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 Rosemead Healthcare Center during CMS and state inspections, most recent first.
Call lights were not kept within reach for three residents whose records showed cognitive impairment, mobility limitations, and fall risk. One resident with hemiplegia, Alzheimer’s disease, and a prior fall had the call light placed above the head in bed; another resident with muscle weakness and gait abnormalities said the call light had been left on the far side of the bed after linen changes; and a third resident with hemiplegia and dementia had the call light hanging on the side rails while seated in a wheelchair. Staff and the DON stated the call light should be within reach.
Failure to Provide Foot Care and Podiatry Follow-Up: A resident with DM and impaired nail integrity had care plan directions for daily foot inspection, foot care, and podiatry follow-up, but staff did not ensure a podiatry visit was documented or completed. On observation, the resident’s feet were very dry with cracked skin and the toenails were long, brown, and untrimmed; staff stated the resident needed lotion and podiatry care, while the SSD said no podiatry appointment had been documented.
GT Site Care and HOB Elevation Not Followed: The facility failed to provide ordered GT site care for one resident, whose dressing was observed loose and not secured with tape, despite orders and care plan instructions for daily site care. The facility also failed to keep another resident’s HOB elevated 30 to 45 degrees during continuous GT feeding, even though the order summary and care plan required it; the resident was observed lying flat while the feeding was running.
A resident with COPD and acute respiratory failure had BIPAP and nebulizer masks left on the bedside table instead of being stored in the clear bag for respiratory supplies, and an RNS and DON stated the masks should be kept in the bag when not in use for infection control. Another resident with COPD and chronic hypoxic respiratory failure had continuous oxygen via NC, but the NC tubing was observed touching the floor and the oxygen level was noted as 3.5 L/min instead of the ordered 2 L/min; the DON stated the tubing should not touch the floor and the physician's order should be followed.
Unlabeled Bisacodyl suppositories were found in a med room refrigerator without a resident name or expiration/opening date, an E-kit contained Levaquin with an expired date sticker, and a resident kept glucose tablets and diclofenac gel in a bedside nightstand despite no order to self-administer or store meds at bedside. RN and DON interviews confirmed the labeling, expiration, and storage issues, and the resident had osteoarthritis and Type II DM with intact cognition.
Expired-Dating Missing on Sanitizer Test Strips: The Dietary Supervisor used test strips to check the concentration of the sanitizing solution in the red bucket used on food prep surfaces, but the strip container had no expiration date. The DS, dishwasher, and Infection Control Nurse all stated they could not confirm the strips were valid or that the solution was being accurately tested, and the facility's Infection Prevention and Control Program required a safe, sanitary environment and prevention of disease transmission.
Open Trash Bin and Trash Accumulation: A large recycling trash bin was observed with its lid open and trash on the floor around the bin area. CS stated there was no more room in the recycling bin and that empty boxes would be left by the bins or placed in regular trash bins until pickup the next day. The IPN, DS, MS, and DON stated trash bin lids should remain closed and trash should not be left on the floor, and facility policy required food waste to be placed in covered garbage and trash cans.
Dirty Dryer Lint Traps and Dusty Resident Fans: Two laundry dryers had thick lint buildup in the lint traps, and staff stated the traps needed cleaning every 2 hours to avoid fire. Two residents also had dusty electric fans in their rooms; one resident had cancer, immunodeficiency, and DM, and the other had HF, CKD, and anemia. Staff observed the fans were dusty, and the facility policy stated resident-room equipment should be kept clean and in safe operating condition.
Failure to Protect Resident Privacy During GT Site Care: A resident with severely impaired cognition and dependence for multiple ADLs was observed during GT site care with the gown lifted and the privacy curtain left open, exposing the resident's abdominal area to the roommate and hallway. RN and DON both stated the curtain and door needed to be closed to protect privacy and dignity, consistent with the facility's Resident Rights - Quality of Life policy.
Advance Directive Documentation Missing From Resident Record: A resident admitted with acute osteomyelitis of the right femur and Type II DM with neuropathy had no AD or POLST documentation in the paper chart or EMR. The H&P noted the resident had decision-making capacity, but nursing and SSD interviews confirmed the AD/POLST should have been in the medical record and available for emergency care, and the facility policy stated copies of the AD would be included in the chart.
Inaccurate MDS Coding for Oxygen Use: A resident with COPD and chronic hypoxic respiratory failure had an active order for continuous oxygen at 2 L/min via NC and was observed receiving oxygen in bed, but the MDS did not document oxygen therapy use. The MDSC stated the assessment was coded incorrectly and should have reflected continuous oxygen use, while the DON stated the resident used oxygen and that MDS submissions must accurately reflect current status.
Improper IV Site Labeling and Dressing Integrity: A resident with UTI, dementia, and muscle weakness had a peripheral IV for antibiotic therapy, with orders to monitor the site each shift and care plan interventions to change and label the dressing. During observation, the DON noted the dressing was loose, the tape was coming out, and the IV dressing was not labeled with the insertion date; the DON stated the site should be labeled and rotated every 72 hours.
A resident with impaired immunity and dependence for ADLs was observed placing a urinal containing urine on top of the side table next to food and drink items. On a later observation, urine was dripping from the urinal onto the table. The TN and IPN stated the urinal should not be on the clean side table because it was an infection control issue and could contaminate the resident’s food or drink; the facility policy stated urinals should be removed from the bedside stand.
A resident with ESBL resistance and a UTI continued receiving Meropenem IV after hospital transfer, but the facility did not complete the SDCF for antibiotic surveillance. The IPN stated the order was not confirmed with the physician and the form was left incomplete, while the DON stated the form was needed to determine whether the resident met criteria before antibiotic therapy.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report highlights insufficient hazard identification and lack of proper supervision in the affected area.
A resident with multiple diagnoses who required significant assistance experienced two falls after falling asleep in a wheelchair. The facility did not ensure the IDT Falls Committee met or documented findings and interventions after these incidents, as required by facility policy. The DON confirmed the lack of documentation and meetings following the falls.
A resident with severe cognitive impairment and multiple comorbidities experienced a fall that was not properly documented in the medical record by an LVN. Although the incident was recorded in risk management, the required details were missing from the resident's progress notes, contrary to facility policy. Both the DON and an RN confirmed that such documentation was necessary to inform the healthcare team.
A resident with dementia and hemiplegia experienced two falls resulting in injuries after staff failed to keep personal items within reach and did not complete a required quarterly fall risk assessment. Additionally, the facility did not develop a care plan to address the resident's or family's preference for dining location, leading to inconsistent support of the resident's rights and autonomy.
A resident with severe cognitive impairment and mobility issues experienced two unwitnessed falls, resulting in injury, due to the facility's failure to promptly revise the care plan after each incident. Despite facility policy requiring care plan updates after significant changes in condition, the care plan was not revised until several days after the second fall, leaving the resident without appropriate, individualized interventions.
A resident with severe cognitive impairment and physical limitations was not consistently allowed to choose their preferred dining location, despite family requests for dining room meals. Staff determined meal location based on their own discretion, and the resident's care plan did not include interventions to address this preference, resulting in a failure to support the resident's right to self-determination.
Two residents in an LTC facility experienced a breach of privacy and dignity during personal care. One resident, who was cognitively impaired, was exposed due to early return to a room being deep cleaned, while another resident was exposed to a roommate during perineal care. Staff acknowledged the lack of privacy and the importance of maintaining resident dignity.
The facility failed to ensure call lights were within reach for three residents, including those with dementia and Parkinson's Disease, leading to potential delays in care. Observations revealed call lights were either on the floor or out of reach, contrary to care plans and facility policy. Staff acknowledged the importance of accessible call lights for resident communication.
The facility failed to provide information regarding Advance Directives (AD) for four residents, potentially leading to treatment against their wishes. Residents with impaired cognition and dependence on staff had incomplete AD Acknowledgement Forms, as confirmed by staff interviews. The facility's policy requires these forms to be filled out and accessible to ensure care aligns with residents' wishes.
A resident with osteomyelitis and diabetes did not receive prescribed IV antibiotics on a specific day, and the midline IV site was not labeled with the date of dressing change, contrary to facility policy. This failure in administration and labeling was confirmed by staff and records, highlighting a lapse in infection control and adherence to professional standards.
