Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riviera Healthcare Center during CMS and state inspections, most recent first.
Infection control practices were not followed when a resident’s catheter drainage bag was observed dragging on the floor, wound care supplies were placed on an overbed table without first creating a clean field, a resident’s dog was observed on an accessible patio with soiled items and feces present, and linen barrels in two rooms for residents on EBP were overflowing and left open with used PPE exposed. The residents involved had significant medical issues including UTI, Alzheimer’s disease, DM, chronic wounds, pressure injuries, and severe cognitive impairment, and the facility’s own policies addressed catheter care, wound care, and keeping linen carts closed.
Improper Trash Disposal and Overfilled Dumpsters: Multiple bags of trash were observed on the ground outside three overfilled dumpsters, and the lids could not close properly because of the amount of trash inside. The DS stated the bags should have been placed inside the dumpsters with the lids fully closed. The MS stated trash should never be left outside the dumpsters and that full dumpsters should prompt notification for additional waste removal. Facility policy required waste to be handled safely and garbage and trash to be removed daily.
A facility failed to properly assess urine characteristics and keep urinary catheter drainage bags off the floor for several residents with indwelling or suprapubic catheters. Staff observed thick, milky sediment in catheter tubing for two residents, but the sediment was not documented in the TAR, and multiple catheter drainage bags were seen resting on or touching the floor. The DON, RN, TN, and IPN stated the sediment should have been identified and catheter bags should be kept off the floor to prevent contamination and infection.
Two residents were not treated with dignity and respect. One resident with schizophrenia, major depression, renal dialysis dependence, anxiety, and impaired cognition was observed with latex gloves on both hands despite a care plan stating mittens were to be used only during dialysis and removed during ADLs and meals; the CNA said the gloves were to stop scratching and acknowledged they did not maintain dignity, and the DON stated they could cause humiliation and emotional distress. Another resident with DM, blindness, hemiplegia, and impaired decision-making was observed eating breakfast without feeding assistance, with food on his clothing, lap, and bed linens; the CNA was unsure about the feeder assignment, the resident said he felt like he did not matter, and the DON stated meals must be provided with dignity.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications: Two residents had psychotropic medication consent issues. One resident with schizophrenia, major depressive disorder, and impaired decision-making skills received Olanzapine 2.5 mg daily, but the record did not show written informed consent before initiation. Another resident with dementia, metabolic encephalopathy, and severely impaired cognition received Depakote for mood swings and Seroquel for psychosis, but the DON confirmed the consent forms had not been renewed every 6 months as required. The facility policy required informed consent for psychotherapeutic drugs, renewal every 6 months, and written notice of dosage changes.
The facility failed to keep a resident room in good repair and failed to provide a working TV for another resident. One resident with dementia, epilepsy, dysphagia, and severe cognitive impairment had chipped paint and exposed wall material above the bed, with the bed rail touching the damaged area. The DON and Maintenance Supervisor stated the damage should have been reported and repaired, and that resident rooms should remain clean, safe, and homelike. Another resident with HTN, dysphagia, and muscle weakness reported the TV had been broken for about two weeks, and the DON stated it should have been kept in working condition.
Unauthorized Bed Positioning as a Physical Restraint: A resident with HTN, dementia, epilepsy, dysphagia, and splenomegaly had a bed positioned directly against the bedroom wall. The DON observed the setup and stated it could function as a physical restraint if it restricted the resident's free movement, and that beds should not be placed against the wall without a physician order and proper assessment.
PRN Ativan orders were continued beyond the 14-day limit for two residents. One resident with schizophrenia, major depressive disorder, and anxiety had a PRN Ativan order written for 60 days, and the Psychiatrist stated it exceeded the 14-day requirement. Another resident with anxiety and major depressive disorder had a similar 60-day PRN Ativan order, and the MAR showed daily administration for 31 doses. The DON stated the facility policy required PRN psychotropic orders to be limited to a specific time period and not renewed beyond 14 days.
Unlabeled IV Tubing During Ceftriaxone Infusion: A resident with dementia and other chronic conditions was receiving IV ceftriaxone when surveyors observed the IV tubing unlabeled. RN confirmed the tubing should have been labeled with the date and time to verify when it was last changed, and the facility policy required all tubing to have the start and change date and time documented.
Missing Oxygen In Use Sign: A resident with pleural effusion and pneumonia was receiving 2L O2 via NC for shortness of breath, but an oxygen in use sign was not posted outside the room. The MDS showed moderately impaired cognition and dependence for several ADLs, and the H&P noted the resident had decision-making capacity. An LVN and the DON stated the sign was needed to warn others not to bring open flames into the room, and the facility P&P required the sign on the outside of the room entrance door.
A resident with ESRD and dependence on dialysis did not have the dialysis e-kit kept at the bedside as directed by the care plan. The resident’s care plan called for emergency bleeding supplies at bedside, but during observation no e-kit was present. An LVN stated the kit was important for managing venous access bleeding and that without it there was a potential for extreme blood loss.
Failure to provide feeding assistance during breakfast: A resident with DM, blindness, hemiplegia, and impaired decision-making was observed alone in the room eating with his hands while food was on his clothing, lap, and linens. CNA staff stated the morning shift was understaffed and could only pass trays, while the DSD and DON said adequate staffing was needed to ensure timely feeding assistance and that residents were not left unattended.
Medication administration and controlled substance counting were not performed as ordered for multiple residents. One resident with a g-tube received iron without the ordered tube-feeding timing and was given zinc in a capsule form instead of the ordered tablet form. Another resident received metoprolol without a meal present despite the order to give it with meals. In a separate finding, a hydrocodone-acetaminophen count was inaccurate because the dose was given but not documented on the controlled substance count sheet.
Medication administration errors exceeded the allowed rate, with 3 errors in 36 opportunities. An LVN gave ferrous sulfate to a resident with a g-tube without holding tube feeding for the ordered time frame, administered zinc sulfate in a capsule form instead of the ordered tablet via g-tube, and gave metoprolol to another resident without a meal present as ordered. The residents had diagnoses including g-tube dependence, anemia, stroke, heart failure, and HTN.
Meal Preferences Not Followed: A resident with chronic respiratory failure with hypoxia, DM, and muscle weakness received a lunch tray with meatballs despite a documented dislike for meatballs. The resident stated the menu rarely changed and that requests for alternate meals were often ignored. The meal ticket confirmed the dislike, and the DS stated the ticket may not have been checked when the tray was served; the DON stated staff must check meal tickets and follow resident food preferences.
Failure to Report Alleged Sexual Abuse: The facility failed to report an alleged sexual abuse incident involving two residents to CDPH, the Ombudsman, and law enforcement. A resident with intact cognition reported that another resident tried to touch his genitals while he was sleeping. An LVN said she separated the residents and notified the RN and ADM, who was the abuse coordinator responsible for reporting abuse allegations. The other resident had dementia with severely impaired cognition and fluctuating decision-making capacity, and the facility record documented sexually inappropriate behavior and a transfer for behavior evaluation.
Missing Comprehensive Care Plans for Multiple Resident Needs: A resident who reported inappropriate sexual touching by a roommate had no care plan for the allegation, another resident with a history of alcohol use and out-on-pass intoxication had no care plan for monitoring or re-education, a resident receiving Depakote and Seroquel had no medication-related care plan, and a resident who used dentures had no denture-related care plan. Staff and the DON confirmed these needs were not reflected in the residents’ comprehensive care plans.
Care plans were not revised for two residents after positive influenza A results. One resident had encephalopathy, dementia, and major depressive disorder and developed a nonproductive cough and audible phlegm; the other had epilepsy, ESRD, and HTN and developed cough, sore throat, body aches, and emesis. Both had influenza testing ordered, both tested positive for influenza A, and both were started on Tamiflu and isolation precautions, but the IPN and DON stated the care plans were not updated to reflect the new diagnosis and needed monitoring.
Failure to Monitor After Allegation of Sexual Abuse: The facility did not complete required 72-hour monitoring for two residents after an allegation of sexual abuse. One resident, who was cognitively intact and able to make decisions, reported that another resident tried to touch his genitals while he was sleeping, but his notes did not show psychosocial monitoring. The other resident, who had dementia, depression, and anxiety with severely impaired cognition, was readmitted after behavior evaluation, but his notes did not show monitoring for sexually inappropriate behavior after return.
Conflicting POLST forms were found for one resident, with one form indicating full life-sustaining treatment and another indicating DNR, comfort-focused care, and no artificial nutrition, with no documentation that the earlier form was voided or removed. In a separate event, an LPN failed to document a resident’s COC after the resident reported that a roommate tried to touch his genitals; the resident was upset, the physician was reportedly notified, and the DON stated the missing documentation prevented care plan development and monitoring for psychosocial distress and trauma.
A CNA failed to follow droplet isolation PPE doffing and hand hygiene for a resident on isolation precautions for suspected influenza, removing PPE outside the room and leaving without hand hygiene. In a separate event, an LVN disconnected a resident’s G-tube connector while the feeding pump was running and stored the connector in the feeding syringe bag, which the IPN and RN stated violated infection control. The residents had significant medical needs, including DM, CKD, severe cognitive impairment, and dependence for ADLs.
Excess Residents in Shared Rooms: Surveyors found two resident rooms that exceeded the allowed occupancy limit, with one room housing five residents and another housing four residents. The ADM confirmed the rooms had five beds each and stated the waiver was requested because the rooms were occupied by more than four residents. During the tour, residents were observed able to move in and out of the rooms, with space for beds, side tables, and care equipment.
