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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palos Verdes Health Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke, DM, and major depressive disorder reported that his roommate was cursing at him, calling him derogatory names, and later allegedly threatening to kill him. A CNA informed an LVN of the verbal altercation in the early morning, and the LVN confirmed with the resident that the roommate had been calling him names, but did not immediately separate the two, believing only supervisory staff could authorize a room change. When the LVN notified the RN supervisor at shift change, the supervisor initially viewed the situation as a misunderstanding, did not promptly interview both residents, and did not immediately report it as abuse, despite facility policies requiring immediate reporting of abuse and separation of residents involved in altercations. As a result, the residents remained together in the same room for a period of time after the alleged verbal abuse and threats occurred.
A resident with a history of stroke, DM, and depression, who was cognitively able to make decisions, reported to a CNA in the early morning that his roommate was cursing at him, calling him derogatory names, and later threatening to kill him. The CNA informed an LVN, who documented the verbal abuse and notified an RN supervisor when she arrived, but the RN initially viewed the situation as a misunderstanding, did not immediately interview both residents, and did not promptly separate them. Although staff acknowledged they were mandated reporters and that abuse allegations must be reported immediately per facility policy, the formal abuse report (SOC 341) was not faxed to the state agency until many hours after the initial allegation, exceeding the policy requirement to report within two hours.
Two residents who were incontinent and dependent on staff for toileting and hygiene reported that CNAs used excessive force and inserted fingers into their rectum during cleaning after bowel movements, one during bed care and one in the shower. Both residents, who had significant medical conditions and impaired or fluctuating decision-making capacity, stated they felt humiliated, violated, and fearful. The CNAs acknowledged providing the care in question, and the DON and nursing staff received reports from family members that the care was rough and involved fingers in the rectal area. These actions did not align with facility policies requiring that residents be treated with dignity, respect, and in a manner that maintains their self-esteem.
Insufficient dietary oversight was identified when the Dietary Supervisor worked only part time on weekends and the RD provided consulting services only once weekly. Surveyors found that kitchen staff did not follow the scheduled menu for pureed diets, therapeutic diets were inaccurate for two residents, the ice machine was not clean and sanitary, and the dishwashing machine was not reaching the proper temperature. The FNS Director job description stated the supervisor was to confer regularly with the Administrator, DON, and dietary consultant regarding department problems and progress.
Open and Overflowing Kitchen Dumpster: The kitchen garbage dumpster was observed completely open with black trash bags overflowing from it. An RD stated dumpsters must remain completely closed, and the DON stated the dumpster should not be overflowing and must stay covered. The open, overflowing dumpster was identified as the kitchen's garbage dumpster.
The facility failed to ensure laundry washing machines reached the required water temperature for proper sanitation, with observed temperatures of 85 degrees Fahrenheit and 80 degrees Fahrenheit and logs showing February temperatures ranging from 85 to 106 degrees Fahrenheit. The Laundry Aide said she only recorded temperatures and was not told to report when they were below range, while the MS stated the water needed to reach 160 degrees Fahrenheit to kill germs. The facility also failed to review and update its IPCP policy annually; the IPN and DON stated the policy had last been reviewed in 2022 despite the facility requirement for annual review.
Meals and diet textures did not match the posted menu or ordered diets for four residents. Two residents on pureed diets were served Salisbury steak instead of the scheduled pork chops meal, and two other residents received coconut cake in the wrong texture during tray line. The dietary aide said he chose the wrong items and placed desserts on the wrong trays, while the DON and RD stated the menu and prescribed therapeutic diets should have been followed.
Unsafe food storage and sanitation practices were observed in the kitchen. A reach-in refrigerator had a broken internal thermometer, the dishwashing machine repeatedly failed to reach the required 120 F, and the ice machine had visible residue and dirt inside. A CK touched a step-on trash can lid and then stirred soup without washing hands, and open bags of flour and pasta were left unsealed in dry storage.
Failure to document vaccine education and ensure immunization administration: Two residents did not have documented education on the risks and benefits of refusing flu and pneumococcal vaccines, and one resident did not receive the flu and pneumococcal vaccines. Records showed one resident had impaired cognition and another had partial capacity, while staff interviews confirmed education was not provided or documented and that vaccine consent/administration documentation was incomplete.
Dishwashing Machine Failed to Reach Required Temperature: A dietary aide ran the dishwasher multiple times, but the temperature gauge remained below the required 120 F, reading 104 F, 110 F, and later 102 F. The dietary supervisor stated the machine should reach 120 F to properly sanitize dishes and utensils, while the aide said it was acceptable to keep using it if chemical sanitation was within range. The RD stated the issue should be reported and addressed to ensure dishes are cleaned properly and to prevent food-borne illnesses.
Failure to Honor Resident Request for Shower: A resident with Parkinson’s disease, dementia, unsteadiness, and a history of falls requested a shower, but staff did not provide one and instead relied on her scheduled shower days. The CNA stated the resident had asked for a shower but it was too late to provide it and admitted the request should have been honored or passed on to the next shift; the DON stated the resident should have received the shower regardless of schedule. The resident’s MDS showed severely impaired cognition and need for partial/moderate assistance with bathing and personal hygiene.
Missing Resident Personal Items Not Located or Replaced: A resident with major depressive disorder, quadriplegia, bed confinement, and chronic pain reported missing pens, pencils, and a personal bottle of hot sauce. The resident said he notified the scheduler, but the scheduler did not notify SW or document a grievance and was waiting for funds to replace the items. The DON stated SW was responsible for interviewing the resident about missing property and that the resident should have been kept updated.
A resident with schizophrenia, anxiety, major depressive disorder, and impaired cognition received PRN Ativan for anxiety and restlessness without documented non-pharmacological interventions first. The PRN order had no stop date, and the DON stated it should have been limited to 14 days; the care plan included giving lorazepam as needed and refocusing behavior, while the LVN confirmed no non-pharmacological interventions were documented before administration.
A resident with DM and a right second-toe diabetic ulcer did not receive the recommended ABI with arterial doppler ordered by the wound MD. The toe was observed swollen and black with a small amount of blood, and the resident said it had been hurting and turning black for about three weeks and he was worried it might need to be cut off. The TXN acknowledged missing the order, and the DON stated the testing should have been completed and noted the toe was black.
A resident with cerebral infarction, hemiplegia, hemiparesis, and seizures had significant dependence for ADLs and mobility, but the facility did not resume RNA services after the resident returned from the hospital. Staff stated the resident had previously received restorative services, the care plan addressed mobility deficits, and the resident should have been receiving RNA due to left-sided weakness, yet no current order was in place and the services were not restarted.
The facility failed to ensure two CNAs completed required annual competency evaluations. During record review with the DON, one CNA’s file had no documentation of annual competency completion, and the DON confirmed the competency had not been completed and was required each year. The DON stated that without the annual competency, the CNA would lack updated knowledge and accountability.
The facility's QAA Committee failed to ensure effective oversight and did not ensure implementation of the 2025 POC for repeat deficiencies cited in the prior survey, including food storage, food prep, sanitation, and annual CNA in-service training. During interview, the ADM acknowledged the prior kitchen and CNA education issues and stated the facility was not currently working on those areas.
Missing COVID-19 Vaccine Education and Documentation: A resident with impaired cognition and no decision-making capacity received the COVID-19 vaccine, but the record lacked documentation that the RP was educated on the risks and benefits before consent was obtained by phone. In addition, an aide had no documentation of COVID-19 vaccine education, offer, or current vaccination status, and the IPN confirmed the vaccine had not been offered.
A resident with DM, muscle weakness, and CVA reported that his room was too small and that belongings blocked his ability to move out of the room easily. Surveyors also found that 18 of 24 rooms, including multiple 2-bed rooms and one 4-bed room, did not meet the required square footage per resident. The ADM acknowledged the rooms were small.
Two CNAs did not have documentation showing completion of the required 12 hours of annual in-service training. The DON confirmed one CNA had not completed the annual in-services and another CNA’s last documented completion was over a year earlier. The facility also did not have a DSD, and the CNA policy required a minimum of 12 hours of continuing education to maintain certification.
A resident with Parkinson's disease, moderately impaired cognition, and dependence on staff for ADLs had Social Security benefits totaling over $27,000 deposited by SSA into the facility's payroll bank account over several months, where the funds were used for employee paychecks instead of being placed in a separate trust or personal funds account. A business manager later discovered the deposits in payroll bank statements and reported them to leadership, but no action was taken to return the money to the resident's estate, and a subsequent review confirmed no reimbursement had occurred. The administrator acknowledged that the resident's funds were co-mingled with facility funds, contrary to the facility's written policy prohibiting resident trust funds from being combined with facility funds.
A resident with Parkinson’s disease and moderately impaired cognition had multiple SSA payments totaling over $27,000 deposited into the facility’s payroll account rather than into a resident trust account. Review of financial records showed no evidence that these funds were ever transferred to the resident’s trust account or refunded after discharge, and a later trust account check covered only a small portion of the amount. Business office staff confirmed that a check from the payroll account to the resident’s trust account was never created, despite facility policy requiring resident refunds within a specified timeframe after discharge.
Three residents with specialized needs did not have individualized care plans in place, including a resident with PTSD, another with intentional weight loss, and a third receiving RNA services for Parkinson's disease. Staff interviews and record reviews confirmed the lack of care plans addressing these specific needs, despite ongoing interventions and clinical documentation.
Surveyors found that multiple food items, including juices, fruits, cooked meats, and cereals, were not properly labeled with open or use-by dates, and some expired items remained in storage. Staff interviews confirmed that these practices did not follow facility policy, which requires all opened and stored foods to be dated to ensure safety.
