Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palazzo Post Acute during CMS and state inspections, most recent first.
Staff failed to respect a resident’s privacy when an RT entered the room without introducing himself or asking permission, and a CNA entered two resident rooms without knocking, introducing himself, or asking permission. The resident had intact cognition and stated she did not feel she had privacy because staff entered without asking. The RT, CNA, LVN, and DON all acknowledged that staff should knock, introduce themselves, and ask permission before entering resident rooms, and the facility’s dignity policy required staff to announce their presence.
Failure to Perform Hand Hygiene Between Resident Rooms: A CNA was observed entering and exiting one resident room without performing hand hygiene and then immediately entering another resident room without sanitizing hands. The CNA stated he forgot to use hand sanitizer, and the DON, CNA 2, and an LVN all stated hand hygiene is required before and after entering resident rooms and between residents' rooms. The facility policy stated hand hygiene should be performed before touching a resident, after touching a resident, and after touching the resident environment or belongings.
The facility failed to provide consistent dialysis-related care for two residents with ESRD. One resident missed scheduled dialysis because transportation did not arrive, and staff did not complete the dialysis communication record with pre- and post-dialysis assessments. Another resident had missing dialysis sign-out documentation, a missing dialysis communication record entry, and exceeded a physician-ordered 1000 ml fluid restriction on multiple days, while staff and the resident stated the restriction was not known to them.
Improperly Closed and Overfilled Dumpsters: Four of four outdoor dumpsters were observed with lids partially open, and the DM stated they needed to be fully closed when not in use to prevent pests from entering. The ADM stated city trash pickup was delayed because of a holiday, leaving several days without pickup, and the facility policy required trash containers to be emptied regularly to prevent overflow.
Failure to Maintain RNA Competency Training: The facility failed to develop and implement a restorative nursing assistants training program to maintain ongoing competency. The DSD stated RNAs weighed residents as part of their duties and education was posted on the Annual Staff Development Education calendar, but an RNA could not recall recent education on weighing residents. The DON stated RNAs required appropriate training, yet review of the 2025 and 2026 calendars showed no weight assessment topic, despite the RNA job description requiring training and actual demonstration for duties including monthly and as-needed resident weights.
A resident with impaired self-care needs was observed with overgrown facial hair and an unkempt appearance, and he said he wanted to be shaved and groomed but had not seen the barber. Another resident with intact cognition and an active physician OOP order was not informed of the pass, despite expressing a desire to go out for personal errands and stating she had been waiting about a week; the DON and SSD acknowledged the order was active and should have been communicated.
Unattended Veterinary Liniment Gel at Bedside: A resident with OA, spondylosis, and occipital neuralgia had a white veterinary liniment gel container left unattended at bedside. The resident said she used it daily for joint pain, while RNA and LVN staff acknowledged the facility knew about the gel and that it was not supposed to be at bedside without a physician order because she could not self-administer medications. The resident's records also showed fluctuating decision-making capacity and no order for the gel.
Urinary Catheter Tubing Not Maintained Free of Sediment: A resident with paraplegia, neurogenic bladder, and a urinary catheter had physician orders to monitor the catheter each shift and flush it as needed for obstruction or sediment. The resident reported lower abdominal discomfort, and staff observed dried sediment and cloudy urine stuck in the catheter tubing with poor drainage into the collection bag. A CNA stated urine should flow freely, and the TX said the tubing should not have sediment and that daily checks and ordered flushing had not been done.
A resident with COPD and opioid dependence had an order for Methadone HCI for pain management. During a narcotic count, two methadone bubble packs on Med Cart 1 were found with fewer doses remaining than the NHRs reflected, and an LVN stated he forgot to sign both NHRs when the dose was administered. The DON stated nurses were supposed to document controlled medication removal immediately for accurate accounting.
A resident on EBP received personal care and repositioning from a CNA without a gown, despite the care plan and orders requiring gowns and gloves for close-contact care. In addition, a pill crusher at the nurses’ station was observed with residue and discoloration, and staff identified it as dirty and needing cleaning to prevent medication cross contamination.
Failure to Re-Offer Pneumococcal Vaccine: A resident with chronic respiratory failure, asthma, and heart failure had a pneumococcal vaccine history showing the last dose was received years earlier with a recommendation for another dose. Although declination forms were signed in prior years, the IPN stated the vaccine was supposed to be re-offered at least yearly. The resident later stated wanting the pneumococcal vaccine, while the facility’s policy required offering pneumococcal vaccines to all residents in accordance with CDC guidance.
Failure to document an itemized personal property inventory for a resident on admission. A resident with multiple diagnoses, including vascular dementia with psychotic disturbance, reported bringing six boxes and four suitcases of belongings that were stored outside her room, and she stated staff never reviewed the contents with her. The inventory listed containers and a few items, but did not identify the contents of each box or luggage and was not signed by the resident or staff; the DON stated the admitting RN was responsible for completing the inventory.
Cluttered and Unclean Resident Room Environment: A resident with muscle weakness, DMII, failure to thrive, anemia, and dependence for most ADLs was observed in a cluttered room with personal care items on the bedside table, an open drawer, a wedge pillow on the floor, a blanket bunched on the bed frame, an empty nutritional shake bottle, old crackers in a paper bag, and a sticky floor. The resident said the facility did not seem to clean as it should, and a CNA confirmed the mess and clutter.
An LVN picked up a resident’s call light from the floor and placed it on the bed sheet without cleaning it first. The resident was cognitively intact, had fractures of the right femur and pubis, DM2, and major depressive disorder, and required assistance with toileting, showering, and transfers. The resident could not reach the call light when asked to press it, and the LVN acknowledged the call light should have been cleaned before being placed on the sheet.
Call Light Not Within Reach: A resident with fx of the R femur and pubis, DM2, and MDD was observed with the call light on the floor and out of reach. The resident, who was cognitively intact and needed assistance with toileting, showering, and transfers, stated he usually got up on his own and could not reach the call light when asked. An LVN confirmed it was not within reach and noted staff were responsible for ensuring call lights were accessible.
A CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, in violation of federal nurse aide registry requirements and the facility’s job description requiring a valid CNA license. The DON had a personnel file printout indicating the CNA’s status was active and employable, but a concurrent CDPH registry search showed no matching data. Review of assignment and attendance sheets confirmed the CNA worked the shift after being called in by a Charge Nurse who did not realize the CNA had been removed from the schedule for lapsed certification. The DSD reported that CNAs with expired certifications are taken off the schedule and payroll and that this CNA had been informed of her limitations, yet she still worked the shift without valid certification.
A resident with a history of severe psychiatric disorders exhibited aggressive behavior requiring 1:1 supervision, but the facility did not update the care plan to reflect this intervention after significant behavioral changes and hospital readmission. Staff interviews and record reviews confirmed that the care plan was not revised as required by facility policy, leaving the resident's current needs and interventions undocumented.
A resident with multiple health conditions, including blindness and psychiatric diagnoses, became agitated after being denied a request to smoke. A CNA attempted to prevent the resident from getting up, but did not notify the RN of the agitation. Another resident, believing the CNA was at risk, struck the agitated resident on the jaw, causing pain and requiring an x-ray. Facility policies required staff to prevent and report abuse, but these were not followed, resulting in physical harm.
Two residents, both with significant medical and behavioral histories, were involved in a physical altercation after one became agitated over smoking restrictions and the other intervened, believing staff were at risk. Staff failed to notify the RN of escalating agitation and did not provide adequate supervision, resulting in one resident being struck and requiring medical evaluation.
A resident with impaired mobility and a high risk for falls was not properly positioned in a wheelchair after a toilet transfer, resulting in a fall. Despite a care plan requiring assistance and safety interventions, staff failed to ensure correct seating before moving the wheelchair, leading to the incident. The resident did not sustain injuries.
The facility failed to properly manage emergency drug supplies, resulting in the absence of a narcotic E-kit for about 24 hours, did not replace E-kits within the required timeframe, and left several drug disposition forms incomplete. Additionally, staff did not adequately follow up or document actions regarding a resident's pending Norco opioid order, leading to delays in medication availability.
Surveyors found that kitchen staff did not keep the ice scooper holder clean, stored personal perishable food in the facility refrigerator, and left personal items in non-designated kitchen areas. The Dietary Food Nutrition Supervisor confirmed these actions violated facility policies for food safety and sanitation.
