Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Primrose Post-acute during CMS and state inspections, most recent first.
The facility failed to act on consultant pharmacist MRR recommendations for two residents with significant psychiatric and cognitive impairment. One resident was receiving Valproic Acid and Mirtazapine, and another was receiving Mirtazapine; in both cases, the pharmacist recommended considering a GDR. The DON stated the recommendations were not addressed by the physician, and there was no documentation that nursing staff notified the physician or that the physician acknowledged and signed the MRR.
Failure to obtain informed consent for psychotropic meds: A resident with schizoaffective disorder, dementia, and MDD received Seroquel and mirtazapine, but the resident representative stated she did not give verbal or written consent and did not have authority to consent for these meds. The RN stated consent was required before psychotropic use and that staff were responsible for obtaining and documenting it, while the facility policy required informed consent before administration.
Failure to notify physician of resident’s diarrhea. A resident with gangrene, CKD, and DM developed diarrhea and received PRN loperamide, but the chart showed no COC or physician notification despite the care plan calling for notification of the MD and responsible party for bowel changes. The RN/TN stated the notification should have occurred and that it was important in case the MD wanted to change the resident’s regimen.
Inaccurate MDS Coding for Schizophrenia: The facility completed inaccurate MDS assessments for two residents by coding schizophrenia in Section I despite records showing schizoaffective disorder, dementia, depression, and no supporting documentation for schizophrenia. The PA and MDSN both confirmed the diagnosis was not supported, and the residents’ MDSs reflected severely impaired cognition, dependence for ADLs, and no indicators of psychosis.
Failure to Provide Ordered 1:1 Feeding Assistance: A resident with dementia, muscle weakness, and GERD had a physician order for 1:1 feeding for cueing, but observations showed no feeder present during lunch on two occasions. The resident’s cognition was severely impaired, and TN confirmed the resident was eating without the required staff assistance, despite the facility policy stating residents who need help with meals will receive it.
Failure to Provide Needed ADL Grooming Care: A resident with MS, hemiplegia, and muscle wasting was dependent on staff for personal hygiene and showering, yet was observed with large amounts of dandruff on the hair, face, and clothes and with untrimmed fingernails. The resident stated a desire for hair washing and nail trimming, and an RN confirmed the grooming care had not been provided as expected under the facility’s ADL policy.
LALM Set Incorrectly for a Resident at High Risk for Skin Breakdown: A resident with dementia, severe cognitive impairment, dependence for ADLs, and high Braden risk had a physician order for a LALM set per body weight. During observation, the TN found the mattress was set at 180 lbs even though the resident weighed 133 lbs, and the TN stated the setting should have been closer to the resident’s weight.
Three Hoyer lifts were observed blocking a fire alarm and posted warning signs in a hallway, and an LVN confirmed the equipment should not have been parked there. In a separate issue, a resident with toxic encephalopathy, muscle weakness, GERD, and impaired cognition was taken off the premises by the BOM to cash a check without being signed out in the OOP log and without an OOP physician order, which the DON confirmed was required.
A resident with respiratory failure, dysphagia, and cerebral infarction was ordered continuous O2 at 2 L/min via N/C, but surveyors observed the resident without the N/C in place and the concentrator set at zero on two occasions. The MDS nurse confirmed the resident should have been receiving continuous O2 at 2 L/min and stated that setting the O2 at zero was not correct per the order.
Physician Visit Frequency Not Met: A resident with CVA, DM, and major depressive disorder was not seen face-to-face by the attending physician at least every 60 days, and the physician documented only one visit over about 4 months while an NP saw the resident multiple times. The resident reported seldom seeing the physician and needing to discuss left knee pain, while the DON confirmed the physician’s limited visits and the facility policy required regular physician evaluations and documentation.
Failure to Obtain Valid Informed Consent for Psychotropic Medications: A resident with schizoaffective disorder, dementia, and MDD received Seroquel and Mirtazapine, but the informed consent forms were incomplete and the resident's representative stated she did not provide verbal or written consent and lacked authority to do so. RN and DON interviews confirmed that valid informed consent was required before psychotropic medications could be given, and the facility policy required consent to be obtained and documented before administration.
Hand hygiene was not performed after an PT picked up gloves from the floor and before donning a new pair of gloves to provide care to a resident with severely impaired cognition and dependence for personal care. The PT acknowledged the floor was dirty and stated hand hygiene should have been done after contact with the contaminated surface and before touching the resident.
Survey Results Not Posted in Accessible Public Area: The facility failed to post the recent CDPH annual survey results for 2024 and 2025 in a prominent, accessible location for residents, family members, and visitors. A hallway survey binder contained only Complaint/FRI information and the last standard survey from 2022, and the ADM stated the binder was incomplete and not updated despite annual recertification surveys having occurred.
Daily nurse staffing information was not updated and posted at the beginning of the day. During observation, the staffing sheet displayed was from the prior day, and the IPN stated the current day's staffing information had not been posted. The IPN and DON stated the posting should show projected and actual hours worked by LPNs and CNAs providing direct care, along with the resident census, and the facility policy required daily posting of direct care staffing numbers.
A resident with hemiplegia, hemiparesis, bilateral knee contractures, and a stage 4 sacral PI had care plans that were not updated quarterly as required. The resident’s skin care plan showed no quarterly review dates, and a later care plan for a diabetic ulcer did not include repositioning even though the IDT had identified it as a non-pharmacological intervention. The DON acknowledged the MDS nurse updated care plans and that failing to update them every quarter meant the facility was not following policy.
A resident with moderate cognitive impairment, urinary retention, and an indwelling catheter, and her responsible party repeatedly requested to speak directly with the attending MD about the resident’s medical condition. An RN documented that the MD and NP were notified and told the responsible party she would ensure the MD made contact, but there was no documented follow-up. The MD later stated he and his office were never contacted about the request, and the NP reported she was not informed and had never spoken with the responsible party on the MD’s behalf. Review of nursing notes by the RN and DON confirmed there was no evidence of follow-up to ensure the communication occurred, despite facility policy stating residents have the right to communicate with and access people and services inside and outside the facility.
A resident with moderate cognitive impairment, urinary retention, obstructive/reflux uropathy, and an indwelling Foley catheter was hospitalized twice for UTI-related complications and readmitted each time. Despite being able to make medical decisions and having a history of active participation in assessments, no readmission IDT meetings were documented after either hospitalization. Progress notes showed only an invitation to a later quarterly IDT, and the resident and her RP reported they were not informed of the care plan to prevent further hospitalizations and UTIs. The SSD, LVN, and DON confirmed that facility policies require IDT meetings within one week of readmission with resident/representative participation, and acknowledged these policies and the resident’s rights to be informed and involved in care planning were not followed.
A resident with an indwelling Foley catheter, urinary retention, and obstructive/reflux uropathy had a care plan intervention directing nursing staff to monitor and document urine output, but facility records and MARs over several months showed that this monitoring was not performed. The DON confirmed that the intervention, initiated in mid-summer, was not implemented, the physician was not contacted at that time, and an order for intake and output every shift was not obtained until months later, despite acknowledging that standard nursing care for a catheterized resident includes measuring and recording output.
A resident with urinary retention, obstructive and reflux uropathy, and a chronic Foley catheter had a physician order and documented plan for urology follow-up that nursing staff did not clarify, order, or schedule. Review of progress notes over multiple months showed no coordination of the urology consultation, and the MD and NP were unsure whether any urology visit occurred or whether recommendations were obtained. An RN acknowledged that licensed nurses are responsible for reviewing MD notes and implementing planned interventions, and that failure to follow up could result in the resident not receiving physician-directed care.
A resident with moderate cognitive impairment, dependent on staff for personal care and using an indwelling catheter, and her responsible party wished to be informed and involved in IDT meetings and care planning. However, the IDT meeting for this resident was rescheduled three times at their request, and these changes were not documented in the progress notes. The SSD acknowledged that the rescheduling, including new dates, reasons, and notification of the IDT, should have been recorded, and the DON confirmed the medical record was incomplete due to this lack of documentation.
Five boxes containing invoices with resident names, DOBs, MRNs, and medical information were left unattended in a parking lot by a maintenance supervisor, exposing the personal and medical information of three residents with significant health conditions. The DON was unaware of the incident, and facility policy required confidential handling and shredding of such documents.
Surveyors found that the emergency dry food storage room was being monitored with an incorrect thermometer intended for cold food handling and freezer use, which did not provide accurate room temperature readings. The Dietary Services Supervisor acknowledged the error and stated that this could impact the safety of stored food, as the actual room temperature was unknown.
The facility did not maintain documentation or provide evidence of effective QAPI activities or governing oversight, as confirmed by the Administrator. This failure led to repeat deficiencies in resident assessments and food and nutrition services, with no records showing that these issues were addressed in QAPI meetings.
