Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Parkview Julian Healthcare Center during CMS and state inspections, most recent first.
Failure to Follow UTI Care Plan: A resident with chronic UTI had a care plan directing staff to check for incontinence every 2 hours, provide hygiene care to soiled areas, and monitor intake and output. During record review, there was no documentation that these interventions were being completed, and the DON stated that if it was not documented, it was not done and that the care plan was not followed.
Failure to Hold Quarterly IDT Care Plan Review: The facility failed to ensure the IDT met with a resident and family to review the care plan after a quarterly MDS. The MR showed the quarterly assessment was completed, but there was no documentation of a care plan meeting. The DON stated the IDT should have met upon readmission and quarterly to review the resident’s current condition, plan of care, and preferences.
A resident's ordered IV antibiotic was not administered as scheduled, with the MAR showing missed doses and the DON confirming it should have been given within four hours of the physician's order. The facility policy states medications are to be administered by an LPN per the attending physician's order.
A resident with contractures on both hands was observed with long fingernails touching her palms. A CNA stated the sharp nails could cut the resident's palms and cause skin breakdown and infection, and the DON stated the resident's fingernails should have been trimmed, filed, and cleaned every Sunday and as needed. The facility policy stated nail care is given to clean and keep the nails trimmed.
A resident's midline catheter care was not provided as ordered. The OLR directed staff to flush the right upper arm midline with 10 ml saline before and after IV meds every shift and to monitor the site for inflammation or infiltration twice daily, but the TAR had no documentation of site monitoring on several shifts and no documentation of saline flushes on several night shifts. The DON stated that if it was not documented, it was not done, and the facility policy required assessment of the insertion site for redness, tenderness, edema, and drainage.
Failure to Complete Ordered Wound and Skin Treatments: A resident with a coccyx skin maintenance order and a left heel stage 3 PI had multiple ordered treatments not documented on the TAR, including skin barrier, Calmoseptine, and wound care with NS, Betadine, calcium alginate, and dry dressing. The DON stated that if there was no documentation, the treatment was not done.
Failure to provide contracture management for a resident with bilateral hand contractures. During observation, the resident had contractures on both hands and no device was in place on either hand. The CNA was unsure whether the resident was supposed to have a device, and the MR showed no intervention for the contractures. The DON stated hand rolls should have been in place on both hands, consistent with the facility’s contracture prevention P&P.
A resident with a GT had an order for daily site care with a T-drain dressing, but during observation the GT site was not covered. The TN stated the site needed a dressing and that it should be changed daily and as needed, and the DON stated the site was supposed to be covered to protect the skin and prevent infection. The facility policy for feeding tube site care directed staff to place a gauze drainage sponge around the site.
A resident on contact isolation for MRSA was cohorted with another resident who was not on isolation precautions, and a CNA entered the room without wearing the required gown and gloves. The door sign directed staff to clean hands and don PPE before entry, and the DON and IP confirmed the facility’s isolation policy was not followed.
A resident experienced multiple falls, and post-fall assessments documented specific interventions such as not leaving the resident unattended in a W/C, use of a floor mat, frequent staff monitoring, ensuring the call light was within reach, checking vitals, and providing safety education during transitional movements. Although these interventions were recorded on Therapy Post-Fall Screens and the falls were documented as changes of condition, the DON confirmed that the high-risk fall care plan was not updated to include these measures, contrary to facility policy requiring IDT review of post-fall assessments and revision of the care plan as indicated.
A resident with severe cognitive impairment, total dependence for toileting, chronic incontinence, and a high fall risk score was not managed in accordance with the facility’s Fall Management Program, Refusal of Treatment policy, and Continence Management Guideline. During a night shift, a CNA observed a wet brief and offered incontinence care, which the resident refused; the CNA did not notify the LVN, did not seek assistance, and did not recheck or re-offer care for nearly two hours, and the resident’s brief was not checked and changed every two hours as required. Later that shift, the CNA found the resident partially off the bed attempting to go to the bathroom, with a wet and soiled brief, and the nurse and CNA assisted the resident back to bed. Subsequent imaging identified a periprosthetic distal femur fracture, and the resident later underwent surgical repair.
A RN documented respiratory distress symptoms for a resident in error, recording observations such as difficulty breathing and sternal retractions that were meant for another individual. The DON confirmed that nursing documentation must be accurate, as per facility policy.
Incomplete and non-individualized activity assessments and care plans were identified for three residents. One resident's assessment and CP lacked personal interests despite a need for 1:1 in-room activities, another resident reported poor vision, interest in audio books, and difficulty seeing a small TV, but his assessment and CP were not specific to his preferences, and a third resident had an incomplete assessment with no documented activity preferences and a CP that was not personalized. Staff also did not consistently engage residents in activities aligned with their stated needs and interests.
Improper food labeling and utensil storage were observed in the kitchen and storage areas. Opened vegetables and butter were stored without required received, opened, or used-by dates, food scoops were left inside dry food bins touching the food, an ice cream scoop with food particles was stored with clean utensils, and two rolls of frozen meat in a hallway freezer were unlabeled. Staff acknowledged the items were not stored or labeled according to facility policy.
Overflowing trash bags were observed in one of three outside trash bins with the lid left open, preventing the bin from being closed. The CDM stated staff should have used the empty trash bin and noted staff know the lid must be able to close to avoid attracting flies or rodents. The facility policy required daily inspection of garbage and trashcans to ensure lids are closed and the area is free of debris.
Improper disposal and storage of used trash bags was observed in multiple areas. A trash bag was left on a resident bathroom floor, another bag containing feces was found in a patio area, and used bags with mopheads and a dirty towel were stored on the laundry room floor. Staff stated the bags should not have been left on the floor, and no facility policy was provided.
A resident receiving continuous O2 via nasal cannula had a physician order to maintain O2 sat above 92% and notify the MD if it dropped below 92%, but no care plan for oxygen was found in the medical record. The MDSC confirmed the resident was on O2 and stated there should have been an oxygen care plan. The facility policy required a comprehensive person-centered care plan with measurable objectives and timetables.
A resident’s abnormal lab results were not reviewed and reported to the MD until several days after receipt, and the resident was kept on contact isolation for ESBL UTI without an individualized care plan. Staff were unable to identify the infection or explain the isolation status, and the contact isolation sign remained posted even after the order was discontinued.
Missing Annual CNA Competency: The facility failed to complete an annual competency for one CNA. Record review showed the CNA was hired in 2024, but no annual competency was in the personnel file. The DSD stated the competency should have been completed in 2025, and the facility policy states the DNS or designee evaluates staff competency in skills and techniques necessary to care for residents' assessed needs.
Patio and Laundry Areas Not Kept Clean and Sanitary: A resident reported wanting to use the patio area with visiting family, but surveyors observed a plastic bag on the patio containing a brown substance that staff identified as feces. Staff could not explain how it got there. In a separate observation, plastic bags were found on the laundry room floor next to the washer, including used mopheads and dirty towels, and an LST stated the bags should not have been stored on the floor.
A resident's grievances regarding food preferences and noise were not properly addressed, as the facility failed to inform the resident of the investigation outcomes or actions taken. Documentation was incomplete, with missing signatures and notifications, and staff confirmed that required follow-up and communication did not occur, contrary to facility policy.
A resident who is fully dependent on staff for toileting hygiene reported waiting up to 40 minutes for assistance after using the call light, despite a history of UTIs. A CNA confirmed that high resident assignments sometimes delay responses to call lights, contrary to facility policy requiring prompt attention.
A resident who managed his own finances experienced repeated unapproved charges on his bank card by a family member. Despite staff awareness and documentation of the financial abuse, the incident was not reported or investigated as required by policy, and no care plan was developed to protect the resident or address his refusal of protection.
