Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park View Post Acute during CMS and state inspections, most recent first.
Food Storage and Preparation Deficiencies: Kitchen observations showed two frying pans with severely worn non-stick coatings, exposed base metal, and carbonized buildup were still hanging on the rack for use. A manual can opener had worn cutting edges with dark discoloration, and refrigerated items including a partially used pastry bag of whipped topping and a case of zucchini were not clearly labeled with open or received dates, despite staff stating foods should be dated for verification.
Improper Disposal of Resident PHI on Dietary Tickets: A dietary aide was observed throwing residents' dietary tickets into the regular trash during tray cleanup, and eight tickets were seen in the garbage with food scraps. The FND confirmed the tickets clearly showed resident names, room numbers, diet orders, allergies, and likes/dislikes, and the DON stated this information was protected health information that should not have been discarded in regular trash.
Failure to Maintain Resident Privacy During Care: Two residents were observed exposed or partially exposed during routine care and while in bed with minimal coverings. One resident with stroke sequelae and limited communication was repeatedly seen unclothed or nearly unclothed with the curtain open and visible from the hallway, while another resident receiving brief care was visible from the hallway and patio because both the privacy curtain and sliding door curtain were open. The DON confirmed the exposure and cited the facility expectation to keep residents covered and curtains closed during care.
Two residents were not supported in their choices and preferences. One resident with COPD and depression repeatedly requested to keep her Albuterol HFA inhaler at bedside for immediate use and felt anxious when she had to wait for it, while call light records showed a delayed response and staff did not ensure the request was honored. Another resident with a fractured femur, DM2, and ESRD reported distress about a loud and hostile roommate and said she spoke to SSA staff but never heard back; the concern was not documented in social services notes, and the DON stated resident concerns about roommates should be respected and documented.
A resident in her 90s with unspecified dementia and a history of spine fractures was ordered Seroquel for dementia with behavioral disturbance, and the consent form listed agitation/dementia with behavioral disturbance as the reason for treatment. However, review of the resident’s MD and psychology notes found no documented diagnosis of dementia with behavioral disturbance, and the pharmacist confirmed the diagnosis was not present in the record.
A resident with cognitive communication deficit, weakness, and mobility needs was newly diagnosed with schizophrenia during stay, but the facility did not submit a new PASRR Level I screening to DHCS after the diagnosis. The chart contained an older PASRR showing depression as the serious mental disorder, and the MDS Coordinator confirmed there was no record of a new PASRR screening after the new psych dx.
Missing wound assessments for a chronic scalp wound: A resident with a chronic scalp wound reported pain and tenderness with dressing changes and concern that the wound was not healing. Although the care plan directed staff to monitor and document the wound’s location, size, treatment, and any abnormalities, progress notes and IDT notes contained no wound assessments or documented progress. An LN stated wound assessments were not documented during dressing changes or periodically, and the DON confirmed no wound assessments were available in the record.
Failure to supervise a resident with severe cognitive impairment and known exit-seeking behavior allowed her to get beyond the secured patio and into the exterior service area. The resident had Alzheimer’s disease, a BIMS score of 4, and repeated elopement risk evaluations, yet staff observed her outside the gated patio walking alone with her walker while she stated she was running away and wanted to leave. Staff interviews confirmed prior attempts to exit and that the DON acknowledged the resident was outside the gate and no longer in the patio.
A resident with Parkinson's disease, dyskinesia, dysphonia, muscle weakness, and intact cognition reported that an unlicensed staff member repeatedly engaged in sexual contact with her during personal care, including digital and penile penetration, despite her saying no. A licensed nurse observed the staff member at the bedside with his pants pulled down, holding his exposed penis, which was pressed against the resident’s buttock while his hand was on her buttock. The business office manager was informed and interviewed the involved staff, and the unlicensed staff member did not deny having his penis exposed. A charge nurse reported the resident said that boundaries were crossed, that the staff member was rough, pushed his fingers on her anus, and lingered too long during care. A police detective later reported that the resident described multiple incidents of sexual contact and that the staff member admitted to inappropriate touching with his penis and fingers on multiple occasions, despite a facility policy of zero tolerance for abuse.
A nurse left a cup with two heart medication pills unattended at the bedside of a resident with multiple cardiac conditions and dementia. The resident was unable to identify the pills, and there was no authorization for self-administration or bedside storage in the medical record or care plan. Facility policy requires medications to be secured and not left at the bedside without a written order. The DON confirmed the incident and acknowledged the safety risk.
A resident with a history of pneumonia, asthma, and COPD was transferred to the hospital, but vital signs were documented in the medical record after the resident had already left the facility. The DON confirmed this was a documentation error, and the facility's policy required timely and accurate recording of vital signs.
Licensed nursing staff did not update a resident's care plan to include BIPAP therapy, despite physician orders and the resident's diagnoses of respiratory failure, sleep apnea, and morbid obesity. As a result, the resident did not receive BIPAP therapy on one occasion due to inoperable equipment, and the care plan did not reflect this essential intervention.
A resident with multiple chronic conditions did not receive ordered BIPAP therapy due to an inoperable machine, and the physician was not notified by nursing staff. Additionally, the same resident missed a scheduled dose of Ozempic® for diabetes management because the medication was unavailable, and again, the physician was not informed. Facility leadership and staff interviews confirmed that required notifications were not made in both cases.
A resident with pulmonary hypertension, end stage kidney disease, and diabetes received incorrect dosages of Uptravi due to staff administering either one or four tablets per dose based on conflicting information between the MAR and the medication bottle label. Nursing staff did not consistently verify the tablet strength, leading to rapid depletion of the medication supply and concerns raised by the family. The DON became aware of the issue after a refill was requested sooner than expected, and facility policy regarding verification of medications brought in by family was not followed.