The facility failed to follow its oxygen administration policy for three residents, leading to potential complications. A resident's nasal cannula tubing was not dated, risking infection. Another resident's inhalation tubing was undated, and no care plan was developed for their oxygen use. Additionally, a third resident's nasal cannula was improperly placed, and a 'no smoking' sign was missing, posing a fire risk.
Three residents requiring dialysis did not have emergency kits at their bedside, as required by facility protocols. This deficiency was identified through observations and interviews, revealing that the absence of E-kits posed a risk of delayed emergency treatment for complications such as bleeding from dialysis access sites. Despite care plans indicating the need for immediate intervention, the necessary emergency supplies were not available, highlighting a lapse in adherence to established care protocols.
The facility failed to follow its policy on the use of bed rails for two residents, leading to potential risks of entrapment and injury. Both residents had grab bars installed without documented attempts of alternative interventions, informed consent, or physician's orders. The residents required varying levels of assistance with daily activities and had moderately impaired cognition.
The facility failed to provide sufficient nursing staff on weekends during Q4 2024, not meeting the required 3.5 nursing hours per patient day and 2.4 CNA direct care hours per patient day on several occasions. The California Department of Public Health denied the facility's request for a workforce shortage waiver, and the facility's policy required these staffing levels. Interviews with the BOM and DON confirmed the staffing shortfalls, which had the potential to affect the quality of care and residents' quality of life.
The facility did not post actual nursing staffing information for three consecutive days, potentially misleading residents and visitors about staffing levels. The Daily Staffing Grid was outdated or missing in Nursing Station 2, contrary to the facility's policy requiring posting in both stations. Interviews confirmed the lack of compliance with the policy.
The facility failed to implement proper infection control measures, including incorrect isolation signage and lack of PPE for residents with MDROs. Residents with infections were not properly isolated, and staff did not adhere to PPE protocols, increasing the risk of infection transmission.
A facility failed to obtain informed consent from a resident's responsible party before administering Ativan, a psychotropic medication. The resident, who was moderately cognitively impaired and required significant assistance, was readmitted with multiple diagnoses. The Assistant Director of Nursing confirmed the absence of consent, which violated the facility's policy and the resident's rights.
A facility failed to accurately code a resident's discharge destination in the MDS, recording it as a short-term general hospital instead of home or community. This error was confirmed by the DON during a review of the resident's records, which indicated the correct discharge destination. The facility's policy requires accurate assessment coordination and certification by a registered nurse.
A facility failed to provide a communication device for a resident whose primary language was Spanish, despite the resident's diagnoses of Parkinson's disease and bipolar disorder. The resident did not have a communication board in their room, which was necessary for effective communication with staff. Interviews with nursing staff confirmed the need for such devices, as outlined in the facility's policy on translation services.
A facility failed to reposition a resident every two hours as required, risking the development of pressure ulcers. The resident, with conditions such as hemiplegia and dependence on dialysis, was observed lying on their back for extended periods. Staff interviews confirmed the necessity of regular repositioning, which was not followed, despite the facility's policy and the resident's care plan indicating the need for such care.
A resident at high risk for pressure ulcers did not receive proper preventive care as ordered. The resident lacked bilateral heel protectors, and the low air loss mattress was set incorrectly, increasing the risk of pressure ulcer development. Staff confirmed these oversights, which were contrary to the facility's policy on pressure ulcer prevention.
A resident experienced severe pain due to the facility's failure to implement non-pharmacological interventions and notify the medical doctor when pain was uncontrolled. Despite a care plan outlining these measures, the resident reported pain levels of 8-9/10 without receiving appropriate interventions or timely medication, leading to significant discomfort.
Expired chicken nuggets were found in the facility's refrigerator, which were confirmed by dietary staff and the RD as expired. The presence of expired food in the kitchen was against the facility's policy on food storage, which requires adherence to good sanitary practices to prevent foodborne illnesses.
A facility failed to complete a required Surveillance Data Collection form for a resident receiving antibiotics for Vancomycin Resistant Enterococcus bacteremia. The resident had moderately impaired cognition and was dependent on staff for daily activities. The Infection Preventionist Nurse was unable to locate the form and was on vacation during the period it should have been completed. The facility's policy emphasizes the importance of monitoring antibiotic use.
The facility failed to maintain a functioning call light system in eight resident rooms, with observations showing inoperable call lights and a lack of alternative call bells provided. Staff interviews confirmed non-compliance with the facility's policy to provide call bells and conduct documented safety rounds when the call system was down, potentially delaying resident care.
A resident with multiple health conditions did not receive their morning medications on time, as observed during a survey. The medications were scheduled for 9 AM but were not administered until after 11 AM. The LVN responsible admitted to falling behind, and the facility's policy requires medications to be given within one hour of the scheduled time to ensure effectiveness.
A resident with significant medical conditions was found with an electronic smoking device in their room, contrary to the facility's policy requiring secure storage and supervision during smoking. Staff interviews revealed that the resident's room sometimes smelled like smoke, and the CNA had reported the issue to a nurse supervisor. The facility's policy prohibited smoking inside and required all smoking materials to be stored securely, but this was not adhered to in this case.
A resident with severe cognitive impairment accessed a meal cart unsupervised and without performing hand hygiene, contrary to the facility's infection control policy. Staff interviews confirmed that residents should not handle meal trays due to safety and infection control concerns, and hand hygiene is required before and after handling trays.
A resident with a history of hemiplegia and dementia fell and sustained a head injury when a CNA attempted a Hoyer lift transfer alone, contrary to facility policy requiring two-person assistance. The resident, dependent on staff for transfers, was injured during the transfer process, highlighting a failure to adhere to safety protocols.
The facility failed to readmit three residents after hospitalization due to a lack of available isolation rooms, despite the residents being cleared for discharge. The residents were initially transferred for emergency medical care, and repeated attempts by the hospital to return them were unsuccessful. The facility's policies on bed hold and transfer/discharge were not adhered to, potentially violating the residents' rights to return.
A resident's medical records were not provided within the required two working days after a request was made, as per the facility's policy. The delay was due to the need for administrative consultation on legal matters, and the records were eventually mailed after the stipulated timeframe.
A facility failed to enforce its COVID-19 Mitigation Plan by allowing two family members to visit a resident under Novel Respiratory Precautions without wearing the required PPE. Despite clear signage, the family members entered the room with only surgical masks. Staff interviews confirmed the oversight, acknowledging the risk of virus spread due to non-compliance with PPE protocols.
Call Lights Left Out of Reach for Three Residents
Penalty
Summary
The facility failed to ensure call lights were within reach and appropriate to the residents’ physical abilities for three sampled residents. The deficiency was identified through observation, interview, and record review, and involved Residents 10, 14, and 26. Facility records and staff interviews showed that each resident had care plan interventions directing staff to keep the call light within reach and to respond promptly to assistance requests, yet the call lights were observed placed where the residents could not reach them. Resident 10 was admitted with diagnoses including hemiplegia, hemiparesis, and Alzheimer’s disease. The record also showed a history of a fall without injury, contracture of the right elbow, moderately impaired cognition, and dependence for upper and lower body dressing. During observation, Resident 10 was lying in bed with the pad sensor call light placed above the resident’s head on the right side of the pillow. The LVN stated the resident could not reach the call light and that it needed to be within reach so the resident could notify staff if unwell or needed help. Resident 14 was admitted with metabolic encephalopathy, muscle weakness, and gait and mobility abnormalities, and the record showed the resident required assistance with bathing, dressing, footwear, eating, oral hygiene, and toileting hygiene. The resident’s care plan identified fall risk and included use of the call light as an available resource. During observation, Resident 14 stated the call light had been left all the way on the other side of the bed after linen changes and that it could not be reached in an emergency. Resident 26 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and unspecified dementia, with records showing fall risk, moderately impaired cognition, and need for assistance with bathing, dressing, toileting, and personal hygiene. During observation, Resident 26 was sitting in a wheelchair at the bottom right side of the bed while the call light was on the left upper side of the bed hanging on the side rails, and the RN stated the resident could not reach it and that it needed to be within reach at all times for safety.
