Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacific Villa, Inc during CMS and state inspections, most recent first.
Infection Control Deficiencies in Water Monitoring and Soiled Linen Handling: The facility failed to consistently monitor and document water temperatures under its Legionella surveillance and water management program, with the AM unable to produce the log and unable to identify reportable temperatures. The facility also failed to ensure dirty linens were placed in plastic bags and securely closed before being placed in an uncovered outdoor laundry bin, and staff observed open bags and loose soiled linens in the bin.
Delayed Dental Care and Denture Follow-Up: The facility failed to provide timely dental services for two residents. One resident with heart failure, COPD, and anxiety disorder had no lower teeth, remained on a pureed diet, and reported waiting months for a lower denture after the dentist made an impression, while the SW did not follow up on the delay. Another resident with bipolar disorder, schizophrenia, and anxiety disorder had missing and broken teeth, an ordered dental consult, and reported tooth pain and difficulty eating harder foods, but the dental appointment was not arranged in a timely manner.
Unlabeled and undated food items were found scattered in the walk-in freezer, including frozen tamales, carrots, turkey, chicken, and roast beef. The ADM stated the items should be labeled and dated and kept in the correct box with an open date, and the DS stated kitchen staff must label food when received so dietary staff know how long it has been in the freezer. Facility policy required all foods stored in the refrigerator or freezer to be covered, labeled, and dated with a use by date.
A resident with COPD, major depressive disorder, and schizoaffective disorder was receiving Remeron for depression and Risperdal for schizoaffective disorder, but the record showed no documented GDR for either psychotropic medication. The RNS confirmed no GDR documentation was present, and the DON stated GDRs are used to reduce unnecessary medications and monitor dosage. The facility policy stated residents on antipsychotic drugs shall receive GDRs and behavioral interventions unless clinically contraindicated.
Failure to Investigate and Report an Injury of Unknown Origin: A resident with a prior shoulder dislocation and psychiatric diagnoses later had a new humeral fracture identified, but staff did not know how the injury occurred and did not initiate an abuse/neglect investigation or report it to CDPH. The DON and RNS both stated the fracture met the facility’s definition of an injury of unknown origin, yet no investigation was started when the injury was discovered.
Failure to Report Injury of Unknown Origin: A resident with a prior R shoulder dislocation and sling use later had an acute humeral fracture identified on x-ray, but the DON and RNS stated the facility did not know how the injury occurred and did not initiate an investigation to rule out abuse or neglect. The injury was not reported to CDPH as an injury of unknown origin, despite the facility policy requiring prompt evaluation and reporting of such injuries.
Failure to Investigate Injury of Unknown Origin A resident with a prior R shoulder dislocation and psychiatric diagnoses later developed an acute humeral fracture while in the facility. Hospital imaging earlier showed no fracture, but a later x-ray revealed a new fracture of unknown cause. The RNS and DON stated they did not know how the injury occurred and did not initiate an investigation or report the incident to CDPH, despite the facility policy requiring prompt evaluation of injuries of unknown origin.
Failure to Assist a Resident With Eating: A resident with lack of coordination, HF, DM, depression, and anxiety was observed in the dining room eating very slowly without staff help, with most of the meal still uneaten after 30 minutes before a CNA later assisted him in his room. The MDS indicated setup or clean-up assistance with eating, the resident stated he needed help, and CNAs reported he takes over an hour to eat and benefits from assistance.
Failure to provide resident-preferred in-room activities: A resident with anxiety, major depression, and moderately impaired decision-making was observed lying in bed and reported feeling bored after his spouse’s death. He said books were only brought occasionally and his in-room TV was not working, while activity logs showed the TV/movie option was not offered according to his preferences. The AD was unaware of the broken TV, and the AA said she had not recently checked his preferences.
Failure to Provide Functional Hearing Aids: A resident with hearing loss, cataracts, schizophrenia, and other chronic conditions was found to be hard of hearing and unable to communicate adequately without hearing aids. Staff reported the resident’s hearing aids were kept in the med cart, were not working because the batteries needed replacement, and were not being consistently offered, despite the care plan calling for adaptive communication equipment to be available and functioning.
A resident with a right shoulder dislocation, schizophrenia, anxiety disorder, and autistic disorder did not receive pain management consistent with the assessed pain level. The MAR showed ibuprofen 600 mg ordered PRN for moderate pain, but it was administered for mild pain ratings and once for severe pain; an LVN acknowledged the medication was given without notifying the physician when pain reached 9/10, and the DON stated ibuprofen would not be enough to relieve that level of pain.
The facility failed to ensure CNA 2 had the required CPR competency because the CNA completed an online-only BLS course without the in-person skills demonstration required by policy. The DSD acknowledged accepting the certificate, and the DON stated that online-only CPR training could prevent staff from performing proper CPR safely or responding appropriately during emergencies.
Failure to Follow Antibiotic Stewardship for a Resident’s Metronidazole Cream: A resident with multiple chronic diagnoses was prescribed metronidazole external cream for rosacea, but the IPN was not informed and McGeers criteria were not followed. An LVN stated she believed only oral antibiotics had to be reported and that the resident was not monitored for effectiveness of the cream. The facility policy required ongoing review of drug regimens, including indication and adequate monitoring.
Inaccurate Activity Attendance Documentation: A resident with anxiety, major depression, muscle weakness, and moderately impaired cognitive skills had activity attendance records that were not signed for several entries. The AA stated other activity staff sometimes assisted and may have failed to sign the records, while also stating that if an activity was not documented it was considered not done. The DON stated that activities completed for each resident must be documented to show they were provided, and the facility policy required accurate, complete, timely documentation signed by the person who provided the service.
The facility failed to implement its Antibiotic Stewardship Program for a resident with UTI, DM, anxiety disorder, and schizoaffective disorder. A urinalysis showed WBCs in the urine, but the urine culture identified normal genitourinary flora with 25,000 CFU/mL and no sensitivity testing, yet Ciprofloxacin was ordered and given for UTI. The IPN stated she did not verify the culture before starting the antibiotic and should have clarified the order with the physician; the DON stated unnecessary antibiotic use could lead to resistance and MDRO.
A resident with major depressive disorder and moderate cognitive impairment reported being struck and expressed fear, indicating a psychosocial change in condition. Despite facility policy requiring physician notification and care plan updates for such changes, staff did not notify the physician or update documentation, citing the resident's history of similar statements. The omission was acknowledged by nursing leadership, and the resident's psychological evaluation reflected ongoing distress.
A resident with major depressive disorder and moderate cognitive impairment reported being struck and expressed ongoing fear, indicating a psychosocial change in condition. Despite staff awareness of the incident and facility policy requiring care plan review after such changes, the care plan was not updated to address the resident's new needs. This resulted in the resident's psychosocial concerns and safety issues not being incorporated into their care plan.
A resident with severe cognitive impairment and a history of schizophrenia poured water on another resident's face while she was receiving ADL care, causing distress and a sensation of drowning. The incident occurred when the CNA briefly left the room, and prior conflicts between the two residents had been observed. The DON was not aware of the incident, but facility policy prohibits abuse by anyone, including other residents.
A resident with intact cognition and dependent on staff for ADLs reported to a CNA that another resident with schizophrenia and severe cognitive impairment poured water on her face, causing distress. The CNA did not report the allegation to the DON or ADM as required by facility policy, resulting in the incident not being reported to CDPH or the ombudsman and preventing a timely investigation.
A treatment nurse failed to wear a gown while providing wound care to a resident with chronic osteomyelitis and peripheral vascular disease who was on enhanced barrier precautions (EBP). Despite clear physician orders and facility policy requiring gown and glove use for high-contact activities like wound care, only gloves were used. Staff interviews confirmed that gowns should have been worn during such care.
Missing window blinds in multiple resident rooms left residents exposed to the parking lot and sunlight, with one resident stating they covered their head when the sun rose and another stating the blinds had been broken for a long time. The DON was aware of the issue, and the MD said the broken blinds had been brought to his attention but he had not followed up; the MD also confirmed the exposure and noted the blinds were being repaired.
Unsanitary Resident Room Conditions: A resident with schizoaffective disorder, hyperlipidemia, and lack of coordination had intact decision-making and needed partial/moderate help with several ADLs. During observation, the resident’s room was found unsanitary with overflowing trash, brown substances on the floor, juice-like stains on the wall, and black stains in the restroom around the toilet. CNA, HK, HS, and DON statements reflected that the room had not been cleaned at the time of the observation.
A resident with moderate cognitive impairment experienced new right hip pain and decreased mobility, later found to be a hip fracture of unknown origin. Staff did not escalate the change in condition to the DON or order diagnostic imaging, and the injury was not reported to the state agency as required by facility policy. The deficiency resulted from lack of communication and failure to follow reporting procedures for injuries of unknown origin.
A resident with moderate cognitive impairment and no prior mobility issues developed new right hip pain and decreased range of motion, requiring increased assistance with daily care. The CNA notified the LVN, who assessed the resident and informed the physician, but did not escalate the change in condition to the DON or initiate further investigation. The resident was later found to have a right hip fracture after transfer to a hospital, but the injury was not reported to the state agency or investigated as required by facility policy.
A resident with a history of orthopedic aftercare, epilepsy, and bipolar disorder experienced new right hip pain and decreased range of motion, requiring increased assistance with ADLs. The LVN assessed the resident but did not report the change of condition to the DON, as required by facility policy. The resident was later found to have a right hip fracture after being transferred to a hospital, and the incident was classified as an injury of unknown origin due to lack of timely reporting and assessment.