Three residents had inaccurate MDS assessments, including failure to code an anticonvulsant medication, omission of a stage 2 pressure ulcer, and not documenting the use of an anticoagulant. These errors resulted in incorrect data being sent to CMS and did not align with facility policy requiring accurate attestation of MDS information.
A resident at moderate risk for pressure ulcers, who was bedfast and required total assistance, developed a stage 2 sacral pressure ulcer after nursing staff failed to apply barrier cream and perform daily skin checks as outlined in the care plan. The omission of these interventions was confirmed by both the treatment nurse and DON, and was contrary to facility policy.
A resident with moderate cognitive impairment and total dependence on staff for personal care was transferred to a hospital without a completed inventory of personal belongings. The Social Service Director and a nurse confirmed that the inventory was not done as required by facility policy, which mandates documentation of resident property upon admission and updates as needed.
A resident with multiple diagnoses and total dependence on staff was found in bed with their call light out of reach, despite care plan instructions and facility policy requiring accessibility. Both an LVN and a CNA confirmed the importance of keeping the call light within reach to allow the resident to request assistance.
A resident with major depressive disorder was admitted without the facility completing and resubmitting a required PASARR Level I screening, despite the diagnosis qualifying as a mental illness. The previous screening from another facility did not identify a serious mental illness, and no Level II evaluation was conducted. The Case Manager confirmed that the omission meant the resident was not referred for appropriate mental health evaluation as required.
A resident with bipolar disorder and schizoaffective disorder did not receive a required PASARR Level II assessment due to the facility's failure to respond to state agency communications and timely resubmit the Level I screening, potentially resulting in unmet psychiatric care needs.
A resident with multiple chronic conditions did not have her Life Vest battery changed at the time ordered by the physician. Instead, an LVN reported only changing the battery when it beeped, rather than following the scheduled order, resulting in the device not being properly monitored as required.
A resident with a history of falls and multiple medical conditions was observed on two occasions with their bed not in the lowest position, despite care plan and physician orders requiring this as part of fall precautions. Both CNA and LVN staff acknowledged the bed should have been lowered, and the DON confirmed this protocol during interviews.
A resident with multiple medical conditions and at risk for nutritional imbalance was served a cold hard-boiled egg at breakfast, which she reported was unappetizing and inedible. Both an LVN and the Dietary Services Supervisor confirmed the egg was cold and should have been reheated before serving, in accordance with dietary service expectations.
A resident with documented lactose intolerance and a preference for Lactaid was repeatedly served low-fat milk instead of lactose-free milk, despite her care plan and dietary records specifying her needs. The resident's tray card did not reflect her dietary restriction, and the Dietary Services Supervisor confirmed the oversight, acknowledging the risk of stomach problems from the provided milk.
Staff did not follow enhanced barrier precautions for a resident with a gastric tube, as a CNA provided care without wearing a gown as required. In a separate case, a CNA failed to perform hand hygiene before and after feeding a dependent resident, despite facility policy and staff acknowledgment of the requirement.
A resident with severe cognitive impairment and multiple medical conditions was prescribed Clindamycin for a sacral wound infection, but the IPN did not complete the required McGeer Criteria Infection Screening Evaluation form within the specified timeframe. This omission meant the appropriateness of the antibiotic order could not be validated, contrary to facility policy.
A resident with dementia and moderate cognitive impairment was the subject of a financial abuse allegation involving their representative. The Social Service Director reported the incident to APS and the DON, but failed to notify CDPH, the Ombudsman, or law enforcement as required. The facility did not conduct or submit the mandated follow-up investigation report to CDPH within five business days, instead submitting it approximately seven months later, in violation of facility policy.
Six resident rooms were found to have less than the required 80 square feet of usable living space per resident, as confirmed by facility staff and policy review. Observations showed that while residents could move about and there was space for necessary equipment, the rooms did not meet regulatory size standards.
The facility failed to report an allegation of physical abuse within the required two-hour timeframe. A resident with severe cognitive impairment was allegedly hit by another resident. The incident was not reported to the CDPH and Ombudsman until the following day, delaying the investigation and potentially placing the resident at risk for further abuse. The LVN did not report the incident to the Administrator, who is responsible for reporting such allegations. The facility had a history of late reporting of abuse allegations.
A resident at high risk for falls did not have floor mats installed as required by their care plan, despite having conditions like metabolic encephalopathy and hemiplegia. An LVN confirmed the absence of mats, and the DON acknowledged that nursing staff were responsible for implementing such interventions. The facility's policy emphasized maintaining residents' well-being through care plan adherence, yet this was not followed.
A resident with dementia reported an alleged abuse incident to a family member, which was overheard by an Activities Assistant and reported to the Social Services Director and DON. However, the allegation was not reported to the State agency within the required 24-hour timeframe, as the family member dismissed the claim as hallucination. The facility's policy mandates immediate reporting, but the incident was not reported until several days later, posing a risk of further abuse.
A facility failed to report a resident abuse incident within the required two-hour timeframe. An altercation occurred between two residents, one with heart failure and the other with schizoaffective disorder. The DON delayed reporting to the state agency to conduct an investigation, resulting in a 14-hour delay. The Administrator acknowledged the delay, citing the need to gather statements and nurses' lack of awareness about reporting procedures.
A resident with a full code status was found unresponsive in bed, and although CPR was initiated, the facility staff failed to call 911, which is a critical step in the emergency response protocol. The resident, who had a history of severe cognitive impairment and required extensive assistance, was pronounced deceased by the physician over the phone without an in-person assessment. Interviews with staff confirmed that the standard procedure was not followed, resulting in the resident's death and placing other residents at risk.
The facility failed to update its Facility Assessment to reflect the accurate resident census, with 64 residents present but only 52-53 accounted for in the assessment. The DON acknowledged the discrepancy, which could lead to the appearance of inadequate care. CMS guidelines emphasize the need for accurate census data to ensure proper resource allocation for resident care.
Two residents in a facility experienced psychological harm due to inadequate restroom access, as their room's layout obstructed the path to the restroom. Both residents, dependent on staff for toileting due to medical conditions, faced challenges as staff had to move a roommate's bed or use an adjacent room to assist them. The facility's policy allowed for adaptations to accommodate residents' needs, but the current setup did not reflect this, leading to the deficiency.
The facility failed to develop care plans for three residents, leading to potential inadequate care. A resident with multiple sclerosis and Huntington's disease lacked a care plan for a fall. Another resident with epilepsy and dyspnea had no plan for oxygen administration. A third resident with Parkinson's disease and a gastrostomy tube lacked a care plan for enteral feeding. Staff acknowledged the importance of care plans in guiding care.
The facility failed to properly label and dispose of medications, leading to potential medication errors. Unlabeled medications for a discharged resident were found in storage, and multi-dose medications for two residents lacked open dates. Staff interviews confirmed these oversights, which violated facility policies on medication storage and disposal.
The facility failed to maintain safe food storage and preparation practices, with several food items not labeled or dated, and staff not adhering to hand hygiene protocols. These deficiencies could lead to confusion about food safety and increased risk of foodborne illnesses.
The facility failed to maintain sanitary conditions in the dumpster area, as observed during an inspection with the Dietary Service Supervisor (DSS). A garbage dumpster was overfilled, preventing the lid from closing, which the DSS acknowledged could attract pests. This violated the 2022 FDA Food Code and the facility's policy on garbage disposal.
A facility failed to document a change of condition and notify the responsible party for a resident transferred to the hospital. The resident, with conditions like acute kidney failure and dementia, had no documented change of condition, violating policy and potentially worsening their condition. Interviews with staff confirmed the oversight, highlighting a breach in communication protocols.