Failure to Provide Foot Care and Podiatry Follow-Up
Penalty
Summary
Provide care and assistance with activities of daily living for a resident who was unable to fully perform them was deficient when the facility did not ensure the resident was seen by a podiatrist as indicated in the care plan and did not maintain the resident’s foot hygiene and nail care. The resident had diagnoses including type 2 diabetes mellitus and heart failure, and the care plan directed staff to inspect the resident’s feet daily, refer the resident to a podiatrist, provide foot care, cut long nails, and monitor and document foot care needs. A later care plan also identified impaired nail integrity related to fungal infection with thickening, brittleness, and deformity of the toenails and directed regular follow-up with a podiatrist. The resident’s history and physical indicated the resident could make needs known but could not make medical decisions, and the MDS showed the resident required substantial to maximal assistance for bathing, dressing, and footwear and partial to moderate assistance for oral and toileting hygiene. During observation, the resident was resting in bed and the feet were dry with long, brown, untrimmed toenails. LVN staff stated CNAs should assist with ADLs including foot care so the feet would not be dry, that there was no podiatry appointment documented in the EHR, and that the SSD was responsible for arranging the appointment. The LVN also stated the resident’s feet were very dry with cracked skin and that the CNAs should have applied lotion and needed to trim the toenails, while also stating the resident was diabetic and needed to see a podiatrist. The SSD stated staff had not documented a need for a podiatry appointment due to dry feet and long toenails, and the DON stated residents’ ADLs should be attended to, lotion should be applied to the feet, and residents with long and dry toenails should be seen by a podiatrist. The facility policy stated toenails are trimmed by CNAs except for residents with diabetes or circulatory impairments and that high-risk residents and residents with hypertrophic, mycotic, and keratotic toenails are referred to a podiatrist as ordered by the attending physician.
GT Site Care and Head-of-Bed Elevation Not Provided as Ordered
Penalty
Summary
The facility failed to provide ordered gastrostomy tube (GT) site care for one resident. The resident had a GT, diagnoses including diabetes mellitus and diverticulosis, and a care plan that required GT site care as ordered because of dysphagia. The physician’s order directed licensed staff to cleanse the GT stoma with normal saline, pat dry, cover with a T-drain sponge, and secure it with tape every day and as needed if soiled or dislodged. During a concurrent observation, the resident was lying in bed with the GT site dressing loose and not secured with tape on the abdomen. The Infection Prevention Nurse stated the dressing should be changed every day and as necessary to prevent skin irritation around the site and to tape the dressing to secure it and prevent accidental pulling during bed mobility. The DON stated the GT site dressing should be changed as needed to keep the GT site clean and dry to prevent infection. The facility policy titled Feeding Tube-Site Care stated that the site of a well-established enteral feeding tube should be inspected daily for signs and symptoms of irritation, gastric leakage, or infection, and that a gauze drainage sponge should be placed around the site for irritation, drainage, or leakage. The facility also failed to keep another resident’s head of bed elevated while continuous GT feeding was running. That resident had diagnoses including encounter for attention to gastrostomy and COPD, was severely cognitively impaired, and was dependent on staff for several activities of daily living. The order summary and care plan required the head of bed to be elevated 30 to 45 degrees during feeding and for one hour after feeding stopped. During observation, the resident was lying flat in bed while connected to ongoing GT feeding, and the LVN stated the head of bed was not elevated to 30 to 45 degrees. The LVN and DON both stated the head of bed should have been elevated during GT feeding.
Respiratory Supplies Not Stored Properly and Oxygen Not Set as Ordered
Penalty
Summary
Resident 67 had diagnoses including acute respiratory failure, COPD, and bronchitis, and the care plan identified COPD exacerbation with inhalation medication delivered via nebulizer and the use of BIPAP to assist breathing and maintain adequate oxygenation. The record also showed the resident had intact cognition and required varying levels of assistance with daily care. During observation, the resident was lying in bed with the BIPAP mask and nebulizer mask left on top of the bedside table instead of being stored in the clear, transparent bag intended for respiratory supplies when not in use. The RNS stated the masks should be stored in the bag to prevent contamination and spread of infection, and the DON stated all respiratory supplies should be stored inside the transparent bag when not in use for infection control. Resident 41 had diagnoses including COPD and Alzheimer's Disease, and the order summary showed an active order for oxygen at 2 L/min via NC continuously for chronic hypoxic respiratory failure. The history and physical indicated the resident had the capacity to understand and make decisions, and the care plan identified the resident as at risk for respiratory distress related to multiple respiratory and cardiac diagnoses, with interventions including oxygen at 2 L/min via NC continuously. During observation in the resident's room, the resident was lying in bed with oxygen via NC in use, and the NC tubing was touching the bedroom floor. The LVN stated the resident's ongoing oxygen level was set at 3.5 L/min and that the tubing should not touch the floor to prevent infection. The DON stated the NC tubing on a resident receiving oxygen should not touch the floor and should be replaced for infection control, and that registered nurses titrate oxygen levels. The DON also stated that for a resident with an order of 2 L of oxygen via NC and a COPD diagnosis, the physician's order should be followed to prevent excessive oxygen administration, and that incorrect oxygen administration could lead to respiratory acidosis. The facility policy stated oxygen tubing, humidifiers, masks, and cannulas are for single use only, are changed weekly and when visibly soiled, and are stored in a plastic bag at the resident's bedside when not in use.
Unlabeled refrigerated suppositories, expired E-kit medication, and resident-kept medications
Penalty
Summary
Three Bisacodyl suppositories were found inside the medication storage room refrigerator at Nursing Station 1 without a box, resident name, or a date showing when the box was opened or when the suppositories would expire. During the observation, RN1 stated the suppositories should have been inside a box with an expiration date and that, if kept in the refrigerator, they should have a date of opening and expiration. The facility’s medication labeling and storage policies stated that medications must be stored to maintain integrity and security and that nonprescription drugs may remain in the original manufacturer’s labeled container with the expiration date clearly readable. An E-kit containing IV medications was inspected and a sticker on the back of the kit identified Levaquin 500 mg with an expiration date of 4/30/24. RN1 stated she was not sure whether the Levaquin inside the E-kit was expired and explained that E-kits were to be checked every shift by the Nursing Supervisor, with opened kits documented and replaced through the pharmacy. The DON stated nursing staff were responsible for checking E-kits for expiration dates and that expired medication should be reported so the pharmacy could exchange the kit. The facility’s policy for emergency medication kits stated the contents are reviewed for usage, necessity, prescribing patterns, upcoming outdates, and recalls. Resident 15, who had diagnoses including osteoarthritis of both knees and Type II DM and was documented as cognitively intact and able to make decisions, had an active order for Diclofenac Sodium External Gel 1% to be applied to both ankles as needed for joint pain. During a medication pass, the resident told LVN 3 to retrieve the resident’s own medication from the nightstand, where LVN 3 found a store brand bottle of glucose tablets and a used tube of Diclofenac Sodium Topical Gel 1% with a minimally intact prescription sticker that did not identify who it was prescribed for. LVN 3, RN1, and the DON stated the resident was not allowed to keep medications at the bedside and had no order to self-administer or keep medications there. The facility’s medication storage policy stated medications were to be stored in locked medication carts and/or locked medication rooms.
Expired-Dating Missing on Sanitizer Test Strips
Penalty
Summary
The facility failed to follow proper food storage and handling practices in accordance with its policy and procedure for the kitchen. During an initial kitchen observation, the Dietary Supervisor used test strips to measure the concentration of the sanitizing solution in the red bucket, which kitchen staff used to sanitize food preparation areas. Upon closer inspection, the test strip container did not have an expiration date, and the Dietary Supervisor stated they were not sure whether the strips were expired because no expiration date was present on the container. During interviews, the kitchen staff dishwasher stated it was their responsibility to test the red bucket solution to ensure it had the required concentration of chemicals to kill bacteria and prevent cross-contamination when food was prepared for residents. The dishwasher stated the test strips being used did not have an expiration date and did not know whether the testing results were correct. The Dietary Supervisor later stated that if the facility used the red bucket solution without knowing whether the test strips had expired, it would not provide an accurate reading and the solution would not effectively sanitize. The Infection Control Nurse also stated that without an expiration date, staff would not know whether the solution had the proper concentration to disinfect food preparation areas. The facility's Infection Prevention and Control Program policy stated the facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.
