Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Postacute Care during CMS and state inspections, most recent first.
A resident with prostate cancer and high fall risk had repeated unwitnessed falls, and a physician ordered a 1:1 sitter after one of the falls. Staff interviews and record review showed the sitter was cancelled because of staffing/overstaffing concerns, and CNAs were instead told to alternate every 30 minutes. The resident did not have continuous 1:1 supervision during the night shift, and he later fell again and sustained a skin tear to his elbow.
Incomplete documentation of meal assistance and intake. A resident with stroke-related right-sided weakness and dysphagia was totally dependent on one staff member for eating, but the chart had multiple missing entries for assistance with eating and amount eaten. CNA staff said they assisted the resident and documented intake electronically, while the DSD confirmed the ADL tasks were incomplete and the DON stated that anything not documented is not done.
The facility failed to provide required quarterly trust account statements to multiple residents and a responsible party whose personal funds were managed in facility-held trust accounts. Several alert and oriented residents reported not receiving any quarterly statements despite having active trust accounts, including residents with documented capacity to make decisions and one with a BIMS score indicating intact cognition. Another resident’s responsible party reported never receiving statements for her family member’s trust account, even though the resident had severe cognitive impairment and the RP was designated to manage finances. The BOM stated that statements were only provided upon request and that none had been issued since his employment began, while the ADM stated statements were supposed to be automatically mailed but acknowledged there was no procedure to ensure they were sent or received, and no relevant policies were produced when requested.
The facility improperly charged four residents’ trust accounts for private room and board during a month when each had documented Medi-Cal coverage. Business records showed that each resident’s trust account was debited the same substantial amount for private room and board while Eligibility Responses confirmed Medi-Cal benefits for that period, and payer setup information or billing practices reflected private pay status instead of Medi-Cal. The BOM acknowledged that these residents were switched from Medi-Cal to private pay despite having billable Medi-Cal benefits and that their trust funds should not have been charged, and the ADM confirmed residents are not supposed to be billed for Medi-Cal-covered services. The facility’s admission agreement also stated that a Medi-Cal-participating facility may not require a resident to remain in private pay status before converting to Medi-Cal coverage, and requested Medi-Cal billing policies were not provided.
The facility changed four residents from Medi-Cal coverage to private pay and debited $16,197.50 from each of their trust accounts for private room and board without obtaining consent from the residents or, where applicable, their responsible party. Business office records and eligibility responses showed that all four residents had billable Medi-Cal benefits for the month in question, yet payer setup documents reflected private pay billing for that period, followed by a later switch back to Medi-Cal-IEHP. The residents, who had diagnoses including dementia, schizophrenia, psychotic disorder, metabolic encephalopathy, and altered mental status, were either self-responsible or had a designated responsible party, but interviews revealed they were unaware of having a facility-managed account or of any large withdrawals, and one responsible party stated she did not know a trust balance existed. The Accounts Receivable Director, Business Office Manager, and Administrator acknowledged that the residents did not request the change to private pay, that the debits were made by facility decision despite Medi-Cal eligibility, that there was no documented consent for the withdrawals, and that residents are not supposed to be charged for Medi-Cal-covered benefits, while census records showed all four residents remained in three-bed rooms with roommates during the period they were charged for private room and board.
A resident with severe cognitive impairment had a trust account balance of over $14,000, far above the $2,000 threshold that staff, including the DAR and BOM, identified as placing Medicaid/SSI eligibility at risk. Although facility practice required notifying the resident or RP and arranging an IDT meeting to discuss spend down when a trust account exceeded this limit, there was no documentation that the RP was informed. The RP later stated she did not know a trust account existed, believed the resident’s Social Security income was used entirely for room and board, and had never been told about the balance or its impact on Medi-Cal/SSI eligibility. Requested policies on notification of account balances and benefit eligibility limits were not provided.
Missed Medication Administration and Follow-Up Failures Multiple residents missed ordered doses of anticonvulsants, an antiviral, antidiabetic medication, thyroid medication, antipsychotics, a blood thinner, and other routine meds because the drugs were not available, not in the cart, or awaiting pharmacy delivery. Records showed repeated eMAR omissions, and staff interviews confirmed that nursing did not consistently contact the pharmacy or notify the MD when doses were missed. One resident with epilepsy missed Lacosamide for an extended period, and another resident with shingles missed several Acyclovir doses because the supply sent was incomplete.
Lack of Written QAPI Plan for Call Light Response Issues: Surveyors found that the facility did not have a written QAPI plan addressing systemic delays in response to residents' call lights. The ADM and DON acknowledged awareness of late call light responses from residents' council meetings, and record review showed the facility had an outdated QAPI policy dated August 2017 describing a facility-wide, data-driven process to improve resident care, outcomes, and safety.
A kitchen steam table was not fully functional for several weeks, with RD audits showing one well at 0.98 degrees F and another steam well not reaching the required 180 degrees F. A resident with DM stated he received cold food, and the RD reported the issue affected her test tray. The MND said he was not aware of the problem until late January, despite facility policy requiring kitchen equipment to be kept in working order.
Staff failed to knock and obtain permission before entering multiple resident rooms. A CNA was observed entering two residents' rooms without knocking, another CNA entered a resident's room without permission, and a Maintenance Director entered three residents' rooms the same way. One resident stated he did not like the unannounced entry and felt his privacy was not respected; the DSD said the facility expected staff to knock and obtain permission before entering rooms for respect and dignity.
Call lights were not within reach for four residents with dementia, blindness, weakness, or communication issues. A resident was yelling for help and could not see the call light, another could not reach it while reporting diarrhea, and two others had call lights placed out of reach or under the bed. Records and care plans directed staff to keep call lights within reach, and the DON confirmed that was the facility expectation.
A facility failed to ensure follow-up information was provided to residents or their RPs regarding the right to formulate an AD for 10 sampled residents. Records showed several residents had intact decision-making capacity or had expressed a desire to complete an AD, while others lacked capacity and had RP involvement, but documentation did not show consistent follow-up with the resident, RP, or ombudsman. The SSD and SSA acknowledged gaps in documentation and follow-up for the AD process.
Insufficient Nursing Staffing and Delayed Call Light Response: Residents reported long waits for call light response, often 25 minutes or more, and several described delays of 30 to 60 minutes for help with needs such as water or incontinence care. CNAs stated the facility was short staffed and assigned too many residents, while the DSD, Staffing Coordinator, and ADM acknowledged staffing shortages and the lack of registry use. Staffing records showed multiple shifts below the facility assessment’s CNA and LVN needs, and an RN stated it was difficult to function as nurse supervisor while also passing meds.
Multiple residents missed ordered meds because pharmacy and facility supply processes failed to keep medications available, including anticonvulsants, antivirals, diabetes and thyroid meds, and Melatonin. New admissions also missed scheduled PPD skin tests because PPD solution was not on hand, and an RN could not locate OTC items in stock rooms or carts. For one resident with asthma/COPD, Albuterol inhalation was not available in the med cart when needed.
A consultant pharmacist failed to identify and report multiple medication irregularities during monthly DRR when nurses documented that several residents did not receive prescribed meds because they were unavailable. The missed doses involved anticonvulsants, antibiotics, thyroid, diabetes, anticoagulant, cholesterol, and psychotropic medications, and the pharmacist stated she reviewed the eMARs but was unaware of the missed doses because she had not received reports about delivery issues.
A resident with a urinary catheter had no EBP signage posted outside the room, a dietary aide touched the kitchen floor and returned to food handling without changing gloves or washing hands, a CNA tried to reapply a nasal cannula that had been on the floor, staff passed meal trays without hand sanitizing between residents, and a suction machine in another resident’s room was unlabeled with contents left in the canister. These events were confirmed by staff interviews and record review, and the facility policies cited in the report required EBP signage, hand hygiene, proper glove use, discarding contaminated respiratory tubing, and emptying suction canisters.
Call Light System Lacked Audible Notification: A resident's call light was observed on at the nurse station panel without any audible sound, and no staff member was present at the nurse's station. The MND, CNA, ADM, and DSD all stated the system had not been sounding, while the ADM confirmed the call light system should have both visual and audible notification. The facility policy stated maintenance is responsible for keeping equipment safe and operable.
Failure to Timely Report Alleged Resident-to-Resident Physical Abuse: A cognitively intact resident with a 1:1 sitter reported that his wheelchair-bound roommate threw a urinal full of urine at him while he was in bed. The CNA sitter witnessed the incident but did not report it because she did not think it was abuse, and the facility did not promptly notify CDPH within the required timeframe after learning of the alleged physical abuse.
A resident had OTC multivitamins and throat lozenges at the bedside without a physician order for self-administration, despite records showing the resident was not assessed as requesting or being able to safely self-administer meds. Another resident receiving Methimazole for hyperthyroidism had no active lab orders or documented thyroid lab results to monitor the medication's effectiveness or safety, and the DON acknowledged the missing orders.
A resident with COPD was observed receiving O2 at 6 LPM even though the MD order was for 2 LPM, and another resident with chronic respiratory failure and COPD was found without ordered continuous O2, with the NC on the floor and later not in use while the resident was out of the room. A third resident’s O2 tubing and storage bag were not labeled per facility practice; an LVN stated the tubing should have been labeled with the resident’s name and date applied and changed weekly.
Food Preference Not Honored for A Resident With No-Lettuce Preference. A resident with mild protein calorie malnutrition and intact cognition was observed eating lunch with lettuce on the plate despite a documented no-lettuce preference on the meal ticket and diet order. The resident stated staff kept bringing lettuce even though she had said she did not want it and could not chew it because she had no teeth. The DS confirmed the preference should have been followed, and the RD stated she was unaware the resident’s preferences were not being honored.
A resident with decision-making capacity and multiple chronic conditions was assessed and approved to self-administer only a specific bowel care medication, yet surveyors observed numerous additional OTC and supplement medications stored at the bedside and taken as needed by the resident without documentation. Nursing staff and the DON reported that residents are not permitted to keep or self-administer medications without physician orders and inclusion on a self-administration assessment, and that self-administered doses must be reported for MAR documentation. The DON confirmed that the medications found at the bedside were not ordered, not included on the self-administration assessment, and were not being tracked, contrary to the facility’s self-administration policy requiring IDT review, secure storage, and clear documentation processes.
A resident with significant neurologic and cognitive impairments, who was dependent on staff for mobility and incontinence care, activated the call light for a brief change and waited 31 minutes before staff responded. During this period, other staff entered the room but did not address the illuminated call light. The assigned CNA was on a meal break, while the TN and a housekeeper later confirmed that all staff are responsible for answering call lights, which facility policy states should be addressed and, if possible, completed within five minutes.
The facility failed to notify four residents and/or their responsible parties when their primary payor was changed from Medi-Cal IEHP to private pay, contrary to resident rights and the facility’s pay source conversion policy. Electronic census records showed that all four residents were converted to private pay effective the same date, but interviews with cognitively intact and moderately impaired residents revealed they were unaware they were paying privately or what the costs were, and a responsible party reported receiving no notification of the change. The BOM, ADM, and DOF gave conflicting accounts of responsibility and communication processes, with the BOM stating she was not informed of the corporate-initiated changes, the ADM stating the BOM should notify residents and report changes in meetings, and the DOF stating that facility leadership should explain and document payor changes, while also acknowledging the decision to convert these residents to private pay was made at the facility level without documented Medi-Cal direction.
A resident with a history of TIA and vascular dementia, documented as self-responsible and able to make decisions, authorized the LTCO in writing to obtain copies of the resident’s financial records, including trust account reports, representative payee documents, and a financial summary of coverage and share of cost. The LTCO emailed this request and the signed consent to the BOM, who stated she normally provides such financial information promptly and is expected to respond within 24 hours and fulfill requests by the next business day. Despite this, the BOM did not provide the requested records, and 12 days elapsed without fulfillment of the request, resulting in a failure to provide timely access to the resident’s financial records as required.