A facility failed to ensure an accurate MDS assessment for a resident with osteoarthritis and contractures, leading to an incorrect recording of no impairment in lower extremities. The MDS nurse acknowledged the error, stating the assessment should have reflected impairment, which is crucial for proper interventions and reimbursement. The DON confirmed the importance of accurate assessments for quality care.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to act on consultant pharmacist medication regimen review recommendations for two residents. Resident 4 had diagnoses of schizoaffective disorder, dementia, and major depressive disorder, and the H&P noted fluctuating capacity to understand and make decisions. The pharmacist’s MRR dated 3/12/2026 identified that Resident 4 was receiving Valproic Acid 500 mg twice daily since 12/2025 and recommended considering a gradual dose reduction. A later MRR dated 6/16/2026 identified that Resident 4 was receiving Mirtazapine 30 mg daily since 2/2025 and also recommended considering a gradual dose reduction. The DON stated these recommendations were not addressed by the physician and that the facility failed to take action by not informing the physician. Resident 7 had diagnoses of schizoaffective disorder, depression, and dementia, and the H&P stated the resident did not have capacity to make medical decisions. The MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, and dressing. The consultant pharmacist’s MRR dated 6/16/2026 identified that Resident 7 was receiving Mirtazapine 15 mg daily since 10/2025 and recommended considering a gradual dose reduction. During interview, the DON stated the MRR was not acknowledged and signed by the physician and there was no documentation that licensed nursing staff notified the physician regarding the pharmacist’s recommendation. The facility policy stated that upon receiving the MRR report, the attending physician reviews, responds to the report, and documents what actions were taken.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotherapeutic medications to one sampled resident. Resident 4 was admitted and readmitted to the facility with diagnoses including schizoaffective disorder, dementia, and major depressive disorder. The record showed that Resident 4 had fluctuating capacity to understand and make decisions, and later assessment documented severely impaired cognition and dependence on staff for oral hygiene, toileting hygiene, and upper and lower body dressing. Physician orders directed Seroquel 25 mg twice daily for schizoaffective disorder and Mirtazapine 30 mg daily for depression, and the MAR showed the resident received both medications from 6/19/2026 through 7/7/2026. During interview, the resident representative stated she was asked to sign a psychotherapeutic informed consent form but did not give verbal or written consent for psychotherapeutic medications and did not have authority to consent for those medications. The RN stated it was the licensed nursing staff's responsibility to obtain informed consent from the resident or representative and discuss side effects, and stated consent was required initially and with medication increases. The RN also stated the resident's representative gave verbal consent for Seroquel and Remeron on 6/19/2026, but the representative denied giving such consent. The facility policy required informed consent from the resident or resident representative before administration of a psychotropic medication and documentation of that consent in the medical record.
Failure to Notify Physician of Resident’s Diarrhea
Penalty
Summary
The facility failed to notify the physician after Resident 1 developed diarrhea on 6/26/2026. Resident 1 was admitted and readmitted to the facility with diagnoses including gangrene, chronic kidney disease, and diabetes mellitus. The resident’s H&P dated 6/30/2026 indicated the resident did not have the capacity to make decisions but was able to make needs known, and the MDS dated 4/23/2026 indicated moderately impaired cognition and substantial to maximal assistance needed for personal hygiene, showers, and dressing. Resident 1’s order summary dated 6/14/2026 included an order for loperamide 2 mg every 6 hours as needed for loose stool, and the care plan for altered gastrointestinal status indicated the goal of normal, formed stool with an intervention to notify the physician and responsible party. The MAR showed loperamide was given on 6/26/2026 for diarrhea, but Treatment Nurse 1 stated during interview that there should have been a COC when the resident had diarrhea and that it was not done. The nurse also stated the care plan intervention was to notify the physician for changes in bowel patterns and that notification was important in case the physician wanted to change the resident’s regimen. The facility policy stated the nurse was to promptly notify the physician of changes in the resident’s medical condition and gather relevant information using SBAR.
Inaccurate MDS Coding for Schizophrenia
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) was completed accurately for two residents who were coded with schizophrenia. Resident 4’s record showed admission and readmission to the facility, with diagnoses including schizoaffective disorder, dementia, and major depressive disorder. Resident 4’s H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decision making, dependence on staff for oral hygiene, toileting hygiene, and upper and lower body dressing, and no potential indicators of psychosis such as hallucinations or delusions. Resident 7’s record showed admission and readmission to the facility, with diagnoses including schizoaffective disorder, depression, and dementia. Resident 7’s H&P stated the resident did not have the capacity to make medical decisions, and the MDS indicated severely impaired cognitive skills for daily decision making, dependence on staff for oral hygiene, toileting hygiene, and dressing, and no potential indicators of psychosis such as hallucinations or delusions. During interview, the PA stated both residents had schizoaffective disorder, not schizophrenia, and that there was no supporting documentation for schizophrenia. The MDS Nurse stated the MDS assessments were completed inaccurately and that Section I should not have been checked for schizophrenia because the facility did not have supporting documentation or evidence for that diagnosis.
Failure to Provide Ordered 1:1 Feeding Assistance
Penalty
Summary
The facility failed to ensure that Resident 13 received a one-to-one feeder during meals, despite a physician order dated 6/5/2026 for 1:1 feeding for cueing. Resident 13’s admission record showed diagnoses including dementia, muscle weakness, and GERD. The H&P dated 2/6/2026 stated the resident did not have the capacity to make decisions but was able to make needs known. The MDS dated 5/12/2026 indicated the resident’s cognition was severely impaired, that the resident was dependent on staff for personal hygiene, shower, and lower dressing, and required supervision for eating. During observations on 7/7/2026 at 12:40 p.m. and 7/8/2026 at 12:53 p.m., Resident 13 did not have a 1:1 feeder present during lunch. On the second observation, the resident was moving food around on the lunch plate. During a concurrent observation and interview on 7/8/2026 at 1:02 p.m., TN 1 confirmed there was no feeder assisting Resident 13 while he was trying to eat lunch and stated there should have been a staff member sitting next to him while he was eating. The facility policy titled Assistance with Meals stated residents shall receive assistance with meals in a manner that meets their individual needs and that nursing services or feeding assistants will help residents who require assistance with eating.
Failure to Provide Needed ADL Grooming Care
Penalty
Summary
The facility failed to ensure that Resident 24 received needed ADL care, including washing the resident’s hair and trimming the resident’s fingernails. Resident 24 was admitted and later readmitted to the facility, and had diagnoses including muscle sclerosis, hemiplegia, and muscle wasting. The resident’s H&P dated 4/22/2026 indicated the resident had the capacity to understand and make decisions, while the MDS dated 5/6/2026 indicated cognition was severely impaired and that the resident was dependent on staff for personal hygiene, showering, and lower body dressing. The care plan for skin, dated 5/11/2025, included an intervention to keep the resident’s skin clean and dry. During observation on 7/7/2026, Resident 24 had large amounts of dandruff in the hair, on the face, and on the clothes, and the fingernails were not trimmed; the resident stated a desire to have the nails trimmed and hair washed. On 7/8/2026, the Treatment Nurse confirmed the fingernails were not trimmed and the resident had large amounts of dandruff, and stated the hair should be washed on shower days at least twice a week and the fingernails should be trimmed by the CNA. The facility’s ADL policy stated residents unable to perform ADLs independently should receive services necessary to maintain good grooming and personal hygiene.
LALM Set Incorrectly for Resident at High Risk for Skin Breakdown
Penalty
Summary
The facility failed to ensure that Resident 13’s low air loss mattress (LALM) was maintained at the correct setting. Resident 13 was admitted with diagnoses including dementia, muscle weakness, and GERD. The resident’s H&P indicated the resident did not have the capacity to make decisions but was able to make needs known. The MDS dated 5/12/2026 showed severely impaired cognition, dependence on staff for personal hygiene, showering, and lower dressing, a weight of 133 lbs., and risk for pressure ulcers. The Braden Scale Assessment dated 5/12/2026 indicated the resident was at high risk for skin breakdown. The physician order dated 2/5/2026 directed staff to provide a LALM and to set it per the resident’s weight. During observation and interview on 7/8/2026, the Treatment Nurse stated the resident weighed 133 lbs. and the LALM was set at 180 lbs. When the order was reviewed, the Treatment Nurse stated the mattress should have been set closer to the resident’s weight of 133 lbs. The facility’s policy stated that LALM pressure settings shall be determined based on the resident’s weight.
Blocked Fire Alarm Area and Improper Resident Sign-Out
Penalty
Summary
Three Hoyer lifts were observed blocking a fire alarm and posted signs in a facility hallway. The sign stated, "Do not park anything in front of fire pull box at any time, keep area clear." During a later observation and interview, LVN 2 confirmed the lifts were still blocking the fire alarm area and stated that mechanical equipment, linen carts, trash cans, and other items should not be parked in front of the signs. LVN 2 said the lifts should not have been parked there and identified the blocked area as a safety hazard. Resident 39 had diagnoses including toxic encephalopathy, muscle weakness, and GERD, and the admission record and H&P indicated the resident had capacity to make medical decisions, while the MDS showed moderately impaired cognition and dependence on staff for personal hygiene, showering, lower dressing, and mobility with use of a wheelchair. The BOM stated she escorted the resident off the facility grounds to cash a check but did not use the OOP log to sign the resident out and believed the resident could leave without clinical or medical clearance. The DON reviewed the sign-out log and physician orders and confirmed there was no OOP order for the resident on that date and no sign-out entry, and stated the resident had to be signed out and have an OOP physician order before leaving the facility.