Two residents with psychiatric diagnoses, both requiring supervision while smoking, were left unsupervised on the patio and became involved in an argument that escalated to physical abuse, resulting in injury. One resident had exhibited escalating behaviors throughout the night, including yelling and demanding cigarettes, but staff did not notify a physician or provide additional monitoring. Facility policies requiring supervision and behavioral monitoring were not followed, leading to the incident.
Two residents, both requiring supervision while smoking due to mental health diagnoses and behavioral concerns, were left unsupervised on the patio during nighttime hours. Despite facility policies mandating direct supervision and restricted access to smoking materials, both residents accessed cigarettes and smoked without staff oversight. One resident, exhibiting aggressive behavior, assaulted the other during this unsupervised period, resulting in physical injury. Staff interviews confirmed lapses in monitoring and supervision, directly leading to the incident.
A resident with multiple medical and cognitive conditions was struck on the face by another resident, resulting in a laceration and swelling. After returning from the hospital, staff did not perform or continue neurological checks to monitor for signs of neurological decline, despite acknowledgment from nursing staff and the DON that such monitoring was necessary following the incident.
The QAPI committee did not address or develop corrective plans for identified deficiencies related to abuse and smoking supervision after a facility-reported incident. The DON confirmed these issues were not included in the QAPI agenda, and the ADM stated they would be reviewed in a future meeting. Facility policy requires a systematic approach to performance improvement, but this was not followed, resulting in repeated deficiencies.
During a Covid-19 outbreak, four staff members, including a CNA, housekeeper, LVN, and the Administrator, were observed not wearing masks in various areas of the facility, despite the facility's policy and reminders from leadership. The facility's Covid-19 Mitigation Plan required all staff to wear PPE, including facemasks, when Covid-19 cases were present, but staff non-compliance was observed and acknowledged by leadership. The outbreak involved two residents who tested positive for Covid-19.
The facility failed to cover three outside grey garbage dumpsters, as confirmed by the DON and ADM. The facility's policies require dumpsters to have tightly fitting lids to prevent attracting pests. This deficiency was observed during a survey.
A resident with severe cognitive impairment was assaulted by her roommate, who also had cognitive impairments, in an LTC facility. The assault occurred while the resident was asleep, resulting in a contusion that required hospital evaluation. The facility's failure to monitor and protect residents from harm led to this deficiency.
The facility failed to discard expired food items, including chicken, salads, and vegetables, found in the refrigerator during a survey. Staff interviews confirmed that the food was outdated and should not have been stored, violating the facility's policies. The Dietary Manager and Director of Nursing acknowledged the risks of foodborne illnesses from consuming expired food.
The facility failed to accurately document advance directives for five residents, leading to potential conflicts with their healthcare wishes. Deficiencies included missing signatures and incomplete documentation, as identified through interviews and record reviews. Staff emphasized the importance of accurate documentation to ensure residents' preferences are respected.
The facility failed to accurately document PASARR screenings for five residents, leading to potential inappropriate placements and delays in needed services. Residents with mental illnesses and cognitive impairments did not receive necessary Level II screenings due to unresponsiveness and oversight by staff, despite facility policies requiring such evaluations.
A facility failed to provide adequate range of motion (ROM) care for three residents, leading to deficiencies in their care plans and physician orders. One resident did not receive passive range of motion (PROM) exercises for both arms and ankles, while another did not receive PROM for elbows, wrists, hands, knees, and ankles, and had improperly positioned hand towels. A third resident did not receive PROM for the left hand. Observations and interviews revealed that these omissions were due to documentation errors, nervousness, and forgetfulness.
The facility failed to maintain infection control practices for four residents. A resident's humidifier was not changed weekly, risking bacterial growth. Another resident on Enhanced Barrier Precautions did not receive care with the required PPE. Additionally, two residents did not receive proper hand hygiene precautions before eye drop administration, violating facility policy.
A resident's call light was found inaccessible, wrapped around the bed rails, causing distress and inability to call for assistance. The resident, with multiple health conditions, required extensive assistance. Staff interviews confirmed the expectation for call lights to be within reach, and the facility's policy supported this requirement.
A resident's bed in an LTC facility was found to be malfunctioning, unable to adjust and leaning to one side, posing a safety risk. Despite the resident's moderate cognitive impairment and need for assistance, the issue persisted for three months. Facility staff, including a CNA, LVN, and Maintenance Supervisor, confirmed the malfunction and acknowledged the safety risk, highlighting a failure to adhere to the facility's bed maintenance policy.
A resident with severe cognitive impairment and multiple diagnoses, including COPD and bipolar disorder, did not receive proper fingernail care, resulting in long and dirty nails. Despite the resident's dependency on staff for personal hygiene, the CNA did not clean the nails, citing refusal without documentation. Interviews with staff revealed a lack of adherence to the facility's policy on nail care, which emphasizes the importance of grooming to maintain residents' self-esteem.
A resident with a history of schizophrenia and other conditions was observed with redness and swelling on the right eye and cheek, which was not documented or reported by the CNA or LVN. The facility's policies require immediate reporting and documentation of skin concerns, which was not followed, leading to a failure in providing necessary care and treatment.
The facility's Restorative Nursing Aide (RNA) staff failed to competently perform range of motion (ROM) exercises and apply splints for three residents with limited mobility. Observations revealed incomplete execution of physician-ordered exercises, with RNAs admitting to oversights and nervousness. The facility had not provided recent in-service training on these tasks, potentially impacting residents' ROM and function.
The facility failed to administer medications as per physician orders, affecting several residents. A resident did not receive risperidone as prescribed, and there was an error in administering calcium with vitamin D. Another resident's docusate sodium order lacked clarity, posing risks of improper treatment. Additionally, discrepancies in the Controlled Drug Record for Vimpat and lorazepam were noted, with the LVN failing to document administration immediately, increasing the risk of medication errors and potential misuse.
A facility failed to monitor a resident's behavior while on Risperdal for psychosis, risking unnecessary medication use. The resident, with severe cognitive impairment and auditory hallucinations, was not monitored for medication effectiveness, contrary to the care plan and facility policy. Staff confirmed the lack of monitoring, acknowledging the risk of unnecessary medication.
A medication error rate of 7.14% was observed in an LTC facility when an LVN failed to administer risperidone and incorrectly gave a combination of calcium with vitamin D instead of separate doses. The resident involved had a history of cognitive impairment and multiple medical conditions. The facility's policy emphasizes the importance of following physician orders and verifying medications against the MAR.
The facility failed to properly store and label medications, leading to deficiencies in medication management. Bisacodyl suppositories and brimonidine eye drops were stored incorrectly, and expired medications were not removed from the Central Supply Room. Additionally, several medications in the carts lacked proper labeling, affecting multiple residents and increasing the risk of medication errors.
A facility failed to document complete RNA treatment records for a resident with limited ROM and mobility. The RNA treatment record for October was incomplete for PROM exercises to the right leg, despite physician orders. The resident, with multiple diagnoses, refused PROM for the right leg, which was not documented. The DMR confirmed the record's incompleteness, highlighting the risk of contractures. The DON stressed the need for accurate records to ensure proper care.
The facility failed to create comprehensive care plans for two residents, one with a history of fabricating stories and another with facial redness and swelling. The absence of specific care plans for these issues was acknowledged by staff, highlighting a risk of delayed care and treatment.
The facility failed to record therapy start and end dates on the MDS for three residents, resulting in incomplete data submission. Residents received therapy for various conditions, achieving significant progress, but the MDS lacked necessary documentation. Interviews revealed staff were unaware of the requirement to include these dates.
A resident was not readmitted to the facility after hospitalization despite available beds, due to a misunderstanding of infection control requirements. The resident, who contracted Candida auris at the hospital, was refused readmission based on the facility's belief that no isolation beds were available. However, guidelines indicated that residents with MDROs do not require single-person rooms. This resulted in the resident staying at the hospital for 11 days before being transferred to another facility.
Infection Control Deficiencies in Water Monitoring and Soiled Linen Handling
Penalty
Summary
The facility failed to implement and document regular monitoring of water temperature under its water management plan. During interviews, the Maintenance Supervisor stated the facility checked water temperature daily in resident rooms, the laundry, and the kitchen and documented it in a log, with temperatures expected to be 110°F to 115°F. The Assistant Maintenance staff later stated he had misplaced the binder containing the water temperature log and was unable to say where it was, and he could not identify what temperatures should be reported to the Administrator or Infection Preventionist Nurse. The Infection Preventionist Nurse reviewed the facility’s Legionella Surveillance policy and stated that failure to monitor and document water temperature could put all residents at risk for Legionnaires’ disease because the facility would not know if the water was contaminated with Legionella. The facility’s Legionella Surveillance policy, revised in 2022, stated that Legionella grows best in water temperatures of 77°F to 108°F and identified temperature controls as a primary prevention strategy. The policy also stated that cold water should be stored and distributed below 68°F, hot water should be stored above 140°F, and circulated at a minimum return temperature of 124°F. The Water Management Program policy, revised in 2022, stated that water temperature logs are used by the water management team to identify where Legionella and other waterborne pathogens can grow and spread in the facility’s water systems. The Administrator stated the Assistant Maintenance staff left the binder at home and temperatures were not being checked consistently. The facility also failed to ensure dirty linens were placed in plastic bags and securely closed before being placed in an open laundry bin outside the facility. During observation, an uncovered large blue bin for dirty linens was seen outside the facility, and dirty linens were observed not placed in a plastic bag and mixed with other plastic bags filled with dirty laundry. Open plastic bags filled with dirty linens were also observed in the bin. The Housekeeping Supervisor stated dirty linens should be placed in a plastic bag and securely closed before being put in the blue bin, and a CNA stated the plastic bag should be closed securely to prevent dirty linens from falling out and causing cross contamination. The Infection Preventionist Nurse stated dirty linens should be bagged and securely closed before placement in the uncovered laundry bin to prevent spread of infection.