Two residents with significant cognitive impairment were not protected from abuse. In one case, a dependent resident with dementia and severe cognitive deficits was left unsupervised on a smoking patio, where a cognitively intact resident was witnessed by a CNA touching the resident’s breast and attempting to raise the resident’s shirt while the resident said "no." In the other case, a resident with traumatic brain injury, Parkinson’s disease, psychosis, and no decision-making capacity was heard screaming while a CNA stood over the resident and repeatedly told the resident to "shut up," as reported by another cognitively intact resident to an LVN. These events occurred despite facility policies stating residents must be free from sexual and verbal abuse and treated with respect and dignity.
Surveyors found that two residents who smoked were keeping cigarettes and lighters at their bedsides, despite staff statements and facility policy that residents were not allowed to have smoking materials and that only activities staff should control them. One resident, with nicotine dependence and decision-making capacity, was documented as a non-smoker and had no current smoking assessment reflecting his actual smoking status, yet was allowed to smoke without a valid assessment or supervision. Another resident, with COPD, diabetes, major depressive disorder, and fluctuating decision-making capacity, had a care plan requiring supervised smoking with all smoking materials kept in a smoking cart, but was observed with both cigarettes and a lighter in her nightstand. The DON confirmed that assessments and practices did not align with facility policy, which allowed independent smokers to keep cigarettes but prohibited residents from keeping lighters.
Staff failed to follow the facility’s hydration process and policy requiring NOC shift CNAs to replace and refill bedside water pitchers daily, resulting in two residents being observed on consecutive days with teal water pitchers only one-quarter full and not refilled. Both residents, who had conditions including DM, CKD, hypotension, lung CA, and a moderate cognitive deficit, reported that their pitchers had not been refilled for at least two days, despite care plans directing staff to encourage fluids, in-between snacks and fluids, and good nutrition and hydration to support skin health. A CNA acknowledged that the NOC shift appeared not to have refilled the pitchers, and the ADM stated that this failure could place residents at risk for dehydration.
An LVN entered the room of a COVID-19 positive resident posted with contact and droplet precaution signage wearing only a surgical mask, gown, and gloves to check blood sugar, despite facility policy and CDC guidance requiring an N95 respirator and eye protection for care in a COVID isolation area. The LVN acknowledged that an N95 and face shield should have been used, and both the IP nurse and DON confirmed that proper PPE for this situation included gown, gloves, N95 respirator, and face shield, in accordance with the facility’s written COVID-19 infection prevention and control policy.
A CNA placed a towel over a non-verbal, dependent resident's mouth during care while the resident was coughing, as the CNA was not wearing a mask. Another CNA witnessed and intervened, removing the towel. The resident was unharmed, and facility leadership confirmed this action violated abuse prevention policy.
A facility failed to report an allegation of physical abuse involving a resident with fluctuating decision-making capacity to CDPH within the required two-hour timeframe. A CNA witnessed another CNA place a towel over a resident's head and mouth but delayed reporting the incident, resulting in a two-day gap before authorities were notified, contrary to facility policy and federal requirements.
A resident with end stage renal disease and significant mobility limitations was transported to dialysis appointments via Uber instead of a wheelchair van, resulting in unsafe transfers, missed or delayed dialysis, and actual injury including a chest-wall hematoma and possible rib fractures. Staff and the resident reported the transportation was inappropriate and uncomfortable, and the facility did not conduct an interdisciplinary assessment of transportation needs prior to arranging Uber rides.
A resident with mobility limitations and recent foot surgery was transported to dialysis appointments in a standard vehicle instead of a wheelchair-accessible van after the facility changed transportation providers without updating the care plan or involving the resident and family. The care plan lacked interventions for safe transport, and the change led to missed treatments, hospitalization, and injury.
The facility had multiple kitchen sanitation and food storage failures, including expired minced garlic left available for use, Romaine lettuce stored exposed to open air, a deeply indented cutting board, and hot water thermos spurs with calcium build-up and grime. Two DA staff did not follow manufacturer directions when testing Quat sanitizer, and dietary staff gave incorrect answers about the dishwasher chlorine concentration, while the RD and DSS stated proper labeling, storage, and sanitation practices were expected.
Failure to Document Follow-Up on AD Requests: The facility did not document follow-up information for 10 residents who either wanted more information about an AD or had no AD on file. Records showed residents with varying cognitive status, including some who were cognitively intact and others with significant impairment, but quarterly SS assessments did not reflect follow-up on their AD preferences. The SSD acknowledged the missing documentation and stated she had not followed up with all residents to honor their requests for the right to formulate an AD.
Missing Annual CNA Performance Evaluations: The facility failed to complete annual performance evaluations for four of five CNAs reviewed. One CNA had no recent evaluation in the personnel file, and three other CNAs had no evaluation found at all. The DSD confirmed that annual evaluations are required and that job performance is to be reviewed at least annually.
Staff failed to follow infection control precautions during direct care for multiple residents on EBP. An LVN and CNAs were observed providing care without the required gown, and one CNA stated she did not check the EBP sign before entering the room. In addition, an LVN cleaned a BP machine with hand sanitizing wipes instead of the facility’s germicidal surface wipes, despite policy and IP guidance requiring proper disinfection of resident-care equipment.
A resident with a history of playing loud music and verbally abusing others was not effectively managed, despite ongoing complaints and documentation of the behavior. Staff failed to implement or update care plans or interventions, resulting in another resident feeling threatened and verbally abused. The responsible resident was cognitively intact and refused offered interventions, but no further actions were taken to address the situation.
A resident with diabetes and peripheral vascular disease developed a new skin avulsion on the left second toe after podiatric treatment. The wound was not consistently evaluated or monitored as a change of condition, and required documentation and shift-to-shift monitoring were not completed, resulting in a deficiency in care.
A resident with asthma remained in the facility after Medicare Part A coverage ended, but the record contained no completed SNF ABN or written notice about financial liability for continued skilled services. The ADM confirmed the SNF ABN was not provided and that the resident was not informed in writing that he was financially liable for the continued skilled services.
Incomplete and Missing Personal Property Inventories: The facility failed to account for two residents’ personal property when one resident’s inventory list could not be located and another resident’s inventory form was missing the staff signature. One resident reported missing partial dentures and had a diagnosis of schizoaffective disorder with intact cognition on MDS, while the other resident, who had dementia and moderate cognitive impairment on MDS, reported missing clothing items. The DON and LVNs stated the inventory forms are used to verify residents’ belongings at admission.
A resident with schizoaffective disorder had PASRR Level II recommendations for psychotherapy/counseling and psychiatry consultation, but the facility did not include these services in the resident’s care plan. The CM confirmed the PASRR recommendations were not followed and that psychotherapy was not provided, despite the determination report stating the facility would incorporate the recommendations into the care plan.
Failure to maintain a resident’s fingernail hygiene. A resident with impaired vision had long, yellow fingernails noted during observation, despite a care plan calling for nail checks, trimming, and cleaning. The resident said he would accept staff help with nail care so he would not scratch himself. A CNA, DSD, and DON all stated CNAs were expected to check and clean fingernails daily, and that the resident should have been offered nail care.
Inconsistent Meal Intake Documentation: A resident with moderate protein-calorie malnutrition had multiple missed meal intake entries in the chart over a 30-day period. Staff interviews confirmed CNAs were responsible for documenting every meal and that licensed nurses were expected to review intake daily, but the record showed repeated gaps in breakfast, lunch, and dinner documentation, preventing consistent monitoring of nutritional status.
Failure to Follow Dental Recommendations: A resident with dysphagia and edentulous oral condition was seen by dental staff and recommended for full upper dentures, perio charting, dental prophylaxis, and full mouth x-rays. The SSD did not follow up on the dental note because she did not understand the recommendations, and there was no documentation that the resident’s dental needs were addressed.
A resident's call light was not working, and the resident stated staff did not respond when it was pressed, forcing him to scream for attention. A CNA and an LVN both confirmed the call light did not function, and another resident said he had been using his own call light to summon staff for the affected resident. The DON stated the call light is meant to notify staff when residents need assistance, and the facility policy required it to be plugged in and functioning at all times.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident was re-admitted with open wounds and peripheral vascular disease, but did not receive wound treatment for three days due to the absence of physician orders and lack of documentation. Staff interviews confirmed that the admitting RN did not obtain or clarify treatment orders, and the facility's policy requiring prompt notification and treatment for skin breakdown was not followed.
A CNA was witnessed by two staff members roughly pushing a cognitively impaired resident multiple times to prevent the resident from getting up from bed. The resident, who had severe cognitive impairment and multiple mental health diagnoses, was found with redness and swelling on the face after the incident. Facility policy prohibits any form of abuse or rough handling.
A resident at high risk for pressure injuries was re-admitted with a blister on the right elbow that was not assessed, documented, or treated by nursing staff. The lack of assessment and intervention allowed the blister to worsen, resulting in a Stage 4 pressure injury with exposed bone, contrary to facility policy and standard nursing protocols.
Failure to Maintain Ordered 1:1 Sitter for a High Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered 1:1 sitter was consistently implemented for Resident 2, who was admitted with diagnoses including prostate cancer and was identified as a high fall risk on the facility’s fall assessment. Resident 2 had multiple unwitnessed falls documented on May 12, 2026 at 4:00 a.m. and May 13, 2026 at 12:50 p.m., and an order for a 1:1 sitter was entered on May 13, 2026. The record and staff interviews indicated that the sitter assignment was later cancelled because of staffing concerns and overstaffing concerns, despite the order being in place. Staff interviews showed that the facility’s plan was for CNAs to alternate every 30 minutes rather than provide a continuous 1:1 sitter, and CNA 2 stated there was no sitter for Resident 2 during the night shift when she was assigned to him. RN 1 stated the sitter assignment was removed due to miscommunication between management and staffing concerns, and that Resident 2 did not have a 1:1 sitter during the night shift beginning at 11:00 p.m. on May 13, 2026. The staffing coordinator also confirmed that a CNA initially assigned as the sitter for the night shift was cancelled due to overstaffing. Resident 2 then had another fall on May 14, 2026 at 1:20 a.m. and was found on the floor mat with a skin tear to his left elbow. LVN 1 stated the resident was very confused and a fall risk, and that after the earlier fall he had been moved closer to the nurses’ station and a 1:1 sitter order was initiated. RN 2 stated the resident needed a 1:1 sitter for safety because he could still get himself onto the floor even when in a wheelchair or low bed. The DON stated the resident should have had a sitter on the night shift of May 13, 2026 as ordered.
Incomplete Documentation of Meal Assistance and Intake
Penalty
Summary
The facility failed to ensure Resident 1’s medical record accurately reflected the care and services provided when multiple meal assistance and meal intake entries were missing from the electronic documentation. Resident 1 was admitted with diagnoses including stroke with right-sided weakness and dysphagia, and the history and physical indicated the resident had the capacity to understand and make decisions. The care plan identified the resident as totally dependent on one staff member for eating. A review of the documentation survey report for May 2026 showed missing entries for assistance with eating and nutrition/amount eaten on multiple dates, including breakfast and lunch on several days and dinner on one date. During interview, Resident 1 stated she needed assistance to eat. CNA 1 stated she assisted Resident 1 with eating and said the resident ate 60% of meals, but also stated missing entries occurred because the computer was not working and the facility did not have Wi-Fi for three days. The DSD stated CNAs are expected to document daily for breakfast, lunch, and dinner, and confirmed the eating and nutrition tasks had incomplete documentation for the month. The DON stated that anything not documented is not done and questioned how staff would know if Resident 1 was eating when there was no documentation.