Surveyors observed that staff failed to follow infection prevention protocols, including not wearing required gowns during direct care for a resident on enhanced barrier precautions and not disinfecting IV injection ports during medication administration. Additionally, the facility's water management plan lacked critical details, such as building and water system descriptions, control measures, and verification steps, as confirmed by facility leadership.
A resident with severe cognitive impairment and multiple mental health diagnoses was allowed to sign medical consent forms and an Advance Health Care Directive without the involvement of a legal representative, despite documentation and staff acknowledgment of the resident's incapacity. Staff obtained verbal consent and witnessed signatures instead of following procedures for residents lacking decision-making capacity.
A resident with a history of falls and neurological conditions experienced a fall, but the care plan was not updated to reflect this incident or to add new interventions. Despite facility policy and staff acknowledgment that care plans should be revised after such events, the last update had occurred months earlier, resulting in a deficiency related to care plan management.
A resident with severe cognitive impairment, dysphagia, and a g-tube was observed with poor oral hygiene, including a tan substance on teeth, dry lips, and a reddened, swollen tongue. Staff interviews revealed oral care was not provided as frequently as care plans required, and the resident's mouth had been in poor condition for some time. The DON confirmed that the observed oral condition was unacceptable and not in line with facility policy.
Staff failed to lock both the bed and the Hoyer lift before placing a sling under a resident with significant mobility impairments and a history of falls. This action was inconsistent with the resident's care plan and facility policy, as confirmed by staff interviews and direct observation.
A resident with multiple medical conditions and frequent incontinence did not receive a quarterly bowel and bladder assessment as required by their care plan. Documentation and staff interviews confirmed that the last assessment was completed several months prior, and facility policy requiring regular continence assessments was not followed.
A resident dependent on g-tube feeding due to dysphagia and malnutrition was found to have an unlabeled flush bag attached to their feeding pump, despite the care plan requiring labeling with date, time, and nurse's initials. Both nursing staff and the DON acknowledged the omission and the associated risk of infection.
A resident with a history of fibromyalgia and skin sensation disturbances experienced facial itching due to a possible allergic reaction. Although a physician ordered Benadryl 25 mg to be given as needed, review of the MAR showed the medication was not documented as administered, and the resident reported not receiving it. Interviews with nursing staff and review of facility policy confirmed the lack of required documentation for medication administration.
The facility did not post the actual hours worked by staff, as required by federal regulations. On the observed day, only projected hours were displayed, and the previous day's actual hours were missing. Interviews with the DSD and DON revealed a misunderstanding of the posting requirements, which were clarified upon reviewing the facility's policy.
A resident with multiple myeloma missed two doses of Pomalyst due to the facility's failure to implement a consistent medication reconciliation system. The resident, who also had type 2 diabetes and end-stage renal disease, was aware of the prescription but reported not receiving the medication as ordered. The DON confirmed the missed doses, and an LVN admitted to not administering the medication due to its unavailability in the medication cart. The facility's policy required medications to be administered safely and as prescribed, which was not followed.
The facility failed to uphold resident dignity and respect, as evidenced by two residents reporting incidents of staff yelling. One resident, with conditions including hypertension and cellulitis, was yelled at by a CNA after assisting another resident. Another resident, with osteoarthritis and reduced mobility, confirmed hearing an argument involving staff. Both residents had intact cognition and required assistance for daily activities, highlighting a breach in the facility's policy on resident rights.
A resident with an amputation site, acute respiratory failure, and an arterial ulcer did not receive necessary care and services. The facility failed to assess and document the ulcer upon admission, did not develop a comprehensive care plan, and did not follow the physician's treatment order. Additionally, the resident's respiratory status was not adequately monitored, leading to their transfer to a hospital where they were diagnosed with further complications and subsequently passed away.
A resident at risk for malnutrition did not receive 17 doses of Megestrol Acetate Suspension due to the medication not being in stock, leading to significant weight loss. The facility failed to maintain accurate medication administration records, marking the medication as administered when it was not available. Interviews with staff revealed a lack of adherence to documentation practices, contributing to the deficiency.
The facility failed to label and date food stored in the kitchen, including bread and various frozen vegetables, as observed during a kitchen tour. Both the Dietary staff and the DON acknowledged that all food should be labeled and dated to prevent food-borne illnesses, in accordance with the facility's policy.
A resident with Type II diabetes and other conditions experienced a significant change in health status with elevated blood sugar levels. The LTC facility failed to develop an individualized care plan to address hyperglycemia, as required by policy, leading to inadequate care and monitoring. Interviews with staff confirmed the oversight in care planning.
A resident with a right heel deep tissue injury did not receive necessary care and services as per their care plan, which included monitoring and documenting changes in the wound's condition. For 16 days, there was no documentation of the wound's status, despite facility policies requiring detailed recording of treatment and assessment data. This oversight was confirmed by staff interviews and posed a risk of infection or worsening of the wound.
A resident with a history of falls did not receive the necessary fall prevention interventions as outlined in their care plan. The facility failed to implement the required measures, such as a yellow star on the wall, a fall risk wristband, and non-skid socks. Additionally, the care plan was not updated following a fall that resulted in a skin abrasion. The facility's policies on fall risk management and care plan updates were not followed.
A resident with acute respiratory failure was not provided with proper respiratory care as their nasal cannula tubing was neither labeled nor stored in a plastic bag, contrary to facility policy. Staff interviews confirmed the tubing should have been labeled and stored correctly to prevent infection, as per the care plan and facility guidelines.
A resident continued to receive Effexor for depression without documented justification beyond 30 days. Despite the absence of verbalized sadness, the Consultant Pharmacist's Medication Regimen Review lacked recommendations or rationale for the medication's continued use. The facility's policy required monthly reviews and reporting of medication irregularities, but no Gradual Dose Reduction was documented.
A resident experienced significant weight loss due to the unavailability of Megestrol Acetate Oral Suspension for 17 days. The medication, intended to stimulate appetite, was inaccurately documented as administered by multiple nurses. The resident's weight dropped from 182 to 156 pounds, and the facility's policies on medication administration and documentation were not adhered to.
A facility failed to store Dorzolamide-Timolol Ophthalmic Solution correctly, as it was found in a refrigerator instead of being stored at room temperature as per manufacturer's guidelines. This improper storage was acknowledged by an LVN and confirmed by the DON, who noted that it could render the medication ineffective for treating a resident's eye condition.
A resident with multiple medical conditions, including dependence on renal dialysis, was inappropriately administered MiraLAX despite experiencing frequent loose stools. The facility failed to notify the physician of the resident's condition change, continuing the laxative treatment without adjustment. Staff interviews revealed a lack of awareness and communication regarding the resident's diarrhea, and the DON acknowledged the oversight. The facility's policies on notifying changes in condition were not followed, posing a risk of dehydration and other complications.
A facility failed to review transfer records for a resident admitted with multiple medical conditions, resulting in missed critical appointments for vascular diagnostics, chemotherapy, and specialist consultations. The oversight occurred because the admitting nurse only reviewed medication pages, leading to a delay in the resident's treatment.
A facility failed to safeguard a resident's personal funds by improperly storing $800 in a narcotic box instead of transferring it to the business office the next business day, as required by policy. The delay and improper storage posed a risk of theft or misuse.
Staff Entered Resident Rooms Without Announcing Themselves
Penalty
Summary
Facility failed to ensure resident privacy was respected when staff entered resident rooms without properly announcing themselves. Resident 1 was admitted with diagnoses including chronic pain, anxiety disorder, opioid dependence, and hypertension, and the MDS dated 7/13/2026 indicated the resident’s cognition was intact. During an observation on 7/22/2026 at 12:05 pm, RT 1 entered Resident 1’s room and stated he was there to do breathing treatment for the roommate, but he did not introduce himself or ask permission before entering Resident 1’s room. During an interview later that day, Resident 1 stated she did not feel she had privacy because staff entered her room without asking. During another observation on 7/22/2026 at 1:05 pm, CNA 1 entered two resident rooms without knocking, introducing himself, or asking permission. CNA 1 acknowledged that staff should knock, introduce themselves, and ask permission before entering a resident’s room, and stated he did not do that and that his action affects residents’ privacy. CNA 2, LVN 1, and the DON also stated that staff should knock, introduce themselves, explain why they are there, and ask permission before entering resident rooms. The facility policy titled dignity, dated 10/2025, stated staff must announce their presence before entering a resident’s room.