A resident with Alzheimer's disease and a high fall risk experienced a fall resulting in a right hip fracture after staff failed to follow the care plan interventions, which included placing a floor mat on the right side of the bed and ensuring the use of nonskid socks. Documentation and staff interviews confirmed that these interventions were not in place at the time of the incident, despite being clearly outlined in the care plan.
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not timely submitting required reports to the CDPH and local ombudsman for two residents involved in incidents. Additionally, the facility did not notify the attending physician or develop a care plan for a resident who experienced financial abuse, contrary to policy requirements.
A resident in a LTC facility did not receive an antibiotic as prescribed by the MD for a surgical wound infection. The Treatment Nurse entered the order incorrectly, administering Keflex every eight hours instead of four times a day. The DON confirmed the inaccuracy, and the facility's policy requires complete and accurate medication orders.
A facility failed to follow its policy on resident weight management for a resident with mild protein-calorie malnutrition, who did not have his weight taken for three months. Despite multiple meal refusals and discomfort with the hoyer lift, no alternative weight measurement methods were used, and the issue was not discussed by the Interdisciplinary Team. The Dietary Manager confirmed that the Quarterly Nutrition Review was inaccurate due to outdated weight data.
A resident was not involved in the care planning process when the facility changed the method of transferring him from his bed to the shower bed. The resident was not informed of the reason for the change, and there was no documentation of a discussion with him prior to the care plan initiation. This failure violated the resident's rights as outlined in the facility's policy.
A resident missed a necessary doctor's appointment for valley fever treatment due to the facility's failure to schedule transportation. The appointment was noted in the resident's order details, but the Social Services Department did not receive a transportation request, which is required for scheduling. The facility's policy indicates that the Social Services Department assists with transportation arrangements, but this was not executed, leading to the missed appointment.
A resident with moderate cognitive impairment was not monitored for respiratory distress after a fire in her room, despite experiencing throat and lung pain, chest pain, and difficulty breathing. The facility's care plan required alert charting and monitoring of vital signs every shift for 72 hours, but this was not documented or conducted, as confirmed by a nurse consultant.
A facility failed to log and timely process medical records requests for three residents, violating its policies on resident access to PHI and third-party disclosures. The requests were delayed by 20 to 31 days, despite a policy requiring action within five days.
The facility failed to properly inventory and secure personal items of two residents upon admission, leading to the presence of dangerous materials like lighters and cigarettes in their possession. Staff confirmed that smoking materials should be stored securely, but this was not done, resulting in a deficiency.
The facility failed to ensure that several residents had signed and dated Advance Directives (ADs) in their medical records, and did not document that other residents were informed about their right to complete an AD. This oversight involved multiple residents whose ADs were either unsigned, undated, or missing entirely, potentially impacting the honoring of their healthcare wishes.
The facility did not complete smoking assessments for several residents who smoked independently, as required by their policy. This failure involved incomplete or delayed assessments for multiple residents, posing a potential safety risk.
A facility failed to administer medications as per physician orders for a resident, with missing documentation for Normal Saline Flush and Unasyn. Key staff lacked current CPR certification, and the facility did not provide required educational programs to all staff, impacting patient care and safety. Additionally, a Maintenance Technician was unaware of policies, leading to unapproved space heaters in residents' rooms.
The facility failed to ensure a safe environment for residents, leading to several deficiencies. A resident at risk for choking was left unsupervised with sugar packets, while ten residents who smoked were not monitored, contrary to facility policy. Additionally, two residents had unauthorized space heaters, and a resident at risk for wandering had an unalarmed door, posing potential safety hazards.
The facility failed to notify the Ombudsman of hospital transfers for two residents, as required by their policy. This was confirmed through record reviews and staff interviews, revealing that no notifications were made for transfers occurring in several instances.
A cook in the facility failed to follow the standardized recipe for pureed meat sauce by using water instead of the specified milk, gravy, or low sodium broth, potentially compromising the nutritive value of meals for residents on a pureed diet. The facility's policy requires adherence to approved recipes to conserve nutritive value, which was not followed in this instance.
The facility failed to maintain sanitary food storage and preparation practices. Expired baking soda, a dented can, and unlabeled and undated food items were found in the dry storage room, freezer, and refrigerator. These deficiencies were confirmed by staff, who acknowledged non-compliance with the facility's policies.
The report highlights deficiencies in facility safety and maintenance, including a water-stained ceiling with mold, unauthorized space heaters in residents' rooms, and a non-functional alarm on a sliding glass door for a resident at risk of elopement. The Maintenance Supervisor was unaware of the water damage, and the Administrator had not approved the space heaters, while the DON confirmed the resident's elopement risk.
A facility failed to complete the informed consent process for a resident receiving Amitriptyline, a psychotherapeutic medication. During a review, it was discovered that the informed consent form lacked a signature of verification, indicating the process was incomplete. This was contrary to the facility's policy, which mandates obtaining informed consent before administering medical interventions requiring it.
The facility failed to maintain a homelike environment for a resident and two other residents. A resident's clothing was damaged due to improper laundering, resulting in bleach stains. Additionally, two residents' rooms had unpainted drywall patches, broken baseboards, and peeling wallpaper, as confirmed by a maintenance technician.
The facility failed to follow its dialysis care procedures for two residents with chest catheters. One resident lacked an order for monitoring her dialysis access site, and both residents were incorrectly assessed for bruit and thrill, which are not applicable for chest catheters. The facility's policy outlines procedures for AV shunts or fistulas, which neither resident had.
The facility failed to complete required PASRR evaluations for two residents. One resident's PASRR Level I screening indicated a positive result for SMI, but the facility did not respond to communication attempts, resulting in an incomplete assessment. Another resident's positive Level I screening required a Level II evaluation, which was not conducted. The facility did not follow its policy requiring in-depth evaluations for positive Level I screens.
A resident on IV antibiotics for osteomyelitis did not receive two doses of Unasyn due to a staffing mix-up, resulting in no registered nurse coverage for a shift. The facility's policy requires sufficient nursing staff to meet resident needs, which was not met in this case.
Two residents were served meals that did not align with their documented preferences, leading to dissatisfaction and an outburst. The facility's policy required adherence to food preferences, but both residents were served Mac and Cheese despite disliking pasta, as confirmed by the CDM.
A resident with a BIMS score of 15, indicating no cognitive impairment, was not provided coffee, their preferred beverage, throughout the day, despite their care plan indicating a need to maintain hydration. Staff, including the Dietary Supervisor and CNAs, did not accommodate the resident's requests, citing a lack of process for beverage preferences outside meal times. The facility's policy stated that resident preferences should be adhered to within reason, but this was not followed.
The facility failed to ensure the Director of Staff Development (DSD) met the required qualifications, as she had only a year and a half of nursing experience instead of the required two years. This discrepancy was confirmed by the Director of Nurses (DON) and had the potential to impact the DSD's ability to provide adequate education to the nursing staff, potentially affecting residents' health and safety.
The facility failed to follow physician's orders for two residents, leading to potential health risks. One resident received an incorrect dosage of Seroquel, while another did not receive a recommended speech therapy evaluation after a choking incident. Both the LVN and DON confirmed these discrepancies.
A facility failed to monitor behaviors for a resident prescribed Quetiapine fumarate for behavior management, leading to potential unnecessary psychotropic medication use. The Director of Nursing confirmed the absence of behavior monitoring records, and an LVN stated that behaviors should be documented in the MAR. The facility's policy required daily monitoring of target behaviors, which was not followed.
Failure to Follow UTI Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident with chronic urinary tract infections. The care plan, dated 4/13/26, directed staff to check at least every 2 hours for incontinence, wash, rinse, and dry soiled areas, and monitor intake and output. During a concurrent interview and record review on 5/5/26 at 1:03 p.m. with the DON, the resident’s medical record showed no documentation that incontinence care was being provided at least every 2 hours and no documentation that urine output was being monitored. The DON stated that if there was no documentation, it was not done, and stated the care plan was not followed.