Delayed Dental Care and Denture Follow-Up
Penalty
Summary
The facility failed to provide timely dental services for two sampled residents. Resident 59 was admitted with diagnoses including heart failure, COPD, and anxiety disorder, and his care plan identified nutritional status risk related to a mechanically altered diet. His MDS showed moderately impaired cognition and substantial to maximal assistance needs with eating and oral hygiene. During observation, he had no lower teeth and stated he had been waiting six months for his lower denture, remained on a pureed diet because he could not chew regular-texture foods, and wanted to eat foods such as a sandwich. The Social Worker stated the dentist made an impression for the lower denture in December 2025, but she did not follow up on its status and acknowledged it was her responsibility to determine the cause of the delay. Resident 32 was admitted with diagnoses including bipolar disorder, schizophrenia, and anxiety disorder. The order summary included a dental consult with treatment as needed and as indicated, and the oral/dental assessment documented missing and unclean teeth. The MDS indicated intact cognition and supervision or touching assistance with eating and oral hygiene. During observation, Resident 32 was eating lunch and had missing and broken teeth in the upper and lower mouth, and he stated that sometimes his teeth hurt and he was unable to eat harder foods like an apple. The Social Worker stated newly admitted residents are typically seen by a dentist within a couple of weeks, but she missed arranging the appointment for Resident 32 due to workload, resulting in the resident not being seen in a timely manner.
Unlabeled and Undated Frozen Food Items
Penalty
Summary
Food items kept in the walk-in freezer were observed unlabeled and undated during a concurrent observation and interview with the Assistant Dietary Manager in the kitchen. The items included a bag of frozen tamales, a bag of frozen carrots, frozen turkey, frozen chicken, and a frozen roast beef that were scattered throughout the freezer and out of their boxes. The Assistant Dietary Manager stated these foods should be labeled and dated, and later stated they should be inside the correct box with an open date so staff would know what the product is and whether it is expired. During a later interview, the Dietary Supervisor stated that when food products are received, kitchen staff need to label the food product and write the date it was received. The Dietary Supervisor also stated dietary staff needed to know how long food has been in the freezer because expired food could cause food borne illness. Review of the facility policy titled Food Receiving and Storage indicated that all foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use by date.
Lack of Documented GDR for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that one sampled resident with diagnoses including COPD, major depressive disorder, and schizoaffective disorder received a documented gradual dose reduction (GDR) for psychotropic medications. Resident 12 had orders for Remeron 0.5 mg for depression and Risperdal 0.5 mg for schizoaffective disorder, but the record review and staff interview showed there was no documentation that a GDR had been completed for either medication. During interviews, the RNS stated that no GDR documentation was present and explained that a GDR is used to ensure the resident receives the right amount of medication and to monitor and decrease dosage. The DON stated that GDRs are done to reduce unnecessary medications that may cause side effects such as sleepiness, which can affect ADLs. The facility policy titled Tapering Medications and Gradual Drug Dose Reduction stated that residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions unless clinically contraindicated.
Failure to Investigate and Report an Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse, neglect, and injury reporting policy for a resident who developed a right humeral fracture of unknown origin. Resident 9 was admitted with a right shoulder dislocation and multiple diagnoses including autistic disorder, schizophrenia, and anxiety disorder. On 1/6/2026, the resident complained of right shoulder pain and was transferred to a GACH; the hospital history noted the resident had been assaulted in another GACH, and the right shoulder x-ray showed no fracture or dislocation, only mild soft tissue swelling. Resident 9 remained on a care plan for right shoulder discomfort and wore a sling. The resident’s records later showed a right shoulder x-ray on 2/23/2026 with a minimally comminuted greater tuberosity fracture and an acute appearing humeral head fracture. A COC evaluation on the same date documented a humeral fracture and transfer to another GACH for orthopedic evaluation. The resident’s H&P noted fluctuating capacity to understand and make decisions, while the MDS documented intact cognition and the need for supervision or touching assistance with several activities. Facility staff stated they did not know how the fracture occurred and did not investigate the injury to rule out abuse or neglect. The RNS stated the fracture should have been investigated and reported immediately as an injury of unknown origin under the facility policy. The DON also stated she did not report the fracture to CDPH, did not initiate an investigation, and did not notify the Administrator when the fracture was discovered. The facility policy stated injuries of unknown origin are to be promptly evaluated and reported in accordance with federal and California regulations, and that physical injury from an unknown source is a possible indicator of abuse, neglect, or exploitation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to CDPH for one resident who sustained a right humeral fracture. The resident had been admitted and later readmitted to the facility with diagnoses including autistic disorder, unspecified dislocation of the right shoulder joint, schizophrenia, and anxiety disorder. The resident was observed with the right arm in a sling, and the record showed a prior change in condition for right shoulder pain and dislocation that resulted in transfer to a GACH for evaluation. The resident’s records showed that a right shoulder x-ray on the earlier hospital visit found no fracture or dislocation, only mild soft tissue swelling. The care plan addressed the shoulder dislocation with pain monitoring, pain medication, and sling use, and rehabilitation screening documented non-weight bearing status to the right upper arm with a soft sling. Later, a right shoulder x-ray revealed a minimally comminuted greater tuberosity fracture and an acute appearing humeral head fracture, and the resident was transferred again for orthopedic evaluation. Interviews with the RNS and DON established that the facility did not know how the fracture occurred and did not initiate an investigation to rule out abuse or neglect when the fracture was discovered. The RNS stated the injury should have been investigated and reported immediately to CDPH under the facility’s Abuse, Neglect, and Injury Reporting Policy. The DON stated she did not report the fracture to CDPH, did not initiate an investigation, and did not notify the Administrator when the fracture was found. The facility policy stated injuries of unknown origin are to be promptly evaluated and reported in accordance with federal and California regulations.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate a humeral fracture of unknown origin for one resident. The resident was admitted with a right shoulder dislocation and had diagnoses including autistic disorder, schizophrenia, and anxiety disorder. Early in the stay, the resident complained of right shoulder pain and was transferred to a general acute care hospital for evaluation. Hospital records from that time showed no fracture or dislocation on right shoulder x-ray, only mild soft tissue swelling, and the resident returned to the facility with a sling and non-weight-bearing status for the right upper arm. On 2/23/2026, a right shoulder x-ray showed a minimally comminuted greater tuberosity fracture and an acute appearing humeral head fracture. A change in condition evaluation documented the humeral fracture and transfer to another hospital for orthopedic evaluation. Facility staff, including the RNS and DON, stated they did not know how the fracture occurred. They also stated the injury was not investigated to determine whether abuse or neglect had occurred, and the DON acknowledged that no report was made to CDPH and no investigation was initiated when the fracture was discovered. The facility’s records and interviews showed the resident had fluctuating decision-making capacity, with MDS documentation indicating intact cognition but needing supervision or touching assistance for several activities. The facility’s policy stated that injuries of unknown origin must be promptly evaluated and reported, and that such injuries include those not observed by staff, inconsistent with the resident’s condition, or lacking sufficient information to determine the cause. Staff interviews confirmed the fracture met the facility’s definition of an injury of unknown origin, but no investigation was started when the injury was identified.
Failure to Assist Resident With Eating
Penalty
Summary
The facility failed to ensure that one sampled resident was assisted with eating during meals. During an observation in the dining room, the resident was seated in a wheelchair, rocking back and forth, and held a spoon in his right hand for 10 minutes before spooning food into his mouth while staff were observed by facility staff. In a later observation, the resident still had 75% of his meal on his plate after 30 minutes without staff assistance, and was then observed in his room being assisted with the meal by a CNA after not being helped in the dining room. The resident’s admission record listed diagnoses including lack of coordination, heart failure, diabetes mellitus, hyperlipidemia, depression, and anxiety. The H&P indicated the resident had the capacity to understand and make decisions. The MDS dated 1/22/2026 indicated the resident needed setup or clean-up assistance with eating. During interview, the resident stated he needed assistance with eating. CNAs stated the resident eats slowly, takes more than an hour to feed himself, rocks back and forth, and benefits from help with eating. The RNS stated the resident could have a potential for weight loss if not assessed properly, and the DON stated a negative outcome for weight loss could result from the resident’s lack of coordination with feeding.