Oxygen Therapy Not Set Per Physician Order
Penalty
Summary
The facility failed to ensure Resident 11 received continuous oxygen at 2 L/min as ordered by the physician. Resident 11’s record showed diagnoses including respiratory failure, dysphagia, and cerebral infarction, and the resident was documented as lacking decision-making capacity with severely impaired cognition and dependence on staff for personal care, bed mobility, and transfers. The resident’s order summary directed oxygen at 2 L/min continuously via nasal cannula from a concentrator tank every shift. During observation on 7/7/2026, Resident 11 was found in the room without the nasal cannula in place and the oxygen set at zero. During a later observation and interview on 7/8/2026, the resident was again observed with the oxygen set at zero. The MDS Nurse stated the resident should have been on continuous oxygen therapy at 2 L/min and not at zero, and stated that not administering the ordered oxygen could cause shortness of breath and lead to hypoxia. The facility’s Oxygen Administration policy stated to verify the physician’s order, turn on the oxygen, and start the flow at the ordered rate.
Physician Visit Frequency Not Met
Penalty
Summary
The facility failed to ensure that one sampled resident was evaluated face-to-face by the physician at least every 60 days and that those visits were documented in the clinical record. Resident 48 was admitted with diagnoses including cerebral infarction, DM, and major depressive disorder. The resident’s H&P indicated capacity for medical decision making, and the MDS dated 5/8/2026 indicated cognition was intact and that the resident was dependent on staff for toileting hygiene and dressing. During interview, Resident 48 stated she seldom saw her physician and reported needing to speak with the physician about left knee pain. Record review and interview with the DON showed that Resident 48 was seen by an NP on multiple occasions from 1/11/2026 through 7/3/2026, but was not seen by the physician during those visits. The DON stated the physician saw Resident 48 once that year on 3/3/2026, which was approximately 120 days after the prior visit. The DON also stated the physician should visit at least once a month and could alternate visits with the NP, and that the physician would document findings in the progress notes after each visit. The facility’s Physician Visits policy required the attending physician to visit at least every 60 days after the first 90 days, and the Facility Assessment indicated attending physicians were required to evaluate patients within 72 hours of admission and at least every 30 days following the initial visit or based on medical needs.
Failure to Obtain Valid Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from the responsible party before administering psychotropic medications to one resident. The resident was admitted and readmitted to the facility with diagnoses including schizoaffective disorder, dementia, and major depressive disorder. The record showed the resident had fluctuating capacity to understand and make decisions, and later had severe cognitive impairment and dependence on staff for oral hygiene, toileting hygiene, and dressing. Physician orders directed administration of Seroquel 25 mg twice daily for schizoaffective disorder and Mirtazapine 30 mg daily for depression, and the medication administration record showed the resident received both medications during the reviewed period. The psychotherapeutic drug informed consent forms for Seroquel and Mirtazapine were documented with verbal consent, but the signature section for the resident or resident representative was blank. The resident's representative stated she did not give verbal or written consent for psychotherapeutic medications and did not have authority to do so, although an RN stated the representative had given verbal consent and that informed consent was required before psychotropic medications could be initiated or administered. The DON also stated there was no valid informed consent obtained for the resident's Seroquel and Mirtazapine. The facility policy required the prescribing clinician to obtain informed consent from the resident or representative and document it in the medical record before administration of a psychotropic medication.
Hand Hygiene Not Performed After Contact With Contaminated Surface
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to perform hand hygiene after handling gloves that had fallen on the floor and before putting on a new pair of clean gloves to provide care to Resident 37. During observation, the Physical Therapist dropped gloves on the floor, picked them up, discarded them, obtained another pair from the glove dispenser, donned the new gloves, and continued care without washing hands or using alcohol-based hand sanitizer. Resident 37 was admitted and readmitted to the facility and had diagnoses including muscle weakness, atrial fibrillation, and dementia. The resident’s MDS dated 4/29/2026 indicated severely impaired cognition and dependence on staff for personal hygiene, showering, and dressing. In interview, the Physical Therapist stated the floor was dirty, that she should have washed her hands after picking up the gloves, and that hand hygiene was important to prevent cross contamination and the spread of infection. The facility’s hand hygiene policy stated hand hygiene is the primary means to prevent the spread of healthcare-associated infections and should be performed after contact with contaminated surfaces and immediately prior to touching a resident.
Survey Results Not Posted in Accessible Public Area
Penalty
Summary
The facility failed to post the recent California Department of Public Health annual survey results for 2024 and 2025 in areas that were prominent and accessible to residents, resident representatives, family members, and visitors. During an observation in the facility hallway, there was one survey binder hanging on the wall, but it contained only the Complaint and Facility Reported Incidents and the result of the last standard survey dated 2/11/2022. During a concurrent interview and record review, the Administrator stated the survey binder was incomplete and not updated. The Administrator stated the facility had annual recertification surveys in 2024 and 2025 and that he was responsible for placing the survey results for the past 3 preceding years in the binder. The Administrator also stated the updated survey results should be available and accessible to the public for transparency. Review of the facility's Resident Rights policy stated residents have the right to examine survey results, and the admission agreement stated the resident has the right to examine the results of the most recent survey and any plan of correction in effect, and that these should be posted in a place readily accessible to residents, family members, and legal representatives.
Daily Nurse Staffing Information Not Updated and Posted
Penalty
Summary
The facility failed to post the updated daily nurse staffing information at the beginning of the day. During a concurrent observation and interview on 7/7/2026 at 8:50 a.m. at Station A, the staffing information posted was dated 7/6/2026. The Infection Preventionist Nurse stated that the nurse staffing information for 7/7/2026 had not been posted and updated, and explained that the posting should include the projected and actual hours worked by licensed nurses and CNAs providing direct care, along with the actual total number of residents living in the facility. The Infection Preventionist Nurse stated the daily nurse staffing information should be prepared the day before and posted before the beginning of the shift, and updated daily so residents, staff, and visitors would know whether there were enough staff present to provide care and accommodate residents' needs. During an interview on 7/8/2026 at 2:40 p.m., the DON stated it was important for the nurse staffing information to be updated and posted daily to show compliance with regulations and to show how many staff the facility planned based on the census to care for and manage the residents living in the facility. A review of the facility's undated policy titled, Posting Direct Care Daily Staffing Numbers, indicated the facility would post on a daily basis for each shift the number of nursing personnel responsible for providing direct care to residents.
Care Plan Not Updated Quarterly for Resident With Multiple Skin Issues
Penalty
Summary
The facility failed to update the care plan for one sampled resident with a comprehensive assessment completed within the required timeframe. Resident 2 was originally admitted and later readmitted to the facility, and had diagnoses including hemiplegia, hemiparesis, contractures of both knees, and a stage 4 pressure ulcer of the sacral region. The resident’s H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated cognition was intact and that the resident was dependent on staff for toileting hygiene, personal hygiene, bathing, lower body dressing, footwear, and mobility. Review of the resident’s care plan titled skin impairment showed a target date but no quarterly review dates between 5/1/2025 and 8/4/2026. An IDT psychotherapeutic review later identified repositioning as a non-pharmacological intervention, but the subsequent care plan report for the resident’s diabetic ulcer to the right lateral calf did not indicate repositioning. During interview, the DON reviewed the care plans and the facility policy titled Comprehensive Person-Centered Care Plans, which stated the interdisciplinary team would review and update the care plan at least quarterly. The DON stated the MDS nurse would update the care plans and acknowledged that if the care plans were not updated every quarter, the facility was not following the policy.
Failure to Facilitate Resident and Responsible Party Communication With Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and her responsible party were able to communicate with the attending physician as requested, thereby not upholding their rights to communication and access to services. The resident was admitted with cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, had an indwelling catheter, and was always incontinent of bowel movements. Her history and physical indicated she was capable of making medical decisions, and the MDS showed moderate cognitive impairment but an ability to understand and be understood, with active participation by the resident and family in the assessment process. On one date, nursing progress notes documented that the physician and nurse practitioner were notified about the responsible party’s request for communication regarding the resident’s medical condition and that the clinical team would follow up. Later that same day, at the nursing station, the responsible party directly requested to speak with the physician, and the RN stated she would notify the physician and ensure contact was made. The resident also stated she wanted to speak with the physician and had requested that the RN have the physician call her or the responsible party, and she was still awaiting that call. In a subsequent interview, the physician reported that neither he nor his office had been contacted by the facility about the responsible party’s request and that he had not spoken with the responsible party. The NP stated she had not been notified of the request and had never spoken with the responsible party on the physician’s behalf. Review of the nursing progress notes with the RN and the DON showed documentation that the physician was notified of the request but no documentation of any follow-up to ensure the request was honored, and the RN acknowledged she did not know if the physician responded and stated she did not have time to follow up. The facility’s resident rights policy stated that residents have the right to communicate with and access people and services inside and outside the facility and to be supported in exercising their rights.