Failure to Provide Quarterly Trust Account Statements to Residents and Representatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required quarterly trust account statements to residents or their responsible parties (RPs) for resident funds managed by the facility. Surveyors interviewed multiple residents and an RP and reviewed medical and financial records. One resident, who was alert and oriented at the time of interview, stated he did not have a bank account or receive mail at the facility, but record review showed his trust account with the facility was opened on November 26, 2025, and his BIMS score indicated severe cognitive impairment. Another resident, alert and oriented, reported that her Social Security checks were sent directly to the facility and that she had a share-of-cost obligation, but she did not receive quarterly statements to track deposits and withdrawals; records showed her trust account was opened on August 1, 2024, and she had capacity to make decisions. A third resident, cognitively intact with a BIMS score of 14, stated he had not received quarterly statements for his trust account, which records showed was opened on November 30, 2018. A fourth resident, who had capacity to make decisions per the history and physical, stated he was unaware if he had a trust account and had not received a quarterly trust account statement, despite records indicating his trust account was opened on September 15, 2025. A fifth resident was alert but nonresponsive and could not be interviewed; her medical record showed severe cognitive impairment with a BIMS score of 0, and that her daughter was the RP. In a phone interview, the RP stated she had never received quarterly statements for this resident’s trust account, which had been opened on September 1, 2024. During a concurrent interview and record review, the Business Office Manager (BOM) stated that the facility’s process was to provide quarterly trust account statements only upon demand request by the resident or RP, and further stated that since his employment began on February 17, 2026, the business office had never provided quarterly trust account statements to residents or RPs. The Administrator later stated that quarterly statements were supposed to be automatically mailed from the business office, but acknowledged there was no procedure in place to ensure residents or RPs actually received the statements and confirmed with the corporate Director of Accounts Receivable that residents or RPs should have been receiving quarterly trust account statements. When policies related to resident trust accounts and quarterly statements were requested, the facility did not provide them.
Improper Charging of Resident Trust Funds for Medi-Cal-Covered Room and Board
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal funds from being charged for services covered by Medi-Cal. For four residents whose records were reviewed, the facility debited their trust accounts for private room and board charges for a month in which they had documented Medi-Cal coverage. Facility business records, including the Trust - Transaction History and Activity Reports, showed that each of these residents’ trust accounts was debited $16,197.50 for private room and board for the same month. Eligibility Response documents dated at the beginning of that month indicated that each of these residents had Medi-Cal covered benefits for that period. Resident 7 was re-admitted with diagnoses including dementia, schizophrenia, and bipolar disorder, and had a BIMS score indicating severe cognitive impairment. Despite an Eligibility Response showing Medi-Cal coverage for the month in question, the Payer Setup Information showed that this resident was billed as private pay, and the trust account was debited $16,197.50 for private room and board. Resident 10, admitted with dementia and a psychotic disorder and documented to have fluctuating capacity but a BIMS score indicating cognitive intactness, similarly had Medi-Cal coverage per the Eligibility Response, yet the Payer Setup Information listed private pay status and the trust account was debited the same amount for private room and board. Resident 11, re-admitted with metabolic encephalopathy and dementia and documented as having capacity to make decisions, also had a Trust - Transaction History showing a $16,197.50 debit for private room and board for the month, while an Eligibility Response confirmed Medi-Cal coverage for that same period. Resident 12, re-admitted with metabolic encephalopathy, dementia, and altered mental status, had severe cognitive impairment per BIMS and a daughter listed as the responsible party. This resident’s Trust - Transaction History and Care Activity Report showed a $16,197.50 debit for private room and board for the month, despite an Eligibility Response confirming Medi-Cal benefits and Payer Setup Information indicating the resident was billed as private pay. In interviews, the Business Office Manager explained that the facility’s process is to recommend residents enroll in Medi-Cal as secondary insurance to avoid private pay charges when Medicare coverage ends, and stated that residents are only transferred to private pay when they do not have secondary insurance. The Business Office Manager acknowledged that on the first day of the month in question, each of the four residents was switched from Medi-Cal to private pay despite documented evidence of billable Medi-Cal benefits for that month, and that their trust accounts should not have been charged $16,197.50 for private room and board. The Administrator similarly stated that residents are not supposed to be charged for Medi-Cal covered benefits and confirmed that these four residents should not have been switched to private pay to cover services that Medi-Cal would have covered. The facility’s standard admission agreement also stated that no Medi-Cal-participating facility may require any resident to remain in private pay status before converting to Medi-Cal coverage, and requested Medi-Cal billing policies were not provided.
Unauthorized Debiting of Resident Trust Funds for Private Pay Charges Despite Medi-Cal Eligibility
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal funds and prevent misappropriation when it unilaterally changed four residents from Medi-Cal coverage to private pay and debited $16,197.50 from each of their trust accounts for private room and board without their or their responsible parties’ consent. For Residents 7, 10, 11, and 12, business office records showed that on a specific date their trust accounts were each debited $16,197.50 for private room and board for a given month, despite documentation that all four residents had Medi-Cal-covered benefits for that same month. Payer setup and eligibility response documents confirmed that these residents were eligible for Medi-Cal (including Medi-Cal-IEHP) and that they were nonetheless billed as private pay for that month, with a later change back to Medi-Cal billing effective the following month. Resident 7 was re-admitted with dementia, schizophrenia, and bipolar disorder, and had a BIMS score of 7 indicating severe cognitive impairment, yet was listed as self-responsible. Facility trust transaction records showed a $16,197.50 debit from this resident’s trust account for private room and board for the month in question, even though an eligibility response documented Medi-Cal coverage for that month. There was no documented evidence that Resident 7 was notified of or consented to being changed to private pay or to the withdrawal from the trust account. During interview, Resident 7 stated he did not know he had a bank account with the facility and indicated that if someone withdrew a large amount of money without his knowledge, he would report it to the bank and law enforcement. Resident 10 was admitted with dementia and a psychotic disorder, had a history and physical noting fluctuating capacity to understand and make decisions, and had a BIMS score of 14 indicating cognitive intactness, and was also listed as self-responsible. Trust transaction records showed a $16,197.50 debit for private room and board for the same month, while eligibility responses documented Medi-Cal coverage for that month and the following month. Payer setup information showed the resident was billed as private pay for that month and then changed to Medi-Cal-IEHP the next month. There was no documented evidence that this resident was notified of or consented to the change to private pay or the trust account debit. In interview, the resident was unsure if he had a bank account with the facility and stated that if someone took his money without his knowledge it would anger him. Resident 11 was re-admitted with metabolic encephalopathy and dementia, was listed as self-responsible, and had a history and physical indicating capacity to make decisions. Trust transaction records showed a $16,197.50 debit for private room and board for the month in question, and an eligibility response documented Medi-Cal coverage for that month. The activity report confirmed the same debit amount and date. There was no documented evidence that this resident was notified of or consented to being changed to private pay or to the withdrawal from the trust account. In interview, the resident was unsure if he had a bank account with the facility and stated he would be upset if someone took money from his account. Resident 12 was re-admitted with metabolic encephalopathy, dementia, and altered mental status, had a BIMS score of 0 indicating severe cognitive impairment, and had a daughter identified as the responsible party. Trust transaction records showed a $16,197.50 debit for private room and board for the month in question, while eligibility responses documented Medi-Cal coverage for that month and the following month. Payer setup information showed the resident was billed as private pay for that month and then changed to Medi-Cal-IEHP the next month. The activity report confirmed the debit from the trust account. There was no documented evidence that the responsible party was notified of or consented to the change to private pay or to the trust account withdrawal. In a phone interview, the responsible party stated she did not know the resident’s trust account carried a balance, believed the resident’s Social Security income was being used for room and board, and reported she had never been notified of or consented to the change to private pay or the debit from the trust account. In interviews, the Accounts Receivable Director stated that Residents 10, 11, and 12 had billable Medi-Cal benefits for the month in question and confirmed that all four residents’ trust accounts were debited $16,197.50 for private room and board without documented notification to or consent from the residents or, for Resident 12, the responsible party. The Director further stated that none of the residents or the responsible party requested a change from Medi-Cal to private pay; the decision was made by the facility. The Business Office Manager stated that the facility’s process was to transfer a resident to private pay only when the resident did not have Medi-Cal as secondary insurance, and acknowledged that there was documented evidence that all four residents had billable Medi-Cal benefits for the month in question and that their trust accounts should not have been charged. The Administrator confirmed that residents are not supposed to be charged for Medi-Cal-covered benefits, that the residents should not have been switched to private pay to cover Medi-Cal-covered benefits, and that there was no documented evidence of consent to the private pay status or the trust account debits. Census records showed that during the relevant dates, all four residents were in three-bed rooms with two roommates, despite being charged for private room and board. The facility’s Abuse Prevention Program policy stated that residents have the right to be free from misappropriation of resident property and that administration will protect residents from abuse.
Failure to Notify Representative of Excess Resident Trust Account Balance
Penalty
Summary
The facility failed to notify a resident’s representative when the resident’s trust account balance exceeded the Supplemental Security Income (SSI) resource limit. The resident, who had diagnoses including metabolic encephalopathy, dementia, and altered mental status, had a BIMS score of 0, indicating severe cognitive impairment, and her daughter was documented as her representative and primary financial contact. A review of the facility’s trust transaction history showed that the resident’s trust account balance was $14,545.99. Interviews with the Director of Accounts Receivable (DAR) and the Business Office Manager (BOM) confirmed that the facility’s process requires notification to the resident or representative when a trust account exceeds $2,000 so that a spend down can be arranged to maintain Medicaid/SSI eligibility. Despite this established process, both the DAR and BOM acknowledged there was no documented evidence that the resident’s representative had been notified of the elevated trust account balance or the need for a spend down. The BOM stated that the usual procedure would include arranging an IDT meeting with the resident and/or representative to discuss the trust account balance, the reason for the spend down, and the amount required, but this did not occur for this resident. In a subsequent interview, the resident’s representative reported she was unaware that the resident had a trust account balance at all and believed the resident’s Social Security income was fully applied to room and board. She stated the facility had never informed her of the trust account balance or how it might affect the resident’s Medi-Cal and Social Security benefits. When policies related to notification of account balances and eligibility limits for Medi-Cal/Social Security were requested, the facility did not provide them.
Missed Medication Administration and Failure to Follow Up on Unavailable Medications
Penalty
Summary
The facility failed to ensure that multiple residents received prescribed medications as ordered, with seven of 39 residents reviewed affected by missed doses documented on the eMAR. The missed medications included anticonvulsants, an antiviral, antidiabetic medication, thyroid medication, antipsychotics, a blood thinner, a statin, and other routine medications. The record review and staff interviews showed that the medications were often documented as not administered because they were not available, not in the cart, or awaiting delivery from the pharmacy. Resident 118, who had epilepsy and intermittent decision-making capacity, did not receive Lacosamide from December 17, 2025, through January 15, 2026. The eMAR showed the medication was signed as not administered during that period, and nursing notes stated the medication was not in the cart and had already been ordered. The record did not show that the physician was notified of the missed doses during that time, and there was no documented monitoring for change of condition or seizure activity during the missed-dose period. The DON stated the medication was not administered because it was not available and that nursing staff failed to contact the physician for the refill. Resident 106 did not receive five doses of Acyclovir for shingles because the pharmacy did not send enough medication to complete the ordered course. Resident 8 missed multiple doses of Atorvastatin, Olanzapine, Risperdal, and Allopurinol in January and February 2026 because the medications were unavailable. Resident 153 missed Lacosamide doses on December 1 and 2, 2025, because the medication was not available. Resident 108 missed multiple doses of Methimazole in December 2025 and January 2026, with documentation showing the medication was not on hand, pending delivery, or not in the cart, and the record did not show follow-up with the pharmacy or physician. Resident 163 missed multiple doses of Glipizide in December 2025, also documented as not on hand or awaiting delivery, without evidence that staff reordered the medication or contacted the pharmacy or physician. Resident 69 missed multiple doses of several medications, including Divalproex sodium, Gabapentin, Buspirone, Keppra, Xarelto, Levothyroxine, and Atorvastatin, across December 2025 and January 2026. Interviews with the DON, ADON, QA nurse, and pharmacy consultant confirmed that when medications were unavailable, nursing staff were expected to contact the pharmacy and notify the physician, but the records reviewed did not show that this occurred for the missed doses identified. The pharmacy consultant also stated she did not identify and report the medication discrepancies during her monthly review of the eMARs for the affected residents.