Failure to Provide Resident-Preferred In-Room Activities
Penalty
Summary
The facility failed to provide one of 18 sampled residents, Resident 63, with activities or regular room visits as part of an ongoing program to support the resident’s chosen activities. Resident 63 was admitted with diagnoses including anxiety, major depression, and muscle weakness. The MDS dated 02/22/2026 indicated the resident’s cognitive skills for daily decision making were moderately impaired and that he required setup or clean-up assistance from staff for ADLs. During observations on 02/24/2026 and 02/25/2026, Resident 63 was found lying quietly in bed, including staring at the walls of his room. In interview, he stated that no one regularly brought him books and that it only happened occasionally during his stay. He said he did not like going out for activities for personal reasons, preferred his in-room television to be working so he could watch programs, and reported that his wife had recently passed away and that he often felt bored. The Activity Director stated she was not aware the resident’s room television was not working and said she did not provide in-room activities herself, primarily conducting rounds. Activity participation logs showed the in-room activity option coded as V4 (movies/TV) was not offered to Resident 63 according to his preferences throughout February 2026. The Activity Assistant stated she thought the resident did not like television and could not recall the last time she checked whether he wanted to watch TV or movies. The DON stated activities should be encouraged for all residents and that resident preferences should be obtained and refusals or actions taken documented.
Failure to Provide Functional Hearing Aids
Penalty
Summary
The facility failed to ensure one resident was offered functional hearing aids that were available for use. The resident’s record showed diagnoses including hypertensive heart disease, osteoarthritis, cataracts, and schizophrenia. The history and physical noted hearing loss and difficulty, that the resident could read lips, and that written questions or statements could be understood when shown to him. The MDS showed the resident required assistance with multiple activities of daily living, including toileting, showering, dressing, eating, oral hygiene, personal hygiene, transferring, and walking. During observation and interviews, the resident was noted to be hard of hearing and stated he had hearing aids but did not wear them because they were too big. CNA staff stated the resident was unable to hear and that communication was done by typing messages on a phone or writing on paper; the CNA had not seen hearing aids at the bedside and was not aware of anything being done to improve hearing. RNA staff stated the resident needed loud speech or lip reading and would benefit from hearing aids. The care plan indicated the resident required hearing aids to communicate and that adaptive communication equipment should be available and functioning, but staff stated the hearing aids were kept in the medication cart, were supposed to be offered by licensed staff, and were not working because the batteries needed replacement. Staff also stated there was no system to check whether the resident was being offered the hearing aids, and the DON stated the resident would not be able to communicate his needs with hearing aids that were not working.
Inadequate Pain Medication Administration for Resident with Shoulder Dislocation
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met for Resident 9. Resident 9 was admitted and later readmitted to the facility with diagnoses including autistic disorder, unspecified dislocation of the right shoulder joint, schizophrenia, and anxiety disorder. The record also noted fluctuating capacity to understand and make decisions in the H&P and intact cognition in the MDS. During observation, Resident 9’s right arm was seen in a sling, and the care plan for alteration in comfort related to the right shoulder dislocation directed pain monitoring every shift and administration of ibuprofen with monitoring for side effects. The MAR showed an order for ibuprofen 600 mg every 12 hours as needed for moderate pain, yet the medication was given on multiple occasions for pain levels of 2/10 and once for a pain level of 9/10. During interview, the LVN stated Resident 9 sometimes received ibuprofen for mild discomfort, acknowledged he should have notified the physician when the pain level reached 9 because ibuprofen was ordered only for moderate pain levels of 5 to 7, and stated he did not call the physician regarding the 9/10 pain level. The DON stated the licensed nurse should have notified the physician when Resident 9’s pain level was 9/10 because ibuprofen would not be enough to relieve the pain. The facility policy on Pain Assessment and Management stated the facility will identify pain in the resident and develop interventions consistent with the resident’s goals and needs.
Inadequate CPR Competency Verification for CNA
Penalty
Summary
The facility failed to ensure CNA 2 had the competency to perform CPR because the CNA completed an online-only Basic Life Support course without the required in-person skills demonstration. During a concurrent interview and record review with the DSD, CNA 2’s BLS certificate and the facility’s CPR policy were reviewed, and the DSD stated she had accepted the online-only certificate even though the facility requires hands-on CPR competency for BLS certification. During an interview with the DON, it was stated that CNAs obtaining BLS certification through online-only courses could negatively impact resident care because staff would be unable to perform proper CPR safely or respond appropriately during emergencies. Review of the facility’s CPR policy showed that staff are to maintain current CPR certification through a provider who evaluates proper technique through in-person demonstration of skills, and that online knowledge components still require in-person skills demonstrations to obtain certification.
Failure to Follow Antibiotic Stewardship for a Resident’s Metronidazole Cream
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for one resident who was prescribed metronidazole external cream for rosacea without meeting McGeers Criteria. The resident’s record showed admission and readmission to the facility, with diagnoses including hypertensive heart disease, osteoarthritis, cataracts, and schizophrenia. The resident’s H&P stated the resident was self responsible, and the MDS indicated the resident required substantial to maximal assistance with toileting, showering, and dressing, and partial to moderate assistance with eating, oral hygiene, personal hygiene, transferring, and walking. During record review and interviews, the Infection Preventionist Nurse stated she had not been informed of the resident’s antibiotic order and that McGeers criteria were not followed because the antibiotic use was not communicated. A Licensed Vocational Nurse stated the resident developed redness on the face and scalp and that metronidazole cream was ordered multiple times, but she did not notify the Infection Preventionist Nurse because she believed only oral antibiotics had to be reported. The LVN also stated the resident was not monitored for effectiveness of the cream. The facility policy stated each resident’s drug regimen must be reviewed on an ongoing basis considering dose, duration, indication, and adequate monitoring, and that drug use must be documented to facilitate appropriate monitoring and resident-centered care.
Inaccurate Activity Attendance Documentation
Penalty
Summary
The facility failed to ensure that the Activity Assistant accurately documented Resident 63’s activity attendance record. During review of the resident’s records, Resident 63 was noted to have been admitted with diagnoses including anxiety, major depression, and muscle weakness. The resident’s MDS dated 02/22/2026 indicated moderately impaired cognitive skills for daily decision-making and that the resident required setup or clean-up assistance from staff for ADLs. During a concurrent interview and record review on 02/26/2026, the Activity Assistant reviewed Resident 63’s activity attendance record and stated she did not know why the dates 2/12, 2/13, 2/14, and 02/24/2026 were not signed. She stated other activity staff sometimes assist with activities and may have failed to sign the records, and she believed the activities were completed for Resident 63 on those dates. The Activity Assistant also stated that if an activity was not recorded or documented, it was considered not done. The DON later stated that any activities completed for each resident must be documented to reflect that they were provided, and that documentation demonstrates the service was provided. The facility policy required staff to maintain accurate, complete, and reliable documentation and to sign entries for services they personally provided.
Failure to Monitor Antibiotic Use and Review Appropriateness of Ciprofloxacin
Penalty
Summary
The facility failed to ensure its Antibiotic Stewardship Program was implemented for one resident who was admitted with diagnoses including UTI, anxiety disorder, DM, and schizoaffective disorder. The resident had a urinalysis from the hospital showing white blood cells in the urine and a urine culture that identified normal genitourinary flora with 25,000 CFU/mL. Despite these results, the resident was ordered Ciprofloxacin 500 mg by mouth twice daily for UTI for 4 days. During interview and record review, the Infection Preventionist Nurse stated she did not verify whether a urine culture had been obtained before starting Ciprofloxacin and acknowledged the culture showed a bacterial count below the threshold required to start antibiotic therapy. She also stated the culture did not include sensitivity testing and that she should have clarified the order with the physician before starting the antibiotic. The Infection Preventionist Nurse stated it was her responsibility to track and monitor antibiotic use to ensure compliance with the Antibiotic Stewardship Program, and the DON stated that giving an antibiotic without proper indication could lead to resistance to most antibiotics and MDRO.
Failure to Notify Physician and Update Care Plan After Resident's Reported Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for one of three sampled residents after the resident reported being struck and expressed fear, indicating a psychosocial change. The resident, who had a history of major depressive disorder and moderate cognitive impairment, reported to the ombudsman that an unknown black male struck him in the stomach. The incident was communicated to facility staff, including an LVN, RNS, and the DON, but there was no documentation of physician notification or care plan review and update in response to the reported allegation. Interviews with staff revealed that the LVN did not notify the physician or document the incident, believing it was unnecessary due to the resident's history of making similar statements. The RNS and DON both acknowledged that a report of being struck and expressing fear constitutes a change in condition, including a psychosocial change, and that facility policy requires physician notification, documentation, and care plan review and update. However, these actions were not taken for the resident in question. A review of the resident's psychological consultation indicated ongoing feelings of unsafety and persecution based on race. The facility's policy and procedure on changes in a resident's condition or status requires prompt notification of the resident, attending physician, and representative of changes in medical or mental condition. Despite this, the required notifications and documentation were not completed following the resident's report of being struck and expressing fear.
Failure to Update Care Plan After Resident's Psychosocial Change in Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident following a reported change in condition. The resident, who had a history of major depressive disorder and moderate cognitive impairment, reported being struck by an unknown individual and expressed ongoing fear for his safety. Despite this significant psychosocial change, there was no documentation that the resident's care plan was reviewed or updated to address his new needs. Interviews with facility staff, including an LVN, RN Supervisor, and the Director of Nursing, confirmed that they were made aware of the resident's allegation and recognized it as a change in condition requiring care plan review and revision. However, the care plan was not updated after the incident was reported. Staff acknowledged that this omission could result in the resident's needs not being addressed, including unresolved fear and psychosocial distress. A psychological consultation further documented the resident's feelings of being unsafe and persecuted, yet these concerns were not reflected in the care plan. Review of facility policy indicated that care plans should be reviewed and revised for residents experiencing a status change, but this procedure was not followed in this case.