Open Trash Bin and Trash Accumulation
Penalty
Summary
The facility failed to properly cover one of three large trash bins, as required by its policy on garbage disposal. During a facility tour, one large recycling trash bin was observed with its lid open, and trash was seen on the floor around the trash bin area. Central Supply Staff stated there was no more room for additional cardboard boxes in the recycling bin and that the new supplies would be removed from the cardboard boxes, with the empty boxes then broken down and left on the side of the trash bins or thrown inside the regular trash bins until pickup the next day. Interviews with the Infection Prevention Nurse, Dietary Supervisor, Maintenance Supervisor, and Director of Nursing confirmed that trash bin lids should remain closed and that trash or trash bags should not be left on the floor around the bins. The Infection Prevention Nurse stated the surrounding floor should be cleaned because it was not sanitary and could attract vermin or cockroaches. The Dietary Supervisor stated the open lid and trash on the floor were not acceptable because they were unsanitary and could cause cross contamination and rodent infestation. The Maintenance Supervisor stated staff had left a trash bag on the floor next to the trash bin overnight and that this was not acceptable because it would attract rodents. Facility policy stated food waste would be placed in covered garbage and trash cans, and that garbage and trash were not permitted to accumulate in any part of the facility.
Dirty Dryer Lint Traps and Dusty Resident Fans
Penalty
Summary
Two laundry dryers in the facility’s laundry room were observed with multiple random thick patches of brown material in the dryer lint traps. During the observation, Housekeeping 2 stated the lint trap had accumulated thick lint and needed to be cleaned every 2 hours to avoid a potential fire. The Maintenance Supervisor later stated the lint had accumulated since the morning of the observation and confirmed the lint trap should have been cleaned every 2 hours to avoid fire. The facility policy on dryer lint trap cleaning stated that lint traps must be cleaned every 2 hours by designated laundry staff personnel. Two residents had electric fans in their rooms that were dusty on the cover and blades. Resident 30 had diagnoses including malignant neoplasm of the cervix, immunodeficiency, and DM, and was documented as having intact cognition and needing partial/moderate assistance with toileting, showering, upper and lower body dressing, and personal hygiene. Resident 90 had diagnoses including heart failure, CKD, and anemia, and was documented as having moderately impaired cognition and needing varying levels of assistance with eating, oral hygiene, dressing, toileting, and showering. During observation, LVN 2 stated the fans were dusty, and the IPN and DON stated equipment in resident rooms should be kept clean and in good working condition.
Failure to Protect Resident Privacy During GT Site Care
Penalty
Summary
The facility failed to promote and treat Resident 66 with respect, privacy, and dignity during care and treatment. Resident 66 was admitted with diagnoses including encounter for attention to gastrostomy and COPD, and the MDS dated 1/21/2026 indicated severely impaired cognition for daily decision making. The MDS also showed the resident was dependent on staff for oral hygiene, toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation and interview on 3/24/2026 at 10:12 a.m., RN 1 was observed in Resident 66's room pulling up the resident's gown and assessing the GT site without pulling and closing the privacy curtain. This exposed the resident's abdominal area to the roommate and the hallway. RN 1 stated the privacy curtain and the resident's door needed to be closed prior to providing care and treatment to provide privacy, comfort, and prevent embarrassment. The DON later stated the privacy curtain needed to be closed prior to providing care and treatment to residents to provide privacy and dignity. The facility's policy titled Resident Rights - Quality of Life stated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that staff promotes, maintains, and protects resident privacy, including bodily privacy, during personal care and treatment procedures.
Advance Directive Documentation Missing From Resident Record
Penalty
Summary
The facility failed to ensure its Advance Directive policies and procedures were implemented for one sampled resident by not having the resident’s Advance Directive or POLST information available in the medical record. Resident 93 was admitted with diagnoses including acute osteomyelitis of the right femur and Type II DM with neuropathy. The admission H&P dated 8/15/2025 stated the resident had the capacity to understand and make decisions, and noted that no POLST or AD record was in the medical record. During record review on 3/25/2026, Resident 93’s paper chart and electronic medical record still did not contain AD or POLST documentation. LVN 1 stated the AD and POLST should be in the medical record and available to nurses for emergency situations to acknowledge and respect the resident’s code status choices and decisions. SSD stated she kept copies of residents’ POLST and Advance Directives in her office, but the original copies should be in the resident’s paper chart or electronic medical record. DON stated the AD and POLST should be kept in the resident’s chart and that nursing staff needed quick access to this information during emergencies. The facility policy stated copies of a resident’s AD would be included in the medical record.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure Resident 41’s MDS accurately coded supplemental oxygen use. Resident 41 was admitted with diagnoses including COPD and Alzheimer’s disease, and the H&P stated the resident had the capacity to understand and make decisions. The OSR showed an active order for oxygen at 2 L/min via NC continuously for chronic hypoxic respiratory failure, and the care plan identified the resident as at risk for respiratory distress with an intervention to administer oxygen at 2 L/min via NC continuously. During observation, Resident 41 was in bed receiving oxygen via NC, and the tubing was touching the bedroom floor. LVN 1 stated the resident had COPD and used oxygen. The MDS dated 12/31/2025 indicated intact cognition and did not document oxygen therapy use while a resident. During interview and record review, the MDSC acknowledged the MDS was coded incorrectly and should have been coded for continuous oxygen use while the resident. The DON stated Resident 41 used oxygen due to respiratory issues and that oxygen use should be indicated on the MDS because submissions must be accurate and reflect the resident’s current status. The facility policy stated the MDS must reflect the resident’s status at the ARD, and the CMS RAI Manual requires the assessment to accurately reflect the resident’s status.
Improper IV Site Labeling and Dressing Integrity
Penalty
Summary
The facility failed to maintain the integrity and proper labeling of a peripheral IV site for one resident. The resident was admitted with diagnoses including UTI, dementia, and muscle weakness, and the MDS indicated moderately impaired cognition and a need for assistance with eating, oral hygiene, toileting, showering, dressing, and personal hygiene. The resident also had an active order to monitor the IV site for signs of inflammation or infiltration every shift, and the care plan identified the peripheral IV line as being used for antibiotic administration with interventions to change and label the IV dressing and monitor the site for inflammation and infiltration. During a concurrent observation and interview, the resident was found lying in bed with a peripheral IV line in the right hand. The DON observed that the IV site dressing was loose and the tapes were coming out, and the dressing was not labeled with the insertion date. The DON stated the peripheral IV line should be labeled with the date it was inserted to keep track of when to change or rotate the IV site, and stated the IV site should be changed or rotated every 72 hours to prevent infection and skin irritation. The facility policy on IV site care stated the purpose was to reduce the risk of local and bloodstream infections through proper routine site maintenance.
Urinal with urine placed on resident’s side table
Penalty
Summary
Provide and implement an infection prevention and control program was not followed for one sampled resident with impaired immunity. Resident 91 was admitted with diagnoses including encephalopathy, respiratory failure, and other immunodeficiencies. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident was dependent for eating, oral and toileting hygiene, showering, dressing, footwear, and personal hygiene. The care plan identified impaired immunity and stated the resident was at risk for contracting infections due to impaired immune status and to keep the environment clean and people with infection away. During observations in the resident’s room, Resident 91 was seen holding a urinal with yellow liquid inside and placing it on top of the side table next to a water pitcher and cup of water. On a later observation, the side table again had a urinal containing yellow liquid, and some urine was dripping on the outside of the urinal onto the table. A urinal holder was attached to the bottom of the bed, but the resident stated the holder could not be reached, so the urinal was placed on the side table. The TN and IPN both stated that a urinal with urine should not be placed on the side table because it was an infection control issue and could contaminate food, drink, or other items on the resident’s clean surface. The facility’s Infection Prevention and Control Program policy stated the facility maintains a safe, sanitary, and comfortable environment, and the Urinal and Bedpan-Offering and Removing policy stated to remove the urinal or bedpan from the resident’s bedside stand.