A resident with Epilepsy and Restless Leg Syndrome did not receive six scheduled medications due to delayed arrival, and the physician was not notified of the missed doses. The DON confirmed the importance of administering medications as ordered and notifying the physician, especially for critical medications like Levetiracetam, which could lead to seizures if missed.
A speech therapist failed to follow contact enteric precautions for a resident with an active Cdiff infection, entering the room without performing hand hygiene, wearing gloves, or donning a gown, and leaving without washing hands with soap and water. The infection preventionist and DON confirmed the importance of these precautions to prevent infection spread.
The facility failed to honor resident rights by not responding promptly to call lights, leading to residents waiting for assistance and experiencing distress. Additionally, the facility did not adhere to its smoking policy, allowing a resident to smoke unsupervised. Staff also used residents' rooms as shortcuts, compromising their privacy.
The facility did not ensure residents knew how to contact the Department to file a complaint. During a Resident Council interview, all 12 residents were unaware of where to find this information. The Activities Director confirmed that the contact details were not discussed in meetings, and the Medical Records Director stated there was no policy on providing this information. The facility's Resident Rights policy mentioned communication with outside agencies but lacked specifics on informing residents.
The facility did not update the survey binder with investigation results since 2021 and failed to inform residents of its location. The Administrator confirmed deficiencies were received after 2021 but not included in the binder. Residents were unaware of the binder's location, and the Activities Director had not discussed it during Resident Council meetings. The facility lacked a policy on informing residents about the binder, despite a policy indicating residents' rights to examine survey results.
The facility failed to maintain a comfortable noise level, disturbing residents' rest and sleep. Multiple residents with intact cognition reported excessive noise, particularly during the night, caused by staff and other residents. Despite being a recurring issue in Resident Council meetings, the noise problem persisted, indicating a failure to adhere to the facility's policy on maintaining a homelike environment.
The facility failed to ensure the Resident Council knew how to file a grievance, as the Social Services Director had not attended meetings due to scheduling conflicts. A review of meeting minutes and interviews revealed that most residents were unaware of the grievance process. The facility's grievance policy did not specify how residents would be informed of their rights or the process.
A facility failed to follow professional standards when an LVN left medications, including potassium chloride, on a resident's bedside without a self-administration order. Additionally, LVNs improperly signed off on IV medications administered by RNs, leading to inaccurate records. The facility's policy requires the administering individual to sign the MAR, which was not adhered to.
Three residents were not provided with activities that matched their interests, leading to potential negative impacts on their well-being. One resident with ALS was not given supplies for her interests, another with heart failure had inaccurate activity evaluations, and a third with pneumonitis was only observed watching TV. The facility's policies on resident-centered activities were not followed.
The facility's QAPI program was ineffective due to inadequate data tracking and reassessment of interventions. The Administrator failed to document call light response times and did not reassess interventions for reducing falls and missing items, despite increases in both areas. The facility's policy emphasized continual assessment, which was not followed.
The facility failed to maintain a safe kitchen environment due to unrepaired cracks and missing tiles on the floor, which were observed during a survey. The Maintenance Supervisor acknowledged the need for repairs and mentioned a proposed grease trap project that included floor replacement, pending approval.
The facility failed to maintain a system for tracking staff compliance with mandatory training, leading to potential inadequacies in staff competency. The DSD could not provide evidence of training participation for all staff, and some mandatory trainings were overdue. This deficiency highlights a gap in the facility's training compliance and tracking system.
A resident with multiple medical conditions was transferred to a hospital due to worsening symptoms, but the facility failed to notify the Long-term Care Ombudsman as required. The Notice of Transfer/Discharge form was incomplete, lacking the resident's name and the date of notification to the Ombudsman. The Social Services Assistant could not find documentation of the notification, and the Social Services Director confirmed the expectation for prompt notification. The facility's policy mandates notifying the Ombudsman simultaneously with the resident or their representatives during emergency transfers.
The facility failed to develop comprehensive care plans for two residents, leading to potential negative outcomes. One resident with ALS and Dysphagia was not engaged in activities reflecting her interests, while another resident with a fractured arm did not have a care plan addressing this condition. The facility's policies on activity assessment and care planning were not followed, impacting the quality of care provided.
A resident with fractures in both arms was inaccurately assessed as medium fall risk upon admission, as the presence of a sling and the fracture diagnosis were not documented. Staff interviews confirmed these omissions, and the DON acknowledged that the fall risk assessment should have included the fracture as a risk factor, which could have led to inadequate precautions.
A facility failed to ensure nursing staff had updated competencies, leading to inadequate care for a resident with complex medical needs. A resident experienced a critical change in condition, but the staff did not notify the physician or document the incident. The Director of Staff Development lacked a system to track mandatory training, resulting in incomplete training records for staff. This deficiency posed a risk to resident safety due to insufficient staff preparedness.
The facility failed to ensure sanitary storage of portable urinals, as observed with two residents in the same room. A strong urine odor was noted, and one resident's urinal was placed on an overbed table next to a drinking mug. A nurse acknowledged the unsanitary condition and moved the urinal. The facility's procedure lacked specific cleaning instructions and did not address handling urinals for residents with UTIs.