Failure to Hold Quarterly IDT Care Plan Review
Penalty
Summary
The facility failed to ensure the Interdisciplinary Team (IDT) met to review care plans quarterly for one of two sampled residents, Resident 1. During a concurrent interview and record review on 5/6/26 at 11:42 a.m. with the DON, Resident 1’s medical record showed a quarterly MDS completed on 3/6/26, but there was no documentation that the IDT met with Resident 1 and the family to review the resident’s care plans. The DON stated the IDT should have met with Resident 1 and the family upon readmission and quarterly. The DON further stated there should have been a care plan meeting on 3/6/26 so the family could be informed of Resident 1’s current condition and current plan of care, and so Resident 1 and the family could be involved in updating the care plan based on their preferences. The facility policy titled Care Planning, dated 11/1/17, stated the care plan must be completed within 7 days after the comprehensive admission assessment and periodically reviewed and revised by a team of qualified persons after each assessment, including comprehensive and quarterly review assessments. The policy also stated the care plan must be prepared by the IDT team and may include the resident and/or family or legal representative.
Failure to Administer Ordered IV Antibiotic
Penalty
Summary
The facility failed to ensure an antibiotic was administered as ordered by the physician for Resident 1. The Order Listing Report dated 5/6/26 showed Ertapenem, ordered every 24 hours for infection for 15 days with a start date of 4/12/26. During a concurrent interview and record review with the DON on 5/5/26 at 2:05 p.m., Resident 1's IV MAR for April 2026 was reviewed and showed the Ertapenem antibiotic was not administered on 4/12/26 and 4/13/26. The DON stated the antibiotic should have been administered within four hours of the physician's orders and that failure to administer it as scheduled would put Resident 1 at risk for unresolved infection and sepsis. The facility policy titled Medication - Administration stated medication will be administered by a Licensed Nurse per the order of an Attending Physician.
Failure to Trim Fingernails for Resident With Hand Contractures
Penalty
Summary
The facility failed to ensure fingernails were trimmed for one sampled resident with contractures on both hands. During a concurrent observation and interview, the resident was seen in her room with contractures on both hands and long fingernails, approximately a quarter inch in length, touching her palms. A CNA stated the resident had long and sharp fingernails that could cut her palms and could cause skin breakdown and infection. The DON stated the resident's fingernails should have been trimmed, filed, and cleaned every Sunday and as needed, and acknowledged that the resident's long and sharp fingernails with contractures on both hands could cause impaired skin integrity and infection. The facility policy stated that nail care is given to clean and keep the nails trimmed.
Failure to Monitor and Flush Midline Catheter as Ordered
Penalty
Summary
The facility failed to provide care for a resident's right upper arm midline catheter as ordered by the physician. The Order Listing Report showed an order to flush the midline with 10 ml saline before and after IV medications every shift, and to monitor the midline site for signs of inflammation or infiltration two times a day, starting 04/14/2026. During review of the Treatment Administration Record with the DON, there was no documentation that the midline site was monitored for signs of inflammation or infiltration on 4/16/26, 4/19/26, and 4/23/26 at 6:30 a.m. There was also no documentation that the midline catheter was flushed with 10 ml normal saline on 4/15/26, 4/19/26, and 4/22/26 on the night shift. The DON stated that if there was no documentation, it was not done. The facility policy for PICC dressing change and site care indicated the insertion site should be assessed for redness, tenderness, edema, and drainage.
Failure to Complete Ordered Wound and Skin Treatments
Penalty
Summary
The facility failed to ensure ordered treatments were completed for one resident with skin care needs and a left heel stage 3 pressure injury. The resident’s Order Summary Report dated 5/6/26 directed staff to apply skin barrier to the coccyx every shift for skin maintenance, apply Calmoseptine to affected areas twice daily for skin maintenance, and cleanse the left heel wound with Normal Saline, pat dry, apply Betadine to periwound maceration, apply calcium alginate to the wound bed, and cover with a dry dressing, with dressing changes daily and as needed for loss of integrity or soiling. During a concurrent interview and record review with the DON, the April 2026 TAR showed no documentation that the skin barrier was applied to the coccyx on 4/4/26 and 4/11/26. The TAR also showed no documentation that Calmoseptine was applied on 4/4/26 at 9 a.m., 4/11/26 at 9 a.m., 4/23/26 at 5 p.m., and 4/26/26 at 9 a.m. In addition, there was no documentation that treatment was done for the resident’s left heel stage 3 pressure injury on 4/4/26, 4/11/26, and 4/26/26. The DON stated that if there was no documentation, the treatment was not done, and confirmed the ordered treatments were not documented as completed.
Failure to Provide Hand Rolls for Resident With Bilateral Hand Contractures
Penalty
Summary
The facility failed to follow its own policy and procedure for contracture prevention when interventions to manage contractures were not provided on both hands for one sampled resident. During observation, the resident was noted to have contractures on both hands and did not have a device on either hand to manage the contractures. A CNA stated she was not sure whether the resident was supposed to have a device on both hands. During record review, the resident’s medical record showed no intervention to manage the contractures on both hands. The DON stated the resident should have had hand rolls on both hands to prevent contractures, restore muscle movement, and protect the resident’s skin. The facility’s policy stated that interventions are implemented to prevent the onset of contractures and to prevent worsening of contractures for residents admitted with contractures.
GT Site Not Covered as Ordered
Penalty
Summary
Resident 2 had a GT site care order in the Order Summary Report dated 5/6/26 that directed staff to cleanse the GT site to the abdomen with normal saline, pat dry, and apply a T-drain daily. During a concurrent observation and interview on 5/6/26 at 9:55 a.m., the Treatment Nurse observed that Resident 2's GT site was not covered with a T-drain dressing. The Treatment Nurse stated the site needed a dressing, said she did not know the GT site did not have one, and stated the T-drain dressing was supposed to be changed daily and as needed. The Treatment Nurse also stated the GT site should be covered with a T-drain dressing to ensure it was clean and to prevent infection. During an interview at 10:03 a.m., the DON stated Resident 2's GT site was supposed to be covered to protect the skin and to prevent infection. The facility policy titled Feeding Tube - Site Care, dated 11/1/17, stated the purpose was to inspect and prevent skin breakdown and complications for residents with feeding tubes and directed staff to place a gauze drainage sponge around the site.
Failure to Follow Contact Isolation Precautions
Penalty
Summary
The facility failed to follow its Resident Isolation - Categories of Transmission-Based Precautions policy for a resident on contact isolation for MRSA. An Order Summary Report dated 5/6/26 indicated the resident was on CONTACT ISOLATION related to MRSA, and a contact isolation sign was posted on the resident’s door stating that before entering the room staff should clean hands and wear a gown and gloves. During an observation on 5/5/26 at 10:31 a.m., CNA 2 entered the resident’s room without wearing a gown and gloves. The resident was cohorted with another resident who was not on isolation precautions. During interview, CNA 2 stated she was aware the resident was on contact precautions but did not wear a gown and gloves before entering the room, and stated she should have followed the sign on the door. The DON confirmed the sign was not followed, and the IP reviewed the facility policy stating that when a private room is not available, the Infection Control Coordinator assesses risks associated with other resident placement, including cohorting, and that gloves and a gown are worn when entering the room. The IP stated the resident was in a room with another resident without isolation precautions and that the policy was not followed.