Incomplete Antibiotic Surveillance Documentation
Penalty
Summary
The facility failed to complete a Surveillance Data Collection Form (SDCF) dated 3/24/2026 for one of five sampled residents, Resident 96, who was receiving antibiotics. Resident 96’s admission record showed diagnoses including ESBL resistance and a UTI. The order summary report dated 3/23/2026 showed a physician’s order for Meropenem IV, 1 gram twice daily for UTI/ESBL urine until 3/30/2026, with administration scheduled for 6 a.m. and 6 p.m. During interview, the Infection Preventionist Nurse stated that when Resident 96 was admitted from the hospital, the resident continued the antibiotics and the facility did not confirm the order with the resident’s physician. The IPN stated the SDCF was not filled out completely and needed to be completed to ensure the resident was screened before initiating antibiotic therapy and to verify that antibiotic use was appropriate and met criteria. The DON also stated the SDCF needed to be completely filled out to determine whether the resident met criteria before receiving antibiotic therapy. The facility’s Antibiotic Stewardship Program policy stated the program was designed to promote appropriate antibiotic use and that the IP would collect and analyze infection surveillance data and monitor adherence to the ASP.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient supervision in the area in question. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Convene and Document IDT Falls Committee After Resident Falls
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) Falls Committee met to review and document findings and interventions after a resident experienced two falls. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, and schizophrenia, required substantial to maximal assistance for several activities of daily living. According to facility records, the resident fell on two separate occasions while in the facility, both times reportedly after falling asleep in a wheelchair. Despite the facility's policy requiring the IDT-Falls Committee to meet within 72 hours of a fall to review the event, conduct a root cause analysis, and document interventions, there was no documentation in the resident's medical record indicating that such meetings occurred after either fall. The Director of Nursing confirmed that the required IDT meetings were not held or documented following these incidents, as evidenced by the absence of relevant entries in the progress notes or IDT assessment forms.
Incomplete Documentation of Resident Fall in Medical Record
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to document the details of a resident's fall in the medical record. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebrovascular disease, dementia, and Alzheimer's disease, was severely cognitively impaired and dependent on staff for most activities of daily living. The facility's records indicated that the resident had experienced multiple falls, with the most recent incidents occurring on consecutive days. On the date in question, the LVN was informed by a Certified Nursing Assistant (CNA) that the resident had fallen, and upon assessment, found the resident lying on the floor beside the bed. Despite the incident being recorded in the facility's risk management system, the LVN did not document the fall or the surrounding circumstances in the resident's progress notes, as required by facility policy. The Change in Condition Evaluation noted the occurrence of the fall but lacked pertinent details about the event. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the fall should have been documented in the resident's medical record to ensure the healthcare team was aware of the resident's status. The facility's policy specified that licensed nurses must document the date, time, and relevant details of such incidents in the nursing notes, which was not done in this case.
Failure to Implement Comprehensive Care Plan and Respect Resident Preferences
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan for a resident with multiple diagnoses, including dementia, hemiplegia, and bullous pemphigoid. The care plan for falls, dated 10/16/2023, required staff to keep the resident's personal items within reach and to complete quarterly fall risk assessments as per the facility's fall protocol. However, staff did not ensure personal items were accessible, and a required quarterly fall risk assessment was not completed in March 2025. These omissions were confirmed through record review and staff interviews, with both the MDS Nurse and DON acknowledging the lack of documentation and the importance of these interventions for fall prevention. The resident experienced two unwitnessed falls, one in March and another in April 2025, resulting in injuries such as redness, skin discoloration, and swelling. Observations showed that the resident's personal items, including glasses and water, were placed on a storage container out of reach, prompting the resident to attempt to retrieve them independently, which led to a fall. Staff interviews revealed that the overbed table was left empty because the resident would knock items off, but no alternative intervention was documented or implemented to ensure items remained within safe reach. Additionally, the facility did not develop a care plan to address the resident's or family’s expressed preference for dining location. Although the family requested that the resident eat meals in the dining room, and staff sometimes accommodated this, there was no documented care plan or consistent intervention to support the resident's right to choose meal location. Staff decisions about meal location were made on a day-to-day basis without reference to a care plan, and both the MDS Nurse and DON confirmed the absence of a documented plan addressing this preference.
Failure to Timely Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to timely revise the care plan for a resident identified as a known fall risk, who experienced two falls from bed on 3/20/2025 and 4/9/2025. Despite the resident's complex medical history, including dementia, hemiplegia, and severe cognitive impairment, the care plan was not updated promptly after each fall event. The care plan in place prior to the incidents had last been revised in 10/2023 and included general fall prevention interventions, but did not reflect the specific circumstances or new interventions following the actual falls. After the first fall on 3/20/2025, documentation showed the resident was found on the floor, but the care plan was not revised to address this incident. Following a second unwitnessed fall on 4/9/2025, which resulted in bruising to the resident's face, the care plan was again not updated until 4/25/2025. Interviews with the MDS nurse and DON confirmed that the care plan should have been revised immediately after each fall, in accordance with facility policy and standard care practices, but this did not occur. Facility policies required that the care plan be reviewed and revised after significant changes in condition, including post-fall events, and that new interventions be implemented as appropriate. The delay in revising the care plan meant that the resident did not receive updated, individualized interventions following each fall, resulting in a lack of appropriate care and services and contributing to recurrent falls and injury.
Failure to Honor Resident's Dining Location Preference
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred dining location during mealtimes. The resident, who had diagnoses including bullous pemphigoid, dementia, and hemiplegia/hemiparesis following a stroke, was assessed as having severely impaired cognitive skills and required moderate assistance with eating and full assistance with transfers. Despite a documented request from the resident's family members for the resident to eat meals in the dining room, staff determined the meal location based on the CNA's decision or upon family request during visitation, rather than consistently honoring the resident's or family's stated preference. Review of the resident's care plan revealed no documented interventions addressing the preference for dining location, and staff interviews confirmed that this preference was not incorporated into the care plan. Facility policies indicated that residents should be allowed to choose their schedules and activities, including meal locations, but these policies were not followed in practice for this resident. The lack of a care plan intervention and inconsistent respect for the resident's and family's wishes led to a failure to promote the resident's right to self-determination and a dignified existence.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents, identified as Residents 75 and 80, during personal care activities. Resident 80, who was moderately cognitively impaired and dependent on staff for personal care, was observed with exposed genitalia and without privacy curtains in their room. This occurred because the room was being deep cleaned, and the resident was brought back too early, resulting in exposure to the hallway and a visitor. Staff members acknowledged the lack of privacy and the importance of providing decency to the resident. Resident 75, who was dependent on staff for perineal care and had a diagnosis of dementia, was exposed to their roommate during a change of incontinence brief. The curtain was left open, compromising the resident's privacy. The CNA involved admitted the oversight and recognized that it would make the resident feel uncomfortable and disrespected. The Assistant Director of Nursing confirmed that the curtain should have been closed to ensure privacy during such care. The facility's policy on resident rights and quality of life emphasizes the importance of maintaining and protecting resident privacy during personal care. However, in these instances, the staff failed to adhere to these guidelines, resulting in a breach of the residents' rights to dignity and privacy.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, which is a critical aspect of accommodating their needs and preferences. Resident 20, who has a history of falling and unspecified dementia, was observed on multiple occasions with the call light out of reach. On one occasion, the call light was hanging on an oxygen concentrator three feet away, and on another, it was found on the floor. Certified Nurse Assistant 3 confirmed that the call light was not accessible, which is against the care plan that requires the call light to be within reach. Resident 55, who has unspecified dementia and is at risk for falls due to gait and balance problems, was also found with the call light out of reach. During an observation, the call light was hanging on the side rails, and the resident confirmed they could not reach it. Registered Nurse 1 acknowledged that the call light should always be within reach, as it is the resident's mode of communication with the staff. Resident 50, diagnosed with Parkinson's Disease and osteoarthritis, was observed with the call light hanging on the opposite side of the bed, making it inaccessible. Certified Nurse Assistant 1 noted that the call light should be placed where the resident can see and use it. The Director of Nursing reiterated that the call light should be placed near the resident's strong arm or hand. The facility's policy on the call system emphasizes that it should be accessible to residents, highlighting the importance of this deficiency.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information regarding Advance Directives (AD) for four of six sampled residents, which could lead to medical or surgical treatment being administered against the residents' wishes. Resident 55, who had moderately impaired cognition and was dependent on staff for various activities, did not have a completely filled out AD Acknowledgement Form. The Assistant Social Service Director (ASSD) confirmed that the form should be filled out completely and discussed with the resident or responsible party to ensure the resident's wishes are followed. Resident 24, with severely impaired cognition and dependence on staff for daily activities, also had an incomplete AD Acknowledgement Form. The ASSD and the Director of Nursing (DON) both stated that the form should be filled out completely upon admission to assess if the resident executed an AD. The DON emphasized that an incomplete form would not be valid. Similarly, Resident 36, who had moderately impaired cognition and was dependent on staff, had an incomplete AD Acknowledgement Form, as confirmed by a Licensed Vocational Nurse (LVN). Resident 190, with moderately impaired cognition and dependence on staff, did not have copies of the Physician Orders for Life-Sustaining Treatment (POLST) or the AD Acknowledgement Form in their chart or uploaded in the PointClickCare system. The LVN and the Social Services Assistant (SSA) both stated that these documents should be accessible to staff to provide care according to the resident's wishes. The facility's policy indicated that if no advance directive exists, the facility should provide the resident with an opportunity to complete the form, and a copy should be maintained as part of the resident's medical record.