Food Storage and Preparation Deficiencies
Penalty
Summary
Food was not stored and prepared under sanitary conditions and in accordance with professional standards in the kitchen for a census of 116. During observation with the Food & Nutrition Director, two 12-inch frying pans were hanging on the kitchen rack and available for use even though both had severely worn non-stick coatings, exposed base metal, and carbonized buildup on the food contact surfaces. The damaged surfaces were not smooth or easily cleanable. The Food & Nutrition Director stated the frying pans were no longer supposed to be used, and the Dietary Resource Consultant stated the pans showed visible excess carbon and buildup that could result in food contamination with shavings from the pan. A manual can opener was observed with significant dark discoloration along the cutting edges, consistent with buildup or corrosion. During interview, the Dietary Resource Consultant acknowledged the blade was visibly worn down, and the Food & Nutrition Director stated that if the area was worn down, it could not be sanitized properly and could cause contamination. In addition, a partially used pastry bag of whipped topping in one refrigerator was marked with black ink that was not legible and had no other open date or use-by date, and a cardboard case of zucchini in another refrigerator had no received date. The Dietary Resource Consultant stated all foods should be labeled with a received date and that labels were used to verify foods were still good to use.
Improper Disposal of Resident PHI on Dietary Tickets
Penalty
Summary
The facility failed to protect resident health information when dietary tickets were discarded in the regular trash during tray cleanup in the kitchen dishwashing area. During observation, a dietary aide removed trays from soiled tray carts and threw residents' dietary tickets into a garbage can with food scraps; eight dietary tickets were seen in the trash, and the Food & Nutrition Director confirmed the tickets clearly displayed residents' names, room numbers, diet orders, allergies, and likes and dislikes. The Director of Nursing later stated that any information with resident identifiers was not to be disposed of in regular trash and confirmed the dietary tickets contained protected health information that should have been placed in a locked confidential information bin for shredding.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
Resident rights were not honored when two sampled residents were not provided privacy during routine care and while accommodating a resident’s preference for minimal coverings. Resident 82, admitted with unspecified sequelae of cerebral infarction and assessed as rarely/never understood on the MDS, was observed multiple times lying in bed unclothed or nearly unclothed with only a bath towel across the chest and a blanket over the lower body. On one observation, the towel had slipped and exposed her breasts, and the privacy curtain was not drawn, leaving her visible from the hallway. A nurse acknowledged the exposure and stated the resident is nonverbal except for one word and typically does not like to wear clothes because she becomes hot easily, usually agreeing only to wear a hospital gown before bed. Resident 5, admitted with pneumonia, need for assistance with personal care, and cognitive communication deficit, was observed receiving brief care with the privacy curtain inside the room not closed and the glass sliding door curtain open, making her visible from both the hallway and the outside patio area. The DON confirmed the resident’s bottom half was visible from both areas because neither curtain was closed. The DON entered the room to speak with the CNA providing care and stated the facility’s expectation is for staff to keep the resident covered and close the curtain during care and any stage of undress; if coverings fall, staff must replace them as soon as they can. The facility policy stated residents shall be examined and treated in a manner that maintains privacy and that a closed door or drawn curtain shields the resident from passers-by.
Failure to Honor Resident Choices for Medication Access and Roommate Concerns
Penalty
Summary
The facility failed to honor resident choice and self-determination for two residents. One resident with COPD and depression, who had a BIMS score of 11 and was noted to value control of her personal belongings, requested that her Albuterol HFA emergency inhaler be kept at her bedside on admission for timely use when short of breath. Her physician order summary indicated the inhaler was ordered to be at bedside, and during interview she stated she had asked multiple times for it to be kept with her because she managed it at home and felt anxious when she had to wait for it. During the same review, call light records showed that the resident pressed the call button and waited 17.23 minutes for a response. An SBAR completed by a licensed nurse documented that the resident felt anxious about her COPD, was worried about getting her inhaler on time, and requested to have the inhaler in her room in case an attack occurred. A licensed nurse stated that if a resident requested a medication at bedside, staff should assess capability and obtain a physician order, and the DON stated resident choices and preferences were important to maintain dignity and independence. Facility policies on self-administration of medicines and resident rights and preferences stated that residents who desire to self-administer medications may do so if determined safe and ordered by a prescriber, and that honoring preferences is part of person-centered care. A second resident with a fractured left femur, DM2, and ESRD, and a BIMS score of 13 with no cognitive impairment, reported ongoing distress related to her roommate. She stated the roommate was loud, made fists, was negative, complained constantly, and became hostile, which made her anxious and affected her rest and mood. The resident said she had spoken to the SSA about the issue but had not heard back, and later stated she still had not received any response from facility staff. The SSD said she had no knowledge of the grievance, the SSA said she had spoken with the resident but had not documented it, and the social services progress notes contained no documentation of the concern. The DON stated that if a resident had concerns about a roommate, staff should respect and honor the resident’s choices and document their response, and the facility grievance policy required concerns to be formally documented, acknowledged, investigated, and resolved.
Unnecessary antipsychotic medication ordered without documented diagnosis
Penalty
Summary
The facility failed to ensure an appropriate indication for use of an antipsychotic medication for one resident, Resident 48. Resident 48’s face sheet showed an admission date of 11/1/22, age in her 90s, and diagnoses including a fall with multiple fractures of the spine and unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. A physician order dated 12/24/25 directed Seroquel 12.5 mg by mouth two times a day for dementia with behavioral disturbance, and a consent form for anti-psychotic medication dated the same day listed the reason for treatment as agitation/dementia with behavioral disturbance. Review of the resident’s physician progress notes and psychology progress notes since 12/24/25 found no diagnosis of dementia with behavioral disturbance. During a phone interview on 3/5/26, Pharmacist A reviewed the resident’s diagnoses and verified that the diagnosis listed in the Seroquel order was not present. The facility policy on Antipsychotic Drugs stated that residents who have not used antipsychotic drugs are not given these drugs unless therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.