Failure to Conduct Readmission IDT Meetings and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct required readmission Interdisciplinary Team (IDT) meetings and include a resident and her responsible party (RP) in the development and implementation of her person-centered plan of care following hospitalizations. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and had an indwelling Foley catheter. A History and Physical dated 7/5/2025 documented that the resident could make her own medical decisions, and a Minimum Data Set (MDS) dated 7/9/2025 showed moderate cognitive impairment but indicated she was able to understand and be understood, did not reject care, and that she and her family were active participants in the assessment process. Record review showed that the resident was admitted with a Foley catheter and later hospitalized in September 2025 and again in December 2025 for complications related to a UTI, after which she was readmitted to the facility. Progress notes for September 2025 contained no indication that a readmission IDT meeting was planned or held. For December 2025, the census tab confirmed a readmission, and progress notes documented that on 12/31/2025 an invitation was sent to the resident and her RP for an IDT meeting; however, this was identified by the Social Services Director as an invitation for a quarterly IDT in January, not a readmission IDT. The progress notes did not show that any readmission IDT meeting occurred in December 2025. During interviews, the resident and her RP stated that after the December hospitalization, facility staff did not inform them about the plan of care to prevent future hospitalizations and UTIs and that they wanted to be involved in the care planning process. The Social Services Director and an LVN both stated that IDT meetings must occur for every readmission to review the resident’s condition, plan care, and uphold the resident’s right to be informed and involved in care planning. The Director of Nursing and Social Services Director confirmed that facility policies titled “Resident Rights” and “Care Planning – Interdisciplinary Team” required that residents and/or their representatives be part of IDT meetings, that such meetings occur within one week of readmission, and that any inability to participate be documented. They acknowledged that these policies were not followed for the resident’s readmissions, and that the resident’s and RP’s rights to be informed of and participate in care planning were not upheld.
Failure to Implement Care Plan Intervention for Foley Catheter Output Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident with an indwelling Foley catheter. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and was documented as having moderate cognitive impairment but able to understand and be understood, without disorganized thinking, acute mental status change, or rejection of care. The resident’s MDS indicated dependence on staff for toileting hygiene, bathing, and personal hygiene, and that the resident and family were active participants in the assessment process. A care plan dated 7/16/2025 for the resident’s indwelling Foley catheter included an intervention for nursing staff to monitor and document the resident’s urine output. Record review of progress notes from 7/2025 through 9/2025 showed no indication that urine output was monitored during that period. The DON confirmed that the care plan intervention to monitor urine output, initiated on 7/16/2025, was not implemented and that the physician was not contacted at that time regarding urine output monitoring. The DON also confirmed that the MARs for 7/2025, 8/2025, and 9/2025 did not show urine output monitoring and that an order to monitor intake and output every shift was not obtained until 10/20/2025, at which point total fluid output monitoring began. The DON stated that standard nursing care for a resident with an indwelling catheter should include measurement and recording of output, and that the failure to implement the care plan intervention from 7/16/2025 until 10/20/2025 placed the resident at increased risk of urinary infection and catheter-related complications. The facility’s policy on comprehensive person-centered care plans indicated that care plans are to describe services furnished to help residents attain or maintain their highest practicable physical well-being.
Failure to Clarify and Implement Physician-Directed Urology Consultation
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that a physician’s documented plan for a urology consultation for one resident was clarified, ordered, and scheduled. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and had an indwelling catheter with complete bowel incontinence. The History and Physical indicated the resident could make medical decisions, and the MDS showed moderate cognitive impairment but the ability to understand and be understood, with no rejection of care and active participation by the resident and family in the assessment process. Physician progress notes dated 9/22/2025 and 10/6/2025 documented a plan for follow-up with urology for urinary retention, and a prior physician order dated 1/27/2025 already indicated a urology consultation for obstructive and reflux uropathy and Foley catheter dependence. Despite these documented plans and orders, review of nursing progress notes for September and October 2025 showed no evidence that nursing staff clarified the physician’s progress notes or coordinated the urology follow-up. During interviews, the physician was unsure whether a urologist had been consulted, and the nurse practitioner stated that she had never reviewed any urology notes or recommendations and did not know if the appointments referenced in the progress notes occurred. The NP stated the resident’s medical history and chronic indwelling catheter placed the resident at high risk of UTIs, sepsis, and hospitalization. An RN acknowledged that licensed nurses are responsible for reviewing physician progress notes, clarifying, and carrying out planned interventions, and stated that nurses should have spoken with the physician to clarify whether a urology appointment was desired, noting that failure to follow up could result in the resident not receiving physician-directed care. The DON reviewed the records and progress notes in conjunction with surveyors, confirming the absence of documentation that the urology consultation was carried out.
Failure to Document Rescheduled IDT Meetings in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical record for one resident when an Interdisciplinary Team (IDT) meeting was rescheduled multiple times. The resident was admitted with a cognitive communication deficit but was documented in the History and Physical as able to make medical decisions and, per the MDS, had moderate cognitive impairment, could understand and be understood, and did not reject care. The MDS also showed the resident was dependent on staff for toileting hygiene, bathing, and personal hygiene, had an indwelling catheter, was always incontinent of bowel, and that the resident and family were active participants in the assessment process. The resident stated she wanted herself and her responsible party to be informed and involved in IDT meetings and care planning decisions. Record review of the resident’s progress notes for the relevant month showed no indication that the IDT meeting had been delayed, rescheduled, or cancelled. The Social Services Director later stated that the resident’s IDT meeting had actually been rescheduled three times at the request of the resident and responsible party, but these changes were not documented in the progress notes. The Social Services Director acknowledged that scheduling or rescheduling of IDT meetings should have been documented in the clinical record, including the new date, the reason for the change, and whether the IDT was informed. The DON stated that the resident’s medical record was incomplete because the cancellations and rescheduling of the IDT meeting, and notification of the care team, were not documented.
Unattended Resident Records with PHI Left in Parking Lot
Penalty
Summary
The facility failed to protect resident-identifiable, personal, and medical information for three sampled residents. During an observation with the Maintenance Supervisor (MS) and the Director of Nursing (DON), five boxes containing invoices with resident names, dates of birth, room numbers, and medical record numbers were found unattended in the facility parking lot. These invoices included information from dietary, lab, intravenous, and equipment services. The MS stated that he had removed the boxes from storage and left them outside in the parking lot approximately two weeks prior, intending to dispose of them later. The DON was unaware of the boxes and stated that documents containing resident information should not have been left outside and should have been shredded. The records reviewed for the three residents included admission records, Minimum Data Set (MDS) assessments, and invoices from pathology and radiology services, all containing sensitive personal and medical information. The residents involved had significant medical conditions such as dysphagia, diabetes mellitus, acute kidney failure, hemiplegia, hypertension, Parkinson's disease, COPD, and major depression, and were all dependent on staff for activities of daily living. The facility's policy required compliance with privacy laws, including HIPAA, and specified that resident information must be kept confidential and properly disposed of, which was not followed in this instance.
Incorrect Thermometer Used in Emergency Food Storage Room
Penalty
Summary
During an observation and interview in the emergency dry food storage room with the Dietary Services Supervisor (DSS), a thermometer labeled for cold food handling and freezer use, with a range of -20 to 70 degrees Fahrenheit, was found in use. The thermometer's gauge was past the 70-degree mark, and the DSS confirmed that it was not the correct type of thermometer for monitoring the room's temperature. The DSS acknowledged that without the correct thermometer, the actual temperature of the room could not be accurately determined, which could affect the safety of the stored food. A review of the DSS job description indicated responsibility for maintaining the food storage area in a safe manner.
Lack of QAPI Documentation and Oversight Results in Repeat Deficiencies
Penalty
Summary
The facility failed to provide meeting minutes and evidence of sufficient governing oversight to demonstrate the maintenance of an effective Quality Assurance and Performance Improvement (QAPI) Program for the last recertification survey of 2024. During an interview, the Administrator confirmed there was no documentation of QAPI activities addressing previous deficiencies in nutrition services and resident assessments. Review of the facility's QAPI policy indicated that the QAPI committee is responsible for helping departments and services implement systems to correct quality of care issues, but there was no documentation to show these responsibilities were fulfilled. This lack of documentation and oversight resulted in repeat deficiencies in resident assessments and food and nutrition services.