Failure to Perform Hand Hygiene Between Resident Rooms
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a CNA was observed entering and exiting one resident room without performing hand hygiene and then immediately entering another resident room without sanitizing hands. During the observation on 7/22/2026 at 1:05 pm in the hallway, CNA 1 entered and exited room [ROOM NUMBER] without performing hand hygiene and then entered room [ROOM NUMBER] without using hand sanitizer. During interviews, CNA 1 stated he did not wash his hands inside either room and forgot to use hand sanitizer outside the rooms, and stated his action could cause infection control issues. CNA 2 stated hand hygiene is important to prevent the spread of infections and staff should perform hand hygiene before and after entering a resident's room. LVN 1 stated hand washing is important for infection control and that not doing proper hand hygiene can increase the risk of spread of infections. The DON stated staff should perform hand hygiene before and after entering resident rooms, especially between residents' rooms. The facility policy titled handwashing/hand hygiene, dated 10/2025, stated hand hygiene should be performed before touching a resident, after touching a resident, and after touching the resident environment or belongings.
Dialysis care, transportation, documentation, and fluid restriction failures
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for two residents who required hemodialysis. One resident had diagnoses including ESRD, metabolic encephalopathy, and diabetes, and the record showed he was readmitted to the facility with a care plan and physician orders for dialysis on Tuesday, Thursday, and Saturday, including assistance with curbside pickup for dialysis transportation. The resident also had an H&P stating he had the capacity to make and understand complex decisions and an MDS indicating he required supervision for ADLs and received dialysis. For this resident, the record showed a routinely scheduled dialysis appointment was missed because transportation did not arrive. The progress note stated the facility Medical Director was informed and that staff would follow up to schedule a same-day make-up dialysis appointment. The record then showed a make-up dialysis was scheduled, but the resident did not go and was instead transferred to an acute care hospital for missed dialysis. During interview, staff stated the resident missed dialysis because transportation was not arranged, and the DON acknowledged the missed dialysis sessions were due to transportation issues. Review of the dialysis communication record also showed no pre- or post-dialysis assessments documented for the make-up dialysis, and staff stated the form should have been completed before departure and upon return. The second resident had ESRD and dependence on hemodialysis, with physician orders for dialysis three times weekly, notification of abnormalities before and after dialysis, post-dialysis weights, and a fluid restriction of 1000 ml per day. Review of the dialysis communication record showed one dialysis date was missing from the facility documentation, and staff confirmed the resident had completed dialysis that day. Progress notes also lacked documentation showing the resident left the facility for multiple dialysis appointments, and staff validated the missing sign-out documentation. In addition, the resident’s fluid intake record showed intake above the ordered 1000 ml limit on several dates, and staff stated the resident was supposed to be on the restriction. The resident and CNA stated they did not know the resident was on a 1000 ml fluid restriction.
Improperly Closed and Overfilled Dumpsters
Penalty
Summary
The facility failed to ensure that four of four dumpsters in the outdoor garbage area were completely closed and not overfilled with trash. During a concurrent observation and interview with the Dietary Manager, all four dumpster lids were observed partially open, and the Dietary Manager stated that garbage containers had to be completely closed when not in use to prevent pests from getting inside. The Dietary Manager also stated that open garbage containers attracted pests and that residents could get sick from diseases spread by pests. During an interview with the Administrator, it was stated that the city's trash pickup did not occur as regularly scheduled on the previous Friday because of a holiday, and several days passed with no trash pickup from the city. During record review, the facility's Garbage Disposal Policy, revised May 2025, indicated that trash containers were to be emptied regularly to prevent overflow, and the Dietary Manager stated that dumpsters were not to be filled beyond capacity so the lid could be completely closed.
Failure to Maintain RNA Competency Training
Penalty
Summary
The facility failed to maintain ongoing competency for restorative nursing assistants (RNAs) by not developing and implementing a restorative nursing assistants training program. During an interview, the Director of Staff Development stated that RNAs weighed residents as part of their job description and daily assignments, and that staff education was provided through written in-service topics posted on the facility’s Annual Staff Development Education calendar. RNA 1 stated that RNAs did weigh residents but could not remember the last time she received education on weighing residents. The Director of Nursing stated that RNAs were required to receive appropriate training to ensure competence in their duties and that weight assessment was one of their primary responsibilities. Review of the facility’s Annual Staff Development Education calendars for 2025 and 2026 showed that the monthly topics did not include weight assessment. Review of the RNA job description showed that RNAs were responsible for providing nursing care using restorative nursing approaches learned through training and actual demonstration, and that their responsibilities included weighing residents monthly and as needed based on facility policy. The facility’s In-service Education Policy stated that ongoing in-service education and training would be provided during orientation, annually, and as needed based on resident care needs or identified competency gaps.
Failure to Maintain Dignity and Communicate Active Out-on-Pass Order
Penalty
Summary
The facility failed to ensure care was provided in a manner that promoted dignity and respect for two residents. One resident was admitted with diagnoses including major depressive disorder, essential hypertension, difficulty walking, and hydronephrosis. His history and physical indicated he had the capacity to understand all decisions, and the care plan identified decreased self-care ability with assistance needed for personal care to improve hygiene and grooming. During observation, he had uneven, overgrown facial hair and a noticeably unkempt appearance due to long hair, and he stated he wanted to be shaved and groomed but had not seen the barber. A CNA stated his facial hair was not neatly shaped and a haircut was not provided. The facility also failed to communicate an active out-on-pass order to another resident. That resident was admitted with hepatic encephalopathy, liver cirrhosis, and anemia. Her history and physical described her as stable, alert, and oriented with no evidence of confusion, and the MDS indicated she made herself understood, understood others, had intact cognitive functioning, and participated in her care. Psychiatric notes documented her desire to go out on pass to go to the store and handle personal concerns, including going to Social Security, and stated she may go out on pass according to facility policy. An order summary showed a physician’s order authorizing her to go out on pass for therapeutic purposes not to exceed four hours for one time. During interview, the resident stated she had informed nurses that she wanted to go outside and was waiting for the physician’s out-on-pass order. Later, she appeared frustrated and stated she had been waiting one week to go out on pass and that it was important to her because it made her feel independent while residing at the facility. The DON stated the order was active and should have been communicated to her, and the SSD stated there was a communication gap and that she should not have been waiting with an active order. Facility policies cited dignity, respectful communication, resident rights, and informing residents of their care planning and treatment.
Unattended Veterinary Liniment Gel at Bedside
Penalty
Summary
The facility failed to provide an environment free from accident hazards when a white veterinary liniment gel container was found unattended at the bedside of Resident 82. During observation and interview, Resident 82 stated she used the gel daily for joint pain, and RNA 1 stated the facility was aware that she had been using it. A concurrent record review showed Resident 82 had diagnoses including osteoarthritis, spondylosis, and occipital neuralgia, and her MDS indicated intact cognition for daily decision-making and varying levels of assistance with ADLs. Further review showed Resident 82's VB-NSAMSCA indicated she may not self-administer medications, and her H&P noted fluctuating capacity to make and understand decisions. The Order Summary Report contained no physician order for the veterinary liniment gel. LVN 1 stated Resident 82 was not supposed to have the liniment at bedside unattended and without a physician order because she did not have the capability to self-administer medications. The DON stated medications were not to be left unattended at bedside and were to be prescribed by the physician.