A resident with right-sided hemiparesis and impaired decision-making capacity was found with her call light placed on her affected side, making it inaccessible. Staff and DON interviews confirmed the expectation that call lights be within reach, and facility policy supported this requirement. The deficiency was identified through observation, interview, and record review.
A resident with diagnoses of schizophrenia and depression was not properly screened for mental illness upon readmission, as the initial PASARR Level I failed to identify these conditions and a new PASARR was not submitted. The DON confirmed the oversight, and facility policy requiring screening for mental disorders on admission and readmission was not followed.
The facility did not complete required annual performance evaluations for several CNAs, as confirmed by both the DSD and DON during interviews and record reviews. This was in direct violation of the facility's policy, which mandates annual evaluations to assess and improve staff performance.
A resident with multiple chronic conditions did not receive full doses of several prescribed oral medications when an LVN left residual medication in the cups during administration, resulting in a medication error rate of 26.92%, far exceeding the acceptable limit. The resident was dependent on staff for care and unable to communicate needs, and the facility's policy for safe and complete medication administration was not followed.
A resident with multiple chronic conditions did not receive the full dose of several prescribed medications during a medication pass, as confirmed by both the LVN and DON. The resident, who was dependent on staff for care and communication, was left with medication remaining in the cups after administration, contrary to facility policy requiring medications to be given as prescribed.
A resident with multiple comorbidities and dependent on staff for care was prescribed and administered Gentamicin for an eye infection without meeting McGeer criteria, as no laboratory culture was performed. Staff interviews and record reviews confirmed the facility did not follow its antibiotic stewardship protocol, which requires proper assessment before antibiotic use.
The facility did not ensure that CNAs completed the required hours of dementia and abuse prevention training, with several staff missing portions or all of the mandated education. This was confirmed through interviews and record reviews, which showed incomplete training documentation and a lack of compliance with facility policies for annual in-service education.
Eighteen resident rooms, including both two-bed and one four-bed room, were found to be below the required 80 square feet per resident. Despite the facility's waiver request and observations indicating residents had enough space for movement and use of mobility aids, the rooms did not meet regulatory size standards.
A resident sustained a fracture and laceration to the left great toe after being hit by a malfunctioning shower room door. The CNA failed to request assistance while transporting the resident, and both the CNA and LVN did not report the door issue in the Maintenance Logbook. The Maintenance Supervisor was aware of the problem but did not ensure it was resolved, leading to the accident.
A resident sustained injuries during transport in a facility van due to the failure to secure her wheelchair with four-point straps. The driver only used a lap seatbelt, and the accompanying CNA was not trained to verify proper securement. As a result, the wheelchair tipped over during a turn, causing the resident to suffer a scalp laceration, hematoma, neck sprain, and shoulder sprain.
A resident sustained injuries due to improper securing of their wheelchair during transport in a facility van. The CNA escorting the resident was unfamiliar with the necessary securing straps, and the driver could not confirm proper anchoring. The facility lacked documentation of training on using the van's seatbelts and four-point straps, contrary to its policy.
A resident with type 2 diabetes and a venous ulcer did not receive proper wound care as per physician's orders, leading to the presence of maggots and a hospital transfer. A nurse's personal emergency and miscommunication between staff resulted in the wound being neglected, causing pain and infection.
The facility failed to implement effective infection control practices, including the use of Enhanced Barrier Precautions (EBP), for residents with wounds and indwelling medical devices, leading to potential cross-contamination. Staff were observed providing care without proper PPE, and there was a lack of EBP signage and isolation carts. The facility also lacked comprehensive policies and procedures for managing residents colonized with MDROs.
The facility did not post daily staffing information, preventing residents and visitors from accessing staffing details to ensure safe ratios. Observations showed no postings at nursing stations, and interviews with the DSD and Assistant DSD revealed a lack of awareness about posting locations. The DON confirmed that actual nursing hours were not posted as required by facility policy.
The facility failed to provide required dementia care training to all CNAs, as revealed through interviews and record reviews. CNAs acknowledged the need for training to improve care for residents with dementia. The DON confirmed the importance of such training, but documentation was lacking. The facility's policy required initial and annual training, which was not adhered to, potentially affecting care quality.
The facility failed to ensure functional and accessible call lights for two residents, one with acute respiratory failure and another with severe cognitive impairment. A resident's call light was not plugged in, preventing them from requesting pain medication, while another's call light was out of reach, hindering their ability to call for help. The DON confirmed the importance of operational call lights to meet residents' needs and prevent potential falls.
The facility failed to implement Gradual Dose Reductions (GDR) for psychotropic medications for three residents, despite recommendations and policy requirements. A resident on Zoloft for depression did not have a GDR attempted, and the physician was not notified of the pharmacist's recommendations. Two other residents on multiple psychotropic medications also lacked GDR attempts or documentation of contraindications. The DON confirmed the absence of necessary documentation and follow-through.
The facility failed to store food in a sanitary manner, with several items in the refrigerator and freezer not dated or labeled, and some expired. This was confirmed by a Dietary Aid and acknowledged by the COO, who stated it was the kitchen staff's responsibility to ensure food items were labeled, dated, and fresh. The DON also emphasized the importance of labeling to prevent residents from consuming expired foods, as per the facility's policy.
The facility's QAA and QAPI committees failed to address systemic issues in infection control, nursing staff monitoring, and injury reporting. Infection control practices, including Enhanced Barrier Precaution for residents with wounds and indwelling devices, were not maintained, and there was no system to ensure call lights were within reach. The Administrator admitted to not identifying these issues before the survey, acknowledging improvement opportunities.
The facility failed to follow its Antibiotic Stewardship protocol for five residents, prescribing antibiotics without meeting the McGeer Criteria. This included administering antibiotics without necessary culture and sensitivity tests or documentation, potentially leading to antibiotic resistance. The Infection Preventionist confirmed the lack of compliance with the facility's policy, which requires antibiotics to be prescribed under the guidance of the stewardship program.
A resident with cognitive impairments and a history of hemiplegia was found with facial bruising and swelling, which was not reported to the CDPH within the required timeframe. Despite staff recognizing the injury as of unknown origin, it was not reported or investigated promptly, contrary to facility policy. This oversight resulted in a deficiency due to the potential risk of unidentified abuse.
A facility failed to label and change a resident's humidifier and oxygen tubing as required, risking respiratory infection. The resident, with a history of respiratory failure, was observed receiving oxygen without proper equipment labeling. The facility's policy mandates changing the equipment every seven days.
A resident with mobility issues and obesity was not provided with a suitable wheelchair, despite expressing discomfort and requesting a larger one. The request was communicated to the Social Service Director, but the Director of Nursing acknowledged it was not addressed appropriately, leading to a deficiency in care.
A facility failed to label a morphine sulfate solution with an open date, as observed during a medication cart review. A resident, admitted with cancer and chronic pain, was at risk of receiving expired medication. The LVN and DON acknowledged the importance of labeling to ensure medication efficacy, as per facility policy.
The facility did not meet the required room size of 80 square feet per resident for 18 rooms, potentially affecting safe nursing care and privacy. Despite a waiver request, observations showed residents had enough space for mobility and no concerns were raised by the Resident Council President.
Failure to Separate Residents and Follow Abuse Policy After Verbal Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and to follow its own policies for resident-to-resident altercations. One resident (Resident 1), who had diabetes mellitus, hemiplegia and hemiparesis following a stroke, and major depressive disorder, reported that his roommate (Resident 2) was antagonizing him and calling him derogatory names such as “faggot” and “cry baby.” Resident 1 had documented capacity to understand and make decisions and was assessed as able to understand others and express his ideas and wants. In the early morning hours, Resident 1 activated his call light and told CNA 1 that Resident 2 was cursing at him, speaking rudely, and calling him names. CNA 1 reported this to LVN 1 around 5:00 a.m. to 5:30 a.m. After being informed of the situation, LVN 1 went to speak with both residents and learned from Resident 1 that Resident 2 had been calling him derogatory names. LVN 1 documented in the progress notes that Resident 1 stated Resident 2 was antagonizing him and calling him names, and later reported to the Registered Nurse Supervisor (RNS 1) that the two residents should have a room change due to the alleged name-calling. However, LVN 1 did not separate the residents at that time, stating she believed only the Social Service Director or RNS 1 could authorize room changes, despite acknowledging that staff should report allegations of abuse immediately and separate residents involved in an altercation. CNA 1 also stated that the residents were not separated immediately, even though he believed they should be separated right away for safety when an altercation occurs. RNS 1 was informed by LVN 1 around 7:15 a.m. to 7:30 a.m. that the residents were having misunderstandings and that one of them should receive a room change. RNS 1 did not report the incident immediately and did not talk to both residents right away because she believed it was a misunderstanding rather than abuse. She stated that at 8:00 a.m. Resident 2 was asleep, and she chose not to interview Resident 1 at that time due to concern that Resident 2 might wake up and become aggressive. Later that morning, during a change in condition evaluation, it was documented that Resident 1 reported Resident 2 had allegedly threatened him by saying, “I will kill you,” while Resident 2 denied making the statement and said Resident 1 started to scream. Resident 1 also told the Social Services Director that he felt depressed about what happened. The facility’s policies required that all resident-to-resident altercations be investigated, reported to nursing leadership and the Administrator, and that residents involved be separated, and that allegations of abuse be reported immediately (defined as within two hours). These policies were not followed when staff failed to immediately separate the residents and did not promptly treat the incident as an allegation of abuse. Resident 2, who had end stage renal disease, diabetes mellitus, pleural effusion, and dependence on renal dialysis, had fluctuating capacity to understand and make decisions but was assessed as able to express ideas and understand others. Documentation for Resident 2 indicated a care plan for potential verbal aggression after the alleged threatening words toward Resident 1. Resident 1 later described that Resident 2 called him “chicken,” “chavala,” “not a man,” screamed at him, and told him he would go to his bed and kick his behind when he was alone in the room. Both LVN 1 and RNS 1 acknowledged in interviews that staff should have reported the allegation of abuse immediately and separated the residents, and that failing to do so could escalate the situation and place Resident 1 in danger and at risk of emotional distress. The facility’s failure to separate the residents and to follow its abuse reporting and resident-to-resident altercation policies resulted in Resident 1 not being free from verbal abuse.
