Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Pasadena Grove Health Center during CMS and state inspections, most recent first.
Misappropriation of Resident Property and Financial Exploitation: A resident with COPD, acute lower respiratory infection, pneumonia, and impaired cognitive skills was found after death to have unauthorized money transfers from the resident’s bank account to a CNA’s account and a credit card opened using the resident’s name and mailed to the CNA’s address. The resident’s cell phone and laptop were also missing after the resident’s belongings were left unsecured in a room closet accessible to others, and the CNA admitted allowing the resident to use her personal phone without notifying a supervisor.
A resident with COPD, atrial fibrillation, difficulty walking, and impaired cognition was given Buspirone HCL for anxiety with a documented manifestation of restlessness. Staff stated the indication was not specific and could be interpreted differently, and the DON confirmed the medication order did not have specific indications and manifestations for treatment.
A resident with hyperlipidemia and significant cardiac history was receiving Atorvastatin for cholesterol management when a DRR noted an allergy to Simvastatin and questioned tolerance to Atorvastatin. The physician subsequently discontinued Atorvastatin, but nursing staff did not follow up with the physician to clarify the treatment plan, obtain lab orders, or secure an alternative statin or other therapy. The DON and RN Supervisor acknowledged that Atorvastatin is usually not abruptly stopped and that appropriate follow-up "went through the cracks," and the consultant pharmacist stated that nurses should not simply discontinue a statin for a possible cross allergy without promptly clarifying the plan with the physician, contrary to facility policy and professional standards.
A resident with COPD, pulmonary fibrosis, and obstructive sleep apnea had a physician’s order for Symbicort inhalation aerosol twice daily as a maintenance respiratory medication, with the care plan directing staff to administer ordered puffers and monitor effects. For a period of about three weeks, the Respiratory Treatment Record showed Symbicort was not administered and progress notes documented the drug as not available, resulting in multiple missed doses. The DON and RT confirmed that the medication was ordered but never received from the pharmacy due to insurance coverage issues, and that Symbicort was the only scheduled inhaler for the resident. The RT did not notify the RN, pharmacy, or MD to obtain an alternative, and this inaction conflicted with facility policies requiring timely medication procurement, administration per MD order, and RT communication with nursing leadership.
A resident with schizophrenia, impaired cognition, and fall risk had a gait belt left on the floor near the bed, creating an obstruction. Another resident with severe cognitive impairment and a history of falls was seen sitting in a wheelchair with the feet dangling instead of resting on the footrests. A Hoyer lift was also left in the hallway with the base wide open, and the laundry area had lint buildup in both dryers with required lint cleaning not documented at the scheduled intervals.
Food Storage and Can Opener Sanitation Deficiencies: The facility failed to keep the kitchen sanitary when a clear container of lentils was left without a properly closed lid and the can opener had dry food residue, including white residue and brown-black buildup. A Dietary Supervisor confirmed the issues, and a Dietary Aide stated containers should be closed to prevent contamination and the can opener should be cleaned after each use; the facility's policies required tight-fitting lids for open products and sanitizing the can opener between uses.
A resident with severe cognitive impairment and diabetes had damaged foam padding on the bedside rails, with tears and a section ripped off, and staff stated the padding was falling apart and not in good condition. In a separate room, a resident with CKD, a history of falls, bradycardia, and severe cognitive impairment had two wash basins and three hand towels placed on the toilet tank during morning care, which staff identified as an unsanitized surface.
Call Light Not Within Resident’s Reach: A resident with dementia, type 2 DM, and difficulty walking had the call light found under the mattress behind the bed, and the resident stated she did not know where it was. A CNA stated the resident could not use the call light to alert staff when help was needed, and the DON confirmed call lights should be within residents’ reach. The facility policy stated call cords are to be placed within the resident’s reach.
Resident Identifiable Information Left on Discarded Oxygen Humidifier: A resident’s oxygen humidifier container, labeled with the resident’s full name and room number, was found in the trash bin in the resident’s room. The resident had diagnoses including bipolar disorder, depression, and type 2 DM, and the MDS showed moderate cognitive impairment with substantial/maximal assistance needed for eating and dependence for several ADLs. The IPN and DSD confirmed the label should have been destroyed before disposal, and the facility’s admission materials and Privacy and Dignity policy stated residents have a right to privacy and confidentiality of clinical records and medical information.
Failure to Complete PASRR Screening on Readmission: A resident with diagnoses including depression, schizophrenia, and psychosis was readmitted without a PASRR Level I screening in the record. The MDS showed moderate cognitive impairment and need for assistance with several ADLs. The MDS coordinator and DON stated the screening should have been completed if it was not done by the transferring hospital.
A resident with severe cognitive impairment and an existing stage 4 sacrococcyx pressure injury was observed using a low air loss mattress set at 180 pounds, while the resident’s stated and documented weight was about 150 to 158 pounds. The physician order required checking the mattress setting and functionality, and the care plan listed a 150 to 160 pound setting range. The LVN and DON both stated the mattress should be set based on the resident’s current weight to support wound healing and prevent further pressure injury.
Improper Placement of Oxygen Nasal Cannula: A resident with COPD and pulmonary edema was ordered supplemental O2 via NC, but during observation the NC prongs were found on the side of the resident’s face instead of in the nares. A CNA confirmed the cannula was not correctly placed, and staff stated the resident would not receive the ordered O2 unless the prongs were in the nose; the DON also stated the resident’s breathing could be affected and the resident could desaturate if the NC was not positioned correctly.
Overflowing Dumpster Left Open: The facility failed to keep one of two dumpsters closed and not overflowing. During observation, a Dietary Supervisor stated the dumpster was overflowing, had a foul odor, and its lid was left open. A Dietary Aide stated dumpsters should not overflow because of odors and the attraction of rodents and insects, and record review confirmed the policy required food waste to be placed in covered garbage and trash cans.
Incomplete documentation was found for three residents. One resident with a pressure injury had wound treatments provided by nursing staff that were not signed on the TAR for several days. Another resident with psychosis and dementia had a Seroquel order that lacked an indication for use, despite the DON noting the order should include the diagnosis. A third resident had pneumonia and COVID-19 vaccine consent forms that were offered but not signed by the resident or documented as signed by the IPN.
A resident with severe cognitive impairment and assistance needs for toileting and ADLs was observed in bed with the call light out of reach, located at the back of the bed and on the floor. An LVN and the DON stated the call light should be within the resident's reach, and the facility policy required call cords to be placed within resident reach so residents can promptly communicate with nursing staff.
Inaccurate Daily Staffing Reports were posted and did not match the Facility Staffing Assignment. The reports showed incorrect RN and LVN totals for day and evening shifts, while the DSD and DON confirmed the postings were not accurate and should have reflected the actual licensed nursing staff and NHPPD.
A resident with dementia, schizoaffective disorder, bipolar disorder, and anxiety had care plans identifying frequent verbal aggression, screaming, and accusations toward staff and others, with interventions directing staff to monitor and document behaviors and medication effectiveness. The January MAR instructed staff on all shifts to tally mood swings and aggressive behaviors, yet no episodes were recorded, despite Change of Condition forms, nursing notes, and staff interviews describing repeated aggressive incidents and hospital transfers for behavior. The Physician Discharge Summary also inaccurately listed elopement attempts as the discharge reason, even though assessments and record review showed no elopement attempts and the DON confirmed the discharge was due to aggressive behavior, contrary to the facility’s policy requiring accurate nursing documentation.
Two residents with cognitive impairment were involved in an incident where one reported being harassed and assaulted by another. The allegation was reported to a nurse, but the facility failed to follow its abuse policy by not reporting the incident to the abuse coordinator or initiating an investigation. Key staff, including the DON and Social Services Director, were not informed, and required documentation and notifications were not completed.
Two residents with cognitive impairment were involved in an incident where one physically and verbally assaulted the other. The assaulted resident reported the event to an RN supervisor, but the required notifications to CDPH, Ombudsman, and police were not made within the mandated two-hour window. Staff interviews and record reviews confirmed that the facility did not follow its abuse reporting policy, resulting in a failure to promptly report the alleged abuse.
A resident with a history of hypertension and cerebral infarct became unusually lethargic and had elevated BP readings over two days. Despite observations by staff and family, the physician was not notified within the required timeframe, and the resident's condition worsened, resulting in hospital transfer for intracranial hemorrhage.
A resident with multiple complex diagnoses repeatedly refused critical medications, including anticonvulsant, antipsychotic, and insulin, over several days. Despite care plan requirements, the physician was not notified after three consecutive refusals, and documentation of resident education and noncompliance was lacking. Insulin was also administered without required blood glucose checks, in violation of facility policy. The DON confirmed these lapses, and facility policies for documentation and monitoring were not followed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with cognitive impairment and significant physical limitations was subjected to an incident where another resident entered her room, touched her leg and gown, and attempted to take her snacks. Staff and nurses were aware of the ongoing behavior of the resident who entered others' rooms, but the issue persisted, resulting in a failure to uphold the affected resident's right to privacy and dignity.