Urinary Catheter Tubing Not Maintained Free of Sediment
Penalty
Summary
Resident 66, who had a history of paraplegia, neurogenic bladder, and urogenital implants, was admitted and later re-admitted to the facility with a urinary catheter in place. The resident’s physician orders directed staff to change the urinary drainage bag as needed for infection, obstruction, or if the closed system was compromised, to flush the catheter with 30 mL of normal saline as needed for obstruction, sediments, and hematuria, and to monitor the catheter every shift for signs and symptoms of UTI, including amber urine, foul odor, poor urine output, and sediment. The care plan also identified the resident as at risk for recurrent UTI and directed staff to flush the catheter as needed for obstruction, sediments, and hematuria and to ensure the tubing remained free of kinks. During an interview, the resident stated feeling uncomfortable in the lower abdomen and asked staff to check the catheter tubing. On observation, the urinary tubing contained dried sediment, and yellowish cloudy urine was stuck in the tubing and was not draining into the collection bag. A CNA stated urine should be free flowing into the collection bag. The TX stated the tubing should not have sediment, that she was supposed to check it daily and flush it per order, and that she had not had time to check the resident until then. The DON stated licensed nurses were supposed to flush the catheter tubing if urine was not draining properly and if there were sediments in the tubing. The facility policy stated it would provide appropriate care and maintenance of urinary catheters and drainage bags according to physician orders, infection prevention standards, and resident needs, and that draining tubing would be kept free from kinks, loops, or obstructions.
Controlled Medication Count Not Documented
Penalty
Summary
The facility failed to ensure accurate accountability of a controlled medication on Medication Cart 1 for one resident’s Methadone HCI. The resident was admitted on 11/21/2025 and re-admitted on 6/1/2026 with diagnoses including bilateral lower limb cellulitis, COPD, and opioid dependence. The resident’s history and physical dated 12/29/2025 indicated the resident had complete ability to make and understand decisions, and the MDS dated 6/8/2026 indicated intact cognition for daily decision-making and moderate to supervision-level assistance with ADLs. The resident had a physician order for Methadone HCI oral 10 mg, 11 tablets for a total of 110 mg by mouth one time daily for pain management, with instructions to hold if sleepy or if respiratory rate was less than 12 per minute. During a concurrent narcotic count, observation, interview, and record review on 6/25/2026, two methadone HCI bubble packs were observed on Med Cart 1, each with two remaining doses. The NHRs for both bubble packs were supposed to show three remaining doses, but the administration history showed the methadone HCI had been administered at 8:07 AM and the LVN stated he forgot to sign both NHRs when the medication was given. The DON stated nurses were supposed to sign and document in the NHR as soon as a controlled medication was removed for proper handling and accurate accounting.
Infection Control Lapses With EBP PPE and Dirty Pill Crusher
Penalty
Summary
The facility failed to maintain infection control measures when CNA 3 provided personal basic care and repositioning to Resident 97 without wearing a gown, even though the resident was on enhanced barrier precautions (EBP). Resident 97 had been admitted and re-admitted with diagnoses including aphasia, dysphagia, and a gastrostomy tube, and the history and physical indicated the resident lacked the ability to make healthcare decisions. The order summary and care plan showed the resident was on EBP and required staff to wear gowns and gloves during direct contact care and close-contact activities such as bathing, peri-care, toileting assistance, and mobility assistance. During the observation, CNA 3 acknowledged the resident was on EBP and stated a gown was supposed to be worn, and RN 1 stated it was important to wear a gown and gloves during close contact due to possible infection control issues. The facility also failed to keep one pill crusher at the nurses’ station clean. During observation, the pill crusher had a reddish-brown color on the hinges and dark powder residue, and LVN 5 stated it was dirty and needed to be cleaned to prevent cross contamination of medications. The IPN stated the facility had infection control practices focused on safety and sanitation, and the DON stated nurses were responsible for cleaning pill crushers to prevent medication cross contamination. The facility policy on cleaning and disinfecting medical equipment stated reusable medical equipment was to be cleaned and disinfected between resident use to reduce the risk of infection and maintain a safe environment.
Failure to Re-Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program for one sampled resident by not re-offering the pneumococcal vaccine yearly in accordance with its policy and current standards of practice. Resident 77 was admitted to the facility on 5/18/2021 and later re-admitted with diagnoses including chronic respiratory failure, asthma, and heart failure. The resident’s H&P dated 1/29/2026 indicated the resident had the capacity to make and understand medical decisions, and the MDS dated 5/10/2026 indicated intact cognition for daily decision-making and varying levels of assistance with ADLs. During a concurrent interview and record review on 6/25/2026, the Infection Preventionist Nurse reviewed Resident 77’s immunization record in CAIR and found the last pneumococcal vaccine was received on 2/3/2016 with a recommendation for a second dose. The medical record showed pneumococcal vaccine declination forms were signed on 5/20/2021 and 3/12/2023, but the IPN stated she was supposed to re-offer the vaccine at least yearly and that Resident 77 was at risk for pneumonia. During an interview the same day, Resident 77 stated wanting to have the pneumococcal vaccine. The facility’s Pneumococcal Vaccine policy stated that pneumococcal vaccines would be offered to all residents and administered in accordance with current CDC recommendations, and the Infection Prevention and Control Program policy stated the facility was to maintain a safe, sanitary, and comfortable environment to help prevent communicable diseases and infections.
Failure to Document Itemized Personal Property Inventory
Penalty
Summary
The facility failed to document an itemized list of personal property for one of three sampled residents upon admission. Resident 2 was admitted with diagnoses including polyneuropathies, chronic pain syndrome, anxiety, major depression, opioid dependence, vascular dementia with psychotic disturbance, and was documented on the MDS as cognitively intact with a BIMS score of 14. The MDS also showed Resident 2 required supervision with eating, oral hygiene, and upper body dressing, moderate assistance with toileting, and substantial/maximal assistance with transfers from bed to chair, toileting, and showering. During a concurrent observation and interview, Resident 2 stated she had brought six boxes and four suitcases of belongings that the facility stored outside her room in a separate closet, and she reported missing items including a second set of bed sheets and pillowcases, a TV screen, and a small white box with jewelry valued at forty thousand dollars. Resident 2 stated staff never reviewed the contents of her boxes and suitcases to record exactly what she had upon admission. The Inventory of Personal Effects listed 12 boxes, four luggage cases, one black plastic bag, two bedside plastic drawers, a cellphone, and a tablet, but did not identify the individual items in each box or luggage and was not signed by staff or Resident 2. The DON stated the admitting RN was responsible for completing the inventory on admission and that each box should be opened and confirmed with the resident.
Cluttered and Unclean Resident Room Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for one resident whose room area was observed to be cluttered and unclean. The resident had diagnoses including muscle weakness, need for assistance with personal care, DMII, failure to thrive, and anemia, and the record indicated the resident had capacity to make complex decisions, intact cognition, and required maximal assistance with ADLs and bed mobility. During an observation with concurrent interview, the resident’s bedside table was found cluttered with personal care items, including incontinence pads, two packages of incontinence briefs, a glove, and a comb, with the drawer left open. Behind the bed, a wedge pillow was on the floor, the resident’s personal blanket was bunched on the bed frame under the raised head of the bed, an empty Glucerna bottle and a crumbled white paper bag with old crackers were also on the bed frame and floor, and the floor was noted to be sticky. The resident stated the facility did not seem to clean as it should and often left a mess. A CNA later verified the clutter and mess and stated the items should not have been under the bed and on the floor.
Infection control failure with unclean call light
Penalty
Summary
The facility failed to ensure a safe and sanitary environment for one sampled resident when an LVN picked up the resident’s call light from the floor and placed it on the bed sheet without cleaning it. Resident 1 was admitted with diagnoses of fracture of the right femur and pubis, type 2 diabetes mellitus, and major depressive disorder. The MDS dated 5/5/2026 indicated the resident was cognitively intact with a BIMS score of 13 and required partial/moderate assistance with toileting and showering, and substantial/maximal assistance with transfers from bed to chair and to the toilet. During a concurrent observation and interview on 5/29/2026, Resident 1 stated he usually does not call for help and gets up and walks with his walker, and he could not reach the call light when asked to press it. At 9:24 p.m., the LVN observed that the call light was on the floor and not within the resident’s reach, picked it up, and placed it on the bed sheet without cleaning it. The LVN stated she should have cleaned the call light first before putting it on the sheet and said it is important to keep it clean to prevent contamination of bed linen. The facility’s Infection Prevention and Control policy stated its purpose was to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that one sampled resident had a call light within reach. Resident 1 was admitted with diagnoses of fracture of the right femur and pubis, type 2 diabetes mellitus, and major depressive disorder. The MDS dated 5/5/2026 indicated the resident was cognitively intact with a BIMS score of 13 and required partial/moderate assistance with toileting and showering, and substantial/maximal assistance with transfers from bed to chair and to the toilet. During observation and interview on 5/29/2026, Resident 1 stated he did not usually call for help and that he got up and walked himself with his walker, and he said the call light was for emergencies. When asked to press it, he could not reach it. At the same time, LVN 1 observed that the resident’s call light was on the floor and not within reach, and stated that it was important for residents to have the call light available to call for help if needed and that staff were responsible for ensuring call lights were within reach during rounds. The resident’s care plan directed that the call light be within reach and answered promptly, and the facility policy stated the call light should be accessible in bed, from the toilet, from the shower or bathing facility, and from the floor.