Failure to Update Care Plan With Post-Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan with fall-related interventions identified after two separate falls. Review of the resident’s Therapy Post-Fall Screens (TPFS) showed that after a fall dated 11/1/25, the TPFS documented that the resident should not be left unattended in a wheelchair, required frequent staff monitoring, a floor mat, and a call light within reach at all times. A subsequent TPFS following another fall dated 3/7/26 documented the need for a floor mat, frequent staff monitoring, vital sign checks, and education of the resident about safety during transitional movements. These specific recommendations were recorded on the TPFS forms but were not incorporated into the resident’s high-risk for falls care plan. During an interview and concurrent record review with the DON, it was confirmed that the resident’s Change of Condition forms dated 11/1/25 and 3/7/26 were both related to falls that occurred while the resident was in bed. The DON reviewed the resident’s high-risk fall care plan and acknowledged that the TPFS recommendations from 11/1/25 and 3/9/26 had not been added to the care plan, despite the facility’s policy titled “Response to Falls.” That policy requires that after each fall, a licensed nurse complete a post-fall assessment and investigation, and that the IDT/Falls Committee review the post-fall assessment within 72 hours to consider changes in the plan of care and revise the resident’s care plan as necessary. The DON stated that falls are reviewed during standup and that the missed updates to the resident’s high-risk fall care plan should have been identified and made at that time.
Failure to Follow Fall, Refusal of Treatment, and Continence Policies for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Management Program, Refusal of Treatment policy, and Continence Management Guideline for a resident with severe cognitive impairment and a history of falls. The resident had diagnoses including generalized muscle weakness, need for assistance with personal care, history of falling, and a prior displaced intertrochanteric fracture of the right femur with surgical intervention. The MDS documented that the resident was wheelchair-bound, totally dependent for toileting hygiene, unable to stand, walk, or transfer to the toilet, and always incontinent of bowel and bladder. The resident’s fall risk evaluation score of 17 indicated a high fall risk, and the care plan identified risk for repeated falls related to deconditioning, gait/balance problems, psychoactive drug use, generalized weakness, prior mechanical fall with right femur fracture, impulsive behavior, and episodes of crawling out of bed, with an intervention to anticipate and meet the resident’s needs. On the night in question, CNA 1 reported that during the 10 p.m. to 6:30 a.m. shift, she checked the resident at approximately 3:30 a.m. and observed that the brief’s wetness indicator had changed color, indicating the brief was wet. CNA 1 stated she offered to change the resident’s brief, but the resident refused. Despite this refusal, CNA 1 did not notify the LVN or the charge nurse as required by the facility’s Refusal of Treatment policy, did not seek assistance from another CNA to help with changing the resident, and did not return to re-offer or attempt to change the brief for the next one hour and 45 minutes. CNA 1 also stated that during that entire night shift she changed the resident only once, after the fall, and did not check and change the resident’s brief every two hours as required by the facility’s Continence Management Guideline, explaining that the resident usually refused at night. At around 5:15 a.m., CNA 1 passed by the resident’s room and saw the resident holding the bed rail with one leg bent on the floor mat; the resident stated she was trying to go to the bathroom to urinate. CNA 1 checked the resident’s brief and found it wet with bowel movement. LVN 1, who was passing medications at that time, was called to the room and observed the resident with most of her hip on the bed and her legs hanging off the bed; LVN 1 and CNA 1 assisted the resident to the ground and then back to bed, and LVN 1 documented that the resident initially had no pain or visible injury. Subsequent imaging on 12/29 showed a periprosthetic distal femur fracture of indeterminate age, and by 12/31 the resident had developed right knee swelling and pain, leading to hospital evaluation where CT imaging confirmed a periprosthetic distal femoral metaphyseal fracture, followed by surgical repair with retrograde intramedullary nailing on 1/3. The facility’s Fall Management Program policy required assisting patients with toileting as appropriate, which was not carried out in accordance with the resident’s identified needs and risk factors. These failures had the potential to result in Resident 1 falling from trying to go to the bathroom and sustaining right distal femur fracture (broken bone) requiring hospitalization and surgery.
Inaccurate Nursing Documentation for Resident Assessment
Penalty
Summary
The facility failed to ensure accurate nursing documentation for one resident when a Registered Nurse (RN) incorrectly recorded respiratory distress symptoms, including difficulty breathing, shallow respirations, sternal retractions, and shortness of breath while lying flat, in the resident's Nurse Advance Skilled Evaluation. During a review, the RN acknowledged that the documentation was entered in error and was actually intended for another, unidentified resident. The Director of Nursing (DON) confirmed that nursing documentation should be accurate, as outlined in the facility's policy and procedure for nursing documentation, which requires records to be concise, clear, pertinent, and accurate. This inaccuracy in documentation had the potential to result in inappropriate care for the resident, as the recorded symptoms did not reflect the resident's actual condition at the time.
Incomplete and Non-Individualized Activity Assessments and Care Plans
Penalty
Summary
The facility failed to ensure that three sampled residents had comprehensive activities assessments and individualized activities care plans that reflected their preferences and interests. Resident 1's Quality of Life Initial Assessment noted that he spent time at home cooking and cleaning, but it did not include personal interests. His care plan stated that he needed 1:1 bedside or in-room visits and activities if unable to attend out-of-room events, but it did not include personalized interests. Activities staff stated they normally did not go into Resident 1's room because he refused activities, although the Activities Director stated staff should still check on and offer activities to him each day. Resident 30 stated he was unable to get out of bed and attend activities, used to be an avid reader, could no longer see well enough to read, and would be interested in audio books but did not have access to any. He also stated he watched television most of the time but had difficulty seeing because the television was small and far away, and he had asked for a bigger television that had not been provided. His Quality of Life Assessment listed books, newspapers, magazines, music, favorite activities, and going outside as important, but did not identify specific preferences or how the facility would accommodate them. His care plan stated he needed a variety of activity types and locations to maintain interests, but the Activities Director stated it was not specific to his personal interests. Resident 75 was observed with an iPad left at the bedside for musical sensory activity. His Quality of Life Assessment was incomplete, with unknown demographic information and no response to activity preference questions, and the Activities Director stated the assessment was incomplete. The Activities Director also stated she had attempted to contact the resident's family but could not provide documentation of that attempt. Resident 75's care plan stated he needed 1:1 bedside or in-room visits and activities if unable to attend out-of-room events, but it was not specific to his personalized activity preferences. The facility policy required activities to meet residents' needs, interests, and preferences through the assessment process and to develop individualized care plans after the initial assessment.
Improper Food Labeling and Unsafe Utensil Storage
Penalty
Summary
Food service safety and sanitary kitchen conditions were not maintained when multiple food items were found improperly labeled or stored during observation. In the dry storage room refrigerator, an opened box of carrots and an opened box of lettuce were present without a received date, opened date, or used-by date. In the same area, an opened box of butter was also stored without labeling. The Dietary Service Supervisor stated each of these items should have been labeled with the received, opened, and used-by date, and the facility policy required food in storerooms, refrigerators, and freezers to be labeled and dated. Additional kitchen observations showed food scoops stored inside dry food bins rather than separately, including a scoop in the flour bin and a scoop in the oatmeal bin, with the scoops touching the food. The facility policy for ingredient bins stated scoops must not be left in the bin and should be kept in a protected container near the bins. An ice cream scoop with food particles and debris was also stored in the clean utensil drawer, and the Certified Dietary Manager stated it had not been cleaned properly. In the hallway freezer outside the kitchen, two unlabeled rolls of frozen meat were found, and the CDM identified them as ground beef but stated they should have been labeled.
Overflowing Trash Bin Left Open
Penalty
Summary
The facility failed to follow its policy and procedure titled Miscellaneous Areas when one of three outside trash bins could not be closed. During a concurrent observation and interview on 12/15/25 at 8:25 a.m. with the Certified Dietary Manager in the area where the trash bins were located, one trash bin was observed with the lid open and trash bags overflowing from the top of the bin. The Certified Dietary Manager stated staff should have placed the trash in the empty trash bin and stated staff know the lid must be able to close to prevent attracting flies or rodents. A review of the facility policy dated 2023 stated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area and that lids are closed, and noted that the trash collection area is a potential feeding ground for vermin and rodents.