Failure to Update PASRR After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to promptly notify the State Mental Health Authority, DHCS, for one of two sampled residents when that resident experienced a significant change in mental health status and received a new diagnosis of schizophrenia, which required referral for PASRR. The resident was admitted with diagnoses including cognitive communication deficit, generalized muscle weakness, need for assistance with personal care, difficulty walking, and presence of a right artificial knee joint. An MDS dated 2/10/26 showed no memory impairment, and the BIMS score was 15, indicating cognitive intactness. The resident’s face sheet listed schizophrenia with an onset date of 2/18/25 and classified it as during stay. A psych/evaluation progress note dated 2/18/25 was the first documentation from the contracted psychological services provider indicating the schizophrenia diagnosis. During interview and record review, the MDS Coordinator reviewed the resident’s most recently scanned PASRR Level I screening dated 6/17/24, which identified depression as the serious diagnosed mental disorder, and stated there was no record of a new PASRR screening after 6/24. The MDS Coordinator agreed that despite the new schizophrenia diagnosis, no new PASRR Level I screening was submitted to DHCS.
Missing wound assessments for a chronic scalp wound
Penalty
Summary
The facility failed to ensure ongoing accurate clinical assessment and documentation for a resident with a chronic wound to the top of the scalp. The resident was admitted with diagnoses including vascular dementia and dysphagia, and his MDS indicated a BIMS score of 14 with no cognitive impairment. During an interview, the resident stated that nurses changed his dressing every other day, that he had pain and tenderness with dressing changes, and that he was concerned the wound was not healing. His care plan directed staff to monitor and document the wound’s location, size, and treatment, and to report abnormalities, failure to heal, signs or symptoms of infection, or maceration to the physician. A review of progress notes from 2/5/26 through 3/5/26 showed no documented head wound assessments and no skin issues noted. The most recent interdisciplinary team notes indicated to continue wound care, but there was no documented discussion of wound assessment or progress toward healing. During interviews, an LN stated she did not document wound assessments when dressing changes were done or periodically, and the DON confirmed there were no wound assessments documented in the medical record or on paper and that the Kaiser wound care nurse had not assessed the resident. The ADON also could not provide any wound assessments, and the DON stated she would be unable to report the current size or characteristics of the wound and that it would be difficult to determine if there was a change in condition.
Failure to Supervise Resident with Elopement Risk
Penalty
Summary
The facility failed to implement supervision and monitoring interventions for one resident with severe cognitive impairment and a documented history of exit-seeking behavior. The resident was admitted with diagnoses including an unspecified intrascapular fracture of the left femur, generalized muscle weakness, unsteadiness on feet, and Alzheimer’s disease with late onset. Her MDS dated 2/4/26 showed significant deficits in orientation, and her BIMS score was 4, indicating severe cognitive impairment. Facility records also showed repeated elopement risk evaluations, including a high-risk score on the LN elopement/wandering tool and a positive score on the N Adv elopement evaluation on 3/2/26. During observation on 3/2/26 at 9:24 a.m., the resident was seen outside the facility’s gated patio in the exterior service area near the dumpsters, walking alone with her walker. While observed outside the secured area, she stated she was running away and wanted to leave the facility. Interviews with staff confirmed awareness that she was an elopement risk and that she had previously attempted to leave the facility on several occasions, including reaching the exterior patio gate and slipping through the first set of double doors into the lobby after a visitor entered. The DON acknowledged that on 3/2/26 the resident was outside the gate and no longer in the patio.
Failure to Protect a Resident From Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. The resident, who had Parkinson's disease with dyskinesia, dysphonia, muscle weakness, and intact cognition per a recent MDS (BIMS score 13), was dependent on staff for care and had contracted limbs. On one occasion, a licensed nurse entered the resident's room and observed an unlicensed staff member standing beside the resident, with his pants pulled down in the front, holding his exposed penis in his hand. The nurse saw his penis pressed against the resident’s left buttock at the gluteal fold while his other hand was on the resident’s left buttock. The resident was lying on her bed with her legs contracted, positioned on the right side of the bed, facing the door, with her buttocks on the edge of the left side of the bed where the unlicensed staff member was standing. Following this event, the business office manager was informed and interviewed both the licensed nurse and the unlicensed staff member. The unlicensed staff member did not deny having his penis exposed in the resident’s room and responded, "I don't know" and "whatever she said" when asked about the allegation. The resident later reported that the unlicensed staff member had been inappropriate with her, that he did things she did not want him to do, and confirmed that he had inserted two to three fingers into her vagina when cleaning her and had put his penis in her vagina more than once, despite her saying no. A charge nurse reported that the resident stated "boundaries were crossed" during personal care, that the staff member sometimes pushed his fingers on her anus, was rough, and lingered too long in her room. A police detective stated that the resident reported multiple instances of the staff member touching her with his penis and inserting his penis and fingers into her vagina, and that the staff member admitted to touching the resident inappropriately with his penis and fingers on multiple occasions. This conduct occurred despite a facility policy stating a zero-tolerance stance toward any form of resident abuse.
Unattended Medications Left at Bedside Without Authorization
Penalty
Summary
A licensed nurse left a cup containing two medication pills unattended on the bedside table of a resident who had diagnoses including hypertension, atrial fibrillation, heart failure, and dementia. The resident was unable to identify the pills or state how long they had been there. The nurse confirmed that the medications were heart medications that had been withheld due to the resident's low heart rate and blood pressure, and admitted to accidentally leaving the medication cup at the bedside. The nurse acknowledged that this action created a risk for the resident, as well as the possibility that another resident could have ingested the medications. Review of the resident's medical record and care plan showed there was no authorization for self-administration or bedside storage of medications. Facility policy requires a written order for bedside medication storage and specifies that missed medications should be returned to secured storage. The Director of Nursing confirmed awareness of the incident and agreed that leaving medications unattended at the bedside was unsafe and could have resulted in another resident accessing the medications.