Failure to Protect Resident from Peer-to-Peer Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident with a history of schizophrenia and severe cognitive impairment poured water on her face while she was receiving assistance with activities of daily living (ADLs). The affected resident, who was dependent on staff for ADLs and had intact cognition, reported feeling like she was drowning as the water covered her face and entered her mouth and throat. Witnesses, including another resident, described the act as intentional and distressing, and noted that staff were present in the room during previous verbal altercations between the two residents. The certified nursing assistant (CNA) providing care to the affected resident had left the room briefly, during which time the incident occurred. Upon returning, the CNA found the resident crying and soaked, and was informed of the water being poured. The CNA also reported prior incidents of conflict between the two residents, including verbal aggression and disputes over personal belongings. The Director of Nursing (DON) was unaware of the incident at the time of the interview but acknowledged that such an act would be considered abuse according to facility policy, which states that residents must not be subject to abuse by anyone, including other residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents. One resident, who was cognitively intact and dependent on staff for activities of daily living (ADLs), reported to a CNA that another resident, who had severely impaired cognition and a diagnosis of schizophrenia, poured water on her face while she was receiving care. The affected resident described feeling as though she was drowning and was observed crying with her upper body soaking wet. The CNA stated that upon returning to the room, she found the resident in distress and was informed of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse to the DON or ADM, the CNA did not report the allegation to the appropriate personnel. The DON confirmed she was unaware of the incident and had not been informed by the CNA. As a result, the incident was not reported to the California Department of Public Health (CDPH) or the ombudsman, preventing a timely investigation and risking the loss or forgetting of critical information.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a treatment nurse provided wound care to a resident with chronic osteomyelitis and peripheral vascular disease without wearing a gown, despite the resident being on enhanced barrier precautions (EBP) due to an open wound. The nurse was observed wearing gloves only while performing wound care on the resident's left plantar foot, even though an EBP sign was posted outside the resident's room and the physician's order specified the use of EBP for this resident. The nurse later stated she was unaware that a gown was required for wound care under EBP. Interviews with the infection control nurse and the director of nursing confirmed that staff are expected to wear gowns and gloves during high-contact care activities, such as wound care, for residents on EBP. The facility's policy also indicated that personal protective equipment, including gowns, is necessary during high-contact activities involving skin openings requiring dressings. The failure to follow these protocols was directly observed and confirmed through staff interviews and record review.
Missing Window Blinds Compromised Resident Privacy
Penalty
Summary
The facility failed to ensure that window blinds were intact and provided adequate visual privacy for 5 of 18 sampled residents. During observation and interview, Resident 1’s room window blinds were missing slats, which allowed sunlight and visibility from the parking lot into the room. Resident 1 stated, “I turn to the opposite side and cover my head when the sun rises.” In another observation, Resident 4’s room had missing pieces in the window blinds, and the room was exposed to the parking lot with sunlight penetrating onto Resident 4’s face. Resident 4 stated that the blinds had been broken for a long time and no one had come to fix them. During interview, the DON stated she was aware of the missing blinds. The MD stated the broken window blinds had been brought to his attention, but he had failed to follow up, and he identified that it was his responsibility to conduct daily rounds. The MD also confirmed that the missing blinds exposed residents to the parking lot and sunlight. Review of the facility’s policies stated that residents have a right to a safe, clean, comfortable, and homelike environment.
Unsanitary Resident Room Conditions
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for one resident. The resident had diagnoses including schizoaffective disorder, hyperlipidemia, and lack of coordination. The resident’s MDS dated 09/19/2025 indicated intact cognitive skill for daily decision-making and that the resident required partial/moderate assistance with oral hygiene, toilet hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation on 11/19/2025 at 9:30 a.m., the resident’s room was observed in an unsanitary condition. Trash was overflowing from the bedside trash can, brown substances were scattered on the floor near the bed, the wall beside the bed had visible juice-like stains, and the restroom had multiple black stains on the floor and around the toilet. CNA 1 stated she had not yet called housekeeping because she was waiting to assist the resident out of the room, and said she should have picked up the trash and cleaned the area even while attending to other residents. HK stated resident rooms were cleaned once per shift and as needed, while HS stated rooms are cleaned daily and housekeepers were expected to make rounds of their assigned areas before leaving. The DON stated she was unaware of the room’s condition and acknowledged that all rooms were undergoing remodeling.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who experienced a significant change in condition, specifically right hip pain and decreased range of motion, which was later diagnosed as a right hip fracture. The resident, who had moderate cognitive impairment and no prior functional limitations in range of motion, was found by a CNA to be unable to move his right leg and required increased assistance with activities of daily living. The CNA notified the LVN, who assessed the resident but did not observe visible bruising or swelling and administered Tylenol for pain. The LVN did not escalate the change in condition to the Director of Nursing (DON) or recommend further assessment, such as an X-ray, and only informed the resident's physician, who ordered additional pain medication but no diagnostic imaging. The resident was subsequently transferred to a general acute care hospital for an unrelated incident, where a right hip fracture was discovered several days later, necessitating surgery. Upon the resident's readmission to the facility, the DON became aware of the hip fracture and, upon review, determined that the injury was of unknown origin, as neither staff nor the resident could explain how it occurred. The facility's policy required that injuries of unknown origin be reported to the state agency immediately, but this was not done because the DON was not informed of the initial change in condition or the injury at the time it occurred. Interviews with staff revealed that the LVN did not consider the resident's complaints and decreased mobility to be significant enough to warrant supervisor notification or further investigation. The DON confirmed that, according to facility policy, the injury should have been reported to the state agency as soon as it was discovered, but this did not happen due to a lack of communication and awareness among staff. The failure to report the injury of unknown origin constituted a deficiency in the facility's abuse, neglect, and exploitation reporting procedures.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was found to have a right hip fracture. The resident, who had a history of orthopedic aftercare, epilepsy, and bipolar disorder, was noted to have moderate cognitive impairment but no prior functional limitations in range of motion. On the morning in question, the resident complained of right hip pain radiating to the knee and was unable to perform activities of daily living without assistance, which was a change from his baseline. The certified nursing assistant (CNA) observed that the resident could not move his right leg and required two people to assist with care, prompting the CNA to notify the charge nurse (LVN). The LVN assessed the resident, noted the new pain and decreased range of motion, but did not observe any bruising or swelling. The LVN administered Tylenol and informed the resident's physician, who ordered additional pain medication but did not order diagnostic imaging. The LVN did not report the change in condition or the new symptoms to the director of nursing (DON), as required by facility protocol. The resident was subsequently transferred to a general acute care hospital for an unrelated issue, where a right hip fracture was discovered several days later. Upon the resident's return to the facility, the DON became aware of the hip fracture and recognized it as an injury of unknown origin. The DON confirmed that the incident was not reported to the state agency as required by both facility policy and regulation, and no investigation was conducted into the cause of the injury. Facility policies reviewed indicated that all injuries of unknown origin must be reported immediately and thoroughly investigated, but these steps were not followed in this case.
Failure to Report Change of Condition Results in Delayed Identification of Hip Fracture
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to demonstrate competency in recognizing and reporting a change of condition (COC) for a resident who developed new right hip pain and decreased range of motion (ROM). The resident, who had a history of orthopedic aftercare, epilepsy, and bipolar disorder, was previously able to ambulate and perform activities of daily living (ADLs) independently. On the morning in question, the resident was unable to move his right leg, required increased assistance from a certified nursing assistant (CNA), and reported significant pain. The CNA notified the LVN, who assessed the resident but did not observe bruising or swelling and attributed the pain to a possible minor cause, administering Tylenol and informing the resident's physician, who ordered additional pain medication but did not order diagnostic imaging. Despite the resident's new symptoms and decreased ROM, the LVN did not report the COC to the Director of Nursing (DON), who was the supervisor on duty. The facility's policy and the LVN's job description required that such incidents or unusual occurrences be reported to supervisory staff for further assessment and investigation. The DON later stated that had she been informed, she would have conducted a comprehensive assessment and recommended further diagnostic evaluation, such as an X-ray. The lack of communication prevented timely intervention and a thorough investigation into the cause of the resident's symptoms. Subsequently, the resident was transferred to a general acute care hospital for an unrelated issue, where a right hip fracture was discovered several days later, necessitating surgery. Upon readmission to the facility, the DON became aware of the fracture and reviewed the records, confirming that the LVN had not reported the initial COC. The incident was classified as an injury of unknown origin, as the cause was unwitnessed and unexplained, and the resident was unable to provide an account of how the injury occurred.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision and Behavioral Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse when two residents, both with significant psychiatric diagnoses, were left unsupervised and engaged in an altercation on the facility patio. Both residents had documented requirements for supervision while smoking, as indicated in their Smoking Assessment Forms, and were supposed to be monitored at all times during smoking activities. Despite these requirements, the residents were able to access the patio unsupervised during the early morning hours, outside of the scheduled smoking times, and became involved in an argument that escalated to one resident physically assaulting the other, resulting in a cut and swelling to the victim's lip. Prior to the incident, one of the residents exhibited escalating behaviors, including yelling, demanding cigarettes, pacing the hallways, and expressing paranoid thoughts about being given methamphetamine. These behaviors were observed by nursing staff throughout the night, but the resident's physician was not notified, and no additional monitoring or intervention was implemented. The assigned CNA was unaware of the residents' whereabouts during her shift and did not recall the altercation, despite being responsible for their care. Staff interviews confirmed that residents were not supposed to smoke at night and that supervision protocols were not followed. Facility policies required staff to supervise residents during smoking, maintain control of smoking materials, and monitor residents with behavioral issues. However, these policies were not adhered to, as evidenced by staff statements and documentation. The lack of supervision and failure to address escalating behaviors directly led to the unsupervised altercation and subsequent injury. The incident was deemed avoidable by facility leadership, who acknowledged that proper supervision and behavioral management were not provided.