Failure in IV Administration and Labeling
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, specifically in the provision of a midline intravenous catheter. Resident 238, who was admitted with osteomyelitis and type 2 diabetes mellitus, required intravenous therapy for antibiotic treatment. However, the facility did not adhere to professional standards of practice and the facility's policy and procedure for midline dressing changes. During an observation, it was noted that the midline intravenous site on Resident 238's right upper arm was not labeled with the date of the dressing change, which is crucial for infection control. Additionally, Resident 238 did not receive the prescribed IV antibiotics on a specific day, as confirmed by both the resident and the facility's records. The Assistant Director of Nursing acknowledged the missed administration and emphasized the importance of timely antibiotic delivery to prevent delays in the resident's healing process and potential worsening of the infection. The facility's policy requires that the IV site be labeled with the date and the licensed nurse's initials to prevent infection, which was not followed in this instance.
Oxygen Administration Policy Failures
Penalty
Summary
The facility failed to adhere to its policy on oxygen administration for three residents, leading to potential complications related to oxygen therapy. For Resident 292, the nasal cannula tubing was not dated, contrary to the medical order requiring weekly changes with labeling. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse, who acknowledged the risk of infection due to the lack of dating, as staff would be unaware of when the tubing was last changed. Resident 43's inhalation tubing set was also not dated, and there was no care plan developed for the resident's oxygen use and breathing treatments. During an observation, a Certified Nurse Assistant noted the absence of a label on the inhalation tubing set, which was not in use. The Director of Nursing confirmed that the tubing should be labeled and stored properly to prevent cross-contamination. Additionally, the lack of a care plan was acknowledged by a Registered Nurse Supervisor, who stated that a care plan is necessary to ensure specific care and interventions for the resident. For Resident 24, the nasal cannula was not placed in both nostrils, and there was no 'no smoking' sign posted outside the resident's room, despite the requirement for oxygen use. This was observed during an interview with a Licensed Vocational Nurse, who noted the absence of the sign, which is essential to prevent fire hazards. The Infection Prevention Nurse confirmed that the nasal cannula needed to be properly placed to ensure the resident received the prescribed oxygen, as improper placement could lead to reduced oxygen saturation and respiratory distress.
Failure to Provide Dialysis Emergency Kits at Bedside
Penalty
Summary
The facility failed to ensure that three residents who required dialysis had a dialysis emergency kit (E-kit) at their bedside, as per the standards of practice. This deficiency was identified during observations, interviews, and record reviews. The absence of E-kits was noted for three residents, all of whom were dependent on renal dialysis due to end-stage renal disease or chronic kidney disease. The lack of E-kits at the bedside posed a potential risk of delayed emergency treatment in case of complications such as bleeding from the dialysis access site. Resident 292, who was alert and oriented, had a care plan indicating the need for immediate intervention in case of dialysis complications. However, during an observation, it was found that there was no E-kit at the bedside. Similarly, Resident 66, who had severely impaired cognitive abilities, also lacked an E-kit despite the care plan specifying the need for a shunt clamp at the bedside for emergencies. The Registered Nurse Supervisor confirmed the absence of E-kits and acknowledged the risk of not having emergency supplies available. Resident 36, who had moderately impaired cognition and was dependent on hemodialysis, also did not have an E-kit at the bedside. The Director of Nursing confirmed the necessity of an E-kit to control bleeding from the dialysis access site. The facility's policy and procedure on dialysis care emphasized the importance of monitoring and maintaining the integrity of dialysis access sites, yet the required emergency kits were not in place, highlighting a lapse in adherence to the established care protocols.
Failure to Implement Policy on Bed Rail Use
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of grab bars/bed rails for two residents, placing them at risk for entrapment and injury. Resident 7, who was admitted with osteoporosis, hemiplegia, and hemiparesis, had grab bars installed on both sides of the bed without documented evidence of alternative interventions being attempted. The resident required substantial assistance with daily activities and had moderately impaired cognition. During an observation, the resident was not using the grab bars while trying to sit in a wheelchair, and there was no informed consent or physician's order for the installation of the grab bars. Similarly, Resident 8, diagnosed with generalized muscle weakness, dementia, and Alzheimer's disease, had grab bars installed without documented attempts of alternative interventions. The resident required partial to full assistance with daily activities and had moderately impaired cognition. During an observation, the resident was in bed with grab bars up on both sides, and there was no informed consent or physician's order documented. The facility's policy required an assessment of alternatives and informed consent before the installation of bed rails, which was not followed in these cases.
Insufficient Weekend Staffing in Q4 2024
Penalty
Summary
The facility failed to provide sufficient nursing staff on seven out of thirteen Saturdays and eleven out of thirteen Sundays during the fourth quarter of 2024, as indicated by the Payroll Based Journal (PBJ) Staffing Data Report. The facility did not meet the required 3.5 nursing hours per patient day on multiple dates, including 7/6/2024, 7/7/2024, 7/13/2024, and others. Additionally, the facility failed to meet the required 2.4 CNA direct care hours per patient day on several dates, such as 7/6/2024, 7/7/2024, 7/13/2024, and others. These deficiencies were confirmed through interviews with the Business Office Manager (BOM) and the Director of Nursing (DON), who acknowledged the shortfall in staffing levels necessary to meet residents' needs. The facility's request for a workforce shortage waiver was denied by the California Department of Public Health, as noted in a letter dated 6/14/2024. The facility's policy and procedure, revised in January 2024, required a minimum daily average of 3.5 nursing hours per patient day, with 2.4 of those hours performed by CNAs. Despite this policy, the facility's staffing levels were insufficient, particularly on weekends, as evidenced by the PBJ Staffing Data Report and interviews with facility staff. The lack of adequate staffing had the potential to affect the quality of care and negatively impact the residents' quality of life.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post actual nursing staffing information for three consecutive recertification days, which could potentially misinform residents and visitors about the staffing levels and affect the quality of care provided. On the first day of observation, the Daily Staffing Grid (DSG) at Nursing Station 1 was outdated, showing the previous day's date, while Nursing Station 2 had no DSG posted at all. This pattern continued over the next two days, with Nursing Station 2 consistently lacking a posted DSG. Interviews with the Director of Staff Development (DSD), Business Office Manager (BOM), and Director of Nursing (DON) revealed that the DSG was only posted in Nursing Station 1, contrary to the facility's policy which requires posting in both stations. The DSD admitted that the DSG was posted at midnight and covered all shifts, but was not accessible to residents, visitors, and staff in Nursing Station 2. The facility's policy mandates that staffing data be posted daily at the beginning of each shift in a clear and accessible manner, which was not adhered to during the survey period.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement and follow proper infection prevention procedures, leading to potential transmission of infectious organisms among residents. Specifically, the facility did not post the correct isolation signs for residents with multidrug-resistant organisms (MDROs) and failed to provide necessary personal protective equipment (PPE) for staff. For instance, Resident 294, who had osteomyelitis and was resistant to certain antibiotics, was not placed under the correct Contact Isolation, and the wrong sign was posted outside their room. Additionally, Resident 66, who had a physician order for Contact Precautions due to Vancomycin-resistant Enterococci (VRE) bacteremia, did not have a PPE cart or isolation sign outside their room, and was improperly cohorted with a roommate who did not have the same infection. Resident 238, who had a midline IV catheter and was at high risk for infection, did not have Enhanced Barrier Precaution (EBP) signage or a PPE cart outside their room. This oversight was confirmed during an observation and interview with the Infection Prevention Nurse, who acknowledged the absence of necessary precautions to prevent the spread of infection. Similarly, Resident 190, who required EBP due to a gastrostomy tube and wound, was not provided with the appropriate PPE by Certified Nurse Assistant 3 during care activities, as the CNA only wore gloves and not a gown. Interviews with various staff members, including Licensed Vocational Nurse 3, Registered Nurse Supervisor 1, and the Infection Prevention Nurse, revealed a lack of adherence to the facility's policies and procedures regarding infection control. The staff acknowledged the risks associated with not following proper isolation protocols, such as cross-contamination and the spread of infections to other residents. The facility's failure to implement these precautions as per their own policies and physician orders posed a significant risk of infection transmission within the facility.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain a signed Informed Consent from the responsible party of a resident prior to administering Ativan, a medication used to treat anxiety disorders. This oversight involved a resident who was readmitted to the facility with diagnoses including toxic encephalopathy, cerebral infarction, and chronic obstructive pulmonary disease. The resident was assessed as moderately cognitively impaired and required substantial assistance with daily activities. The physician's order for Ativan was documented, but the necessary informed consent was not found in the resident's clinical record. During an interview and record review, the Assistant Director of Nursing acknowledged the absence of the informed consent and emphasized the importance of obtaining consent for psychotropic medications due to their potential adverse effects. The facility's policy on psychotherapeutic drug management requires that residents or their responsible parties be informed of the risks and benefits of such medications before consent is obtained. However, this procedure was not followed, resulting in a violation of the resident's rights and the potential for the resident to receive medication without the responsible party's approval.