Untimely Reporting of Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse and to follow its own abuse reporting policy. Resident 1, who had diabetes mellitus, hemiplegia and hemiparesis following a stroke, and major depressive disorder, was cognitively able to understand and make decisions and could understand others and express his needs. On the early morning of 3/28/2026, Resident 1 reported to CNA 1 that his roommate, Resident 2, was cursing at him, speaking rudely, and calling him derogatory names such as “faggot” and “cry baby.” CNA 1 stated he received this report around 4:30–5:00 a.m. and relayed it to LVN 1 around 5:00 a.m. Resident 1 later told surveyors that Resident 2 also called him “chicken,” “chavala,” “not a man,” screamed at him, and said he would go to Resident 1’s bed and “kick his behind” when he was alone. LVN 1 documented in progress notes at 5:21 a.m. that Resident 1 reported Resident 2 was antagonizing him and calling him names. LVN 1 stated that during her shift, around 6:00 a.m., she spoke with both residents after CNA 1’s report and learned of the name-calling from Resident 1. She then informed RNS 1 when RNS 1 arrived around 7:15 a.m., requesting a room change because the residents were arguing. RNS 1 acknowledged being informed between 7:15 a.m. and 7:30 a.m. that the two residents were having “misunderstandings” and that one should be moved, but she did not immediately treat the situation as abuse, did not immediately interview both residents, and did not immediately separate them. RNS 1 stated she was aware the alleged abuse occurred at 5:30 a.m. and that at 8:00 a.m. Resident 2 was asleep; she chose not to interview Resident 1 at that time because she was concerned Resident 2 might wake up and become aggressive. Later that morning, a Change in Condition evaluation for Resident 1, timed at 10:09 a.m., documented that between approximately 9:30 a.m. and 10:00 a.m., RNS 1 interviewed both residents and that Resident 1 reported Resident 2 had threatened him by saying, “I will kill you.” A corresponding Change in Condition note for Resident 2, timed at 10:20 a.m., recorded Resident 1’s allegation that Resident 2 threatened to kill him, while Resident 2 denied making threats and stated he only told Resident 1 to be quiet in another language. The facility’s SOC 341 form showed that the suspected dependent adult/elder abuse report was faxed to the California Department of Public Health at 2:20 p.m. on 3/28/2026. The facility’s abuse policy, revised 4/2021, required that suspected abuse, neglect, exploitation, or misappropriation be reported immediately to the administrator and other officials, defining “immediately” as within two hours of an allegation involving abuse. Staff interviews, including CNA 1, CNA 2, LVN 1, and RNS 1, confirmed their understanding that all staff are mandated reporters, that allegations of abuse must be reported immediately, and that residents involved in an altercation should be separated immediately, but in this case the allegation was not reported to the state agency within the required two-hour timeframe.
Failure to Maintain Resident Dignity During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents’ dignity during incontinent care and bowel movement cleanup. Resident 1, who had diagnoses including cerebral infarction, seizures, left-sided hemiplegia, and brain compression, was assessed as dependent on staff for toileting, showering, personal and oral hygiene, and dressing, and was always incontinent of urine and bowel. The resident’s H&P indicated he did not have capacity to understand and make decisions. During an interview, Resident 1 reported that CNA 1 wiped him hard after a bowel movement, stated that CNA 1 was “digging in his rectum,” and said he told CNA 1 to stop and to get out of his room, but CNA 1 laughed at him. Resident 1 stated he felt violated, upset, mad, and expressed wanting to kill CNA 1. Resident 1’s responsible party later reported to LVN 1 that CNA 1 was digging too deep in the anal area and did not stop when Resident 1 said stop. Resident 2 had diagnoses including generalized muscle weakness, lack of coordination, difficulty walking, and end-stage renal disease, and was documented as having fluctuating capacity to understand and make decisions. The MDS indicated Resident 2 could express ideas and wants, required substantial to maximal assistance with toileting, showering, and dressing, and was frequently incontinent of urine and always incontinent of bowel. Resident 2 reported that CNA 2 wiped him with force and placed two fingers in his rectum in the shower, stating this occurred four times during cleaning. Resident 2 stated he felt humiliated and was afraid CNA 2 would find out his personal information and where he lives. CNA 1 acknowledged being assigned to Resident 1 on two days and stated Resident 1 accused him of inserting his fingers in the resident’s rectum. CNA 2 acknowledged being assigned to Resident 2 on a day when the resident had a bowel movement, and described placing the bed flat, removing the diaper, and using wipes to clean the perineal area while Resident 2 was tense and instructed to relax. The DON stated that a family member of Resident 2 reported CNA 2 was rough and put two fingers in Resident 2’s rectum. The DON also described that proper handling and cleaning require explaining to residents before touching them, asking if they are comfortable, and stopping and calling the charge nurse if a resident is uncomfortable and says stop. Facility policies on Quality of Life – Dignity and Resident Rights required that residents be treated with dignity, respect, kindness, and in a manner that promotes and enhances self-esteem and self-worth, which was not followed in these incidents.
Insufficient Dietary Oversight and Food Service Deficiencies
Penalty
Summary
Sufficient staff with the appropriate competencies and skill sets were not employed to carry out food and nutrition services, including qualified dietetic oversight for 46 of 46 sampled residents. The Dietary Supervisor stated he worked only on weekends and was serving part time, and the Administrator confirmed the Dietary Supervisor worked only part time and only during weekends. The Administrator also stated the last full-time Dietary Supervisor resigned on 1/28/2026, that the facility had a contracted Registered Dietitian who came once a week, and that the facility did not advertise to hire a full-time Dietary Supervisor, relying instead on word of mouth. During the survey, multiple food service problems were identified. Kitchen staff did not follow the scheduled menu for pureed diets, therapeutic diets were inaccurate for two residents, the ice machine was not clean and sanitary, and the dishwashing machine was not reaching the correct temperature for a low-temperature dishwasher. The Registered Dietitian stated the kitchen should have a full-time Dietary Supervisor to provide oversight and ensure compliance with food and safety regulations. The facility's Food and Nutrition Services Director job description stated the supervisor was to confer regularly with the Administrator, DON, and dietary consultant and keep them informed of problems and progress in the department.
Open and Overflowing Kitchen Dumpster
Penalty
Summary
The facility failed to ensure the trash receptacle outside the kitchen was covered, not overflowing, and properly disposed of. During a concurrent observation and interview on 2/09/2026 at 8:40 a.m., the garbage dumpster outside the kitchen was observed to be completely open, with black trash bags overflowing from it, and [NAME] 1 identified it as the kitchen's garbage dumpster. During later interviews, the Registered Dietitian stated that garbage dumpsters must be kept completely closed and that an open and overflowing dumpster could attract insects and rodents, potentially leading to infestation. The DON also stated that the dumpster should not be overflowing with trash and must remain covered, and that improper disposal of trash could attract unwanted pests and insects.
Laundry Water Temperature and IPCP Policy Review Deficiencies
Penalty
Summary
The facility failed to ensure that the water temperature reached the required 160 degrees Fahrenheit for proper sanitation when washing residents' laundry in two of three washing machines. During observation in the laundry room, two washing machines were running while the temperature gauge used to monitor the water temperature read 85 degrees Fahrenheit. Review of the Daily Washer Temperature Log showed the washer temperature was expected to be between 140 degrees Fahrenheit and 160 degrees Fahrenheit, but the recorded temperatures for February ranged from 85 degrees Fahrenheit to 106 degrees Fahrenheit. The Laundry Aide stated she checked the thermometer when the washer began its cycle and recorded the temperature on the log, and said she had been instructed only to record the temperature and not to report when it failed to reach the required range. During a concurrent observation, the Maintenance Supervisor used a hand-held thermometer to check the water temperature of a running washing machine and found it was only 80 degrees Fahrenheit. He stated he would need to adjust the water heater and that the water temperature must reach 160 degrees Fahrenheit to kill germs, with a possibility of cross-contamination when the temperature does not reach 160 degrees Fahrenheit. The facility's Washer Temperature policy stated that hot water washing at temperatures above 160 degrees Fahrenheit for at least 25 minutes was recommended. In a separate finding, the facility failed to review and update its Infection Prevention and Control Program policy annually. The Infection Preventionist Nurse stated he did not know the IPCP policy needed annual review, and the DON stated the IPCP policies were last reviewed in 2022 even though the facility policy required annual review and updates as needed.