Insufficient Room Space per Resident: The facility failed to provide at least 80 sq. ft. per resident in 31 rooms, including rooms with 2- and 3-resident capacity. A census review and Room Variance Waiver showed the rooms did not meet the federal space requirement, and during a tour with the ADM, space was observed for residents to move around and for beds, side tables, and care equipment. The ADM stated the waiver was submitted because the rooms measured less than 80 sq. ft. per resident capacity.
A resident with a history of craniotomy and severe cognitive impairment was not consistently wearing a physician-ordered cranial helmet, as observed and confirmed by staff who were unable to locate the helmet or determine how long it had been missing. The resident's care plan and orders required the helmet to be worn at all times except during showers, but this was not followed, and the resident experienced wound dehiscence and infection requiring antibiotics and wound care. Staff interviews also revealed lapses in communication and follow-up with the physician regarding the resident's care.
A facility failed to maintain a safe environment and provide adequate supervision, leading to a resident's fall and fracture. An LVN left a resident unsupervised, resulting in a fall, while an Activity Staff member failed to verify supervision. Additionally, fall prevention measures were not implemented, including the absence of fall mats and risk indicators. A Morse Fall Scale assessment was not conducted after another resident's fall, increasing the risk of further incidents.
A resident in an LTC facility refused wound care, but the facility failed to notify the primary care physician, breaching professional standards. The resident, who required assistance for daily activities and had specific wound care orders, refused treatment on a specific date. Despite facility policy requiring notification of the physician in such cases, this was not done, risking delayed healing and complications.
The facility failed to implement its isolation precautions policy for two residents. A CNA was observed feeding a resident with candida auris without wearing a gown, and another CNA entered and exited a room of a resident with an ESBL infection without PPE, carrying a used gown outside. Both actions were against the facility's policy requiring PPE for contact isolation.
The facility failed to maintain sanitary food handling practices, as a Dietary Aide did not change gloves between handling food and nonfood items, and an ice scooper was left uncovered in a hallway. The Dietary Supervisor confirmed that these practices were against infection control policies, potentially leading to cross-contamination and foodborne illnesses.
The facility failed to implement and develop person-centered care plans for several residents, leading to deficiencies in care. A resident at high risk for falls did not have floor mats placed as ordered, increasing the risk of injury. Another resident with pressure ulcers was left soiled for extended periods, contrary to the care plan. Additionally, care plans for specific medications were not developed for three residents, hindering proper monitoring and treatment. Staff acknowledged these oversights, emphasizing the importance of care plans for effective resident care.
The facility failed to implement proper interventions for pressure ulcer prevention and care for nine residents. Several residents had low-air-loss mattress settings that did not match their weights, potentially worsening their pressure ulcers. Additionally, a resident was left soiled for hours, and another was not repositioned as required, leading to skin damage. These deficiencies were acknowledged by staff, highlighting a lack of adherence to care plans and physician orders.
The facility failed to implement enhanced barrier precautions (EBP) for four residents with severe pressure ulcers, increasing the risk of MDRO spread. Observations revealed a lack of appropriate signage and PPE, despite facility policy and CDC guidance requiring EBP for residents with wounds. Staff interviews confirmed reliance on signage to determine EBP needs, which was absent for these residents.
The facility failed to obtain informed consent for psychotropic medications and bed side rails for three residents. A resident with depression and dementia received medications without consent documentation. Another resident with schizophrenia and anxiety received medications and bed rails without proper staff verification. A third resident with anxiety and depression was given lorazepam without a physician's signature on the consent form. Staff interviews confirmed the deficiency, and the facility's policy was not followed.
A facility failed to protect a resident's confidential information by not removing their name from a GT feeding bottle before disposal. The resident, with multiple medical conditions and impaired cognitive skills, had their personal information exposed, violating HIPAA requirements. An LVN confirmed the oversight, acknowledging the need to remove or obscure the name to maintain confidentiality.
A resident experienced unplanned weight loss over several months, dropping from 260 to 252 pounds, without the care plan being revised to address this issue. The facility also failed to involve the RD in the care planning process, despite policy requirements for multidisciplinary input. The resident's care plan included interventions like encouraging increased oral intake but was not updated despite continued weight loss.
A resident with severe cognitive impairment and chronic conditions was administered Norco by an LVN, who failed to document the administration on the MAR and Pain Assessment Flowsheet. This discrepancy was discovered during a review of the resident's medication records, revealing a risk of double dosing. The DON confirmed that proper documentation was required to prevent such risks, as outlined in the facility's medication administration policy.
The facility failed to provide communication boards for three residents who did not speak English, as required by their care plans. This deficiency was identified through observations and interviews, revealing that the absence of language boards hindered effective communication and potentially delayed care. The residents involved had various medical conditions and required assistance with daily activities, highlighting the importance of proper communication tools.
The facility failed to ensure that dependent residents were regularly taken out of bed, affecting three residents. Observations showed that these residents were consistently found lying in bed over several days. Their medical records indicated cognitive impairments and dependency on staff for ADLs. Interviews with staff revealed that while residents were allowed to choose when to get out of bed, it was important for their socialization and health. The deficiency could negatively impact the residents' well-being and psychosocial status.
A resident with severe cognitive impairment and a high risk of falls did not have floor mats placed on both sides of their bed as required by physician orders. Observations showed only one mat on the right side, and staff confirmed the absence of a mat on the left side, contrary to the facility's fall prevention policies.
A resident on a no added salt diet experienced unplanned weight loss due to the facility's failure to provide salt alternatives and refer the resident to a Registered Dietician (RD) as ordered. The resident complained of unappetizing meals, leading to decreased intake. Despite documented weight loss, the care plan was not revised, and the RD was not involved until months later. Interviews revealed the Dietary Supervisor did not order salt alternatives from a more expensive vendor, and the facility's policy for multidisciplinary care planning was not followed.
The facility failed to display 'No Smoking/ Oxygen in Use' signs for two residents using oxygen, posing a potential fire hazard. Despite the facility's policy requiring such signage, observations revealed its absence in the rooms of residents with significant medical conditions, including dementia and COPD. Staff interviews confirmed the oversight and acknowledged the associated risks.
A facility failed to accurately document the administration of Norco for a resident, leading to a discrepancy between the Medication Count Sheet and the actual number of tablets. The LVN admitted to not recording a dose after administration, which was confirmed by the DON. The facility's policy requires accurate documentation to prevent drug diversion.
A resident on a no added salt (NAS) diet experienced unplanned weight loss and dissatisfaction with meals due to the facility's failure to provide salt alternatives. The resident, with heart failure and hypertension, used high-sodium hot sauce packets for flavor, unaware of their sodium content. The Dietary Supervisor did not order salt alternatives from a more expensive vendor, and the LVN failed to check for high-sodium condiments, contributing to the deficiency.
A resident on a no added salt (NAS) diet was provided Tapatio brand hot sauce packets without physician notification or orders, despite having heart failure, stroke, and hypertension. The dietary supervisor admitted the resident received the packets due to preference, and the resident was unaware of the high sodium content. The facility's policy required a care plan to address dietary dissatisfaction, which was not implemented.
The facility failed to ensure that three residents understood the binding arbitration agreements they signed upon admission. Despite having intact cognitive skills, the residents were not adequately informed about the nature of the arbitration agreement, which waived their right to resolve disputes in court. Interviews revealed that the residents did not receive clear explanations from the facility staff, highlighting a deficiency in communication and understanding.
The facility was found to have overcrowded resident rooms, with one room accommodating five residents and another four, exceeding the regulatory limit. A waiver was submitted for these rooms, which were used for higher acuity residents, but the Administrator acknowledged the risk of decreased space and potential discomfort for residents.
The facility failed to provide the required minimum square footage per resident in 31 rooms, with measurements falling short of federal regulations. Despite space for movement and necessary equipment, the rooms did not meet the 80 sq. ft. per resident requirement. A room variance waiver was submitted, acknowledging the space constraints but asserting no adverse effects on residents' health and safety.
A resident was not readmitted to a facility after hospitalization despite being deemed appropriate to return. The resident, initially admitted with cellulitis and a pressure ulcer, refused some care, leading to a hospital transfer. The facility's IDT decided against readmission, citing the resident's refusal of care, despite available beds and the facility's capability to provide necessary care.
A facility failed to conduct pain assessments every shift for a resident with severe cognitive impairment and multiple health issues, as ordered by the physician. The resident's MAR showed a missed pain assessment during a specific shift, confirmed by both an LVN and the DON. The facility's policy required consistent pain assessment, highlighting a lapse in adherence to the protocol.
A resident with multiple medical conditions, including a previous fracture and functional quadriplegia, was injured when a CNA attempted to reposition her alone without adjusting the low air loss mattress settings. This led to the resident sliding near the edge of the bed and sustaining a fracture that required hospitalization. The care plan specified a two-person assist and proper mattress adjustments, which were not followed.