Inaccurate Documentation of Vital Signs After Resident Discharge
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had been transferred out of the facility. Specifically, vital signs were documented in the resident's medical record after the resident had already been discharged to the hospital. The resident, who had a history of pneumonia, asthma, and chronic obstructive pulmonary disease, was admitted in June 2025 and transferred to the hospital on June 28, 2025 at 7:32 p.m. However, the medical record showed that vital signs were recorded for this resident at 12:15 a.m. on June 29, 2025, after the resident was no longer present in the facility. During an interview and record review, the DON confirmed that the transfer form indicated the resident was no longer in the facility at the time the vital signs were documented. The DON acknowledged that this was an error in documentation. The facility's policy required that vital signs be obtained, recorded, and reported in a timely and accurate manner, which was not followed in this instance.
Failure to Develop and Implement Care Plan for BIPAP Therapy
Penalty
Summary
Licensed nursing staff failed to develop and implement a resident-centered care plan for a resident who required Bilevel Positive Airway Pressure (BIPAP) therapy. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypercapnia, sleep apnea, and morbid obesity. Although a physician ordered BIPAP therapy at bedtime for obstructive sleep apnea, the resident's care plan for altered respiratory status was not updated to include this intervention. Review of facility records confirmed that the care plan did not address BIPAP therapy, and the Medication Administration Record showed the resident did not receive the ordered BIPAP therapy on a specific date due to the equipment being inoperable. Interviews with facility staff confirmed that care plans are intended to address the whole person and should be updated to reflect changes in care needs. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan based on the resident's needs. However, the lack of a care plan intervention for BIPAP therapy decreased the facility's ability to provide individualized care and ensure the resident's safety, as the therapy was not administered as ordered.
Failure to Notify Physician of Inoperable BIPAP and Missed Diabetes Medication
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician after a resident's BIPAP machine became inoperable, resulting in the resident not receiving the ordered BIPAP therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia, type 2 diabetes, sleep apnea, and morbid obesity, was instead provided with oxygen via nasal cannula. There was no documentation that the physician was informed of the BIPAP issue, despite facility leadership and the physician stating that such notification was expected. Additionally, the same resident did not receive a scheduled dose of Ozempic®, a medication prescribed for diabetes management, because the medication was not available. The medication administration record and progress notes confirmed the missed dose, and interviews with staff and the physician indicated that the physician was not notified of the omission. The facility's policies required medication administration in accordance with prescriber orders, but there was no policy specifically addressing physician notification for medication errors or omissions. Interviews with the DON, ADON, and licensed nurse confirmed the missed BIPAP therapy and medication dose, as well as the lack of physician notification in both instances. The DON acknowledged the importance of notifying the physician about missed medications and high-risk medication omissions, but also stated that discretion was left to the licensed nurse. The facility's documentation and staff interviews confirmed that the required notifications did not occur.
Medication Administration Error Due to Dosage Confusion
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident with end stage kidney disease, diabetes, and pulmonary hypertension was not given the correct dosage of Uptravi (selexipag). The resident was admitted with a physician's order for Uptravi 200 mcg tablets, four tablets by mouth twice daily (totaling 800 mcg per dose). However, the medication bottle provided by the family was labeled for 800 mcg tablets, with instructions to give one tablet twice daily. Nursing staff administered the medication based on the Medication Administration Record (MAR), which directed four tablets per dose, without consistently verifying the actual tablet strength on the medication bottle label. This led to confusion and inconsistent administration, with some staff giving one tablet and others giving four, depending on whether they followed the MAR or the bottle label. Interviews revealed that staff did not always read the medication bottle label and relied solely on the MAR, resulting in the medication supply depleting faster than expected. The family raised concerns after noticing the medication was running out quickly and questioned the staff's ability to read the label. The Director of Nursing became aware of the issue when a refill was requested earlier than anticipated and began investigating the discrepancy. Facility policy required that medications brought in by family be properly labeled and verified by a physician or pharmacist prior to use, but there was no documentation that this verification had occurred for this medication.
Failure to Administer Medications and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice. Specifically, the resident did not receive six of her scheduled medications, which included Atorvastatin, Latanoprost, Dorzolomide, Ropinorole, Levetiracetam, and Lubiprostone. These medications were not administered as they were still awaiting arrival. The resident had been admitted with diagnoses of Epilepsy and Restless Leg Syndrome, conditions that require consistent medication management to prevent adverse health outcomes. Additionally, the facility did not notify the physician when the resident missed her scheduled medications. The Director of Nursing confirmed that the resident should have received these medications as ordered and acknowledged the importance of notifying the physician, especially regarding the missed dose of Levetiracetam, which could lead to seizure activity. The facility's policy on medication administration emphasizes the necessity of accurate and timely administration according to the physician's order, highlighting a deviation from established procedures in this case.
Failure to Follow Contact Enteric Precautions for Cdiff
Penalty
Summary
The facility failed to adhere to contact enteric precautions for a resident with an active Clostridium Difficile (Cdiff) infection, which is highly contagious and can be life-threatening. During an observation, a speech therapist entered the resident's room without performing hand hygiene, wearing gloves, or donning a gown, as required by the precautionary measures. Upon leaving the room, the speech therapist also failed to wash her hands with soap and water, which is a critical step in preventing the spread of infection. The infection preventionist and the director of nursing both confirmed the necessity of following these precautions to prevent the spread of Cdiff. The signage posted outside the resident's room clearly indicated the need for hand hygiene, gown, and gloves before entry, and soap and water handwashing upon exit. The speech therapist acknowledged not following these procedures, which constitutes a break in infection control and poses a safety issue for both staff and other residents.