Lack of Written QAPI Plan for Call Light Response Issues
Penalty
Summary
The facility failed to have a written Quality Assurance Performance Improvement (QAPI) plan in place to address systemic process issues related to timely response to call lights. During the recertification survey conducted between February 23, 2026, and March 3, 2026, surveyors identified systemic issues with timely response to residents' call lights, which was cross-referenced to F725. The deficiency was based on interview and record review showing that the facility did not have a QAPI program that identified, corrected, and improved the issues related to timely response to call lights for residents. On February 27, 2026, the Administrator and Director of Nursing were interviewed and the facility's QAPI program was reviewed. The Administrator stated the QAPI committee included the Administrator, DON, Medical Director, Infection Preventionist, Director of Staff Development, and department heads. The Administrator also stated he was aware of late responses to residents' call lights from residents' council meetings. A review of the facility document titled Quality Assurance and Performance Improvement (QAPI) Plan, dated August 2017, showed the facility's stated policy to maintain an ongoing, systematic, proactive, facility-wide, data-driven process to measure, assess, carry out, and improve resident care, outcomes, and safety.
Kitchen Steam Table Not Maintained in Working Order
Penalty
Summary
The facility failed to ensure the kitchen steam table was maintained in a safe operating condition when it was not fully functional from December 19, 2025, to February 3, 2026. During a February 24, 2026 interview, Resident 89 was observed lying in bed, awake and alert, and stated he received his food cold and believed the food would come out of the kitchen cold. Resident 89’s record showed he was admitted with diabetes and had been determined to have the capacity to understand and make decisions. During a February 26, 2026 interview, the Registered Dietician stated she conducted monthly audits and that the fourth steam table wells were not fully functional in her December 2025 and January 2026 kitchen audits. She stated the expectation was to always maintain all kitchen equipment fully functional and that hot foods should stay hot so they remain hot when delivered to residents. Her audit documentation noted that the fourth well of the steam table was 0.98 degrees Fahrenheit in December 2025, and that steam well #3 did not reach the appropriate temperature of 180 degrees Fahrenheit in January 2026. An email from the RD to the Administrator and DON stated the main finding was the temperature being greater than 180 degrees Fahrenheit and that this impacted her test tray because two items did not reach the appropriate temperature. The Maintenance Director stated he was not aware of the steam table problem until late January 2026. Facility policy required kitchen equipment to be maintained in working order and maintenance to keep equipment safe and operable at all times.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to ensure staff knocked and received permission before entering resident rooms for six of 14 sampled residents, including Residents 15, 18, 87, 67, 81, and 183. During concurrent observations and interviews, a CNA was observed entering Residents 15 and 18's rooms without knocking or obtaining permission, and the CNA stated he should have knocked prior to entering for privacy, to let them know, and for dignity. Another CNA was observed entering Resident 87's room without knocking or obtaining permission and stated she should have knocked prior to entering the resident's room. A Maintenance Director was also observed entering the rooms of Residents 67, 81, and 183 without knocking or obtaining permission, and stated he should have knocked prior to entering for respect and privacy. Resident 81 later stated he did not like that the Maintenance Director entered his room earlier without knocking and said the Maintenance Director did not respect his privacy. The Director of Staff Development stated it was the facility's expectation that staff knock and obtain permission before entering a resident's room for respect and dignity. The facility policy titled Resident Rights stated employees shall treat all residents with kindness, respect and dignity.
Call Lights Not Within Reach for Four Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for four residents, including residents with dementia, blindness, limited mobility, and communication difficulties. The deficiency was identified through observation, interview, and record review for Resident 5, Resident 30, Resident 87, and Resident 162, all of whom were found without a reachable means to contact staff for assistance while in their rooms or in bed. Resident 162 was observed yelling for help while lying in bed and stated she needed to be changed and could not see her call light. A CNA confirmed the call light was not within reach. Her record showed diagnoses including dementia and blindness, and her care plan directed staff to be sure the call light was within reach and to provide prompt response to requests for assistance. Resident 87 stated he had diarrhea and needed help but could not reach the call light, which was observed hanging on the rail out of reach. His record included anxiety disorder and muscle weakness, and his care plan directed staff to be sure the call light was within reach and to encourage use of the bell for assistance. Resident 30, who could not be understood when attempting to speak and had vascular dementia, was observed with the call light placed on top of a suction machine on the bedside drawer, not within reach. Resident 5 was observed on multiple occasions with the call light underneath the bed or on the floor beneath the bed while she was in bed or sitting up for breakfast. She stated she was unaware of how to reach or call the nurse from her room and had to go to the hallway to locate a nurse if she needed assistance. The DON stated the facility policy required the call light to be within reach and that staff were expected to check call light placement at the beginning of the shift; the policy also stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Failure to Provide Follow-Up on Advance Directive Requests
Penalty
Summary
The facility failed to ensure that 10 of 39 residents reviewed had follow-up information regarding the formulation of an advance directive (AD) provided to the resident or the resident representative. The deficiency involved Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176, and the record review showed repeated instances where residents expressed interest in completing an AD or had no AD on file, but the documentation did not show that the facility followed up with the resident, the resident representative, or the ombudsman as indicated. Resident 14 stated she was unsure whether the facility had asked her about formulating an AD and said she would like to know more. Her record showed she had capacity to understand and make decisions, and social service documentation noted that she wanted to formulate an AD, but there was no documented evidence of follow-up information being provided from December 2024 through February 2026. Resident 156 stated she was unsure of any follow-up regarding an AD. Her record showed she could make needs known but could not make medical decisions, and social service documentation indicated the resident was awaiting an ombudsman visit to complete the AD form, with no documented evidence of follow-up correspondence from October 2025 through February 2026. Resident 176 stated he wanted to know more about an AD because he had not spoken with staff about his right to formulate one. His record showed he had capacity to understand and make decisions, and social service documentation indicated he wanted to formulate an AD, but there was no documented evidence of follow-up from December 2024 through February 2026. Similar documentation gaps were identified for Residents 1, 10, 15, 30, 57, 89, and 106, including residents with intact decision-making capacity, residents with severe cognitive impairment, and residents whose records reflected that they wanted to move forward with an AD or had no AD in place, but whose records did not show that the resident or responsible party received follow-up information about the right to formulate an AD. During interview, the Social Service Director and Social Service Assistant stated that the facility’s process was to ask residents or responsible parties about ADs, offer assistance if no AD was available, and send requests to the ombudsman for verification. The SSA stated the ombudsman was inconsistent with follow-up, that she conducted monthly audits, and that she could not identify documentation showing she submitted AD requests to the ombudsman for all sampled residents. She also stated she did not follow up for all sampled residents to honor their requests for the right to formulate an AD and should have. The facility policy stated residents should be provided written information about the right to refuse or accept treatment and to formulate an AD, that assistance should be offered if no AD existed, and that staff should document the resident’s decision and review advance directives annually.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to have a licensed nurse in charge on each shift. Surveyors reviewed resident council minutes for December 2025, January 2026, and February 2026, which showed repeated resident complaints that call lights were not being answered in a timely manner. During an interview with residents who attended the council, residents stated that nursing response to call lights often took 25 minutes or more. Multiple residents described delayed assistance after using call lights. One resident who was dependent on nursing care and had diagnoses including cerebral infarction, ankle contractures, and a left artificial hip joint stated that it sometimes took one hour for staff to respond when she needed fresh water. Another resident with diagnoses including parkinsonism, cerebral infarction, hemiplegia, and hemiparesis stated that after becoming incontinent, she waited about 30 to 45 minutes for help with cleaning. A resident with paraplegia stated there was not enough staff and that it took too long to get help after pressing the call light, while another resident with blindness and generalized anxiety disorder was observed yelling for help and stated staff took too long to come assist her. Staff interviews and records showed the staffing concerns were ongoing. CNAs stated the facility was short staffed, that the shortage affected timely response to call lights, and that they were assigned too many residents to provide safe and adequate care. The DSD and Staffing Coordinator stated registry staff were needed to help with shortages, but the Administrator said registry was not used when the facility was short staffed. The Administrator verified staffing shortages on several February 2026 dates, and the staffing schedule showed shortages compared with the facility assessment, which called for 8 LVNs and 22 CNAs on days, 6 LVNs and 17 CNAs on evenings, and 5 LVNs and 14 CNAs on nights based on an average census of 171. One RN also stated it was difficult to perform the nurse supervisor role efficiently while assigned to the medication cart.
Medication and OTC Supply Availability Failures
Penalty
Summary
Pharmaceutical services were not provided in a timely manner for multiple residents because ordered medications were unavailable when needed. For Resident 118, the eMAR showed that Lacosamide was not administered from December 17, 2025, through January 15, 2026, and the DON stated the medication was missed because of an ordering problem with the pharmacy refill that was not identified and addressed until January 15, 2026. The DON also stated the missed doses were not discussed with the pharmacy or pharmacy consultant. For Resident 106, five doses of Acyclovir were missed on February 22 and 23, 2026, and the PO stated a pharmacy technician made a refill balance error that delayed delivery. Additional residents, including Residents 8, 153, 13, 163, 108, and 69, had multiple missed doses of ordered medications in December 2025, January 2026, and February 2026 because the medications were not available. The facility also failed to ensure required PPD skin tests were available and administered as scheduled for new admissions. Resident 182 did not receive the Step 1 PPD skin test on the evening of February 20, 2026, because the PPD solution was not available. Resident 185 and Resident 184 also did not receive their scheduled Step 1 PPD tests on February 21, 2026, due to medication unavailability. Resident 186’s record did not show the scheduled PPD test was administered, and the IPN stated the nurse probably did not give it because there was no PPD solution available. The IPN stated the facility was notified that PPD solution was unavailable and that the order was placed with the pharmacy, but delivery was still pending several days later. The facility did not establish a system to ensure OTC medications were readily available for residents’ use. Residents 176 and 167 both missed ordered Melatonin doses because the medication was not on hand and was awaiting facility stock. During observation, the IPN could not locate OTC items for Resident 167, including an eye drop and nasal spray, and later confirmed Melatonin was not available in the OTC stock room. The SC stated she ordered central supply stock from a list but did not maintain an active inventory, and the DON stated there was no system in place to keep inventory for OTC medications. In addition, for Resident 106, Albuterol Sulfate Inhalation was not available in the medication cart when checked, and the LVN stated the medication had been removed because it was empty and needed to be reordered, leaving the resident without medication for shortness of breath or wheezing as ordered.