Meals and diet textures did not match the menu or ordered diets
Penalty
Summary
The facility failed to ensure that four sampled residents received meals according to the scheduled dietary menu and their prescribed diet textures. Resident 2 and Resident 32 were served a pureed meal that included mixed vegetables, pureed rice, and pureed Salisbury steak, even though the facility menu for the meal listed pork chops with gravy, herbed rice, mixed vegetables, a dinner roll with margarine, coconut cake, and a beverage. A dietary aide stated the Salisbury steak was chosen instead of the menu item, and the DON stated the recommended menu should have been followed. Resident 16 and Resident 41 were observed during tray line receiving coconut cake in textures that did not match their diet orders. Resident 16, who had diagnoses including DM and dysphagia and had an order for controlled carbohydrate mechanical soft texture with nectar/mildly thick liquids, received coconut cake in a mince and moist texture. Resident 41, who had diagnoses including dysphagia, DM, dementia, and a benign neoplasm of the meninges and had an order for regular diet with mechanical soft texture, received coconut cake in a regular texture. The dietary aide stated he was confused and placed the desserts on the wrong trays. Record review showed Resident 2 had diagnoses including seizures, dysphagia, aphasia, and HTN, and was assessed as needing assistance with eating and other activities and receiving a mechanically altered diet. Resident 16 and Resident 41 both had care plans and physician orders directing specific diet textures, and the RD stated inaccurate therapeutic diets and incorrect food texture can run the risk of aspiration and that kitchen staff should follow the menu approved by the RD. Facility policy stated deviations from posted menus are recorded, including the reason for substitution or deviation, and the diet orders policy stated prescribed diet orders are to be provided by Food and Nutrition Services.
Unsafe Food Storage, Dishwashing, and Hand Hygiene Practices
Penalty
Summary
Food was not stored and handled in a safe and sanitary manner in the kitchen and dry storage areas. During an initial kitchen observation, the reach-in refrigerator had no working internal thermometer; the external digital display read 39 F, and the internal thermometer was cracked and remained at 30 F even after being left out on the counter for several minutes. The Dietary Supervisor stated the kitchen staff had been relying only on the external digital display for refrigerators and freezers, and the Registered Dietician stated that not having an internal thermometer was not standard practice. The dishwashing machine was observed operating below the required temperature. A Dietary Aide ran the machine and the temperature gauge read 104 F, then later 110 F after five cycles, and then 102 F during another cycle. Staff stated the machine should read 120 F to properly sanitize dishes and utensils, but the machine was still being used while not reaching that temperature. The facility policy stated inadequate temperatures should be reported and corrected immediately, and that dishwashing should stop until the temperature is adjusted. The ice machine was observed with yellow residue on a paper towel used to wipe the lid, along with dirt and black areas inside the machine. Staff stated the machine had been cleaned by wiping it down, but also stated it should be taken apart and serviced by a technician to completely clean it. In addition, a kitchen employee touched the lid of a step-on trash can and then returned to stir soup without washing hands first. In the dry storage area, an open brown bag of flour and an open bag of pasta were found stored on a shelf, and staff stated the flour should have been transferred to a sealed container and the pasta should have been stored in a sealed bag or container.
Failure to document vaccine education and ensure immunization administration
Penalty
Summary
The facility failed to ensure that two residents were provided education regarding the risks and benefits of refusing influenza and pneumococcal vaccines, and failed to ensure one resident received the influenza and pneumococcal vaccine. The deficiency involved Resident 4, Resident 6, and Resident 19 during review of immunization records, care plans, physician orders, and staff interviews. Resident 4 was admitted and later re-admitted with diagnoses including frontal lobe and executive function deficit following cerebral infarction. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated cognition was severely impaired. The care plan directed staff to educate the resident and responsible party on the purpose, side effects, and importance of the Covid and flu vaccine. During interview and record review, the influenza vaccine record showed the vaccine was given and consent was received over the phone by the responsible party, but the LVN stated there was no documentation that the responsible party was given education. The IPN also stated vaccination education was not given and that the responsible party should have been educated. Resident 6 was admitted with ESRD. The H&P stated the resident had capacity to understand and make decisions, while the MDS indicated moderately impaired cognition and documented that influenza and pneumococcal vaccines were offered and refused. Physician orders indicated flu vaccine was to be administered and that the resident may have annual influenza and pneumococcal vaccines. During interview and record review, the LVN stated there were no informed consent documents or documentation that the resident was given education for either vaccine, and the IPN stated vaccination education was not offered or given and that no informed consent had been obtained on admission for influenza and pneumonia. Resident 19 was admitted with syncope. The H&P stated the resident had partial capacity to understand and make decisions, and the physician order indicated the resident was capable of giving informed consent and may have annual influenza and pneumococcal vaccines. The MDS documented that influenza vaccine was not received and was offered and declined, and that pneumococcal vaccine was not up to date and was offered and declined. During interview and record review, the LVN stated there was no documentation of vaccine administration on the MAR, and the IPN stated the licensed nurse was responsible for offering the vaccine upon admission. The IPN also stated there was a vaccination informed consent in the physical chart signed by an RN.
Dishwashing Machine Failed to Reach Required Temperature
Penalty
Summary
The facility failed to ensure the dishwashing machine was maintained in a safe and operational condition when its temperature did not reach the recommended 120 degrees Fahrenheit. During a concurrent observation and interview on 2/9/2026 at 8:50 a.m., the Dietary Aide ran the dishwashing machine and the temperature gauge read 104 F. The Dietary Aide stated it was okay to continue using the dishwasher even though the temperature was not reaching 120 F as long as the chemical sanitation level was within 50 to 100 parts per million. The Dietary Supervisor later stated the dishwasher should read 120 F to properly sanitize and kill bacteria present on dishes and utensils. The dishwasher was observed to remain below the required temperature after repeated cycles. The Dietary Aide ran the dishwasher five times and the temperature gauge still did not reach 120 F, with the gauge reading 110 F after five cycles. Later that day, the temperature gauge read 102 F during another cycle. The Dietary Supervisor stated he did not know the dishwasher was not working until 10:30 a.m. and would call a service provider. The Administrator stated he was notified around 11:00 a.m. that the dishwasher was not reaching the required temperature. The Registered Dietician stated the dishwasher not reaching 120 F should be reported and addressed to ensure dishes are cleaned properly and to prevent food-borne illnesses among residents. The facility policy stated inadequate temperatures should be reported and corrected immediately, and if hot water does not meet requirements, dishwashing should stop until the temperature is adjusted.
Failure to Honor Resident Request for Shower
Penalty
Summary
The facility failed to honor one resident’s right to self-determination by not accommodating her request for a shower. During an interview, the resident stated she wanted a shower, but staff refused to provide one, and she had not received a shower for some time. Her record showed she was admitted and readmitted to the facility with diagnoses including Parkinson’s disease without dyskinesia, unspecified dementia, unsteadiness of feet, and a history of falling. Her MDS dated 11/12/2025 indicated severely impaired cognitive ability to think, learn, remember, use judgment, and make decisions, and that she required partial/moderate assistance with bathing/showering and personal hygiene. A CNA stated the resident refused a shower and did not have one the prior week, but did receive a bed bath. The CNA also stated the resident asked for a shower the day before the interview, but it was late to provide one and it was not her scheduled shower day. The CNA said the resident’s shower schedule was Mondays, Wednesdays, and Fridays, but acknowledged that the resident did not need to wait for her shower day and that she should have either provided the shower or notified the charge nurse or incoming shift CNA. The DON stated the resident should have been given a shower regardless of the schedule and that not providing one when requested can violate resident rights. The facility policy on Resident Self Determination and Participation stated each resident is allowed to choose activities and schedule health care consistent with their interests, values, assessments, and plan of care, including personal care needs.
Missing Resident Personal Items Not Located or Replaced
Penalty
Summary
The facility failed to ensure missing personal items belonging to one resident, including colored pencils, pens used for activities, and a personal bottle of hot sauce, were located or replaced. The resident was admitted and readmitted with diagnoses including major depressive disorder, quadriplegia, bed confinement, and chronic pain. A physician progress note stated the resident had the capacity to understand and make decisions, and the MDS showed the resident was dependent on nursing staff for showering and transferring and needed substantial to maximal assistance with toileting, dressing, and rolling. During interview, the resident stated he was missing pens, pencils, and a bottle of hot sauce, and said he had told the scheduler about the missing items. He reported that after returning from a shower, his pens and pencils were gone, and that he originally had two bottles of hot sauce but now only one remained. A CNA stated the resident had colored pencils and that his belongings sometimes fell onto the floor. The scheduler stated she was waiting for funds to replace the items and had not notified the social worker or documented a grievance, while the DON stated the scheduler was supposed to notify social work regarding missing items and communicate updates to the resident.
PRN Ativan Used Without Documented Non-Pharmacological Interventions or Stop Date
Penalty
Summary
The facility failed to ensure Resident 5 was free of chemical restraints when Ativan (lorazepam) was used as a PRN psychotropic medication without documented non-pharmacological interventions first. Resident 5 was admitted with diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, and the MDS showed moderately impaired cognition with substantial to maximal assistance needed for bathing, dressing, toileting hygiene, and oral hygiene. The H&P noted fluctuating capacity to understand and make decisions, but the resident was able to make decisions for daily living activities. The physician order for Ativan 0.5 mg by mouth every six hours as needed for anxiety manifested by restlessness had an indefinite duration, and the care plan for anxiety and constant yelling included administering lorazepam as needed and attempting to refocus behavior to something positive. During interview and record review, the LVN stated there were no non-pharmacological interventions documented in the MAR before Ativan was administered PRN, and identified examples such as repositioning, dimming lights, or providing water that should be used before giving the medication. The DON stated the PRN Ativan order should have had a stop date and a 14-day duration, and that nurses should assess behavior and offer non-pharmacological interventions before administering Ativan because it could be unnecessary and act as a chemical restraint when used to quiet the resident instead of first attempting other interventions. The facility policy reviewed stated PRN antipsychotic medication duration should be indicated in the order and that behavioral interventions should be attempted before use.