CNA Allowed to Work Overnight Shift Without Active Certification
Penalty
Summary
Surveyors identified that one CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, contrary to federal nurse aide registry requirements and the facility’s own job description, which requires a valid CNA certification. During interview and record review with the DON, the CNA’s Licensing & Certification Verification Detail Page in the personnel file showed an active, employable status with a future expiration date, which the DON had relied upon. However, when the DON searched the California Department of Public Health (CDPH) website during the same review, no data was found for the CNA, confirming that the CNA did not have an active certification on the registry at the time she worked the shift. Further review of the nursing assignment and attendance sign‑in sheets for the overnight shift confirmed that the CNA had signed in and worked that shift. The DON stated that the situation occurred because the evening shift Charge Nurse, attempting to cover a CNA call‑off, contacted this CNA, who was known for helping cover shifts, and did not recognize that she had been removed from the schedule due to lapsed certification. In a separate telephone interview, the DSD explained that CNAs with lapsed certifications are removed from the monthly schedule and payroll until their certification is valid, and that this CNA had been informed of what she could and could not do with an expired certification. The DSD also noted that the CNA should have known her status when the system would not allow her to clock in, yet she knowingly worked the shift without a valid CNA certification.
Failure to Update Care Plan for Aggressive Behavior and 1:1 Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's aggressive behavior and need for 1:1 supervision following significant changes in the resident's condition. On one occasion, the resident exhibited aggressive behavior, including spitting at a nurse, which resulted in a physician's order for 1:1 supervision. Despite this, a care plan reflecting the new intervention was not created or updated on the same day. Documentation and interviews confirmed that the care plan did not include the required interventions for aggressive behavior or 1:1 supervision at that time. Subsequently, the resident was transferred to a general acute care hospital for further evaluation due to increased agitation and aggression. Upon readmission to the facility, the care plan still lacked updates to address the resident's aggressive behavior and the need for 1:1 supervision. Multiple staff interviews, including those with LVNs, an RN, and the DON, confirmed that the care plan was not revised to reflect the resident's current needs and interventions after these significant events. Record reviews and staff statements indicated that the facility's policies and job descriptions required care plans to be updated with any significant change in a resident's condition or upon readmission from a hospital stay. However, these procedures were not followed, resulting in the absence of an accurate and current care plan for the resident during periods of behavioral escalation and after hospital readmission.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place when a resident, who was blind and had a history of schizophrenia, bipolar disorder, and nicotine dependence, became agitated after being told by a CNA that it was not time to smoke. The CNA attempted to prevent the resident from getting up due to fall risk, but did not notify the RN of the resident's agitation. Another resident, who had type 2 diabetes, blindness in one eye, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident struck the first resident on the jaw, causing pain that required an x-ray to rule out a fracture. The facility's records and interviews confirmed that the agitated resident was attempting to get up from bed to smoke outside of designated hours, and the CNA intervened to prevent a fall. The second resident, witnessing the interaction, interpreted the agitated resident's behavior as threatening toward the CNA and decided to intervene physically. The staff responded to the incident after hearing a commotion, separated the residents, and later moved the aggressor to another room. The injured resident reported pain and anger following the incident, and the x-ray showed no fracture. Review of facility policies indicated that staff are expected to identify and prevent all forms of abuse, including resident-to-resident abuse, and to notify the charge nurse immediately if there are concerns about resident behavior or policy violations. The policies also require staff training in abuse prevention and management of aggressive resident behavior. In this case, the failure to notify the RN of the resident's agitation and the lack of effective intervention allowed the physical altercation to occur, resulting in harm to a resident.
Failure to Prevent Resident-to-Resident Physical Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for two residents, resulting in one resident being struck by another. On the night of the incident, a resident with a history of blindness, schizophrenia, bipolar disorder, and nicotine dependence became agitated after being denied the opportunity to smoke outside of designated hours. The certified nursing assistant (CNA) attempted to calm the resident and prevent him from getting up due to his fall risk, but did not notify the registered nurse (RN) of the resident's escalating agitation. Another resident, who had blindness in one eye, diabetes, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident moved in his wheelchair and struck the agitated resident on the jaw. The incident was witnessed by staff, and the two residents were separated. The struck resident experienced jaw pain and required an x-ray, which showed no fracture. Interviews and record reviews confirmed that the facility's staff did not provide adequate supervision to prevent the altercation. The care plan for the agitated resident required monitoring for unsafe smoking practices and immediate notification of the charge nurse if the smoking policy was violated, but this was not followed. The facility's policies also required staff to protect residents from abuse, including resident-to-resident physical aggression, but these measures were not effectively implemented during the incident.
Failure to Implement Fall Prevention Care Plan During Transfer
Penalty
Summary
The facility failed to implement care plan interventions designed to prevent falls for a resident with a history of impaired gait, balance issues, and a high risk for falls. The resident, who was cognitively intact and required substantial assistance with transfers, was admitted with diagnoses including abnormalities of gait and mobility, lack of coordination, and a need for assistance with personal care. The care plan for this resident included interventions such as adapting the environment for safety, anticipating and meeting the resident's needs, and assisting with all transfers or ambulation. Despite these interventions, on the date of the incident, the resident was not properly positioned in the wheelchair after being transferred from the toilet by a CNA, which resulted in the resident sliding off the wheelchair and falling to the floor. Interviews and documentation confirmed that the CNA did not ensure the resident was seated properly in the wheelchair before moving it, and both the LVN and DON acknowledged that the resident was sitting close to the edge of the seat at the time of the fall. The facility's policies emphasized the importance of individualized, resident-centered safety interventions and the implementation of care plan measures to prevent accidents. However, these measures were not followed during the transfer, directly leading to the fall event. The resident did not sustain injuries as confirmed by subsequent x-rays.
Deficient Management and Documentation of Emergency Drug Supplies and Medication Orders
Penalty
Summary
The facility failed to ensure proper management and documentation of emergency drug supplies (E-kits), resulting in several deficiencies. Upon delivery from the pharmacy, the facility did not receive the correct narcotic E-kit and instead received a C-II E-kit, leaving the facility without a narcotic E-kit for approximately 24 hours. Staff interviews and observations revealed that the narcotic E-kit was missing from its designated location, and only C-II E-kits were present. The facility's policy required staff to check medications against pharmacy order sheets and retain a signed delivery receipt, but this process was not followed, leading to the absence of the required narcotic E-kit. Additionally, the facility did not replace the E-kit within 72 hours of first use, as required by policy. Review of the narcotic E-kit logbook showed entries for medication use that were several weeks apart, indicating that the kit was not replaced in a timely manner. The Director of Nursing confirmed that the dates on the log should not be more than 72 hours apart, but this standard was not met. Furthermore, the facility failed to ensure that drug disposition forms were properly completed; seven forms were found with missing dates and nurse signatures, and some lacked a witnessing nurse's signature altogether. The facility also did not adequately follow up on a resident's order for Norco 10-325 mg, a potent opioid, which was pending authorization from the pharmacy. The medication was not available in the resident's medication drawer, and there was no documentation of follow-up with the pharmacy until prompted by the surveyor. The facility's policy required documentation of non-delivery and follow-up, but this was not done for the resident's Norco order.