The facility did not follow its policy to report an allegation of physical abuse within the required two-hour timeframe. A cognitively impaired resident, dependent on staff for care, reported being touched inappropriately by another resident. Although the incident was disclosed to staff, it was not reported to the administrator or authorities until nearly four hours later, contrary to facility policy and regulatory requirements.
Three residents in an LTC facility were found with neglected nail hygiene, despite being dependent on staff for ADLs. One resident had dirty, jagged nails, another had skin tears from scratching with untrimmed nails, and a third had fungal-infected nails. Staff failed to maintain nail care as per care plans, and there was no documentation of residents refusing care.
The facility failed to follow proper food storage and labeling practices, resulting in improperly labeled and expired food items in the kitchen. During an observation, several food items were found without proper labeling, including butter, pork sausage links, chopped spinach, raisins, tea bags, food thickener, and chicken gravy mix. The Dietary Services Supervisor confirmed that the facility's policy requires labeling with received and use by dates, and items must be discarded after the use by date to ensure food safety for residents.
The facility failed to provide education, offer, and document the 2024-2025 COVID-19 vaccinations for two residents and the staff. A resident with cognitive impairments and another with dementia did not have up-to-date vaccinations, and there was no record of consent or administration. Additionally, the facility lacked documentation for staff vaccinations, as the Infection Prevention Nurse found no records of staff being offered or receiving the vaccine.
The facility failed to ensure call lights were within reach for two residents, both with moderate cognitive impairments and at risk for falls. One resident's call light was found on the floor, while another's was between the side rails and mattress, making them inaccessible. Staff confirmed the call lights were not within reach, contrary to facility policy, which requires call cords to be accessible for resident communication.
A facility failed to accurately complete the PASRR assessment for a resident with schizophrenia, depression, and dementia. The PASRR Level I Screening incorrectly indicated no serious mental illness, despite the resident's psychiatric diagnoses and medication use. Staff interviews revealed confusion over responsibility for PASRR accuracy, contributing to the deficiency.
A resident with schizophrenia, dementia, and Parkinsonism, assessed at high risk for falls, experienced an unwitnessed fall. The facility failed to update the resident's fall care plan following the incident, despite policies requiring care plan revisions after falls. This oversight was confirmed by the MDS Nurse and DON, highlighting a deviation from established procedures.
A resident with a history of contracture and hemiplegia did not receive prescribed Restorative Nursing Services, including PROM exercises and hand splint application, as ordered by the physician. The care plan was not updated to reflect new orders, and multiple days of services were missed, leading to a deficiency in care. Interviews confirmed the failure to execute the necessary interventions to prevent contractures and maintain mobility.
A resident receiving oxygen therapy at 5 LPM did not have a physician's order, as required by the facility's policy. Despite the resident's intact cognitive skills, multiple observations confirmed the absence of a documented order. Interviews with the DON, MDSN, and an LVN corroborated this deficiency, highlighting a failure to adhere to the facility's oxygen administration policy.
A facility failed to provide adequate dialysis care for a resident with ESRD by not ensuring the prescribed fluid intake of 1800 ml per day and not monitoring the resident's AVF for dialysis access. The resident's fluid intake was consistently below the prescribed amount, and there was no documentation of shunt site monitoring every shift, as required by the care plan and facility policy. This failure had the potential to cause dehydration and delay in detecting complications.
A resident with dementia and other conditions was prescribed chewable Aspirin for stroke prophylaxis. However, the resident swallowed the tablet whole instead of chewing it, as observed by an LVN. The DON confirmed that the medication should have been separated to ensure proper administration. This failure could potentially affect the medication's absorption and effectiveness.
A facility failed to act on a pharmacist's recommendations during a Medication Regimen Review for a resident with quadriplegia, seizures, and encephalopathy. The resident received a higher than recommended dose of Aspirin for CVA prophylaxis, which was not addressed by notifying the physician, as required by facility policy. The oversight led to the resident continuing the higher dose throughout February, despite potential gastrointestinal side effects.
The facility failed to keep the lids of a dumpster closed as per policy, potentially attracting vermin. Observations revealed the dumpster with open lids and an unsecured gate. Interviews with the Maintenance and Dietary Supervisors confirmed the policy requirement to keep lids closed to prevent disease transfer.
A facility failed to provide hospice services for a resident with end-stage cardiovascular accident by not scheduling required visits from hospice nurses and CHHAs as per the care plan. The hospice calendar for February 2025 was incomplete, and there was no documentation of CHHA visits for January and February 2025. Interviews with staff confirmed the lack of scheduled visits and documentation, contrary to the facility's end-of-life care policy.
A resident was inappropriately administered antibiotics despite not meeting the necessary criteria according to the facility's Antibiotic Stewardship protocol. The resident, admitted with sepsis and other conditions, received a full course of Invanz without meeting Loeb's Minimum Criteria. The Infection Prevention Nurse and DON acknowledged the oversight, highlighting a lapse in protocol adherence.
A resident with multiple health conditions did not receive a pneumococcal vaccine despite consenting to it, due to an oversight by the Infection Prevention Nurse who failed to review the resident's medical records. The facility's policy requires documentation of vaccination or reasons for non-vaccination, which was not followed.
The facility failed to post accurate nursing hours, as the information displayed on 2/25/2025 was dated 2/24/2025, leading to non-compliance with the facility's policy. This was confirmed by the IPN and DON, who acknowledged the discrepancy in the posted data.
The facility did not meet the required 80 square feet per resident in 31 rooms, as observed during a survey. Despite the deficiency, residents and staff reported no issues with space, and a waiver request was submitted, indicating the rooms were sufficient for care and privacy. The Department recommended approval of the waiver.
The facility failed to monitor intake and output for two residents with indwelling catheters, as required by its policy. One resident was readmitted with a UTI, CKD, and anemia, while another was admitted with a UTI and urinary retention. Both care plans required intake and output monitoring, which was not performed. The DON stated there was no physician's order for monitoring, but facility policy mandated it for residents with catheters.
Two residents in an LTC facility did not receive appropriate pain management as per physician's orders. One resident with quadriplegia reported severe pain but was given medication for mild pain without notifying the physician. Another resident with cancer received medication for mild pain despite experiencing moderate pain. Facility policies on pain management and physician notification were not followed.
A resident's rights were violated when his cellphone was confiscated by staff without his consent, despite being self-responsible. The phone was removed based on a request from a family member without legal authority, and staff failed to document the action or inform the resident. The facility's policy requires residents to be informed and their consent documented when personal possessions are taken.
A resident with quadriplegia and chronic kidney disease, who was being monitored for hematuria, did not have a urine sample collected for urinalysis as ordered by the physician. Despite the physician's order, the nursing staff failed to follow through, and no laboratory requisition form was completed or sent. The facility's policy on coordinating laboratory services was not adhered to, resulting in a deficiency in providing timely laboratory services.
A facility failed to provide a communication board for a resident with limited English proficiency, despite the resident's need for such an aid due to language barriers. The resident, with diagnoses including diabetes, schizophrenia, and dysphagia, required assistance with daily activities and had moderate cognitive impairment. Interviews and observations confirmed the absence of the communication board, contrary to the facility's policy to support residents with language barriers.
A facility failed to create and implement a care plan for a resident with inappropriate behavior and wandering tendencies. Despite reports of inappropriate comments and observed wandering, the MDS Nurse did not develop a care plan, and the Elopement Risk Assessment was not updated to reflect the resident's high risk. The facility's policy required care plans to be updated with changes in the resident's condition, which was not done.
A resident with a history of inappropriate behavior and wandering was inadequately supervised, resulting in them entering another resident's room and an allegation of inappropriate touching. Despite the resident's need for supervision, the facility failed to update their care plan and elopement risk assessment, contrary to their policies.
A resident with quadriplegia and intact cognitive skills was unable to use the standard call light due to paralysis. The call light was tied to the bed rail and out of reach, and the resident resorted to calling 911 for help. The facility's policy required adaptive call lights based on residents' needs, which was not provided.
The facility failed to ensure call lights were within reach and answered promptly for two residents, leading to potential delays in care. One resident, with multiple health issues, often found his call light out of reach and experienced delayed responses, especially at night. Another resident, with multiple sclerosis, had to use her phone to call for assistance due to an inaccessible call light. Staff interviews confirmed the facility's policy of keeping call lights within reach and responding within five minutes, but these measures were not consistently followed.
Misappropriation of Resident Property and Financial Exploitation
Penalty
Summary
The facility failed to prevent misappropriation of property for one resident. The resident was admitted with COPD, acute lower respiratory infection, and pneumonia, and the MDS dated 4/10/2026 indicated the resident was moderately impaired with cognitive skills for daily decision making. The resident also required varying levels of assistance with dressing, bed mobility, and eating. After the resident died, a Social Services Director was notified of an allegation of financial exploitation involving the resident. The resident’s friend reported that unauthorized money transfer transactions had been made from the resident’s bank account and that a credit card had been opened under the resident’s name and mailed to a CNA’s address. The Administrator later confirmed that the bank transactions were linked to the CNA’s phone number and mailing address, and the CNA acknowledged that her phone number and address were used in the transactions and credit card application. The CNA stated she had allowed the resident to use her personal phone on one occasion and admitted she had not notified a supervisor of that incident. She also stated she had provided the resident with occasional assistance obtaining items outside the facility. The resident’s friend reported two money transfers from the resident’s account to the CNA, and the CNA stated she contacted her bank after the transactions appeared. In addition, the resident’s belongings were inventoried after death, and the inventory listed the resident’s cell phone and laptop, but those items were later found missing from the boxes stored in the resident’s room closet. The SSD and ADM stated the belongings had been left in the room closet, an area accessible to others, rather than being secured in the SSD office as usual.