Failure to Complete Ordered Vascular Testing for Diabetic Toe Ulcer
Penalty
Summary
The facility failed to ensure that the recommended ABI with arterial doppler was completed for a resident with a right second-toe diabetic ulcer. The resident was admitted with diagnoses including heart failure, tinea pedis, and DM, and his H&P indicated he had the capacity to understand and make decisions. His MDS showed intact cognition and partial/moderate assistance with ADLs. The TAR documented treatment for the right second-toe diabetic ulcer with daily cleansing using normal saline and betadine, and the care plan addressed altered skin integrity with a wound consult and follow-up treatment as indicated. During observation, the resident’s right second toe was swollen, black, and had a small amount of blood. The resident stated the toe had been hurting for about three weeks and had started turning black, and he was worried it might have to be cut off. The wound doctor’s progress note indicated an ABI and arterial doppler were recommended for the ulcer, but the treatment nurse stated she was responsible for ensuring the recommendation was completed and acknowledged she must have missed it. The DON stated she was aware the ABI and arterial doppler had not been completed and that it should have been done, and she noted the toe was black and the resident might require amputation.
Failure to Resume Restorative Nursing Services for a Resident With Mobility Deficits
Penalty
Summary
The facility failed to ensure that Resident 4 received appropriate treatment and services to maintain or improve range of motion and mobility. Resident 4 was admitted and later readmitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, and seizures. The MDS dated 12/16/2025 indicated the resident rarely or never made decisions regarding daily tasks and was dependent on nursing staff for rolling, transferring, toileting, showering, dressing, and hygiene. The MDS also indicated the resident received zero days of the Restorative Nursing Program. During interview, LVN 1 stated Resident 4 did not have current physician orders for RNA services, although the resident should have had them due to left-sided weakness. The care plan for mobility deficit, initiated 6/29/2025, stated the resident would be referred to the RNA program as prescribed. RNA 1 stated the resident had previously been receiving RNA services, but after readmission from the hospital no new order was received and the services were not resumed. The DOR and DON both stated that RNA services had previously been ordered, but nursing did not reorder them after the resident returned from the hospital. The facility policy stated residents may receive restorative nursing care as needed and may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care.
Failure to Complete Required CNA Annual Competency Evaluations
Penalty
Summary
The facility failed to ensure two Certified Nursing Assistants (CNAs) had completed required annual competency evaluations. During a concurrent interview and record review with the Director of Nursing, the employee file for CNA 3 was reviewed and contained no documentation showing completion of the annual competency. The DON stated CNA 3 did not complete the annual competency and confirmed that annual competencies were required each year. The DON also stated that without completing the annual competency, CNA 3 would lack updated knowledge and accountability. The facility policy titled Competency of Nursing Staff, dated 3/2025, stated that all nursing staff must meet the specific competency requirements of their licensure and certification requirements defined by state law and that licensed nurses and nursing assistants employed or contracted by the facility will participate in a facility-specific, competency-based staff development and training program and demonstrate specific competencies and skill sets necessary to care for residents.
QAA Oversight Failed to Ensure Prior POC Was Implemented
Penalty
Summary
The facility's QAA Committee failed to provide effective oversight of facility operations and failed to ensure implementation of the 2025 Plan of Correction addressing deficient practices identified during the previous 2025 recertification survey. The report states that the prior survey had cited repeat deficiencies related to food storage, food preparation, and sanitation, as well as failure to ensure required annual in-service training for CNAs was completed. During interview and record review, the Administrator stated that QAPI was used to track issues and implement improvements, and acknowledged that deficiencies had been cited during the prior year's survey related to the kitchen and CNA education. The Administrator also stated the facility was not currently working on those areas and that the facility would begin addressing these issues to ensure resident safety. Review of the facility's QAPI policy showed that the program was intended to continuously examine and revise processes and systems, and that it incorporated findings from the annual facility assessment into the program.
Missing COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that COVID-19 vaccine education was provided to a resident and/or the resident’s representative before vaccination, and failed to maintain required documentation for one staff member’s COVID-19 vaccination status. Resident 4’s record showed the resident was originally admitted on 9/14/2024 and later re-admitted with diagnoses including frontal lobe and executive function deficit following cerebral infarction. The resident’s H&P dated 11/12/2025 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 12/16/2025 indicated severely impaired cognitive skills for daily decision making. The immunization record showed COVID-19 vaccine was given on 10/3/2025 and informed consent was received by phone from the responsible party on 9/17/2025, but the LVN stated there was no documentation that the responsible party was given education about the vaccine. The IPN also stated vaccination education was not given and that the resident’s responsible party should have been educated about the COVID-19 vaccine. During review of staff immunization documentation, Dietary Aide 1 had no documentation of COVID-19 vaccine, COVID-19 vaccine education, or that the vaccine had been offered. The IPN stated no COVID-19 vaccine had been offered and identified the risk to residents as transmission of the virus. The facility policy titled COVID-19, Prevention and Control, revised 4/4/2025, stated all health care providers would be provided information regarding the requirement to receive the COVID-19 vaccine and that the IP nurse or designated staff would obtain and document the current vaccination status of all health care providers, including COVID-19 immunization.
Insufficient room size for resident comfort and required space standards
Penalty
Summary
The facility failed to ensure adequate room size and space to support the comfort and well-being of one resident, Resident 34. Resident 34 was admitted with diagnoses including DM, muscle weakness, and CVA. The resident's H&P indicated he had the capacity to understand and make decisions, and the MDS showed his cognition was intact and that he required substantial to maximal assistance with ADLs. During interview, Resident 34 stated his room was way too small, that it was intended for only one person, and that he did not leave his room often because it took too much time to move his belongings out of the way in order to exit. The facility also failed to ensure that 18 of 24 resident rooms met the required 80 square feet per resident. During record review with the Administrator, the facility's Waiver Request on Room Variance identified multiple rooms with two beds and one room with four beds that measured less than the required space per resident. The Administrator stated the rooms were small and that the facility does its best to ensure residents were comfortable. The facility policy on Accommodation of Needs stated the environment and staff behaviors are directed toward assisting residents in maintaining and/or achieving safe independent functioning, dignity, and well-being, and that adaptations may be made to the physical environment, including the resident's bedroom and bathroom.
Missing Annual CNA In-Service Training
Penalty
Summary
Two CNAs did not have documentation showing completion of the required 12 hours of annual nurse aide in-service training. During a concurrent interview and record review with the DON, the employee file for CNA 3 showed no documentation of the required annual in-services, and the DON stated CNA 3 had not completed them. The file for CNA 4 showed the last completion of the required 12 hours of annual in-services was on 4/29/2024, and the DON stated the annual 12-hour in-service requirement must be completed each year. The DON also stated CNAs who do not complete their required in-services will lack the necessary knowledge to provide proper care and will have no accountability. The facility did not currently have a DSD, and the DON stated, "I need a DSD that is good with teaching." The facility policy titled Certified Nursing Assistant, dated 5/2017, stated CNAs must attend a minimum of 12 hours continuing education programs provided by the center in order to maintain certification.
Co-mingling of Resident Social Security Funds with Facility Payroll Account
Penalty
Summary
The facility failed to properly manage and safeguard a resident's personal funds by allowing the resident's Social Security benefits to be deposited into the facility's payroll account and used for employee paychecks over a six-month period. The resident, who had Parkinson's disease, moderately impaired cognition, and was dependent on staff for ADLs, had Social Security payments totaling $27,568.37 deposited by the Social Security Administration into the facility's payroll bank account on multiple occasions. Bank statements showed deposits made on behalf of the resident in one large lump sum followed by monthly deposits, all going into the payroll account rather than a separate resident trust or personal funds account. The business manager who discovered the issue while reviewing payroll bank statements reported that the deposits occurred over several months and informed the former administrator, the facility owner, and the payroll assistant, but no efforts were made to return the funds to the resident's estate. A subsequent review by a new business manager confirmed there was no evidence that the resident's Social Security funds had been returned, and no check had been issued from the payroll account to the resident's trust account. The current administrator acknowledged that the resident's Social Security funds were co-mingled with the facility's payroll account and stated that the appropriate action would have been to return the funds to the resident's trust or estate. The facility's undated policy on resident trust funds stated that money deposited to the account should not be used or combined with facility funds, which was not followed in this case.