Infection Control Practices Not Followed
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed when Resident 9’s indwelling urinary catheter drainage bag was observed dragging on the floor while the resident was propelling himself out of the room in a wheelchair. Resident 9 had diagnoses including UTI and Alzheimer’s disease, was documented as having severe cognitive impairment, and was dependent on staff for several activities of daily living. The resident’s care plan directed staff to provide foley catheter care every shift and monitor the indwelling catheter, and the facility’s catheter care policy stated the catheter tubing and drainage bag are to be kept off the floor. The facility also failed to follow its wound care policy during treatment for Resident 5’s right great toe wound. During wound care preparation, the LVN placed wound care supplies on the resident’s overbed table without first using a disposable cloth or paper towel to establish a clean field. Resident 5 had diagnoses including gangrene of the toe, DM, and chronic ulcer of the right foot, was documented as lacking capacity to understand or make decisions, and had moderate cognitive impairment with dependence on staff for personal hygiene, lower body dressing, and bathing. The facility’s wound care policy stated that a disposable cloth is to be used to establish a clean field on the overbed table before placing supplies. The facility had a system in place for a resident’s pet dog on the premises, but during observation the dog was tethered on an outside patio accessible to residents, lying on blankets and wheelchair pads, with the wheelchair soiled and dog feces present in the patio area. The Administrator stated the facility did not have a policy related to having an animal on the premises. In addition, linen barrels in the rooms of Residents 6 and 7, both of whom were on Enhanced Barrier Precautions, were observed overflowing with soiled PPE and left open, exposing the used PPE. Resident 6 had stage 4 pressure ulcers and a gastrostomy tube and was dependent on staff for all ADLs, while Resident 7 had sacral stage 3 pressure injury, local skin infection, and a chronic ulcer of the right lower leg. The facility’s linen handling policy stated the cart must always be kept closed when not in use.
Improper Trash Disposal and Overfilled Dumpsters
Penalty
Summary
Garbage and refuse were not properly disposed of in the facility’s designated dumpster area. During a concurrent interview and observation, three dumpsters were seen in the trash disposal area with multiple bags of trash placed on the ground outside the dumpsters. The dumpsters were overfilled, and their lids could not close properly because of the amount of trash inside. The Dietary Supervisor stated the trash bags should not have been left on the ground and should have been placed inside the dumpsters with the lids fully closed. During an interview, the Maintenance Supervisor stated all trash generated by the facility should be placed inside the designated dumpsters and that dumpster lids should remain closed to prevent exposure to the environment. The Maintenance Supervisor also stated trash should never be left on the ground outside the dumpsters and that when dumpsters become full, staff should notify maintenance or administration so additional waste removal can be arranged. Facility policy stated infectious and regulated waste shall be handled and disposed of in a safe appropriate manner, and garbage and trash are not permitted to accumulate and are removed from the facility daily.
Urinary catheter care and urine assessment not completed
Penalty
Summary
The facility failed to ensure urine characteristics were appropriately assessed and failed to keep urinary catheter drainage bags off the floor for five sampled residents. The deficient practices involved residents with indwelling urinary catheters or a suprapubic catheter, including residents with dementia, severe cognitive impairment, dependence on staff for toileting and other ADLs, and diagnoses such as chronic kidney disease, vascular dementia, neuromuscular bladder dysfunction, and prior UTI. For one resident with an indwelling urinary catheter, the record showed orders and a care plan to monitor urine for color, odor, sediment, cloudiness, blood, and output. During repeated observations, thick off-white, milky sediment was visible in the catheter tubing, but the TAR did not document sediment during the observed period. The treatment nurse stated the sediment should have been identified as early as possible because it could indicate a UTI, and the infection preventionist stated the sediment was present as early as the first observation and should have been identified by treatment nurses, licensed nurses, and/or CNAs. For another resident with a suprapubic catheter, similar observations showed thick, milky sediment in the tubing over multiple observations, but the TAR again did not document sediment. The IPN stated the sediment should have been identified because it could indicate a UTI. In addition, three residents with urinary catheters had drainage bags observed resting on or touching the floor during multiple observations. Staff interviews, including the DON and RN, stated catheter bags should be kept off the floor to prevent contamination and infection, and the facility policy stated catheter tubing and bags were to be kept off the floor to prevent catheter-associated UTIs.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to ensure two residents were treated with dignity and respect. Resident 103 had diagnoses including schizophrenia, major depressive disorder, dependence on renal dialysis, and anxiety, and the MDS indicated moderately impaired cognition and dependence on staff for ADLs. Although the care plan stated mittens were to be applied only during dialysis sessions and removed during ADLs and mealtimes, Resident 103 was observed lying in bed with latex gloves on both hands, and later was again observed with latex gloves on both hands while seated in a wheelchair during care. A CNA stated the gloves were being used to prevent scratching of the resident’s lips and mouth and acknowledged that applying latex gloves did not maintain dignity. The DON stated staff were expected to follow the care plan and provide care in a manner that maintained dignity and respect, and stated latex gloves had the potential to cause humiliation and emotional distress. Resident 31 had diagnoses including DM, blindness glaucoma, low vision in the right eye, blindness in the left eye, hemiplegia, and hemiparesis affecting the left dominant side. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills for daily decision making and a need for set-up assistance with oral hygiene, personal hygiene, and upper body dressing. During breakfast, Resident 31 was observed seated at the edge of the bed eating with his hands while oatmeal, eggs, and juice were on his clothing, lap, and bed linens, and no staff were providing feeding assistance. A CNA stated she was busy with other residents and did not know whether Resident 31 was assigned a feeder that day. Resident 31 stated he always feeds himself and said, "I am legally blind and I feel like I don't matter in this facility." The DSD later reviewed the assigned feeders document showing the CNA was assigned to Resident 31 for feeding assistance during the day shift, and the DON stated staff must ensure residents receive meals with dignity and that feeder assignments should promote a sense of belonging so residents feel respected.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and/or renew informed consent for psychotropic medications for two residents. For one resident, the record showed diagnoses of schizophrenia, major depressive disorder, and diabetes mellitus, with moderately impaired cognitive skills for daily decision making and dependence on staff for activities of daily living. The physician ordered Olanzapine 2.5 mg daily for schizophrenia, and the MAR showed the medication was administered for 39 doses, but the medical record did not show written informed consent was obtained before the medication was started. For the second resident, the record showed diagnoses of dementia, metabolic encephalopathy, psychosis, hypertension, and hyperlipidemia. The H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decision making. Physician orders included Depakote 125 mg, 2 capsules every 12 hours for mood swings, and Seroquel 50 mg daily for psychosis manifested by angry outburst. During interview and record review, the DON stated the consent forms for Depakote and Seroquel had not been renewed as required. The DON stated informed consent should be obtained and documented prior to initiating or changing Olanzapine, and that consents for medications such as Depakote and Seroquel must be renewed at least every six months and maintained in the medical record. The facility policy titled Informed Consent also stated renewal every 6 months and written notice of dosage changes.
Room Damage and Nonfunctioning TV
Penalty
Summary
The facility failed to maintain resident rooms in good repair and failed to ensure a functioning television was provided for two residents. One resident, admitted with diagnoses including HTN, dementia, epilepsy, dysphagia, and splenomegaly, had fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills and dependence on staff for ADLs. During observation, a vertical indent with chipped paint and exposed underlying material was seen on the wall above and adjacent to the right side of the resident’s bed, with the bed rail touching the damaged area. During interview, the DON stated resident care areas should be maintained in good repair and free from damaged surfaces to ensure a clean, sanitary, and safe environment. The DON stated the bed placed against the wall potentially caused the wall damage and that the damage should have been reported to maintenance and repaired immediately. The DON also stated that chipped paint or exposed material could not be properly cleaned and disinfected, and that this did not meet facility standards for maintenance and infection control. The Maintenance Supervisor stated walls should be promptly repaired when scrapes or holes were present and that resident rooms were expected to maintain a home-like environment. A second resident, admitted with diagnoses including HTN, dysphagia, and muscle weakness, had intact cognition and required maximum assistance from staff for ADLs. During observation, the resident was sitting at the bedside looking at a television screen, and the television was nonfunctioning. The resident stated the television had not been working for approximately two weeks and that staff had been informed, but no action was taken to repair or replace it. The DON stated the television should be maintained in working condition and that allowing it to remain non-functional did not promote a comfortable and homelike environment.
Unauthorized Bed Positioning as a Physical Restraint
Penalty
Summary
The facility failed to ensure that one of six sampled residents, Resident 64, was free from the use of an unauthorized physical restraint when the resident's bed was positioned directly against the bedroom wall. Resident 64 was admitted to the facility with diagnoses including HTN, dementia, epilepsy, dysphagia, and splenomegaly. The resident's H&P dated 3/4/2026 indicated fluctuating capacity to understand and make decisions, and the MDS dated 12/28/2026 indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for ADLs. During a concurrent observation and interview on 3/10/2025 at 3:46 p.m., the DON observed Resident 64's bed positioned directly against the wall in the resident's room and stated the wall damage correlated with the bed being placed there. The DON stated that placing a resident's bed directly against the wall could be considered a physical restraint if it restricted the resident's ability to freely move, and stated beds should not be positioned against the wall unless there was a physician's order and proper assessment supporting the need. The DON also stated the practice was not in accordance with facility policy and should not have occurred.
PRN Ativan Orders Continued Beyond 14 Days
Penalty
Summary
The facility failed to ensure PRN Ativan orders were not continued beyond 14 days for two residents. Resident 103 had diagnoses including schizophrenia, major depressive disorder, and anxiety, and the MDS indicated moderately impaired cognition and dependence on staff for ADLs. A physician order dated 3/10/2026 directed Ativan 1 mg by mouth every 6 hours as needed for anxiety with a 60-day duration and stop date of 5/9/2026. During interview and record review, the Psychiatrist stated the order exceeded the 14-day PRN requirement and that the resident should be reevaluated every 14 days with clinical justification documented if the PRN psychotropic medication continued beyond 14 days. Resident 83 had diagnoses including anxiety and major depressive disorder, and the MDS indicated moderately impaired cognition and dependence on staff for ADLs. A physician order dated 2/9/2026 directed Ativan 1 mg by mouth every 6 hours as needed for anxiety with a 60-day duration and stop date of 4/10/2026. The MAR showed Ativan 1 mg was administered daily from 2/9/2026 through 3/11/2026 for a total of 31 doses. During concurrent interview and record review, the DON stated the facility policy required PRN psychotropic medication orders to be written for a specific time period and not renewed beyond 14 days, and stated the two residents' Ativan orders were not in alignment with that policy.