Unnecessary Psychotropic Medication Lacked Specific Indication
Penalty
Summary
The facility failed to ensure one of two sampled residents was free from unnecessary psychotropic medication use when Resident 2 was given Buspirone HCL without a specific indication. Resident 2 was admitted with diagnoses including COPD, unspecified atrial fibrillation, and difficulty walking, and the MDS dated 4/7/2026 showed moderately impaired cognitive skills for daily decision making, need for assistance with multiple activities of daily living, and behavior symptoms. Resident 2's April 2026 MAR showed Buspirone HCL 2.5 mg by mouth three times daily for anxiety manifested by restlessness, ordered on 4/4/2026 and discontinued on 4/15/2026. During interviews and record review, LVN 1 and LVN 2 stated the documented indication and manifestation of restlessness were not specific and could be interpreted differently by staff. The DON stated psychotropic medication orders should have specific and accurate indications and manifestations so staff can observe the same behavior and evaluate whether the medication is effective, and stated Resident 2's Buspirone medication did not have specific indications and manifestations for treatment.
Failure to Follow Professional Standards After Discontinuation of Statin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to meet professional standards of quality in managing a statin medication for Resident 1. The resident was admitted with multiple cardiovascular diagnoses, including hypertensive heart disease with heart failure and combined systolic and diastolic heart failure, and had a documented diagnosis of hyperlipidemia. The admission orders included Atorvastatin 20 mg by mouth at bedtime for hyperlipidemia. The resident’s MDS showed moderately impaired cognitive skills for daily decision making and dependence on staff for several ADLs. A Drug Regimen Review dated 4/4/2026 documented an allergy to Simvastatin and questioned whether the resident could tolerate Atorvastatin. On 4/6/2026, the physician discontinued Atorvastatin. The DON later stated that the DRR did not indicate that Atorvastatin should be stopped, only that there was a question about tolerance due to the Simvastatin allergy, and acknowledged that Atorvastatin was usually not abruptly stopped. The RN Supervisor confirmed that Atorvastatin was discontinued on 4/6/2026 and stated that, after stopping cholesterol medications, staff should contact the physician for laboratory orders to determine baseline levels and to ask if a new order is needed to replace the discontinued medication. The RN Supervisor stated there was no follow-up after Atorvastatin was discontinued and that the necessary follow-up had “gone through the cracks.” The consultant pharmacist stated that when there is a possible cross allergy, licensed nurses should not wait to contact the physician to switch the medication and that the medication should not just be discontinued because of a possible cross allergy without clarifying the plan. Facility policies required licensed nurses to verify medications and directions for use with physician orders and promptly report discrepancies and omissions, and required staff to provide services in compliance with laws, regulations, and professional standards. The failure to follow up with the physician regarding alternative therapy and laboratory monitoring after discontinuation of Atorvastatin constituted the deficient practice.
Failure to Provide Ordered Symbicort for Resident With Chronic Respiratory Conditions
Penalty
Summary
The deficiency involves the facility’s failure to administer Symbicort Inhalation Aerosol as ordered by the physician for one resident over a 20‑day period. The resident was admitted with diagnoses including COPD, pulmonary fibrosis, and obstructive sleep apnea, and had an order dated 4/3/2026 for Symbicort 160-4.5 mcg/act, two puffs inhaled orally twice daily for COPD. The resident’s care plan, dated 4/6/2026, identified risk for altered respiratory status/difficulty breathing related to these conditions and included an intervention for staff to administer medications/puffers as ordered and monitor for effectiveness and side effects. The MDS dated 4/7/2026 documented that the resident had moderately impaired cognitive skills for daily decision making, was dependent for several ADLs, and received oxygen therapy. Record review of the resident’s Respiratory Treatment Record for April 2026 showed that from 4/4/2026 through 4/23/2026, Symbicort was not administered, with the RTR indicating “other/see progress notes” twice daily. Progress notes for the same dates documented that the medication was not available. During concurrent interview and record review on 4/23/2026, the DON confirmed that Symbicort was ordered twice daily to help with respiratory conditions and acknowledged that it had not been administered from 4/4/2026 to 4/23/2026, resulting in 39 missed doses. The DON stated that the RT had reported Symbicort was not covered by the resident’s insurance and that the RT did not communicate with the RN, pharmacy, or MD to seek an alternative medication. In an interview, the RT stated that Symbicort was ordered on 4/4/2026 but was not received from the pharmacy, and that on 4/10/2026 the pharmacy reported the medication was not covered by the resident’s insurance. The RT stated that as of 4/23/2026 the resident still had not received Symbicort and that Symbicort was the only scheduled inhaler for the resident. The RN Supervisor stated that upon admission, if Symbicort is not covered by insurance, staff should follow up with the pharmacy right away and that RT staff should follow up by contacting the pharmacy or notifying the RN Supervisor. Facility policies and procedures for the RT job description, medication administration, and medication ordering and receiving from pharmacy required RT to keep the RN Supervisor informed, required medications to be administered per physician order by a licensed nurse, and required timely receipt of medications from the pharmacy with prompt reporting of discrepancies and omissions. These documented expectations were not met in this case, resulting in the ordered Symbicort not being provided.
Unsafe resident environment and equipment hazards
Penalty
Summary
A black synthetic gait belt, approximately 5 feet long, was observed on the floor near a resident's bed in the room of a resident with schizophrenia, difficulty walking, moderately impaired cognitive skills for daily decision making, and moderate fall risk. The resident used a walker and wheelchair and required substantial to maximal assistance with walking. During the observation, the gait belt was confirmed by an LVN to be on the floor, and an RNA later stated it had been forgotten there and could cause the resident to trip and fall. The DON reviewed the facility policy stating the environment should be kept free of obstructions and clutter to prevent accidents. A resident with difficulty walking and a history of falls was observed sitting in a wheelchair with the feet dangling far from the footrests while a CNA watched the resident. The resident was later seen being wheeled in the hallway with the feet still dangling and not resting on the wheelchair footrests. The resident's MDS showed severe cognitive impairment for daily decision making and dependence or substantial assistance with several activities of daily living. The OT stated the feet should not hang while sitting in the wheelchair and should be on the footrest, and the DON stated the wheelchair was too high and should have been evaluated for proper height to prevent the feet from dangling. A Hoyer lift was observed parked in the hallway unplugged with the base wide open, and staff stated it was kept there because there was no storage area. An RNA stated the base should be closed because it could cause a trip and fall accident, and the DON stated the lift should have been placed where there was no traffic and that the open base could pose an accident hazard. In the laundry room, both dryers had lint buildup in an internal compartment between the lint screens and lint vent, and the laundry staff had not cleaned the lint traps at the required two-hour intervals. The maintenance supervisor stated the lint present was a fire hazard, and the facility log was blank for the required cleaning times.
Food Storage and Can Opener Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the food service area in a clean and sanitary condition and failed to follow its food-handling policies by not ensuring that a clear container of lentils was properly covered with a tight-fitting lid and that the can opener was sanitized and free of dry food residue. During a kitchen observation and interview on 3/31/2026 at 12:46 PM, the Dietary Supervisor stated that the container of lentils did not have its lid properly closed. During a separate kitchen observation and interview on 4/1/2026 at 8:18 AM, the Dietary Supervisor stated that the can opener contained dry food residue, including a white unknown residue and brown-black buildup. During interviews on 4/2/2026, a Dietary Aide stated that containers should be properly closed to prevent insects and dust from entering and that the can opener should be cleaned after each use. Review of the facility's Food Storage policy and Can Opener Use and Cleaning policy showed that open products should be stored in containers with tight-fitting lids and that the can opener should be sanitized between uses; the Dietary Supervisor stated these policies were not followed.
Damaged Bed Rail Padding and Unsanitary Placement of Care Supplies
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for two residents. One resident, who had acute respiratory failure, type 2 diabetes mellitus, and severe cognitive impairment, had quarter bedside rails ordered to support bed mobility and transfers. During observation, the black foam padding on the left bedside rail was damaged, with multiple tears and a section ripped off. EVS staff stated the padding was damaged and falling apart, and the LVN stated it should be in good condition to protect the resident and that damaged padding could potentially cause harm or injury. The DON later reviewed the facility policy requiring a safe, clean, comfortable, and homelike environment and stated the damaged padding was not acceptable and was not safe, comfortable, or homelike. Another resident, who had chronic kidney disease, a history of falls, bradycardia, and severe cognitive impairment, was observed during morning care with two wash basins and three hand towels placed over the toilet tank in the restroom. The CNA stated these items were used for morning care and should never be placed on the toilet tank, and that the toilet tank should not be considered a clean surface for placing supplies. The IPN stated that placing wash basins and towels over the toilet tank was unsanitized because flushing can aerosolize particles and contaminate the items with bacteria.