Failure to Maintain Sanitary Food Storage and Staff Practices in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Specifically, the ice scooper holder was found to be dirty during an inspection, despite cleaning logs indicating it had been cleaned. The Dietary Food Nutrition Supervisor (DFNS) confirmed the ice scooper holder should always be kept clean to prevent contamination, and acknowledged that a dirty holder could lead to a break in infection control. Facility policy required all containers used with ice to be kept clean and stored in a sanitary manner. Additionally, staff were found to be storing personal perishable food in the facility's refrigerator and placing personal items, such as a tumbler, in non-designated areas within the kitchen. The DFNS confirmed that personal food and belongings are not allowed in the kitchen or food service production areas, as outlined in the facility's policies. These actions were observed during a kitchen inspection and were acknowledged by the DFNS as violations of facility policy.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and follow its infection prevention and control program in several key areas. During medication administration observations, a nurse did not don a gown as required by the facility's Enhanced Barrier Precautions (EBP) policy when providing direct care to a resident identified as needing enhanced precautions. The nurse acknowledged forgetting to wear the gown, and both the infection preventionist and another nurse confirmed that medication administration and taking vital signs are considered direct care activities that require the use of gowns and gloves under EBP. The facility's policy specified that EBP is used to prevent the spread of multi-drug-resistant organisms and requires targeted gown and glove use in addition to standard precautions. Additionally, another nurse failed to disinfect the vial top and injection ports with alcohol swabs during the preparation and administration of intravenous vancomycin for a resident. The nurse stated that disinfection was not necessary, which was contradicted by the infection preventionist and the facility's policy. The policy required strict aseptic technique, including disinfecting all injection ports with a sterile alcohol swab for at least 30 seconds before access. The facility's water management plan was also found to be insufficient. The plan lacked essential details such as a description of the building, the population it housed, and a comprehensive description of the water system. It did not identify areas where Legionella could grow and spread, nor did it include control measures or verification steps to ensure the plan was being followed. Interviews with facility leadership confirmed that the water management plan was not personalized or adequate for the facility's needs, and did not meet the requirements outlined in the facility's own policy and procedures.
Failure to Obtain Legal Representative for Severely Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident who was severely cognitively impaired and lacked decision-making capacity had a legal representative to assist with medical decisions. The resident, who had diagnoses including major depressive disorder, schizophrenia, cataracts, and anxiety disorder, was documented in both the Minimum Data Set and History & Physical as being unable to understand or make decisions. Despite this, the facility obtained verbal consent from the resident for psychotropic medication and had the resident sign an Advance Health Care Directive and other documents, with staff acting as witnesses, rather than involving a legal representative. Interviews with staff confirmed that the resident had periods of confusion and limited vision, and that staff were aware of the resident's lack of capacity. The Social Services Assistant acknowledged not knowing the facility's advance directives policy, and the DON confirmed the resident's incapacity. The Medical Director stated that in cases of cognitive decline, a bioethics meeting and possible appointment of a conservator should occur. The facility's policy indicated residents have the right to appoint a legal representative, but this was not followed for the resident in question.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following a fall incident. The resident, who had a history of Parkinson's disease, encephalopathy, unsteadiness on feet, lack of coordination, and previous falls, was admitted with these diagnoses and was identified as being at risk for falls. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required varying levels of assistance with activities of daily living, but had not experienced any falls since admission until the incident in question. On the date of the incident, the resident experienced a fall and was found sitting on the floor holding onto his walker. The assessment following the fall noted no injuries, and the physician was notified, resulting in an order for an x-ray. Despite this event, a review of the resident's care plan revealed that it had not been updated or revised to reflect the fall or to include any new interventions. The last revision to the care plan had occurred several months prior to the fall. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plan should have been updated after the fall to include additional interventions and ensure staff were aware of the necessary care. The facility's policy also required care plans to be reviewed and updated after significant changes in a resident's condition, such as a fall. The failure to update the care plan after the resident's fall constituted the deficiency identified in the report.
Failure to Provide Effective Oral Hygiene Care for Dependent Resident
Penalty
Summary
The facility failed to provide effective oral hygiene care for a resident who was dependent on staff for all activities of daily living, including oral care. The resident had significant medical conditions, including dysphagia, a gastrostomy tube, and malnutrition, and was assessed as having severely impaired cognitive skills and poor memory. The care plan specified that oral care should be provided three times daily, but observations revealed the resident had a tan substance on her teeth, dry lips, and a substance on her reddened, swollen tongue. Interviews with staff indicated that oral care was being performed only twice daily, and the CNA acknowledged that the resident's mouth had appeared in poor condition for some time. The RN confirmed the poor state of the resident's mouth and indicated that such a condition would warrant notifying a physician and seeking further interventions. The dental hygienist, who had seen the resident recently, noted difficulty in providing care due to the resident's lack of cooperation and was unable to confirm whether consistent oral care was being provided. Subsequent observations showed some improvement in the resident's oral condition, but documentation and interviews confirmed that the facility's policy of maintaining moist lips and oral tissues and preventing oral infection was not consistently followed. The DON stated that daily oral care is especially important for residents with g-tubes and acknowledged that the observed condition of the resident's mouth was unacceptable.
Failure to Lock Bed and Hoyer Lift During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNA2 and CNA3) failed to lock both the bed and the Hoyer lift before placing the sling under a resident with a history of hemiplegia, hemiparesis, cerebral infarction, aphasia, and previous falls. The resident's care plan specifically required a safe environment with bed wheels locked and assistance with all transfers due to impaired gait, balance, and mobility. During the observed transfer, neither the bed nor the Hoyer lift was locked, contrary to the care plan and facility policy. Interviews with the involved CNAs, a Licensed Vocational Nurse, and a Registered Nurse confirmed that both the bed and the Hoyer lift should have been locked to ensure safety and prevent accidents. The facility's policy on using mechanical lifts also required staff to ensure the lift was stable and locked before use. The failure to follow these procedures was directly observed and acknowledged by staff, representing a lapse in implementing required safety measures for the resident.
Failure to Complete Required Bowel and Bladder Assessments
Penalty
Summary
The facility failed to perform a quarterly bowel and bladder assessment for a resident as required by the resident's care plan. The care plan specified that assessments should be completed on admission, quarterly, and as needed, but documentation showed that the last assessment was performed on 2/14/2025, with no subsequent assessments recorded. This omission was confirmed during interviews with both a registered nurse and the Director of Nursing, who acknowledged that the quarterly assessment had not been completed as required. The resident involved had multiple medical diagnoses, including congestive heart failure, cirrhosis of the liver, reduced mobility, and adult failure to thrive. The resident was cognitively intact, able to make needs known, and required substantial assistance with toileting hygiene. The resident was frequently incontinent of both bowel and bladder, and the care plan included a goal to prevent complications from incontinence, such as skin breakdown or infection. Despite these needs, the required ongoing assessments to monitor and manage the resident's continence status were not performed according to the care plan schedule. Facility policy and procedure documents indicated that comprehensive, person-centered care plans should be developed and implemented for each resident, including measurable objectives and timeframes. The policies also required ongoing assessment and management of urinary continence and incontinence, with regular documentation and review. The failure to follow these policies and the resident's care plan resulted in a deficiency related to the lack of timely bowel and bladder assessments.
Failure to Label G-Tube Flush Bag for Resident Receiving Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident with a history of aphasia, dysphagia, and malnutrition, who was dependent on gastrostomy tube (g-tube) feeding, was observed to have a flush bag attached to their g-tube pump that was not labeled with the date, time, and nurse's initials. The resident's care plan specifically required that the formula container, syringe, and administration set be labeled with the resident's name, date, time, and nurse's initials. During observation and interview, both the treatment nurse and an LVN confirmed that the flush bag was not labeled as required. Further interviews with the LVN and the Director of Nursing confirmed that the lack of labeling on the flush bag could result in not knowing when the flush was hung and could pose a risk of infection. Review of the facility's policy indicated requirements for labeling the formula but did not specifically address labeling of the flush bag. The failure to label the flush bag as outlined in the resident's care plan constituted the deficiency.
Failure to Administer and Document Physician-Ordered Medication for Allergic Reaction
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident. The resident, who was admitted with diagnoses including fibromyalgia and disturbances of skin sensation, experienced facial itching due to a possible allergic reaction. The resident was cognitively intact and required varying levels of assistance with activities of daily living. On the date of the incident, the resident complained of facial itching, and a Change in Condition Evaluation was completed. The primary physician was notified and gave an order to administer Benadryl 25 mg orally every six hours for 14 days as needed for itching. This order was documented in the resident's physician order and care plan, which included the intervention to administer Benadryl as needed for itching. However, review of the Medication Administration Record (MAR) showed that the Benadryl was not signed as given on the date of the incident. The resident later stated in a telephone interview that she did not receive the Benadryl. The LVN involved stated she administered the medication, but there was no documentation to support this. Both the registered nurse supervisor and the director of nursing confirmed during interviews and record reviews that the MAR was not signed and there was no other documentation indicating the medication was given. Facility policy requires that the individual administering medication must document the administration on the MAR, including date, time, dosage, route, symptoms, results, and signature. The lack of documentation and failure to administer or record the administration of Benadryl as ordered constituted the deficiency.