Unlabeled IV Tubing During Ceftriaxone Infusion
Penalty
Summary
The facility failed to ensure IV tubing was labeled with the date and time for one resident receiving ceftriaxone 1 gram IV daily. The resident had been admitted and readmitted to the facility and had diagnoses including muscle weakness, dementia, and hypertension. The resident's MDS dated 1/28/2026 indicated moderately impaired cognitive skills for daily decision making and set-up assistance was needed for oral hygiene, toileting, and upper body dressing. On 3/8/2026, the physician ordered ceftriaxone by IV and directed that the IV tubing be changed every 24 hours. During an observation on 3/9/2026 at 10:10 a.m., the resident was seen in bed with ceftriaxone infusing, and the IV tubing was unlabeled. During a later interview and record review, RN 1 reviewed a photograph of the tubing and confirmed it was unlabeled. RN 1 stated it was important to label the IV tubing with the date and time to verify when it was last changed, and stated that if the tubing was not labeled there was a potential risk for bloodstream infection. The facility policy titled Administration Set/Tubing Changes, revised 1/2026, stated all tubing was to be labeled with the start and change date and time, and any tubing observed without a label must be changed and then labeled accordingly.
Missing Oxygen In Use Sign
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when an oxygen in use sign was not posted outside the room of Resident 105 while the resident was receiving supplemental oxygen. Resident 105 was admitted and later readmitted to the facility with diagnoses including pleural effusion and pneumonia. The MDS dated 2/3/2026 indicated the resident had moderately impaired cognition, was dependent for toileting, bathing, and lower body dressing, and required oxygen therapy. The H&P dated 11/6/2025 indicated the resident had the capacity to understand and make decisions. Physician orders dated 2/25/2026 directed oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During observations on 3/9/2026 at 10:27 a.m. and 2:09 p.m., the resident was lying in bed receiving 2L of oxygen via nasal cannula, and no oxygen in use sign was posted outside the doorway. During interviews, an LVN stated the sign had to be posted while the resident was on oxygen therapy to prevent open flames from igniting a fire, and the DON stated the sign was necessary to remind those entering the room not to bring any open flames because supplemental oxygen could cause a fire. The facility policy titled Oxygen Administration, revised 1/2026, indicated to place an Oxygen in Use sign on the outside of the room entrance door.
Dialysis E-Kit Not Kept at Bedside
Penalty
Summary
The facility failed to ensure a dialysis emergency kit was kept at the bedside for one resident who required dialysis services. Resident 142 was admitted with diagnoses including dependence on dialysis, end stage renal disease, and muscle weakness. The resident’s MDS indicated intact cognitive skills for daily decision making and substantial assistance was needed for toileting, showering, and lower body dressing. The H&P stated the resident had the capacity to understand and make decisions. The resident’s care plan for emergency bleeding, initiated on 2/12/2026, directed staff to ensure a dialysis e-kit was placed at the bedside for management of emergency bleeding at the venous access site and to include gauze dressing, wrap bandage, and tape. During observation on 3/9/2026, no dialysis e-kit was seen at the bedside in the resident’s room. An LVN stated the e-kit was important to have at the bedside to manage bleeding in an emergency and that without it there was a potential for extreme blood loss. The facility policy on end-stage renal disease stated the dialysis e-kit was to be available at the nurses’ station or at bedside.
Failure to Provide Feeding Assistance During Breakfast
Penalty
Summary
The facility failed to provide feeding assistance during breakfast for one of seven sampled residents. Resident 31 was admitted with diagnoses including DM, blindness glaucoma, low vision to the right eye, blindness to the left eye, hemiplegia, and hemiparesis affecting the left dominant side. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident’s cognitive skills for daily decision making were moderately impaired. The MDS also showed the resident required set-up assistance for oral hygiene, personal hygiene, and upper body dressing. During an observation in the resident’s room, the resident was seen alone, seated upright at the edge of the bed with a breakfast tray present. The resident was eating with his hands, and oatmeal, eggs, and juice were observed on the resident’s clothing, lap, and bed linens. CNA 1 stated that when the morning shift was understaffed, staff could only pass breakfast trays and could not help feeder residents as scheduled. The DSD and DON stated that adequate staffing and assignments were important to ensure residents received timely feeding assistance and were not left unattended. The facility policy stated that competent nursing staff are scheduled and assigned to meet resident needs.
Medication Administration and Controlled Substance Count Deficiencies
Penalty
Summary
Safe medication administration practices were not followed for a resident with a gastrostomy tube, iron deficiency anemia due to blood loss, and cachexia. The physician ordered Ferrous Sulfate oral solution 220 mg/5 ml, 7.4 ml via g-tube daily, one to two hours before or after tube feeding. During observation, the LVN paused the tube feeding shortly before giving the medication and resumed the feeding shortly after administration, rather than holding the feeding for the ordered time frame. The LVN stated the medication was not administered as ordered because the feeding was only paused briefly around the dose. The same resident also had an order for Zinc Sulfate 220 mg via g-tube once daily, but during medication administration observation the LVN prepared a capsule formulation, opened it, poured the contents into a medication cup, and administered it via g-tube. The MAR indicated the ordered form was a tablet. The LVN stated the pharmacy supplied capsules rather than tablets and acknowledged the medication given was not in accordance with the physician’s order. A second resident with diagnoses including cerebral infarction, heart failure, and hypertension had an order for Metoprolol Tartrate 25 mg one tablet twice daily with meals. During observation, the medication was administered when no meal tray was present, and the LVN stated the resident had eaten breakfast earlier that morning. In a separate finding, a controlled substance count for Hydrocodone-Acetaminophen 10-325 mg was inaccurate: the bubble pack contained 19 tablets while the Medication Count Sheet showed 20 tablets remaining. The ADON stated the count was inaccurate, and the LVN stated he administered the dose but forgot to document it on the Medication Count Sheet.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, with 3 medication errors out of 36 opportunities for an overall error rate of 8.33% for two sampled residents. The errors involved Resident 1 and Resident 132 during medication administration observations and record review. The facility’s policy required medications to be administered safely, in accordance with the order, and with the correct right resident, right medication, right dosage, right time, and right route. Resident 1 was admitted with diagnoses including gastrostomy, iron deficiency anemia due to blood loss, and cachexia, and the MDS indicated severely impaired cognitive skills for daily decision making. The physician ordered Ferrous Sulfate oral solution 220 mg/5 ml, 7.4 ml via g-tube daily, one to two hours before or after tube feeding. During observation, the LVN paused the tube feeding shortly before giving the ferrous sulfate and resumed the feeding shortly after administration. The same resident also had an order for Zinc Sulfate oral tablet 220 mg via g-tube daily, but the LVN prepared and administered a capsule formulation by opening the capsule and pouring the contents into a medication cup before giving it via g-tube. Resident 132 was admitted and readmitted with diagnoses including cerebral infarction, heart failure, and hypertension, and the MDS indicated intact cognitive skills for daily decision making. The physician ordered Metoprolol Tartrate oral tablet 25 mg one tablet two times a day with meals. During observation, the LVN administered the medication when no meal tray was present, and the resident had eaten breakfast earlier that morning. The LVN stated the medication was not administered as ordered with meals.
Meal Preferences Not Followed
Penalty
Summary
Food was not served in a manner consistent with a resident’s stated preferences when Resident 124 received meatballs at lunch despite having a documented dislike for meatballs on the meal ticket. Resident 124 was admitted with chronic respiratory failure with hypoxia, diabetes mellitus, and muscle weakness, and was described in the H&P as having the capacity to understand and make decisions. The MDS indicated the resident was cognitively intact and required setup and clean-up assistance with ADLs. During observation and interview, Resident 124 stated the menu rarely changed, that meatballs were repeatedly served despite her dislike of them, and that requests for alternate meals were often ignored. A concurrent review of the meal ticket confirmed the dislike for meatballs, and the Dietary Supervisor stated the ticket may not have been checked when the meal was served. The DON stated staff must check meal tickets and ensure residents’ food preferences are followed. The facility policy stated nursing and food personnel will serve trays after checking that food preferences are correct.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the State Agency, the Ombudsman, and local law enforcement. Resident 61, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hypertension, had intact cognition, was independent with eating, oral hygiene, and toileting, and had capacity to understand and make decisions. During an interview, Resident 61 stated that while sleeping on 1/29/2026, Resident 7 tried to touch his genitals, and he reported the incident to LVN 3. Resident 61 stated Resident 7 was later sent out of the facility and placed in a different room upon return. Resident 7 had diagnoses including dementia, major depressive disorder, and anxiety disorder, with severely impaired cognition and fluctuating capacity to understand and make decisions. The facility's COC documented sexually inappropriate behavior toward Resident 61 and an order to send Resident 7 to a GACH for behavior evaluation. LVN 3 stated she was told by Resident 61 about the incident, separated the residents, and reported it to RN 1 and the ADM, who was the abuse coordinator. The ADM stated he was responsible for reporting abuse allegations to CDPH, law enforcement, and the Ombudsman, but the facility did not make the required immediate report. The facility policy stated alleged abuse, neglect, exploitation, or mistreatment would be reported immediately, but no later than two hours, to the state agency, the local/state ombudsman, and law enforcement.