Failure to Reconcile and Return Resident SSA Funds After Discharge
Penalty
Summary
The facility failed to ensure that a resident’s personal funds were properly managed, reconciled, and returned upon discharge. The resident, who had Parkinson’s disease, was admitted in 2020 and had moderately impaired cognition and dependence on staff for ADLs per an MDS dated 4/2/2024. The census showed the resident was discharged on 4/28/2024. Review of the facility’s payroll bank account statements from 7/14/2021 through 12/3/2021 showed that multiple SSA payments totaling $27,568.37 were deposited into the facility’s payroll account on behalf of this resident. These deposits included one large payment of $19,913.37 and subsequent monthly deposits of $1,531.00. There was no evidence that these SSA funds were ever transferred into the resident’s trust account while the resident was in the facility. Further review of the facility’s transaction report for 1/1/2020 through 1/31/2026 indicated that as of 10/2025, the total due for the resident’s share of cost was zero and the total owed to the resident was zero, despite the SSA deposits into the payroll account. The resident’s trust account showed only a copied check dated 12/10/2024 in the amount of $1,843.70, issued more than seven months after the resident’s discharge, with no documentation that the SSA funds deposited between 7/2021 and 12/2021 were ever credited to the trust account or refunded to the resident within the facility’s policy timeframes. Interviews with the former and current business office managers confirmed that the SSA checks had been deposited into the payroll account, that a trust account for the resident was opened in 1/2022, and that no check from the payroll account was created and deposited into the resident’s trust account to return those funds. The facility’s policy stated that upon permanent discharge, a refund must be issued within three days, and within 30 days when a resident expires, which was not followed in this case.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three residents with specific clinical needs. One resident with a diagnosis of post-traumatic stress disorder (PTSD), depression, anxiety, and dementia did not have a care plan addressing PTSD, despite staff interviews confirming that certain care approaches could trigger the resident's PTSD symptoms. The absence of a care plan for PTSD was acknowledged by both nursing and social services staff, as well as the Director of Nursing, who stated that such a plan was necessary for staff to understand and meet the resident's needs. Another resident, admitted with morbid obesity, bilateral artificial knee joints, and anxiety, experienced intentional weight loss as part of a personal health goal. The resident's weight loss was documented in the medical record and discussed with the registered dietician and dietary staff. However, there was no care plan in place to guide staff on monitoring the weight loss, ensuring it remained within safe parameters, or supporting the resident's goals, as confirmed by nursing staff and the DON. A third resident, diagnosed with Parkinson's disease, dementia, and muscle weakness, was receiving Restorative Nursing Aide (RNA) services for bilateral upper extremity active range of motion exercises. Despite active physician orders and ongoing RNA interventions, there was no care plan outlining the goals or interventions for these services. Nursing staff and the DON confirmed the absence of a care plan, noting that such documentation is necessary to ensure proper care and to track the resident's progress.
Failure to Properly Date and Remove Food Items in Storage
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and labeling practices. During an inspection of the refrigerator and freezer, a tray of individually poured orange and cranberry juices, as well as trays with open containers of fruit, were found without dates. A container of cooked ham remained in the refrigerator past its use-by date, and a container of cooked chicken with mushrooms lacked a use-by date. Additionally, several containers of cold breakfast cereals and bags of cooked fish and roast beef in the freezer were not labeled with use-by dates. Staff interviews confirmed that these items should have been labeled with open and best-by dates to ensure food safety. The Dietary Supervisor acknowledged awareness of the unlabeled and expired food items, stating that all opened food must be dated to ensure it is safe for consumption. Review of the facility's policy and procedure on food receiving and storage confirmed that all foods stored in the refrigerator or freezer must be covered, labeled, and dated with a use-by date. The observed failures to date and remove expired food items were not in accordance with the facility's established policies.
Call Light Not Within Reach for Resident with Hemiparesis
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by policy and procedure. Resident 42, who had a history of cerebral infarction resulting in hemiparesis of the right arm and lacked decision-making capacity, was observed with her call light placed on her right side, the side affected by weakness. The resident required partial to moderate assistance with activities of daily living, according to her Minimum Data Set assessment. Staff interviews confirmed that all facility staff were responsible for ensuring call lights were within easy reach of residents, and the Director of Nursing emphasized the importance of this practice. The facility's policy also specified that call lights should be within easy reach when residents are in bed or confined to a chair. The failure to position the call light appropriately for Resident 42 was identified through observation, interview, and record review.
Failure to Complete Required PASARR Level II Evaluation for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorders received a required Level II Preadmission Screening and Resident Review (PASARR) evaluation. The resident was originally admitted and later readmitted with diagnoses including schizophrenia, depression, and seizures. Despite these diagnoses, the admission record and subsequent assessments did not trigger a PASARR Level II evaluation, as the initial PASARR Level I incorrectly indicated the absence of mental disorders. The Director of Nursing (DON) acknowledged responsibility for reviewing PASARRs and confirmed that a new PASARR should have been submitted upon the resident's readmission, especially after the diagnoses of schizophrenia and depression were established. The resident's medical records indicated significant cognitive and functional impairments, including dependence on staff for multiple activities of daily living and a lack of capacity to make decisions. The facility's policy required all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders per the PASARR process. However, this process was not followed for the resident in question, resulting in the resident not being appropriately screened for mental illness upon readmission.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for Certified Nursing Assistants (CNAs), specifically for CNA 1, CNA 2, and CNA 4. During a review of employee files with the Director of Staff Development (DSD), it was found that none of these CNAs had an annual performance evaluation for 2024, despite the facility's policy requiring such evaluations at least annually. The DSD acknowledged not being aware that performance evaluations were to be conducted annually. The Director of Nursing (DON) confirmed that annual evaluations are expected and are used to recognize staff strengths and address weaknesses. The facility's policy, dated September 2001, also specifies that performance evaluations are to be completed at least annually and are tied to compensation reviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to properly administer medications to a resident with multiple diagnoses, including diabetes mellitus, rheumatoid arthritis, and dementia. The LVN crushed and prepared each of the resident's prescribed medications in separate cups with applesauce, but did not ensure that the full doses were administered. After the medication pass, it was observed and confirmed by the LVN that residual medication remained in the cups, resulting in incomplete dosing for the resident. This incident led to seven medication errors out of 26 opportunities, resulting in a medication error rate of 26.92%, which is significantly above the acceptable threshold of less than 5%. The resident was dependent on staff for all activities of daily living and had limited ability to communicate or understand others, further emphasizing the need for accurate medication administration. The facility's policy required medications to be administered safely, timely, and as prescribed, which was not followed in this instance.
Failure to Administer Complete Medication Dose
Penalty
Summary
A resident with diagnoses including diabetes mellitus, rheumatoid arthritis, and dementia was admitted to the facility and had multiple physician orders for medications such as hydroxychloroquine, vitamin C, memantine, metformin, multivitamin-mineral, prednisone, and senna. The resident was assessed as rarely or never able to express ideas or understand others and was dependent on nursing staff for daily activities. During a medication pass, an LVN crushed and administered the resident's medications, but did not ensure the full dose was given, as some medication remained in the medicine cups after administration. The LVN confirmed that the resident did not receive the complete dose of the prescribed medications, which was also acknowledged by the DON. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance. The failure to administer the full dose of medication was directly observed and confirmed through staff interviews and record review.
Failure to Follow Antibiotic Stewardship Protocol for Ocular Infection
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol for one resident who was prescribed an antibiotic without meeting the required McGeer criteria. The resident, who had a history of schizophrenia, depression, and seizures, was dependent on nursing staff for most activities of daily living and lacked the capacity to make decisions. The resident was prescribed and administered Gentamicin Sulfate Solution for a right eye infection, despite only presenting with symptoms of a swollen and teary eye and without a laboratory culture being performed to confirm the infection. Interviews with facility staff, including the Infection Preventionist Nurse and the Director of Nursing, confirmed that the Surveillance Data Collection Form did not indicate a culture was done and that the resident did not meet the McGeer criteria for antibiotic use. The facility's policy required antibiotics to be prescribed and administered under the guidance of the antibiotic stewardship program, which was not followed in this case.
Failure to Ensure Completion of Required Dementia and Abuse Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required dementia and abuse prevention trainings upon hire and annually, as evidenced by a review of four CNA employee files. Specifically, one CNA had only four out of the five required hours of dementia training, another had only two out of five required hours, a third had no dementia or abuse training, and a fourth had only three out of five required hours of dementia training and no abuse training. These findings were confirmed during interviews with the Director of Staff Development (DSD) and the Administrator, both of whom acknowledged the importance of these trainings and the facility's policy requirements. Record reviews further indicated that the DSD was responsible for maintaining current Department of Health-approved orientation and in-service training programs, including 24 hours of annual in-service education for CNAs. Facility policies required annual in-services to ensure nurse aide competence, including training in dementia management and resident abuse. Documentation of training participation, including hours completed and competency assessments, was also required but not consistently present in the reviewed files.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 18 out of 24 resident rooms met the required minimum of 80 square feet per resident for multiple occupancy rooms, as specified by regulations. During the survey, it was found that these rooms, which included both two-bed and one four-bed room, were below the required square footage per resident. The measurements of these rooms ranged from approximately 147 to 159 square feet for two-bed rooms and 318.55 square feet for the four-bed room, all falling short of the standard. The deficiency was identified through observation, interviews, and review of facility records, including a waiver request submitted by the Administrator for room size variances. Interviews with facility staff and the Resident Council President revealed no reported concerns regarding the room sizes. Observations conducted over several days indicated that residents had sufficient space to move freely within their rooms, with adequate room for beds, side tables, and the use of mobility aids such as wheelchairs, walkers, or canes. The report did not note any impact on the provision of nursing care or resident privacy as a result of the room sizes.
Resident Injury Due to Malfunctioning Shower Room Door
Penalty
Summary
The facility failed to ensure a safe environment for a resident who was being transported to a shower room, resulting in an accident. The incident involved a Certified Nurse Assistant (CNA) who was pulling the resident on a shower chair into the shower room when the door, which was malfunctioning, hit the resident's left foot. This resulted in a fracture and laceration of the resident's left great toe, requiring medical attention and suturing at a general acute care hospital. The resident had a history of Alzheimer's Disease and osteoporosis, requiring substantial assistance with daily activities. The deficiency was further compounded by the failure of the CNA and a Licensed Vocational Nurse (LVN) to report the malfunctioning door in the Maintenance Logbook, as per the facility's policy. The CNA admitted to using his foot to stop the door and acknowledged that he should have requested assistance to prevent the accident. The LVN also failed to recognize the door's malfunction as a problem, as it had always functioned in that manner, and did not report it as broken. The Maintenance Supervisor was aware of the door issue but did not ensure it was resolved, as the door stopper was reattached after being removed. The Registered Nurse Supervisor and the Administrator confirmed that the incident could have been avoided if the malfunctioning door had been reported and addressed. The facility's policy required maintaining the building in a safe and operable manner, which was not adhered to in this case.