Call Light Not Within Resident’s Reach
Penalty
Summary
The facility failed to ensure that the call light was within arm’s reach for one resident, Resident 7, during an observation and interview in the resident’s room. Resident 7’s call light was found under the mattress behind the bed, and the resident stated she did not know where the call light was. Resident 7’s admission record showed diagnoses including dementia, type 2 diabetes mellitus, and difficulty walking. The MDS dated 3/3/2026 indicated moderate impairment in cognitive skills for daily decision making and that the resident required substantial/maximal assistance with eating and was dependent for oral hygiene, toileting hygiene, lower body dressing, and putting on/taking off footwear. During interview, a CNA stated the call light was not within Resident 7’s reach and that the resident would not be able to use it to alert staff when help was needed. The DON stated call lights should be within reach so residents can use them to call for help and get assistance if desired. The facility’s policy titled, Communication - Call System, stated the facility provides a mechanism for residents to promptly communicate with nursing staff and that call cords will be placed within the resident’s reach in the resident’s room.
Resident Identifiable Information Left on Discarded Oxygen Humidifier
Penalty
Summary
The facility failed to keep a resident’s personal and medical records private and confidential when an oxygen humidifier container labeled with the resident’s full name and room number was found in the trash bin in the resident’s room. The resident was admitted with diagnoses including bipolar disorder, depression, and type 2 diabetes mellitus, and the MDS dated 3/9/2026 indicated moderate impairment in cognitive skills for daily decision making, substantial/maximal assistance with eating, and dependence with oral hygiene, toileting hygiene, lower body dressing, and putting on/taking off footwear. During an observation in the resident’s room, surveyors found the labeled oxygen humidifier container discarded in the trash. The Infection Prevention Nurse confirmed that the container was in the trash bin and stated the resident’s identifiable information must be destroyed before discarding it. The Director of Staff Development also stated that identifiable information must be removed before throwing medical equipment or supplies in a regular trash bin and that resident information should not be visible to unauthorized individuals. The facility’s admission packet and Privacy and Dignity policy stated that residents have a right to privacy and confidentiality of personal clinical records and medical information.
Failure to Complete PASRR Screening on Readmission
Penalty
Summary
The facility failed to complete a PASRR Level I screening for one resident who was readmitted to the facility. The resident’s record showed diagnoses of depression, schizophrenia, and psychosis, and the MDS dated 1/27/2026 indicated moderate impairment in cognitive skills for daily decision making, partial/moderate assistance with toileting hygiene and showering, and supervision with eating, oral and personal hygiene, upper and lower body dressing, and putting on/taking off footwear. The record also showed active diagnoses of depression, psychotic disorder, and schizophrenia. The resident’s medical record did not show a PASRR Level I screening for the 11/23/2025 readmission. The record did include a positive PASRR Level I screening from 8/4/2023, with a note that the resident was unable to complete a Level II evaluation on 8/8/2023 because the resident had no serious mental illness. During interview, the MDS coordinator stated the EMR did not contain a PASRR Level I screening from the transferring hospital and that a PASRR Level I screening should be completed to determine whether the resident has mental illness and to coordinate with the state agency for further evaluation and proper placement if positive. The DON also stated the PASRR Level I screening should have been completed if it was not done at the hospital upon readmission.
Low Air Loss Mattress Set Incorrectly for Resident With Stage 4 Pressure Injury
Penalty
Summary
The facility failed to ensure that Resident 21’s low air loss mattress was set at the correct weight setting in accordance with the resident’s current weight and the facility’s wound care guidance. Resident 21 was admitted with a diagnosis that included a pressure ulcer and had severe cognitive impairment, dependence with toileting, and assistance needs for several activities of daily living. The physician’s order directed use of the low air loss mattress for skin maintenance treatment and to check the setting and functionality, and the care plan identified a mattress setting range of 150 to 160 pounds based on the resident’s weight and comfort. During observation, Resident 21 was found lying in bed with the low air loss mattress set at 180 pounds. The resident stated she weighed around 150 pounds, and the EMR listed her weight as 158 pounds. The resident also had an existing stage 4 sacrococcyx pressure injury documented on the wound weekly observation tool. LVN 2 stated the mattress setting should be based on the resident’s current weight and not 180 pounds to avoid pressure on the sacral area and promote wound healing. The DON stated the mattress should be set based on the resident’s weight to prevent development of another pressure injury. The facility’s wound management and pressure reducing mattress policies stated that residents with wounds should receive treatment to promote healing and prevent new pressure ulcers, and that specialty mattresses should be set according to the resident’s height and weight.
Improper Placement of Oxygen Nasal Cannula
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident 66. The resident was admitted and later readmitted with diagnoses including COPD and pulmonary edema. The MDS dated 1/19/2026 indicated the resident had moderate impairment in cognitive skills for daily decision making and required varying levels of assistance with activities of daily living. The care plan, initiated on 5/2/2025 and revised on 5/12/2025, identified impaired gas exchange related to increased oxygen demand and included an approach to administer oxygen as ordered. A physician order dated 3/6/2026 indicated supplemental oxygen at 2 LPM via NC as needed, with titration up to 5 LPM to keep oxygen saturation above 90 percent as needed. During an observation on 3/31/2026 at 9:44 AM, Resident 66 was lying in bed with oxygen at 2 LPM, but the NC prongs were not in the resident's nose and were seen on the left side of the resident's face. A CNA who entered the room confirmed the NC was not correctly placed. Staff interviews later confirmed that the prongs should be in the nostrils for the resident to receive the ordered oxygen, and the DON stated the resident's breathing could be affected and the resident could desaturate if the NC prongs were not correctly placed. The facility policy required checking that oxygen was flowing through the tubing and placing the NC prongs into the nares.
Overflowing Dumpster Left Open
Penalty
Summary
The facility failed to ensure that one of two dumpsters was kept closed and not overflowing, contrary to its Garbage and Trashcan Use and Cleaning policy and procedure. During a concurrent observation and interview in the facility parking lot, the Dietary Supervisor stated that one dumpster was overflowing with trash, had a foul odor, and its lid was left open. During a later interview, a Dietary Aide stated that dumpsters should not overflow because of odors and the attraction of rodents and insects, which could potentially cause illnesses such as stomachache and diarrhea. Record review with the Dietary Supervisor confirmed that the facility's policy required food waste to be placed in covered garbage and trash cans.
Incomplete wound care, medication, and vaccine documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three sampled residents. For one resident with a sacro-coccyx pressure injury and severe cognitive impairment, the Treatment Administration Record did not reflect wound care treatments that staff stated were provided on three consecutive days. The TAR showed a daily order for normal saline, collagen powder, iodoform packing strips, and a super absorbent dressing, but the treatments were not signed as completed on those dates. For another resident with psychosis and dementia, the physician order for Seroquel 25 mg twice daily did not include an indication for use. The DON reviewed the medication reconciliation, physician order, and psychiatrist notes and stated the order was incomplete because it should have included the diagnosis for the medication. Staff also stated the order should be clarified with the psychiatrist when an indication is missing, and the facility's psychotherapeutic drug management policy required psychotherapeutic medication orders to include the indications and manifestations of the disorder treated. For a third resident with mild cognitive impairment, the pneumonia vaccine consent and COVID-19 vaccine consent forms were not signed. The resident stated the IPN offered both vaccines but did not ask for a signature, and the IPN confirmed the vaccines were offered but the consent forms were not signed. The facility's informed consent policy required the informed consent to be signed by the resident or representative and the physician, and the nursing documentation policy required documentation to be concise, clear, pertinent, and accurate.
Call Light Not Within Resident's Reach
Penalty
Summary
The facility failed to ensure that the call light was within arm's reach for Resident 21, who was observed in bed sleeping with the call light out of reach, located at the back of the bed and on the floor. Resident 21 was admitted with diagnoses including anxiety disorder and bipolar disorder, and the MDS dated 1/16/2026 indicated severe impairment in cognitive skills for daily decision making. The MDS also showed the resident was dependent with toileting, required partial/moderate assistance with oral hygiene, showering, lower body dressing, and putting on/taking off footwear, and required supervision with eating, upper body dressing, and personal hygiene. During the observation on 3/31/2026 at 8:38 AM, the resident's call light was not accessible. During interviews, LVN 1 stated call lights should be within residents' arm's reach so they can use them to call whenever they need help, and the DON stated the call light should be within reach of Resident 21 so she could use it when she needs assistance or has concerns that require attention. The facility's policy titled Communication - Call System stated that the facility provides a mechanism for residents to promptly communicate with nursing staff and that call cords will be placed within the resident's reach in the resident's room.