Missing Comprehensive Care Plans for Abuse Allegation, Alcohol Use, Psychotropic Medications, and Denture Needs
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for four sampled residents. The facility policy stated that a comprehensive care plan with measurable objectives and timetables is to be developed and implemented for each resident, with ongoing assessment and revision as the resident’s condition changes. In the cited records and interviews, care plans were missing for specific resident needs that were identified in the chart, progress notes, observations, and staff interviews. Resident 61 was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hypertension. His MDS indicated intact cognition, independence with eating, oral hygiene, and toileting, and his H&P stated he had the capacity to understand and make decisions. On 1/29/2026, he told staff that his roommate tried to touch his genitals while he was sleeping, and LVN 3 stated he was very upset. Review of his active and resolved care plans showed no care plan addressing the allegation of inappropriate touching by the roommate. LVN 3 and the DON both stated a care plan should have been developed after the abuse allegation and that one was not in place. Resident 93 had diagnoses including alcohol abuse, other stimulant abuse, alcoholic cirrhosis, hepatic encephalopathy, end stage renal disease, noncompliance with medical treatment, and schizophrenia. His MDS and H&P indicated intact decision-making capacity, and his MDS showed moderate assistance was needed for ADLs. Records showed he returned from out-on-pass intoxicated on one occasion, with smell of alcohol, slurred speech, drowsiness, impaired coordination, and vomiting, and on another occasion returned agitated with bleeding to the right side of his lip while carrying a brown paper bag and refusing inspection. Review of his care plans showed no interventions for monitoring, assessing for alcohol use, or re-educating him on the risks of alcohol consumption. The ADON stated he had a known history of alcohol use while out on pass and that these interventions were not included in the care plan. Resident 41 had diagnoses including dementia, metabolic encephalopathy, psychosis, hypertension, and hyperlipidemia. His H&P described fluctuating capacity to understand and make decisions, and his MDS indicated severely impaired cognitive skills for daily decision making and need for supervision or touching assistance with toileting, showering, and lower body dressing. Physician orders showed Depakote 125 mg, 2 capsules every 12 hours for mood swings, and Seroquel 50 mg daily for psychosis manifested by angry outburst. The DON stated all active medications were expected to be incorporated into the comprehensive care plan, including the purpose of the medication, monitoring parameters, and potential adverse effects, but the care plan did not include Depakote or Seroquel. Resident 14 had diagnoses including diabetes mellitus, major depressive disorder, and hypertension. Her MDS indicated intact decision-making capacity and maximum assistance with ADLs. During observation, her dentures were seen on the top of the bedside table, and she stated she used them during meals. Review of her medical record showed no care plan related to denture use. The ADON stated a care plan should have addressed safe use of dentures, monitoring of oral health status, and staff awareness of her denture-related needs.
Care plans not revised after positive influenza A results
Penalty
Summary
The facility failed to revise the care plans for two residents after they tested positive for influenza A. Resident 6 was admitted with diagnoses including encephalopathy, dementia, and major depressive disorder, and records showed the resident had intact cognition on the MDS but was dependent on staff for multiple activities of daily living. A change in condition note documented a nonproductive cough and audible phlegm, influenza testing was ordered, and the lab later showed influenza A positive. The care plan in place addressed the cough and phlegm with interventions to test for influenza, encourage deep breathing and coughing exercises, and monitor vital signs, but it was not revised after the positive influenza A result. Resident 104 was admitted with diagnoses including epilepsy, end stage renal disease, and hypertension. The MDS indicated intact cognition and moderate assistance needs with oral hygiene, upper body dressing, and personal hygiene, and the H&P stated the resident had capacity to understand and make decisions. A change in condition note documented cough, sore throat, body aches, and two episodes of emesis, with influenza testing ordered. The lab later showed influenza A positive, and the change in condition note included droplet isolation precautions and Tamiflu 75 mg twice daily for five days. The care plan in place addressed flu-like symptoms and emesis with monitoring vital signs and assessing for worsening symptoms, but it was not revised after the positive influenza A result. During interview, the IPN stated both residents' care plans were not revised when they tested positive for influenza A and additional interventions were needed. The IPN stated the revisions were necessary to know how to treat and monitor the residents, including Tamiflu and monitoring for adverse reactions, and stated that without the revisions the residents were at risk of treatment and other interventions not being carried out. The DON also stated the care plans should have been revised after the positive influenza A results and that the interventions should have included Tamiflu treatment and additional monitoring.
Failure to Monitor After Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct 72-hour monitoring after an allegation of sexual abuse involving two residents. One resident, who had type 2 diabetes mellitus, chronic kidney disease, and hypertension, was cognitively intact, independent with eating, oral hygiene, and toileting, and had capacity to understand and make decisions. He stated that while he was sleeping, the other resident tried to touch his genitals, and he reported being very upset and told an LVN. The resident was sent out of the facility and later placed in a different room upon return, but his progress notes from the days after the allegation did not show psychosocial monitoring for distress. The LVN stated the resident should have been monitored for at least 72 hours, and the SSD stated she was not aware of the incident details and did not know he was the alleged victim. The second resident had dementia, major depressive disorder, and anxiety disorder, with severely impaired cognition and fluctuating capacity to understand and make decisions. He was transferred to an acute care hospital for behavior evaluation after the incident and later readmitted with a diagnosis of bizarre behavior. Although his progress notes showed he was monitored for 72 hours after readmission, they did not show monitoring for sexually inappropriate behavior. The LVN stated he had been sent for evaluation for sexually inappropriate behavior toward another resident and was not monitored for that behavior when he returned, and the DON stated licensed nurses were responsible for that monitoring to determine whether treatment was effective or if additional referrals were needed.
Conflicting POLST Forms and Missing Change-in-Condition Documentation
Penalty
Summary
Resident 147’s medical record was incomplete and inaccurate because two conflicting POLST forms were present in different parts of the chart. The resident was admitted and later readmitted with diagnoses including palliative care, COPD, and dysphagia. The MDS indicated moderately impaired cognition and dependence on staff for toileting, showering, and lower body dressing. The H&P stated the resident did not have the capacity to understand and make decisions. During record review with RN 1, one POLST in the medical record binder indicated full life-sustaining measures with long-term artificial nutrition, while another POLST in the hospice binder indicated the surrogate decision maker selected DNR, comfort-focused treatment, and no artificial means of nutrition. There was no documentation showing that the earlier POLST had been voided, superseded, or removed from the active record. RN 1 stated that having both conflicting POLST documents could lead licensed staff to follow the incorrect POLST during a life-threatening emergency. Resident 61’s change in condition was also not documented after the resident reported that a roommate tried to touch his genitals. The resident was admitted and readmitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hypertension. The MDS indicated intact cognition and independence with eating, oral hygiene, and toileting, and the H&P stated the resident had capacity to understand and make decisions. LVN 3 stated the resident was very upset, that a COC should have been documented in the eHR, and that she recalled calling the physician but did not document it. The DON stated the COC should always be documented and that the lack of documentation resulted in no care plan and no interventions such as monitoring for psychosocial distress and trauma.
Infection Control Lapses With Droplet Isolation and G-Tube Handling
Penalty
Summary
Infection prevention and control measures were not followed for a resident placed on droplet isolation precautions for suspected influenza. The resident had diagnoses including type 2 DM, HTN, and CKD, and the record showed fluctuating capacity to understand and make decisions. A CNA entered the room wearing PPE, but after providing care, removed gloves and a face shield outside the room, reentered to remove the gown, then exited while holding the resident’s water pitcher and walked down the hallway without performing hand hygiene. The CNA stated he did not doff PPE correctly and forgot hand hygiene, and the IPN stated PPE should have been removed inside the room and hand hygiene performed afterward. A second infection control issue involved a resident with a G-tube and severe cognitive impairment who required dependent assistance with ADLs and lacked capacity to understand and make decisions. During observation, the resident’s G-tube was disconnected while the feeding pump was running, and the G-tube connector was stored inside the G-tube feeding syringe bag. LVN 3 stated the G-tube feeding tube should not be stored in the syringe bag because it violated infection control and that the tubing should be capped or the whole tubing system replaced if the cap was missing. The IPN and RN 1 both stated the G-tube feeding tube should be capped and never stored in the syringe bag because it would violate infection control. The facility records also reflected policies requiring hand hygiene before and after direct resident contact and before and after entering isolation settings, as well as aseptic technique for enteral feedings. The LVN job description stated adherence to infection control, universal precautions, OSHA, and safety standards. The observed practices for both residents did not follow those stated infection control procedures.
Excess Residents in Shared Rooms
Penalty
Summary
The facility failed to ensure that two of 50 resident rooms accommodated no more than four residents in each room. A review of the facility census dated 3/9/2026 showed one five-resident occupied room and one four-resident occupied room. A review of the Room Variance Waiver letter dated 3/9/2026, submitted by the Administrator, showed that the identified rooms each had five beds and were being used for higher acuity residents requiring more care. During a concurrent facility tour observation and interview on 3/12/2026 at 10:00 a.m. with the Administrator, surveyors observed five residents in one room and four residents in another room. The residents were able to move in and out of the rooms, and there was space for the residents' beds, side tables, and care equipment. The Administrator stated there was a risk of decreased space for the residents, staff, and equipment, and a risk that the residents would feel uncomfortable. The Administrator also stated the room waiver was submitted for the rooms because they were occupied by more than four residents.