Improper Disposal and Storage of Used Trash Bags
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when three used trash bags were observed disposed of unsafely in resident care areas. In one resident bathroom, a plastic trash bag containing trash was found on the floor next to the trash can. During a concurrent observation and interview, an LVN stated the CNA should have placed the bag in the trash can and that it should not have been on the floor. In another observation, a clear plastic trash bag was seen on the ground in the patio area outside a resident room and contained a brown substance. During a concurrent observation and interview, Transportation/Help opened the bag while wearing gloves and identified the contents as feces; the MS stated he was not sure how the bag got there. In the laundry room, plastic bags were stored on the floor next to the washer, and when the IP opened them, one bag contained used mopheads and another contained a used dirty towel. The LS stated the bags of trash should not have been stored on the floor. A facility policy and procedure was requested, but none was provided.
Missing Oxygen Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 89, who had a physician order for continuous oxygen at 5 LPM via nasal cannula to maintain O2 saturation above 92% and to notify the MD if O2 dropped below 92%. During observation, Resident 89 was receiving oxygen through a nasal cannula. During concurrent interview and record review, the MDS Coordinator stated Resident 89 was receiving oxygen via nasal cannula and that no care plan for oxygen was found in the resident's medical record, adding that there should have been a care plan for oxygen. The facility policy titled Care Planning stated that a comprehensive person-centered care plan will be developed for each resident and will include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs.
Delayed Lab Review and Isolation Care Planning Failures
Penalty
Summary
Resident 75 had abnormal laboratory results received by the facility on 12/1/25, but the results were not reviewed and reported to the physician until 12/4/25. During interview and record review, the Infection Prevention nurse stated the lab results needed to be reported when received, and the DON confirmed the results were received on 12/1/25 and reported three days later. The DON stated the review and physician notification was not timely and that care of Resident 75 was delayed. Resident 75 was placed on contact isolation for ESBL in the urine, with a physician order dated 11/17/25. On 12/15/25 and 12/17/25, staff observed a contact isolation sign posted outside the resident’s room, and staff interviewed at the room stated they did not know what type of infection Resident 75 had. RN staff reviewed the record and stated they did not know why the resident was still on contact isolation, and the MDS Coordinator confirmed there was no care plan for the resident’s contact isolation and infection. The DON stated it was the responsibility of the IDT to develop and implement care plans for each resident, and there were no IDT notes for Resident 75. The record also showed Resident 75 completed meropenem treatment on 11/29/25, and the DON stated the resident would stay on contact isolation for three additional days after antibiotics were completed. However, the DON also stated Resident 75 had not been taken off contact isolation, and the Infection Prevention nurse confirmed the contact isolation order was discontinued on 12/4/25 and the sign outside the room should have been removed that day. The resident remained on contact isolation for 13 days after the physician order was discontinued.
Missing Annual CNA Competency
Penalty
Summary
The facility failed to ensure annual competencies were completed for one sampled employee, CNA 1. During a concurrent interview and record review on 12/18/25 at 10:48 a.m. with the Director of Staff Development, CNA 1's personal file was reviewed and showed that CNA 1 was hired on 6/5/24, but there was no annual competency completed for the employee. The Director of Staff Development stated that an annual competency should have been completed in June 2025, but none was completed. The facility's policy titled, Care Standards, dated 11/1/17, stated that the DNS or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs.
Patio and Laundry Areas Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to ensure the patio area located between Station B and Station C was maintained in a clean and sanitary manner. During an interview, Resident 52 stated he would like to have a cover or umbrella on the patio area so he could sit there with family or children who visit outside his room. During an observation in Resident 52's room and onto the patio area, a plastic bag was seen on the ground across the courtyard in the resident's patio area, and the bag contained a brown substance. During a concurrent observation and interview, Transportation/Help put on gloves and opened the bag, stating it was poop, and the Maintenance Supervisor stated he was not sure how the trash bag got there. The Administrator stated the outdoor patio area located between the resident rooms on C wing and the resident rooms on B wing could be used by residents and that residents could exit outside to the patio area with their families. During a later observation in the laundry area, plastic bags were seen on the floor next to the washer. The Infection Preventionist put on gloves and lifted the plastic trash bag, revealing a second trash bag underneath that contained used dirty towels; the first bag contained used mopheads. The Laundry Staff stated the bags of trash should not have been stored on the floor. A facility policy and procedure was requested, but none was provided.
Failure to Inform Resident of Grievance Outcomes
Penalty
Summary
The facility failed to follow its grievance policy and procedure for one resident who reported multiple concerns, including issues with food preferences and excessive noise from a roommate's television. The resident stated that after requesting to speak with the administrator and kitchen staff regarding these concerns, no one had come to address them. Review of the Resident Grievance/Complaint Investigation Reports showed that while the complaints were documented, there was no evidence that the resident was informed of the outcome of the investigations or any actions taken to resolve the grievances. Key sections of the reports, such as signatures, dates, and notifications to the concerned party, were left blank. Interviews with facility staff, including the DON, confirmed that grievances are routed to the Social Services Director and then to the responsible department, with the administrator ultimately responsible for ensuring investigation, resolution, and communication of outcomes to the resident. However, documentation revealed that no follow-up with the resident was recorded, and the required sign-offs were missing. The facility's policy requires that residents be informed of the findings and corrective actions in a timely manner, which was not done in this case.
Delayed Call Light Response for Dependent Resident
Penalty
Summary
The facility failed to accommodate a resident's needs by not ensuring timely response to call lights. During an interview, a resident reported having to wait up to 40 minutes after using the call light to be changed following a bowel movement. The resident, who is cognitively intact and fully dependent on staff for toileting hygiene, also reported a history of urinary tract infections since admission. Review of the resident's Minimum Data Set confirmed her dependence for toileting hygiene. A Certified Nursing Assistant (CNA) stated that she is sometimes responsible for up to 17 residents during her shift and may be delayed in responding to call lights when attending to other residents. The facility's policy requires nursing staff to answer call bells promptly and courteously. However, the observed delays in responding to the resident's call light requests indicate that this policy was not consistently followed.
Failure to Report and Investigate Financial Abuse and Develop Protective Care Plan
Penalty
Summary
The facility failed to follow its Abuse Prevention and Prohibition Program policy by not reporting and investigating the misappropriation of a resident's property to the California Department of Public Health and the local ombudsman. A resident, who was cognitively intact and managed his own finances, reported that his brother had made unapproved charges on his bank card after being given permission to use a limited amount. Despite multiple incidents of unapproved charges by the brother, staff did not report or investigate the situation, as the resident did not wish to press charges and was aware of his brother's actions. Interviews with staff, including the Behavioral Health Worker, Social Services Director, and Administrator, confirmed that the resident's brother had repeatedly used the resident's bank card without full approval. The Social Services Director and Administrator acknowledged the unapproved charges but did not initiate an investigation or report the incident, citing the resident's reluctance to take action against his brother. Documentation in the resident's social services notes indicated awareness of the financial abuse and discussions with the resident about the risks and benefits, but no formal reporting or investigation occurred as required by facility policy. Additionally, the facility did not develop or implement a care plan to protect the resident from further financial abuse, nor did it address the resident's refusal to be protected from his brother. The Director of Nursing confirmed that no care plans were created or updated in response to the financial abuse incidents. The facility's care planning policy requires comprehensive, person-centered care plans to address changes in a resident's condition or behavior, but this was not followed in this case.
Failure to Follow Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to follow the individualized care plan for a resident with Alzheimer's disease, hemiplegia, muscle weakness, and a high risk for falls. The care plan specifically required the use of a floor mat on the right side of the bed and ensuring the resident wore nonskid socks when getting out of bed. Multiple assessments and evaluations, including the Minimum Data Set and Fall Risk Evaluation, identified the resident as severely cognitively impaired and at high risk for falls, necessitating these interventions. Despite these documented interventions, records and interviews revealed that on several occasions, including the incident in question, the required floor mat was not in place and the resident was not wearing nonskid socks. On the day of the fall, the resident was found on the floor on the right side of the bed, without a floor mat and barefoot. Staff interviews confirmed a lack of awareness of the resident's fall risk status and the specific interventions outlined in the care plan. Previous post-fall evaluations also documented instances where the floor mat was missing and appropriate footwear was not used. As a result of these failures to implement the care plan, the resident sustained a fall resulting in a right hip intertrochanteric fracture, requiring hospitalization and surgical intervention. The facility's own policy emphasized the importance of developing and following a comprehensive, person-centered care plan based on assessed needs, but this was not adhered to in the resident's case.