Inaccurate MDS Coding of Discharge Destination
Penalty
Summary
The facility failed to ensure the accurate coding of a resident's discharge destination in the Minimum Data Set (MDS), which is a federally mandated resident assessment tool. Specifically, Resident 85 was discharged to home or community, but the MDS inaccurately recorded the discharge destination as a short-term general hospital. This discrepancy was identified during a review of Resident 85's records, including the Admission Record, Order Summary Report, and Progress Notes, which all indicated that the resident was discharged to home or community. The Director of Nursing (DON) confirmed the error during an interview and acknowledged that the MDS should have been coded to reflect the correct discharge destination. The facility's policy and procedure for the Resident Assessment Instrument (RAI) process, dated 10/1/2023, mandates that each resident's assessment be coordinated and certified by a registered nurse, with all individuals completing a portion of the assessment signing and certifying its accuracy. The failure to accurately code the discharge destination resulted in incorrect reporting to the Centers for Medicare and Medicaid Services (CMS), potentially impacting the interventions provided to address specific care concerns for Resident 85.
Failure to Provide Communication Device for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication device in the language understood by Resident 189, who was admitted with diagnoses of Parkinson's disease and bipolar disorder. The resident's primary language was Spanish and Castilian, as indicated in the Admission Record. During an observation and interview, it was noted that Resident 189 did not have a communication board in their room, which was necessary for effective communication with the staff. Interviews with Registered Nurse Supervisor 1 and RN 2 confirmed that non-English speaking residents should have access to a communication board or translator to prevent miscommunication. The facility's policy on Translation or Interpretation Services stated that translation and interpretation services should be culturally relevant and appropriate for individuals with limited English proficiency. Despite this policy, the necessary communication tools were not provided to Resident 189, potentially affecting their ability to communicate needs and delaying care.
Failure to Reposition Resident as Required
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for Resident 292 by not turning and repositioning the resident every two hours as required. Resident 292, who was admitted with conditions including hemiplegia, hemiparesis, dependence on dialysis, and peripheral vascular disease, was identified as being at risk for developing pressure ulcers. The care plan for Resident 292 specifically indicated the need for turning and repositioning every two hours to prevent skin breakdown. Observations and interviews revealed that Resident 292 was left lying on their back for extended periods without being repositioned. The resident reported that staff did not turn them because it took too long. The Assistant Director of Nursing confirmed the necessity of repositioning residents, especially those on dialysis, every two hours to prevent skin breakdown. A Certified Nursing Assistant, unfamiliar with Resident 292's care, acknowledged the risk of wound development if the resident was not turned regularly. The facility's policy also required repositioning every two hours, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention care for a resident, identified as Resident 27, who was at high risk for developing pressure ulcers due to conditions such as peripheral vascular disease, paraplegia, and muscle contracture. The resident's medical orders included the use of bilateral heel protectors and a low air loss mattress set according to the resident's weight to prevent pressure ulcers. However, during an observation, it was noted that the resident did not have the heel protectors on, and the low air loss mattress was set incorrectly at 150 pounds, while the resident weighed 122 pounds. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, confirmed that the heel protectors were not in use and the mattress setting was incorrect, both of which could lead to the development of pressure ulcers. The facility's policy emphasized the importance of mechanical offloading and pressure-reducing devices in preventing pressure ulcers, but these measures were not properly implemented for Resident 27, leading to a deficiency in care.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 140, as outlined in the resident's care plan. The care plan specified the use of non-pharmacological interventions for pain management, such as gentle range of motion exercises, meditation, positioning, massage, and music, and required documentation of the resident's response to these interventions. However, the facility did not implement these non-pharmacological measures, nor did they document any attempts to do so, despite Resident 140 experiencing severe pain levels between 8-9/10 over several days. Additionally, the facility did not notify Resident 140's medical doctor when the resident's pain remained uncontrolled with the current pain medication regimen. The resident was prescribed Gabapentin, Oxycodone Hydrochloride, and Acetaminophen for pain management, but continued to report severe pain, particularly in the left abdomen, which was exacerbated by breathing. Despite these complaints, there was no documentation of any communication with the resident's physician to reassess or adjust the pain management plan. The failure to provide timely and appropriate pain management resulted in Resident 140 experiencing significant discomfort, having to wait over an hour for pain medication, and not receiving any documented non-pharmacological interventions. Interviews with the nursing staff revealed an acknowledgment of the importance of non-pharmacological interventions and the need to document them, yet these measures were not implemented or recorded in the resident's medical record.
Expired Chicken Nuggets Found in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as evidenced by the presence of expired chicken nuggets in the refrigerator. During an initial tour of the kitchen, a clear plastic bag of chicken nuggets with an expiration date was observed. Dietary staff confirmed that the chicken nuggets were expired. The Consultant Registered Dietitian and the Dietary Supervisor both acknowledged that the expired chicken nuggets should not have been in the refrigerator, emphasizing the importance of discarding expired food to prevent potential foodborne illnesses. The facility's policy and procedure on food storage indicated that food items should be stored and prepared in accordance with good sanitary practices.