Insufficient Room Space per Resident
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 31 of 50 residents' rooms, including Rooms 1, 2, 3, 4, 5, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, and 49. A review of the facility census dated 3/9/2026 showed four rooms had capacity for two residents each and 27 rooms had capacity for three residents each. A review of the Room Variance Waiver letter dated 3/9/2026 stated that 31 rooms did not meet the 80 sq. ft. requirement under federal regulations and that the waiver was submitted in accordance with the special needs of the residents. During a concurrent facility tour observation and interview on 3/12/2026 at 10:00 a.m. with the Administrator, space was noted in the 31 rooms for residents to move in and out of the rooms, and there was space for the residents' beds, side tables, and care equipment. The Administrator stated there was a risk of decreased space for residents, staff, and equipment, and a risk that residents would feel uncomfortable. The Administrator also stated the room waiver was submitted for the 31 rooms because they measured less than 80 sq. ft. per resident capacity of the rooms.
Failure to Ensure Resident Wore Cranial Helmet as Ordered
Penalty
Summary
The facility failed to ensure that a resident who had undergone a craniotomy consistently wore a cranial helmet as ordered by the physician. Observations revealed that the resident was not wearing the helmet on multiple occasions, and both a CNA and an LVN were unable to locate the helmet or determine how long it had been missing. The resident's care plan and physician orders specified that the helmet should be worn at all times except during showers, but staff interviews confirmed that this was not being followed. The resident had severe cognitive impairment, was dependent on staff for activities of daily living, and had a history of behaviors such as removing the helmet and picking at the surgical site. Record reviews indicated that the resident had a surgical incision with staples on the head and had experienced episodes of wound dehiscence and infection, requiring antibiotics and wound care. Staff interviews further revealed a lack of communication and follow-up with the resident's physician regarding the care plan and orders. The failure to ensure the resident wore the cranial helmet as ordered placed the resident at risk for further injury and delayed healing, as directly noted in the report.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for two residents, leading to significant deficiencies in care. A Licensed Vocational Nurse (LVN) left a resident unattended and unsupervised at a nurse's station, despite the resident being at high risk for falls. The resident subsequently fell and sustained a displaced subcapital left femoral neck fracture, requiring surgical intervention. The LVN admitted to not ensuring another staff member was supervising the resident, which could have prevented the fall. Additionally, an Activity Staff member left the same resident at a nurse's station without verifying that a charge nurse was present to supervise. This lack of verification and communication contributed to the resident being left unsupervised, increasing the risk of falls. The facility's policy required staff to inform the charge nurse whenever a resident was transferred to a supervised area, which was not followed in this instance. The facility also failed to implement necessary fall prevention measures for both residents. One resident did not have bilateral fall mats at her bedside as ordered by the physician, and neither resident had fall risk indicators outside their rooms or on their mobility aids, as required by their care plans. Furthermore, a Morse Fall Scale assessment was not conducted following the second resident's fall, which is a critical step in assessing and mitigating fall risks. These deficiencies placed both residents at risk for further falls and injuries.
Failure to Notify Physician of Resident's Wound Care Refusal
Penalty
Summary
The facility failed to notify the primary care physician when a resident refused wound care, which is a breach of professional standards of quality. The resident, who was cognitively intact and dependent on assistance for activities of daily living, had been admitted with diagnoses related to orthopedic aftercare following a surgical amputation. The Treatment Administration Record (TAR) for January 2025 indicated specific wound care orders for various parts of the resident's body, including the left below-knee amputation site and other areas requiring monitoring and treatment. On January 5, 2025, the resident refused all wound care, but the physician was not informed of this refusal, as confirmed by a Licensed Vocational Nurse and the Director of Nursing. The facility's policy required documentation of the practitioner's notification and response in cases of treatment refusal, which was not adhered to in this instance. This oversight placed the resident's wounds at risk for delayed healing and potential complications, as noted in the report.
Failure to Implement Isolation Precautions
Penalty
Summary
The facility failed to implement its policy and procedure for isolation and transmission-based precautions for two residents. For Resident 3, a CNA was observed feeding the resident without wearing a gown, despite a contact isolation sign outside the room indicating the need for PPE. The resident was on contact isolation due to a diagnosis of candida auris, a serious fungal infection. The CNA acknowledged the oversight, and the LVN confirmed that the CNA should have been wearing a gown and gloves to prevent the transmission of organisms. For Resident 4, another CNA entered and exited the resident's room without wearing any PPE, despite a contact isolation sign indicating the requirement. The resident was on contact isolation due to an ESBL infection in the urine. The CNA was observed leaving the room with a used isolation gown in hand, which should have been discarded inside the room. The LVN confirmed that the gown should not have been taken out of the room as it was contaminated. The facility's policy indicated that gloves and disposable gowns should be used upon entering a contact precaution room, and contaminated gowns should not contact potentially contaminated surfaces or items in the resident's room.
Deficient Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation practices in the kitchen, as observed during a survey. A Dietary Aide (DA 1) did not change gloves between handling food items and nonfood items, such as touching a doorknob and receiving a menu slip from nursing staff. Despite being trained to change gloves after touching nonfood items, DA 1 continued to handle resident food trays and drinks without removing the gloves, which was against the facility's infection control policy. The Dietary Supervisor confirmed that staff were instructed to change gloves to prevent cross-contamination and foodborne illnesses. Additionally, the facility did not provide a closed container for the ice scooper, which was left uncovered and exposed to air in the hallway. A resident in a wheelchair was observed touching the scooper while using the table to propel himself. The Dietary Supervisor acknowledged that the kitchen staff were responsible for ensuring the scooper was covered to prevent contamination. The facility's policy indicated that proper glove use and covering of utensils were essential to prevent foodborne illnesses.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans and interventions for several residents, leading to deficiencies in care. For Resident 72, the facility did not implement the physician's order to place floor mats on both sides of the bed, which was crucial due to the resident's high risk of falls. Despite the care plan indicating the need for fall interventions, observations revealed that only one floor mat was consistently placed on the right side of the bed, contrary to the physician's orders. This oversight was confirmed by both a CNA and an RN, who acknowledged the discrepancy and the potential risk of injury to the resident. Resident 39 experienced a significant lapse in care as the facility failed to maintain cleanliness and timely incontinence care, as outlined in the care plan. The resident, who had multiple pressure ulcers, reported being left soiled for extended periods during the night shift, which was corroborated by the resident's roommate and the treatment nurse. The treatment nurse emphasized the importance of timely perineal care to prevent the worsening of pressure ulcers, and the RN confirmed that the care plan was not followed, which could hinder the healing process and increase the risk of infection. Additionally, the facility did not develop care plans for the use of specific medications for Residents 92, 65, and 130, which are essential for monitoring potential adverse reactions and ensuring proper treatment. Resident 92's care plan did not address the use of Plavix, lorazepam, and morphine sulphate, while Resident 65's care plan lacked details on Eliquis and tramadol. Similarly, Resident 130's care plan did not include escitalopram, lorazepam, Risperdal, and Valproic Acid. The MDS Coordinator and the DON both acknowledged the absence of these care plans, highlighting the importance of having them to monitor for side effects and ensure the medications' effectiveness in treating the residents' conditions.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper interventions to prevent the formation and worsening of pressure ulcers for nine residents. Several residents were observed with low-air-loss mattress (LALM) settings that did not correspond to their actual body weights, which could negatively impact their existing pressure ulcers. For instance, Resident 24's LALM was set for 50 lbs, while their actual weight was 161 lbs, and the physician's order was not clarified. Similarly, Resident 72's LALM was set for a range of 600 to 1000 lbs, despite their weight being 137 lbs. These incorrect settings were acknowledged by the treatment nurse, who stated that the settings could adversely affect the residents' wounds. In addition to incorrect LALM settings, the facility failed to maintain adequate hygiene and repositioning protocols for residents with pressure ulcers. Resident 39 was left soiled for extended periods, up to five and a half hours, which was against the care plan that required cleaning after each episode of incontinence. This neglect was confirmed by both the resident and their roommate, who reported that staff did not respond to call lights during the night shift. The treatment nurse and a registered nurse emphasized the importance of timely cleaning to prevent worsening of pressure injuries and infections. Furthermore, Resident 92 was not repositioned every two hours as required by their care plan, which led to the development of moisture-associated skin damage on their sacrum. Observations showed that Resident 92 remained in the same position for several hours, contrary to the physician's order and care plan interventions. The registered nurse confirmed that failure to reposition residents with limited mobility could lead to pressure injuries and increased risk of infection.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for four residents, increasing the potential for the spread of multidrug-resistant organisms (MDROs). Resident 72, who was admitted with severe cognitive impairment and a Stage IV pressure ulcer, did not have signage indicating the need for EBP, despite the presence of a roommate who required such precautions. Observations over two days confirmed the absence of appropriate signage and EBP implementation for Resident 72. Resident 24, admitted with quadriplegia and a Stage III pressure ulcer, also lacked signage and personal protective equipment (PPE) outside their room. Multiple observations confirmed the absence of EBP signage and PPE, even when a phlebotomist was present, indicating a failure to follow necessary precautions. Interviews with staff revealed a reliance on signage to determine EBP requirements, which was not present for Resident 24. Residents 62 and 39, both with severe pressure ulcers and other significant health issues, similarly lacked EBP signage and implementation. Observations showed that signage only indicated EBP for their roommates, not for the residents themselves. The Infection Preventionist Nurse confirmed that the facility's policy required EBP for residents with wounds, as per CDC guidance, but this was not being followed, posing a risk for MDRO spread.