Failure to Identify and Report Missed Medications During Monthly Drug Regimen Review
Penalty
Summary
The Pharmacy Consultant failed to identify and report medication irregularities during the monthly drug regimen review for multiple residents when licensed nurses documented in the eMAR that prescribed medications were not administered on multiple occasions because the medications were unavailable. The report identified eight residents reviewed for pharmacy services, including residents who missed medications such as Lacosamide, Acyclovir, Atorvastatin, Olanzapine, Risperdal, Allopurinol, Methimazole, Glipizide, Divalproex sodium, Gabapentin, Buspirone, Keppra, Xarelto, and Levothyroxine. The missed doses occurred across December 2025, January 2026, and February 2026. For Resident 118, the eMAR showed Lacosamide was not given from December 17, 2025, to January 15, 2026. Resident 106 did not receive five doses of Acyclovir on February 22 and February 23, 2026. Resident 8 missed multiple doses of Atorvastatin, Olanzapine, Risperdal, and Allopurinol in January and February 2026. Resident 153 did not receive Lacosamide on December 1 and 2, 2025, and Resident 108 missed Methimazole on multiple occasions in December 2025 and January 2026. The record review also showed Resident 163 did not receive Glipizide on multiple occasions in December 2025, and Resident 69 missed multiple doses of Divalproex sodium, Gabapentin, Buspirone, Keppra, Xarelto, Levothyroxine, and Atorvastatin in December 2025 and January 2026. During interview, the Pharmacy Consultant stated she reviewed the residents' medical records and eMAR monthly and was supposed to identify and report medication discrepancies, but she did not identify or report these missed doses and was unaware the residents had missed medications due to unavailability because she had not received reports from the facility about delivery issues. The facility policy stated the consultant pharmacist reviews MARs, TARs, and physician orders at least monthly to ensure proper documentation of orders and administration of medication to residents.
Infection Control Failures During Resident Care, Food Handling, and Equipment Use
Penalty
Summary
The facility failed to implement infection prevention and control measures for a resident with a urinary catheter and ESBL history. Resident 66 was observed in bed with a urinary catheter, but there was no Enhanced Barrier Precaution signage posted outside the room. RN 2 entered the room to administer an IV antibiotic using hand hygiene and gloves, and later stated that the resident had a urinary catheter and that EBP signage should have been posted. The Infection Preventionist stated that residents with devices such as urinary catheters should be placed on EBP, and the facility policy required clear signage outside the resident room for residents with indwelling medical devices. The facility also failed to maintain proper hand hygiene and glove use during food service. During tray line observation, a Dietary Aide touched the kitchen floor with gloved hands, then returned to food handling without removing the gloves, washing hands, or changing gloves. In interview, the Dietary Aide stated he continued using the same gloves from the start of the tray line. The Registered Dietitian stated kitchen staff should perform handwashing and change gloves between tasks, and the FDA Food Code cited in the report required hand cleaning after activities that contaminate the hands and limited single-use gloves to one task. In another infection control event, a CNA attempted to place a nasal cannula that had been on the floor back onto Resident 106. The resident refused, and the CNA then placed the tubing on the headboard. The CNA stated the tubing should have been discarded and replaced with a new labeled cannula, and the Infection Preventionist stated a nasal cannula found on the ground must be discarded and replaced. The report also documented a CNA passing meal trays to multiple residents without sanitizing hands between residents, and a suction machine in Resident 30's room that was not labeled with the resident identifier and had fluid and secretions left in the canister. The QA Nurse and Infection Preventionist both confirmed these were infection control issues, and the suctioning policy required the collection container to be emptied and rinsed according to facility protocol.
Call Light System Lacked Audible Notification
Penalty
Summary
The facility failed to ensure that the call light system was fully functional when the call light panel did not have an audible sound. During observation in the hallway at Station 3 between rooms [ROOM NUMBERS], the Maintenance Director approached room [ROOM NUMBER] and asked the resident if he needed help. The call light for room [ROOM NUMBER]A was on, and the call light panel on the wall at Station 3 showed the light for room [ROOM NUMBER] with no audible sound. No staff member was present at the nurse's station at that time. During interviews, the Maintenance Director stated he was not aware whether the call light system should have an audible sound and said he would check for wiring problems or other reasons the sound was not working. A CNA stated she had not heard any sound from the call light panel since she started working at the facility and responded by seeing the light rather than hearing an alert. The Administrator stated the call light system should have both visual and audible notification and was not aware it lacked an audible sound. The Director for Staff Development also stated she had not heard any audible sound from the call light system since she started working at the facility in August 2025. Later, the Maintenance Director stated the call light panel wiring had been fixed and the system now had sound when the light was on. The facility policy stated the maintenance department is responsible for maintaining buildings, grounds, and equipment in a safe and operable manner at all times.
Failure to Timely Report Alleged Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported within two hours to the California Department of Public Health for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis, had decision-making capacity per the H&P, and had a BIMS score of 14 indicating he was cognitively intact. He also had a physician order for a 1:1 sitter every shift due to fall risk. During an interview, the resident stated that his previous roommate, who was in a wheelchair, took a urinal hanging at the foot of his bed and threw it at him, causing him to get wet with urine. He stated he did not report the incident to the nurse until the next day and could not recall the exact date of the incident. The resident later told the RN supervisor that his roommate had thrown a urinal full of urine at him while he was lying in bed, and the SBAR documented that the resident was alert and oriented x3-4 and able to express his needs. The facility’s sitter, a CNA, stated she witnessed the incident but did not report it because she did not think it was abuse. The DSD stated the CNA should have reported the incident immediately, and the administrator stated he was not aware of the incident until after the resident reported it to the RN. CDPH received a voicemail from the facility reporting a resident-to-resident altercation without names, followed by a written report the next day. The facility policy stated that alleged abuse, neglect, exploitation, or mistreatment would be reported to the proper agencies as guided by regulations.
Unordered Bedside Medications and Missing Thyroid Lab Monitoring
Penalty
Summary
The facility failed to ensure that Resident 47 had a physician's order for medications found at the bedside. During observation, a bottle of Equate Complete Multivitamins and a pack of OTC throat lozenges were seen on the resident's bedside table, and the resident stated he took both on his own. He said the nurses were aware he was self-administering them, but the QA nurse stated the facility had no documented evidence that the resident had requested self-administration, no physician's order for self-administration of the multivitamins, and no order for the throat lozenges. The resident's admission assessment and quarterly risk assessment both indicated he did not request self-medication administration and was deemed unable to safely self-administer medications. The facility also failed to ensure laboratory monitoring was in place for Resident 108 while receiving Methimazole for hyperthyroidism. The resident's record showed a physician's order for Methimazole 5 mg, 0.5 tablet daily, and the eMAR showed the medication was administered during the month reviewed. However, the medical record did not identify any current or past laboratory results to evaluate the effectiveness or safety of the medication therapy. Further review showed there were no current or active laboratory orders for thyroid monitoring, such as TSH or other thyroid studies, while the resident was receiving Methimazole. During interview, the DON stated there should be laboratory orders in place to monitor the effectiveness of the thyroid medication and acknowledged there were no orders in place. The resident's history included hyperthyroidism, and the report cited DailyMed information stating Methimazole can cause hypothyroidism and requires routine monitoring of TSH and free T4 levels.
Oxygen Orders Not Followed and Tubing Not Labeled
Penalty
Summary
Respiratory care was not provided as ordered for Resident 29 and Resident 106. Resident 29, who had diagnoses including acute bronchitis and COPD, was observed in bed receiving oxygen by nasal cannula at 6 LPM. The physician order dated October 7, 2025 directed oxygen at 2 LPM via nasal cannula, and LVN 2 and LVN 1 confirmed the ordered rate was not being followed. Resident 29 stated she needed oxygen because she was short of breath and reported her nose was dry, which LVN 2 stated could occur with oxygen at 6 LPM. Resident 106, who had diagnoses including chronic respiratory failure with hypoxia and COPD, had a care plan and physician order directing continuous oxygen at 2 LPM via nasal cannula, titrated to 2 to 4 LPM to keep oxygen saturation at or above 92 percent, with oxygen saturation monitored every shift. On February 24, 2026, the resident was observed without oxygen: the nasal cannula was on the floor next to the bed, and later the resident was seen in a wheelchair outside near the smoking area and then in the activities dining room without oxygen. LVN 1 stated the resident was not wearing oxygen as ordered and that she should have ensured the oxygen was applied continuously and checked oxygen saturation. Resident 181, who had COPD and was receiving oxygen at 2 LPM via nasal cannula, was observed with oxygen tubing and a clear bag hanging on the oxygen concentrator that were not labeled. The resident stated he required continuous oxygen. LVN 4 stated the tubing should have been labeled with the resident's name and the date it was applied, and that she could not identify whether the tubing had been changed. She also stated the tubing should be changed weekly to prevent moisture buildup and labeled so staff could identify who it belonged to.
Food Preference Not Honored for Resident With Documented No-Lettuce Preference
Penalty
Summary
The facility failed to ensure that Resident 108’s food preference was honored when the resident was served lettuce despite a documented preference of no lettuce. During an observation on February 23, 2026, Resident 108 was eating lunch and had a lettuce salad on the plate. The resident stated that staff had been told she did not want lettuce, that they kept bringing her lettuce, and that she did not have teeth and could not chew it. The meal ticket on the resident’s table listed “No lettuce” and “Dislikes: Vegetables (lettuce),” and the diet order also reflected “No lettuce” and “Dislikes: Vegetables (Lettuce).” Resident 108 was admitted with a diagnosis that included mild protein calorie malnutrition, and the MDS dated January 1, 2026, indicated a BIMS score of 14. During interviews on February 26, 2026, the Dietary Supervisor stated that Resident 108 had an order preference of no lettuce and that dietary preferences were expected to be followed, with staff checking the meal ticket before serving meals. The Registered Dietitian stated she was not aware the resident’s preferences were not being honored and confirmed that residents have the right to have preferences honored to ensure adequate nutritional intake. The facility policy titled Resident Food Preferences stated that individual food preferences would be assessed upon admission and as soon as practicable, and that the dietician or nursing staff would identify a resident’s food preference.
Failure to Follow Self-Administration of Medication Policy for Bedside Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure for self-administration of medications for one resident. The resident was admitted with multiple serious conditions, including acute and chronic respiratory failure, lumbar radiculopathy, chronic pain syndrome, acetonuria, and was receiving palliative care. A History and Physical indicated the resident had capacity to make decisions. A Quarterly Risk Assessment for Self-Administration of Medications dated February 3, 2026, documented that the resident requested to self-administer medications, that nursing recommended the resident could self-administer, and specifically listed only docusate sodium 100 mg as a bowel care medication to be self-administered as needed. During observation, surveyors found multiple medications stored at the resident’s bedside in two zippered cosmetic bags, including acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, docusate sodium 250 mg, potassium 99 mg, and Hair Skin and Nails vitamins. The resident stated she kept these medications at the bedside and took them as needed, reporting daily use of docusate sodium 250 mg for constipation and as-needed use of the other medications, including ZzzQuil Pure Zzzs Melatonin Gummies for sleep. The resident also stated she was not required to keep a record of, or inform nursing staff about, the medications she took. Interviews with LVNs, the RN, and the DON showed inconsistency between facility practice and the self-administration policy. Multiple nurses stated residents were not allowed to keep medications at the bedside or self-administer unless there was a physician’s order and a completed self-administration assessment, and that residents who self-administer must inform nursing so doses can be documented on the MAR. The DON confirmed there was a self-administration assessment for the resident but acknowledged that the medications found at the bedside were not on the assessment and not ordered by the physician, and confirmed that acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, potassium 99 mg, and Hair Skin and Nails vitamins were not included on the Quarterly Risk Assessment. The facility’s written policy required IDT evaluation of appropriateness, safe and secure storage, determination and instruction regarding documentation responsibility, and removal of any unauthorized bedside medications, which was not followed in this case.