Failure to Report and Address Abuse Allegations
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Prohibition Program policy, resulting in several deficiencies. The Director of Nursing (DON) confirmed that the facility did not submit the SOC 341 form to the California Department of Public Health (CDPH) and the local ombudsman for two residents involved in an unwitnessed altercation. This lapse in communication led to a delay in reporting the incident. Additionally, the facility did not submit a 5-day investigation report to the local ombudsman and CDPH for another resident who was a victim of financial abuse, exceeding the required timeline. Furthermore, the facility did not notify the attending physician of the financial abuse allegation concerning the same resident, leaving the physician unaware of the situation. The facility also failed to develop a care plan to address the resident's mental or psychosocial needs following the discovery of financial abuse. These actions were contrary to the facility's policy, which mandates immediate reporting of abuse allegations and reassessment of residents to update care plans as necessary.
Failure to Administer Antibiotic as Prescribed
Penalty
Summary
The facility failed to ensure that an antibiotic order was administered as prescribed by the Medical Doctor for a resident. The resident was admitted for surgical aftercare and was prescribed Keflex to treat a surgical wound infection. The Medication Administration Record indicated that the resident received Keflex every eight hours from February 13 to February 20, contrary to the Medical Doctor's order of four times a day for ten days. During an interview, the Treatment Nurse acknowledged entering the Keflex order incorrectly and not following the Medical Doctor's orders. The Director of Nursing confirmed that the Keflex order was inaccurate. The facility's policy and procedure for physician orders require that all medication orders include the name, dosage, frequency, duration, route, and condition/diagnosis for which the treatment is ordered, which was not adhered to in this case.
Failure to Monitor Resident Weight and Nutrition
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the assessment and management of resident weights, specifically for one resident who did not have his weight taken for three months. This oversight was identified during a review of the resident's records, which showed that the last recorded weight was from several months prior. The resident, diagnosed with mild protein-calorie malnutrition, had multiple meal refusals documented over the course of January, which could have impacted his nutritional status. Despite these refusals and the resident's condition, no alternative methods for weight measurement were employed, and the resident's weight was not discussed by the Interdisciplinary Team during this period. Interviews with the Dietary Manager and Director of Nursing revealed that the facility's Quarterly Nutrition Review was inaccurate due to outdated weight data. The resident expressed that he refused to be weighed at times because the hoyer lift caused discomfort, yet no alternative methods were offered. The facility's policy required weights to be taken upon admission and then regularly thereafter, but this was not followed. The Director of Nursing acknowledged that alternative methods, such as measuring arm circumference, were not utilized, and the resident's refusal to be weighed was not addressed by the Interdisciplinary Team.
Resident Not Involved in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident was involved in the comprehensive person-centered care planning process, resulting in a violation of the resident's rights. The resident, who had been transferred via sheet from his bed to the shower bed since January 2024, was informed by facility staff that this method of transfer would no longer be used. The resident was not given a reason for this change, and there was no documentation of a discussion with the resident regarding the change in transfer method. During interviews and record reviews, it was revealed that the facility's Administrator and Director of Nursing were unable to provide documentation of any discussion with the resident about the change in transfer method prior to the initiation of the care plan on December 21, 2024. The facility's policy on resident rights, revised in November 2017, states that residents have the right to participate in decisions and care planning and to be fully informed of their treatment. The lack of documentation and failure to involve the resident in the care planning process led to the deficiency.
Failure to Schedule Transportation for Resident's Doctor Appointment
Penalty
Summary
The facility failed to ensure that transportation was scheduled for a resident's necessary doctor's appointment, resulting in the resident missing the appointment. The resident, who was being treated for valley fever, a serious lung infection, had an appointment scheduled on December 16, 2024, as indicated in the order details dated December 4, 2024. However, the social services note from the same day indicated that transportation was not arranged, leading to the appointment being rescheduled. Interviews with the Social Services Director and the Director of Nursing revealed that the transportation request was not received by the Social Services Department, which is responsible for scheduling transportation. The Director of Nursing confirmed that the nurses are responsible for entering the order into the resident's medical record and filling out a transportation request to be given to the Social Services Director. The facility's policy on referrals to outside services states that the Social Services Department may assist in making transportation arrangements as necessary, but this process was not followed, resulting in the missed appointment.
Failure to Implement Care Plan After Fire Incident
Penalty
Summary
The facility failed to implement a care plan for a resident following a fire incident in the resident's room. The resident, who had moderate cognitive impairment, experienced throat and lung pain, chest pain, and difficulty breathing after inhaling smoke from the fire. Despite these symptoms, the facility did not monitor the resident for respiratory distress as required. The resident reported that the nurses did not monitor her after the fire, which occurred on December 21, 2024. The facility's care plan for the resident, dated December 21, 2024, indicated that the resident should be placed on alert charting to assess any changes in medical condition, with vital signs, including oxygen saturation and respiration, checked every shift for 72 hours. However, a review of the resident's medical records revealed no documentation of alert charting or monitoring of vital signs from December 21 to December 23, 2024. The nurse consultant confirmed that the required monitoring was not conducted, which was a deviation from the facility's care planning policy.
Failure to Log and Timely Process Medical Records Requests
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding resident access to protected health information (PHI) for three of four sampled residents. Specifically, the medical records requests (MRR) for these residents were not logged, which is a requirement according to the facility's policy titled 'Resident Access to PHI.' This policy mandates that the facility document the date of the request, the employee addressing the request, the date of the facility's response, the action taken, and whether a review of the facility's initial response was requested. During an interview and record review, the Medical Records (MR) staff confirmed that no log was maintained for the MRRs of the three residents, potentially leading to delays in reviewing and acting upon these requests. Additionally, the facility did not comply with its policy titled 'Third Party Disclosures of Protected Health Information,' which requires timely action on communication requests. The MRRs for the three residents were not sent to the requesting office within the required timeframe, with delays ranging from 20 to 31 days. The policy specifies that requests for PHI by a resident's attorney prior to filing a lawsuit should be addressed within five days. The failure to act upon these requests in a timely manner resulted in a violation of the residents' rights to have their MRRs processed promptly.
Failure to Inventory and Secure Residents' Personal Items
Penalty
Summary
The facility failed to ensure that personal items of two residents were properly inventoried upon admission, which led to the potential for unaccounted personal items and the presence of dangerous materials. During observations and interviews, it was found that one resident had a lighter and cigarettes on his bedside table, which he stated he was allowed to keep upon admission. A Certified Nursing Assistant confirmed the presence of these items and stated that residents should not have lighters or smoking materials in their possession, as they should be stored in a locked box with a nurse or activity staff. Another resident also had smoking materials, including a lighter, which were not properly inventoried or secured as per the facility's smoking policy. The facility's staff, including a Registered Nurse and a Licensed Vocational Nurse, confirmed that the smoking policy and procedure were explained to residents upon admission, and that a personal inventory should be completed to track residents' belongings and ensure safety. However, the inventory for one resident did not document the presence of a lighter or cigarettes, and there was no documentation of a refusal to search the resident's bag. The facility's policy indicated that all smoking materials should be stored securely, but this was not adhered to, leading to the deficiency.