Failure to Complete Antibiotic Surveillance Form
Penalty
Summary
The facility failed to complete a Surveillance Data Collection form for a resident receiving antibiotics, which is a requirement under their Antibiotic Stewardship Program. The resident, who had moderately impaired cognition and was dependent on staff for various daily activities, was receiving Daptomycin intravenously for Vancomycin Resistant Enterococcus bacteremia. Despite the resident's condition and the ongoing antibiotic treatment, the necessary surveillance form was not filled out to ensure the appropriateness of the antibiotic use. During an interview, the Infection Preventionist Nurse (IPN) admitted to being unable to locate the Antibiotic Surveillance Form for the resident. The IPN was on vacation during the period when the form should have been completed and was unaware of why it was not done. The Assistant Director of Nursing confirmed the necessity of antibiotic stewardship to determine if residents meet the criteria before receiving antibiotic therapy. The facility's policy on the Antibiotic Stewardship Program emphasizes the importance of collecting and analyzing infection surveillance data to monitor adherence to the program.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was functioning in eight of 35 resident rooms, specifically Rooms 7, 20, 21, 24, 25, 26, 29, and 36. Observations revealed that call lights in these rooms did not activate lights above the room doors or at the nurses' station panel. Additionally, some residents in these rooms were not provided with call bells as an alternative means of communication, contrary to the facility's policy. The Maintenance Log for October 2024 indicated issues with call lights in several rooms, but the facility did not adequately address these issues. Interviews with staff, including the Director of Maintenance and the Director of Nursing, confirmed that the facility's protocol required providing call bells when call lights were inoperable, which was not consistently done. Furthermore, there was no documentation of resident safety check rounds, which were supposed to be conducted hourly when the call system was not functioning. This lack of adherence to the facility's policy and procedures had the potential to delay care for residents, as staff would not be aware of residents' needs without a functioning call system.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer medications timely for a resident, identified as Resident 3, as per the facility's policy and procedure on medication administration. Resident 3, who was admitted with multiple diagnoses including type 2 diabetes mellitus, muscle wasting, dysphagia, and dementia, was scheduled to receive morning medications at 9 AM. However, during an observation at 11 AM, it was noted that the medications had not yet been administered. The Licensed Vocational Nurse (LVN) responsible for administering the medications admitted to falling behind on the medication schedule. The facility's policy requires medications to be administered within one hour before or after the scheduled time to ensure their effectiveness. Interviews with the LVN, a Registered Nurse (RN), the Director of Staff Development (DSD), and the Director of Nursing (DON) confirmed the importance of timely medication administration to maintain therapeutic drug levels. The failure to administer medications on time had the potential to negatively affect Resident 3, who was dependent on these medications for managing their health conditions.
Failure to Secure Smoking Devices and Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure that smoking devices were stored securely for a resident, as per the facility's policy and procedure and the resident's care plan. On a specific date, a resident was observed with an electronic smoking device resting on their lap in their room, which had a fruity smoke-like smell. The resident, who had been admitted with several medical conditions including hemiplegia and hemiparesis, required substantial assistance with activities of daily living and was unable to ambulate due to medical conditions or safety concerns. The resident's care plan indicated that they were allowed to smoke only in designated areas and required supervision while smoking. Interviews with staff revealed that the resident had been seen with the electronic smoking device in their room, and the room sometimes smelled like smoke. The Certified Nursing Assistant (CNA) stated that smoking in a shared room was a safety issue and could potentially harm other residents due to secondhand smoke inhalation. The facility had a designated smoking area and schedule, and the Activities Director or receptionist assisted residents during smoking hours. However, the CNA was unsure if the Director of Nursing or the Administrator had been informed about the resident having the electronic smoking device. The Director of Nursing confirmed that the facility's policy prohibited smoking inside the facility and required all smoking materials to be stored in a secure lock box. The facility's policy aimed to respect the choice to smoke while maintaining a safe environment for all residents. The policy applied to both cigarettes and electronic cigarettes, and residents who could not smoke independently and safely were to be accompanied by staff. Despite these policies, the resident was found with a smoking device in their room, indicating a lapse in adherence to the facility's smoking policy.
Infection Control Breach: Resident Accesses Meal Cart Unsupervised
Penalty
Summary
The facility failed to adhere to infection control practices for one resident, who accessed the meal cart unsupervised and without performing hand hygiene. This incident involved a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dysphagia. The resident independently retrieved their meal tray from the cart without staff assistance, which was against the facility's infection control policy. Interviews with staff, including a CNA, RN, DSD, IP, and DON, confirmed that residents should not access meal carts due to safety and infection control concerns. The staff acknowledged that hand hygiene should be performed before and after handling meal trays, and residents should not be allowed to remove trays themselves. The facility's policy emphasized the importance of maintaining a safe and sanitary environment to prevent disease transmission, which was not followed in this instance.
Failure to Follow Hoyer Lift Protocol Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) followed the required protocol for using a Hoyer lift. The resident, who had a history of hemiplegia, hemiparesis, and dementia, was at high risk for falls and required total dependence on staff for transfers. Despite the facility's policy mandating two-person assistance for Hoyer lift transfers, CNA 1 attempted to transfer the resident alone, leading to the resident falling from a shower chair and sustaining a head laceration. The incident occurred when CNA 1 was transferring the resident from the bed to a shower chair using the Hoyer lift without assistance from another staff member. During the transfer, the resident fell and hit their head on a doorknob, resulting in a laceration that required medical attention and sutures. The resident was subsequently transferred to a hospital for further evaluation and treatment of the injury. Interviews with facility staff, including the Director of Rehabilitation, Director of Staff Development, and Director of Nursing, confirmed that the facility's policy required two-person assistance for Hoyer lift transfers to ensure resident safety. The CNA admitted to not following this protocol, which directly contributed to the resident's fall and injury. The facility's policy and procedure titled 'Total Mechanical Lift' clearly indicated that at least two people should be present during such transfers, highlighting the failure to adhere to established safety protocols.
Failure to Readmit Residents After Hospitalization
Penalty
Summary
The facility failed to readmit three residents to the nursing home after they were cleared for discharge from a General Acute Care Hospital (GACH). These residents were initially transferred to the hospital for emergency medical care due to various health conditions. Resident 2 was transferred for sepsis, Resident 3 for right eye bleeding due to thrombocytopenia, and Resident 4 for abdominal issues related to a gastrostomy tube. Despite being cleared for return, the facility did not readmit them, citing a lack of available isolation rooms. Interviews with the Director of Care Coordination at GACH revealed that repeated attempts were made to contact the facility for the residents' return, but the facility staff indicated that no isolation rooms were available. The facility's Infection Preventionist and Admissions Coordinator confirmed that the facility was accepting new residents and could cohort residents with the same infection, but could not accommodate those with different types of isolation needs. The facility's bed hold policy allowed for a seven-day hold, after which residents could be readmitted if not on isolation. The Director of Nursing acknowledged the importance of readmitting the residents for continuity of care and because the facility was their home. However, the facility's policy and procedure on bed hold and transfer/discharge indicated that residents should be readmitted to the first available bed if they met the criteria for skilled nursing care. The failure to readmit these residents was a deficiency in adhering to these policies, potentially violating the residents' rights to return to the facility.
Delay in Providing Resident's Medical Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical records within the stipulated two working days as per their policy and procedure titled 'Resident Access to PHI.' The resident, who was admitted with conditions including sequelae of cerebral infarction, dysphagia, and mobility issues, had the capacity to understand and make decisions. A request for the resident's medical records was made by the resident's requesting party on June 25, 2024, via fax. However, the facility did not fulfill this request within the required timeframe. Interviews with the Medical Records staff and the administrator revealed that the request was acknowledged, but there was a delay in processing due to the need to consult with administration regarding legal matters. The Medical Records staff confirmed the importance of timely provision of records for reasons such as insurance, billing, and health. Despite the facility's policy requiring records to be provided within two working days, the records were only mailed on July 8, 2024, resulting in a delay for the requesting party.
Failure to Enforce PPE Use for Visitors in COVID-19 Precaution Area
Penalty
Summary
The facility failed to implement its Mitigation Plan regarding visitation guidelines for COVID-19, specifically for a resident under Novel Respiratory Precautions. Two family members were allowed to enter the resident's room without donning the required personal protective equipment (PPE), which included an N95 mask, face shield, gown, and gloves. This oversight was observed during a visit, where the family members were only wearing surgical masks despite the clear signage outside the room indicating the need for full PPE. Interviews with staff, including a Certified Nursing Assistant (CNA), the Assistant Director of Nursing (ADON), and the Infection Preventionist Nurse (IPN), confirmed that the family members were not informed of the PPE requirements. The staff acknowledged that the failure to enforce these precautions could potentially lead to the spread of the COVID-19 virus within the facility. The facility's Mitigation Plan clearly stated that visitors should be provided with PPE and instructed on its proper use, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 6,960 citations issued within 25 miles in the last 12 months — including the 31 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Anita Convalescent Hospital | 1.4 mi | ★★★★★ | 17 | 0 |
| Baldwin Gardens Nursing Center | 1.6 mi | ★★★★★ | 16 | 0 |
| Valley View Post Acute | 1.7 mi | ★★★★★ | 3 | 0 |
| Mission Care Center | 1.8 mi | ★★★★★ | 25 | 0 |
| Sunset Manor Conv Hosp | 1.9 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.