Failure to Honor Resident Rights and Privacy
Penalty
Summary
The facility failed to honor the rights of several residents by not responding promptly to call lights, leading to residents waiting for assistance for 20 minutes or more. This delay resulted in multiple residents experiencing distressing situations, such as urinating or soiling themselves while waiting for help. For instance, Resident 20 urinated in bed and felt terrible about it, while Resident 55 feared for his wife's safety as she attempted to get out of bed after a long wait. Resident 69 expressed feeling bad after soiling his bed, and Resident 76 had to sleep on a wet bed until the morning shift arrived to clean him. Additionally, the facility did not adhere to its smoking policy, as evidenced by Resident 42 wheeling himself across the parking lot to smoke without staff supervision. Despite being informed that the facility was non-smoking, Resident 42 was not provided with a Safe Smoking Evaluation upon admission, and his requests for assistance in obtaining cigarettes were ignored. The facility's failure to assess and accommodate Resident 42's smoking needs, as outlined in their policy, put him at risk of potential harm. Furthermore, the facility staff used residents' rooms as shortcuts to enter and exit the building, compromising the residents' privacy. Residents, including Resident 3, Resident 63, and Resident 51, reported feeling that their privacy was violated when staff used the sliding doors in their rooms to access the back patio. This practice was against the facility's policy, which emphasized respecting residents' privacy and using designated exit doors instead.
Failure to Inform Residents of Complaint Filing Process
Penalty
Summary
The facility failed to ensure that residents were informed about how to contact the Department to file a complaint. During a confidential Resident Council interview, all 12 residents present were unaware of where to find the contact information for the Department. One resident mentioned that while residents' rights were reviewed during meetings, the specific information on how to contact the Department was not discussed. The Minimum Data Set (MDS) assessments indicated that three residents, including the one who spoke, were cognitively intact, while seven had moderate cognitive impairment. The Activities Director, responsible for coordinating the Resident Council meetings, confirmed that the contact information for filing complaints was not discussed during these meetings. Additionally, the Medical Records Director revealed that the facility did not have a policy on providing residents with the necessary contact information. The facility's policy on Resident Rights, last revised in February 2021, stated that residents have the right to communicate with outside agencies, but it did not specify how this information should be provided to the residents.
Failure to Update Survey Binder and Inform Residents
Penalty
Summary
The facility failed to update the survey binder with the results of complaint and facility-reported incident investigations for three years, and did not notify residents of its location. During a record review and interview, it was revealed that the survey binder, located in the hallway outside the Administrator's office, lacked updates since 2021. The Director of Nursing confirmed the absence of investigation results in the binder, attributing it to the lack of deficiencies since the 2021 survey. However, the Administrator later confirmed that the facility had received deficiencies after 2021, which were not included in the binder. During a Resident Council interview, all 12 residents were unaware of the binder's location. The Activities Director, responsible for coordinating Resident Council meetings, admitted that the location of the survey binder was not discussed during meetings. Additionally, the Medical Records Director confirmed the absence of a policy on informing residents about the binder's location. The facility's policy on Resident Rights, last revised in 2021, indicated that residents have the right to examine survey results, yet this was not effectively communicated or facilitated.
Excessive Noise Levels Disturb Residents' Rest
Penalty
Summary
The facility failed to ensure a comfortable noise level for four of the twenty-four sampled residents, which compromised their right to a safe, clean, comfortable, and homelike environment. Residents reported excessive noise levels at various times, particularly during the night, which disturbed their rest and sleep. Resident 3, with an intact cognition score of 15, reported hearing staff talking loudly and laughing as late as 10:30 p.m. Similarly, Resident 63, with a cognition score of 13, and Resident 51, with a cognition score of 15, also complained about the noise caused by staff and other residents during the night. The issue of noise was a recurring topic in Resident Council meetings over the past four months, as documented in the meeting minutes. Complaints included loud staff and students in hallways, particularly during the NOC shift, and bursts of loud noise and laughter at various times. Despite some improvements noted in the minutes, the problem persisted, with residents expressing dissatisfaction with the noise levels and the impact on their sleep. Anonymous residents also reported similar issues, with one stating that the noise and lack of sleep made her feel unwell. The Activities Director acknowledged the ongoing noise issues and stated that they were addressed in Resident Council meetings and followed up with the Interdisciplinary Team (IDT). However, the resolution of these issues was informal, often based on whether the Resident Council president mentioned them again. The facility's policy on maintaining a homelike environment emphasized comfortable sound levels, yet the persistent noise complaints indicated a failure to adhere to this policy.