Inaccurate Daily Staffing Reports Posted
Penalty
Summary
The facility failed to ensure the Daily Staffing Report posted on 3/31/2026 and 4/2/2026 was accurate and reflected the correct total number and actual hours of licensed nursing staff directly responsible for resident care, as required by the facility's policy and procedure. On 3/31/2026, the posted Daily Staffing Report showed a census of 65 and zero RNs for the day shift, while the Facility Staffing Assignment showed a total of three RNs for that shift. On 4/2/2026, the posted Daily Staffing Report showed a census of 65 with 0 RN and 3 LVNs for the day shift, and 1 RN and 2 LVNs for the evening shift. A concurrent review of the Facility Staffing Assignment for 4/2/2026 showed 2 RNs and 2 LVNs for the day shift, and 0 RN and 3 LVNs for the evening shift, which did not match the posted report. During interview, the DSD stated the posted staffing reports were not accurate because they did not match the Facility Staffing Assignment and should have been corrected to accurately reflect NHPPD. The DON stated the Daily Staffing Report should be accurate to determine whether the facility was meeting the required number of staff and NHPPD to ensure safe staffing and quality of care. The facility's policy stated it would post daily the total number of licensed and unlicensed nursing staff directly responsible for resident care per shift, including RNs, LVNs, and CNAs.
Inaccurate Behavior Monitoring and Discharge Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation for a resident with multiple psychiatric diagnoses, including dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and anxiety disorder. The resident’s care plans, initiated and updated in December and January, identified verbal aggression, racial and derogatory remarks, screaming at others, and accusations that staff were hurting or stealing from her. Interventions included administering medications as ordered and monitoring and documenting behaviors, including the time and day of occurrences, as well as monitoring for side effects and effectiveness of psychotropic medications. Despite these documented behavior problems and care plan directives, the resident’s January MAR instructed staff on all three shifts to monitor episodes of mood swings manifested by aggressive behavior toward others and to tally them with hashmarks every shift, yet the MAR showed no mood swing or aggressive behavior episodes from early January through late January. This lack of documentation conflicted with multiple staff interviews and other records. The DON and CNA reported that the resident was verbally aggressive toward staff and residents, screamed at CNAs and nurses, especially during medication administration, and exhibited aggressive behavior about three times a week, sometimes daily since December. Change of Condition forms and nursing notes showed transfers to the hospital due to aggressive behavior in December and January, further contradicting the absence of behavior tallies on the MAR. Additionally, the Physician Discharge Summary inaccurately documented the reason for the resident’s discharge as attempts to elope, even though the Elopement Risk Assessment rated the resident as low risk for elopement and a review of Change of Condition reports and nursing notes from late January to early February revealed no elopement attempts. The DON confirmed that the true reason for discharge was the resident’s aggressive behavior, not elopement, and acknowledged that the discharge summary was inaccurate. The facility’s own nursing documentation policy required concise, clear, pertinent, and accurate documentation, which was not met in the behavior monitoring on the MAR or in the stated reason for discharge on the Physician Discharge Summary.
Failure to Investigate and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure for two residents when it did not investigate an allegation of abuse. On 12/18/2025, one resident reported to a registered nurse that she was being harassed and assaulted by another resident. The reporting resident described an incident where the other resident went through her clothes, punched her in the chest, called her derogatory names, and made offensive remarks. The resident stated she reported this incident to the nurse, but there was no evidence that the allegation was reported to the abuse coordinator or that an investigation was initiated as required by facility policy. Both residents involved had moderately impaired cognitive skills for daily decision making and required varying levels of assistance with activities of daily living. The resident who reported the abuse had diagnoses including type 2 diabetes mellitus, hypertension, and schizoaffective disorder, while the other resident had diagnoses including malignant neoplasm of the vulva, chronic diastolic heart failure, and cardiomegaly. Despite the report of abuse, the staff member who received the allegation did not follow the facility's policy to report and investigate the incident, and key personnel such as the Social Services Director and Director of Nursing were not informed in a timely manner. Interviews with staff confirmed that the facility's abuse prevention and reporting policy was not followed. The Social Services Director and Director of Nursing both stated they were unaware of the abuse allegation until after the fact, and the registered nurse admitted she did not report the incident as required. The facility's policy mandates prompt investigation and reporting of abuse allegations to appropriate authorities, but this process was not initiated, and documentation was lacking.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged abuse incident involving two residents to the required authorities within the mandated two-hour timeframe after the allegation was reported to a Registered Nurse Supervisor (RNS). According to interviews and record reviews, one resident, who had moderately impaired cognitive skills and required assistance with daily activities, reported being physically assaulted and verbally abused by another resident. The assaulted resident informed the RNS about the incident, but the RNS did not report the allegation to the California Department of Public Health (CDPH), Ombudsman, or local law enforcement as required by facility policy and state regulations. Staff interviews confirmed that all facility staff are mandated reporters and are aware that suspected abuse or allegations of abuse must be reported to the appropriate state agencies immediately or within two hours of becoming aware of the incident. Despite this, the RNS did not follow the facility's abuse policy, and the Director of Nursing (DON) was not informed of the abuse allegation or the reason for the police visit to the facility. The Social Services Director (SSD) also was not notified about the incident or the involvement of law enforcement until after the fact. A review of the facility's Abuse Prevention and Prohibition Program policy indicated that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the state survey agency, adult protective services, law enforcement, and the Ombudsman. The failure to report the abuse allegation in a timely manner was confirmed through staff interviews and documentation review, demonstrating noncompliance with both facility policy and regulatory requirements.
Failure to Timely Notify Physician of Change in Condition and Elevated Blood Pressure
Penalty
Summary
The facility failed to immediately notify the physician of a resident's change in condition, specifically for a resident with a history of hypertension and cerebral infarct. On two consecutive days, the resident was observed by staff and family to be sleepier than usual, which was a deviation from their normal behavior. Despite these observations being reported to licensed nursing staff, there was no timely notification to the physician regarding the resident's altered mental status. On the morning of the second day, the resident's blood pressure was recorded at 153/91 mmHg, which was elevated compared to normal values. The facility's policy required that such changes in condition be reported to the physician within 15 minutes. However, the physician was not notified of the elevated blood pressure at that time. Progress notes indicated that the physician was only made aware of the resident's refusal of medication, not the elevated blood pressure or the change in mental status. Later that day, the resident's condition deteriorated further, with blood pressure rising to 210/92 mmHg and the resident becoming lethargic and unresponsive. The resident was subsequently transferred to a hospital, where a CT scan revealed a significant intracranial hemorrhage. Interviews with staff and review of records confirmed that the physician was not notified in a timely manner about the resident's change in condition, contrary to facility policy and the care plan instructions.
Failure to Notify Physician and Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that medications were administered to meet the needs of a resident and in accordance with professional standards of practice. Specifically, a resident with multiple diagnoses, including depression, schizoaffective disorder, psychosis, anxiety disorder, insomnia, and type 2 diabetes mellitus, experienced multiple episodes of medication refusal involving anticonvulsant, antipsychotic, and insulin medications. Despite care plan interventions requiring physician notification after three consecutive refusals, the physician was not notified of these repeated refusals. The care plan also required monitoring and documentation of noncompliance, as well as education for the resident and family, but these actions were not consistently documented or performed. The resident's Medication Administration Record (MAR) showed numerous refused doses of critical medications over several days, including anticonvulsant, antipsychotic, antidepressant, and insulin. Additionally, insulin was administered on several occasions without obtaining the required blood glucose checks beforehand, contrary to the facility's policy and procedure for medication administration. The Director of Nursing (DON) confirmed that the physician was not notified of the refusals and that licensed nurses did not document education provided to the resident regarding medication refusals. The DON also acknowledged that the Interdisciplinary Team (IDT) did not address the resident's refusal of blood glucose checks and medication refusals as required by policy. A review of the facility's policies indicated that documentation of medication refusals should include the date and time, the medication refused, the resident's reason for refusal, the name of the person attempting administration, information provided to the resident about the consequences of refusal, the resident's condition, and notification of the attending physician. The policies also required that vital signs or testing, such as blood glucose monitoring, be completed and recorded prior to medication administration. These procedures were not followed, resulting in deficient practice related to medication administration and documentation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency is based on the observation that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting procedures were not followed as mandated. The report specifically notes the lack of timely communication and documentation to the appropriate authorities regarding both the suspicion and the outcome of the internal investigation.