Delayed Call Light Response for Dependent Resident
Penalty
Summary
The facility failed to ensure a resident’s call light was answered in a timely manner, resulting in a 31‑minute delay in response to a request for incontinence care. The resident involved had multiple significant diagnoses, including cerebral infarction with resulting hemiplegia and hemiparesis affecting the right dominant side, muscle wasting and atrophy, major depressive disorder, bilateral ankle contractures, vascular dementia, epilepsy, bilateral foot drop, and schizophrenia. The resident reported using the call light when needing a brief change or assistance and stated he was unable to get out of bed without help. He also stated that call light response times were very slow and varied depending on which staff were working. During observation at the bedside, the resident pressed the call light at 11:06 a.m., illuminating the light in the room and above the doorway. While the call light remained on, a staff member entered the room and assisted the roommate, and a housekeeper entered the room but did not address the active call light. The call light was not answered until 11:37 a.m., when the Treatment Nurse entered and responded, confirming that a 31‑minute wait was unacceptable and that all staff were responsible for answering call lights. The CNA assigned to the resident stated she had been on lunch break during this time and that all staff were responsible for answering call lights, which should be answered within five minutes. The housekeeper stated she cleans resident rooms and can answer call lights. The facility’s “Answering the Call Light” policy indicated that staff should ensure timely responses, notify appropriate staff if another person is needed, and complete tasks within five minutes if possible.
Failure to Notify Residents and Families of Conversion From Medi-Cal to Private Pay
Penalty
Summary
The deficiency involves the facility’s failure to notify four residents and/or their responsible parties of changes in their primary payor status from Medi-Cal IEHP to private pay, as required by resident rights and the facility’s own policy. Record review showed that each of the four residents had Medi-Cal IEHP as the primary payor prior to January 1, 2026, and that their primary payor was changed to private pay effective January 1, 2026, in the PointClickCare (PCC) census records. The facility’s policy titled “Pay Source Conversion” states that Social Services is responsible for notifying the family of non-coverage and anticipated payment, and that the resident and/or responsible party must be informed of their financial obligations when there is a conversion from one primary pay source to another. Resident 2 was admitted with a history of transient ischemic attack and was documented as self-responsible, with an MDS indicating intact cognition. Resident 3 was admitted with dementia, also documented as self-responsible, and had an MDS indicating intact cognition. Resident 4 was admitted with dementia, had a responsible family member, and an MDS showing she was rarely/never understood with moderately impaired cognition. Resident 5 was admitted with metabolic encephalopathy and had an MDS indicating moderately impaired cognition. Despite these documented conditions and responsible party designations, interviews with Residents 2, 3, and 5 revealed that they were unaware they were currently paying privately for their stays, did not know the cost, and reported that no one had discussed these financial changes with them. Resident 4 was non-responsive at the time of attempted interview, and later her responsible party reported not receiving any notification of the payor change or information about the cost. Interviews with staff confirmed that required notifications were not provided. The Business Office Manager (BOM) stated that her department is responsible for notifying residents and responsible parties of payor changes via a notice of insurance change letter, but reported that the Director of Finance (DOF) at the corporate office initiated the payor changes on December 31, 2025, without informing her. The Accounts Receivable Director stated that the BOM, Administrator (ADM), or Social Services Director (SSD) should inform residents about becoming private pay. The Social Service Assistant stated that the BOM is responsible for payor changes and that she had never dealt with payor changes. The ADM stated the BOM is supposed to give notice of payor status changes to residents and report such changes in stand-up meetings, but he was not aware of the corporate-initiated changes and the BOM did not report any payor changes. The DOF stated that BOM, SSD, and sometimes ADM should explain payor changes and document their actions, and later clarified that no written Medi-Cal recommendation was received and that the decision to change the four residents to private pay was made at the facility level. These actions and inactions resulted in residents and responsible parties not being notified of the change from Medi-Cal to private pay and their resulting financial obligations.
Failure to Timely Provide Resident Financial Records Requested by Ombudsman
Penalty
Summary
The facility failed to provide copies of financial records within the required timeframe after a request was made on behalf of a resident by the Long-Term Care Ombudsman (LTCO). The resident involved was admitted with a history of transient ischemic attack and vascular dementia and was documented as self-responsible, with a Minimum Data Set indicating capacity to understand and make decisions. The LTCO emailed the Business Office Manager (BOM) requesting the resident’s trust account report, any representative payee documents from the last 12 months, and a financial summary of coverage and share of cost, and included a consent form signed by the resident authorizing release of this information. During an interview, the BOM stated that she typically provides requested financial information to residents or responsible parties within 10–15 minutes and that, for non-responsible parties, she obtains resident consent via a signed form. She acknowledged receiving the LTCO’s email request and consent form and stated that she is expected to respond to financial record requests within 24 hours and fulfill them by the next business day. The BOM further acknowledged that she should have responded and fulfilled this request by the next business day but had not done so, and that 12 days had elapsed since the request was made. The facility’s policy allowed up to 30 days for providing copies of personal or medical records but also recognized the right of the LTCO to examine resident records in accordance with state law. The failure to provide the requested financial records within two business days constituted a violation of the resident’s and the resident’s representative’s rights.
Failure to Prevent Sexual and Verbal Abuse of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual abuse by another resident and verbal abuse by staff. In the first incident, a cognitively impaired resident with dementia, Alzheimer’s disease, major depressive disorder, and a BIMS score of 3 was involved. This resident had been assessed as lacking capacity to make decisions and was dependent on others for domestic tasks and safety awareness. On the date of the incident, the resident was on the smoking patio without staff supervision during a 4 p.m. smoke break. A CNA reported hearing this resident saying "no, no, no" and then observed a male resident touching the resident’s breast with one hand while attempting to raise the resident’s shirt with the other hand. The CNA noted that there were no other residents present and no staff supervising the smoking patio at that time. The male resident involved was cognitively intact, with a BIMS score of 15 and documented capacity to make decisions. In a subsequent interview, he stated that the cognitively impaired resident had held and kissed his hand and that he did not touch her breast or shirt, although a psychiatric note later documented that he stated he felt invited and began fondling her. The facility’s five-day follow-up report stated that staff witnessed the aggressor touching the victim’s breast and that evidence suggested the allegation of sexual abuse occurred. The DON acknowledged that the dependent resident required supervision and should not have been outside on the smoke patio without supervision. The second incident involved verbal abuse of another cognitively impaired resident with traumatic brain injury, Parkinson’s disease, psychosis, no decision-making capacity, and a BIMS score of 0, indicating the resident was rarely or never understood. Early in the morning, another resident with normal cognition reported to an LVN that he had seen a CNA hovering over this impaired resident and heard the CNA tell the resident to "shut up" while the resident was crying or screaming. The witness later described hearing screams that were not the resident’s normal screams, then observing the CNA standing over the resident and repeatedly saying "shut up" before leaving the room and going to the linen cabinet. The incident was documented in an SBAR as alleged verbal abuse, and an interdisciplinary post-event note recorded that the alleged perpetrator was sent home and the resident was assessed with no injury. The administrator stated that residents should be in a safe environment at all times and free from verbal abuse. Facility policies on Abuse Prevention and Resident Rights stated that residents have the right to be free from sexual and verbal abuse and to be treated with kindness, respect, and dignity.
Failure to Control Resident Smoking Materials and Maintain Accurate Smoking Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to resident smoking and smoking materials. During observation and interview, one resident was found sitting in bed with a sitter present and stated he was a smoker who kept his cigarettes and lighter in his jacket by the bedside. He produced a pack of cigarettes and a lighter from his jacket pocket and stated he only smoked on the smoking patio. Another resident, observed alert and oriented in a wheelchair at bedside, stated she was a smoker and kept her smoking materials in her nightstand drawer. She removed a lighter and a pack of cigarettes from the top nightstand drawer and also stated she only smoked on the smoking patio. When interviewed, the LVN stated residents were not allowed to have smoking materials and that only activities staff were supposed to have residents’ smoking materials. During this interview, the first resident again produced his cigarettes and lighter, and the LVN confirmed he should not have smoking materials with him. Record review for this resident showed a readmission with diagnoses including end stage renal disease, nicotine dependence, and an above-knee amputation, and a history and physical indicating he had capacity to make decisions. However, his smoking assessment documented him as a non-smoker and did not reflect his current smoking status as a smoker. There was no documented smoking assessment reflecting his current status until the concurrent observation and interview on the survey date, confirming he had been allowed to smoke without a valid smoking assessment and without supervision. For the second resident, record review showed admission diagnoses including COPD, diabetes mellitus, and major depressive disorder, with a history and physical indicating fluctuating capacity to understand and make decisions. Her quarterly smoking assessment documented that she was a smoker, a safe smoker, and independent. Her care plan stated she smoked cigarettes and was independent, with a goal that she would smoke safely with supervision, and interventions specifying that activity staff would keep all smoking materials in the smoking cart at all times, give one cigarette and light it for her, and supervise all residents. The DON stated that facility process required smoking assessments on admission and quarterly, that independent smokers could keep cigarettes but not lighters, and that residents were not allowed to have lighters. The DON acknowledged that the first resident’s assessment did not reflect his current smoking status and that he should not be smoking without an assessment or supervision, and that the second resident, although assessed as an independent safe smoker, should not have had a lighter at bedside under facility policy.
Failure to Provide Fresh Bedside Water and Hydration per Policy
Penalty
Summary
The facility failed to ensure bedside water pitchers were filled or that fresh water was offered daily for two residents, resulting in water pitchers remaining only one-quarter full over multiple days. On two consecutive mornings, one resident was observed alert and oriented in a wheelchair with a teal bedside water pitcher that was one-quarter full; the resident reported that CNAs usually refilled his water but that it had not been done that morning, and later stated the pitcher had not been refilled either the previous day or that day. A CNA later confirmed, in the resident’s presence, that the NOC shift appeared not to have refilled this resident’s water pitcher for two days. This resident’s records showed diagnoses including diabetes mellitus, chronic kidney disease, and hypotension, and care plans directing staff to encourage fluids during the day to promote prompted voiding, assist and encourage in-between fluids and snacks due to risk for protein malnutrition, and encourage hydration related to hyperglycemia and skin integrity. Another resident was observed on two consecutive days with a teal water pitcher on the nightstand that was one-quarter full, first while alert, oriented, dressed, and eating lunch, and later with the water level unchanged from the prior day. This resident stated that CNAs usually refilled her water pitcher but that it had not been filled that day, and later reported it had not been filled the previous day or that day. In a subsequent observation with a CNA present, the CNA stated that the NOC shift is responsible for filling all residents’ water pitchers daily before the end of shift and acknowledged that it appeared the NOC shift did not refill this resident’s pitcher. This resident’s records indicated diagnoses including chronic kidney disease and lung cancer, a BIMS score of 11 indicating a moderate problem with thinking, and a care plan intervention to encourage good nutrition and hydration to promote healthier skin. The Administrator stated that the facility’s process is for NOC shift CNAs to replace and refill residents’ water pitchers with fresh water daily toward the end of each shift and acknowledged that failure to refill pitchers could place a resident at risk for dehydration. The facility’s policy on Resident Hydration and Prevention of Dehydration stated that nurses’ aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care.