Failure to Post Actual Staff Hours as Required
Penalty
Summary
The facility failed to comply with the federal requirement to post the actual hours worked by staff daily in an area accessible to the public. On the observed day, the Direct Care Services Hours Per Patient Day (DHPPD) actual hours were not posted, only the projected hours were displayed. This deficiency was identified during an observation on 11/12/2024, where it was noted that the DHPPD for the previous day (11/11/2024) was also missing. Interviews with the Director of Staff and Development (DSD) and the Director of Nursing (DON) revealed a misunderstanding of the posting requirements. The DSD was unsure if actual hours needed to be included, while the DON initially believed only projected hours were necessary. However, upon reviewing the facility's policy, the DON acknowledged that actual hours for the previous day should have been posted alongside the current day's projected hours. The facility's policy clearly stated that shift staffing information, including actual hours worked, must be recorded and maintained for 24 hours in a single location.
Failure to Administer Pomalyst as Prescribed
Penalty
Summary
The facility failed to implement a consistent and accurate system for reconciling the administration of Pomalyst, an oral chemotherapeutic capsule prescribed for a resident with multiple myeloma. This failure resulted in the resident missing two doses of the medication on specified dates. The resident, who was admitted with multiple diagnoses including multiple myeloma, type 2 diabetes mellitus, and end-stage renal disease, was prescribed Pomalyst to be taken on specific days. However, the medication was not administered as ordered, leading to missed doses. During interviews, it was revealed that the resident was aware of the prescription but reported not receiving the medication as prescribed. The Director of Nursing confirmed the missed doses upon reviewing the Medication Administration Record. An LVN admitted to not administering the medication on one occasion due to being unable to locate it in the medication cart. The pharmacist emphasized the importance of administering Pomalyst as prescribed to avoid potential side effects. The facility's policy indicated that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure dignity and respect for two residents, resulting in a deficiency related to resident rights. Resident 2, who was admitted with conditions including hypertension, low back pain, anemia, and cellulitis, reported an incident where a CNA yelled at them and another resident for questioning the care provided. This incident occurred after Resident 2 assisted another resident who was cold and uncovered. Resident 2 expressed that staff frequently yelled during the night shift, which was inappropriate behavior. Resident 7, who was admitted with osteoarthritis, anemia, reduced mobility, and lack of coordination, corroborated the occurrence of yelling, having heard an argument involving multiple people around the same time as Resident 2's incident. Both residents had intact cognition and required varying levels of assistance from staff for daily activities. The facility's policy on resident rights, revised in 2016, mandates that employees treat all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to a resident with multiple medical conditions, including an amputation site, acute respiratory failure with hypoxia, and an arterial ulcer on the right lower leg. The facility did not assess or document the condition of the resident's arterial ulcer upon admission, nor did they develop a comprehensive care plan that included the physician's order for treatment of the ulcer. The treatment order, which required daily care for 21 days, was not followed, resulting in the resident not receiving treatment for over two weeks. Additionally, the facility did not adequately monitor the resident's respiratory status as per the continuous oxygen therapy care plan. There were discrepancies in the documentation of the resident's oxygen saturation levels, and the facility failed to administer the correct amount of oxygen as required. This lack of proper monitoring and treatment contributed to the resident's transfer to a general acute care hospital, where they presented with altered levels of consciousness, shortness of breath, and right ankle pain. The resident's condition deteriorated further at the hospital, where they were diagnosed with soft tissue ulceration with underlying osteomyelitis, pulmonary edema, and adjacent atelectasis. Despite the hospital's efforts, the resident passed away three days after the transfer. Interviews with facility staff revealed that the treatment order was incorrectly documented, and the care plan was not initiated upon admission, leading to a lack of interventions for the resident's wounds.
Failure to Administer Medication Leads to Resident Weight Loss
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 78, who was at risk for malnutrition. Resident 78 did not receive 17 doses of Megestrol Acetate Suspension, an appetite stimulant, as ordered by the physician. This failure was due to the medication not being available in stock, and the facility did not maintain accurate medication administration records. The medication was marked as administered on multiple occasions when it was not available, leading to significant weight loss for the resident. Resident 78 was admitted with several diagnoses, including an intracranial abscess, hearing loss, and gastroesophageal reflux disease. The resident had intact cognition and required assistance with activities of daily living. Despite being at risk for malnutrition, as indicated by a Mini Nutrition Evaluation score, the facility's interventions to administer the appetite stimulant were not followed. The medication administration records inaccurately reflected that the medication was given, even though it was not in stock, as confirmed by interviews with the nursing staff and the Director of Nursing. The facility's policies and procedures required that medications be administered according to prescriber orders and documented immediately after administration. However, the facility failed to adhere to these policies, resulting in Resident 78 experiencing more than a five percent weight loss in one month. The Registered Pharmacist confirmed that the medication was requested but not delivered until a later date. Interviews with the nursing staff revealed a lack of awareness and adherence to proper documentation practices, contributing to the deficiency.
Failure to Label and Date Stored Food
Penalty
Summary
The facility failed to ensure that food stored in the kitchen was properly labeled and dated, which could potentially lead to food-borne illnesses for all residents receiving food from the kitchen. During an initial kitchen tour, surveyors observed several items in the walk-in refrigerator that were unlabeled and undated, including unopened and opened bags of whole wheat bread, hamburger buns, and various frozen vegetables such as broccoli, spinach, mixed vegetables, peas, carrots, and cauliflower. The Dietary staff confirmed that these items were not labeled or dated, acknowledging that all food stored in the kitchen should be labeled and dated to track their usability and prevent food-borne illnesses. The Director of Nurses also confirmed that all food stored in the kitchen should be labeled and dated to ensure the safety of the residents. A review of the facility's policy and procedure on labeling and dating foods indicated that all food items in storage areas, including the storeroom, refrigerator, and freezer, need to be labeled and dated. The policy specifies that food delivered to the facility should be marked with a received date, and newly opened food items should be labeled with an open date and a use-by date according to various storage guidelines. This deficiency highlights a failure to adhere to the facility's established procedures for food safety.
Failure to Develop Individualized Care Plan for Resident with Diabetes
Penalty
Summary
The facility failed to develop an individualized person-centered care plan for a resident, identified as Resident 40, who was admitted with diagnoses including Type II diabetes, unsteadiness on feet, and major depressive disorder. Despite the resident's condition requiring specific interventions, the facility did not create a care plan addressing hyperglycemia after a significant change in the resident's condition was noted. On 3/7/2024, Resident 40 experienced an elevated and uncontrolled blood sugar level of 495 mg/dl, yet no care plan was developed to manage this condition. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed that licensed staff were required to develop and implement care plans with appropriate interventions following a change in a resident's condition. However, this was not done for Resident 40, leading to a lack of care and monitoring. The facility's policy indicated that care plans should be revised as residents' conditions change, but this was not adhered to in this case, resulting in the deficiency.
Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a right heel deep tissue injury (DTI) as per the comprehensive assessment and professional standards of practice. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was admitted with a diagnosis of pressure-induced deep tissue damage. The care plan for the resident, initiated shortly after admission, included interventions to monitor and document changes in the wound's condition, such as color, drainage, odor, sensation, and pain, as well as weekly measurements of the wound. However, these interventions were not implemented for a period of 16 days. During this period, there was no documentation in the resident's medical record or the Treatment Administration Record (TAR) regarding the condition of the right heel DTI. This lack of documentation included essential details such as the wound's color, drainage, odor, sensation, and measurements, which were required by the care plan. Observations and interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the absence of documentation and highlighted the potential risk of infection or worsening of the wound due to this oversight. The facility's policies and procedures for charting, documentation, and wound care required detailed recording of treatment and assessment data, including the date and time of procedures, assessment findings, and the resident's response to treatment. Despite these requirements, the facility did not adhere to its own policies, resulting in a failure to track the resident's progress and potentially compromising the resident's care.