Failure to Inform Resident Council on Grievance Process
Penalty
Summary
The facility failed to ensure that the Resident Council was informed about how to file a grievance, which could potentially lead to unresolved resident issues. During a review of the Resident Council Meeting Minutes over the past four months, it was noted that the council had requested the Social Services (SS) department to attend a meeting to discuss grievances, theft, and loss, as well as to meet new SS staff. However, the Social Services Director (SSD) had not attended the meetings due to scheduling conflicts, specifically needing to pick up her children from school at the same time as the Resident Council meetings. In a confidential interview, 10 out of 12 residents did not know how to file a grievance. The facility's grievance policy, last revised in January 2022, identified the SSD as the grievance official but did not specify how residents would be informed of their right to file a grievance or the grievance process itself. Among the residents interviewed, three were cognitively intact, while seven had moderate cognitive impairment, indicating a significant portion of the residents might not fully understand the grievance process without proper guidance.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice when a Licensed Vocational Nurse (LVN) left several medications, including a physician-prescribed potassium chloride, on a resident's bedside table without a physician's order for self-administration. The resident, who was diagnosed with alcoholic cirrhosis, had medications left by the LVN for self-administration, despite only having an order to self-administer supplements she purchased herself. The LVN signed off on the medication administration record as if the medications had been administered, without verifying that the resident had taken them. Additionally, the facility did not follow proper procedures for documenting the administration of intravenous (IV) medications. LVNs were signing off on the administration of IV medications and saline flushes that were actually administered by Registered Nurses (RNs). This practice was confirmed through record reviews and interviews, where it was noted that LVNs were not authorized to administer IV medications, and the RNs who administered the medications should have been the ones signing the medication administration records. The facility's policy on administering medications requires that the individual who administers the medication must sign the medication administration record. However, this policy was not followed, leading to inaccurate medical records and potential medication errors. The Director of Nursing acknowledged the issue and confirmed that LVNs were signing off on IV medications administered by RNs, which is outside their scope of practice.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide appropriate activities for three residents, leading to potential negative impacts on their well-being. Resident 78, diagnosed with Amyotrophic Lateral Sclerosis and Dysphagia, was observed not participating in any activities and lacked supplies for her interests such as drawing, painting, and gardening. Her care plan did not reflect her interests, and the Activities Director confirmed that these supplies were not provided. Resident 33, with a diagnosis of Heart Failure, was also not engaged in activities and was often seen in her room or hallways with her eyes closed. Although she expressed an interest in reading and sports, her activity evaluations did not reflect these preferences. The Activities Assistant admitted to copying and pasting previous evaluations without interviewing the resident, which led to inaccurate documentation of her interests. Resident 4, diagnosed with Pneumonitis, was observed only watching TV and not participating in other activities. She expressed a preference for painting, drawing, and socializing, but these were not included in her activity evaluations or care plan. The Activities Assistant confirmed that she did not interview Resident 4 and copied previous evaluations, failing to update the resident's preferences. The facility's policies require that activities be based on comprehensive assessments and resident preferences, which were not adhered to in these cases.
Ineffective QAPI Program and Lack of Data Tracking
Penalty
Summary
The facility failed to establish an effective Quality Assurance Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) program. The Administrator was unable to demonstrate that the interventions in place for various quality improvement projects were reassessed for effectiveness. During an interview and record review, it was revealed that the Administrator had not consistently tracked or documented data related to call light response times, despite having a system capable of doing so. Additionally, the facility's 'angel rounds' lacked documentation to verify that residents were asked about call light response times. The facility also failed to implement effective interventions to reduce resident falls and missing items. Despite a significant increase in falls from February to March 2024, the Administrator believed the interventions were effective, although only one intervention was mentioned. Similarly, the number of missing items increased in April 2024, yet the Administrator maintained that the interventions were effective. The facility's policy on QAPI, last revised in September 2020, emphasized the importance of continual assessment and monitoring, which was not adhered to, as evidenced by the lack of data tracking and ineffective interventions.
Unrepaired Kitchen Floor Tiles Pose Safety Hazard
Penalty
Summary
The facility failed to maintain a safe and functional environment in the kitchen due to unrepaired cracks and missing tiles on the kitchen floor. During an initial observation, a sunken circular cut on the tile with dark matter or accumulated dirt was noted beside the drain on the contaminated side of the dishwashing section. Further observations revealed cracks on the floor tile below the low-temperature dishwasher and on the clean side of the dishwashing section. A follow-up visit also identified a broken tile on the floor by the corner of the kitchen center island near the entrance door. During an interview, the Maintenance Supervisor acknowledged the issues, explaining that the circular cut was a clean-out drain used for unclogging. The Maintenance Supervisor stated that the tiles needed to be changed. A concurrent record review revealed a proposed grease trap project, which included plans to replace the kitchen floor, but it required approval from the Department of Health Care Access and Information. The Food Code 2017 was reviewed, indicating that materials for indoor surfaces should be smooth, durable, and easily cleanable, which the current state of the kitchen floor did not meet.