Failure to Ensure Proper Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that six of the twenty sampled residents had a signed and dated Advance Directive (AD) in their medical records. During interviews and record reviews, it was found that the ADs for these residents were either unsigned or undated. Specifically, the Social Service Director (SSD) confirmed that the ADs for Residents 58, 87, 193, 22, 17, and 70 were present in their medical records but lacked necessary signatures and dates. This oversight could potentially lead to situations where the residents' healthcare wishes are not honored in emergency medical situations. Additionally, the facility did not document that five of the twenty sampled residents were informed about their right to complete an Advance Directive or had evidence of declining to complete one. The SSD confirmed that there were no ADs in the medical records of Residents 344, 4, 68, 60, and 45, nor was there documentation indicating that these residents were informed of their rights regarding ADs. The facility's policy requires that upon admission, staff should obtain a copy of a resident's AD or inform them of their right to complete one, which was not adhered to in these cases.
Failure to Conduct Timely Smoking Assessments
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding smoking assessments for residents who smoke independently on the smoking patio. Specifically, the facility did not complete smoking assessments for ten out of eleven sampled residents, which is a requirement to ensure safety while smoking. The Minimum Data Set Coordinator acknowledged that a smoking assessment should have been conducted upon re-admission for Resident 42, but it was not completed until a later date. This oversight was consistent across multiple residents, as their smoking assessments were either incomplete or not conducted in a timely manner. The facility's policy, dated February 1, 2022, mandates that all smokers be assessed for smoking safety at the time of admission and at least quarterly. However, the review of smoking assessments for several residents, including Residents 17, 24, 42, 43, 62, 78, 89, 243, and 245, revealed that the assessments were either incomplete or not conducted according to the policy. This failure to perform timely and complete smoking assessments resulted in residents not being evaluated for safety while smoking, posing a potential risk of burns or other injuries.
Medication Administration and Staff Training Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered according to physicians' orders for a resident, identified as Resident 82. The IV Medication Administration Record (MAR) for Resident 82 showed multiple instances where there was no documentation of the administration of Normal Saline Flush and Unasyn, a medication used to treat infection. The Director of Nursing confirmed the lack of documentation for these medications on specific dates, which could potentially lead to the worsening of the resident's infection. The facility's policy requires that medications be administered by a licensed nurse per the physician's order and documented accordingly, which was not adhered to in this case. Additionally, the facility did not ensure that three key staff members, including a Registered Nurse, the Director of Staff Development, and the Director of Nursing, had current CPR certification. The personnel files reviewed showed expired or missing CPR certifications, which is against the facility's policy that mandates all clinical staff to maintain active CPR certification. This oversight could potentially hinder the staff's ability to perform life-saving procedures during emergencies. Furthermore, the facility failed to provide the required educational programs to its staff, including 57 Certified Nursing Assistants and 27 Licensed Nurses. The Director of Staff Development was unable to provide sign-in sheets or documentation for various mandatory training topics, such as infection control, patient rights, and safety measures. This lack of training documentation suggests that not all staff received the necessary education to perform their duties effectively, which could impact patient care and safety. Additionally, the Maintenance Technician was unaware of the facility's policy regarding the use of personal space heaters, resulting in two residents having unapproved heaters in their rooms.
Deficiencies in Supervision and Safety Measures
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for several residents, leading to multiple deficiencies. One resident, who was at risk for choking, was left unsupervised in the dining room and was observed putting sugar packets into her mouth and chewing on them. This resident had a severely impaired cognitive ability, as indicated by her Minimum Data Set, and her care plan specifically noted a behavior of eating non-food items, with an intervention to remove unnecessary paper items from meal trays. Additionally, the facility did not adequately supervise residents who smoked. Ten residents who smoked were not monitored with smoking materials and were allowed to smoke unsupervised, contrary to the facility's policy that required all smoking activities to be scheduled and supervised by staff. Smoking materials were found in residents' possession, and some residents were observed smoking without supervision. The facility's policy stated that all smoking materials should be locked up, and residents who could not smoke independently should be accompanied by staff, but these protocols were not followed. Furthermore, two residents had space heaters in their rooms without authorized approval, posing a potential fire hazard. The facility's policy required the administrator's approval for electrical appliances, and the administrator confirmed that no space heaters were authorized. Another resident, who was at risk for wandering and elopement, had an unlocked and unalarmed sliding glass door in her room, which could have allowed her to leave the facility unnoticed. The facility's policy required functioning alarms for residents at risk of elopement, but this was not adhered to in this case.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of the Ombudsman during resident transfers. Specifically, the facility did not send a notice of transfer to the Ombudsman for two residents, Resident 42 and Resident 50, when they were transferred to the hospital. This oversight was identified during a review of Resident 42's medical record, which showed transfers on three separate occasions without any indication of Ombudsman notification. An interview with the Minimum Data Set Coordinator confirmed that no Ombudsman notification was done for these hospital transfers. Similarly, for Resident 50, transfer forms dated September and October indicated hospital transfers, but there were no corresponding Ombudsman notifications. This was confirmed during a review of the facility's transfer/discharge binder, where the Social Services Director acknowledged the absence of Ombudsman notifications for those months. The facility's policy, dated April 2024, clearly states that a copy of the Notice of Proposed Transfer/Discharge must be provided to the Ombudsman at the same time it is given to the resident or their representative, which was not followed in these instances.
Deviation from Pureed Food Recipe
Penalty
Summary
The facility failed to adhere to its policy and procedure for food preparation, specifically in the preparation of pureed meals. During an observation and interview, a cook was found to have deviated from the standardized recipe for pureed meat sauce by using water instead of the specified milk, gravy, or low sodium broth. This deviation occurred while preparing meals for residents on a pureed diet, potentially compromising the nutritive value of the food provided to them. The facility's policy, dated 2023, mandates that food be prepared using methods that conserve nutritive value, flavor, and appearance, and that approved recipes be followed precisely. The cook acknowledged the error during a review of the recipe, which clearly indicated the use of specific fluids to maintain the nutritional integrity of the meal. This oversight in following the recipe could lead to nutritive impairment for residents requiring a pureed diet.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to maintain food storage and preparation areas in a sanitary manner, as observed during a survey. In the dry storage room, 11 boxes of baking soda were found to be expired, and a dented can of Pork and Beans was improperly stored with regular canned goods. Additionally, a plastic bag of dry pasta noodles was found unlabeled and undated. These observations were confirmed by a staff member, who acknowledged that the items should have been properly labeled, dated, and stored according to the facility's policy and procedures. Further deficiencies were noted in the kitchen's freezer and refrigerator. An unlabeled and undated bag of hash browns was found in the freezer, and in the refrigerator, pitchers of red and brown liquids, as well as glasses of milk and juices, were also unlabeled and undated. The facility's policy requires all food items in storage areas to be labeled and dated, and all prepared foods to be covered, labeled, and dated. The staff member confirmed these items were not in compliance with the facility's policy.
Facility Safety and Maintenance Deficiencies
Penalty
Summary
The report identifies several deficiencies related to the safety and maintenance of the facility. In one instance, a water stain with black mold was observed on the ceiling above a resident's bed, indicating a potential leak. The Maintenance Supervisor acknowledged the water damage but found no documentation of staff notifying him about the issue, despite the facility's standard operating procedures highlighting the health risks associated with excessive moisture and mold. Additionally, space heaters were found in the rooms of two residents without the necessary approval from the Administrator, who stated that such appliances are not allowed due to fire risks. Furthermore, a resident identified as a wanderer and at risk for elopement had an unlocked sliding glass door with a non-functional alarm, contrary to the care plan and facility policy. The Director of Nursing confirmed the resident's risk status and the requirement for a functioning alarm to ensure safety.