Failure to Supervise Residents During Smoking Results in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that two residents, both assessed as requiring supervision while smoking, were adequately monitored while smoking on the patio during the early morning hours. Both residents had documented mental health diagnoses, with one having moderately impaired cognitive skills and fluctuating decision-making capacity, and the other with intact cognition but a history of aggressive behavior. Facility records, including Smoking Assessment Forms and care plans, specified that both residents must be supervised at all times while smoking and required the use of protective non-flammable aprons. Despite these requirements, both residents were left unsupervised on the patio, outside of the scheduled smoking times, and were able to access cigarettes without staff oversight. On the night in question, one resident exhibited escalating aggressive behavior, repeatedly requesting cigarettes from staff, pacing the hallways, and making threats. Staff interviews confirmed that there were no scheduled smoking breaks during the night shift, and that residents were not supposed to have cigarettes or lighters in their possession. However, both residents managed to access the patio and smoke unsupervised. During this time, an altercation occurred between the two, resulting in one resident being punched multiple times in the face and sustaining a cut and swelling on the lip. The incident was reported by the injured resident upon re-entering the facility, and staff observed visible injuries. Interviews with facility staff, including CNAs, LVNs, the Director of Staff Development, and the DON, revealed a lack of awareness and supervision regarding the residents' whereabouts and activities during the night. Staff acknowledged that supervision was required for both residents while smoking, and that the incident could have been prevented with proper monitoring. Facility policies reviewed also confirmed the requirement for direct supervision of residents with restricted smoking privileges. The failure to supervise these residents while smoking and to monitor aggressive behavior directly led to the altercation and resulting injury.
Failure to Monitor Neurological Status After Resident Assault
Penalty
Summary
The facility failed to monitor a resident for signs and symptoms of neurological decline after the resident was struck on the face by another resident. The affected resident had a history of human immunodeficiency virus disease, morbid obesity, schizophrenia, and bilateral knee contractures, and was noted to have fluctuating capacity for decision-making and moderately impaired cognitive skills. After the incident, the resident was found with a five-centimeter laceration above the left eyebrow, minimal bleeding, and swelling. The resident was transferred to a general acute care hospital and later returned to the facility the same day. Despite the incident and the resident's return from the hospital, staff did not continue neurological checks or monitor the resident's neurological status. Interviews with nursing staff and the Director of Nursing confirmed that neurological assessments were not performed after the resident's return, even though such monitoring was recognized as necessary due to the potential for serious brain injury following facial trauma. The lack of post-incident neurological monitoring constituted the identified deficiency.
QAPI Committee Failed to Address Abuse and Supervision Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to address, maintain, and develop an effective plan to correct identified problems related to abuse and accident following a facility-reported incident. Despite the identification of deficiencies concerning abuse and smoking supervision during an investigation, these issues were not included in the QAPI/QA Committee agenda. The Director of Nursing (DON) acknowledged that the problems were not addressed in the QAPI meeting and stated that the facility holds meetings every three months, with the last meeting not covering the identified concerns. The DON also recognized the importance of QAPI in preventing reoccurrences of abuse and ensuring a safe environment for residents, as well as the need for adequate staff supervision. The Administrator (ADM) confirmed that issues of abuse, smoking, and supervision were not reviewed in the previous QAPI meeting but indicated plans to include them in the next meeting. A review of the facility's policy and procedure for the QAPI Change Process showed that the facility is expected to use a systematic approach to performance improvement, including developing corrective action plans and tracking performance after identifying root causes. However, the committee did not follow these procedures after the deficiencies were identified, resulting in repeated deficient practices related to abuse and supervision.
Failure to Enforce Mask Use During Covid-19 Outbreak
Penalty
Summary
The facility failed to ensure that staff consistently wore masks during a Covid-19 outbreak, as required by its own Covid-19 Mitigation Plan and the most recent California Department of Public Health PPE guidance. Observations on multiple occasions revealed that four out of ten sampled staff members, including a Certified Nursing Assistant (CNA) responsible for Covid-19 screening, a housekeeper, a Licensed Vocational Nurse (LVN), and the Administrator, were not wearing masks in various areas of the facility. The CNA stated she did not believe mask-wearing was mandatory during the outbreak, while the LVN admitted to not wearing a mask due to discomfort from heat. The Administrator acknowledged forgetting to wear a mask in the nursing station, and the housekeeper was observed vacuuming without a mask in the lobby. Interviews with facility leadership, including the Infection Preventionist Nurse (IPN), Housekeeping Supervisor (HKS), Director of Nursing (DON), and Administrator, confirmed awareness of the Covid-19 outbreak and the expectation that all staff should wear masks. The IPN reported that reminders were given to staff during morning huddles, but some staff may have perceived Covid-19 as a normal illness and did not adhere to mask protocols. The DON and HKS both stated that mask-wearing was necessary to prevent the spread of infection, especially given the vulnerability of the resident population. A review of the facility's Covid-19 Mitigation Plan Manual indicated that all staff should wear recommended PPE, including facemasks, when Covid-19 cases are identified in the facility. Despite this policy, staff non-compliance with mask-wearing was observed and acknowledged by both staff and leadership during interviews. The failure to follow established infection control practices occurred while two residents were confirmed positive for Covid-19, and the outbreak had been ongoing since at least 5/28/2025.
Uncovered Garbage Dumpsters
Penalty
Summary
The facility failed to ensure that three outside grey garbage dumpsters were covered, as observed during a survey. During an observation and interview with the Director of Nursing (DON), it was confirmed that the dumpsters were uncovered and without their lids. The DON acknowledged that the lids should be on when not in use to prevent attracting unwanted animals and pests. Additionally, the Administrator (ADM) confirmed that the facility staff are aware of the requirement to keep the dumpsters covered. A review of the facility's undated policies and procedures indicated that garbage and refuse containers should be covered when not in use, and dumpsters should have tightly fitting lids to prevent the accumulation of garbage outside the dumpsters.
Resident Assaulted by Roommate Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from physical assault by another resident, resulting in a deficiency. The incident involved Resident 1, who was assaulted by her roommate, Resident 2, while under the facility's care. Resident 1, who had severe cognitive impairment due to unspecified dementia and schizophrenia, was asleep in her bed when Resident 2 attacked her unprovoked, hitting her with a fist and then a shoe. This assault led to Resident 1 sustaining a contusion on her left upper and lower eyelid, necessitating a transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 2, who also had cognitive impairments due to unspecified dementia, anxiety disorder, and paranoid schizophrenia, was observed by a Certified Nursing Assistant (CNA) hitting Resident 1. The CNA witnessed the assault and reported it to the Director of Nursing (DON), who confirmed the injury upon entering the room. The facility's policy and procedure on abuse, neglect, and exploitation clearly state that residents must not be subject to abuse by anyone, including other residents, yet this policy was not effectively implemented to prevent the incident. The facility's failure to monitor and ensure the safety of Resident 1 led to the assault, as acknowledged by the Administrator, who stated that it was impossible to monitor all corners of the facility. This incident highlights a significant lapse in the facility's duty to protect its residents from harm, as outlined in their own policies. The deficiency was identified through interviews and record reviews conducted by surveyors, who documented the events leading to the assault and the subsequent medical evaluation and treatment of Resident 1.
Failure to Discard Expired Food in Facility
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator was not outdated, as observed during a survey. Various food items, including chicken, seasoned hash brown potatoes, potato salad, macaroni salad, tomatoes, bread, lettuce, and freezer-burned meat, were found to be stored past their expiration dates. These observations were confirmed during interviews with the Dietary Manager (DM) and other staff members, who acknowledged that the food was outdated and should not have been stored in the refrigerator. The facility's policy and procedures for food storage, which dictate that no food should be kept beyond its expiration date and that freezer-burned food must be discarded, were not followed. Interviews with the DM and the Director of Nursing (DON) highlighted the potential risks associated with consuming expired food, such as foodborne illnesses and compromised food quality. The DM explained that food is labeled with the date it is opened, and staff are expected to follow expiration dates to prevent foodborne illnesses. The DON emphasized that consuming expired food could lead to food poisoning and stomach sickness among residents. The facility's failure to adhere to its own policies and procedures for food storage and handling was evident in the observations and interviews conducted during the survey.