Failure to Obtain Informed Consent for Medications and Bed Rails
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications and using bed side rails for three residents. Resident 9, who was diagnosed with depression and dementia, lacked the capacity to make decisions. Despite this, the facility administered mirtazapine and memantine without obtaining informed consent from the responsible party. The medical records did not contain any documentation of informed consent for these medications. Resident 68, diagnosed with schizophrenia and anxiety disorder, had moderately impaired cognitive skills but was capable of making decisions. The facility administered Ativan and Zyprexa without proper verification of informed consent, as the consent forms lacked the facility staff's signature. Additionally, the informed consent for the use of bilateral upper bed side rails was also missing the necessary staff signature. Resident 121, with severe cognitive impairment due to anxiety and depression, was administered lorazepam without a physician's signature on the informed consent form. Interviews with facility staff, including an LVN and the ADON, confirmed that informed consent was incomplete and that medication or treatment should not have been initiated without all required signatures. The facility's policy required informed consent to be obtained and verified before administering psychotropic medications or using side rails, but this was not adhered to in these cases.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by not removing identifiable health information from a gastrostomy tube (GT) feeding bottle before disposing of it in the trash. During an observation, a GT feeding bottle with the resident's name was found in the trash can in the resident's room. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the resident's name should have been removed or blackened out before disposal to comply with the Health Insurance Portability and Accountability Act (HIPAA) requirements. The resident involved, identified as Resident 100, had multiple medical conditions, including diabetes mellitus, dysphagia, chronic obstructive pulmonary disease, and hypertension. The resident was also noted to have severely impaired cognitive skills and was dependent on others for self-care and mobility. The facility's policy on maintaining the dignity and confidentiality of clinical information was not adhered to, as evidenced by the failure to protect the resident's personal information on the discarded GT feeding bottle.
Failure to Revise Care Plan and Involve RD in Weight Loss Management
Penalty
Summary
The facility failed to revise the care plan for a resident who did not meet the goal of maintaining her body weight without additional weight loss. The resident, who had diagnoses of heart failure and stroke, was admitted to the facility and had no cognitive impairment, allowing her to eat independently. Despite a care plan goal to maintain her weight, the resident experienced unplanned weight loss over several months, dropping from 260 pounds to 252 pounds. The care plan, dated September 8, 2024, included interventions such as encouraging increased oral food intake but was not revised despite continued weight loss. Additionally, the facility did not involve the Registered Dietician (RD) in the care planning process for the resident's weight loss. The RD was not consulted until November 14, 2024, despite the facility's policy requiring multidisciplinary input, including from the RD, for care planning related to weight loss. The policy also required monitoring and reassessment, which were not adequately addressed, as the care plan was not updated to reflect the resident's ongoing weight loss and potential causes, such as poor oral intake.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) properly documented the administration of Norco, a medication used to treat moderate to severe pain, for a resident. The LVN did not sign the Medication Administration Record (MAR) and Pain Assessment Flowsheet immediately after administering the medication. This oversight was identified during a review of the resident's medication records, which revealed a discrepancy between the number of doses recorded and the actual number of tablets remaining in the medication bubble pack. The resident involved had a history of dementia, chronic kidney disease, and contractures, and was dependent on staff for various activities of daily living. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and the need for pro re nata (PRN) pain medication. The LVN admitted to administering Norco to the resident but failing to document the administration on the MAR and Pain Assessment Flowsheet, which are essential for tracking medication administration and assessing the effectiveness of pain management. The Director of Nursing (DON) confirmed that the facility's policy required nurses to document medication administration immediately after giving the medication to ensure proper communication and prevent potential double dosing. The facility's policy on administering medications outlined the necessary documentation steps, including recording the date, time, dosage, and any symptoms or results observed. The failure to document the administration of Norco as per the facility's policy posed a risk of double dosing and potential overdose for the resident.
Failure to Provide Communication Boards for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that nursing staff used communication boards for three residents who did not speak English, the predominant language of the facility. This deficiency was identified through observations, interviews, and record reviews. Resident 15, who only spoke Spanish, did not have a language board in their room, despite their care plan indicating the need for one. The resident's family confirmed the language barrier, and a Certified Nursing Assistant (CNA) acknowledged the absence of the board, which was necessary for effective communication. Similarly, Resident 84, who spoke limited English, also lacked a language board in their room. The resident's care plan specified the need for a Spanish language board, but it was not provided. A CNA confirmed the necessity of the board to communicate with the resident and prevent delays in care. The resident's medical history included hepatic failure, dysphagia, hypertension, chest pain, and anemia, with intact cognitive skills for daily decision-making. Resident 40, who had fluctuating capacity to understand and make decisions, was also without a Spanish language board. Despite being able to communicate in both English and Spanish, the care plan required a Spanish board to facilitate communication. Observations and interviews with staff confirmed the absence of the board, which was essential for meeting the resident's needs. The facility's policy on interpreter services mandated the provision of communication boards for non-English speakers, which was not adhered to in these cases.
Failure to Transfer Residents Out of Bed
Penalty
Summary
The facility failed to ensure that dependent residents were taken out of bed, affecting three out of eight sampled residents. Observations revealed that Resident 121 was consistently found lying in bed watching television over several days. The resident's records indicated severe cognitive impairment and dependency on staff for activities of daily living (ADLs). The ADL flowsheet showed that Resident 121 was not transferred out of bed from the beginning of November until the 14th. Similarly, Resident 5 was observed lying in bed during multiple observations. The resident's medical history included major depressive disorder and anxiety disorder, with severe cognitive impairment noted in the Minimum Data Set (MDS). The ADL flowsheet for October showed limited instances of being transferred out of bed, and none from November 1st to 14th. Resident 14 was also observed lying in bed during several observations. The resident had a diagnosis of anxiety disorder and hemiplegia, with moderate cognitive impairment and dependency on staff for ADLs. The ADL flowsheet indicated that Resident 14 was not transferred out of bed throughout October and the first half of November. Interviews with staff, including Licensed Vocational Nurses and the Director of Staff Development, revealed that the facility allowed residents to choose when to get out of bed. However, it was acknowledged that getting residents out of bed was important for socialization, preventing depression, and offloading pressure from the body. The Assistant Director of Nursing stated that staff should offer all residents the opportunity to get out of bed daily to aid circulation and provide a change in environment. The failure to regularly transfer these residents out of bed was identified as a deficiency that could negatively impact their well-being and psychosocial status.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure that floor mats were placed on both sides of the bed for a resident with a history of falls, increasing the potential for injury. The resident, who was admitted with diagnoses including lack of coordination, generalized muscle weakness, osteoporosis, and Alzheimer's disease, was assessed as having severe cognitive impairment and was dependent on staff for activities of daily living and mobility. Physician orders specifically required floor mats on both sides of the bed to minimize injury risk, and the resident was part of the Falling Star Program due to a high risk of falls as indicated by a Morse Fall Scale score of 55. Observations and interviews revealed that only one floor mat was consistently placed on the right side of the resident's bed, contrary to the physician's orders and the facility's policies. Staff, including a CNA and an RN, confirmed the absence of a floor mat on the left side of the bed, acknowledging the discrepancy with the physician's orders. The facility's policies required staff to implement appropriate fall interventions, which were not followed in this case, as evidenced by the lack of a floor mat on both sides of the bed as prescribed.
Failure to Provide Salt Alternative and RD Referral Leads to Resident Weight Loss
Penalty
Summary
The facility failed to provide a salt alternative seasoning for a resident on a no added salt (NAS) diet, as well as failed to refer the resident to a Registered Dietician (RD) as ordered by the physician. The resident, who had diagnoses including heart failure, stroke, and high blood pressure, experienced unplanned weight loss over several months. Despite the physician's order for a NAS diet, the facility did not have salt alternatives available, which led to the resident's complaints of unappetizing and flavorless meals, resulting in decreased intake of facility-provided meals. The resident's weight loss was documented from June to November, with a total loss of 14 pounds. The facility's interdisciplinary care team did not address the resident's weight loss in care conferences, and dietary staff were not present at these meetings. The resident's care plan was not revised to address the ongoing weight loss, and the RD was not involved in the care planning process until November, despite a physician's order in September to refer the resident to the RD. Interviews with facility staff revealed that the Dietary Supervisor was aware of the lack of salt alternatives but did not order them from a more expensive vendor. The RD confirmed that she had not received any referrals for the resident prior to November. The facility's policy indicated that care planning for weight loss should be a multidisciplinary effort, including input from the RD, but this was not followed. The resident expressed feeling hungry and noted that the weight loss was unintentional.
Failure to Display Oxygen Safety Signage
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with its policy for two residents, as observed by surveyors. Specifically, the facility did not display 'No Smoking/ Oxygen in Use' signs on the doors or inside the rooms where oxygen was being used for two residents. This oversight was noted during multiple observations over two days, where both residents were using oxygen concentrators at their bedsides without the required signage. Resident 32, who was using oxygen via a nasal cannula, had a history of congestive heart failure, pneumonia, epilepsy, generalized muscle weakness, and dementia. The resident's cognitive skills were severely impaired, and they were dependent on assistance for self-care and mobility. Despite these conditions, the necessary safety signage was absent from their room, as confirmed by both a CNA and an RN during interviews. Similarly, Resident 15, who also required oxygen, had diagnoses including sepsis, pleural effusion, COPD, anemia, and dementia. Although this resident was more independent in daily activities, the absence of 'No Smoking/ Oxygen in Use' signs was again noted. An RN confirmed the lack of signage and acknowledged the potential fire hazard posed by this deficiency. The facility's policy, revised in 2010, clearly required such signage for oxygen administration, but it was not adhered to in these cases.