Incomplete Informed Consent for Psychotherapeutic Medication
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding informed consent for psychotherapeutic medication for one of the sampled residents. During an interview and record review, it was found that the informed consent for a resident receiving Amitriptyline, a medication used to treat symptoms of depression, was incomplete. The Minimum Data Set Coordinator (MDSC) confirmed that the signature of verification on the informed consent form was blank, indicating that the consent process was not completed. This oversight occurred despite the facility's policy requiring verification of informed consent prior to administering any medical intervention that necessitates such consent.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for three residents, as evidenced by issues with laundry services and room maintenance. Resident 17 experienced damage to personal clothing due to improper laundering, resulting in bleach stains and the need to discard several shirts. During an interview, the laundry services staff acknowledged that clothing might not have been sorted correctly, leading to bleach damage. Additionally, the rooms of Residents 62 and 75 were found to have unaddressed maintenance issues, including unpainted drywall patches, broken baseboards, and peeling wallpaper. These conditions were observed during interviews with a maintenance technician, who confirmed that the building required significant cosmetic repairs. These deficiencies contributed to an environment that was not homelike for the affected residents.
Failure to Follow Dialysis Care Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Dialysis Care' for two residents, resulting in deficiencies in monitoring and assessing dialysis access sites. Resident 69, who had a dialysis catheter on her chest, did not have an order for monitoring her dialysis access site, and the type of access was not documented in her Order Summary Report. Additionally, the staff incorrectly assessed for bruit and thrill, which are not applicable for a chest catheter, as they are typically associated with an arteriovenous (AV) shunt or fistula in the arm. Similarly, Resident 67, who also had a dialysis catheter on her chest, was subjected to inappropriate assessments for bruit and thrill, as documented in her Progress Notes. The facility's policy specifically outlines the procedure for assessing an AV shunt or fistula, which neither resident had. These actions indicate a failure to provide accurate and appropriate care for the residents' dialysis access sites, as the staff did not follow the established procedures for the type of dialysis access the residents had.
Failure to Complete PASRR Evaluations for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for Pre-Admission Screening and Resident Review (PASRR), resulting in deficiencies for two residents. For Resident 68, the PASRR Level I screening indicated a positive result for Serious Mental Illness (SMI), but the facility did not respond to multiple communication attempts within 48 hours, leading to an incomplete assessment and failure to resubmit the PASRR. This inaction prevented the necessary Level II evaluation from being conducted, as required by the facility's policy. Similarly, for Resident 69, the PASRR Level I screening also indicated a positive result, necessitating a Level II Mental Health Evaluation. However, the facility did not conduct the required Level II evaluation. The facility's policy clearly states that a positive Level I screen requires an in-depth evaluation by the state-designated authority before admission to a nursing facility, which was not followed in these cases.
Inadequate Staffing Leads to Missed Medication Doses
Penalty
Summary
The facility failed to ensure adequate staffing to meet the care plan needs of a resident, specifically in administering necessary medications. Resident 82, who was on IV antibiotics for osteomyelitis related to the right foot and ankle, did not receive two scheduled doses of Unasyn on October 27, 2024. The care plan required the administration of antibiotics as per the medical doctor's orders, but the IV Medication Administration Record (IV MAR) showed no documentation of the 6 a.m. and 12 p.m. doses being administered on that day. During an interview and record review with the Director of Nursing (DON), it was revealed that the facility experienced a scheduling mix-up and was unable to secure registered nurse coverage for the day shift on October 27, 2024. This staffing issue directly led to the missed doses of medication for Resident 82. The facility's policy on staffing, which was reviewed, mandates that sufficient nursing personnel be available to meet resident needs, but this was not adhered to in this instance.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Food Preference' by not honoring the meal preferences of two residents, Resident 24 and Resident 43. During an observation and interview, it was noted that Resident 24 was served Mac and Cheese for lunch, despite her documented dislike for pasta. The Certified Dietary Manager (CDM) confirmed that Resident 24's Meal Tray Ticket (MTT) indicated a dislike for pasta, and acknowledged that Mac and Cheese should not have been served to her. Similarly, Resident 43 was also served Mac and Cheese, which was against his documented meal preference as indicated on his MTT. This led to an angry outburst from Resident 43. The CDM confirmed that Resident 43's MTT also indicated a dislike for pasta, and acknowledged the error in serving him Mac and Cheese. The facility's policy stated that residents' food preferences should be adhered to within reason, and substitutes for disliked foods should be provided from the appropriate food group.
Failure to Accommodate Resident Beverage Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations and follow the care plan for a resident, leading to potential dehydration and poor oral moisture and skin elasticity. The resident expressed dissatisfaction with not being able to receive coffee, their preferred beverage, throughout the day. Despite the resident's requests, staff members, including the Dietary Supervisor and Certified Nursing Assistants, did not provide coffee, citing reasons such as the kitchen being closed or not having a process to accommodate beverage preferences outside of meal times. The resident's care plan indicated a potential fluid deficit and the need to maintain hydration, yet the facility did not adhere to this plan. The Director of Nursing acknowledged that beverage provision should be based on resident choice, especially for residents with a BIMS score of 15, indicating no cognitive impairment. The facility's policy on food preferences stated that resident preferences should be adhered to within reason, but this was not followed in the case of the resident's coffee preference.
DSD Lacks Required Nursing Experience
Penalty
Summary
The facility failed to ensure that the Director of Staff Development (DSD) met the required qualifications for the position, specifically having a minimum of two years of experience as a Licensed Nurse. During an interview and record review, it was revealed that the DSD received her Licensed Vocational Nurse (LVN) license in February 2023 and had only about a year and a half of nursing experience by the time she started working as a DSD in June 2024. This lack of experience did not meet the job qualifications outlined in the DSD's job description, which required a minimum of two years of experience as a Licensed Nurse in supervision and providing care in a long-term care facility. The Director of Nurses (DON) confirmed during an interview that the job description for the DSD position indeed required two years of nursing experience. The failure to meet this requirement had the potential to impact the DSD's ability to provide adequate education to the nursing staff, which could negatively affect the residents' health and safety. The report highlights the discrepancy between the DSD's qualifications and the job requirements, emphasizing the importance of adhering to established criteria for such critical roles within the facility.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to potential adverse health concerns. For Resident 1, the physician's order dated 4/5/24 indicated a change in the dosage of Quetiapine Fumarate (Seroquel) from 50 mg to 75 mg to be administered in the afternoon for aggression. However, upon review on 5/20/24, it was found that Resident 1 was still receiving the 50 mg dosage in the evening, with three doses missing from the medication card. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that Resident 1 was not receiving the correct dosage as per the updated physician's order. For Resident 2, a Change in Condition Evaluation (COCE) dated 5/26/24 noted symptoms of choking, with a recommendation for a speech therapy evaluation (STE). However, during a review on 6/14/24, the DON was unable to provide documentation that the STE had been completed, acknowledging that it should have been done. The facility's policy on Telephone Orders for Medication, dated 11/1/17, outlines the procedure for documenting orders, but it appears this was not followed in these instances.
Failure to Monitor Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that behaviors were monitored for one of the sampled residents, leading to the potential for unnecessary psychotropic medication administration. Resident 1 was prescribed Quetiapine fumarate, an antipsychotic medication, for behavior management. However, during a review of Resident 1's care plan, it was found that there was no documentation of behavior monitoring. The Director of Nursing confirmed the absence of behavior monitoring records and acknowledged that Resident 1's behaviors should have been monitored. Additionally, a Licensed Vocational Nurse stated that behaviors should be documented in the Medication Administration Record when residents are on psychotropic medications. The facility's policy on psychotherapeutic drug management required daily monitoring of target behaviors, charting by exception, which was not adhered to in this case.
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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 Bakersfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Health Facility | 2.6 mi | ★★★★★ | 16 | 0 |
| Valley Healthcare Center | 2.8 mi | ★★★★★ | 26 | 0 |
| The Orchards Post-acute | 4.2 mi | ★★★★★ | 2 | 0 |
| San Joaquin Nursing Center And Rehabilitation Cent | 4.8 mi | ★★★★★ | 18 | 0 |
| The Rehabilitation Center Of Bakersfield | 5.3 mi | ★★★★★ | 23 | 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.