Inaccurate MDS Assessments for Medications and Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in incorrect data being transmitted to CMS. For one resident with a history of cerebrovascular accident, congestive heart failure, and hypertension, Gabapentin was ordered for neuropathic pain, but the MDS assessment did not encode this medication as an anticonvulsant under section N0415. The MDS nurse confirmed that Gabapentin should have been classified as an anticonvulsant based on its pharmacological class, regardless of the prescribed reason, and acknowledged the assessment was completed inaccurately. Another resident, diagnosed with cerebrovascular accident, left elbow contracture, and osteoarthritis, developed a stage 2 pressure ulcer on the sacrum prior to discharge. However, the discharge MDS assessment failed to record the presence of this stage 2 pressure ulcer in section M0300. The MDS nurse stated that the assessment reference date for skin conditions was seven days and admitted to providing incorrect information in the discharge assessment sent to CMS. A third resident, with diagnoses including hypertension, diabetes mellitus, and hyperlipidemia, was prescribed Eliquis, an anticoagulant, as documented in the order summary and care plan. Despite this, the MDS assessment did not reflect the resident's use of an anticoagulant. The MDS nurse confirmed the omission and stated that inaccurate assessments could affect the interventions provided to residents. Facility policy required all staff completing any portion of the MDS to attest to the accuracy of the information, but this was not adhered to in these cases.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Nursing staff failed to implement the care plan interventions for a resident who was admitted with intact skin and identified as being at moderate risk for pressure ulcer (PU) development. The resident's care plan included applying barrier cream and performing daily skin checks to prevent skin breakdown, but these interventions were not carried out. Documentation showed that the resident was bedfast, had limited mobility, and required total assistance with personal care, placing them at increased risk for PU. Despite these risk factors, there was no evidence that barrier cream was applied or that daily skin assessments were documented. As a result of these omissions, the resident developed a stage 2 pressure ulcer on the sacral area, which was identified when the resident was transferred to the hospital. Interviews with the treatment nurse and DON confirmed that the prescribed interventions were not followed, and the facility's policy required daily skin inspections and use of barrier products for residents at risk. The lack of adherence to the care plan and facility policy directly led to the development of the pressure ulcer.
Failure to Complete Inventory of Personal Belongings Upon Resident Transfer
Penalty
Summary
The facility failed to complete an inventory of personal belongings for a resident who was transferred to a General Acute Care Hospital (GACH). The resident, who had a history of cerebrovascular accident with hemiplegia, left elbow contracture, and osteoarthritis, was dependent on staff for daily activities such as oral hygiene, dressing, and personal hygiene. The resident's cognitive skills were moderately impaired, requiring cues and supervision for decision-making. Upon review, it was found that the Inventory of Personal Effects form was not completed or signed by a facility representative at the time of the resident's transfer to the hospital. Interviews with the Social Service Director (SSD) and a Registered Nurse (RN) confirmed that it was the SSD's responsibility to track and safeguard residents' personal belongings, and that the inventory should be completed immediately at the time of transfer or discharge. The facility's policy required that residents' personal belongings be inventoried and documented upon admission and updated as necessary. The SSD acknowledged the importance of this process to prevent loss or theft and to protect residents' rights, but the required documentation was not completed for this resident.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, cerebral vascular accident, hypertension, and generalized muscle weakness was found to have their call light out of reach while in bed. The resident was assessed as being dependent on staff for all activities and was care planned as being at risk for falls, with specific instructions to keep the call light within reach. During an observation, the call light was found hanging behind the resident's head, making it inaccessible. Interviews with both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed that the call light should be within the resident's reach to allow them to call for assistance and prevent accidents. Review of the facility's policy also indicated that call lights must be accessible to residents in various settings, including in bed. The failure to ensure the call light was within reach constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Complete and Resubmit PASARR Screening for Resident with Mental Illness Diagnosis
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident who had a diagnosis of major depressive disorder (MDD). The resident was admitted with diagnoses including MDD, cerebrovascular accident with hemiplegia, and hypertension. Review of the resident's Minimum Data Assessment indicated moderately impaired cognitive skills and a need for substantial assistance with daily activities. The PASARR Level I screening, completed by another facility prior to admission, indicated no serious mental illness and the case was closed without a Level II evaluation. During an interview and record review, the Case Manager acknowledged that a new PASARR Level I screening should have been completed and resubmitted due to the resident's diagnosis of MDD, which is considered a mental illness. The Case Manager stated that a positive Level I screening would have triggered a Level II mental health evaluation and referral to the state mental health agency. The PASRR reference manual also indicated that a significant change in a resident's mental condition requires prompt notification to the state authority for re-evaluation.
Failure to Complete Required PASARR Level II Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a required Pre-Admission Screening and Resident Review (PASARR) Level II assessment was completed for a resident with mental health diagnoses. The resident was admitted with diagnoses including hypertension, bipolar disorder, and schizoaffective disorder, and was dependent on staff for several activities of daily living. Documentation from the Department of Health Care Services indicated that a Level II mental health evaluation was required for this resident. Despite receiving notification from the state agency, the facility did not respond to multiple attempts at communication regarding the Level II evaluation. The Medical Records Director acknowledged that the Level I screening was not resubmitted within the required timeframe after the case was closed due to lack of response. As a result, the resident may not have received the necessary psychiatric care as mandated by federal requirements.
Failure to Change Life Vest Battery as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a history of hypertension, diabetes mellitus, and congestive heart failure had the battery in her Life Vest changed according to the physician's order. The resident was dependent on staff for several activities of daily living and had a care plan indicating the need for Life Vest checks as ordered. The physician's order specified that the Life Vest battery should be changed every morning at 6:00 a.m. On the day of the survey, it was found that the night shift did not change the Life Vest battery at the ordered time. A Licensed Vocational Nurse stated that he only changed the battery when it beeped, indicating a low battery, rather than following the scheduled order. The nurse acknowledged that the physician had specified the time for the battery change and that failure to do so could result in the device not monitoring the resident's heart rhythm.
Failure to Maintain Bed in Lowest Position for Resident on Fall Precautions
Penalty
Summary
A deficiency was identified when staff failed to ensure that a resident's bed was maintained in the lowest position as required by the care plan and physician orders for fall precautions. The resident, who had diagnoses including dementia, epilepsy, repeated falls, and muscle weakness, was admitted with a history that placed them at increased risk for falls. The care plan specifically directed that the bed be kept in the lowest position to mitigate this risk. Observations on two separate occasions found the resident's bed not in the lowest position while the resident was in bed. Certified Nursing Assistant 1 and a Licensed Vocational Nurse both acknowledged during interviews that the bed should have been lowered in accordance with fall precaution protocols. The Director of Nursing also confirmed that beds should be kept in the low position to reduce harm from falls. These findings were based on direct observation, record review, and staff interviews.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hypertension, diabetes mellitus, and hyperlipidemia was served a hard-boiled egg at breakfast that was cold and unappetizing. The resident, who was cognitively intact and at risk for nutritional imbalance, reported to surveyors that she frequently received cold food and was unable to eat the cold egg provided. Observations confirmed that the egg was cold to the touch, as verified by both a Licensed Vocational Nurse and the Dietary Services Supervisor, who acknowledged that the egg felt as if it had just come out of the refrigerator and should have been reheated. The Dietary Services Supervisor further stated that eggs are stored in the refrigerator but are expected to be reheated before serving. The job description for the Dietary Services Supervisor included responsibility for ensuring food is appetizing and meets residents' needs. The failure to provide food at an appetizing temperature resulted in the resident being unable to consume the requested protein item at breakfast.
Failure to Accommodate Lactose Intolerance in Dietary Service
Penalty
Summary
The facility failed to honor a resident's preference and medical need for lactose-free milk, despite clear documentation of lactose intolerance and a stated preference for Lactaid at all meals. The resident's admission record, history and physical, and dietary pre-screen all indicated lactose intolerance and a preference for Lactaid. The resident's care plan also specified that the facility would cater to her food preferences. However, during observation, the resident was served low-fat milk with her meal, and her tray card did not indicate her lactose intolerance or preference for Lactaid. The resident reported experiencing abdominal pain and diarrhea when consuming regular milk and stated that she continued to receive low-fat milk with every meal, contrary to her requests. The Dietary Services Supervisor confirmed the resident's lactose intolerance and acknowledged that the provided milk could cause her stomach problems. Facility policy required that resident preferences be detailed on tray cards and that trays be checked for accuracy before delivery, but these procedures were not followed in this case.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) and proper hand hygiene protocols for two residents. For one resident with multiple diagnoses including dementia, epilepsy, unspecified immunodeficiency, dysphagia, and a gastric tube, staff did not wear a gown while providing care, despite physician orders and facility policy requiring EBP for residents with medical devices. The Certified Nursing Assistant (CNA) involved acknowledged not wearing the required gown, and both the Director of Nursing and Infection Preventionist Nurse confirmed that gowns and gloves are necessary under EBP to prevent the spread of multidrug-resistant organisms. In a separate incident, another resident who was dependent on staff for all activities did not receive care in accordance with hand hygiene protocols. The CNA failed to perform hand hygiene before and after feeding the resident and after leaving and re-entering the room, contrary to facility policy. The CNA admitted forgetting to perform hand hygiene, and the Infection Preventionist Nurse confirmed the requirement to wash or sanitize hands before and after resident contact to prevent infection transmission.