Failure to Use Required PPE for COVID-19 Isolation Resident
Penalty
Summary
The deficiency involves a failure to implement appropriate infection prevention and control practices for a resident with confirmed COVID-19. On January 8, 2026, signage posted outside the resident’s room clearly indicated both contact and droplet precautions, instructing that everyone must clean their hands before entering and when leaving the room, and that providers and staff must put on gloves and a gown before room entry. The droplet precaution sign further required that eyes, nose, and mouth be fully covered before entering. The resident’s admission record, dated January 9, 2026, documented a diagnosis of COVID-19. The facility’s written policy on Infection Prevention and Control for COVID-19 Infection, dated June 2023, required all staff to wear fit-tested NIOSH-approved N95 respirators in any indoor space where there are residents in isolation, and specified that eye protection is required when caring for residents in the COVID isolation area. Despite these posted precautions and written policies, on January 8, 2026, at 12:25 p.m., an LVN preparing to check the COVID-positive resident’s blood sugar level was observed donning only a surgical mask, gown, and gloves before entering the room. During a concurrent interview, the LVN acknowledged that the contact and droplet precaution signs were posted to be followed to avoid transmitting bacteria and confirmed that the resident had COVID-19. The LVN further stated she was wearing a surgical mask, gown, and gloves when she entered the room and acknowledged she should have worn an N95 mask and a face shield. In subsequent interviews, the Infection Preventionist Nurse and the Director of Nursing both stated that the LVN should have worn the proper PPE—gown, gloves, N95 respirator, and face shield—before entering the isolation room. CDC Infection Control Guidance for SARS-CoV-2, cited in the report, recommends that healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection use an NIOSH-approved N95 or higher-level respirator, gown, gloves, and eye protection.
Resident's Mouth Covered with Towel by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) placed a towel over the mouth of a resident who was non-verbal, dependent for activities of daily living, and had severely impaired decision-making capacity due to a cerebral infarction. The incident occurred while the CNA was providing care and the resident began coughing. The CNA, not wearing a mask at the time, covered the resident's mouth with a towel for at least one minute, reportedly to protect herself from the resident's cough. Another CNA witnessed the event, removed the towel, and advised the CNA that such actions were inappropriate. The resident was assessed following the incident and was found to have no injuries and was calm and in no distress. Interviews with staff and facility leadership confirmed that placing a towel over a resident's mouth is not acceptable practice and is contrary to the facility's abuse prevention policy, which prohibits physical abuse. The facility's policy emphasizes residents' rights to be free from abuse, including physical abuse.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported to the California Department of Public Health (CDPH) within the required two-hour timeframe after the allegation was made. The incident involved a Certified Nursing Assistant (CNA) placing a towel over the resident's head and mouth and telling the resident to be quiet. Another CNA witnessed the event but did not immediately report it to a supervisor, instead choosing to wait and report it directly to the Director of Staff Development (DSD) two days later. The facility's policy and federal requirements mandate immediate reporting of such allegations, but the CNA misunderstood the reporting timeframe and delayed notification. The resident involved had a history of cerebral infarction and fluctuating decision-making capacity. Following the incident, the resident was assessed and found to have no injuries or distress, and the physician was notified. Interviews with facility staff confirmed that the expectation was for immediate reporting of abuse allegations, but the delay resulted in the incident not being reported to CDPH until two days after it occurred. Documentation showed that the CNA had previously acknowledged understanding the mandatory reporting requirements.
Failure to Provide Safe and Appropriate Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that a resident received necessary care and services in accordance with her comprehensive assessment and professional standards of practice by not conducting a comprehensive interdisciplinary assessment of her transportation needs for dialysis appointments. The resident, who had end stage renal disease, type 2 diabetes, and a recent amputation of two toes, required substantial to maximal assistance with transfers and was dependent on a wheelchair for mobility. Despite these needs, the facility arranged for her to be transported to dialysis appointments via Uber, which required unsafe and uncomfortable transfers from her wheelchair to a standard vehicle three times a week. Documentation and interviews revealed that the resident missed or experienced delays in dialysis appointments due to transportation issues, including the facility's failure to pay for appropriate wheelchair van services and the subsequent use of Uber. The resident expressed discomfort and fear regarding the Uber transportation, stating that the cars were difficult to enter and exit, and that she was transferred by staff in a manner that was physically challenging and unsafe. Staff, including CNAs and nurses, reported difficulties in transferring the resident and acknowledged that Uber was not an appropriate mode of transportation for her condition. The facility's own rehabilitation department was not consulted to assess the resident's transportation needs prior to the decision to use Uber. As a result of these actions and inactions, the resident sustained actual harm, including a right chest-wall hematoma, soft-tissue swelling, and possible rib fractures after being transported in a standard vehicle. The unsafe transportation practice continued even after the injury, with the resident being exposed to further risk of harm. The facility's failure to provide safe and appropriate transportation, as well as the lack of interdisciplinary assessment and communication, directly led to the resident's injuries and missed or delayed dialysis treatments.
Removal Plan
- Resident 1 was assessed by assigned licensed nurse for any adverse effects of being transferred to dialysis using Uber Health transportation.
- Resident 1 was assessed by PT to determine whether Resident 1 can tolerate the car or wheelchair van transportation.
- The Care Plan was updated to reflect current transportation information for dialysis.
- A new contract for wheelchair transport was drawn up by the ADM.
- An ad hoc QAPI Committee meeting was held to discuss changes in contracted dialysis transportation services.
- Inservice training was conducted by DON and/or DSD with licensed staff regarding use of contracted dialysis transportation.
Failure to Update Care Plan for Dialysis Transportation Needs
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan to address the transportation needs of a resident who required dialysis. After the resident's transportation method was changed from a wheelchair-accessible van to a standard vehicle (Uber), there was no interdisciplinary assessment or update to the care plan to reflect this significant change. The change in transportation was made without discussion or involvement of the resident or her family, and there was no documentation of their participation in the care planning process. The care plan did not include interventions for transportation to dialysis, transfer assistance, or mobility safety, and was not revised after the transportation method changed or after the resident sustained an injury. The resident had a history of foot surgery and was not supposed to put pressure on her feet, requiring a lifted van for safe wheelchair transfer. Despite this, the facility arranged for transportation via Uber, which did not accommodate her functional limitations. The decision to switch transportation providers was made by the corporate office due to payment issues, and the staff responsible for social services and case management did not communicate this change to the resident or her family. As a result, the resident was transported in an inappropriate vehicle, leading to missed dialysis treatments, hospitalization, and physical injury.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen during observations, interviews, and record review. In the walk-in refrigerator, a 32 oz jar of minced garlic was observed half empty with an open date of July 30, 2025 and a use-by date of August 20, 2025. The Dietary Services Supervisor stated the jar was expired and should have been thrown out, and the Registered Dietitian stated kitchen items should be labeled to avoid passing the use-by date. Several Romaine lettuce bags were observed in the walk-in refrigerator exposed to open air and touching the rack rather than being stored in designated containers or bags. The Dietary Services Supervisor stated the lettuce should not be exposed to open air or contact the rack to avoid potential cross-contamination. The Registered Dietitian stated food items stored in the refrigerator or freezer should be properly stored in designated containers or bags, sealed, and not exposed to air. A brown cutting board near the cook's preparation table was observed with multiple deep indentations, and the Dietary Services Supervisor stated it was not in good condition and should have been discarded. Two hot water thermos spurs near the steam table were observed with calcium build-up and brown grime above the spurs, and the Dietary Services Supervisor stated they should not have calcium build-up or grime. In addition, two dietary staff did not follow the manufacturer's instructions when testing Quat sanitizer, and two dietary staff gave incorrect answers about the dishwasher chlorine concentration. The report states the dishwasher manufacturer's guidelines required 50-100 ppm available chlorine, while staff stated different and incorrect ranges during interview.
Failure to Document Follow-Up on Advance Directive Requests
Penalty
Summary
The facility failed to ensure that 10 of 38 residents reviewed for Advance Directives had follow-up information documented regarding the formulation of an Advance Directive. The residents identified were Residents 1, 9, 13, 28, 36, 123, 126, 155, 157, and 168. Record review showed that each of these residents had an Advance Healthcare Directive form indicating either that they had not executed an advance directive and wanted more information, or that they had not executed one for other stated reasons, but the chart did not contain documented evidence that follow-up information about the right to formulate an AD was provided to the resident or the resident representative. Resident records reflected differing cognitive and decision-making statuses. Resident 1 had capacity to understand and make decisions, yet the record showed no documented follow-up after the resident indicated uncertainty about having an AD. Resident 9 had severe cognitive impairment with a BIMS score of 3 and was documented as lacking capacity to make healthcare decisions, while Resident 13 had moderate cognitive impairment with a BIMS score of 7 and Resident 28 had a BIMS score of 0. Resident 36 had a BIMS score of 12 and was documented by H&P as having capacity to understand and make decisions. Residents 123, 126, 155, 157, and 168 were also documented with varying BIMS scores, including cognitively intact residents, and several stated during interview that they were unsure whether they had received information or wanted more information about an AD. The Social Service Director stated that during admission, residents capable of making decisions were asked whether an AD was available, and if not, the facility offered assistance in formulating one. She also stated that AD requests were sent to the Ombudsman and that she conducted monthly audits. However, during concurrent record review, she acknowledged that she did not document follow-up during quarterly assessments for the 10 residents to determine whether they wished to formulate an AD, and stated she had not followed up with all residents to honor their requests for the right to formulate an AD. The facility policy required written information on the right to refuse or accept treatment and to formulate an AD, documentation of the resident’s decision to accept or decline assistance, and annual review of advance directives.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for four of five certified nurse assistants (CNAs 1, 2, 4, and 5). On September 10, 2025, a review of five CNA personnel files showed that CNA 1, hired on February 1, 2016, had a most recent annual performance evaluation dated April 27, 2020, while CNA 2, hired on August 13, 2024, and CNA 4 and CNA 5, both hired on June 4, 2024, had no annual performance evaluation in their files. During a concurrent interview and record review, the Director of Staff Development stated that each CNA is required to have an annual performance evaluation, that additional training would be provided if staff were found to need improvement in certain areas, and that the lack of evaluations created a potential risk that staff deficiencies would go unaddressed. The Director of Staff Development also stated performance evaluations are to be kept in personnel files for at least five years, and the facility policy titled Performance Evaluation stated that job performance shall be reviewed at least annually.
Infection Control Lapses During Resident Care and Equipment Disinfection
Penalty
Summary
Proper infection prevention and control measures were not followed when staff failed to use required PPE during direct resident care for multiple residents on Enhanced Barrier Precautions. An LVN entered one resident’s room and provided contact care without wearing a gown, and later stated the resident was on EBP and that the gown should have been worn. A CNA was also observed entering another resident’s room and providing care without an isolation gown, and stated the resident was on EBP and that the gown had been forgotten. The Infection Preventionist stated staff were expected to follow designated precaution protocols and wear the required PPE. The deficiency also involved a blood pressure machine used for resident care. An LVN was observed cleaning the machine with hand sanitizing wipes and stated those wipes were being used for infection control and were believed to be appropriate for sanitizing the equipment. The Infection Preventionist stated that medical devices should be disinfected with disposable germicidal surface wipes after each resident use and that hand sanitizing wipes were not recommended for disinfecting blood pressure machines. The facility policy stated resident-care equipment and reusable durable medical equipment are to be cleaned and disinfected according to current CDC recommendations and OSHA bloodborne pathogens standards. Another CNA was observed assisting a resident with a gown change while wearing gloves but no isolation gown, despite an EBP sign posted outside the room. The CNA stated she did not look at the EBP sign before entering and acknowledged that not wearing the proper PPE could cause cross-contamination and spread germs between residents. The resident’s record showed diagnoses including ESBL resistance, and the order summary and care plan indicated Enhanced Barrier Precautions with gown and gloves required during direct care.
Failure to Prevent Resident-to-Resident Verbal Abuse and Address Ongoing Disruptive Behavior
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, resulting in the affected resident feeling threatened. Specifically, one resident repeatedly played loud music in his room, which disturbed others. When another resident requested that the music be turned down, the first resident responded with verbal threats and derogatory language. This behavior was ongoing for months, as noted in interviews and progress notes, and was not effectively addressed by staff. The resident responsible for the loud music and verbal abuse was cognitively intact and had a diagnosis of bipolar disorder, but refused interventions such as headphones when offered. Despite multiple complaints and documentation of the disruptive behavior, the facility did not implement or update care plans or interventions to address the ongoing issue. Staff interviews revealed that the only action taken in response to a previous grievance was to move a different resident out of the room, rather than addressing the root cause. The Director of Nursing and other staff acknowledged that the behavior should have been care planned and that interventions were lacking, which contributed to the escalation of the situation and the resulting verbal abuse.