Deficiency in Staff Training Compliance Tracking
Penalty
Summary
The facility was found to lack a system for tracking staff compliance with mandatory training, which could lead to inadequate staff competency and poor quality of care. During an interview, the Director of Staff Development (DSD) presented a binder of in-person training sessions provided over the last four months, including topics such as bowel & bladder, urinary tract infections, abuse, pressure injuries, and infection control. However, the DSD could not provide a clear method for tracking staff participation in these mandatory trainings, relying instead on staff to attend and follow up if they missed a session. Evidence was requested for five sampled Licensed Nurses, but the DSD could only provide online training records for four of them, with no evidence for the fifth nurse, Licensed Staff H, regarding specific trainings. Further investigation revealed inconsistencies in the training records. The Administrator was asked to provide a list of annual mandatory trainings and evidence of completion by night shift staff. The records showed that some mandatory trainings were overdue by several years, and some staff had not received required refresher courses. The facility's job description for the DSD emphasized the responsibility to ensure all educational programs comply with applicable standards to maintain high-quality resident care, highlighting a significant gap in the facility's training compliance and tracking system.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long-term Care Ombudsman's office regarding the transfer of a resident, identified as Resident 209, to a hospital. Resident 209 had been admitted with multiple medical diagnoses, including fractures in both arms, cognitive communication deficit, and muscle weakness. On a specific date, the resident's condition worsened, prompting a transfer to a local acute care hospital's emergency room. However, the Notice of Proposed Transfer/Discharge form, completed by Licensed Staff G, was missing the resident's name and the date the notice was mailed to the Ombudsman. This oversight was confirmed during interviews with the Medical Records Director and Licensed Staff G. Further investigation revealed that the Social Services Assistant could not find any documentation indicating that the Ombudsman's office was notified of the transfer. The Social Services Assistant explained that the usual process involved the nurse filling out the form and social services notifying the Ombudsman, typically by fax. However, in this case, the form was incomplete, and the notification was not sent. The Social Services Director confirmed that staff were expected to inform the Ombudsman of hospital transfers promptly. The facility's policy, as outlined in All Facilities Letter 17-27, requires notification to the Ombudsman at the same time notice is provided to the resident or their representatives, especially in emergency transfers to a hospital.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential negative outcomes. Resident 78, diagnosed with Amyotrophic Lateral Sclerosis and Dysphagia, was admitted with interests in activities such as drawing, painting, music, reading, writing, and gardening. However, her care plan did not reflect these interests, and she was observed not participating in any activities, spending her time staring at the wall. The Activities Director confirmed that the care plan was not based on the initial activity evaluation and that supplies for independent activities were not provided to Resident 78. Resident 209, who had a fractured right arm from a fall prior to admission, did not have a care plan addressing this condition. Despite the presence of a sling on his arm during the admission skin assessment, the care plan was not updated to include the fracture. The Director of Nursing acknowledged that the care plan should have included the right arm fracture but was not opened at the time of the incident, leading to a focus solely on the left humerus fracture. The facility's policies on activity assessment and care planning were not adhered to, resulting in deficiencies in the care plans for both residents. The lack of comprehensive care plans for Resident 78 and Resident 209 had the potential to impact their quality of care, as the facility did not ensure their needs and preferences were adequately addressed.
Inaccurate Fall Risk Assessment for Resident with Arm Fractures
Penalty
Summary
The facility failed to accurately assess the fall risk of a resident, identified as Resident 209, which potentially contributed to a fall incident. Upon review, it was found that Resident 209 had been admitted with multiple medical diagnoses, including fractures in both arms, cognitive communication deficit, and muscle weakness. However, the admission assessment did not document the presence of a sling or mention the arm fracture, and the fall risk assessment inaccurately categorized the resident as medium risk without considering the fracture diagnosis. Interviews with staff revealed that the omission of the sling and fracture in the admission assessment was an oversight. Licensed Staff L acknowledged that the sling should have been documented, and the fall risk assessment should have included the fracture as a risk factor. The Director of Nursing confirmed these omissions and stated that an inaccurate fall risk assessment could lead to inadequate precautions being implemented for the resident. The facility's policy on fall risk assessment emphasizes the importance of identifying residents at risk for falls and implementing preventative care plans, which was not adhered to in this case.
Deficiency in Nursing Staff Competency and Training
Penalty
Summary
The facility failed to ensure that its nursing staff had the appropriate competencies to care for residents, as evidenced by the lack of updated annual competencies for a licensed staff member, and the Director of Staff Development (DSD) not having a system to track staff participation in required training. Specifically, Licensed Staff B did not have updated competencies for assessing and documenting changes in a resident's condition, which led to a failure to provide timely emergency care to a resident with significant medical needs. The resident, who had a complex medical history including a frontal lobe stroke, respiratory failure, and other serious conditions, experienced a critical change in condition that was not properly addressed by the staff. The report details an incident involving a resident who was found with low oxygen saturation and an unstable heart rate. Despite these alarming signs, Licensed Staff B did not notify the physician or document the change in condition, nor did she have the necessary competencies to manage the situation effectively. The resident was on oxygen therapy, and the staff failed to follow the physician's orders for oxygen administration, which required notifying the doctor if the oxygen saturation fell below a certain level. Additionally, the staff did not adhere to infection control protocols, as evidenced by the lack of personal protective equipment use during high-contact care activities. Furthermore, the DSD was unable to provide evidence of mandatory training completion for certain staff members, indicating a lack of oversight and tracking of staff competencies. The DSD's failure to ensure that all staff received necessary training, either in-person or through an online platform, contributed to the overall deficiency in staff preparedness and competency. This lack of training and competency assessment posed a risk to the safety and well-being of residents, as staff were not adequately equipped to handle changes in residents' conditions or adhere to facility policies and procedures.
Inadequate Sanitary Storage of Portable Urinals
Penalty
Summary
The facility failed to ensure the sanitary storage of portable plastic urinals used by residents, which had the potential to increase the risk of infection and disease transmission. During an initial tour and resident interview, a strong smell of urine was noted in a resident's room. Resident 32, occupying Bed C, mentioned that he used a portable urinal to urinate in bed and that his Certified Nursing Assistant (CNA) only rinsed it occasionally. This indicates a lack of consistent cleaning and storage practices for the urinal. A follow-up observation revealed that Resident 71, occupying Bed A in the same room, had a portable urinal placed on top of his overbed table next to his drinking mug, further contributing to unsanitary conditions. Licensed Nurse A (LN A) acknowledged the unsanitary nature of the situation and moved the urinal under the table, suggesting there was a designated place for it. The facility's procedure for handling urinals lacked specific instructions on cleaning materials and did not address the handling of urinals used by residents with urinary tract infections, indicating a gap in the facility's infection prevention and control program.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Santa Rosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summerfield Health Care Center | 0.8 mi | ★★★★★ | 4 | 0 |
| Santa Rosa Post Acute | 0.8 mi | ★★★★★ | 29 | 0 |
| Spring Lake Village | 1.6 mi | ★★★★★ | 10 | 0 |
| Blue Oak Post-acute | 2.4 mi | ★★★★★ | 33 | 0 |
| Northvine Postacute Care | 3.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.