Incomplete Advance Directives Documentation
Penalty
Summary
The facility failed to accurately document advance directives for five out of seven residents, which could potentially lead to conflicts with the residents' healthcare wishes. The deficiencies were identified through interviews and record reviews, revealing that the advance directive acknowledgments were either incomplete or lacked necessary signatures. For instance, Resident 5's advance directive was signed by the physician two years after the interdisciplinary team completed it, rendering it invalid. Similarly, Resident 21's advance directive lacked a decision on whether to formulate an advance directive and was missing a physician's signature. Resident 36's advance directive acknowledgment was incomplete, lacking a witnessed signature, a physician's dated signature, and documentation of the resident's mental condition and prognosis. The document also failed to indicate whether the resident's mental condition was consistent with the advance directive. Resident 65's acknowledgment was missing a physician's signature and did not document discussions about the resident's diagnoses, prognosis, and mental condition. Additionally, Resident 68's acknowledgment did not indicate a choice regarding the formulation of an advance directive and lacked a physician's signature and acknowledgment of a durable power of attorney. Interviews with facility staff, including the Social Services Director and the Director of Nursing, highlighted the importance of accurately completing advance directives to ensure residents' preferences are respected. The facility's policy and procedure on advance directives require the Director of Nursing or designee to notify the attending physician for appropriate documentation in the resident's medical record. However, the deficiencies in documentation and oversight could lead to delays in care or treatment, as noted by the Registered Nurse Supervisor.
Inaccurate PASARR Documentation and Screening Deficiencies
Penalty
Summary
The facility failed to ensure accurate documentation of the Preadmission Screening and Resident Review (PASARR) for five residents, leading to potential inappropriate placement and delay of needed services. Resident 19 was admitted with schizophrenia and anemia, and although the Minimum Data Set (MDS) indicated cognitive intactness and delusions, the PASARR Level I screening was negative despite the presence of a mental illness and psychotropic medication prescription. Resident 21, with schizophrenia and bipolar disorder, had a positive Level I screening requiring a Level II screening, which was not completed due to unresponsiveness from facility staff. Resident 45, diagnosed with schizophrenia, bipolar disorder, and major depressive disorder, also had a positive Level I screening requiring a Level II screening, which was not completed. Resident 65, with dementia and schizophrenia, required a Level II screening due to a positive Level I screening, but this was missed by the Infection Preventionist Nurse (IPN). Resident 84, with hyperlipidemia and type 2 diabetes, was taking antipsychotic medication, yet the PASARR Level I screening inaccurately indicated no serious mental illness or psychotropic medication use. Interviews with the IPN and Director of Nursing (DON) highlighted the importance of accurate PASARR documentation and completion of Level II screenings when indicated, to ensure residents receive appropriate care. The facility's policy stated that individuals with mental disorders or intellectual disabilities should only be admitted if deemed appropriate by the state authority, and any new or possible serious mental disorders should prompt a Level II review. However, the facility failed to adhere to these guidelines, resulting in the deficiencies noted.
Failure to Provide Adequate Range of Motion Care
Penalty
Summary
The facility failed to provide appropriate care for three residents with limited range of motion (ROM) and mobility, as observed through various deficiencies in their care plans and physician orders. Resident 5 did not receive passive range of motion (PROM) exercises for both arms from December 1 to December 19, 2024, despite physician orders and care plans indicating the need for such exercises five times per week. Additionally, PROM was not provided to Resident 5's ankles on December 19, 2024, as required. Observations revealed that Resident 5's joints were in a flexed position, and the resident was unable to fully extend both elbows or straighten both legs. Interviews with staff confirmed the omission of PROM exercises due to a transition to a new electronic documentation system. Resident 20 also did not receive the necessary PROM exercises for elbows, wrists, hands, knees, and ankles, as outlined in the care plan and physician orders. The resident's hand towels were not positioned correctly, and PROM was not performed prior to applying hand rolls and ankle splints. Observations showed that Resident 20's joints were in a flexed position, and the resident had visible tremors and unclear speech. Interviews with staff indicated that PROM exercises were not performed due to nervousness and oversight, and the hand towels did not stay in place due to the positioning of the resident's fingers. Resident 68 did not receive PROM exercises for the left hand, despite care plans and physician orders specifying the need for such exercises to maintain ROM and prevent contractures. Observations showed that Resident 68 had limited ROM in the left shoulder and elbow, and the resident was able to perform active range of motion (AROM) exercises with the right arm. Interviews with staff confirmed the omission of PROM exercises for the left hand, which was attributed to forgetfulness. The facility's policy and procedure for preventing decline in ROM emphasized the importance of moving each joint through its ROM, which was not consistently implemented for these residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices for four residents, leading to potential risks of infection. For Resident 73, the humidifier was not changed weekly as required, which could lead to bacterial growth and potential infection. The humidifier was dated 12/8/2024, and staff interviews confirmed the importance of changing it weekly to prevent infections. The facility's policy indicated that respiratory therapy equipment should be changed every 72 hours or as per the manufacturer's recommendation, which was not adhered to in this case. Resident 20, who was on Enhanced Barrier Precautions (EBP) due to having a G-tube, did not receive care with the appropriate Personal Protective Equipment (PPE). During a session of passive range of motion exercises and application of splints, the staff member did not wear a protective gown, which is required for high-contact activities under EBP. Interviews with staff confirmed that a gown should be worn during such activities to prevent infections, especially for residents with indwelling devices like G-tubes. For Residents 27 and 54, the facility failed to implement proper hand hygiene precautions before administering eye drops. The Licensed Vocational Nurse (LVN) did not wash hands or change gloves after touching various surfaces and before administering eye drops, which is against the facility's policy. The policy requires hand hygiene before and after medication administration to prevent contamination and ensure resident safety. Interviews with the LVN and the Director of Nursing confirmed the importance of hand hygiene in preventing infections during medication administration.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. Resident 42, who was part of a random sample of 20 residents, was observed to have their call light wrapped around the back of the bed rails, making it inaccessible. This observation was made during an interview with the resident, who expressed distress and difficulty in reaching the call light. The resident had been admitted with multiple diagnoses, including hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The Minimum Data Set (MDS) indicated that the resident had intact cognitive skills but required extensive assistance for various daily activities. Interviews with facility staff, including a Certified Nurse Assistant (CNA), a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed the expectation that call lights should always be within reach of residents. The CNA admitted to forgetting to place the call light within reach after attending to the resident. Both the LVN and DSD emphasized the importance of having the call light accessible to ensure residents can call for assistance, especially in emergencies. The facility's policy on answering call lights also stipulated that call lights should be within easy reach when residents are in bed or confined to a chair.
Resident's Bed Malfunction Poses Safety Risk
Penalty
Summary
The facility failed to ensure that a resident's bed was not broken, which had the potential to put the resident at risk for accidents while in bed. The resident, who was admitted with diagnoses including hypertensive heart, psychosis, glaucoma, and muscle weakness, was found to have a bed that did not function properly. The bed was unable to go up and down and was leaning to the left side. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, reported the issue to nurses and maintenance staff multiple times over a period of three months. Observations and interviews with facility staff, including a CNA, LVN, and the Maintenance Supervisor, confirmed the bed's malfunction and the potential safety risk it posed. The Maintenance Supervisor acknowledged the entry in the maintenance report log indicating the bed's malfunction and admitted that residents should not have broken beds due to safety concerns. The facility's policy required regular inspections and maintenance of bed equipment, but this was not adhered to in this case, leading to the deficiency.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for Resident 29, who was observed to have long and dirty fingernails on multiple occasions. Resident 29, who has severe cognitive impairment and requires extensive assistance with activities of daily living (ADLs), was admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and bipolar disorder. Despite the resident's dependency on staff for personal hygiene, the Certified Nursing Assistant (CNA) did not clean the resident's nails, citing the resident's refusal, which was not documented or reported to the charge nurse as required. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that there was a lack of adherence to the facility's policy and procedure regarding nail care. The LVN acknowledged that treatment nurses are trained to assist with trimming residents' fingernails, but this was not done for Resident 29. The DON confirmed that CNAs are responsible for cleaning and cutting nails during ADLs and emphasized the importance of documenting care refusals. The facility's policy on quality of care and dignity indicates that residents should be groomed according to their preferences to maintain self-esteem and self-worth.
Failure to Monitor and Treat Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident, who had redness on the right side of the cheek, was monitored and received appropriate treatment. The resident, who had a history of schizophrenia, major depressive disorder, gastro-esophageal reflux disease, and hypertensive heart disease, was observed with redness and swelling to the right eye and a small bump with redness below the right eye. Despite the resident reporting a bug bite to the nursing staff, the Certified Nursing Assistant (CNA) who noticed the redness did not document or report it. Similarly, the Licensed Vocational Nurse (LVN) observed the redness but did not complete a change of condition report, notify the doctor, or update the care plan, assuming the redness was caused by the resident's glasses. The Registered Nurse Supervisor and the Director of Nursing confirmed that there was no documentation of a skin inspection, assessment, care plan, or change of condition for the resident's redness. The facility's policy requires nursing assistants to report any skin concerns immediately and for licensed nurses to document changes in condition and notify the doctor. The lack of documentation and communication regarding the resident's skin condition represents a failure to provide necessary care and treatment, as outlined in the facility's policies and procedures.