Medication Documentation Discrepancy
Penalty
Summary
The facility failed to ensure accurate and complete documentation of the administration of Norco, a medication used to treat moderate to severe pain, for a resident. The resident, who was admitted with diagnoses including dementia, chronic kidney disease, and contractures, was prescribed Norco to be administered every six hours as needed for severe pain. During an observation and interview, it was found that there was a discrepancy between the number of Norco tablets recorded on the Medication Count Sheet and the actual number of tablets remaining in the bubble pack. Specifically, the Medication Count Sheet indicated that 24 doses should remain, but only 23 doses were present in the bubble pack. The Licensed Vocational Nurse (LVN) responsible for administering the medication admitted to not documenting the administration of a dose on the Medication Count Sheet after giving it to the resident. The Director of Nursing confirmed that the LVN was responsible for documenting the administration of controlled medications immediately after dispensing them to ensure accountability and prevent drug diversion. The facility's policy on controlled substances requires that an individual resident controlled substance record be maintained, including the number of doses on hand and the signature of the nurse who administered the dose.
Failure to Provide Salt Alternatives for NAS Diet
Penalty
Summary
The facility failed to provide a salt alternative seasoning for a resident on a no added salt (NAS) diet, leading to complaints of unappetizing and flavorless meals. This deficiency was identified for a resident who had been admitted with diagnoses including heart failure, stroke, and hypertension. Despite having the capacity to understand and make decisions, the resident experienced consistent weight loss over several months, which was not planned or intentional. The resident resorted to using high-sodium hot sauce packets to add flavor to her meals, unaware of their sodium content, due to the unavailability of salt alternatives. Interviews with the Dietary Supervisor (DS) revealed that the facility did not have salt alternatives available, and the DS had not ordered them from a more expensive vendor despite knowing their importance for residents on a NAS diet. The DS acknowledged that decreased palatability could lead to reduced food intake and weight loss. The Licensed Vocational Nurse (LVN) responsible for checking meal trays admitted to not checking for high-sodium condiments, which could exacerbate the resident's medical conditions. The facility's Registered Dietician confirmed that the resident was not on a planned weight loss regimen, and the Registered Nurse (RN) noted that the facility should have addressed the resident's oral intake and food palatability. The facility's policies indicated that care planning for weight loss should be a multidisciplinary effort, including input from the RD, and that documenting meal refusal due to non-compliance was inappropriate. However, these policies were not effectively implemented, contributing to the resident's undesirable weight loss and dissatisfaction with meals.
Failure to Adhere to NAS Diet for Resident
Penalty
Summary
The facility failed to notify the physician and obtain orders before providing Tapatio brand hot sauce packets to a resident on a no added salt (NAS) diet. The resident, who had heart failure, stroke, and hypertension, was observed with hot sauce packets on her meal tray, despite her diet restrictions. The dietary supervisor acknowledged the absence of salt alternatives and admitted that the resident was given hot sauce packets due to her preference, even though it was not compliant with her dietary orders. The resident was unaware of the high sodium content in the hot sauce and used it to enhance the flavor of her meals, as no salt alternatives were available. The licensed vocational nurse confirmed that the resident's physician was not informed about the hot sauce use, and the registered dietician was only consulted after the issue was identified. The facility's policy indicated that staff should create a care plan that satisfies the resident if they are unhappy with their prescribed diet, but this was not done in this case.
Failure to Ensure Residents Understood Arbitration Agreements
Penalty
Summary
The facility failed to ensure that three residents understood the binding arbitration agreement they entered into upon admission. The residents, identified as Resident 39, 107, and 339, were not adequately informed about the nature of the arbitration agreement, which is a method of resolving disputes without going to court. Despite having intact cognitive skills for daily decision-making, as indicated by their Minimum Data Set (MDS) assessments, these residents were not provided with a clear explanation of the arbitration agreement by the facility staff. Interviews with the residents revealed that they were unaware that signing the agreement waived their right to resolve disputes in court. The deficiency was further highlighted during interviews with the facility's Admissions Coordinator and Administrator. The Admissions Coordinator acknowledged her responsibility to explain admission paperwork, including the arbitration agreement, to residents or their representatives. However, the residents reported that they did not receive such explanations. The Administrator emphasized the importance of ensuring residents understand the complex terms of the arbitration agreement and their right to accept or decline it. This lack of communication and understanding led to the residents unknowingly entering into binding arbitration agreements with the facility.
Overcrowding in Resident Rooms
Penalty
Summary
The facility failed to comply with regulations regarding the maximum number of residents per room, as observed during a survey. Specifically, two rooms were found to accommodate more residents than allowed. Room [ROOM NUMBER] had five residents, and room [ROOM NUMBER] had four residents, exceeding the limit of four residents per room. This was confirmed through a review of the facility's Census dated 11/12/2024, which listed the residents occupying these rooms. Additionally, a Room Variance Waiver letter submitted by the Administrator indicated that these rooms were used for higher acuity residents requiring more care, and the waiver was intended to address the special needs of these residents without adversely affecting their health and safety. During a facility tour and interview with the Administrator, it was observed that the rooms had sufficient space for residents to move around, and there was adequate room for beds, side tables, and care equipment. However, the Administrator acknowledged the risk of decreased space for residents, staff, and equipment, and the potential discomfort for residents due to the overcrowding. The waiver was submitted because the rooms were occupied by more than the allowed number of residents, highlighting the facility's awareness of the issue but not addressing the regulatory requirement.
Deficient Room Space in Facility
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, affecting 31 out of 50 rooms. According to federal regulations, each resident in a shared room should have at least 80 square feet of space. However, the facility's census and room measurements revealed that several rooms did not meet this requirement. Specifically, rooms designated for two residents measured between 142.30 and 157.98 square feet, while rooms for three residents measured between 197.96 and 259.48 square feet, all falling short of the required space per resident. During a facility tour and interview with the Administrator (ADM), it was noted that although there was space for residents to move and for necessary furniture and equipment, the rooms did not meet the federal space requirements. The ADM acknowledged the risk of decreased space for residents, staff, and equipment, which could lead to discomfort for the residents. A room variance waiver had been submitted for these 31 rooms, indicating that the space constraints were recognized by the facility but were deemed not to adversely affect the residents' health and safety or their ability to achieve their highest practicable well-being.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident who was transferred to a General Acute Care Hospital (GACH) after refusing care at the facility. The resident, who was initially admitted with cellulitis, type two diabetes mellitus, and a pressure ulcer, was deemed appropriate to return to the facility by the hospital. Despite the resident's willingness to return and the facility's capability to provide necessary care, the facility refused readmission, citing the resident's previous refusal of care. The resident's initial assessment indicated they were alert, oriented, and cooperative, with multiple open lesions due to cellulitis and an unstageable pressure injury. The resident refused some medications and care, leading to a transfer to the hospital. The facility's interdisciplinary team (IDT) discussed the resident's refusal of care but did not explore alternative options or assess the reasons for the refusal. The facility's policy allowed for readmission if a bed was available, which was the case, but the IDT decided against it, stating the resident's refusal of care as the reason. Interviews with facility staff revealed that the resident was not combative and had agreed to return to the facility if treated for pain and cellulitis. The facility's Director of Nursing (DON) and administrator confirmed the decision not to readmit the resident, despite available beds and the facility's ability to provide necessary care. The facility's assessment and policies indicated they could manage the resident's conditions, but the decision was made based on the resident's initial refusal of care, which was not considered a behavior issue by the facility.
Failure to Conduct Pain Assessments as Ordered
Penalty
Summary
The facility failed to ensure that pain assessments were conducted every shift for a resident, as ordered by the physician. The resident, who had a history of a broken left hip bone, gait and mobility abnormalities, generalized muscle weakness, osteoporosis, contracture of the right hip, and unspecified dementia, was dependent on staff for activities of daily living and mobility. The Minimum Data Set indicated that the resident had severely impaired cognitive skills, which could hinder their ability to communicate pain effectively. During a review of the resident's Medication Administration Record (MAR) for October 2024, it was found that the staff did not assess the resident's pain during the 3:00 PM to 11:00 PM shift on October 9, 2024. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that the pain assessment was missed, despite the physician's orders requiring such assessments every shift. The facility's policy and procedure on pain management emphasized the importance of identifying and assessing pain consistently, especially in residents at risk of having pain.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that Resident 1 was free from injury as indicated in the resident care plan. Resident 1, who had diagnoses including a nondisplaced transverse fracture of the left tibia and fibula, osteoporosis, and functional quadriplegia, was dependent on staff for all activities of daily living. The care plan specified that Resident 1 required a two-person assist for bed mobility, transferring, and toileting, and that staff should handle the resident gently and carefully during care. However, during an incident on 3/16/2024, a CNA attempted to reposition Resident 1 by herself without adjusting the low air loss mattress settings, which led to Resident 1 sliding near the edge of the bed and experiencing pain due to sudden movement. This resulted in a fracture of the left lower leg that required hospitalization for evaluation and treatment. The CNA did not follow the care plan's instructions to use a two-person assist and to adjust the mattress settings, contributing to the resident's injury. Interviews with staff confirmed that the CNA did not change the mattress settings and attempted to reposition the resident alone, contrary to the care plan and facility policies. The Director of Nursing and other staff acknowledged that the proper procedures were not followed, which led to the resident's injury. The facility's policy emphasized the importance of safety and supervision to prevent accidents, but these measures were not adequately implemented in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Pico Rivera
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookfield Healthcare Center | 0.8 mi | ★★★★★ | 11 | 0 |
| Colonial Gardens Nursing Home | 1.2 mi | ★★★★★ | 14 | 0 |
| Villa Del Rio Gardens | 1.3 mi | ★★★★★ | 0 | 0 |
| El Rancho Vista Health Care Center | 2.2 mi | ★★★★★ | 23 | 0 |
| Downey Community Health Center | 2.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.