Failure to Secure Wheelchair During Transport Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation from a medical appointment, resulting in the resident sustaining injuries. The incident involved a resident who was transported in a facility van while seated in a wheelchair. The driver did not secure the wheelchair using the required four-point straps, which are designed to anchor the wheelchair at four separate points to the vehicle. Additionally, the resident was only secured with a lap seatbelt, which was insufficient to prevent the wheelchair from tipping over during transit. The resident, who had multiple medical conditions including end-stage renal disease, muscle weakness, and osteoporosis, was accompanied by a Certified Nursing Assistant (CNA) who was not adequately trained in securing the wheelchair. The CNA did not verify that the wheelchair was properly anchored before the van departed. As the van approached the facility and made a left turn on an uphill slope, the wheelchair tilted backward, causing the resident to hit her head on the van lift. This resulted in a scalp laceration, hematoma, neck sprain, and shoulder sprain. Interviews with the CNA, the driver, and other staff members revealed a lack of adherence to the facility's transportation policy, which mandates the use of seatbelts and proper wheelchair securement. The driver admitted to not using the four-point straps, and the CNA acknowledged her unfamiliarity with the securement process. The facility's investigation confirmed that the driver had been trained on the proper use of the straps but failed to apply this knowledge during the incident.
Failure to Ensure Proper Training for Resident Transport
Penalty
Summary
The facility failed to ensure that staff, including a Certified Nursing Assistant (CNA), had the necessary training and competency evaluation for transporting residents using the facility van. This deficiency resulted in an incident where a resident's wheelchair was not properly secured during transport, leading to the wheelchair tilting back and the resident sustaining injuries. The resident, who had end-stage renal disease, muscle weakness, and other conditions, was being transported back to the facility when the wheelchair was not anchored correctly, causing it to tilt and the resident to hit her head, resulting in a scalp laceration, hematoma, neck sprain, and shoulder sprain. The CNA involved in the incident admitted to not being familiar with the straps used to secure the wheelchair and failed to ensure the resident was strapped in with a seatbelt. The driver of the van also could not confirm if the wheelchair was anchored properly. The Director of Staff Development acknowledged that there was no documentation of in-service training regarding the use of the van's seatbelts and four-point straps prior to the incident. The facility's policy required that wheelchairs be properly strapped during transport, but this was not adhered to, leading to the resident's injuries.
Failure to Provide Proper Wound Care Leads to Hospital Transfer
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident with a right medial leg venous ulcer, as per the physician's orders and care plan. The resident, who had a diagnosis of type 2 diabetes mellitus and was at risk for developing pressure ulcers, was admitted and readmitted to the facility. The care plan indicated that the resident's wound should be treated with Gentamicin Sulfate External Ointment and covered with a dressing, but this was not consistently done. On one occasion, a Licensed Vocational Nurse (LVN 1) was unable to change the resident's dressing due to a personal emergency and asked another nurse (LVN 2) to complete the task. However, LVN 2 mistakenly treated a different wound on the resident's foot, leading to the right medial leg wound being neglected. This oversight resulted in the wound developing a foul odor, green exudate, and the presence of maggots, causing the resident to experience pain and requiring transfer to a General Acute Care Hospital for further evaluation. Interviews with the nursing staff and a review of the physician's orders revealed that the complete wound care treatment was not properly documented or communicated, leading to the failure in treatment. The Director of Nursing acknowledged that the nursing staff did not ensure the accuracy of the wound care treatment as per the physician's orders, which contributed to the resident's wound not being treated on the specified date.
Inadequate Infection Control Practices for MDROs
Penalty
Summary
The facility failed to implement effective infection control practices to prevent the spread of multidrug-resistant organisms (MDROs) among residents. Specifically, the facility did not ensure that personal protective equipment (PPE) was accessible and readily available to staff providing direct care to residents at high risk of acquiring MDROs. Observations revealed that there were no Enhanced Barrier Precaution (EBP) signages or isolation carts outside the rooms of residents with wounds and indwelling medical devices, such as urinary catheters and gastrostomy tubes. This lack of proper signage and equipment availability led to staff entering rooms without the necessary protective gear, increasing the risk of cross-contamination. The deficiency involved 11 residents who were not placed on EBP despite having conditions that warranted such precautions. These residents included individuals with deep tissue injuries, stage 3 and 4 pressure ulcers, tracheostomies, and other indwelling devices. Interviews with staff, including physical and occupational therapists, revealed a lack of awareness and adherence to EBP protocols. Staff members were observed performing care activities, such as wound dressing changes and physical therapy, without wearing the required gowns and gloves, further contributing to the potential spread of infections. Additionally, the facility lacked comprehensive policies and procedures regarding the application of EBP for residents known to be colonized with MDROs or those with open wounds and indwelling medical devices. The Infection Prevention Nurse admitted that EBP had not been implemented for the affected residents, and there were no care plans in place to address their specific needs. This oversight in infection control practices posed a significant risk of cross-contamination and transmission of MDROs within the facility.
Removal Plan
- Residents 247, 246, 36, 37, 38, 1, 9, 346, 96, 17, and 42 were placed on EBP. EBP signages were posted on all the resident's rooms and isolation carts were available outside each room.
- All residents identified had a physician order with reason for EBP.
- Comprehensive plan of care were initiated for all 11 identified residents.
- Self-responsible residents were informed of EBP, and resident representatives were informed for residents who were not responsible.
- In-services with teach back were initiated to all staff regarding EBP.
- EBP policy and procedure was initiated and reviewed by Interdisciplinary Team (IDT) which included the ADM, the DON, the Social Services Designees, the Activities Director, the Infection Preventionist (IP), the Director of Staff Development (DSD) and representatives from the rehabilitation department.
- The DON in-serviced the IP designee for the following identified noncompliance: Line listing, infection control rounding, and EBP.
- EBP brochures were available to families, visitors, vendors, and staff at the front lobby of the facility.
- Adherence monitoring of EBP including donning of PPE during high contact activities will be performed by IP, charge nurse, and Registered Nurse supervisor daily every shift.
- The DON and/or designee will perform random adherence monitoring for all facility staff until substantial compliance was observed.
- Adherence monitoring tool will be kept in a binder upon completion and will be reviewed weekly by IDT to ensure identification of need for continued education of all staff. Facility staff will be in-serviced as needed.
- Possible admission inquiry to the facility will be reviewed by DON, Admission coordinator, and/or Administrator for MDRO, wounds, indwelling medical devices and EBP will be initiated accordingly.
- Residents admitted without wound and/or indwelling medical devices but acquire during facility stay will be placed on EBP.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted and updated daily, which resulted in residents and visitors being unable to access the facility's staffing information to verify safe staffing ratios. During an observation, it was noted that there was no posting of nursing hours at either of the two nursing stations. Interviews with the Director of Staff Development (DSD) and the Assistant DSD revealed that they were unaware of where the nursing hours were posted, and it was confirmed that actual daily staffing hours were not posted prior to each shift. Additionally, the type of nurses working each shift was not posted. The Director of Nursing (DON) acknowledged that nursing hours should be posted in areas visible to both staff and visitors, but confirmed that the facility was not posting the actual hours of each nursing staff working prior to each shift. A review of the facility's policy and procedure titled 'Posting Direct Care Daily Staffing Numbers' indicated that the facility was required to post daily for each shift the number of nursing personnel responsible for providing direct care to residents.
Deficiency in Dementia Care Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required dementia care training necessary to maintain the competence of the nursing staff's knowledge and skills. This deficiency was identified through interviews and record reviews, revealing that several CNAs had not completed the necessary training. During interviews, CNAs expressed that they had not received all dementia care training and acknowledged that such training would be beneficial in improving their ability to care for residents with dementia. The facility's Director of Nursing (DON) confirmed that dementia care training was required for all CNAs and emphasized its importance in enhancing staff competency and the quality of care for residents with dementia. Further investigation into facility staffing files showed a lack of documentation confirming that all CNAs had completed the required dementia care training. The Director of Staff Development (DSD) also confirmed the absence of such documentation. The facility's policy and procedure on dementia care, revised in November 2018, indicated that nursing assistants should receive initial training in dementia care, with annual in-services and performance reviews to guide further education. Despite this policy, the facility did not ensure compliance, potentially leading to delays and interruptions in the provision of necessary care for residents with dementia.
Failure to Ensure Functional and Accessible Call Lights for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents by not ensuring their call lights were functional and within reach. Resident 42, who was admitted with acute respiratory failure, chronic kidney disease, hypertension, and hyperlipidemia, had a call light that was not plugged in completely, rendering it non-functional. This was observed during a visit by a CNA, who acknowledged the importance of having a working call light to ensure the resident's needs, such as pain medication, were met. The Director of Nursing (DON) confirmed that all staff were responsible for ensuring call lights were operational, as non-functional call lights could prevent timely assistance and recognition of changes in a resident's condition. Resident 16, who had severe cognitive impairment and required maximum assistance for all activities of daily living, was observed multiple times with a call light that was unplugged and out of reach. This resident, diagnosed with unspecified vascular dementia, dysphagia, and essential hypertension, was unable to call for help due to the inaccessible call light. The DON acknowledged that if a resident cannot reach the call light, it could lead to unmet needs and potential falls. The facility's policy on answering call lights emphasized the importance of ensuring call lights are plugged in, functional, and within easy reach of residents.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents, identified as Resident 21, Resident 4, and Resident 18, underwent a Gradual Dose Reduction (GDR) for their psychotropic medications within the required timeframe. Resident 21 was admitted with diagnoses including anxiety, depression, schizophrenia, and bipolar disorder and was prescribed Zoloft for depression. Despite recommendations for a GDR, there was no documentation that the physician was notified of these recommendations, and no GDR was attempted. The Director of Nursing (DON) confirmed the lack of follow-through from the licensed staff regarding the pharmacist's recommendations. Similarly, Resident 4, with diagnoses of schizophrenia, bipolar disorder, depression, and anxiety, was prescribed multiple psychotropic medications, including fluoxetine, quetiapine, and risperidone. The Minimum Data Set (MDS) indicated no GDR was attempted, nor was it documented as clinically contraindicated. Resident 18, diagnosed with dementia, depression, and anxiety, was also on quetiapine without a GDR attempt or documentation of contraindication. The DON acknowledged the absence of GDR documentation for Residents 4 and 18. The facility's policy on antipsychotic medication use required appropriate physician response to medication issues, which was not adhered to in these cases.