Failure to Complete Infection Screening Evaluation Prior to Antibiotic Use
Penalty
Summary
The facility failed to complete the McGeer Criteria Infection Screening Evaluation for one of two sampled residents who was prescribed antibiotics. Specifically, a resident with a history of cerebrovascular accident with hemiplegia, congestive heart failure, and hypertension was admitted and later readmitted to the facility. The resident was noted to have severely impaired cognitive skills and was totally dependent on staff for daily care activities. A physician ordered Clindamycin for a sacral wound infection, but the Infection Preventionist Nurse (IPN) did not complete the required McGeer Criteria Infection Screening Evaluation form within three days of the antibiotic order. During a review of the resident's clinical records, the IPN confirmed that the form, which serves as a guide to determine if the resident meets the criteria for antibiotic use, was not filled out. The facility's policy and procedure on infection surveillance requires the use of standard definitions and criteria for infections, but this was not followed in this case. The IPN acknowledged that without completing the evaluation, she could not validate the appropriateness of the antibiotic prescribed.
Failure to Timely Report and Investigate Alleged Financial Abuse
Penalty
Summary
The facility failed to implement its abuse prevention and reporting policy by not submitting the results of an investigation into an allegation of financial abuse to the California Department of Public Health (CDPH) within five working days of the incident. The incident involved a resident with dementia, osteoarthritis, and acute kidney failure, who was moderately cognitively impaired and dependent on staff for daily care. The Social Service Director (SSD) reported the suspected financial abuse by the resident's representative to Adult Protective Services (APS) and informed the Director of Nursing (DON), but did not notify CDPH, the Ombudsman, or law enforcement as required by facility policy and state regulations. A review of records showed that the initial report to APS was made on the day of the incident, but the required report to CDPH was not submitted until approximately seven months later. The facility's policy mandates that a follow-up investigation report be provided to CDPH within five business days of the incident, but this was not done. The SSD acknowledged during interviews that she was a mandated reporter and that the facility did not conduct or submit the required investigation findings to CDPH in a timely manner.
Resident Bedrooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of usable living space per resident in multiple resident bedrooms for six out of 30 resident rooms. During a facility tour, it was observed that residents in the affected rooms were able to move in and out of their rooms, and there was space for beds, side tables, and resident care equipment. However, the Maintenance Supervisor confirmed that these rooms did not meet the 80 square feet per resident requirement. A review of the facility's policy indicated that bedrooms should measure at least 80 square feet per resident in double rooms and at least 100 square feet in single rooms. The specific rooms identified had between three and four beds each, with total square footage ranging from 181 to 286 square feet, resulting in less than the required space per resident.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy by not reporting an allegation of physical abuse within the required two-hour timeframe. This incident involved two residents, where one resident allegedly hit another. The incident occurred on the evening of December 5, 2024, but was not reported to the California Department of Public Health (CDPH) and the Ombudsman until the following day, December 6, 2024, at 12:29 p.m. This delay in reporting resulted in a delay in the investigation by the CDPH and had the potential to place the affected resident at risk for further abuse. The affected resident, who was allegedly hit, had a history of unspecified dementia, cerebral infarction with hemiplegia, and metabolic encephalopathy, and was assessed to have severely impaired cognitive skills for daily decision-making. The resident required moderate assistance with personal care activities. The resident who allegedly committed the abuse had intact cognitive skills and required supervision for personal care activities. The facility's policy required immediate reporting of abuse allegations, defined as within two hours for incidents involving abuse or serious bodily injury. During interviews, it was revealed that the Licensed Vocational Nurse (LVN) who was aware of the incident did not report it to the Administrator, who is the designated abuse coordinator. The Administrator was responsible for reporting such allegations to the CDPH and Ombudsman. The LVN acknowledged that the allegation should have been reported sooner to ensure the safety of the resident and to allow for a timely investigation. The facility had been cited in the past for late reporting of abuse allegations, indicating a pattern of non-compliance with reporting requirements.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to install floor mats for a resident who was identified as high risk for falls, as indicated in the resident's care plan. The resident, who had a history of metabolic encephalopathy, hemiplegia, dementia, and cerebral infarction, was assessed as high risk for falls. The care plan specifically required floor mats to be placed on both sides of the resident's bed to prevent injury from falls. However, during an observation, it was noted that the floor mats were not in place, which was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged the absence of the mats and the potential risk of injury to the resident. The Director of Nursing (DON) stated that it was the responsibility of the nursing staff to implement care plan interventions, including the provision of floor mats for the resident. The facility's policy on care plans emphasized the importance of providing services to maintain the residents' highest practicable level of well-being, which includes adhering to the care plan interventions. Despite this policy, the failure to provide the necessary floor mats as outlined in the care plan was observed, indicating a lapse in the implementation of prescribed safety measures for the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State agency within the required 24-hour timeframe. The resident, who had diagnoses including dementia, urinary tract infection, hemiplegia, and cerebral infarction, reported to a family member over the phone that someone attempted to crawl into her bed and rape her. The family member dismissed the claim as hallucination and confusion. The Social Services Director was informed of the allegation by the Activities Assistant, who overheard the conversation, and subsequently reported it to the Director of Nursing. Despite being informed, the Director of Nursing did not report the allegation to the State agency, citing the family member's dismissal of the claim as the reason. The Administrator was only informed of the incident several days later. The facility's policy requires immediate reporting of such allegations, defined as within two hours for serious bodily injury or within 24 hours for other allegations. The failure to report the allegation in a timely manner was acknowledged by the staff involved, recognizing the potential risk of further abuse to the resident.
Delayed Reporting of Resident Abuse Incident
Penalty
Summary
The facility failed to implement its abuse Policy and Procedure (P&P) regarding the timely reporting of an abuse incident to the State Licensing/Certification Agency. The policy required that any allegation of abuse be reported immediately, but no later than two hours. However, an incident involving physical assault between two residents was reported to the state agency approximately 14 hours after it occurred. The Director of Nursing (DON) was informed of the altercation shortly after it happened, but delayed reporting to conduct an investigation first. Resident 1, who had diagnoses including heart failure, end-stage renal disease, and hypertension, was physically assaulted by Resident 2, who had schizoaffective disorder, diabetes, and hypertension. Despite the facility's policy, the DON and Administrator acknowledged the delay in reporting the incident, attributing it to the time taken to gather statements and a lack of awareness among nurses about completing the report. This delay in reporting had the potential to hinder the state agency's investigation and placed residents at risk for further abuse.
Failure to Call 911 During CPR for Unresponsive Resident
Penalty
Summary
The facility failed to implement its emergency procedures for cardiopulmonary resuscitation (CPR) by not calling 911 when a resident, who had a full code status, was found unresponsive in bed. The resident, identified as Resident 65, was observed by a Certified Nurse Assistant (CNA) to be flaccid, cool to touch, and nonresponsive. Despite initiating CPR, the facility staff did not call 911, which is a critical step in the emergency response protocol. Resident 65 had a medical history that included encephalopathy, sepsis, acute respiratory failure, and pneumonia. The resident was severely cognitively impaired and required extensive assistance with activities of daily living. On the day of the incident, the resident was found unresponsive at 4:00 a.m., and CPR was performed by two Licensed Vocational Nurses (LVNs) for 20 minutes. However, 911 was not called, and the resident's physician was notified instead, who pronounced the resident deceased over the phone without an in-person assessment. Interviews with facility staff, including the Director of Nursing (DON) and a Registered Nurse (RN), confirmed that the standard procedure during a code blue is to initiate CPR and call 911 immediately. The facility's policy also indicated that staff should continue CPR until emergency medical personnel arrive. The failure to call 911 during the emergency for Resident 65 resulted in the resident's death and placed other residents with full code statuses at risk of not receiving timely life-saving measures.
Removal Plan
- Cardio-Pulmonary Emergencies/CPR in-services were initiated for all licensed staff and certified nurse assistants (CNAs).
- Physician Orders for Life-Sustaining Treatment (POLST) in-services was initiated by the DSD to licensed nurses. Training referred to the section titled Directions for Healthcare Provider.
- The Director of Staff Development (DSD) conducted a review of the employee files pertaining to the nursing dept, specially checking for CPR certifications. The DSD did not find any expired CPR certificates.
- The DON conducted an in-service informing licensed nurses about the notification procedures following a death in the facility which included prompt notification to the DON and Administrator.
- An annotated provider was invited to provide the nursing staff an in-service regarding emergency response during CPR.
- During daily clinical meetings, the DON will review all reported changes in condition to ensure comprehensive assessment of changes, evaluation of initial interventions, identification of additional needs, implementation of adjustments, follow-up, and thorough documentation.
- The Registered Nurse Supervisor will review admissions with a particular focus on POLST and their accurate completion. Any review findings will be completed by the RN, and a summary will be submitted to the DON.
- The RN Supervisor will review any changes of a resident's condition and report any concerns to the DON to ensure adequate interventions were provided.
