychosocial decline. The facility's neglect in addressing the resident's needs and preferences was identified as a deficiency in providing care according to professional standards of practice.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident's fall risk upon admission, which led to a deficiency in providing necessary care and services to prevent accidents and falls. The resident, who was admitted with diagnoses including Parkinson's disease, anoxic brain damage, a history of falling, and diabetes mellitus, was incorrectly assessed as being at low risk for falls. The fall risk assessment did not account for the resident's predisposing conditions such as Parkinson's disease and the use of medications like anti-convulsants, hypoglycemics, and antihypertensives, which should have indicated a higher fall risk. The Director of Nursing acknowledged that the fall risk assessment was not correctly coded, failing to reflect the resident's actual risk factors. This oversight meant that the resident was not identified as being at high risk for falls, which could have led to inadequate preventive measures being implemented. The facility's policy required that fall risk factors be documented and interventions be included in the care plan, regardless of the fall risk evaluation score, but this was not done in this case.
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What surveyors actually found near you
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Cheviot Hills Post Acute | 0.1 mi | ★★★★★ | 24 | 0 |
| Southern California Hosp At Culver City D/p Snf | 0.6 mi | ★★★★★ | 9 | 0 |
| Meadowbrook Behavioral Health Center | 1.5 mi | ★★★★★ | 16 | 0 |
| Vista Del Sol Care Center | 1.8 mi | ★★★★★ | 26 | 0 |
| Mar Vista Country Villa Healthcare & Wellness | 1.8 mi | ★★★★★ | 3 | 0 |
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