Failure to Maintain Resident Privacy and Dignity Due to Inadequate Monitoring
Penalty
Summary
A resident with multiple medical conditions, including type 2 diabetes, end stage renal disease, and hypertension, was admitted to the facility and assessed as having moderately impaired cognitive skills and requiring significant assistance with daily activities such as toileting and bathing. The resident reported that another male resident entered her room without permission, touched her leg and gown, and attempted to take her snacks. Staff interviews and documentation confirmed that the male resident had a pattern of entering other residents' rooms, taking their belongings, and required frequent redirection by staff. The affected resident expressed discomfort and fear during the incident, stating she was unable to get up and feared retaliation if she resisted. Staff, including CNAs and nurses, were aware of the male resident's behavior, as he was known to enter other residents' rooms and take their items. Despite this knowledge, the male resident continued to access other residents' rooms, including the incident where he touched the affected resident and attempted to take her snacks. Facility policies reviewed indicated a requirement to promote privacy, dignity, and respect for residents, but these were not upheld in this instance, resulting in a failure to maintain the resident's right to privacy and dignity.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and procedure to ensure that an allegation of physical abuse was reported to the California Department of Public Health (CDPH), local law enforcement, and the Ombudsman within two hours, as required. The incident involved a resident with multiple diagnoses, including type 2 diabetes mellitus, end stage renal disease, and hypertension, who was cognitively impaired and dependent on staff for daily activities. This resident reported that another male resident entered her room and touched her leg and gown, which made her feel uncomfortable and fearful. The event was initially reported by a Certified Nurse Assistant (CNA) to the charge nurse around 7:30 PM, and the resident's responsible party later called the facility to report the same allegation. Despite the facility's policy requiring immediate reporting of abuse allegations, the Licensed Vocational Nurse (LVN) did not report the incident at the time it was disclosed, citing being occupied with medication administration. The LVN also did not instruct another nurse to report the allegation to the administrator. The administrator was eventually informed of the incident around 9:30 PM, and the abuse allegation was officially reported at 11:11 PM, nearly four hours after the initial disclosure. The Director of Nursing (DON) confirmed that the reporting should have occurred within two hours of the resident's claim, and the delay was acknowledged during interviews and record reviews. The second resident involved, who also had cognitive impairment and mental health diagnoses, was identified as the individual who entered the female resident's room. Staff interventions included 1:1 monitoring and notification of the physician, but the primary deficiency was the failure to report the abuse allegation within the required timeframe. The facility's policy, reviewed with the DON, clearly stated that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the appropriate authorities.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services for three residents who were dependent on staff for activities of daily living (ADLs). Resident 28, who was admitted with diagnoses including dysphagia, depression, and diabetes mellitus, was observed with dirty, long, and jagged fingernails. Despite the care plan indicating the need for nails to be kept clean and trimmed, observations and interviews revealed that Resident 28's nails were not maintained, potentially leading to skin injury and infection. There was no documentation of the resident refusing nail care, and staff acknowledged the importance of maintaining proper hygiene to prevent health issues. Resident 27, admitted with conditions such as dysphagia, diabetes mellitus, and hemiplegia, also exhibited signs of neglect in nail care. Observations showed Resident 27 scratching themselves with dirty and jagged nails, resulting in skin tears and blood smears. The care plan required nails to be kept clean and trimmed, but interviews with staff confirmed that the resident's nails were not properly maintained, increasing the risk of self-harm and infection. No documentation was found indicating that Resident 27 refused nail care. Resident 38, with diagnoses including encephalopathy and dementia, was found with long, discolored, and potentially fungal-infected nails. The care plan specified that nails should be kept clean and trimmed, yet observations showed significant neglect in nail care. Interviews with staff revealed that the condition of Resident 38's nails was not reported to the charge nurse or physician, despite the visible signs of fungal infection and detachment from the nail bed. The facility's policy required referral to a podiatrist for such conditions, but this was not done, leaving the resident at risk of infection.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its food storage handling practices as outlined in its policy and procedure, which led to the presence of improperly labeled and expired food items in the kitchen's refrigerators, freezers, and dry storage. During an observation and interview with the Dietary Aide and Kitchen Aide, several food items were found without proper labeling, including an opened cube of butter, a carton of pork sausage links, a bag of chopped spinach, and multiple boxes of raisins and tea bags. Additionally, cans of food thickener and a bag of chicken gravy mix were not labeled with use by dates, contrary to the facility's policy. The Dietary Services Supervisor (DSS) confirmed that the facility's policy requires all food items to be labeled with a received date and a use by date once opened, and that items must be discarded after the use by date to ensure food safety for residents. The facility's Policy and Procedure on Food Storage and Handling, which was revised recently, mandates labeling and dating of all food items and storage products, with specific guidelines for storing opened products in containers with tight-fitting lids. The failure to follow these procedures had the potential to result in foodborne illness among the 50 residents consuming food at the facility.
Failure to Document and Administer COVID-19 Vaccinations
Penalty
Summary
The facility failed to adhere to its COVID-19 vaccination policy by not providing education, offering, and documenting the 2024-2025 COVID-19 vaccinations for two residents and the staff. Resident 2, who was admitted with diagnoses including schizophrenia, dementia, and Parkinsonism, had a moderately impaired cognitive ability and required substantial assistance for daily activities. The Minimum Data Set (MDS) indicated that Resident 2's COVID-19 vaccination was not up to date, and there was no record of consent, refusal, or administration of the vaccine. The Infection Prevention Nurse (IPN) confirmed that consent was not obtained, and the resident had not received the vaccination. Similarly, Resident 17, diagnosed with dementia, depression, and hypothyroidism, also had moderately impaired cognitive skills and was dependent on assistance for various activities. The MDS for Resident 17 showed that their COVID-19 vaccination was not up to date, and there was no documentation of consent, refusal, or administration of the vaccine. The IPN acknowledged the absence of a consent or declination form and confirmed that Resident 17 had not received the vaccine. Additionally, the facility did not maintain records for staff vaccinations, as there was no documentation indicating which employees were offered, received, or declined the 2024-2025 COVID-19 vaccine. The IPN, who took over the responsibility for employee immunizations after the departure of the Director of Staff Development, found no documentation for the staff's COVID-19 vaccinations. The facility's policy required education and offering of the vaccine to staff and residents, with proper documentation, but these steps were not followed, placing residents and staff at risk of COVID-19 infection.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 17 and 28, had their call lights within reach, which is a necessary accommodation for their needs. Resident 17, who has diagnoses including dementia, depression, and hypothyroidism, was observed with a call light on the floor, out of reach. This resident, who is dependent on assistance for various activities and at moderate risk for falls, was unable to locate the call light to request help. A Certified Nursing Assistant confirmed the call light was not supposed to be on the floor and should have been within the resident's reach. The Director of Nursing acknowledged that call lights are essential for residents to contact staff in emergencies and for assistance. Similarly, Resident 28, who has conditions such as dysphagia, depression, and diabetes, was found with a call light positioned between the side rails and mattress, making it inaccessible. This resident, who requires substantial assistance for daily activities and is at moderate risk for falls, was unaware of the call light's location and resorted to yelling for assistance. A Licensed Vocational Nurse confirmed the call light was out of reach and emphasized its importance for resident communication. The facility's policy mandates that call cords be placed within residents' reach, highlighting the deficiency in adhering to this policy.
Inaccurate PASRR Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accurate completion of the Preadmission Screening and Resident Review (PASRR) assessment for a resident with a mental illness. The resident, who was initially admitted and later readmitted to the facility, had diagnoses of schizophrenia, depression, and dementia with behavioral disturbance. Despite these diagnoses, the PASRR Level I Screening indicated that the resident did not have a serious mental illness or related condition, which was inaccurate. This discrepancy was identified during a review of the resident's records, which showed the resident was on antipsychotic and antidepressant medications and had a history of psychiatric disorders. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for ensuring the accuracy of the PASRR assessments. The Director of Nursing indicated that the Registered Nurse Supervisor was responsible for the PASRR's accuracy, while the Registered Nurse Supervisor believed the MDS Nurse was responsible. However, the MDS Nurse stated that the Admissions Coordinator was responsible for the PASRR. This lack of clarity and accountability contributed to the inaccurate completion of the PASRR, potentially affecting the resident's access to necessary psychiatric treatment and evaluation.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to update and revise the fall care plan for a resident, identified as Resident 2, following an unwitnessed fall. Resident 2, who was initially admitted with diagnoses including schizophrenia, dementia with behavioral disturbance, Parkinsonism, and difficulty in walking, was assessed to be at high risk for falls. Despite this, the resident's fall care plan, last revised in July 2024, was not updated after a fall incident on October 6, 2024. The Minimum Data Set (MDS) indicated that Resident 2 required substantial assistance for various movements, and the fall risk assessments showed an increase in fall risk from moderate to high. However, the care plan did not reflect these changes or the fall incident, which was acknowledged by the MDS Nurse and the Director of Nursing (DON) during interviews. The facility's policy and procedure for fall management and care planning require that care plans be revised following a fall to implement new interventions and ensure resident safety. Despite these guidelines, the care plan for Resident 2 was not updated after the fall, which was confirmed by both the MDS Nurse and the DON. The failure to revise the care plan after the fall incident was a deviation from the facility's established policies, potentially placing Resident 2 at risk for further falls.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide Restorative Nursing Services as ordered by the physician for a resident, leading to a deficiency in care. The resident, who had a history of right hand contracture, hemiplegia, hemiparesis, and chronic respiratory failure, was not receiving the prescribed passive range of motion (PROM) exercises and hand splint application consistently. The physician's orders included PROM exercises for the right upper extremity and bilateral lower extremities, as well as the application of a Carrot hand splint, but these were not carried out as required. The resident's care plan, which was supposed to be updated with new orders for restorative nursing services, was not revised to include the bilateral lower extremity exercises. The Restorative Nursing charting showed multiple instances where the resident did not receive the ordered services, with several days missing for both the hand splint application and PROM exercises. Observations confirmed that the resident's right hand was closed in a fist, indicating a lack of proper intervention. Interviews with the Restorative Nursing Assistant (RNA) and the Director of Nursing (DON) revealed that the RNA services were not being performed as ordered, and the care plan was not updated accordingly. The RNA acknowledged that the services were necessary to prevent contractures and maintain mobility, but they were not executed as prescribed. The DON emphasized the importance of following physician orders to monitor and improve the resident's condition, which was not happening in this case.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had a physician's order for the treatment. Resident 16, who was admitted with diagnoses including dysphagia, pneumonia, and pleural effusion, was observed multiple times with oxygen administered via nasal cannula at 5 liters per minute (LPM). Despite the resident's cognitive skills being intact, there was no documented physician's order for the oxygen therapy in the resident's medical records. Interviews with the Director of Nursing (DON), the Minimum Data Set Nurse (MDSN), and a licensed vocational nurse (LVN 1) confirmed the absence of a physician's order for the oxygen therapy. The facility's policy and procedure for oxygen administration, which requires a physician's order specifying the flow rate, method of administration, and other details, was not followed. This oversight had the potential to negatively impact the resident's breathing pattern, as the proper dosage and route of administration were not verified by a physician's order.