Failure to Properly Label and Store Food
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of infectious agents causing foodborne illnesses. During an observation and interview with a Dietary Aid, it was confirmed that several food items in the refrigerator and freezer were not dated or labeled, and some were expired. Items such as red pepper, lettuce, ground beef, egg trays, enchilada sauce, apple sauces, pork beans, tuna chunks, green beans, broccoli, and vanilla ice cream were found without delivery dates or use-by dates. This lack of proper labeling and expiration management was acknowledged by the Chief Operating Officer (COO), who stated that it was the responsibility of all kitchen staff to ensure food items were labeled, dated, and fresh. The Director of Nursing Service (DON) also confirmed the necessity of labeling food items with delivery dates, use-by dates, and opened dates to prevent residents from consuming expired foods. The facility's policy and procedure on food storage indicated that leftover food should be labeled and dated before refrigeration and used within three days or discarded. However, the facility failed to adhere to these guidelines, potentially exposing residents to spoiled food and the risk of foodborne illness.
Failure in Infection Control and Monitoring Systems
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to implement corrective actions for systemic problems identified in infection control practices, monitoring of nursing staff, and reporting and investigating injuries of unknown origin. Specifically, the facility did not maintain a system to implement infection control practices, including Enhanced Barrier Precaution (EBP) for residents with wounds, indwelling devices, and tracheostomies to prevent the spread of multidrug-resistant organisms (MDROs). Additionally, there was no system in place to ensure that nursing staff kept call lights within residents' reach, and there was a lack of a systemic approach to reporting and investigating injuries of unknown origin. During an interview, the Administrator admitted to not being able to identify systemic issues prior to the recertification survey and acknowledged the facility's opportunities for improvement in the deficient practices mentioned. The facility's policy on Quality Assurance and Performance Improvement (QAPI) Program indicated that the QAPI Committee is responsible for overseeing and implementing the program, collecting and analyzing performance data, and identifying and resolving care quality problems. However, the failure to address these systemic issues placed residents at risk for not receiving the necessary quality treatment and increased the risk of cross-contamination and infection.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for five residents who were prescribed antibiotics without meeting the McGeer Criteria. These criteria are essential for determining the necessity of antibiotic treatment in long-term care facilities. The deficiency was identified through interviews and record reviews, revealing that antibiotics were administered without proper justification, such as culture and sensitivity tests, which are required by the facility's policy. Resident 11 was prescribed Levaquin for a sore throat and productive cough without a culture and sensitivity test or a chest x-ray, as required by the McGeer Criteria. The resident expressed reluctance to take the medication, and the Infection Preventionist confirmed that the necessary criteria were not met. Similarly, Resident 19 was started on Azithromycin for pneumonia without documentation of meeting the McGeer Criteria. Residents 25, 247, and 346 were also prescribed antibiotics without meeting the required criteria. Resident 25 was given Levaquin for pneumonia, Resident 247 was prescribed Amoxicillin-Pot Clavulanate, and Resident 346 received levofloxacin via a jejunostomy tube. The Infection Preventionist acknowledged the lack of documentation for meeting the McGeer Criteria for all five residents, which could lead to antibiotic resistance and other health risks. The facility's policy on Antibiotic Stewardship, revised in 2016, mandates that antibiotics be prescribed and administered under the guidance of the program, with lab results communicated to the prescriber to determine the necessity of antibiotic therapy.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the California Department of Public Health (CDPH) within the required two-hour timeframe for a resident who exhibited swelling and bruising on the right facial cheek area. The resident, who was not cognitively intact and had a history of hemiplegia and hemiparesis following a cerebral infarction, was transferred to a General Acute Care Hospital (GACH) with these injuries. The incident was initially observed by a Certified Nursing Assistant (CNA) and reported to a Licensed Vocational Nurse (LVN), who failed to notify the Director of Nursing (DON) or report the incident to CDPH, despite recognizing it as an injury of unknown origin. Interviews with facility staff, including the DON and the Administrator, confirmed that the incident should have been reported and investigated to rule out potential abuse. The facility's policy and procedure on reporting and investigating abuse, neglect, and injuries of unknown origin require immediate reporting to the administrator and relevant authorities. The policy defines immediate reporting as within two hours for incidents involving abuse or serious bodily injury. The failure to adhere to these procedures resulted in a deficiency, as the injury was not reported or investigated in a timely manner, potentially leaving the resident and others at risk of unidentified abuse.
Failure to Label and Change Oxygen Equipment
Penalty
Summary
The facility failed to ensure that the humidifier and oxygen tubing for a resident were labeled with the date of change, which is a requirement according to the facility's policy. This oversight was identified during an observation and interview with an LVN, who noted that the resident was receiving oxygen at 5 liters per minute via humidified nasal cannulas, and the equipment was not labeled with a date. The LVN acknowledged that the oxygen tubing and humidifier should be changed every seven days to prevent possible respiratory infections. The resident involved had a medical history that included acute respiratory failure, chronic kidney disease, hypertension, and hyperlipidemia. The resident required partial assistance with daily activities and had a physician's order for oxygen therapy to maintain adequate oxygen saturation levels. The Director of Nursing confirmed that charge nurses are responsible for checking the dates on humidifiers and oxygen tubing to ensure they are changed as required. The facility's policy, revised in 2010, mandates that oxygen equipment be dated and replaced every seven days.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to provide a larger sized wheelchair for a resident, identified as Resident 4, which was necessary to promote mobility and maintain independence. Resident 4 was admitted with diagnoses including lack of coordination, muscle wasting and atrophy, difficulty walking, and obesity. The Minimum Data Set (MDS) assessment indicated that Resident 4 was dependent on nursing staff for various activities, including transferring from the bed to a chair. During an interview, Resident 4 expressed a desire to get out of bed but reported that the provided wheelchair caused pain and was not suitable, indicating a need for a special, larger wheelchair. The Restorative Nurse Aide (RNA 1) confirmed that Resident 4 had requested a bigger wheelchair and had communicated this request to the Social Service Director (SSD). The SSD acknowledged awareness of the request and stated that she was working on it. However, the Director of Nursing (DON) later admitted that Resident 4's request for a different wheelchair was not addressed appropriately. The facility's policy on social services emphasizes identifying and meeting the medical-related social needs of residents, which was not fulfilled in this case, leading to the deficiency.
Failure to Label Morphine Sulfate Solution with Open Date
Penalty
Summary
The facility failed to ensure that the morphine sulfate solution used for a resident was labeled with an open date, as required by professional principles and the facility's policy. This oversight was identified during an observation of the medication cart, where it was noted that the bottle of morphine sulfate solution did not have an open date label. The Licensed Vocational Nurse (LVN) acknowledged that the medication should have been labeled with the date it was opened to track its usability and ensure it is not expired. Resident 22, who was receiving the morphine sulfate solution, had been admitted with diagnoses including malignant neoplasm of the colon, chronic obstructive pulmonary disease, and chronic pain. The resident's cognitive status was intact, and they required assistance with personal hygiene tasks. The Director of Nursing (DON) confirmed the importance of labeling medications with the open date to prevent the administration of outdated medication, which could lead to reduced efficacy and potential adverse reactions. The facility's policy on administering medication also emphasized the need to record the open date on multi-dose containers.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that 18 out of 24 residents' rooms met the required space of 80 square feet per resident. The rooms in question included 18 rooms with two beds each and one room with four beds, all of which were below the required square footage per resident. This deficiency was identified through observation, interviews, and record reviews, indicating a potential risk for inadequate provision of safe nursing care and privacy for the residents. During the survey, the facility's administrator provided a waiver request for room variances, asserting that the reduced room sizes would not compromise the health, welfare, and safety of the residents. Despite the waiver, the surveyors noted that the rooms did not meet the regulatory requirements. However, observations during the survey period showed that residents had enough space to move freely, and there were no concerns from the Resident Council President regarding room sizes. Each room was equipped with beds, side tables, and had adequate space for mobility aids, suggesting that the room size did not affect the nursing care or privacy provided to the residents.
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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 Lomita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lomita Post-acute Care Center | 1.1 mi | ★★★★★ | 30 | 0 |
| Torrance Memorial Med Ctr Snf/dp | 2.7 mi | ★★★★★ | 3 | 0 |
| Sunnyside Nursing Center | 2.8 mi | ★★★★★ | 27 | 1 |
| Seacrest Post-acute Care Center | 3.1 mi | ★★★★★ | 35 | 1 |
| Los Palos Post-acute Care Center | 3.1 mi | ★★★★★ | 4 | 0 |
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