- The DSD will provide weekly reports on the emergency response CPR review for newly hired staff, if applicable. For employees who undergo annual reviews, the DSD will report monthly to the DON.
- The emergency response system will be reviewed during the annual competency evaluation by the DSD and reported to the DON for acknowledgement.
- The Administrator will update the Quality Assessment & Assurance (QA&A) committee during Quality Assurance (QA) meetings for progress of action plan or if revisions are necessary.
Inaccurate Resident Census in Facility Assessment
Penalty
Summary
The facility failed to update and provide an accurate resident census in its Facility Assessment, which is crucial for determining the resources necessary to care for residents competently. On May 7, 2024, the facility census indicated there were 64 residents, but the Facility Assessment, last revised on January 1, 2024, accounted for only 52-53 residents. This discrepancy was identified during a review on May 10, 2024, when it was noted that the Facility Assessment did not match the current census for the provision of Activities of Daily Living (ADL). During interviews, the Director of Nursing (DON) acknowledged the mismatch between the recorded census and the actual number of residents receiving care. The DON admitted responsibility for maintaining an accurate census and expressed uncertainty about the cause of the error. The Administrator also confirmed that the Facility Assessment should reflect all metrics of care provided to residents, emphasizing the risk of appearing as if some residents were not being cared for. The Centers for Medicare and Medicaid Services (CMS) guidelines require facilities to evaluate their resident population and identify necessary resources for person-centered care, highlighting the importance of accurate census data.
Inadequate Restroom Access for Residents
Penalty
Summary
The facility failed to provide adequate space for two residents, Resident 28 and Resident 39, to access their room's restroom, resulting in psychological harm due to the fear of soiling themselves. Both residents were dependent on staff for assistance with toileting due to their medical conditions, which included dementia, polyneuropathy, hemiplegia, and severe cognitive impairments. Observations revealed that the restroom access was obstructed by a roommate's bed, requiring staff to move the bed or take the residents through an adjacent room to use the restroom. Interviews with the residents and staff highlighted the challenges faced due to the inadequate space. Resident 28 expressed feeling rushed and afraid of soiling herself, while Resident 39 felt frustrated and feared not reaching the restroom in time. Staff members, including a CNA and an LVN, confirmed the need to move the roommate's bed to assist the residents, although the LVN was unaware of the specific procedures used by staff at that station. The Director of Nursing acknowledged the difficulty in accessing the restroom and the potential risks involved, such as limiting residents' ability to use the restroom freely and increasing the risk of falls. The facility's Administrator did not initially believe that the inadequate space reduced the quality of care but recognized the challenges it posed for both staff and residents. The facility's policy on accommodating individual needs indicated that adaptations could be made to the physical environment, such as moving furniture to prevent obstruction. However, the current room arrangement did not align with this policy, leading to the deficiency identified by the surveyors.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which could potentially lead to inadequate care. Resident 44, who has multiple sclerosis, Huntington's disease, and insomnia, did not have a care plan addressing a fall that occurred on March 22, 2024. Despite being dependent on staff for activities of daily living, there was no documented plan to guide staff in providing appropriate care following the fall. Both the Registered Nurse and the Director of Nursing acknowledged the absence of a care plan and emphasized its importance in ensuring residents receive the necessary care and interventions. Resident 16, diagnosed with epilepsy, dyspnea, hemiplegia, and encephalopathy, also lacked a care plan for oxygen administration. The resident, who is dependent on staff for daily activities and lacks decision-making capacity, did not have a documented plan to guide staff in managing their care needs. The Licensed Vocational Nurse confirmed the absence of a care plan and highlighted the risk of improper care without it. Similarly, Resident 53, with Parkinson's disease, asthma, congestive heart failure, and adult failure to thrive, did not have a care plan for their gastrostomy tube. The resident, who is dependent on staff for daily activities and lacks decision-making capacity, had a physician's order for enteral feeding but no care plan to guide staff in its administration. The Licensed Vocational Nurse and the Director of Nursing both recognized the importance of care plans in guiding staff and ensuring proper care for residents.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications, leading to potential medication errors. For one resident who was discharged, nine medications were found unlabeled in the medication storage closet. The medications included Mirtazapine, Metoprolol, Atorvastatin, Famotidine, Eliquis, and Carbidopa-Levodopa. The Registered Nurse (RN) responsible for collecting and labeling these medications did not follow the facility's policy, which requires labeling with the resident's name, discharge location, and date of transfer. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the absence of labeling and acknowledged the risk of medication errors due to improper storage. Additionally, the facility failed to label multi-dose medications with an open date for two residents. One resident was receiving lactulose for constipation, and another was receiving insulin lispro for diabetes management. During an observation, it was noted that the multi-dose vial of insulin lispro and the container of lactulose did not have open dates. The Licensed Vocational Nurse (LVN) stated that the open date is crucial for determining the expiration of the medication, and the absence of this information could lead to the administration of expired and potentially ineffective medication. The facility's policies on medication storage and disposal were not adhered to, as evidenced by the lack of labeling and proper disposal of medications. The facility's policy requires that discontinued or outdated medications be returned to the pharmacy or destroyed, and that multi-dose containers be labeled with the date opened. The failure to comply with these policies was confirmed by the DON, who acknowledged that such oversights could result in medication errors and ineffective treatment for residents.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Several food items in the dry storage area, Refrigerator 1, Freezer 1, Freezer 2, and Freezer 3 were not dated and labeled, which could lead to confusion about the freshness and safety of the food. The Dietary Service Supervisor acknowledged that all food items should be labeled and dated according to the facility's policies. The facility's policies from 2018 require labeling and dating of all food items upon delivery and during storage to ensure proper rotation and usage. Additionally, there were multiple instances of inadequate hand hygiene and glove use among the dietary staff. Dietary Aide 1 did not wash hands or wear gloves while cleaning a stainless-steel table, and another staff member handled a scooper with bare hands. Dietary Aide 2 failed to wash hands after picking up a dirty towel from the floor. These actions were contrary to the facility's hand hygiene policy and the 2022 U.S. Food and Drug Administration Food Code, which emphasize the importance of handwashing to prevent cross-contamination and foodborne illnesses.
Improper Garbage Disposal
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster area in a sanitary manner. During an observation and interview with the Dietary Service Supervisor (DSS), it was found that one garbage dumpster was overfilled, preventing the lid from closing. The DSS acknowledged that the open lid was due to the overfilled trash and stated that open trash bins attract unwanted pests. This situation was in violation of the 2022 U.S. Food and Drug Administration Food Code, which requires outside receptacles to have tight-fitting lids to prevent the scattering of garbage and entry of pests. Additionally, the facility's policy and procedure on food-related garbage and refuse disposal, revised in 2017, mandates that outside dumpsters be kept closed and free of surrounding litter.
Failure to Document Change of Condition and Notify Responsible Party
Penalty
Summary
The facility failed to ensure a change of condition was documented and the responsible party was notified for a resident who was transferred to the hospital. The resident, who had diagnoses including acute kidney failure, cerebral infarction, dementia, and hypertension, was admitted to the facility with the capacity to understand and make decisions. Despite this, there was no documentation of a change of condition for the hospital transfer, which is a requirement according to the facility's policy. Interviews with the LVN and the DON revealed that the lack of documentation meant there was no way to confirm if the physician or responsible party was notified, potentially leading to the resident's condition worsening. The facility's policy mandates that a nurse must notify the resident's representative of significant changes in the resident's status, including hospital transfers, within twenty-four hours, except in emergencies. This deficiency violated the resident's rights and the responsible party's right to be informed.
Inaccurate MDS Assessment for Resident's Range of Motion
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, specifically regarding functional limitation in range of motion. The resident, who was admitted with diagnoses including osteoarthritis and contractures, had a Rehab Joint Mobility Screen Assessment indicating severe impairment in range of motion in multiple joints. However, the MDS assessment inaccurately recorded no impairment in the lower extremities, which was acknowledged as incorrect by the MDS nurse during a review. The MDS nurse admitted that the assessment should have been coded to reflect impairment on both sides of the lower extremity, emphasizing the importance of accuracy for proper interventions and facility reimbursement. The Director of Nursing confirmed that the standard practice is to provide accurate MDS assessments to ensure adequate and quality care. The facility's policy requires individuals completing portions of the MDS to certify the accuracy of their assessments, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 8,068 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Inglewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Century Villa, Inc | 0.2 mi | ★★★★★ | 12 | 0 |
| Inglewood Health Care Center | 0.7 mi | ★★★★★ | 32 | 0 |
| Hyde Park Healthcare Center | 0.8 mi | ★★★★★ | 30 | 0 |
| Lotus Care Center | 1 mi | ★★★★★ | 14 | 0 |
| Centinela Skilled Nursing & Wellness Centre West | 1.5 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.