Failure to Provide Adequate Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end-stage renal disease (ESRD) by not ensuring the resident received the prescribed 1800 milliliters of fluids per day. The resident's care plan and physician orders specified a fluid restriction of 1800 ml per day, with detailed allocations for dietary and nursing shifts. However, a review of the Medication Administration Record (MAR) for February showed that the resident's daily fluid intake ranged from 240 ml to 960 ml, with only two days reaching closer to the prescribed amount. This significant underloading of fluids had the potential to cause dehydration, as noted by the registered nurse during the interview. Additionally, the facility did not adequately monitor the resident's arteriovenous fistula (AVF) for dialysis access, as required by the facility's policy and the resident's care plan. The care plan indicated that the resident was at risk for infection at the shunt site and required monitoring for symptoms of infection, as well as physical inspection for redness, swelling, or pain. However, the medical records for February did not show evidence of staff monitoring the shunt site every shift, as confirmed by the registered nurse during the interview. The Director of Nursing (DON) acknowledged the importance of monitoring intake and output to prevent dehydration or fluid overload and emphasized the need for staff to check the fistula for proper functioning and signs of infection. The facility's policy on dialysis care required staff to inspect the shunt site for various symptoms once per shift, but this was not documented in the resident's records. The lack of adherence to these protocols resulted in a failure to provide the necessary care for the resident's dialysis needs.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a medication was administered per the physician's order for one of the residents, identified as Resident 21. The resident, who had a history of dementia with agitation, metabolic encephalopathy, and hypertension, was prescribed a chewable Aspirin tablet of 81 mg to be taken once daily for stroke prophylaxis. However, during an observation, it was noted that the resident swallowed the Aspirin tablet whole instead of chewing it, as required for proper absorption. This was confirmed by the Licensed Vocational Nurse (LVN 2) who administered the medication, acknowledging that the resident drank all her medications at once, including the chewable Aspirin. The Director of Nursing (DON) later stated that the Aspirin should have been separated from the other medications to ensure it was chewed. The facility's policy on medication administration, revised in 2017, indicated that medications should be administered by a licensed nurse according to the physician's order. The failure to administer the Aspirin as prescribed had the potential to delay absorption and decrease the effectiveness of the medication, which could affect the resident's wellbeing.
Failure to Act on Pharmacist's Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to act upon the Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR) for a resident in January 2025. The resident, who had diagnoses including quadriplegia, seizures, and encephalopathy, was receiving Aspirin 325 mg daily for CVA prophylaxis, which was higher than the recommended dose of 81 to 162 mg. The consulting pharmacist noted this irregularity and recommended clarification with the medical doctor due to potential gastrointestinal side effects from the higher dose. However, the facility did not notify the physician or follow up on the pharmacist's recommendation, resulting in the resident continuing to receive the higher dose throughout February 2025. Interviews with facility staff, including the Registered Nurse Supervisor and the Director of Nurses, revealed that the monthly MRR was not reviewed or acted upon as required by the facility's policy. The Director of Nurses acknowledged that the Quality Assurance team and nursing staff should have reviewed the MRR to prevent potential medication misuse or overdose. The facility's policy mandates that any irregularities reported by the pharmacist must be reviewed and acted upon by the attending physician, with documentation of the physician's response within 30 days, which did not occur in this case.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the lids of a garbage container (dumpster) remained closed as required by the facility's policy on garbage and trash can use and cleaning. During observations on two separate occasions, the dumpster was found with one or both lids open, and the gate to the dumpster area was not closed. This was contrary to the facility's policy, which mandates that dumpster lids be kept closed at all times to prevent the attraction and spread of vermin. Interviews with the Maintenance Supervisor and Dietary Supervisor confirmed that the facility policy required the dumpster lids to be closed to keep out flies and rodents and prevent disease transfer. A review of the facility's policy further indicated that food waste should be placed in covered garbage and trash cans.
Failure to Ensure Hospice Services for Resident
Penalty
Summary
The facility failed to ensure the provision of hospice services for a resident by not adhering to the hospice care summary order. The resident, who was under hospice care due to a terminal prognosis of end-stage cardiovascular accident, required visits from hospice nurses and certified home health aides (CHHA) as per the care plan. However, the hospice calendar for February 2025 was incomplete, lacking scheduled visits from skilled nurses (SN) and CHHAs, which were necessary for the resident's comfort and symptom management. The record review revealed that the hospice plan of care summary orders required CHHA services twice a week and SN visits once a week. Despite this, the hospice monthly calendar showed missing scheduled visits for both SNs and CHHAs throughout February 2025. Additionally, there was no documentation in the hospice flow sheet for January and February 2025 indicating that CHHAs visited the resident, highlighting a lack of coordination and documentation of hospice services. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed the absence of scheduled visits and documentation. The hospice performance improvement coordinator also acknowledged that hospice staff should sign in using the hospice binder when visiting residents. The facility's policy on end-of-life care emphasized the need for care plans to reflect hospice interventions as ordered, which was not adhered to in this case.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol, resulting in the inappropriate administration of antibiotics to a resident. Resident 206, who was admitted with diagnoses including sepsis, urinary tract infection, and extended spectrum beta lactamase resistance, was administered Invanz, an antibiotic, for six days. However, the resident did not meet the Loeb's Minimum Criteria for initiating antibiotics, which include a temperature greater than 100°F or 2.4°F above baseline, and at least one additional symptom such as rigors or delirium. Despite this, the resident received the full course of antibiotics without the necessary criteria being met. The Infection Prevention Nurse acknowledged that the resident did not meet the criteria for antibiotic use and that the physician should have been notified. The Director of Nursing stated that a time out for antibiotic use should have been conducted after three days to reassess the necessity of the antibiotic. The facility's policy on Antibiotic Stewardship emphasizes the importance of monitoring antibiotic use to prevent resistance and adverse events, but this protocol was not followed in the case of Resident 206.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to administer a pneumococcal vaccination to a resident, despite obtaining consent for the vaccine. The resident, who was admitted with diagnoses including end-stage renal disease, type 2 diabetes mellitus, and a history of myocardial infarction, was identified as being at higher risk for complications from pneumococcal disease due to their immunocompromised status. The resident's medical records indicated that the pneumococcal vaccine was ordered and consent was obtained on February 7, 2025, but the vaccine was not administered. The Infection Prevention Nurse acknowledged the oversight, stating that they did not review the resident's medical records for vaccinations and failed to administer the vaccine. The Director of Nursing confirmed that all residents are offered and educated about immunizations, and that consented immunizations should be administered. The facility's policy on pneumococcal disease prevention requires documentation of vaccination or reasons for non-vaccination, but this was not adhered to in this case.
Inaccurate Posting of Nursing Hours
Penalty
Summary
The facility failed to post accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD) information as required by their policy and procedure. On 2/25/2025, the posted nursing hours for direct care staff were observed to be inaccurate as they were dated 2/24/2025 instead of the current date. This discrepancy was confirmed during an interview with the Infection Preventionist Nurse (IPN), who acknowledged that the posted information was not accurate for the day in question. Further review of the facility's Policy and Procedure (P&P) with the Director of Nursing (DON) revealed that the facility's policy required the posting of the current date and the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. The policy also mandated that this information be posted daily at the beginning of each shift in a clear and readable format accessible to residents and visitors. The DON confirmed that the facility did not comply with these requirements, as the posted information on 2/25/2025 was outdated, thus making it inaccurate.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that 31 of 31 resident rooms met the required minimum of 80 square feet per resident in multiple resident rooms. This deficiency was identified during an initial tour observation, interviews, and record reviews. The rooms in question were found to be below the required square footage, with some rooms providing as little as 69.3 square feet per resident. Despite the deficiency, interviews with residents and staff indicated that there were no complaints regarding the room sizes, and staff were able to perform their tasks without space concerns. The facility's Client Accommodation Analysis Form and room waiver request confirmed the deficiency, listing specific rooms and their measurements, which fell short of the regulatory requirements. The waiver request indicated that the rooms, although smaller than required, were deemed sufficient for nursing care, comfort, and privacy of the residents. The Department recommended approval of the room waiver request for all 31 rooms, acknowledging the facility's efforts to address the space limitations.