Failure to Implement and Update Fall Prevention Plan
Penalty
Summary
The facility failed to implement and update the Risk for Falls Care Plan for a resident with a history of falls, identified as Resident 64. The care plan, dated 12/5/2023, included interventions such as a yellow star on the wall above the headboard, a gold star on the name plate, a yellow fall risk wristband, yellow non-skid socks, and a yellow star on the wheelchair. These interventions were not implemented, as observed on 5/8/2024, when the resident was seen without the required fall prevention items. Additionally, the care plan was not revised following a fall on 2/16/2024, which resulted in a skin abrasion on the resident's right anterior forearm. The facility's policy on Falls and Fall Risk Management, revised in 3/2018, requires a resident-centered fall prevention plan to be implemented and updated as needed. However, the care plan for Resident 64 was not updated after the fall, and the interventions were not in place, as confirmed by the Director of Nursing during an interview. The facility's policy on comprehensive person-centered care plans, revised in 7/2017, also mandates that care plans be revised when there is a significant change in a resident's condition, which was not adhered to in this case.
Failure to Properly Label and Store Nasal Cannula Tubing
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not ensuring the nasal cannula (NC) tubing was labeled and stored in a plastic bag. The resident, who was admitted with acute respiratory failure with hypoxia and dependence on supplemental oxygen, had a care plan that required continuous oxygen therapy at two liters per minute via NC to maintain oxygen saturation above 93%. Observations revealed that the NC tubing was not labeled and was improperly stored, either hanging over a tube feeding machine or placed inside a bedside drawer. Interviews with staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the NC tubing should have been labeled with the date and stored in a plastic bag to prevent contamination and infection. The facility's policy indicated that the oxygen cannula and tubing should be changed every seven days or as needed and stored in a plastic bag when not in use. The failure to adhere to these protocols put the resident at risk for infection and complications associated with oxygen therapy.
Lack of Justification for Continued Antidepressant Use
Penalty
Summary
The facility failed to provide documented justification for the continuation of the antidepressant medication Effexor beyond 30 days for a resident diagnosed with major depressive disorder, among other conditions. The resident was admitted with diagnoses including major depressive disorder, osteoarthritis, and difficulty in walking. The care plan for the resident included administering medications as ordered and monitoring for side effects and effectiveness, but there was no review date indicated for the goal of being free of depression symptoms. The resident received Effexor daily, and there were no episodes of verbalization of sadness recorded during this period. The Consultant Pharmacist's Medication Regimen Review (MRR) from January to April did not include any recommendations, actions, or rationale for the continued administration of Effexor. The facility's policy required the consultant pharmacist to review each resident's medication regimen monthly and report any non-life-threatening medication irregularities to the attending physicians. However, there was no documentation of a Gradual Dose Reduction (GDR) for the resident, which the Director of Nurses acknowledged as important to ensure the necessity of the prescribed medications.
Medication Error Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically by not having the medication Megestrol Acetate Oral Suspension available for administration for 17 days. This medication was prescribed to stimulate the resident's appetite, and its absence led to significant weight loss. The resident, who was admitted with various medical conditions including intracranial abscess and gastroesophageal reflux disease, was at risk for malnutrition due to the lack of medication. During a medication pass observation, it was noted that the medication was not available in the medication cart, and the Licensed Vocational Nurse (LVN) inaccurately marked the medication as administered. This error was repeated by multiple nurses over the course of several days, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that the medication was not delivered until much later, and the Registered Pharmacist corroborated that the medication was requested but not delivered until a later date. Interviews with staff and the resident's representative revealed that the resident had not been eating well and experienced a significant weight loss from 182 pounds to 156 pounds. The Registered Dietician noted that the resident's oral intake was initially stable but declined due to the lack of the appetite stimulant and ongoing antibiotic treatment. The facility's policies on medication administration and documentation were not followed, contributing to the deficiency.
Improper Storage of Ophthalmic Solution
Penalty
Summary
The facility failed to ensure the safe storage of Dorzolamide-Timolol Ophthalmic Solution, a medication used to treat high pressure in the eyes, for a resident. During an observation and interview, it was found that the medication was stored in a refrigerator at 40 degrees Fahrenheit, contrary to the manufacturer's requirement of storing it between 68 to 77 degrees Fahrenheit. The Licensed Vocational Nurse (LVN) acknowledged the improper storage and indicated that the medication should not have been refrigerated, as this could render it ineffective. The Director of Nursing (DON) confirmed that the Dorzolamide-Timolol should not have been stored in the refrigerator, as improper storage could lead to the medication being ineffective in treating elevated eye pressure. The facility's policy on medication storage, dated April 2019, requires that drugs and biologicals be stored under proper temperature, light, and humidity controls, which was not adhered to in this instance.
Failure to Adjust Laxative Administration for Resident with Loose Stools
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident experiencing a change in bowel condition, specifically frequent loose stools. The resident, who was admitted with multiple medical conditions including multiple myeloma, malnutrition, and dependence on renal dialysis, was prescribed MiraLAX, a laxative, to be taken every 12 hours for constipation. Despite the resident experiencing frequent loose stools, the facility continued administering the laxative without notifying the physician or adjusting the treatment plan. The resident's medical records indicated frequent loose bowel movements over several weeks, yet there was no documentation of the physician being informed of this change in condition until much later. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's diarrhea, with some staff members unaware of the resident's condition or the need to adjust the laxative dosage. The Director of Nursing acknowledged that the resident should not have been given MiraLAX with loose stools and that the physician should have been notified sooner. The facility's policies required prompt notification of changes in a resident's condition, but this was not adhered to in this case. The resident's diarrhea was eventually linked to chemotherapy and dialysis, and the laxative was deemed unnecessary. The failure to address the resident's change in condition in a timely manner posed a risk of dehydration and other complications, highlighting a deficiency in the facility's care and communication processes.
Failure to Review Transfer Records Leads to Missed Appointments
Penalty
Summary
The facility failed to thoroughly review the transfer records from the general acute hospital (GACH 1) for a resident admitted on 3/16/24. The resident had multiple follow-up appointments arranged by GACH 1 for vascular diagnostics, chemotherapy, and consultations with a hematologist and pulmonologist. However, the facility did not review the inpatient progress notes that contained these appointments. Instead, the admitting registered nurse (RNS) only reviewed the medication pages to transcribe the admission orders and verify them with the resident's primary physician. This oversight resulted in the resident missing several critical medical appointments scheduled between 3/18/24 and 4/25/24. Interviews with the director of nursing (DON) and RNS 1 revealed that GACH 1 did not inform the facility about the resident's appointments during the pre-admission report. The facility's policies on charting, documentation, and admission were reviewed, indicating that documentation should be complete and accurate, and preliminary resident information should be documented upon admission. Despite these policies, the failure to review the transfer records thoroughly led to a delay in the resident's treatment for multiple myeloma, anemia, and other conditions requiring substantial assistance with daily activities.
Failure to Safeguard Resident's Personal Funds
Penalty
Summary
The facility failed to safeguard personal funds for one resident. The Licensed Vocational Nurse (LVN) retrieved $800 from the resident and placed the money in the narcotic box instead of following the proper procedure. The resident, who was cognitively intact and required maximum assistance with daily activities, had been admitted with $900, of which $100 was kept in their wallet and $800 was stored in the medication cart by staff. The Social Services staff observed the $800 in the medication cart the following day, but it was not removed and placed in the business office until two days later. The facility's policy required that the money be transferred to the business office on the next available business day, with the transaction requiring two signatures. The delay in transferring the funds and improper initial storage in the narcotic box led to the potential risk of the resident's personal funds being stolen or misused.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollywood Premier Healthcare Center | 0 mi | ★★★★★ | 6 | 0 |
| Fountain View Subacute And Nursing Center | 0 mi | ★★★★★ | 36 | 0 |
| The Meadows On Sunset Post Acute | 0.6 mi | ★★★★★ | 45 | 0 |
| Alexandria Care Center | 0.6 mi | ★★★★★ | 47 | 0 |
| Hollywood Presbyterian Medical Center D/p Snf | 1.1 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.