Failure to Monitor and Document New Wound Following Podiatric Procedure
Penalty
Summary
The facility failed to complete appropriate monitoring and documentation for a resident who experienced a new skin avulsion on the left second toe following podiatric treatment. The resident, who had diagnoses of diabetes mellitus and peripheral vascular disease, was noted to have a new wound on August 18, 2025, as documented in the skin check. However, subsequent skilled evaluations on August 19 and August 21, 2025, did not identify any skin issues, indicating inconsistent evaluation of the wound. The Treatment Nurse confirmed that the skin avulsion was a new finding and should have been treated as a change of condition, requiring documentation and ongoing monitoring to track the wound's progress. Interviews with facility staff, including the DON, revealed that the wound was not monitored every shift for three days as required by facility policy for a change of condition. The facility's policy states that significant changes in a resident's condition require interdisciplinary review and thorough documentation. The lack of consistent monitoring and documentation for the resident's new wound resulted in a deficiency related to the facility's failure to provide care and treatment according to orders, resident preferences, and goals.
Failure to Provide Written SNF ABN
Penalty
Summary
The facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for Resident 92, who was admitted with a diagnosis that included asthma. Resident 92’s Medicare Part A coverage began on April 17, 2025 and ended on July 1, 2025, and the resident remained in the facility for long term care after Medicare coverage ended. A review of Resident 92’s record showed no documentation of a completed SNF ABN form or any written notice informing the resident of financial liability for continued services after Medicare Part A ended. During a concurrent interview and record review on September 11, 2025, the Administrator stated that the SNF ABN was not provided and that the resident had not been informed in writing that he was financially liable for continued skilled services.
Incomplete and Missing Personal Property Inventories
Penalty
Summary
The facility failed to ensure reasonable care for the protection of residents’ property for two residents when personal inventory documentation was not available for one resident and incomplete for another. Resident 120 stated she had partial dentures upon admission but no longer has them and feels shy without them. Her admission record showed a diagnosis of schizoaffective disorder, and her history and physical noted intermittent capacity to make decisions. Her MDS dated June 26, 2025, showed a BIMS score of 14, indicating intact cognitive function. During interview, the RNS stated that dentures are documented on the resident’s inventory list when a resident comes in with them, but she could not locate Resident 120’s inventory list. The DON stated staff should have completed an inventory list of all belongings upon admission, including dentures if present, and that the list is used to account for residents’ belongings. Resident 147 stated he had been missing personal belongings, including two sweaters and three t-shirts. His admission record showed a diagnosis of dementia, and his MDS dated August 25, 2025, showed a BIMS score of 12, indicating moderate cognitive impairment. During record review, LVN 1 stated the inventory of personal belongings lacked the staff signature. LVN 2 stated staff should sign the inventory form upon admission to account for personal belongings, and that the signed inventory serves as proof of what the resident had at admission. LVN 2 further stated that without the staff signature, the facility could not verify what belongings the resident actually had at admission, and the incomplete form had the potential to result in missing and unaccounted for items.
PASRR Recommendations Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to incorporate the recommendations from Resident 123’s PASRR Level II determination and evaluation into the resident’s care plan. Resident 123 was admitted with schizoaffective disorder, and the PASRR individualized determination report identified recommended specialized services that included psychotherapy/counseling and psychiatry consultation and/or follow-up care for psychopharmacological intervention and monitoring of mental conditions. During a concurrent interview and record review with the Case Manager, the facility stated that Resident 123’s PASRR recommendations were not followed. The Case Manager confirmed that psychotherapy/counseling and psychiatry consultation were not addressed in the resident’s current care plan, and that psychotherapy was not provided to Resident 123. The facility policy titled Admission Criteria stated that after completion of the Level II evaluation, the state PASRR representative determines what specialized or rehabilitative services the individual needs.
Failure to Maintain Resident Fingernail Hygiene
Penalty
Summary
The facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene of one resident’s fingernails. Resident 174 was admitted with diagnoses including acquired absence of the right eye and glaucoma with cloudy vision in the left eye. The resident’s care plan included checking nail length and trimming and cleaning nails on bath day and as necessary, with changes reported to the nurse. During an observation and interview, Resident 174 was seen sitting on his bed, alert and oriented, with his right eye shut, and his fingernails were observed to be long and yellowish in color. The resident stated he had previously been able to maintain his own nail care when he could see better and would not mind staff helping cut his fingernails so he would not scratch himself. A CNA also observed that the resident’s fingernails were long and yellow and stated they should have been maintained to prevent infection. The DSD and DON stated CNAs were expected to check and clean residents’ fingernails daily and that Resident 174 should have been offered nail care daily.
Inconsistent Meal Intake Documentation
Penalty
Summary
The facility failed to adequately monitor the nutritional status of one resident when meal intakes were not consistently documented. Resident 126 was admitted on May 7, 2025, with a diagnosis including moderate protein-calorie malnutrition, and the resident’s history and physical indicated the resident had the capacity to understand and make decisions. The resident’s MDS dated August 12, 2025, showed a BIMS score of 14, indicating the resident was cognitively intact. A review of the resident’s Nutrition-Amount Eaten record for breakfast and lunch between August 11, 2025, and September 10, 2025, showed multiple missed documentation entries, including several days with no meals documented and additional dates with missing breakfast, lunch, or dinner entries. During interviews, an LVN stated there were multiple missed meals documented and that it was the responsibility of CNAs to document all meals daily, while a CNA stated all meal intakes should be documented to determine whether a resident is experiencing weight loss. The DON stated CNAs were responsible for documenting every meal intake and licensed nurses were expected to review meal intake documentation daily. The facility policy stated nursing personnel would evaluate and document food and fluid intake of residents.
Failure to Follow Dental Recommendations
Penalty
Summary
The facility failed to follow dental recommendations for Resident 138, who was admitted with diagnoses including oropharyngeal dysphagia and had a BIMS score of 13 on the August 2025 MDS. The resident’s nutritional assessment documented edentulous oral condition. A dental progress note from August 15, 2025, documented that the resident wanted full upper dentures and listed recommendations for periodontal charting with updated medical history, completion of a DC054 form for new full upper dentures, a new full upper denture, dental prophylaxis with Cavitron, and a full mouth x-ray annually. Records showed no documentation that the Social Service Director followed up on these dental recommendations. During interview, the resident was observed sitting in a wheelchair with missing upper teeth and stated he wanted dentures and was unsure whether he would receive them. The SSD stated she was responsible for coordinating dental appointments, saw the resident’s dental visit note, but did not follow up because she did not understand the recommendations and did not call the dental office for clarification. Dental staff confirmed the recommendations for dentures, prophylaxis, perio charting, and full mouth x-rays, and the DON stated there was no documentation of follow-up for the resident’s dental needs.
Nonfunctioning Resident Call Light
Penalty
Summary
The facility failed to ensure that a working call light system was available for one resident's bathroom and bathing area, affecting Resident 5. Resident 5 stated that the call light was not working because staff did not come when it was pressed, and that staff would walk by while he had to scream to get their attention. During a concurrent observation, a CNA pressed Resident 5's call light button and confirmed it was not working, and an LVN also stated the call light was not working and should be functioning to properly respond to resident needs. Another resident in the room stated he would press his own call light button to summon staff for Resident 5. The DON stated the call light serves as a notification for residents who need assistance and that if it was not functioning, residents' needs could not be addressed in a timely manner. The facility policy stated the call light should be plugged in and functioning at all times.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Timely Wound Treatment Upon Admission
Penalty
Summary
The facility failed to provide wound treatment for a resident's left lower extremity open wound for three days following admission. Upon review, the resident was re-admitted with diagnoses including a non-pressure ulcer of the left foot and ankle and peripheral vascular disease. Hospital discharge documents and progress notes indicated the presence of open wounds on the resident's left lower and posterior leg and left foot. The skilled nursing facility's admission assessment also documented a skin breakdown on the left lower leg, and a Braden Skin Risk Assessment classified the resident as mild risk for pressure ulcers. However, there was no physician's order for wound treatment from the date of admission through the following three days, and the Treatment Administration Record showed no documentation of wound care being provided during this period. Interviews with facility staff revealed that the admitting RN did not obtain or clarify treatment orders for the resident's wounds, nor was the wound described in the medical records. The Quality Assurance Nurse and Assistant Director of Nursing confirmed that the expected process was for the admitting nurse to conduct a full body assessment, notify the physician, and secure treatment orders, with follow-up and shift endorsement if clarification was needed. The facility's policy required licensed nurses to notify the practitioner for any skin breakdown requiring treatment upon admission, but this was not followed, resulting in a lack of timely wound care for the resident.
Failure to Prevent Physical Abuse of a Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA 1) was observed by two other staff members to have roughly pushed a resident with severe cognitive impairment multiple times to prevent the resident from getting up from bed. The resident, who had diagnoses including psychosis, anxiety, Parkinson's disease, schizoaffective disorder, depression, and a cognitive communication deficit, was noted to have a BIMS score of 1, indicating severe cognitive impairment. The care plan for this resident included interventions to interact in a peaceful manner due to a history of anxiety and wandering. On the evening of the incident, two CNAs witnessed CNA 1 push the resident down by the shoulders, causing the resident to fall back onto the bed. Both CNAs reported seeing redness and swelling on the resident's face, and one heard slapping noises, though did not see slapping. The resident was heard yelling for help and to stop. The Registered Nurse assessed the resident and confirmed redness and swelling on the left cheek. Facility policy prohibits any form of abuse or rough handling of residents.
Failure to Assess and Treat Blister Led to Stage 4 Pressure Injury
Penalty
Summary
The facility failed to properly assess and treat a blister on the right elbow of a resident who was re-admitted with a history of chronic wounds and high risk for pressure injuries, as indicated by a Braden Scale score of 12. Upon re-admission, the resident's right elbow was wrapped with a bandage, and a blister the size of a ping-pong ball was present, but this was not documented, assessed, or reported to the physician. No treatment order was obtained for the blister at that time, and the presence of the bandage was not investigated further by the admitting nurse. Subsequent interviews and record reviews revealed that the licensed nurses did not perform or document a head-to-toe skin assessment upon re-admission, as required by facility policy. The wound was not unwrapped or measured, and the physician was not notified. The lack of assessment and documentation meant that no care plan or treatment was initiated for the blister, despite the resident's high risk for skin breakdown and pressure injuries. As a result of these failures, the blister on the resident's right elbow worsened and progressed to a Stage 4 pressure injury, with full-thickness skin loss and exposed bone. Staff interviews confirmed that the expected protocol was not followed, and the facility's own policies required immediate assessment, documentation, and intervention for any skin issues identified upon admission or re-admission.
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.
Illustrative
What surveyors actually found near you
We read the 1,104 citations issued within 25 miles in the last 12 months — including the 3 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 Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Terrace Care Center | 2.7 mi | ★★★★★ | 4 | 0 |
| Citrus Grove Post Acute | 2.9 mi | ★★★★★ | 20 | 0 |
| Riverside Heights Healthcare Center, Llc | 3.3 mi | ★★★★★ | 0 | 0 |
| Alta Vista Healthcare & Wellness Centre | 3.7 mi | ★★★★★ | 6 | 0 |
| Villa Health Care Center | 3.9 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverside Postacute Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.