Failure to Monitor Intake and Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to monitor the intake and output for two residents with indwelling catheters, as required by the facility's policy. Resident 1, who was readmitted with diagnoses including a urinary tract infection, chronic kidney disease, and anemia, was noted to have an indwelling catheter. The care plan for Resident 1 indicated the need to monitor and document intake and output, but this was not done. Similarly, Resident 3, admitted with a urinary tract infection and urinary retention, also had an indwelling catheter. The care plan for Resident 3 required monitoring and documentation of intake and output, which was not performed. During a review of the facility's policies, it was found that intake and output recording is mandatory for residents with indwelling catheters. The Director of Nursing stated that the facility did not have documentation for the intake and output of these residents because there was no physician's order for such monitoring. However, the facility's policy clearly required intake and output monitoring for residents with indwelling catheters, regardless of a physician's order. This oversight had the potential to delay necessary care and services for the residents.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents as per the physician's orders and facility policy. Resident 1, who was admitted with diagnoses including quadriplegia, depression, and anxiety, reported a pain level of 7/10. Despite this, the Licensed Vocational Nurse (LVN) administered acetaminophen 650 mg, which was only indicated for mild pain levels of 1-3, without notifying the physician of the increased pain level. The Registered Nurse Supervisor confirmed that the physician was not informed, and non-pharmacological interventions were not provided while waiting for further pain management orders. Resident 2, diagnosed with malignant neoplasm of the right breast, depression, and anxiety, experienced a pain level of 4 on two occasions. However, the Director of Nursing (DON) noted that acetaminophen 500 mg was administered, which was only indicated for mild pain levels of 1-3, contrary to the physician's order. The facility's policy required notifying the physician of any new onset or change in pain, which was not adhered to in these cases. The facility's policies on pain management, medication administration, and change of condition notification were not followed, leading to the inappropriate administration of pain medication and failure to notify the physician of changes in the residents' pain levels. This oversight had the potential to result in unnecessary and preventable pain for the residents, as the facility staff did not adhere to the established protocols for managing and reporting pain.
Resident's Rights Violation: Cellphone Confiscation
Penalty
Summary
The facility failed to honor the rights of a resident by not allowing him to keep his personal cellphone at his bedside, as per his request. The resident, who was admitted with diagnoses including quadriplegia, depression, and anxiety, was identified as a self-responsible party. Despite this, the facility staff removed his cellphone shortly after admission, allegedly to prevent him from making calls to emergency services, without his consent or proper documentation. The resident's cellphone was found in a medication cart, and staff members were aware of its location but did not return it to him. Interviews with staff revealed that the removal of the cellphone was based on a request from a family member who did not have legal authority to make decisions for the resident. The facility's policy requires that residents be informed and their consent documented when their personal possessions are taken, which was not followed in this case. The Director of Nursing acknowledged that the resident's rights were violated, as he was self-responsible and should have been allowed to retain his cellphone. The facility's policy emphasizes the importance of treating residents with respect and dignity, allowing them to exercise their rights without interference. The lack of documentation and failure to follow the resident's wishes were identified as key issues leading to this deficiency.
Failure to Obtain Urine Sample for Urinalysis
Penalty
Summary
The facility failed to obtain a urine sample for urinalysis as ordered by the physician for a resident with quadriplegia, urinary tract infection, and chronic kidney disease. The resident was admitted with an indwelling catheter and was being monitored for hematuria. Despite the physician's order for a urinalysis with culture and sensitivity on the day hematuria was noted, the sample was not collected or sent to the laboratory. Interviews with the nursing staff revealed a lack of follow-through on the physician's order. The Licensed Vocational Nurse acknowledged not obtaining the urine sample and was unsure if the Treatment Nurse had done so. The Minimum Data Set Registered Nurse confirmed that no laboratory results were available because the urine sample was not sent out, and there was no documentation of a laboratory requisition form being completed or the laboratory being contacted for specimen collection. The Director of Nursing emphasized the importance of executing physician orders to determine the presence of a urinary tract infection and the type of bacteria involved. However, a review of the facility's policy indicated that laboratory services should be coordinated and documented, which was not adhered to in this case. The failure to collect and process the urine sample as ordered resulted in a deficiency in providing timely laboratory services to meet the resident's needs.
Failure to Provide Communication Board for Resident with Language Barrier
Penalty
Summary
The facility failed to provide a communication board for one resident, who was identified as having a language barrier, which was necessary for effective communication. The resident, who was admitted with diagnoses including type 2 diabetes mellitus with chronic kidney disease, schizophrenia, and dysphagia, was noted to have moderate cognitive impairment and required assistance with daily activities. Despite the resident's limited English proficiency and the facility's policy to aid residents with language barriers through communication boards, no such board was available in the resident's room. Interviews with the resident and staff confirmed the absence of a communication board, which was supposed to facilitate communication between the resident and the staff. The facility's policy emphasized the importance of providing communication aids to ensure residents with limited English proficiency have equal access to services. However, observations revealed that the communication board was neither present in the resident's current room nor in the previous room, indicating a lapse in adhering to the facility's policy and procedures.
Failure to Develop Individualized Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized resident-centered care plan for a resident who exhibited inappropriate behavior and wandering tendencies. Despite receiving a report from the transferring facility about the resident's inappropriate comments to female staff, the MDS Nurse did not observe such behavior during admission and therefore did not develop a care plan addressing it. Additionally, the resident was noted to be wandering on a specific date, but a care plan for wandering was not developed, which was contrary to the facility's policy. The resident's Elopement Risk Assessment initially indicated a low risk for wandering, but after episodes of wandering were observed, the assessment should have been updated to reflect a high risk. The Director of Nursing acknowledged that the resident should have been monitored and supervised according to policy due to the high risk of wandering. The facility's policy required care plans to be updated with changes in the resident's condition or needs, but this was not done, leading to a deficiency in care planning for the resident.
Inadequate Supervision Leads to Resident Wandering and Allegation
Penalty
Summary
The facility failed to provide adequate supervision for a resident who exhibited inappropriate behavior and episodes of wandering. This deficiency was observed when the resident wandered into another resident's room, leading to an allegation of inappropriate touching. The resident, who was admitted with diagnoses including adult failure to thrive, COPD, and hypertension, was noted to have intact cognitive skills for daily decision-making but required supervision for various activities. Despite a report from a transferring facility indicating the resident's inappropriate behavior, no care plan was developed upon admission as the behavior was not observed initially. The facility's policy required monitoring for behavioral triggers such as wandering, but the resident's Elopement Risk Assessment was not updated to reflect the increased risk after wandering episodes were observed. The Director of Nursing acknowledged that the resident should have been monitored and supervised according to policy. The facility's policy on safety and elopement risk reduction emphasized the need for monitoring and supervision to ensure resident safety, which was not adequately implemented in this case.
Failure to Provide Accessible Call Light for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a call light was within reach and did not provide an adaptive call light for a resident with quadriplegia, anxiety disorder, and generalized muscle weakness. The resident was dependent on others for daily activities and had intact cognitive skills for decision-making. The care plan indicated the use of a phone to call the facility for help instead of a call light. However, during an observation, the call light was found tied to the bed rail and not within the resident's reach. The resident expressed the inability to use the call light due to paralysis and the need for an adaptive device that could be activated by blowing air. The Director of Nursing acknowledged the issue and attempted to place the call light within reach, but the resident confirmed the inability to use it due to nerve damage. The resident resorted to calling 911 for help as they did not have the nurse station's number. A Certified Nursing Assistant confirmed that the resident called for help by yelling, which was not always effective. The facility's policy required call lights to be within reach and adaptive devices to be provided based on residents' needs, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were within reach and not answering them promptly. Resident 1, who was admitted with multiple health issues including a complete atrioventricular block, right-sided hemiplegia, and moderate cognitive impairment, reported that his call light was often out of reach, leading him to rely on his roommate's call light for assistance. He expressed frustration over the delayed response times, particularly during the night shift, which exceeded the facility's policy of answering within five minutes. Resident 4, diagnosed with multiple sclerosis and chronic pain syndrome, also experienced issues with her call light being out of reach. On one occasion, she had to use her cell phone to call the nurses' station for assistance with a diaper change, as her call light was not accessible. Observations confirmed that her call light was placed at the head of her bed, out of her reach, and she had to request staff assistance to reposition it. Interviews with facility staff, including a CNA, a Registered Nurse Supervisor, and the Director of Staff Development, confirmed that the facility's policy required call lights to be within residents' reach and answered within three to five minutes. The staff acknowledged the importance of adhering to this policy to prevent potential accidents or emergencies. However, the facility's failure to consistently implement these measures resulted in the deficiency noted in the report.
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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 Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Foothill Heights Care Center | 0.1 mi | ★★★★★ | 23 | 0 |
| Pasadena Nursing Center | 0.1 mi | ★★★★★ | 27 | 0 |
| Cedar Pine Post Acute | 0.2 mi | ★★★★★ | 11 | 0 |
| Saint Vincent Healthcare | 0.4 mi | ★★★★★ | 15 | 0 |
| Brighton Care Center | 0.4 mi | ★★★★★ | 25 | 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.