Inadequate Competency in Restorative Nursing Aides
Penalty
Summary
The facility failed to ensure that its Restorative Nursing Aide (RNA) staff were competent in providing range of motion (ROM) exercises and applying splints to residents with limited mobility. This deficiency was observed in three residents, each with specific physician orders and care plans that were not fully adhered to by the RNA staff. Resident 5, diagnosed with muscle wasting and dementia, was supposed to receive passive range of motion (PROM) exercises to both legs, including the ankles, followed by the application of knee splints. However, during an observation, the RNA staff failed to perform PROM on the ankles, which was acknowledged by the RNA as an oversight. Resident 20, with diagnoses including epilepsy and Alzheimer's disease, had physician orders for PROM exercises to both arms and legs, along with the application of hand rolls and ankle splints. During an observation, the RNA staff did not perform PROM on several joints, including elbows, wrists, hands, knees, and ankles, before applying the splints and hand rolls. The RNA admitted to feeling nervous, which contributed to the incomplete execution of the prescribed exercises. Resident 68, who had hemiplegia and hemiparesis following a cerebral infarction, was to receive active range of motion (AROM) exercises on the right arm and PROM on the left arm. The RNA staff demonstrated AROM exercises incorrectly on the left side and failed to perform PROM on the left hand. Interviews with the Director of Rehabilitation (DOR) and a Physical Therapist revealed that the RNA staff had not received recent in-service training on ROM exercises and splint application, with the last training sessions occurring several years prior. The Director of Nursing (DON) acknowledged that the lack of competency in RNA staff could lead to a decline in residents' ROM and function.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and professional standards of practice, affecting several residents. For Resident 54, the facility did not administer risperidone as prescribed, which is crucial for managing psychosis. Additionally, there was an error in administering a combination of calcium with vitamin D instead of separate doses, leading to potential medication errors. The Licensed Vocational Nurse (LVN) involved acknowledged the mistake and the importance of following physician orders to prevent negative health impacts. Resident 440's case involved a lack of clarity in the physician's order for docusate sodium, a medication used for constipation. The order did not specify the dose and frequency, which posed a risk of overtreatment or undertreatment, potentially leading to diarrhea and dehydration. The LVN recognized the need for clarification with the physician to ensure safe administration. The Director of Nursing (DON) confirmed that the staff should have sought clarification to prevent such risks. For Residents 23 and 13, there were discrepancies in the Controlled Drug Record (CDR) for Vimpat and lorazepam, both controlled substances. The LVN failed to document the administration of these medications immediately, leading to inconsistencies in the medication count. This oversight increased the risk of medication errors and potential misuse or diversion of controlled substances. The DON emphasized the importance of immediate documentation to maintain accurate tracking of controlled substances.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor the behaviors of a resident who was prescribed psychotropic medication, specifically Risperdal, for psychosis manifested by auditory hallucinations. The resident, who was admitted with severe cognitive impairment and a diagnosis of psychosis, was dependent on activities of daily living and lacked the capacity to make decisions. Despite the care plan indicating the need to monitor and document the effectiveness and side effects of Risperdal, there was no evidence of behavior monitoring related to the resident's auditory hallucinations. Interviews with facility staff, including an LVN, RN supervisor, and the Director of Nursing, confirmed the absence of behavior monitoring for the resident's use of Risperdal. The staff acknowledged that without monitoring, it was impossible to determine the medication's effectiveness, potentially leading to unnecessary medication use. The facility's policy required ongoing evaluation of the effects of psychotropic medications on residents, but this was not adhered to in the case of the resident in question.
Medication Error Rate Exceeds 5% Due to Administration Mistakes
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication pass for a resident, resulting in a medication error rate of 7.14%. The error involved the failure to administer risperidone, a medication prescribed for psychosis, and the incorrect administration of a combination of calcium with vitamin D instead of separate doses as per the physician's orders. This error was observed during a medication pass conducted by an LVN. The resident involved had a history of fluctuating cognitive capacity and required assistance with daily activities. The resident's medical conditions included hypertensive heart disease, Type 2 Diabetes Mellitus, vitamin D deficiency, anxiety disorder, and bipolar disorder. The resident's medication orders included risperidone, calcium, and vitamin D, among others, which were not administered correctly during the observed medication pass. The LVN acknowledged the mistake, stating that she did not administer risperidone and incorrectly gave a combination of calcium with vitamin D. The Director of Nursing confirmed that the nurse should have verified the medication orders to prevent such errors. The facility's policy on medication administration emphasizes the importance of following physician orders and verifying medications against the Medication Administration Record (MAR).
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. During an inspection, it was observed that bisacodyl suppositories were stored in a refrigerator at 42°F, contrary to the manufacturer's requirement of room temperature storage. Additionally, brimonidine tartrate ophthalmic solution was improperly stored in the refrigerator, and an opened Lantus Solostar pen was not discarded after 28 days, as required. These storage issues affected at least two residents, potentially compromising the safety and effectiveness of the medications. Further inspection revealed expired medications in the Central Supply Room, including zinc sulfate, vitamin D3, and hydrogen peroxide. These products were not removed despite being past their expiration dates, posing a risk to residents if used. The facility's failure to discard these expired items indicates a lack of adherence to proper medication management protocols. Additional deficiencies were found in the medication carts, where several medications, including Fiasp, Novolog, and latanoprost eye drops, were either expired or lacked proper labeling with open dates. This oversight affected multiple residents and increased the risk of medication errors. The facility's policies on medication storage and labeling were not followed, as evidenced by the presence of expired and improperly stored medications, which could lead to adverse health outcomes for residents.
Incomplete RNA Treatment Records for Resident's PROM Exercises
Penalty
Summary
The facility failed to ensure complete documentation of Restorative Nursing Aide (RNA) treatment records for a resident with limited range of motion and mobility. Specifically, the RNA treatment record for October 2024 was incomplete for the provision of passive range of motion (PROM) exercises to the resident's right leg, despite physician orders indicating that PROM should be provided to both legs five times per week. The RNA treatment record only included initials for PROM to the left leg, leaving the right leg section blank. The resident, admitted in August 2024, had diagnoses including dementia, bipolar disorder, anxiety disorder, and rhabdomyolysis. During an observation in December 2024, the resident refused PROM exercises for the right leg, which the RNA did not document for the entire month of October. The Director of Medical Records confirmed the incompleteness of the record, acknowledging the potential risk of contractures due to the lack of documented care. The Director of Nursing emphasized the importance of accurate medical records to ensure all treatments and care are provided and documented.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for two residents, leading to potential delays in care and treatment. For one resident, who was admitted with diagnoses including bipolar disorder and major depressive disorder, the care plan did not address the resident's behavior of fabricating stories. Despite being moderately cognitively impaired and requiring substantial assistance with personal care, the care plan only focused on minimizing episodes of irritability related to anxiety. Both a Licensed Vocational Nurse and the Director of Nursing acknowledged the absence of a care plan addressing the resident's fabrication of stories, which is crucial for staff awareness and management of the resident's behavior. Another resident, admitted with schizophrenia, major depressive disorder, and hypertensive heart disease, exhibited redness and swelling on the right side of the face, including a small bump under the right eye. Despite these observations, there was no care plan documented to address these symptoms. A Licensed Vocational Nurse confirmed the lack of a care plan and expressed concern about the potential for infection, neglect, or hospitalization due to the absence of documented interventions. The Director of Nursing stated that licensed nurses are responsible for developing and implementing care plans to monitor and respond to changes in residents' conditions.
Incomplete MDS Documentation for Therapy Services
Penalty
Summary
The facility failed to accurately record the start and end dates of therapy services on the Minimum Data Set (MDS) for three residents, resulting in incomplete information being submitted to the Federal database. Resident 14, who was admitted with multiple diagnoses including type 2 diabetes mellitus and major depressive disorder, received occupational and physical therapy services. However, the MDS did not reflect the therapy start and end dates, despite the resident having completed therapy and achieved the highest level of functional independence. Similarly, Resident 21, admitted with conditions such as bipolar disorder and epilepsy, underwent occupational and physical therapy. The therapy aimed to improve activity tolerance and safety awareness, among other goals. Despite the completion of therapy and the resident reaching the highest practical level, the MDS failed to include the necessary therapy dates, leading to an incomplete assessment. Resident 26, who had contractures and other medical conditions, also received therapy services to enhance mobility and independence. The therapy was completed, and the resident achieved maximum potential, yet the MDS did not document the therapy dates. Interviews with the Director of Rehabilitation and the MDS Coordinator revealed a lack of awareness regarding the requirement to record these dates in the MDS, contributing to the deficiency.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite available beds, due to a misunderstanding of infection control requirements. The resident, who had been transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of abnormal lab results, was stabilized and deemed appropriate for transfer back to the facility. However, the facility refused readmission, citing a lack of available isolation beds due to the resident contracting Candida auris, a highly contagious yeast, at the hospital. This decision was made despite the facility's daily census indicating available male beds during the period in question. The facility's refusal to readmit the resident was based on the belief that they could not accommodate the resident's infection control needs. However, an All Facility's Letter indicated that residents with multidrug-resistant organisms (MDROs) do not require single-person rooms and can be managed with Enhanced Barrier Precautions. The facility's policy stated that residents should be readmitted upon the first availability of a bed, which was not adhered to in this case. Consequently, the resident remained at the hospital for 11 days before being transferred to another skilled nursing facility, leading to potential risks of confusion and disorientation due to displacement.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,373 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Long Beach Healthcare Center | 0.1 mi | ★★★★★ | 8 | 0 |
| Pacific Care Nursing Center | 0.2 mi | ★★★★★ | 6 | 0 |
| Bixby Towers Post-acute Rehab | 0.7 mi | ★★★★★ | 6 | 1 |
| Catered Manor Care Center | 0.9 mi | ★★★★★ | 15 | 0 |
| Atlantic Memorial Healthcare Center | 1.1 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pacific Villa, Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.